Physical activity is beneficial across all aspects of health. It has a pivotal role in preventing and treating a range of non-communicable diseases including obesity, cardiovascular disease, diabetes and cancer. It is also well-documented that physical activity is a crucial tool in the prevention and management of mental illness (Physical Activity Guidelines Advisory Committee, 2018).
The UK-wide guidelines for physical activity published in 2019 state that adults (19-64 years) should undertake 150 minutes of moderate intensity activity or 75 minutes of vigorous intensity activity per week (UK Chief Medical Officers Guidelines Writing Group, 2019). However, a large percentage of adults do not achieve the recommended levels of aerobic physical activity; 34.1% of adults in England failed to meet the guidelines in 2020-2021 (Office for Health Improvement and Disparities (OHID), 2022), and 54% of adults in Scotland in 2020 (Scottish Government, 2021).
Physical activity has far broader therapeutic benefits than any pharmaceutical treatment, potentially saving NHS resources and reducing the need to endure medication side-effects (Public Health England, 2020). Promoting physical activity is therefore of critical importance. Health professionals are ideal providers of this promotion; a large portion of the population have contact with a form of health professional and they are viewed as trusted and respected role models for health advice (Gagliardi et al, 2015).
Despite health professionals' key role in combating inactivity, a small body of evidence suggests that physical activity counselling levels among doctors are low (Anis et al, 2004; Adelman et al, 2011; Smith et al, 2011; Barnes and Schoenborn, 2012). Indeed, although a recent study reported that 58% of 978 doctors surveyed in Norway were counselling patients on physical activity (Belfrage et al, 2018), there are no recent data on counselling levels among doctors in the UK. Furthermore, most of the existing literature focuses on doctors, but nurses are also well-positioned to counsel and may have more contact time with patients (Butler et al, 2018). Limited evidence suggests that physical activity counselling levels among nurses are more promising than doctors (Douglas et al, 2006; Buchholz and Purath, 2007), but again there is a lack of recent data on this.
Several studies have investigated health professionals' attitudes towards physical activity counselling; Lobelo and de Quevedo (2016) conducted a systematic review and reported conflicting information as to how important health professionals consider physical activity counselling in their role; they included a US study of 100 haemodialysis health professionals, which reported that 72% of participants did not consider it their responsibility to promote physical activity (Painter et al, 2004), whereas another US study that included 279 students, faculty and staff at a chiropractic college reported that 76% felt that being a role model for patient education was important (DuMonthier et al, 2009). A UK study of 757 GPs, practice nurses and health visitors reported that 90% of participants agreed that physical activity promotion is important in primary care (Douglas et al. 2006). Better understanding of the attitudes among doctors and nurses may reveal contributing factors to inadequate counselling.
An association between personal physical activity habits and counselling practices has previously been established; health professionals who are themselves more active are more likely to counsel on physical activity (Holtz et al, 2013; Lobelo and de Quevedo, 2016; Belfrage et al, 2018). Assessing whether health professionals are meeting guidelines on physical activity is therefore of interest. Research publications from the USA and some European countries have indicated that doctors undertake more physical activity than the general population (Howe et al, 2010; Stanford et al, 2012; Stanford et al, 2013). However, a recent UK study of 245 doctors reported that only 58% of participants were meeting the aerobic activity guideline of 150 minutes of moderate intensity physical activity each week (Crane et al, 2021). Similarly, 56% of nurses in a Canadian study (Lamarche and Vallance, 2013) and 53% in a UK-based study (Blake and Harrison, 2013) were meeting aerobic activity guidelines. A systematic review concluded that doctors carry out more physical activity than nurses (Lobelo and de Quevedo, 2016), but to date there does not appear to be any recent UK study that has compared the physical activity levels of doctors and nurses.
Various factors relating to a health professional's career may also influence counselling practice, including stage of career and roles. There are conflicting studies evaluating the impact of stage of career on physical activity counselling; a survey of 326 doctors in San Francisco reported that doctors over the age of 35 years were more likely to counsel on physical activity than those younger (Walsh et al, 1999), whereas another survey of 4074 primary care physicians found that younger participants felt more confident to counsel (Diehl et al, 2015). Another study evaluated 38 physicians over an 8-week period and identified no effect of age or years in practice on counselling (Anis et al, 2004). In addition, although the existing research focuses mainly on primary care, there is some evidence to suggest that GPs may be more likely to counsel than hospital doctors (Belfrage et al, 2018). No equivalent data are available on role and career stage relating to nurses.
