|Baseline Data - June 1997
The physician survey contributes to the regional scan of heart health promotion activity in the Western Health Region in 1997. The regional scan serves as baseline data for the five year dissemination phase of research underway through Heart Health Nova Scotia and the Western Region's Heart Health Partnership. Physician support/involvement in activities proposed by the Heart Health Partnership will enhance the likelihood of heart health promotion dissemination throughout the region. The information from this survey provides insights about physician practices and the likelihood of future involvement in community-based CVD prevention.
The survey questionnaire was similar to a Canadian Heart Health Initiative Ontario Project (CHHIOP) survey designed to measure changes in physician CVD prevention practices over time (The Heart Health Action Program - Final Evaluation Report 1995). The survey was reviewed by representatives from Dalhousie's Continuing Medical Education (CME) program who subsequently supported the survey (see Appendix). Aligning our interests with CME was important since the questionnaire asked about education in preventing heart disease, and addressed physicians' experience and beliefs about behavioural change approaches. The results would identify or verify education needs related to CVD prevention. In addition, CME was important for survey credibility with physicians and maximizing response rates.
A list of 170 Western Health Region family physicians was received from the Nova Scotia Medical Society. The survey questionnaire was mailed to all 170 physicians with the letter encouraging them to participate in the survey. A brief description of the Heart Health Partnership was attached to the letter (see Appendix). Two days of continuing medical education at Dalhousie University (valued at $300) was offered as an incentive. A stamped and return addressed envelope was sent with the questionnaire. Approximately two weeks following the initial mailing, a reminder was sent to physicians who had yet to respond.
Within approximately one month following the initial mailing, 95 questionnaires were returned and 86 of those questionnaires were usable. The remaining nine were not completed for the following reasons--one physician dealt solely with allergies, one dealt with geriatric medicine, two were emergency physicians, one was an anaesthetist, one was not practising, one did not see patients, and two were retired. The following reviews each question and summarizes physicians' responses.
The first question addressed how often physicians asked new patients about smoking, physical activity, and eating habits. Table 1 shows that 91% of physicians asked about smoking often. Fewer physicians' asked about physical activity (51%) and eating habits (45%) often. This tendency is consistent with physicians charting practices shown in Table 2 where typically there was a system or section to record smoking (79%), but not physical activity habits, eating habits or Body Mass Index (BMI). Given that weight is viewed as an increasing problem associated with the risk of CVD this may signal an important area for record keeping and intervention (1995 Nova Scotia Health Survey Report).
Table 1 - First Visit With New Patients
|During the first visits with new patients in your office, how often do you ask them about their:||Often||Sometimes||Never|
|Cigarette smoking behaviour||91%||9%||0|
|Physical activity habits||51%||47%||2%|
N = 86
Table 2 - Physicians' Charting Practices
|On your patients' charts, do you have a system or a section to record:||N||Yes|
|Physical activity frequency||82||23%|
|Body Mass Index (BMI)||82||16%|
Question 3 asked how often specific strategies were used to assist smokers. Table 3 shows that self-help materials were offered often by 49% of physicians. Setting a date to quit smoking was a less frequently used intervention strategy. Most physicians (83%) offered advice of some kind often, and most physicians (77%) recommended a stop smoking program often.
Table 3 - Strategies Used to Assist Smokers
|With your patients who smoke, how often do you:||N||Often||Sometimes||Never|
|Offer self-help materials||83||49%||46%||5%|
|Help set a stop smoking date||83||30%||48%||22%|
|Recommend a stop smoking program||85||77%||22%||1%|
|Offer advice yourself||84||83%||17%||0|
Tables 4 and 5 show the percent of physicians who use various strategies (often, sometimes, never) for increasing physical activity and decreasing fat consumption. For physical activity, Table 4 shows self-help materials were offered sometimes by 50% and never by 44% of physicians. Activity plans and recommending a program, club or consultant were more likely done sometimes by more than half of the physicians. Many fewer physicians (56%) offered advice about exercise to patients often compared to offering advice about smoking often (83% - see Table 3).
