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148   Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees

Canada
Published: 2016-12-14
Peer Reviewed  
Age Range: 22–83 years
No. of Participants: 209
Cdnsciencepub.com 

Sponsors

The workshop program was supported by the Lawson Foundation, and MWO was supported by the Lawson Foundation and Acadia University Research Fund.

Authors

The Authors:
1. Myles W. O'Brien
2. Christopher A. Shields
3. Paul I. Oh
4. Jonathon R. Fowles

Affiliations:

1. School of Kinesiology, Acadia University, 550 Main Street, Wolfville, NS B4P 2R6, Canada (M.W.O., C.A.S., J.R.F.)
2. Cardiovascular Prevention and Rehabilitation Program, Toronto Rehabilitation Institute/University Health Network, Toronto, ON, Canada (P.I.O.)

Summary

The Exercise is Medicine Canada (EIMC) initiative encourages healthcare professionals to incorporate physical activity counseling and exercise prescriptions into their practice. This study evaluated how healthcare providers viewed and practiced these concepts before and after EIMC training. Among 209 participants (physicians, allied health professionals, and exercise professionals), the study found that physicians typically saw more patients but were less likely to discuss exercise. Post-training, 87% of physicians proposed changes, with many planning to prescribe exercise more often and improve their counseling, indicating a positive impact of the EIMC workshops.

Results

The study assessed healthcare providers' views and practices regarding physical activity counseling and exercise prescription before and after attending Exercise is Medicine Canada (EIMC) workshops. It found that 78% of physicians see more than 15 patients daily, while 93% of allied health professionals (AHPs) see fewer than 15. Only 48% of physicians regularly counsel patients on exercise, compared to 72% of AHPs. Exercise professionals (EPs) showed the highest confidence in providing physical activity information at 92%, while physicians and AHPs reported lower confidence levels of 52% and 56%, respectively.

Challenges in counseling were notable, with physicians experiencing more difficulty than AHPs and EPs. Key barriers included lack of patient interest, resources, and time, with 85% of physicians providing written exercise prescriptions in less than 10% of appointments. However, post-workshop, 87% of physicians expressed a desire to change their practice, with 47% planning to prescribe exercise more routinely and 33% aiming to improve their counseling on physical activity, indicating a positive shift in their approach.

These results also indicate that providing workshop education increases confidence and capacity for physicians and AHPs to perform these functions as part of regular clinical care.

Variables

In the study, several variables and factors were measured to evaluate the outcomes. These can be categorized as follows:
1. Demographic Variables
- Age: Participants' ages were recorded, with a mean of 45 years.
- Sex: Gender distribution was noted (77 males and 127 females).
- Professional Background: Participants included physicians, allied health professionals (AHPs), and exercise professionals (EPs).
2. Professional Practice Variables
- Number of Patients Seen: Participants reported the number of patients they see daily.
- Time Spent with Patients: The duration of patient consultations was measured.
- Frequency of Exercise Counseling: Participants indicated how often they included physical activity counseling in their sessions.
3. Confidence and Knowledge Variables
-Confidence Levels: Participants rated their confidence in providing physical activity information and assessing patient readiness.
- Knowledge on Physical Activity Counseling: Self-reported knowledge levels regarding physical activity counseling were assessed.
4. Barriers to Exercise Prescription
- Perceived Barriers: Participants identified barriers such as lack of time, knowledge, and patient interest.
- Difficulty Rating: Participants rated the difficulty of including physical activity counseling in their sessions on a scale from 1 (not at all difficult) to 5 (very difficult).
5. Post-Workshop Changes
- Intended Practice Changes: Participants were asked to describe changes they planned to implement in their practice following the workshop.
- Confidence Post-Workshop: Changes in confidence levels regarding exercise prescription were evaluated immediately after the workshop.
6. Statistical Analysis Variables
- Group Comparisons: Differences across the three professional groups (physicians, AHPs, and EPs) were analyzed using ANOVA and chi-square tests to assess demographic and practice variables, confidence, and barriers.

