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Changing physical activity counseling outcomes among future health professionals.

INTRODUCTION

Regular physical activity (PA) has been identified as a very important factor in achieving health and wellbeing (32). According to Dr. Adrian Hutber, Vice President of Exercise is Medicine, "Physical activity has the ability to prevent or manage chronic disease in a way that no pill or other intervention does" (35). Nevertheless, 85% of Canadian adults are not active enough to receive health benefits (17), which according to the Canadian Society for Exercise Physiology (CSEP) requires 150-minutes per week of moderate to vigorous PA (MVPA) (5).

Unfortunately, physical inactivity not only affects individual health, but it also affects the Canadian economy. In 2009, it was estimated that the health cost of physical inactivity was $6.8 billion, representing 3.7% of the country's overall healthcare spending (35). The economic burden of physical inactivity, and related health concerns, continues to increase and is now approximately $29 billion per year. In fact, research proposes that simply increasing PA rates in Canada by 1% per year could save approximately $2.1 billion annually (18).

PA is clearly linked to the management and/or prevention of various diseases and disorders, such as cardiovascular disease, certain forms of cancer (e.g., breast, colon), hypertension, metabolic syndrome, obesity, psychosocial disorders, and Type 2 diabetes (2, 10). This highlights the importance of public health efforts aimed at reducing the rate of physical inactivity and associated chronic diseases in Canada. Statistics regarding PA counseling in healthcare present a cause for concern, as it has been found that the majority of U.S. adults (i.e., 67%) reported receiving no advice or information about exercise from their healthcare professionals (20). Although 72% of patients believed their family doctors should discuss health problems related to physical inactivity (36), it has been shown that the rate of PA counseling might actually be decreasing (20).

It has been suggested that family physicians are in an ideal position to educate patients on the benefits of regular PA and to counsel them on how to increase activity levels (15). Physicians see their patients regularly and can easily monitor the progress of PA implementation and provide guidance. PA promotion in primary care has been found to be effective. Specifically, Orrow et al. (26), found significant increases in self-reported PA levels in sedentary adults following a 12-month PA intervention recommended by a healthcare professional. Despite the important role healthcare professionals could play in PA promotion, it has been reported that family physicians - in the United States (U.S.) - spend just one-and-a-half to three minutes providing health education and counselling during a typical patient visit (21).

Lack of education has been identified as a primary barrier for many health professionals with regard to PA counselling in clinical settings (19, 34). Twenty-four percent of U.S. medical school Deans believe that their students are well prepared to counsel patients on PA after graduation, despite the fact that the majority (i.e., 64%) believe that medical education should provide future doctors with the skills and knowledge to effectively provide PA counseling (13). However, 51.7% of medical schools do not offer any courses related to PA counseling to their students (6). A study involving internal medicine residents at Oregon Health Sciences University measured the impact of PA counselling workshops on medical residents' confidence to provide counselling in clinical settings. Results indicated that educational interventions could effectively improve the self-efficacy of medical residents with regard to PA counselling, as well as the self-reported frequency of PA promotion (11). It is important to note that other members of the healthcare team, including diabetes educators and nurses, can have a substantial impact on patient selfcare and health outcomes as well (37).

In considering the important role of healthcare professionals in lifestyle counselling, Dillman et al. (9) measured the efficacy of diabetes educators in Atlantic Canada with regard to PA counselling. Findings suggested that these individuals lacked confidence in their ability to counsel about, prescribe, and make referrals for PA. They also lacked confidence in the ability of patients to perform PA (9). Expanding on the results of this initial study, Shields et al. (33) facilitated a series of workshops aiming to give healthcare practitioners proper training in PA promotion. A consistent increase was observed in healthcare professionals' confidence to provide PA counselling following the intervention (33). Increasing confidence to promote PA in healthcare practitioners may impact their future PA counselling practice.

