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Physical activity advising in primary health care in Scotland: An overview of knowledge, attitudes and current practice amongst primary health care staff

Acknowledgements

Serena Meloni and Ann Kerr (NHS Health Scotland) for their valuable comments and suggestions regarding the final report.
Gordon Prescott for statistical advice.
Carol Bugge for her advice regarding the interview data analysis.
Fiona Spence for help with data entry.
Jill Jones from the Institute of Applied Health Sciences and Netta Clark from the Department of General Practice (both University of Aberdeen) for their help with data transcription.
Mary Duncan from the Department of Public Health for secretarial support.
And of course, we would like to thank the study participants, without whose input, this study would not have taken place.

Introduction

This is the final report of a study commissioned by NHS Health Scotland of an exploration of the attitudes, beliefs and practice of Scottish primary health care (PHC) staff associated with promoting physical activity (PA) with clients during routine health care consultations during 2004. Primary health care staff, in the context of this study, includes general practitioners (GPs), health visitors (HVs) and practice nurses (PNs). The report presents the background to the study; its aims, and objectives; and methods; the main findings and conclusions.

The study indicates while the general advice given by participants is sound; there is scope for improvement in the message about frequency, intensity and duration that could be given to patients, i.e. that at least 30 minutes of moderate level intensity physical activity is accumulated on 5 or more days per week. Most participants discuss PA regularly with some of their patients, but there is no evidence of any systematic assessment of patients related to decisions to provide advice about PA or, in the advice that was given across all PHC staff groups taking part in the study. PA advice is offered to patients based on the PHC professional assessment of the relevance of the topic to their presenting condition, and their personal, socio-economic and/or environmental circumstances. There was no evidence of any formal fitness assessments of patients taking place in decisions to intervene with PA advice (or not). There were no noticeable differences in the types of advice given by all groups - although there were some differences noted between GPs and PNs, and HVs in terms of the characteristics of patients they would give PA advice to, and the amount to time that they spent on this task. There were high levels of enthusiasm related to promoting PA within the PHC community, which is regarded by most as a legitimate role.

This work also found that the existence of exercise prescribing schemes/formalised arrangements with local leisure facilities, a locally conducive environment, and specific exercise classes helped to support PA advising as routine. Barriers to this included a perceived lack of national policy priority, an apparent lack of space and resources, lack of perceived patient motivation; the patientÂ’s presenting condition; time; remuneration (for a small number), and a possible lack of self efficacy related to the role of PHC professionals. At the moment, recording of PA data in PHC is largely ad hoc and patchy, and suggests that the data quality would not be suitable for audit or research purposes at this time. Some HVs and PNs would welcome the opportunity for specific training in this area and all groups would welcome the development of guidelines for specific medical conditions. There is also a need to investigate patientsÂ’ attitudes and beliefs associated with the role of PHC staff in helping them to increase their PA levels and/or to maintain the changes, and the role of exercise referral schemes from the perspective of the service providers and patients.

Background

Benefits of physical activity

The health benefits of regular PA are widely accepted. Taylor (2003) amongst many others suggests that regular PA has a positive effect on physical and mental health as well as enhancing quality of life. Mutrie (2003) contends that a sedentary lifestyle has been associated with at least ? 17 unhealthy conditions?, all of which are associated with disease or are considered as risk factors for chronic disease such as non-insulin diabetes and osteoporosis. Yet, evidence suggests that there are increasing levels of physical inactivity in Scotland (Shaw et al., 2000) despite the fact that there are generally high levels of awareness of the benefits of exercise within the wider population (Mutrie, 2003).

Primary health care setting and health promotion

Health professionals are regarded as key professional groups, who are well placed to encourage PA at a population level as well as with high-risk groups e.g. those suffering from diabetes, hypertension, ischemic heart disease (Naidoo & Wills, 2000). It has been estimated that over a three-year period, 90% of the population will be in contact with a GP (Lawlor et al., 1999). Taylor (2003) also suggests that GPs and other health care professionals are still well regarded by the majority of the population, and that this perception represents an opportunity to promote PA within the primary health care setting. The Scottish Executive (2002) recommends that:

?Adults of working age who come into contact with primary care should be offered personal counselling to become more active and should be referred to appropriate activities.?