Full Study




Abstract


The Exercise is Medicine Canada (EIMC) initiative promotes physical activity counselling and exercise prescription within health care. The purpose of this study was to evaluate perceptions and practices around physical activity counselling and exercise prescription in health care professionals before and after EIMC training. Prior to and directly following EIMC workshops, 209 participants (physicians (n = 113); allied health professionals (AHPs) (n = 54), including primarily nurses (n = 36) and others; and exercise professionals (EPs) (n = 23), including kinesiologists (n = 16), physiotherapists (n = 5), and personal trainers (n = 2)) from 7 provinces completed self-reflection questionnaires. Compared with AHPs, physicians saw more patients (78% > 15 patients/day vs 93% < 15 patients/day; p < 0.001) and reported lower frequencies of exercise counselling during routine client encounters (48% vs 72% in most sessions; p < 0.001). EPs had higher confidence providing physical activity information (92 ± 11%) compared with both physicians (52 ± 25%; p < 0.001) and AHPs (56 ± 24%; p < 0.001). Physicians indicated that they experienced greater difficulty including physical activity and exercise counselling into sessions (2.74 ± 0.71, out of 5) compared with AHPs (2.17 ± 0.94; p = 0.001) and EPs (1.43 ± 0.66; p < 0.001). Physicians rated the most impactful barriers to exercise prescription as lack of patient interest (2.77 ± 0.85 out of 4), resources (2.65 ± 0.82 out of 4), and time (2.62 ± 0.71 out of 4). The majority of physicians (85%) provided a written prescription for exercise in <10% of appointments. Following the workshop, 87% of physician attendees proposed at least one change to practice; 47% intended on changing their practice by prescribing exercise routinely, and 33% planned on increasing physical activity and exercise counselling, measured through open-ended responses.



Résumé


L’exercice, un médicament Canada (EUMC) est une initiative pour la promotion du counseling en matière d’activité physique et la prescription d’exercice dans les soins de santé. Cette étude a pour objectif d’évaluer les perceptions et les pratiques au sujet du counseling en matière d’activité physique et la prescription d’exercice chez les professionnels de la santé avant et après une formation EUMC. Avant et immédiatement après les ateliers d’EUMC, 209 participants dont 113 médecins, 54 professionnels alliés de la santé (AHP) incluant 36 infirmières et autres, 23 professionnels de l’activité physique (EP) incluant 16 kinésiologues, 5 physiothérapeutes et 2 entraîneurs personnels provenant de 7 provinces remplissent des questionnaires d’autoréflexion. Comparativement aux AHP, les médecins rencontrent plus de patients (78 % > 15/jour vs 93 % < 15/jour, p < 0,001) et rapportent une plus faible fréquence de counseling en matière d’activité physique au cours d’une consultation régulière de patients (48 % vs 72 % dans la plupart des consultations, p < 0,001). Les EP se sentent plus sûrs de procurer des renseignements au sujet de l’activité physique (92 ± 11 %) comparativement aux médecins (52 ± 25 %, p < 0,001) et aux AHP (56 ± 24 %, p < 0,001). Les médecins rapportent avoir plus de difficulté à inclure dans les consultations le counseling en matière d’activité physique (2,74 ± 0,71 sur 5) comparativement aux AHP (2,17 ± 0,94, p = 0,001) et aux EP (1,43 ± 0,66, p < 0,001). Les médecins mentionnent que les obstacles les plus importants à l’égard de la prescription d’exercice physique sont le manque d’intérêt du patient (2,77 ± 0,85 sur 4), de ressources (2,65 ± 0,82 sur 4) et de temps (2,62 ± 0,71 sur 4). La majorité des médecins (85 %) ont rédigé une prescription d’exercice physique dans <10 % des consultations. À la suite de l’atelier et dans des réponses ouvertes, 87 % des médecins présents proposent au moins une modification dans leur pratique, 47 % ont l’intention de modifier leur pratique en prescrivant régulièrement de l’activité physique et 33 % prévoit d’accroître le counseling en matière d’activité physique. [Traduit par la Rédaction]