Table 4 - Strategies Used to Increase Physical Activity
|With your patients who exercise fewer than 3 times per week & have no contraindications, how often do you:||N||Often||Sometimes||Never|
|Offer self-help materials||82||6%||50%||44%|
|Help make an activity plan||84||19%||55%||26%|
|Recommend a fitness consultant, club or community facility or program||84||17%||60%||23%|
|Offer advice yourself||84||56%||42%||2%|
Table 5 shows for reducing fat consumption, self-help materials were offered often by 61% of physicians, referral to a nutritionist was made often by 70% of physicians, and 54% of physicians recommended specific programs such as Weight Watchers sometimes. A larger proportion of physicians (80%) offered advice about reducing fat consumption often than increasing physical activity often (56%).
Table 5 - Strategies Used to Decrease Fat Consumption
|With your patients who you believe need to reduce fat consumption, how often do you:||N||Often||Sometimes||Never|
|Offer self-help materials||86||61%||30%||7%|
|Refer to a nutritionist/dietitian||86||70%||30%||0|
|Recommend a program (eg. Weight Watchers)||86||37%||54%||9%|
|Offer advice yourself||85||80%||20%||0|
Table 6 reviews factors that prevent physicians from helping patients change behaviours. Low patient interest/motivation was the factor noted often by the highest percentage of physicians (58%), lack of time was next (41%) followed by lack of effectiveness in achieving behaviour change (34%). Lack of reimbursement was often a factor for 30% and sometimes a factor for 33% of physicians. Lack of patient education materials was often a factor for 27% and sometimes a factor for 45% of physicians. This suggests a need for patient education materials. Only 11% reported that lack of professional training was often a factor in helping patients change behaviour.
Table 6 - Factors Preventing Physicians From Helping Patients Change Behaviours
|How often do each of the following prevent you from helping patients change behaviours:||N||Often||Sometimes||Never|
|Low patient interest/motivation||85||58%||40%||2%|
|Lack of time||86||41%||50%||9%|
|Lack of effectiveness in achieving behaviour change||85||34%||54%||12%|
|Lack of reimbursement by provincial MSI||81||30%||33%||37%|
|Lack of patient educational materials||86||27%||45%||28%|
|Lack of professional training||85||11%||58%||32%|
|Organization of your professional practice||82||4%||44%||52%|
When asked about participation in continuing education for the three CVD risk factor areas during the past two years, Table 7 shows about one half of physicians reported participating in smoking cessation (48%) and nutrition related education (45%) while about one quarter participated in education about approaches to increase physical activity (27%).
Table 7 - Participation in Continuing Education
|In the past two years, did you participate in any continuing education (formal or personal) in:||N||Yes|
|Approaches to smoking cessation||85||48%|
|Approaches to reducing fat consumption||86||45%|
|Approaches to encouraging physical activity||86||27%|
|CVD risk factor screening or monitoring||85||79%|
Despite this moderate rate of participation, Tables 8 and 9 show most physicians (72 - 77%) were interested in continuing education in each of the three CVD risk reduction areas, and even more physicians (88 - 91%) were interested in receiving educational materials.
Table 8 - Interest in Participating in Continuing Education
|Are you interested in participating in continuing medical education in:||N||Yes|
|CVD risk factor screening and monitoring||84||77%|
|Behaviour change approaches to smoking cessation||85||72%|
|reducing fat consumption||84||76%|
|increasing physical activity||85||77%|
Table 9 - Interest in Receiving Information
|Are you interested in getting information on:||N||Yes|
|The Heart Health Partnership project||83||81%|
|Patient education materials on behaviour change approaches to smoking cessation||85||88%|
|reducing fat consumption||85||91%|
|increasing physical activity||85||89%|
Question 10 asked physicians to rate how strongly they believed that specific behaviour changes could reduce the risk of CVD. Table 10 shows 95% of physicians strongly agreed that reducing smoking can reduce the risks of CVD for their patients. Reducing fat consumption, increasing physical activity and reducing weight were also important, but the strength of their agreement in addressing these risk areas was less than smoking. Reducing stress was an area that many physicians (21%) were unsure about for reducing the risk of CVD.
