Training health professionals to provide physical activity counselling
Introduction
Physical inactivity is the fourth leading risk factor for global mortality.1 Substantial research supports the benefits of regular physical activity (PA) in the prevention and treatment of chronic medical conditions.2,3 Sedentary patients cost more to care for4 and a 2016 report5 conservatively estimated that physical inactivity cost international health care systems over INT$53.8 billion worldwide in 2013. Despite the substantive evidence, 27.5% of adults globally participate in insufficient levels of PA to maintain health with the highest incidence of sedentarism in high income countries (36.8%).6
The World Health Organization (WHO) defines a health professional (HP) as individuals that study, diagnose, treat and prevent human illness, injury and other physical and mental impairments.7 For the purposes of developing guidelines for their education and training, the WHO provide a list of HP occupations that includes medical doctors (generalists and specialists), nurses and midwifes, dentists, pharmacists, dieticians and nutritionists, and other therapy related occupations.7 These HPs are ideally placed to promote PA. Patients view them as credible sources of health information including advice regarding PA.8 Of all HPs, primary care medical doctors tend to have longer-term relationships with their patients, with 80% of individuals in the United States (US) visiting at least once per year.9 This makes the primary care setting ideal for long-term behaviour change counselling. The aims of this paper are to provide evidence for the effectiveness of PA counselling by HPs along with current best practice models. Further, we will present several case studies that the authors have been involved with to improve PA counselling behaviours of HPs, with a focus on primary care medical doctors.
Section snippets
Effectiveness of HPs PA counselling
There is strong evidence that HP PA counselling leads to increases in PA of patients.10, 11, 12 A recent systematic review that included 16 studies found that HP PA counselling increased PA energy expenditure by 1.8 metabolic equivalent (MET)hours/week and with a more intensive HP patient interaction this increased to 2.8 METhours/week.12 This is an improvement of approximately 60 extra minutes/week of moderate PA equating to more than a third of the current PA guidelines. Cost effectiveness of
Changing HP PA counselling behaviour
HP PA counselling behaviour is dependent on three components: capability, opportunity and motivation (COM-B).21 Barriers to HP providing PA counselling include a poor understanding of how and why to prescribe exercise or where to refer a patient to obtain the best PA prescription (capability),22 lack of time within consultations (opportunity),22,23 as well as limited PA and behaviour change counselling skills (capability).24,25 Education in lifestyle medicine is considered necessary to allow
Changing patient PA behaviour
Effectively encouraging patients to change their health behaviours is a critical skill for HPs. Implementing a behaviour change intervention may appear to be a daunting task without adequate training in the area. The 5 A's behaviour change framework (Fig. 1) is recommended to guide a HP/patient PA behaviour change interaction: 1) Assess current PA (type, frequency, intensity, and duration); PA contraindications; patient's readiness for change and self-confidence to change behaviour; 2) Advise
Brief PA counselling
Implementing the 5 A's behaviour change framework illustrated in Fig. 1 is hampered by a lack of time within HP consultations. Often these are patient initiated and therefore generally based around an acute complaint/condition experienced by the client/patient. Therefore, a standard consultation time is usually insufficient to implement all aspects of the 5 A's framework to influence PA behaviour. This can be exacerbated for the HP when there are a range of lifestyle related issues to consider,
Case studies
The following case studies detail different approaches that the authors have been involved in to improve the training of HPs to provide PA counselling to their patients. The discussion of these cases covers the context, overview, and key learnings of the cases. Table 2 lists key considerations when including PA curriculum into HP training.
Conclusions
The PA counselling from HPs leads to increased PA and better health outcomes for their patients. However, there remains a large evidence-practice gap between HP knowledge of the contribution of physical inactivity to chronic disease prevention and management, and routine effective assessment and prescription of PA. This is recognized as being partially due to insufficient coverage of these topics in the HP curricula, especially for medical students. While significant barriers exist to adding
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgement
AW is a Medical Research Future Fund (MRFF) Translating Research into Practice (TRIP) Fellow funded by the Australian Government.
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