Introduction


Physical inactivity is a primary component of chronic disease risk, and is estimated to cause 6%–10% of major noncommunicable diseases worldwide (Lee et al. 2012). Canada’s physical activity guidelines recommend 150 min of moderate to vigorous aerobic physical activity per week in bouts of 10 min or more combined with 2 days of engaging in muscle and bone strengthening exercises to achieve health benefits (Tremblay et al. 2011). Despite the benefits of being physically active, only 15% of Canadian adults achieve aerobic physical activity guidelines when measured objectively using accelerometry (Colley et al. 2011). This lack of physical activity and associated increase in sedentary behaviour likely accounts for a majority of the decrease in physical fitness of Canadians, compared with 30 years ago (Shields et al. 2010).


Physical activity counselling and exercise prescription in health care


Since the population’s mean level of physical activity is well below the required duration and intensity for health benefits, it has been suggested that promoting physical activity is public health’s “best buy” (Morris 1994, p. 813; Lawlor et al. 1999). Primary care providers have been suggested as opportune agents for physical activity promotion because of their frequent and prominent interaction with the general population. Specifically, it has been shown that 79% of Canadians see a medical doctor in a given year, more than any other health care provider (CCHS 2014). Further, patients view such professionals as the primary source of credible information regarding healthy lifestyle decisions (Tulloch et al. 2006). A systematic review and meta-analysis by Orrow et al. (2012) provided evidence for the benefits of exercise prescriptions from primary care providers on patients’ self-reported physical activity. Physical activity prescription by Canadian physicians has been shown to improve patients’ fitness and exercise confidence while decreasing body mass index and systolic blood pressure (Petrella et al. 2003). Despite this, just 16% of Canadian family physicians provide written physical activity prescriptions to their patients (Petrella et al. 2007). This is similar to rates in the United States, where only one-third of patients report receiving physical activity and exercise (PAE) counselling of any form in the previous year (Barnes and Schoenborn 2012). Physicians commonly report lack of time, knowledge, and tools or resources as barriers to physical activity counselling and prescription (McKenna et al. 1998; Hébert et al. 2012); however, education on proper physical activity counselling and exercise prescription can result in acutely higher self-efficacy and frequency of physical activity promotion among family physicians (Swinburn et al. 1998; Howe et al. 2010; Jorgensen et al. 2012).



Physical activity counselling and exercise prescription training


Training physicians in brief physical activity counselling using a 5-step (ask, assess, advise, assist, and arrange), patient-centered model increased the frequency of physician physical activity counselling and subsequent patient physical activity levels (Marcus et al. 1997). A recent study by Windt et al. (2015) examined the impact of a 3-h educational workshop on physical activity counselling and prescription in family physicians (n = 25) in British Columbia, Canada. The educational content included: (i) assessing patient’s physical activity levels, (ii) using motivational interviewing techniques to encourage physical activity, and (iii) providing written physical activity prescriptions when appropriate. One month after the workshop, the number of attendees who self-reported providing written physical activity prescriptions increased from n = 10 (40%) to n = 17 (68%), while also significantly increasing self-reported confidence (6.2 –7.0 out of 10) and knowledge (6.0–7.1 out of 10 (Windt et al. 2015)).



Exercise is Medicine


Exercise is Medicine® (EIM) was created in 2007 by the American College of Sports Medicine in partnership with the American Medical Association (Sallis 2009). The original purpose was “to make the scientifically proven benefits of physical activity the standard in the U.S. health care system” with the vision to have health care providers assess physical activity and provide counselling and (or) referral to help support patients’ meeting guidelines for physical activity (Exercise is Medicine 2015). In 2009, EIM began a multinational collaboration to make its objectives a global effort (Exercise is Medicine 2015). In 2012, the Canadian Society of Exercise Physiology (CSEP) adopted the EIM initiative, creating Exercise is Medicine Canada (EIMC: Exercise is Medicine Canada 2015). EIMC’s mission is to provide national leadership in promoting physical activity as a chronic disease prevention and management strategy to improve the health of Canadians with the vision that more Canadians meet the Canadian Physical Activity and Sedentary Behavior Guidelines (Exercise is Medicine Canada 2015). The goals of EIMC are to: (i) increase the number of health care professionals who are assessing, prescribing, and counselling patients in physical activity and (ii) facilitate the collaboration between health care and exercise professionals in the prevention and treatment of chronic disease. Recently, EIMC embarked on a national program of workshops to train health care professionals to make physical activity counselling, prescription, or referral a key component of every health care visit.