The aim of this study was therefore to evaluate physical activity levels, attitudes towards physical activity counselling and counselling practices of UK doctors and nurses.
The research questions were:
- What percentage of UK doctors and nurses meet the UK aerobic physical activity guidelines?
- How important do UK doctors and nurses consider physical activity counselling to be as part of their role?
- How often do UK doctors and nurses carry out physical activity counselling?
- Is personal attainment of the UK aerobic physical activity guidelines related to attitudes towards counselling and counselling practices?
- Are there differences in attitudes or counselling practices according to graduation year?
- Are there differences in attitudes or counselling practices between doctors and nurses and between primary or secondary care?
Methods
Study design
The study included two cross-sectional, anonymised, online surveys, using the platform from Jisc, conducted in 2018/19 (survey 1) and 2019/20 (survey 2). The authors' institution's research ethics committee approved the studies.
Surveys
Both surveys required participants to be English-speaking, a qualified doctor (survey 1 and 2) or nurse (survey 2), over the age of 18 and to consent to participation via an online informed consent process. Both surveys consisted mostly of numerical multiple-choice answers and were split into sections focusing on background, physical activity habits and counselling practices.
Background data asked questions relating to graduation year, type of doctor or health professional and role in relation to primary or secondary care.
Physical activity habits were evaluated using the first two questions of the original Scot-PASQ survey (NHS Health Scotland, 2012) and categorised participants into achieving or not achieving the guideline of 150 minutes of aerobic physical activity each week. Counselling practices were assessed using two questions; first, participants were asked to estimate the proportion of patients with which they had discussed physical activity in the past week using a 6-point Likert response (1=none, 2=less than 25%, 3=25-50%, 4=50-75%, 5=more than 75%, 6=all patients). Participants were then asked to rate their perceived importance of physical activity counselling as part of their role on a scale of 1 (not at all important) to 10 (extremely important).
Pilot surveys were carried out to identify errors or misleading questions (n=10 with survey 1 and n=5 with survey 2). No comments were made so the original surveys were used in the final studies. The final surveys consisted of six questions and seven questions respectively (due to an additional question regarding profession in survey 2) and took approximately 3 minutes to complete.
Participant recruitment
Participants were recruited through social media (Facebook, Twitter) and convenience distribution. Survey 1 was shared on an academic twitter page and survey 2 was distributed with the monthly members' email for the Royal College of Physicians and Surgeons of Glasgow. The surveys were open for 11 and 12 weeks respectively.
Data analysis
The data from both questionnaires were first exported into Microsoft Excel for compiling relevant data and differentiating surveys and health professionals before being analysed using IBM SPSS version 24 Statistics (IBM Corporation, Armonk, NY).
Descriptive statistics of demographic data and results in each category are presented as numbers and percentages. Chi-square analysis of independence (c2) was used to determine if there were significant differences between doctors and nurses in achievement of the physical activity guidelines.
Mann Whitney-U tests were used to determine differences between doctors and nurses for counselling rates, perceived importance of physical activity counselling and whether counselling practices differed according to attainment of the guidelines. The same analysis was also used to determine a difference in counselling rates between primary and secondary care. Effect sizes were calculated using the formula r=Z/√N. Kruskal Wallis test was used to determine if graduation year affected counselling. Statistical significance was set at P<0.05.
Results
A total of 460 doctors and 169 nurses completed the survey; 340 doctors were from survey 1 and 120 doctors and all the nurse responses were from survey 2. Table 1 summarises the study participant demographics.
Table 1. Study participant demographics
| Profession | Number | Primary care (general practice) | Secondary care (hospital) | Graduation year before 1991 | Graduation year 1991 to 2009 | Graduation after 2009 |
|---|---|---|---|---|---|---|
| Doctor | 460 | 97 | 363 | 142 | 251 | 67 |
| Nurse | 169 | 30 | 138 | 48 | 91 | 30 |
| Total | 629 | 127 | 501 | 190 | 342 | 97 |
Over 70% of participants were doctors and the majority of both doctors (78.9%) and nurses (81.7%) who completed the survey worked in secondary care. The majority were professionals graduating between 1991 and 2009 (54.6% of doctors and 53.8% of nurses), although data were distributed across the three graduation-year categories.
