Adoption of positive health behaviour among primary care physicians: a cross-sectional pilot study from Lebanon

In Lebanon, primary care physicians (PCPs), including family doctors and GPs, are the main healthcare providers at the primary care level. The difference between the two is that GPs practice medicine directly after medical school without additional specialisation, while family physicians complete a family medicine residency before starting practice. PCPs have an essential role in counselling and providing health education, which are integral components of comprehensive care.

Health behaviour includes practices, actions, and habits that positively or negatively affect one’s health status.1 In Lebanon, there is a high prevalence of risky health behaviour. Among the adult population, 38.5% are smokers, 45.8% do not have adequate physical activity, 13.8% have hypertension, 5.9% have diabetes mellitus (DM), 38.0% are overweight, and 27.4% are obese.2

Studies have shown better counselling of patients when the doctors themselves have a healthy lifestyle.3–7 The issue of whether or not doctors themselves adopt positive health behaviour has been studied in some countries, with mixed results. However, no such studies were done in Lebanon or the Arab region.

This article presents the results of a preliminary study in Lebanon, which assesses the level of PCPs’ adherence to positive health behaviour, including the implementation of preventive recommendations.

A cross-sectional questionnaire-based survey was conducted among a convenience sample of 227 PCPs attending the Annual Lebanese Family Medicine Conference, held in Beirut in 2014. A 22-item-survey was used, with questions about physicians' demographics and adherence to different components of health behaviour, covering such topics as smoking status, exercise habits, cancer screening, and immunisation compliance.

### Sociodemographic characteristics

The response …


Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs. The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2 This is important as delayed treatment has unfavourable consequences. 1, 3 We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture. This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting. He immediately had difficulty walking and 3 hours later consulted an on-call GP. Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found. Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze. Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact. The patient was advised to elevate the foot and wait 2 weeks for improvement. Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient. Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination. Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon. Simmonds-Thompson's test was clearly positive. The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon. A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound. The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen ( Figure 1). Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap ( Figure 2). Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000. Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture. GP-confirmed complete Achilles tendon rupture using pocket-sized ultrasound: a case report Introduction The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs. The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2 This is important as delayed treatment has unfavourable consequences. 1, 3 We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture. This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting. He immediately had difficulty walking and 3 hours later consulted an on-call GP. Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found. Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze. Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact. The patient was advised to elevate the foot and wait 2 weeks for improvement. Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient. Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination. Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon. Simmonds-Thompson's test was clearly positive. The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon. A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound. The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen ( Figure 1). Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap ( Figure 2). Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Discussion
Tromsø Hospital serves a large area with a population of approximately 160 000. Between 2010-2014 an average of 21 patients per year were referred by their GP for suspected Achilles rupture.

Introduction
The incidence of complete Achilles tendon rupture is 18 per 100 000 patient-years 1 and is usually diagnosed clinically by GPs. The extent of clinical misdiagnosis is unknown in Norway, but may be high. 2 This is important as delayed treatment has unfavourable consequences. 1, 3 We report how a GP, with no clinical ultrasound experience, recorded images with a pocket-sized ultrasound device (PSUD) under supervision to confirm a complete Achilles tendon rupture. This could present a new indication for GP ultrasound.

Case report
A 36-year-old man experienced acute pain above the right heel accompanied by an audible snap while sprinting. He immediately had difficulty walking and 3 hours later consulted an on-call GP. Posterior ankle swelling with a tender depression 3 cm proximal to the calcaneum was found. Active plantar flexion against resistance was weak and Simmonds-Thompson test was 'partially positive' on applying a strong calf-squeeze. Based on these findings, calf muscle rupture was diagnosed as the Achilles tendon was thought to be intact. The patient was advised to elevate the foot and wait 2 weeks for improvement. Two days later a second GP, who was aware of a history of an audible snap, considered complete tendon rupture and reexamined the patient. Findings included an absent right heel raise due to weakness, minimal active plantar flexion against gravity and lying prone, significant right ankle swelling without bruising, and an altered angle of declination. Palpation elicited no ankle bony tenderness, yet a painful gap was identified 6 cm proximal from the calcaneal attachment, along the line of the Achilles tendon. Simmonds-Thompson's test was clearly positive. The positive Simmond's triad indicated a clinical diagnosis of complete rupture of the Achilles tendon.
A 3.4-8 MHz linear array probe PSUD (VScanÔ dual probe, GE Healthcare), set at a depth of 3.5 cm, was used under the supervision of a rheumatologist experienced in ultrasound. The tendon was enlarged from 1 cm to 6 cm above the calcaneal insertion, where a clear gap was seen ( Figure 1). Two hours later a radiologist-performed ultrasound (LOGIQ E9Ô, GE Healthcare) and reported an enlarged distal tendon and a complete rupture at 5-6 cm from the calcaneal attachment, creating a 2.7 cm blood-filled gap ( Figure 2). Surgical exploration 8 days post-injury found a complete Achilles tendon rupture '5-10 cm above the ankle joint'.