There has been a mushrooming of schemes that promote PA over the last 10 years. However there is a lack of consensus about the effectiveness of these initiatives in effecting changes in PA at the population level (Riddoch et al., 1998 { Riddoch, C., Puig-Ribera, A., & Cooper, A. (1998). Effectiveness of Physical Activity Promotion Schemes in Primary Care: a review. (Vol. 14). London: Health Education Authority. However, Ashenden et al. (1997) found a modest increase in the number of patients who reported increased levels of PA attributed to GP counselling in a systematic review of literature of such interventions.

Effective health promotion is known to require a variety of approaches and strategies operating over time to make a difference (Naidoo & Wills, 2000). It is important to ensure that all elements of a health promotion approach or programme are implemented or are operating as intended before a judgement is made about the effectiveness of it, in terms of process, impact and outcome (Wimbush & Watson, 2000). Therefore, if PHC staff are considered an important part of a wider health promotion strategy to make the Scottish population more active, it is crucial to understand their beliefs and current practice in this area (Scottish Executive, 2002). To date few studies have been conducted in Scotland to explore current practice and perceptions of PHC staff related to PA promotion.

Studies conducted in England, Australia and New Zealand suggested that common issues appeared to support or prevent GPs in advising patients about PA as routine. Swinburn et al. (1997) found in a study of New Zealand GPs that there was widespread acceptance about their role in promoting PA and that most felt comfortable about discussing the subject within the context of a medical consultation. It was easier to discuss the subject with high-risk groups. . The same study suggested that GPs also preferred to issue a so-called ?green prescription? at the same time as offering verbal advice. It was suggested that the prescription helped to formalise the discussion and enabled the GP to discuss and agree a set of specific set of goals with the patient.

Lack of time was the major constraint in Lawlor et al. ?s (1999) questionnaire study of GPs in Bradford, England. They found that the GPs? perceptions about the relevance of PA to the presenting condition and their beliefs about the likelihood of patients complying with their advice played a major role in determining whether they offered advice of not. Swinburn et al. (1997) also described perceived barriers to promoting PA as part of a medical consultation included lack of time; lack of confidence in providing advice; lack of financial reimbursement; insufficient knowledge about the benefits of exercise; lack of tools to assess and prescribe exercise and that patients lacked motivation to engage in PA. However, they also found that participants believed that if they knew the patient well, and were skilled in providing advice that they thought they would need less time to discuss and prescribe PA. Ashenden et al. (1997) also suggested that the main barriers to PHC staff providing general lifestyle advice was lack of time, lack of remuneration and a belief that their advice would not be taken up by patients.

Research aim

The aim of this study was to:

Provide an overview of knowledge, attitudes and current practice amongst primary care staff regarding related to physical activity, as part of their daily consultations.

Objectives

The objectives were set out under three broad areas related to: (1) current practice, (2) knowledge and the (3) advising process. The specific objectives were set out to:

Practice

Construct a profile of health professionals who routinely advise patients on physical activity, according to professional qualification, experience and age.

Determine the proportion of members of PHC teams who routinely advise patients to be physically active.

Determine how they assess the need for advice on physical activity.

Determine what advice health professionals give in terms of type, intensity, duration and frequency of physical activity recommended.

Determine what data staff record, who is responsible for recording this data, how often they are updated, and who has access to them.

Knowledge

Understand what information PHC staff have on the benefits of physical activity in relation to the main common conditions (e.g. obesity, diabetes, arthritis, cardiovascular deficiencies) and other conditions like pregnancy that are dealt with in PHC settings.

Identify what monitoring data are presently collected, who is responsible for their collection, whether other data would be useful, what are the barriers encountered in their collection, and what is the best working model to collect them.

Advising process

Identify barriers to advising patients to be physically more active.