Achievement of the UK physical activity guidelines
Responses showed that 78.3% of doctors and 73.4% of nurses achieved 150 minutes of physical activity in the previous week (Table 2). There were no significant differences between the professions in meeting the guidelines (c2(1, N=629)=1.665; P=0.197; odds ratio 1.306; 95% CI 0.870-1.962).
Table 2. Achievement of aerobic guidelines, perceived importance of counselling and level of counselling
| Profession | Percentage who achieve the aerobic guidelines | Importance of PA counselling – median (IQR) | Level of counselling – median (IQR) |
|---|---|---|---|
| Doctors | 78.3% | 8.00 (3) | 2.00 (1) |
| Nurses | 73.4% | 8.00 (3) | 2.00 (2) |
IQR=interquartile range
Perceived importance of counselling
The median perceived importance of physical activity counselling was 8 out of 10 (Table 2). There was no significant difference between the professions in the perceived importance of physical activity counselling (median=8; U=36140; z=-1.370; P=0.171; effect size r=-0.0308).
Physical activity counselling frequency
Counselling rates were low, with neither doctors nor nurses counselling more than 50% of their patients (Table 3; the highest reported median was 3, which equates to 25-50% of patients). Counselling rates were significantly higher among doctors than nurses (median=2; U=32311; z=-3.347; P=0.01; r=- 0.1335). Furthermore, physical activity counselling rates were also significantly higher in primary care than secondary care (median=2; U=26786; z=-2.965; P=0.003; r=-0.1200) (Table 3).
Table 3. Levels of counselling in the primary and secondary care setting and year of graduation
| Profession | Primary care – median (IQR) | Secondary care – median (IQR) | Primary and secondary care – median (IQR) | Grad year before 1991 – median (IQR) | Grad year 1991 to 2009 – median (IQR) | Grad year after 2009 – median (IQR) |
|---|---|---|---|---|---|---|
| Doctors | 3.00* (1) | 2.00* (2) | 2.00 (1) | 2.00 (2) | 2.00 (1) | 2.00 (1) |
| Nurses | 3.00* (2) | 2.00* (2) | 2.00 (2) | 2.00 (2) | 2.00 (3) | 2.00 (2) |
| Both | 3.00* (1) | 2.00* (2) | 2.00 (1) | 2.00 (1) | 2.00 (1) | 2.00 (2) |
IQR=interquartile range
* significant difference between primary and secondary care and doctors and nurses in counselling rates (P<0.05)Attainment of guidelines and perceived importance of counselling
There was no difference in perceived importance of counselling between those who did or did not meet the guidelines for both doctors (median=8; U=17967; z=-0.28; P=0.978, r=-0.0131) (Table 4) and nurses (median=8; U=2477; z=-1.127; P=0.260; r=-0.0867) (Table 5).
Table 4. Levels of counselling and counselling importance in doctors who did and did not meet the aerobic physical activity guideline
| Doctors | Level of counselling – median (IQR) | Perceived importance of counselling – median (IQR) |
|---|---|---|
| Met guideline | 2.00 (1) | 8.00 (5) |
| Did not meet guideline | 2.00 (2) | 8.00 (3) |
IQR=interquartile range
Table 5. Levels of counselling and counselling importance in nurses who did and did not meet the aerobic physical activity guideline
| Nurses | Level of counselling – median (IQR) | Perceived importance of counselling – median (IQR) |
|---|---|---|
| Met guideline | 2.00 (2) | 8.00 (5) |
| Did not meet guideline | 2.00 (2) | 7.00 (5) |
IQR=interquartile range
Achievement of the guidelines and counselling practices
There were no differences in level of counselling practices between those who did or did not meet the guidelines for both doctors (median=2; U=17399; z=-0.528; P=0.598; r=-0.0211) (Table 4) and nurses (median=2; U= 2788; z= -0.007; P=0.994; r=0.00028) (Table 5).
Graduation year effect on counselling levels
There was no difference in the level of counselling between graduation years (c2 (10, N=629)=8.048; P=0.0624) (Table 3).