Introduction
Last summer our small medical team visited the Calais 'Jungle'. Since that time much has changed and the camp is being demolished and by the time this article is read, it will probably be long gone. Some youngsters are finally being brought to the UK under the 'Dubs' amendment. However, once this camp is cleared it will not solve the ongoing flight of refugees from war torn areas: other camps are already appearing.

July 2016
A young Afghan man caught his finger on a sharp point while trying to cross a barbed wire fence. The finger was partially degloved. He attended the local hospital, where they placed a few sutures, but now, 2 weeks later, the skin is necrotic and the underlying tissue looks infected. He is in danger of losing his finger. A middle-aged Sudanese man has been having rigors and is generally unwell. He says it is similar to when he last had malaria.
A young Ukrainian woman complains of lower back pain and urinary frequency. The paths of these three people may never have crossed; yet here they are, denizens of the Calais Jungle. They turn up to a makeshift primary care 'clinic' that we set up in the heart of the unofficial refugee camp one weekend in July 2016.
With only basic medical supplies, we are immediately challenged by what we see. How can we arrange secondary care for the young Afghan in danger of losing his finger? We try to persuade him to return to the original local hospital, but he is reluctant. It was not a good experience for him the first time round.
With the other two patients, it is easier. They can attend the Salam clinic run by a local association during weekdays. Later, we receive word that malaria has been confirmed in our Sudanese patient.
More people arrive, presenting with scabies, rat bites, tinea, chest infections, and wheezing from inhaling smoke from fires lit to cook and keep warm in their tents at night. We examine a severely malnourished 2-year-old boy. We meet several of the camp's 600 unaccompanied children, at grave risk of sexual exploitation. We learn that there is inadequate safeguarding in place to protect them. A young Eritrean man comes in worried about his eye. He has sustained direct ocular trauma from a rubber bullet, and will never see normally again out of that eye. We see haematomas from police batons, and hear about children being exposed to tear gas again and again (Figure 1).

The reality
These are no ordinary patients. They have travelled far from home to escape war, poverty, and misery. They have endured personal odysseys to get here, experienced untold hardships, and suffered unimaginable privations. Many have survived the loss of their families, torture, and rape. Their journeys over, for the moment at least, they must make their homes in the Calais Jungle. Their new shelters are in many cases mere tarpaulin covers, and their new beds just rugs on the ground. They own next to nothing. There is little for them to do, besides use their ingenuity to cross the English Channel in search of a better life. They are vulnerable to exploitation, crime, injury, and disease. Potentially violent clashes with local police, with other ethnic groups resident in the Jungle, or local far

Background and method
In Lebanon, primary care physicians (PCPs), including family doctors and GPs, are the main healthcare providers at the primary care level. The difference between the two is that GPs practice medicine directly after medical school without additional specialisation, while family physicians complete a family medicine residency before starting practice. PCPs have an essential role in counselling and providing health education, which are integral components of comprehensive care. Health behaviour includes practices, actions, and habits that positively or negatively affect one's health status. 1 In Lebanon, there is a high prevalence of risky health behaviour. Among the adult population, 38.5% are smokers, 45.8% do not have adequate physical activity, 13.8% have hypertension, 5.9% have diabetes mellitus (DM), 38.0% are overweight, and 27.4% are obese. 2 Studies have shown better counselling of patients when the doctors themselves have a healthy lifestyle. [3][4][5][6][7] The issue of whether or not doctors themselves adopt positive health behaviour has been studied in some countries, with mixed results. However, no such studies were done in Lebanon or the Arab region.
This article presents the results of a preliminary study in Lebanon, which assesses the level of PCPs' adherence to positive health behaviour, including the implementation of preventive recommendations.
A cross-sectional questionnaire-based survey was conducted among a convenience sample of 227 PCPs attending the Annual Lebanese Family Medicine Conference, held in Beirut in 2014. A 22item-survey was used, with questions about physicians' demographics and adherence to different components of health behaviour, covering such topics as smoking status, exercise habits, cancer screening, and immunisation compliance.

Sociodemographic characteristics
The response rate was 60.4% (137 PCPs), with 51.1% males and 48.9% females. The mean age was 41.3 (±12 years). Twenty-seven (19.7%) reported having a previous medical condition, and 54.0% were affiliated to an academic institution.

Non-communicable diseases
One hundred and thirty (95.6%; MD = 1) physicians had measured their blood pressure (BP) within the past 2 years. Sixty-eight (88.3%) of the eligible physicians had undergone lipid profile screening within the past 5 years, and 93.0% of those eligible for DM screening had undertaken it within the past 3 years.