Current study


The purpose of this study was to evaluate perceptions and practices around physical activity counselling and exercise prescription in health care professionals before and after EIMC training. This specific aims of the study evaluated: (i) the confidence and attitudes toward, and barriers around, physical activity counselling in primary care practice expressed by health care providers in Canada and (ii) the immediate impact of the training sessions on the confidence for physical activity counselling and plans to incorporate physical activity content and strategies into practice. To reach the public health goals on physical activity, it has been suggested to involve all health professionals as active facilitators of the physical activity message (King 2000). Therefore, outcomes were analyzed across 3 distinctly different groups of health care professionals who experience different clinical perspectives, including medical doctors, allied health professionals (AHPs, i.e., primarily nurses), and exercise professionals (EPs).




Methods



Workshop delivery


As this project was an educational initiative, workshops were advertised through respective provincial or health regional bodies and offered in major centres around the country that showed an interest and (or) availability for the educational opportunity. Health care professionals voluntarily attended the workshop for their own interest and the potential to obtain continuing medical education credits. The 6-h workshop was typically presented by 1 exercise physiologist and 1 physician. The workshop was interactive in nature with the following 5 learning objectives: (i) be able to discuss the health benefits and safety of regular exercise with patients, (ii) use the exercise vital sign (time spent engaging in moderate–vigorous exercise multiplied by the number of days spent engaging in such activity, in minutes per week) as part of periodic health evaluation, (iii) provide basic exercise counselling and prescription for patients as part of the periodic health evaluation, (iv) be able to utilize a motivational counselling framework for health behaviour change, and (v) understand how to monitor aerobic exercise intensity and perform basic resistance exercises. Participants were provided a self-reflection questionnaire to fill out before, during, and after the training session (done in stages, taking ∼5–10 min to complete) describing their current practice history, exercise prescription barriers, and the initial impact of the workshop. Participant answers helped to direct workshop emphasis and discussion. The focus of the workshops was on delivery of content and there was not a formal recruitment of participants for a research project per se. At the end of the workshop, participants were given the opportunity to volunteer their questionnaire to EIMC for quality assurance and research evaluation. By providing the questionnaire to EIMC, participants consented to de-identified secondary use of their data for research evaluation. This evaluation carried the approval of the Acadia University Research Ethics Board. Questionnaires were gathered (by the organizing party), placed into an envelope, and sent to the data clerk to de-identify responses.



Participants


Participants (n = 209) were recruited from 10 EIMC workshops delivered across 7 provinces including Alberta (n = 77), British Columbia (n = 5), Manitoba (n = 10), Nova Scotia (n = 35), Ontario (n = 52), Quebec (n = 17), and Saskatchewan (n = 10); 3 participants did not provide a location. The participants were male (n = 77) and female (n = 127) over the age 22 years (mean ± SD (range): 45 ± 12.5 (22–83 years)). Participants included physicians (n = 113), AHPs (n = 54), and EPs (n = 23). EPs were defined as those who have received extensive and formal education on the execution and instruction of exercise and practice exercise prescription on a regular basis (e.g., kinesiologists, physiotherapists, personal trainers, etc.).



Self-reflection questionnaire


Given that there are no previously validated questionnaires to identify physician confidence around physical activity counselling or to quantify their physical activity prescription behaviours, and our primary objective for use of a questionnaire was for self-assessment by participants during a time-pressured workshop, we created a self-reflection questionnaire for this project that was concise and relevant to the workshop objectives but still provided meaningful information to inform future practice. Sections of the questionnaire were based on previous work in the area; activity prescription questions were adapted from the national survey by Petrella et al. (2007), confidence variables were incorporated because of the known impact on PAE counselling self-efficacy (Hébert et al. 2012), and inclusion in other studies to evaluate physical activity prescription training (Dacey et al. 2013). The questions regarding demographic information, current practice history, barriers, and postworkshop reflection were based on previous research in diabetes education (Dillman et al. 2010; Shields et al. 2013).