Identify any support needed to sustain advice as routine.

Assess how systematic PHC staff are in advising patients on physical activity.

Methods

The following research methods were used to address the aims and objectives. These included:

A postal questionnaire survey of PHC staff was conducted in four selected health board areas (details under sampling and recruitment). These areas were chosen to reflect the diversity of GP practices within Scotland with respect to urban/rural location and practice population size.

A series of structured, in-depth face-to-face and telephone interviews were conducted with a purposive sample of 30 GPs, practice nurses and health visitors who were based in each health board area.

Research rationale

Individual social research techniques are inherently methodologically and philosophically limited. (Brannen 1992; Neuman 2000) Therefore, a mixed-methods approach was chosen to collect data about structural influences (e.g., practice policies and facilities related to PA, personal training opportunities, that are likely to have a bearing on staff attitudes and behaviours), while at the same time allowing respondents to express their own views. Using the methods outlined above, the findings were triangulated in order to compensate for any inherent limitations in the individual research techniques (Newman and Benz 1998). Using qualitative and quantitative methods in combination help to (a) explain quantitative findings; (b) enlarge on the findings; and (c) as part of triangulation.

Ethical approval

Before the study commenced, ethical approval was sought and granted by the Multiple Research Ethics Committee (MREC) as the study involved surveying and interviewing NHS staff and, the use of NHS premises for this purpose. In addition, ethics approval was sought and granted from each Local Research Ethics Committee (LREC) involved.

Questionnaire study

Sampling and recruitment

The questionnaire survey used a purposive sample of health board areas, selected to reflect the different geographical locations of PHC centres in Scotland.

The selected regions were:

East Coast

1. Tayside (urban)
2. Aberdeenshire (rural)

West Coast

1. Western Isles (geographically remote)
2. Ayrshire and Arran (mixed urban and rural).

By choosing these areas, the sample overall, is approximately representative of GP practices throughout Scotland.

NB. We chose to survey all GPs and the limited number of health visitors and practice nurses in all PHC centres in the selected health board areas for the following philosophical and logistical reasons.

1. Given the predicted GP response rate of 50% we considered that it was important to maximise the number of GP respondents to the questionnaire.
2. The NHS Health Scotland and the researchers perceived GPs as having a key role in determining individual practice policy and priorities.
3. A mailing list for GPs in the four Health Board areas was obtained from NHS Information Services Division (ISD). This list contained information on GP principals in each of the practices: name, address, age, gender and practice code. The mailing list did not include GP registrars, assistants or associates. However, there was not an up to date centralised list of health visitors or practice nurses available at health board level. A pragmatic decision was taken to use the PHC centre as the sampling unit.

Pilot study

The questionnaire was developed based on a review of the literature pertinent to the research questions. The questionnaire and the study approach were piloted in five GP practices in Aberdeen (Hundley and van Teijlingen, 2002). These practices included 35 GPs, ten PNs and ten HVs. Following this, minor adjustments were made to the questionnaire.

In order to maximise the response rate, it was considered important to limit the time taken for participants to complete the questionnaire by restricting length of questionnaire and the type of questions contained in it (Edwards et al, 2002: McColl et al, 2001) Therefore, the final version questionnaire consisted of four pages of mainly closed questions.

General practitioners

All GPs posted a copy of the questionnaire, and an information sheet with an invitation to participate in the interview study.

Practice nurses and health visitors

The questionnaire was posted to the ?Practice Nurse? or ?Health Visitor? at each of the GP practices: one copy of the questionnaire was posted to the PN or HV in single-handed GP practices and two questionnaires were posted the PNs & HVs in practices that had two or more GP partners. In the cover letter, staff were asked to return the extra copy of the questionnaire and indicate on the front cover if there was only one PN or HV in the practice. PNs and HVs who received the questionnaire were also invited to take part in the interview study.

One reminder letter was sent to all potential respondents after three weeks to boost the response rate.