Discussion
This study aimed to evaluate physical activity counselling practices among doctors and nurses, and whether this varies with personal attainment of the UK guidelines for aerobic physical activity, with stage of career, and between primary and secondary care. The results from this survey indicate that despite doctors and nurses thinking of physical activity counselling as an important part of their role, counselling levels in practice are low. Doctors were counselling more patients than nurses, and counselling rates were higher in primary care than secondary care. Graduation year was not implicated as a predictor of perceived importance of physical activity promotion or counselling levels.
The surveys found that 78.3% of doctors and 73.4% of nurses met the UK guideline for aerobic physical activity of 150 minutes each week. Generally, the level was considerably higher than that of the general population; 65.9% of adults in England in 2020-2021 (OHID, 2022) and 46% of adults in Scotland in 2020 (Scottish Government, 2021) met the aerobic physical activity guidelines. Several studies have similarly reported that doctors in the USA are more active than the general population (Howe et al, 2010; Stanford et al, 2013; Lobelo and de Quevedo, 2016). However, the present study is discordant with a recent UK study, which reported that only 58% of UK doctors meet the physical activity guidelines (Crane et al, 2021). The current study also differs from the existing evidence for nurses, with studies reporting that as low as 56% of nurses in a Canadian study (Lamarche and Vallance, 2013) and 53% of nurses in a UK-based study (Blake and Harrison, 2013) were meeting the physical activity guidelines. Reasons for this discrepancy are difficult to explain, since all studies have used a similar questionnaire recall approach. The study population in this case does, however, indicate that doctors and nurses in the UK are a relatively active cohort.
The existing literature proposes that doctors are more active than nurses; a systematic review by Lobelo and de Quevedo in 2016 – including studies based mostly in the USA but also the UK, Canada, Spain, India, Colombia and the Netherlands – reported that 45-90% of doctors met the physical activity guidelines compared with 39-70% of other health professionals (nurses and dietitians). However, none of the studies directly compared doctors and nurses. This is the first study to compare the physical activity levels of doctors and nurses in the UK, and there appears to be no significant difference between the two professions with respect to meeting the aerobic physical activity guidelines.
Median perceived importance of physical activity counselling was 8 out of 10. The existing evidence here is conflicting, as previously described (Painter et al, 2004; DuMonthier et al, 2009). The present study is in line with another UK study, which reported that 90% of GPs, practice nurses and health visitors thought that physical activity promotion was important in primary care (Douglas et al, 2006).
Nonetheless, counselling levels were low, at less than 50% for both professions. Several studies have similarly reported inadequate levels of counselling for doctors (Anis et al, 2004; Adelman et al, 2011; Smith et al, 2011; Barnes and Schoenborn, 2012; Belfrage et al, 2018). The evidence for nurses is scarcer but also supports the suggestion that counselling levels are low for these health professionals (Douglas et al, 2006; Buchholz and Purath, 2007)
However, the current study did find that doctors discussed physical activity with significantly more patients than nurses did. A previous study of 757 primary care staff reported contradicting findings: health visitors and practice nurses were more likely than general practitioners to offer physical activity advice (Douglas et al, 2006). Lack of knowledge, lack of time and the topic not being relevant to the setting were identified as barriers to counselling. The ways that these factors may influence doctors and nurses differently requires further exploration.
The existing literature has suggested that there is an association between personal physical activity habits and promotion of physical activity (Holtz et al, 2013; Lobelo and de Quevedo, 2016; Belfrage et al, 2018). Conversely, a single randomised controlled trial of 102 GPs found no correlation between personal physical activity habits and physical activity promotion (James et al, 2009). The present study similarly found no association between attainment of the guideline on aerobic physical activity and perceived importance or level of counselling in either doctors or nurses. More purposeful sampling and larger sample sizes are needed to confirm the relationship between physical activity levels and counselling among these health professionals.
There are several conflicting studies evaluating the relationship between stage of career and physical activity promotion (Walsh et al, 1999; Anis et al, 2004; Diehl et al, 2015). The present study identified no link between graduation year and perceived importance of physical activity promotion or level of counselling. It has been theorised that improvements to training curricula better equip more recent graduates to counsel on physical activity (Diehl et al, 2015), but it is possible that despite this, education remains inadequate. Indeed, in a survey of 148 nurse practitioners, 63% of participants stated that their training included no formal teaching on preventive medicine (Lamarche and Vallance, 2013). Comparatively, a study of 395 medical students at Edinburgh Medical School reported that less than 10% of participants felt adequately trained to counsel on physical activity (Osborne et al, 2017). The scarcity of training in physical activity promotion in medical school curricula necessitates intervention to improve confidence and competence in counselling (Gates, 2015).