Demographics


Attendees self-reported their age, sex, and province they currently practice in. Attendees were given options that best described their sex, ethnicity, area of professional practice, and time working in that practice (e.g., <2 years, 2–4 years, etc.).



Current practice history


Participants were asked to select from a variety of options that best described the number of patients they work with per day (e.g., <5, 5–10, etc.) and the amount of time they spend with each patient (e.g., <10 min, 11–20 min, etc.). They then were asked how often they include PAE in their patient counselling sessions (<10%, 11–25, 26–50, 51–75, 76–100) and how knowledgeable they are on the subject matter (not at all, slightly, moderately, very, extremely). They were also provided options (<10%, 11%–25%, etc.) for the percentage of patients they are currently assessing and recommending and prescribing physical activity or exercise. Their confidence regarding perceived ability to provide PAE information, assess patient physical activity readiness, answer patient’s physical activity questions, provide physical activity advice to patients with special consideration (e.g., hypertension, cardiovascular disease risk), and make appropriate referrals was individually assessed on a scale of 0%–100% using 10% intervals.



Barriers to prescription


Participants were asked to rate “how difficult is it to include counselling on PAE into sessions with clients?” on a scale of 1 (not at all difficult) to 5 (very difficult). They were then provided a list of common barriers to PAE counselling (time, knowledge, etc.) and asked, in an open-ended response which barriers apply to them and to rate their impact on a scale of 1 (does not prevent me from counselling) to 4 (completely prevents me from counselling). Next, they were asked to reflect on their biggest challenge in helping a patient achieve a physically active lifestyle and how they may overcome this challenge.



Postworkshop reflection


Directly following the workshop, participants were asked if their confidence to provide information, assess readiness, provide a program, and appropriately refer was higher, lower, or unchanged compared with the start of the workshop. Participants then rated how likely it is they will use the EIMC prescription pad on a scale of “definitely will not” to “definitely will”. Next, they were asked in open-ended fashion to describe 2 ways in which they planned to change their respective practice as a result of attending the EIMC workshop.




Data analysis


French questionnaires were translated into English prior to analysis. Statistics were completed in SPSS (IBM SPSS Statistics for Windows, Version 23.0. IBM Corp., Armonk, NY). Descriptive statistics are presented in the text as mean ± standard deviation, range, or proportion (%) and were calculated on practice and demographic variables for the 3 professional categories. Data analysis was done in 5 steps. First, differences across groups for demographics and professional practice variables were analyzed by ANOVA (age only) and χ2 (all other variables). Second, ANOVAs were completed on social cognitions of counselling confidence, self-reported physical activity counselling knowledge, and perceived difficulty. Third, χ2 analyses were used to compare the proportion of reported barriers between groups, and ANOVA was used to assess differences in impact rating across groups for the identified barriers. Fourth, quantitative textual analysis was done to examine the ‘biggest challenge’ physicians face in counselling and strategies to overcome these challenges, as well as postulated changes to current practice as a result of workshops. Fifth, χ2 analyses were done to assess differences in provider confidence across groups directly after the workshop. Statistical significance was accepted at p < 0.05.




Results



Demographics


Participants were split into 3 distinct groups including: physicians (n = 113) comprised of family physicians (n = 103) and specialist physicians (n = 10); AHPs (n = 54) comprised of registered nurses (n = 26), nurses (n = 7), social workers (n = 4), nurse practitioners (n = 3), and other health care providers (n = 11); and EPs (n = 23) comprised of kinesiologists (n = 16), physiotherapists (n = 5), and personal trainers (n = 2). The demographics of these groups are provided in Table 1. An ANOVA demonstrated statistically significant differences (p < 0.05) between physicians and AHPs for age. χ2 demonstrated statistically significant differences between physicians and AHPs for patients per day, time per patient, and inclusion of physical activity content. Physical activity content was also significantly different between AHPs and EPs. On average, physicians tended to be older, have more experience in their field, and see more patients per day but spend less time with patients. There were statistically significant differences between physicians and EPs age, sex, number of patients, time per patient, and physical activity content.