Data management

Returned questionnaires were checked for completeness, coded and the data entered into a Microsoft Access database by a data administrator. The dataset was checked for anomalies and a 10% random sample was checked to ensure accuracy of the data entry.

Data analysis

The data was analysed by professionals groups: GPs, PNs and HVs as agreed by the research team a priori. Categorical data was compared using chi-squared tests. Continuous characteristics were compared using at-tests or ANOVA as appropriate. Data was analysed using SPSS v12.0 for Windows.

In-depth interviews

Sampling and recruitment

A combination of stratified, random sampling of all GP practices selected for the questionnaire study, and then purposive sampling within the selected practices was used to identify potential participants to try to ensure that an equal number of GPs, HVs and PNs from urban and rural practices were interviewed. After the practice has been identified, contact was made with the practice manager to identify three potential participants based in the practice who were invited to take part by the researcher. Despite vigorous attempts to recruit participants through an initial contact with the practice manager of the selected practices - consistent with the criteria described above - this process yielded very little success. In the end, only seven participants were recruited ?opportunistically? through the practice manager, a local GP or a local public health coordinator. The remaining 23 participants were recruited from an invitation to participate in the study contained in the questionnaire.

The majority of the interviews were conducted by telephone in order to minimise interruption to the health care providers. In order to check whether or not telephone interviews are different from standard face-to-face interviews a small number face-to-face (n=4) in different localities was conducted. Potential interviewees were telephoned at work to make an appointment for a future telephone or face-to-face interview at a time and place convenient to them.

Sampling and recruitment

A combination of stratified, random sampling of all GP practices selected for the questionnaire study, and then purposive sampling within the selected practices was used to identify potential participants to try to ensure that an equal number of GPs, HVs and PNs from urban and rural practices were interviewed. After the practice has been identified, contact was made with the practice manager to identify three potential participants based in the practice who were invited to take part by the researcher. Despite vigorous attempts to recruit participants through an initial contact with the practice manager of the selected practices - consistent with the criteria described above - this process yielded very little success. In the end, only seven participants were recruited ?opportunistically? through the practice manager, a local GP or a local public health coordinator. The remaining 23 participants were recruited from an invitation to participate in the study contained in the questionnaire.

The majority of the interviews were conducted by telephone in order to minimise interruption to the health care providers. In order to check whether or not telephone interviews are different from standard face-to-face interviews a small number face-to-face (n=4) in different localities was conducted. Potential interviewees were telephoned at work to make an appointment for a future telephone or face-to-face interview at a time and place convenient to them.

Data collection

Interviews were conducted using a structured topic guide (See Appendix 2). The topic guide was designed to explore in more depth most of the issues covered by the questionnaire. However, the interviews also specifically focussed on issues relating to:

• factors perceived to inhibit or support PA promotion in the health care consultation
• factors perceived as important in enabling sustained patient behaviour change
• beliefs about the health benefits of PA for high risk groups versus the wider population
• GPs? attitudes towards and beliefs about their role and self efficacy in promoting PA in the context of the PHC setting identification of training needs and ideas about the optimum methods to receive that trainingdata collection and quality issues.

Three researchers were specifically trained to conduct the interviews. The interviews were audio-recorded with the participants? explicit permission.

Data analysis

The audiotapes were fully transcribed, and transcripts (along with the field notes) were read and reread by the three researchers. Using the data and the topic guide, emergent themes and categories were identified by each researcher. The results of this work were then discussed by all to reach agreement on themes and, to identify consistent and exceptional cases within the data. A coding frame was then established and each transcript was coded and analysed using QSR NVivo software. Illustrative quotes were then identified.

Results

Questionnaire

Respondent characteristics

GPs

In total, 181 GP practices were included in the questionnaire survey: 26 were single-handed practices with the remaining 155 practices having two or more GPs.

The questionnaire was posted to 802 GPs and returned by 431 (54%). Two GPs were on maternity leave, one was away and 52 questionnaires were blank, resulting in 376 useable questionnaires and giving an overall response rate of 47% (376/799).