The purpose of this pilot study was to investigate the impact of an evidence-based PA educational intervention on future health professionals' attitudes, beliefs, confidence and knowledge with regard to promoting PA in clinical settings. The objectives were to: (1) assess the current attitudes, beliefs, confidence and knowledge of students in health-related fields with regard to PA promotion, as well as their beliefs about obesity; (2) develop and implement an evidence-based PA education intervention for students in health-related fields; and (3) measure changes in attitudes, beliefs, confidence and knowledge with regard to PA promotion and beliefs about obesity following the intervention. Based on previous research, it was hypothesized that after participating in an evidence-based PA intervention, students' confidence and knowledge with regard to PA promotion in clinical settings would increase. It was also expected that students would have more positive attitudes and beliefs with regard to the importance of promoting PA to patients of all shapes and sizes in order to prevent and manage chronic conditions.

METHODS

Participants

Students in health-related undergraduate programs such as general sciences (e.g., biology, biochemistry), health sciences, human kinetics, nursing, pharmacy, and social work; as well as students in health-related graduate programs or second-degree professional undergraduate programs (i.e., medicine) were targeted to participate in this study. Additionally, students in health-related graduate programs or second-degree professional undergraduate programs (i.e., medicine) were invited to participate. The goal was to recruit undergraduate and graduate students from a wide variety of academic backgrounds, regardless of year of study at Memorial University, so that participants would hold varying attitudes, beliefs, confidence, and knowledge about PA promotion and obesity. Despite extensive recruitment efforts by the research team, the majority of participants (54.2%) were found to be completing, or had previously completed, an undergraduate degree in human kinetics. Complete demographic characteristics for participants are presented in Table 1. Additionally, the PA and sedentary behaviour practices of participants are reported in Table 2. To summarize, 70% of participants reported meeting the CSEP PA guidelines, and the majority (79.2%) reported receiving at least 30-minutes of MVPA per day.

Procedures

Ethical approval was obtained from the host institution ethics committee. Participants were recruited through social media (i.e., Twitter, Facebook) and email, classroom visits and discussions, and announcements posted by various faculties at the host institution. Interested participants were encouraged to attend the PA education session. Questionnaires were administered prior to and following the intervention to measure its effect on the attitudes, beliefs, confidence, and knowledge of students in health-related degree programs with regard to PA counselling, as well as their beliefs about obesity. Prior to completing the baseline questionnaire, participants were informed about the purpose and procedures of the study, and that completing the questionnaire implied consent. These surveys were collected before the seminar began to reduce bias when completing the post-intervention questionnaires. Each student participating in the intervention was assigned a number on an index card, to allow for the matching of their baseline and postintervention questionnaires. No information that could be used to identify participants was requested.

Students then participated in a one-hour seminar focusing on the benefits of regular PA, and its promotion in clinical settings. The session featured brief PowerPoint presentations on PA promotion and counselling (30-minutes), PA behaviour change (15minutes), and health communication strategies in clinical settings (15-minutes).

The section on PA promotion discussed the various types of training and their associated benefits, as well as the importance of PA counseling with regard to preventing, managing and treating chronic disease. The PA behaviour change component focused on strategies that can be used to effectively modify patients' behaviour, and increase PA adherence (e.g., goal-setting). Finally, the section on health communication strategies emphasized the need for professionals to engage empathically with individuals of all shapes and sizes. Given that weight bias, stigma, and discrimination have been observed in professionals and students in health-related fields, it is important to educate students on the importance of discussing weight and health in a safe and caring way (4, 29). The post-intervention survey was administered immediately following the completion of the PA education intervention.

Measures

Questionnaires from recent Exercise is Medicine literature were reviewed in order to gain an understanding of the various types of questions used to measure changes in the attitudes, beliefs, confidence and knowledge of current and future healthcare professionals (9, 33). A questionnaire was then developed based on the information gathered to best measure the attitudes, beliefs, confidence and knowledge of participants in this current study. Specifically, the questionnaire package contained questions to collect participant demographics (e.g., age, gender), perceived barriers to PA counselling, PA practices, attitudes, beliefs and knowledge about PA, weight and health, and confidence with regard to PA promotion. The personal PA practices section included a series of questions assessing weekly PA habits and average leisure-time PA over the course of the previous month. The leisure score index from the Godin Leisure Time Exercise Questionnaire (LSI) was used to assess the frequency of light, moderate, and vigorous PA over a typical week, and was modified to include average duration (14). The LSI has been extensively validated (16), and was used to calculate the percentage of participants engaging in the 150-minutes of weekly MVPA recommended by CSEP to obtain health benefits (5).