Counselling rates were significantly higher in primary care than secondary care in this study. This is concurrent with the findings of Belfrage et al (2018), who surveyed 526 doctors and found that GPs were more likely to counsel than hospital doctors. An interview-based study of 11 UK junior doctors explored attitudes surrounding this; a theme that emerged from discussion was that the participants considered physical activity counselling for disease prevention the role of GPs and saw the main focus of secondary care as treating the presenting problem rather than addressing the cause (Osinaike and Hartley, 2021). Recognising the role of physical activity in management as well as prevention could improve attitudes towards physical activity counselling in the hospital setting.
Limitations
This is one of the largest studies comparing physical activity habits and counselling practices of different health professionals and therefore the findings provide a useful insight into this area. However, there are limitations. The voluntary nature of the survey and the use of social media for recruitment may have resulted in self-selection bias and also excluded doctors and nurses who were not users of social media, resulting in inaccurate population representation. Furthermore, the use of a survey carries the inherent risk of self-report bias; socially desirable responding could have given rise to higher reported rates of physical activity and counselling than actual levels.
This study's small sample size of 629 may have resulted in statistically insignificant findings, thus failing to identify true correlations in the data. In addition, 460 doctors but only 169 nurses participated, challenging the validity of comparisons between the groups.
Physical activity level was assessed using questions from the Scot-PASQ, which is a well-established tool (Physical Activity, and Health Alliance, 2018). However, it was not designed for use in this study and therefore may have lacked the necessary detail for comparing physical activity habits. Furthermore, since the commencement of this study, the Scot-PASQ guidance was updated. In line with the 2019 UK-wide guidance, the Scot-PASQ now includes explicit reference to the possible contribution of vigorous intensity activity to achieving the guideline on aerobic physical activity (Public Health Scotland, 2023), which was not included in the original Scot-PASQ questions (NHS Health Scotland, 2012) or in the question set used for this study.
Future direction
As one of the earliest studies comparing physical activity counselling between doctors and nurses, future research on a larger scale is indicated to better understand the trends reported. As the majority of the existing studies are survey-based, there is a need to use different methods to more objectively quantify physical activity levels and counselling rates.
More detailed assessment of physical activity habits could reveal more about the effect on counselling practices. In addition, evaluating the impact counselling has on patient behaviour is needed to determine its efficacy and inform educational interventions for health professionals.
Conclusion
This study aimed to evaluate levels of aerobic physical activity, attitudes to counselling and counselling practices of doctors and nurses and variation with stage of career and between primary and secondary care. The authors found that both doctors and nurses are more active than the general population but despite this physical activity counselling levels were low; this is concordant with the existing evidence in this area. Counselling rates were higher in doctors compared with nurses and in primary care compared with secondary care but stage of career had no impact on counselling levels. These conclusions are not so well-established in the literature and thus further evidence is needed. Further research into educational interventions and effective counselling methods may help to fight inactivity and reduce its widespread burden.
KEY POINTS
- Physical activity counselling is vital across all aspects of health care
- This study aimed to evaluate different factors that may influence beliefs and practices around counselling including personal physical activity habits, profession, stage of career and healthcare setting
- Uncovering these relationships could elicit areas for intervention within the health service to improve attitudes and practices surrounding physical activity education
- Counselling rates were higher in doctors compared with nurses but stage of career had no impact on counselling levels
- Counselling rates were significantly higher in primary care than in secondary care – this may reflect training on preventive medicine, or different perceptions of the focus of secondary care
CPD reflective questions
- What factors could explain the disparity found between doctors' and nurses' physical activity habits and counselling practices?
- How could more detailed analysis of health professionals' personal physical activity habits reveal more about the effect on beliefs about counselling and counselling practices?
- What kind of interventions could be used to improve health professionals' attitudes towards counselling?
- How could the impact of physical activity counselling on patient behaviour be investigated?