 


 



PAE counselling


Physicians and AHPs had lower self-perceived knowledge compared with EPs (9% and 13% vs 96% reporting very knowledgeable and above). The majority of physicians and AHPs believe they are moderately knowledgeable, 57% and 50%, respectively. Results were significantly different between EPs and both physicians and AHPs (p < 0.001). The vast majority of physicians (89.2%) reported having some difficulty including it into patient sessions compared with 73.1% and 34.8% of AHPs and EPs, respectively.



Provider PAE confidence


Providers’ confidence to perform a series of PAE counselling actions and self-efficacy PAE composite score is included in Table 2. Physicians had less confidence for the majority of variables compared with AHPs, and both had less confidence compared with EPs. AHPs were more confident to assess PAE and appropriately refer (p < 0.05) compared with physicians. Relative to EPs, physicians had less self-reported confidence to provide PAE information (52% vs 92%; p < 0.005), assess PAE (44% vs 85%; p < 0.005), answer PAE questions (52% vs 90%; p < 0.005), provide PAE advice (43% vs 83%; p < 0.005), and appropriately refer (46% vs 86%; p < 0.005).

 



Barriers to PAE counselling


Table 3 outlines the percentage of providers that report applicable barriers to PAE counselling and their respective impact rating out of 4. Overall, physicians and AHPs cited more barriers and rated the barriers higher than EPs (Table 3). Physicians identified “lack of time” as having greater impact than both AHPs and EPs. AHPs identified ‘other lifestyle changes as more important’ as having greater impact than EPs. A “lack of evidence for effectiveness of exercise” was similarly rated by a low proportion at a low-impact level by all 3 groups. Attendees wrote out their “biggest challenge” in helping their patients achieve a physically active lifestyle. Using quantitative textual analysis these responses were separated into themes. Table 4 outlines the primary themes reported by physicians. The most commonly cited include patient interest (25.7%), lack of time (24.8%), and lack of knowledge (11.5%). Respondents were then asked to state how they would overcome this challenge (51 responses). Three themes emerged including counselling patients (23.9%), use of resources (15.9%), and use a quantifiable measure (5.3%).




Postworkshop reflection


The vast majority (n = 98/113; 86.7%) of physician attendees proposed at least 1 change to practice as a result of the EIMC workshops, with 11.5% (n = 13/113) identifying 1 change, 61.1% (n = 69/113) identifying 2 changes, and 14.2% (n = 16/113) identifying 3 changes, resulting in 205 individual responses of what changes to make. Analysis of the raw responses revealed 3 primary change themes: prescribe physical activity or exercise (identified by 46.9% of the n = 113 sample), counsel patients (32.7%), and ask patients about PAE (20.4%) (Table 5). Attendees rated their likeliness to use the EIMC prescription pad resource, the majority of health care professionals selected they will very likely use the resource with 92.8% of physicians (n = 103) reporting “very likely” or “definitely will” compared with 82.7% of AHPs (n = 43) and 71.4% of EPs (n = 15) (p < 0.05 physicians vs EPs). All confidence variables were statistically different between physician and EPs, whereas all but ‘appropriate PAE referral’ was statistically different between AHPs and EPs. Table 6 displays the percentage of providers that report having higher confidence for respective variables following the workshop. The vast majority (79%–98%) of physicians and AHPs reported higher confidence for a range of physical activity practices directly following the workshop.

 






 




Discussion


The purpose of this study was to evaluate perceptions and practices around physical activity counselling and exercise prescription in health care professionals before and after EIMC training. As expected, the results of this analysis clearly demonstrate that physicians and AHPs have lower confidence for physical activity counselling and prescribe exercise far less in their regular clinical practice than EPs do. These results also indicate that providing workshop education increases confidence and capacity for physicians and AHPs to perform these functions as part of regular clinical care. Information from this work will help to detail distinct areas of contrast in training and practice between these groups to direct education and training efforts in the future.