Attitudes, beliefs and knowledge about PA were measured using items generated in other Exercise is Medicine research. Specifically, these concepts were measured using a 5-point scale ranging from "strongly disagree" (1) to "strongly agree" (5). The questionnaire included three items to assess attitudes, three beliefs, and four knowledge. It is generally accepted in the literature that a Cronbach's alpha value of greater than 0.6 is desirable for survey research (24). The alpha values were above 0.6 for attitudes and knowledge, while the alpha value for beliefs was between 0.5 and 0.6. Research has suggested that the smaller the number of items the greater the likelihood of the reliability analysis using Cronbach's alpha to be inaccurate (8). The alpha values obtained in the present study are lower than those reported in previous research using these questionnaires, however, Nunnally contends that reliability estimates are likely to be poor in cases in which the reliability coefficient is based on a relatively small sample size (23). As such, the research team considered the alpha values mentioned above to be acceptable for this pilot study. The answers to the questions from each of the three categories were summed and a mean score was calculated. For attitudes, a higher score indicates that the participant considers PA to be important to overall health and wellbeing, while a higher score in beliefs reflects that a participant believes it is important for health practitioners to provide PA counselling to their clients. Furthermore, a higher score in knowledge indicates that a participant has a strong understanding of PA promotion and associated health benefits.

Confidence was measured using six-items that assessed confidence in promoting PA under various circumstances (0%= not at all confident; 100%= completely confident). Confidence measures assessed confidence to perform PA counselling based on personal knowledge (4 items: a value > .9), confidence in assessing the readiness of a patient to begin PA (1 item), and (3) confidence in referral of patients requiring additional clearance or information before beginning a PA program (1 item). The confidence to perform PA counselling items were averaged to provide an overall indication of confidence out of 100% (8, 31).

Attitudes, beliefs, and knowledge about weight and health were measured using the Beliefs About Obese Persons Scale (BAOP) scale (1), which is an 8-item Likert rating scale designed to assess beliefs about the causes of obesity. The BAOP is a reliable instrument and has been used extensively in the literature (28, 30). In the present study, the alpha value for the BAOP measure was above 0.7. Each question on the BAOP scale asks individuals to indicate the extent to which they agree (+3) or disagree (-3) with a specific statement about the causes of obesity. Items 1, 3-6, and 8 are multiplied by -1 to reverse their scoring, and are then added to the remaining items to create a total. This total is then added to 24 to provide an overall BAOP score for the questionnaire. Higher scores indicate a stronger belief that obesity is not under an individual's control (1, 30).

Statistical Analysis

The demographic characteristics of participants in this study were analyzed using descriptive statistics and frequencies. Self-reported moderate and vigorous PA frequency and duration were used to calculate participant's weekly moderate and vigorous PA, in order to determine how many participants met the CSEP PA guidelines. Descriptive statistics were used to calculate the frequencies of PA and sedentary behaviours, as well as the perceived barriers to PA counselling. Furthermore, paired samples t-tests were conducted to evaluate the impact of the PA education intervention on attitudes, beliefs, confidence, and knowledge.

RESULTS

Barriers to Physical Activity Counselling

The perceived barriers to PA counselling are presented in Table 3. Specifically, 70.8% of participants believed it would be somewhat difficult to include PA counselling in their respective health-based professions. The top three barriers to PA counselling in clinical settings included: lack of client interest in PA and exercise (62.5%), client preference for medication-based treatment over lifestyle modification (50%), and lack of time in client interactions to provide adequate counselling (45.8%).

