d walking environments for their obese patients.

4. DISCUSSION

In this study, we explored the role of family physicians and their perceptions about environmental influences in promoting physical activity and walking in obese patients. In the population we surveyed, the majority of family physicians recognized the benefit of physical activity for health, even among their obese patients. In line with clinical guidelines [17], discussions about physical activity are now becoming integral routine part of ambulatory clinical practice.

Effective behavioral counseling in primary care settings calls for an awareness of the five A’s, Assess, Advise, Agree, Assist, and Arrange [18]. This involves asking patients about their engagement in certain behaviors, advising them about desired goals, seeing if they agree, assisting them in identifying and overcoming barriers through evidence-based behavior change strategies, and arranging. While we found strong endorsement for general physical activity goal-setting and treatment plans, there was less agreement on the importance of discussing general barriers to physical activity, especially in regards to addressing environmental barriers. There was less attention to the use of written prescriptions or contracts which have been shown to be an effective strategy for promoting physical activity [19].

Modeling is another important behavior change strategy and while more physically active than the general adult population or those in Texas just slightly over half of the surveyed family physicians (56.3%) were meeting the Surgeon General’s recommended physical activity guidelines themselves. We are inclined to believe that physicians who are more physically active themselves might be more likely to prescribe exercise, indicating the importance of physicians meeting the recommended guidelines for their own health as well as being a role model for their patients.

In preparing for this research, we found sparse literature on the discussions about the physical environment in medical encounters. This research provides an initial glimpse at what physicians know about the physical environment as a facilitator or a barrier to physical activity, and how this knowledge is translated into clinical practice. We have documented reasons why this knowledge is not being translated into practice, with time being the major factor mentioned, as similarly reported in other studies examining lifestyle discussions in the medical encounter [9].

As with any exploratory study, there are a few limitations to be addressed. Among these are selection and recall bias. Although all family physicians were approached voluntarily to participate, not all of them did. It is likely that those who participated may have been more physically active than those who did not respond but we could not determine this since we did not have data on nonrespondents’ physical activity. To limit recall bias associated with self-reports the survey was designed to limit responses to the last few patient-physician encounters. Moreover, while we were careful in the construction of the survey to emphasize that there were no “right or wrong” responses, self-reported data are always subject to the potential of socially desirable responses, and can not be verified without more costly record abstractions or actual clinical observations. In the survey, the word “sometimes” used in the “often-sometimes-never” 3-item scale may have appeared vague and somewhat subjective to the respondents. Providing more quantifiable, less subjective options could have removed the perceived vagueness.

The small sample size resulted in our inability to relate physician responses to physician characteristics (e.g., age, gender, and race/ethnicity) or to examine the interrelationships among study variables. The limitations of this study clearly point to the need to conduct future larger research to explore current physician practices and to identify best practices for assisting physicians in introducing environmental factors in discussions of lifestyle risk factors. Finally, this study involved only one health plan, which may limit its generalization to other settings outside our large integrated healthcare organization. However, working with CenTexNet enabled us to obtain responses from clinicians working in several different clinical settings throughout the system. Moreover, the involvement of the Family Medicine Department Leadership on the front end of the study combined with value put on research by CenTexNet members, resulted in an excellent response rate of nearly 60% which exceeds the typically low rates of other physician surveys [20].

In summary, we believe that physicians have an important role in helping their obese patients overcome barriers to physical activity. It is clear that most physicians have some knowledge about the environment and physical activity, but fewer do not routinely interact with their obese patients about the environmental concerns. Given our study findings documenting several enabling factors affecting physician discussions of environmental issues, we see a need for targeted information and provision of useful tools to assist physicians to help their obese patients. Many physicians believe that strategies to overcome environmental barriers are important and many would like to have knowledge about safe places near patients’ home in order to refer them to engage in physical activity. Toward this end, study investigators have created a web-based resource guideline for family physicians that could be downloaded and given to patients. This includes a motivational cover page confirming the importance of physical activity for health, combined with a resource guide that points patients to places in their community where they could engage in various types of physical activity in safely and conveniently.

5. ACKNOWLEDGEMENTS

This work was supported by a Scott & White Institutional Research Fund #070940 awarded to the lead author (SF). Portions of the data were presented at the 2009 Agency for Healthcare Research & Quality National Practice-Based Research Network (PBRN) Research Conference, Bethesda, MD, June 24-26, 2009.

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