“You’ve Got to Pick Your Battles”: A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice
Abstract
:1. Introduction
2. Materials and Methods
Ethics Approval and Consent to Participate
3. Results
3.1. Survey Responses
3.2. Interview Responses
4. Discussion
Methodological Considerations
5. Conclusions
5.1. Implications for Practice
- GPs feel like PA promotion is being “dumped on them” and more of a collaborative effort with health and exercise professionals is needed to promote exercise medicine.
- The Moving Medicine initiative is a high-quality resource to support PA promotion in primary care as part of the Moving Healthcare Professionals Programme. Better marketing, education, and integration of such resources into primary care is needed where it can have the greatest public health impact.
- PA promotion and exercise medicine needs to be made a key priority within primary care. This may include improved undergraduate training, education provision for existing health professionals, better links with exercise professionals, and consideration of PA-related QOFs, as suggested by GPs in the present study.
- Moving from paper-based to electronic systems may facilitate exercise referrals in primary care.
5.2. Implications for Research
- Advocation of multi-level approaches (e.g., socio-ecological model) when evaluating complex interventions, specifically those relating to PA promotion and exercise medicine.
- As social prescription (which enables primary care professionals to refer patients to a range of local, non-clinical services) was stated by most GPs as a promising model to embed PA into primary care, evaluation of social prescription is needed to determine: (a) what a social prescribing model looks like in practice, (b) what staff competencies are optimum for social prescribing, and (c) the impact social prescribing has on PA promotion.
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
References
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Survey Participant Demographics (n = 56) | |
---|---|
Age (years) | 45.5 ± 11.3 |
Sex (% Female) | 28 (50%) |
Ethnicity (% White British) | 43 (77%) |
Years worked as a GP | 16 ± 11 |
Full-time | 29 (52%) |
Average surgery Index of Multiple Deprivation # | 2 ± 2 |
GP activity levels Meeting the PA recommendations * | 3.4 ± 1.8 days/week of ≥30 min of MVPA 13 (23%) |
Interview Participant Demographics (n = 7) | |
Age (years) | 41.9 ± 12.2 |
Sex (% Female) | 2 (29%) |
Ethnicity (% White British) | 5 (71%) |
Years worked as a GP | 14 ± 12 |
Full-time | 6 (86%) |
Average surgery Index of Multiple Deprivation # | 3 ± 2 |
GP Referral Statistics | |
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How often did GPs ask patients about their PA levels | Every consultation = 1 (2%) Most consultations = 12 (21%) Some consultations = 43 (77%) Never = 0 Other = 0 |
How many referrals did GPs make to the local exercise referral scheme per month | 0 = 11 (20%) 1–5 = 43 (77%) 5–10 = 2 (4%) >10 = 0 |
GP referral to other PA initiatives (Multiple answers allowed) | Fitness centres (other than local exercise referral scheme) = 22 (39%) Parkrun = 23 (41%) Forever active (local fitness initiative targeted at over-50s) = 4 (7%) Other 13 = (23%) Summary of qualitative responses: Walking/cycling groups. Health trainer (health behaviour support and link to local initiatives). Weight management. Yoga. Tai chi. Liverpool Football Club Foundation (local charity providing health and wellbeing support through PA) No response = 15 (27%) |
Facilitators and barriers to referral | |
What prevents GPs from making referrals to the exercise referral scheme? (Multiple answers allowed) | Lack of motivation = 22 (39%) Lack of knowledge about initiatives or how to refer = 14 (25%) Lack of belief in effectiveness = 1 (2%) Lack of time within consultations (other priorities) = 34 (61%) Personally don’t believe exercise is an effective treatment = 0 Other = 9 (16%) Summary of qualitative responses: Not always relevant. Patient unable to access facilities. Practice nurse makes referrals (n=3). Unclear referral pathway. Paper referral form asks unnecessary questions. No response = 2 (4%) |
What would encourage GPs to refer an exercise referral scheme? (Multiple answers allowed) | Electronic referral system = 38 (68%) Clearer marketing information about content = 26 (46%) Clearer marketing information about eligibility = 25 (45%) If the scheme was more physical activity focused, rather than only based at fitness centres = 17 (30%) Better feedback about patient progress = 15 (27%) Knowledge of effectiveness = 8 (14%) Other = 10 (18%) Summary of qualitative responses: Referral system needs to be quick and easy, shouldn’t need patient data like height and weight or pulse. Self-referral (n=6). Role for non-clinical support workers. No response = 1 (2%) |