Changes in Attitudes, Beliefs, Confidence and Knowledge

Table 4 presents the effects of the PA education intervention on attitudes, beliefs, confidence, and knowledge about PA counselling, as well as the beliefs about obesity. Specifically, significant increases were found for attitudes [t (23) = 2.30, p = .031], beliefs [t (22) = 3.43, p = .002] and knowledge [t (23) = 3.80, p = .001] of the participants from baseline to post-intervention. Statistically significant increases in participants' confidence to perform counselling based on personal knowledge [t (22) = 5.71, p = .001], confidence to assess a client's readiness for PA [t (22) = 2.29, p = .032], and confidence to refer patients requiring additional clearance or information before beginning PA [t (23) = 4.05, p = .001] were also observed. Finally, there was a statistically significant decrease in the BAOP score representing beliefs about obese persons [t (23) = -2.34, p = .029].

DISCUSSION

The primary purpose of this pilot study was to investigate the impact of an evidence-based PA educational intervention on future health professionals' attitudes, beliefs, confidence and knowledge with regard to promoting PA in clinical settings. Results revealed that a one-hour evidence-based PA educational intervention was effective in improving the attitudes, beliefs, confidence and knowledge of students in health-related fields with regard to PA counselling. These findings are in line with previous work illustrating how PA education sessions can increase the confidence of healthcare professionals to deliver PA counselling (11, 33). Furthermore, it has been shown that similar PA education interventions have increased self-reported rates of PA counselling among health care professionals (11). The main barriers to PA counselling identified in this study are consistent with those suggested in PA counselling research (20). Lack of personal knowledge with regard to PA has also been identified in literature as a major barrier, although the high PA levels of participants in this study might explain why knowledge was not identified as a perceived barrier to PA counselling. It is well established in the literature that the PA counselling practices of many healthcare professionals are inadequate (19, 20). Again, it is important to consider that the majority of medical schools in the U.S. (51.7%) do not offer any courses related to PA counselling (6). Evidently, the lack of education for students in health-related programs, including medicine, with regard to PA counseling is an issue (6). Furthermore, it has been suggested that existing PA education in medical school curricula should be modified to address students' personal PA behavior patterns and to incorporate a combination of both theory and counselling practice experience (7). The results of this study illustrate the importance of increasing PA education in health-related programs. Given the fact that significant increases in the attitudes, beliefs, confidence, and knowledge of students with regard to PA counseling were observed following the one-hour intervention, it is expected that the implementation of courses related to PA counseling would have an even greater, long-term impact on their future practice. Efforts to incorporate PA education into national medical curricula in the U.S. have led to an increase in the amount of PA education available, however, much more needs to be done to increase the efficacy of future healthcare professionals with regard to PA counselling (6).

In contrast to our findings that the intervention had a positive impact on the attitudes, beliefs, confidence, and knowledge of PA counselling, it is important to note that the mean BAOP score decreased from baseline to post-intervention (17.38 to 15.46). Higher numbers on the BAOP scale indicate a stronger belief that obesity is not only under a person's control (30), but rather is the result of a multitude of other social determinants of health (i.e., poverty, education, socio-economic status) (31). This contradicted the original hypothesis regarding the expected changes in a participant's beliefs about health and weight, given that the final component of the PA education intervention discussed important health communication strategies, with emphasis placed on the need for health-related professionals to engage empathically with people of all shapes and sizes. Weight bias, stigma, and discrimination in health-related fields are shown to have negative physiological and psychological implications that can increase the risk of unhealthy behaviours (4, 29). Although it was expected that participants would gain an understanding of the complexity of external factors influencing an individual's body weight, the results indicated otherwise. It should be noted that the initial section of the intervention took a weight-based health approach where PA was discussed in relation to the risk of obesity and chronic disease. It is likely that this initial discussion regarding the importance of PA in reducing health risks in fact negatively contributed to perceptions about health and weight.

Strengths & Limitations

This study was an evidence-based intervention illustrating the effectiveness of a PA education session in improving the attitudes, beliefs, confidence, and knowledge of students with regard to PA counselling and promotion. Despite the fact that the study involved a sample of physically active individuals, many of who had received formal education or training on the benefits of regular PA, results indicated a significant improvement in most of the outcomes measured. Previous PA education literature suggests that improvements in PA counselling outcomes following short educational interventions, such as the one piloted in the present study, can remain three months after the initial intervention (11).