Practice nurses

Questionnaires were posted to 336 PNs (310 from list of two or more GPs in the practice and 26 from single partner practices). Nineteen were returned marked ?only one PN in this practice? giving a possible response from 317 PNs. In total, 220 were returned (69%): eight of these were blank, giving a final response rate of 67% (212/317).

Health visitors

Questionnaires were posted to 330 HVs (298 from list of two or more GPs in the practice, 19 single-handed practices and 13 to a complete list of HVs in Western Isles). Forty-one were returned blank and marked ?only one HV at this practice? giving a possible response from 289 HVs. In total 177 were returned (61%): eight were blank, giving a final response rate of 59% (169/289).

Overall response (Table 1)

• completed questionnaires were received from 757 responders, giving an overall response rate of 54%
• questionnaires were completed by at least one GP in 80% of the practices
• between the GPs, Aberdeenshire had the best response rate with almost 60% of GPs returning a questionnaire
• PNs had the best response rate overall with little differences between health board areas
• HVs had a slightly lower response rate than PNs
• Aberdeenshire had best response overall with Ayrshire and Arran the lowest.

Table 1: Response rates to questionnaire survey, n (%)

	Practices 1	GPs	PNs 2	HVs 2	Overall
Aberdeenshire	28/34 (82%)	124 /211 (59%)	61/ 88 (69%)	43 / 77 (56%)	228/ 376 (61%)
Ayrshire	48/61(79%)	109 /266 (41%)	64/ 101 (63%)	56 / 97 (58%)	229/ 464 (49%)
Tayside	58/72 (81%)	124 / 295 (42%)	75/ 110 (68%)	65/ 102 (64%)	264 / 507 (52%)
Western Isles	11/14 (79%)	19 / 27 (70%)	12/ 18 (67%)	5 / 13 (39%)	36 / 58 (62%)
Total	145/181 (80%)	376/ 799 (47%)	212/317(67%)	169 / 289 (59%)	757 /1405(54%)

¹ questionnaire returned by at least one GP in the practice
² have adjusted denominators to account for those questionnaires returned as only one PN or HV attached to the practice

Note: Figures from the ISD website for 2003, advise in the headcount statistics that there are 93 HVs in Ayrshire & Arran, 104 in Tayside and 15 in Western Isles (data not available for Aberdeenshire): the final denominators in this study are similar.

The demographic characteristics of the respondents are shown in Table 2.

There were significant differences in the age of responders although the absolute difference is small, with HVs slightly older by 2-3years.

The average age of GPs nationally is 44.7years (ISD) and very similar to our respondents

Thirty five percent of GP respondents were female which is also similar to the national data (39.5% GPs female)

Unsurprisingly, the majority of the PNS and HVs were female (1.3% of HVs in Scotland are male (ISD)).

Two thirds of GP were Members or Fellows with the Royal College of General Practitioners, which is similar to the national statistics (the Royal College of General Practitioners (Scotland) & ISD).

The PNs had slightly higher mean number of years since graduation than the GPs and HVs. However, they had less years working experience in General Practice.

HVs were more likely to have degree compared to PNs (64% vs 23).

Forty four percent of PNs had completed further qualifications e.g. asthma, diabetes, family planning certificates.

Table 2: Demographic characteristics of respondents

	GP	PN	HV	P 1
Age in years, mean (SD)	44.9 (8.2)	45.9 (7.5)	47.4 (7.8)	0.003
Sex (female), n (%)	131 (35%)	205 (99.5%)	162 (97%)
Years since graduation, mean (SD)	21.5 (8.4%)	24.5 (8.5%)	22.2 (10.2%)	0.01
Years in general practice, mean (SD)	15.9 (8.3%)	11.3 (6.5%)	15.2 (7.8%)	0.00
MRCGP/ FRCGP or Degree	249 (66%)	49 (23%)	108 (64%)

¹ ANOVA

Glossary of terms

GP	General Practitioner
HV	Health Visitor
PN	Practice Nurse
PHC	Primary Health Care
PA	Physical Activity