Most effective ways to communicate with GPs (Multiple answers allowed) | Hard copy leaflets = 34 (61%) Hard copy posters = 30 (54%) Leaflets for referrers with exercise referral scheme information on = 23 (41%) Short instructional video = 10 (18%) Exercise referral scheme representatives to present details at GP forums = 16 (29%) An additional event for GPs = 2 (4%) Online circulation of initiative information = 34 (61%) Other = 3 (5%) Summary of qualitative responses: Receptionists and other non-clinical staff involvement (GPs not the only people in contact with patients). No response = 4 (7%) |
Moving Medicine engagement | |
GP awareness of Moving Medicine initiative | 8 (14%) |
GP use of Moving Medicine initiative | 3 (5%) |
SEM Level * | Themes | Example Quotes |
---|---|---|
Policy level-Factors affected by national policy. | ||
Provision of education | “you need to increase the doctors’ understanding so they’re more willing to say... Don’t reach for your prescribing pad, as it was, reach for your exercise referral sheets” (P1,M,39). “Most doctors are very willing to learn new things, especially if they can get a CPD point out there” (P1,M,39). | |
Priority | “… trying to shoehorn that [PA counselling/referral] in your ten-minute consultation… I suppose, yes, we’re doing it [exercise referral] on an ad hoc basis if we’ve got time to put it into consultation, and sometimes you think, "Oh yes, I could have mentioned the scheme but didn’t have enough time to today” (P2,M,36). We get people coming in asking about three things at once, and then it’s trying to prioritise, and unfortunately again, either GPs or the patients sometimes push that [PA counselling/referral] lower down the list than it should be” (P3,F,53). | |
Organisational level-Factors related to resources, programmes, and services. | ||
Feedback | “I’ve never had a document [from the exercise referral scheme], I’ve never had a phone call, I’ve never had anything at all” (P6,M,44). | |
E-referral system | “I think we’ve got to move towards electronic, haven’t we? If it self-populates with pulse, blood pressure, height, weight, any other information, medical conditions that are relevant, it would be a lot easier” (P3,F,53). | |
Interpersonal level-Factors related to GP interaction with others, including factors that are “intrapersonal” to the patient. | ||
PA as everybody’s business | “… from hospital doctors to people in the gym, they’re all going to say “go to your GP”, and most of the time they’re not the person that they should be going to, and I think we feel like work is always being dumped on the GP” (P7,F,31). | |
Individual patient factors | “You sort of have to tailor it to the patient’s personality. For example, if they are depressed, then the motivation to go out of the front door isn’t there, and some people just never had that habit of doing exercise, so trying to work out a way to just introduce it, like a ten-minute walk or… inside the house maybe to start with, and then maybe trying to build it up from there to doing this [PA] referral scheme” (P2,M,36). “sometimes you’ve got to pick your battles and go with what’s the most important thing, what does the patient want from that consultation on that day” (P7,F,31). | |
Intrapersonal level-Factors related to solely GPs at the individual level. | ||
Knowledge | “I didn’t have as good an understanding until I went to the re-launch of the Exercise for Health [local exercise referral scheme], they had lots of speakers, [which] sort of re-invigorated me referring people” (P3,F,53). | |
GP PA levels/personal interest | “I have a personal interest in it [exercise], and therefore I’m a bit more motivated to know a bit more and promote that as a treatment in its own right. So probably my enthusiasm for referring, and therefore my understanding, I would suspect, is probably a bit more than some of the others [GPs]” (P1,M,39). |
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Buckley, B.J.R.; Finnie, S.J.; Murphy, R.C.; Watson, P.M. “You’ve Got to Pick Your Battles”: A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice. Int. J. Environ. Res. Public Health 2020, 17, 7428. https://doi.org/10.3390/ijerph17207428
Buckley BJR, Finnie SJ, Murphy RC, Watson PM. “You’ve Got to Pick Your Battles”: A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice. International Journal of Environmental Research and Public Health. 2020; 17(20):7428. https://doi.org/10.3390/ijerph17207428
Chicago/Turabian StyleBuckley, Benjamin J. R., Stephanie J. Finnie, Rebecca C. Murphy, and Paula M. Watson. 2020. "“You’ve Got to Pick Your Battles”: A Mixed-Methods Investigation of Physical Activity Counselling and Referral within General Practice" International Journal of Environmental Research and Public Health 17, no. 20: 7428. https://doi.org/10.3390/ijerph17207428