A number of limitations were identified in the present study. This project was a pilot study following a pre-experimental design (i.e., one-group pretest-posttest design), with a goal of determining the feasibility of future projects related to PA counseling, and to explore the impact of such an intervention with future health professionals. Although this study follows a pre-experimental design, the research team considers it to be a valuable addition to Exercise is Medicine -related literature since it identifies, in addition to a number of significant results, several important challenges (i.e., recruitment issues) which must be considered in future PA education research. While the experimental design was weaker, administering the post-test immediately after the intervention increased the likelihood that our results can be attributed to the intervention. Additionally, since the Exercise is Medicine field is a growing area of research, this step is necessary before large-scale randomized controlled trials can be conducted. It should be noted that our intention was to deliver the intervention exclusively to medical students, however, the researchers faced a number of challenges in recruiting participants from this population. Although we extensively recruited in the medical school, the researchers deemed it necessary to open the intervention to students from a number of other health-related programs. Students of all health-related academic backgrounds were encouraged to attend the PA education session, but it is likely that the students who chose to attend had an interest in learning about PA and counselling. This assumption is supported by the PA practices of participants reported in Table 1, as well as by the fact that the majority of participants had an undergraduate background in human kinetics. This limited the potential for comparison between movement science and non-movement science students. Furthermore, it demonstrated the challenges associated with recruiting participants who do not have an interest in PA. The small sample size, which resulted despite an elaborate recruitment plan, also made it difficult to examine any differences existing between movement science and non-movement science students."

Clinical Implications

The results indicate the effectiveness of a one-hour PA education intervention in increasing the attitudes, beliefs, confidence, and knowledge of students in health-related fields with regard to PA counselling. As previously discussed, it has been well established in literature that there is a need for greater PA education for future healthcare professionals. Further research is required to investigate whether a similar intervention could improve 'actual' PA counselling practices based on the increase in counselling efficacy observed.

The results also indicate that it is imperative that future PA counselling not be framed within the weight-based health paradigm (25), but a wellness-based health paradigm. This is in-line with new evidence that suggests the prevention of chronic disease needs to take a body positive and mental health approach in order to reduce the negative psychological and physiological consequences of weight bias and discrimination (3). Future PA education and counselling interventions need to incorporate new emerging PA models that promote greater access to the benefits of PA for all bodies (27).

In considering the long-term implications of increased clinical PA counselling in Canada, the Government of New Zealand serves as a model of a healthcare system that effectively employs exercise prescription. Introduced in 1998, the "green prescription" (GRx) system encourages healthcare professionals, particularly physicians, to provide written advice to patients to increase their PA levels. The program encourages general practitioners to target conditions associated with physical inactivity, and it has been used by over 80% of family physicians in the country (25). Patients are encouraged to manage their own health by becoming physically active and improving nutrition, with family physicians serving as a source of advice and support. The GRx intervention has proven to be effective with regard to increasing national PA levels and improving health outcomes across the country, without any evidence of adverse effects (12). Thus, further research in Canada should investigate not only the benefits of PA counselling in clinical settings, but also the potential impact of PA/exercise prescription on the health of our population.

ACKNOWLEDGEMENTS

The authors would like to thank Dr. Kevin Power of Memorial University for his assistance during the preparation of the evidence-based PA education intervention, as well as Dr. Jonathon Fowles of Acadia University and Exercise is Medicine Canada for his guidance and support in the development of this project.

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AUTHOR CORRESPONDENCE:

Erin McGowan, PhD

Assistant Professor, School of Human Kinetics and Recreation

Memorial University

Physical Education Building (PE 2022B)

St. John's, NL, Canada, A1C 5S7

Email: emcgowan@mun.ca

Phone: 1-709-864-7269

Jared M. Ryan, Erin M. Cameron, & Erin L. McGowan

School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John's, NL, Canada
Table 1. Demographic Characteristics of Intervention
Participants, N = 24.