Table 10 - Behaviour Changes to Reduce the Risk of CVD
|Please indicate how strongly you believe the following behaviour changes can reduce the risk of CVD for your patients.||Strongly Agree||Agree||Unsure||Disagree||Strongly Disagree|
|Reduce or quit smoking||95%||5%||-||-||-|
|Reduce fat consumption||65%||30%||5%||-||-|
|Increase physical activity||69%||29%||2%||-||-|
N = 86
Question 11 asked physicians to rate how strongly they believed that specific strategies were necessary to reduce the risk of CVD. Table 11 shows 92% of physicians strongly agreed that personal behaviour change is necessary to reduce the risk of CVD for their patients. While 95% agreed that drug treatment is necessary, only 42% strongly agree. There were 73% who agreed that community strategies such as programs and policy changes were necessary, and 21% were unsure community strategies were necessary. The percentages were relatively the same for environmental strategies, which could be viewed as the same or as part of community strategies. Twenty-nine percent of physicians strongly agreed that social support strategies (family, friends, support groups, etc.) were necessary to reduce the risk of CVD, while 51% agreed and 18% were unsure about the need for this strategy.
Table 11 - Strategies Necessary to Reduce the Risk of CVD
|Please indicate how strongly you believe that the following is necessary to reduce the risks of CVD for your patients.||Strongly Agree||Agree||Unsure||Disagree||Strongly Disagree|
|Personal behaviour changes (smoking, physical activity, etc.)||92%||8%||-||-||-|
|Drug treatment (to reduce blood pressure, high cholesterol)||42%||53%||2%||2%||-|
|Community wide strategies (programs, policy changes, etc.)||24%||49%||21%||5%||1%|
|Environmental strategies (food labelling, walking trails, etc.)||22%||46%||26%||4%||2%|
|Social support strategies (family, friends, support groups, etc.)||29%||51%||18%||-||2|
N = 86
Finally, physicians were asked about participating in local organizations or groups to apply preventive strategies to reduce the risk of CVD. Table 12 shows only 6% reported being involved in the past year, and 20% reported being involved prior to the past year. When asked about future involvement, 42% expressed an interest in working with local organizations or groups to reduce the risks of CVD. The Heart Health Partnership views this result favourably as the effort to disseminate heart health promotion innovations through the Western Health Region evolves.
Table 12 - Participation in Local Organizations or Groups to Reduce the Risk of CVD
|Have you been involved with local organizations or groups to apply preventive strategies to reduce the risk of CVD . . .||N||Yes|
|in the past year ?||86||6%|
|prior to the past year ?||86||20%|
|Are you interested to be involved with organizations or groups in your community to apply preventive strategies to reduce the risk of CVD?||85||42%|
Summary and Discussion
The intent of this survey was to examine 1) physicians' practice of behavioural approaches to CVD prevention, 2) barriers to applying behaviour change approaches, 3) interest in continuing medical education, 4) beliefs about behaviour change and CVD risk reduction, and 5) past and future involvement with local groups and organizations to reduce risks of CVD. Responses from 86 of 170 physicians in the Western Health Region add to the baseline information about heart health promotion/CVD prevention activities in the Region in 1997.