Vaccinations
Eighty-eight physicians (65.2%; MD = 2) had received a tetanus vaccine within the past 10 years, and 69 physicians (50.4%) had been immunised against influenza within the past year. However, only five (12.8%) of the 39 eligible physicians had received the pneumococcal vaccine. Significantly more physicians affiliated to academic institutions were immunised against tetanus (P = 0.002) and influenza (P = 0.049). Age was found to be the only significant predictor for vaccination compliance after adjusting for academic affiliation, type of practice, and sex using a logistic regression model. For each additional year of age, the odds of taking the influenza vaccine was decreased multiplicatively by 0.94 (95% confidence interval [CI] = 0.902 to 0.980; P = 0.03), whereas the odds of taking the tetanus vaccine was decreased multiplicatively by 0.93 (95% CI = 0.894 to 0.977; P = 0.03).

Cancer screening
As for cancer screening, 14 (37.8%) of the physicians eligible for colon cancer screening had undergone either colonoscopy or fecal occult blood test. Significantly more physicians working in academic institutions had undergone screening for colon cancer (P = 0.007). Mammography was undergone by 20 (69.0%) of the eligible female physicians, and Pap smear was undergone by 29 (43.9%) of all female physicians.

Differences in practices by degree of specialisation
The only statistically significant differences between family physicians and GPs were that a higher number of GPs had smoked in the past (P = 0.016), and a greater number of family physicians had been immunised against influenza (P = 0.032).

Substantial barriers
Perceived barriers to adopting positive health behaviour among PCPs were lack of time (72.7%), risks associated with some preventive services and vaccines' side effects (12.1%), uncertainty of vaccines' effectiveness (10.6%), costs (9.1%), and lack of knowledge (9.9%). Only lack of time was found to be significant when comparing the perceptions of physicians who were working in academic institutions with those who weren't (P< 0.001).

Discussion
This survey showed that PCPs in Lebanon follow the preventive practice guidelines of cardiovascular risk factors, but that there is variable adherence to the other components of positive health behaviour, such as immunisations and cancer screening.
The mean age of PCPs in this study was 41.3 years and 51.1% were males. These results are comparable to those reported in a previous study conducted among Lebanese family physicians, showing an average age of 40.7 years and 56% male participants. 8 Academic physicians reported better health behaviour, which may be attributed to university hospitals' policies (for example, a no smoking policy), easy access to screening services, and being 'role models' for residents and staff. Compared to the general Lebanese population, Lebanese PCPs smoked less (24.1% versus 38.5%), exercised more adequately (63.7% versus 54.2%), and were less overweight or obese (46.0% versus 65.4%). 2 With physicians having a healthier lifestyle than the wider community, they can be role models for their patients with regards adopting positive health behaviour.
There is limited data about this topic internationally and regionally, therefore comparing the Lebanese PCP's health behaviour with that of other countries is limited. Regarding lifestyle behaviors, compared to the literature, 24.1% of Lebanese PCPs were current smokers, 63.7% exercised adequately, and 46.0% were overweight or obese, versus 1.8%, 58.1%, and 34.7% respectively in US physicians. 3 On the other hand, PCPs in Lebanon were highly adherent to screening for cardiovascular risk factors, which was in keeping with Western studies with regards to BP and lipid profile measurements. 9,10 As for vaccination, Lebanese PCPs' adherence to influenza and tetanus vaccines was similar to the rates reported in the literature. 6,9,11 However, adherence rate to pneumococcal vaccine was far less than that reported among Israeli PCPs in 2013 (44.5%). 6 When it comes to cancer screening, the compliance for different types varied. The adherence to colon cancer screening was low in this survey (37.8%); this is slightly better than that reported among PCPs in Spain (24%), 11 but much worse than that reported among Israeli PCPs (60.9%) 6 and US physicians (75%). 3 As for breast cancer, more than two-thirds of the female physicians in Lebanon screen for it through mammograms, a result that correlates with the literature. 3,6,11 In the case of cervical cancer, the observed difference in screening between physicians in Lebanon (43.9%) and in Spain (73%) 11 may be due to some cultural concerns hindering unmarried Lebanese females from having a Pap smear.
There were several limitations in this pilot study. These include selection bias, since the sample was composed only of physicians attending the conference, who may have been more located in the city area, and who may be more academically affiliated; and the use of self-reported data, which cannot be externally confirmed.
Lower age and being affiliated to an academic institution are important predictors of the adherence level of PCPs to positive health behaviour. Improvement in physicians' adoption of positive health behaviour and adherence to preventive services, particularly in immunisations and cancer screening, is recommended. This study sets grounds for future research to assess PCPs' beliefs about, knowledge of, and adherence to the preventive recommendations guidelines in Lebanon and the international community. It opens doors for setting interventions to increase the physician's adherence to different components of positive health behaviour through addressing the main barriers mentioned in this study.

Funding
No funding was received for this study.

Ethical approval
The approval of the institutional review board at the American University of Beirut Medical Center was secured prior to the initiation of the study.

Provenance
Freely submitted; externally peer reviewed.