Characteristic                    Overall n

Age                               23.2 (5.1)
  Mean (SD)
Gender
  Male                            9 (37.5%)
  Female                          15 (62.5%)
Current degree program
  Undergrad                       19 (79.2%)
  Grad                            4 (16.7%)
  Professional (i.e., medicine)    1 (4.2%)

Undergraduate degree
  Human kinetics                  13 (54.2%)
  Health science                   1 (4.2%)
  General science                 8 (33.3%)
  Social work                      2 (8.3%)

Table 2. Physical activity and sedentary practices of
intervention participants, N = 24.

Characteristic                                       Overall n (%)

Days per week of 30 minutes MVPA                        0 (0%)
  1                                                     0 (0%)
  2                                                    5 (20.8%)
  3                                                    4 (16.7%)
  4                                                    6 (25.0%)
  5                                                    7 (29.2%)
  6                                                    2 (8.3%)
  7                                                    1 (4.2%)
Hours per day spent sitting
  <4                                                  14 (58.3%)
  4-6                                                  6 (25.0%)
  6-8                                                  3 (12.5%)
  8+                                                   3 (12.5%)
Hours of daily screen time
  <2                                                   8 (33.3%)
  2-4                                                  9 (37.5%)
  4-6                                                  4 (16.7%)
  6+                                                   2 (8.3%)
Do you consider yourself to be sedentary?
  Yes                                                 19 (79.2%)
  No                                                   3 (12.5%)
  Unsure                                               1 (4.2%)
Interested in increasing level of daily PA
  Disagree                                             5 (20.8%)
  Neutral                                             18 (75.0%)
  Agree/strongly agree                                  0 (0%)
Importance of incorporating PA into daily schedule
  Unimportant                                          24 (100%)
  Important                                             0 (0%)
  Unsure

Table 3. Barriers to physical activity counseling among students
in health-related programs.

Characteristic                                          Overall n (%)

Would it be difficult to include physical
  activity counseling into future practice?
    Not at all difficult                                  7 (29.2%)
    Somewhat difficult                                   17 (70.8%)
    Very difficult                                         0 (0%)
Barriers to counseling (Would it prevent counseling?)
  Lack of time in patient interactions
    No/Rarely                                            13 (54.2%)
    Yes                                                  11 (45.8%)
  Lack of PA education in school
    No/Rarely                                            17 (70.8%)
    Yes                                                   7 (29.2%)
  Lack of personal PA experience
    No/Rarely                                             21(87.5%)
    Yes                                                   3 (12.5%)
  Personal knowledge
    No/Rarely                                            19 (79.2%)
    Yes                                                   5 (20.8%)
  Patient/client not interested in exercise
    No/Rarely                                             9 (37.5%)
    Yes                                                  15 (62.5%)
  Other lifestyle changes more important
    No/Rarely                                            17 (70.8%)
    Yes                                                   7 (29.2%)
  Patients/clients prefer medication management
    No/Rarely                                            12 (50.0%)
    Yes                                                  12 (50.0%)
  Lack of evidence for the effectiveness of exercise
    No/Rarely                                            21 (87.5%)
    Yes                                                   3 (12.5%)

Table 4. Attitudes, Beliefs, Confidence, and Knowledge about
Physical Activity Counselling and Beliefs about Obesity Pre-
and Post-Intervention, N = 24.

Characteristic                Mean (SD)

Attitudes
  Pre                        4.60 (0.41)
  Post                       4.75 (0.37)
Beliefs
  Pre                        4.49 (0.61)
  Post                       4.84 (0.24)
Confidence in Knowledge
  Pre                       63.37 (20.91)
  Post                      71.08 (18.64)
Confidence in Assessing
Readiness                   63.04 (20.98)
  Pre                       70.00 (16.79)
  Post
Confidence in Referral      59.58 (24.22)
  Pre                       70.83 (21.65)
  Post
Knowledge
  Pre                        4.61 (0.44)
  Post                       4.88 (0.26)
Beliefs About Obese
Persons                     17.38 (4.73)
  Pre                       15.46 (6.63)
  Post
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Title Annotation:Clinician's Corner
Author:Ryan, Jared M.; Cameron, Erin M.; McGowan, Erin L.
Publication:Clinical Kinesiology: Journal of the American Kinesiotherapy Association
Article Type:Report
Geographic Code:1CANA
Date:Sep 22, 2017
Words:5544
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