The results of the self-reflections revealed physicians and AHPs have low physical activity counselling knowledge and experience great difficulty incorporating PAE into their counselling sessions. Few physicians report being very or extremely knowledgeable (9%) compared with 89% who report having at least some difficulty. This is especially important as the knowledge of, and confidence towards PAE counselling and prescription is indicative of how frequently they perform such actions (Pinto et al. 1998; Huijg et al. 2015).

Physicians and AHPs also reported more physical activity counselling barriers and the impact of these barriers higher than EPs. Consistent with previous literature (McKenna et al. 1998), the most cited physician barrier was lack of time. However, the second most cited barrier and rated the highest impact was patients’ interest in physical activity (93%; 2.77 ± 0.85 out of 4) which differs from work by Windt et al. (2015) where patient interest was viewed as fifth most impactful barrier. AHPs (primarily nurses) and EPs both reported patients’ interest in PAE as the most common and impactful barrier. These results are consistent with diabetes educators’ low confidence in their patients to increase their PAE (Dillman et al. 2010); however, this previous work also suggests that changing health care providers’ perceptions of patients may influence their PAE practices. Providing workshop training increased diabetes educators’ efficacy, perceived patient knowledge and improved diabetes educators’ confidence in their patients to perform PAE (Shields et al. 2013).

Open-ended responses regarding the biggest challenge of incorporating PAE into their counselling sessions rated patient disinterest as the primary barrier among physicians. Counselling patients emerged as the primary theme to help patients overcome their PAE practice challenges. This is especially important when noting that physicians and AHPs identified higher confidence in their ability to perform a series of PAE-promoting behaviours following the workshop. The majority of EPs identified higher confidence to perform PAE practices as a result of the workshop but to a significantly lesser extent compared with other health care professionals; this is likely attributed to their relatively higher preexisting PAE confidence. These results show that the workshop increased confidence to perform PAE counselling and their perceived abilities to help their patients overcome inactivity obstacles.

The workshops educated attendees on current tools and resources to help their patients achieve active lifestyles. Most notably the EIMC prescription pad tool was emphasized. Almost all physicians reported “very likely” or “definitely will” use the tool (93%) compared with 83% of AHPs and 71% of EPs. Following the workshop, physician attendees were asked how they would change their current practice as a result of the EIMC workshop and 87% reported they would; the most common themes were to prescribe more PAE (54% of respondents) and to perform more PAE counselling (38% of respondents). These results support the need to increase awareness of tools and resources that support PAE prescription (Joy et al. 2013), while also providing insight into the importance of offering PAE training as part of continuing education, which is an untapped area of research (Hoffmann et al. 2016). Hoffmann et al. (2016) identified other factors that contribute to the under-prescription of exercise interventions in clinical care that include a lack of awareness among many clinicians and patients about the effectiveness of exercise interventions, poor knowledge about what comprises an effective exercise intervention, a lack of relevant training and educational opportunities available to medical practitioners, and inadequate descriptions of exercise interventions in published trials and reviews. The EIMC workshops provided with this national education program address these deficiencies and demonstrate an intention by participants to change practice as a result of this education to apply practical and specific exercise strategies in clinical practice.

The primary objectives of EIMC are to (i) increase the number of health care professionals who are assessing, prescribing, and counselling patients in physical activity and (ii) facilitate the collaboration between health care and EPs in the prevention and treatment of chronic disease. The results of this study are promising as physicians intend on making changes to their practice as a result of participating in the EIMC workshop. Future work should confirm if intentions lead to changes in practice or if other avenues of training, such as including PAE as a core component of medical school curricula, are effective at changing physician behaviours in clinical practice over time. Regarding the increased collaboration between health care and EPs, the workshops presented information on how to make referrals to “qualified” EPs including regulated health professionals such as physiotherapists, sport medical doctors, and sport chiropractors and certified exercise professionals identified under the EIMC recognition program that have the education, scope of practice, and liability insurance to work with individuals with either 1 stable medical condition (EIMC level 1) or 2 or more medical conditions (EIMC level 2). Physician confidence to refer improved as a result of the workshops and “use of resources” was identified as a strategy by many physicians and AHPs as a way to support patient physical activity; however, specific reference to use of exercise professionals in communities did not come up in the contextual analysis of specific strategies to overcome challenges. Given that use of EPs, such as CSEP-Certified Personal Trainers®, CSEP-Certified Exercise Physiologists®, or registered kinesiologists, are only beginning to be included in family health care teams (Moore et al. 2015), referral processes to EPs in health care and in communities is something that needs to be developed to further support EIMC.