Smoking, fat consumption, and physical activity are behaviours linked to the level of risk for cardiovascular disease; and are important areas for intervention by community-based heart health programs across the country and worldwide. Most physicians who responded to this survey strongly agreed or agreed that behaviour change in these areas can reduce the risk of CVD for their patients. The survey also showed that physician's action in these three areas varied. Physicians asked patients about smoking habits and charted smoking more often than eating or physical activity habits. Most physicians were likely to give advice in the three risk areas, but fewer gave advice regarding physical activity. Recommending a smoking program or referring patients to a nutritionist were strategies often used by most physicians, but recommending a fitness or activity program was a strategy that most physicians used sometimes. Forty-nine percent of physicians offered self-help materials often for smokers and 61% of physicians offered self-help materials often to patients who needed to reduce fat consumption. In contrast only 6% offered self-help materials often for exercise or physical activity and 44% never offered self-help materials in this risk factor area.
While physicians view that they play an important role in CVD prevention, they often lack the ability to be involved in prevention programs. Mann and Putnam (1989) noted that "most physicians appear to take a reactive rather than a proactive approach with their patients, discussing CVD risk reduction only when elevated risk factors appear or are likely to do so" (p. 53-54). They found that there were several barriers to practising CVD prevention depending on the risk factor (Mann & Putnam, 1990), including lack of counselling skills, lack of belief in personal effectiveness, lack of time, lack of patient commitment and motivation, etc. In the current study, low patient interest and motivation was indicated by 58% of physicians as a reason that often prevents them from helping patients change behaviour. This was followed by lack of time (41%) and lack of effectiveness in achieving behaviour change (34%). Lack of professional training sometimes (58%) and often (11%) was indicated as a factor that prevented physicians from helping patients achieve behaviour change. This result is consistent with a recent CME needs assessment which reported that a course in counselling skills was requested by many physicians (Connection, March 1997).
When considering personal behaviour change alongside other approaches to CVD prevention, most physicians (92%) strongly agreed that personal behaviour change was necessary to reduce the risk of CVD. The result was unanimous when combined with those who agreed (8%). Almost all physicians (95%) strongly agreed or agreed that drug treatment was necessary. However, there was much less agreement on the need for community-wide strategies, environmental strategies, and social support strategies to reduce the risks of CVD. A much smaller proportion of physicians (24%) strongly agreed with the need for community-wide strategies, and a similar proportion (21%) were unsure. This may indicate a lack of understanding about how these strategies contribute to personal behaviour change, a topic that is being examined more extensively in the health promotion literature under ecological approaches or the social ecology of health promotion (American Journal of Health Promotion, March/April 1996).
Physician participation in continuing medical education during the past two years varied in a pattern similar to action on the three risk areas. Previously it was noted that physicians more often gave advice on smoking cessation and reducing fat consumption. About one half of physicians had participated in education for smoking cessation and reducing fat consumption, but only a quarter of physicians participated in education to encourage physical activity. However, physicians showed a greater level of interest in continuing medical education (72-77%), and receiving patient education materials (88-91%) in each of the three CVD risk areas. This provides evidence of a need and desire for some form of education and materials addressing behaviour change approaches to CVD risk reduction.
Finally, there is reason for optimism that family physicians will become involved in the community-based heart health promotion dissemination strategy being developed by the Heart Health Partnership in the Western Health Region. Eighty-one percent of physicians responded that they wanted information about the Partnership project, and 42% expressed an interest to be involved with local organizations or groups in their community to apply preventive strategies to reduce the risk of CVD.
American Journal of Health Promotion (1996). Special Issue: Social Ecology, 10, 247-328.
Connection (1997). Needs assessment survey helps target CME efforts. Connection, March 1997, 4, p.2.
Heart Health Resource Centre (1995). Heart health action program: Final evaluation report. Ontario Public Health Association.
Mann, K.V. and Putnam, R.W. (1990). Barriers to prevention: Physician perceptions of ideal versus actual practices in reducing cardiovascular risk. Canadian Family Physician, 36, 665-670.
Mann, K.V. and Putnam, R.W. (1989). Physicians' perceptions of their role in cardiovascular risk reduction. Preventive Medicine, 18, 45-58.
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