Limitations


Due to the reliance on self-reported data there is an inherent risk for response bias. The individuals who took part in the workshop did so out of their own interest and thus the workshop may have attracted individuals who already practice PAE counselling and prescription or at least viewed it as beneficial. Therefore, the results identified in this study may represent the “early adopter” group of clinicians that actually would be expected to have much higher confidence and prescription practices than the wider group of clinicians. Additionally, providers may have responded in what they perceive to be a socially desirable way; reporting higher rates, knowledge, and confidence of PAE counselling and prescription. Since provider’s self-reported rates of physical activity content in sessions are generally higher than patient-reported data and direct observation (Stange et al. 1998; Podl et al. 1999), they may have over-reported some of their responses in this current study. Conversely, it is likely that actual knowledge and confidence toward PAE counselling and prescription in the greater population of physicians and AHPs is probably even lower than that reported in this study.

Given the practical use of the self-reflection questionnaire and the goal to compare measures from this work to previous data, portions of the questionnaire were adapted from previous work in both physician counselling and diabetes education. Therefore, although sections of the questionnaire have been used previously, the questionnaire as a whole was created specifically for this education initiative and has some inherent drawbacks. For example, using categorical based data (<10%, 11%–25%, 26%–50%, 51%–75%, 75%–100%) decreases the ability to run descriptive statistics on exact numerical data, but it allowed for easier completion by attendees. As well, the uneven intervals limited analysis, but they were implemented for the purpose of identifying providers who perform actions less than 10%, allowing for more informative data.



Strengths


To our knowledge, there is only 1 other study that evaluated Canadian primary care providers’ physical activity counselling and prescription practices in conjunction with a training workshop (Windt et al. 2015); however, the study was limited to exclusively family physicians (n = 25) in British Columbia following a 3-h workshop. This distinction makes this study the first to assess physical activity counselling and exercise prescription practices of physicians, AHPs, and EPs across Canada following a full day (6 h) of PAE training. As well, incorporating continuing medical education credits provided an incentive to attend for qualifying attendees, illustrating that it is a recognized, national education program. Open-ended responses allowed providers to identify how they would change their practice initially which reinforced the workshops impact on promoting physical activity counselling and exercise prescription among physicians in regular clinical care.




Conclusion


The evidence of the present study highlights the current PAE counselling and prescription practices of health care providers across Canada. Physicians and AHPs have less knowledge and confidence and report more barriers compared with EPs and physical activity counselling and prescription rates are low. The EIMC training workshops increased providers’ confidence to perform physical activity counselling and exercise prescription, which resulted in proposed changes to their practice. Although this study is descriptive in nature, this report is an important first step in determining barriers to including physical activity assessment and prescription in clinical practice. These early intentions to change clinician behaviour are very encouraging and supportive of the EIMC objectives. Future research should follow-up on providers’ physical activity practices to evaluate their ability to follow through on postulated practice changes, and further work should encourage greater collaboration for reciprocal referral to and from EPs to support patient PAE.


Conflicts of Interest


JRF is the chair of the national advisory council for EIMC. PO is an EIMC faculty and has a Chair in Cardiovascular Prevention and Rehabilitation at the University Health Network sponsored by GoodLife Fitness.




Acknowledgements


We thank Susan Yungblut for oversight of the EIMC program and assistance with the coordination of the workshops, data collection, and review of the paper. The workshop program was supported by the Lawson Foundation, and MWO was supported by the Lawson Foundation and Acadia University Research Fund.



 

 

 

 

 




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