Evaluation of Physical Activity Counseling in Primary Care Using Direct Observation of the 5As

Abstract

BACKGROUND The 5As (ask, advise, assess, assist, arrange) are recommended as a strategy for brief physical activity counseling in primary care. There is no reference standard for measurement, however, and patient participation is not well understood. This study's objectives were to (1) develop a coding scheme to measure the 5As using audio-recordings of primary care visits and (2) describe the degree to which patients and physicians accomplish the 5As. METHODSWe developed a coding scheme using previously published defi nitions of the 5As, direct-observation measures, and evaluation of audio-recorded discussions of physical activity. We applied the coding scheme to 361 audiorecorded visits by patients reporting low levels of physical activity and 28 physicians in northeast Ohio. RESULTSThe coding scheme achieved good inter-rater agreement for each of the 5As (κ = 0.62-1.0). A total of 135 visits included discussion of physical activity. Although ask tasks occurred in 91% of visits, it infrequently elicited suffi cient detail about current activity. Patient readiness to change physical activity (assess) was infrequently directly elicited by the physician (24%), but readiness was commonly expressed by the patient in response to an assessment of current level of physical activity (53%). Ambivalence was infrequently followed by physician assistance (49%).CONCLUSIONS Our newly developed measure showed that (1) physicians infrequently assess patient readiness to change, (2) patient expressions of ambivalence are common, and (3) specifi c mention of recommended guidelines for exercise is nearly absent. Future work should increase clinician skills in exploring ambivalence and readiness to change, as well as improve explicit mention of recommended guidelines for physical activity.

Need for increased promotion of physical activity by health care professionals

“…Using the 5As (ask, advice, assess, assist, and arrange) may also serve as a useful framework for health care professionals to ask about current PA levels, advise a change, assess readiness to change, assist with goal-setting, and arrange a follow-up (Ockene et al, 1995(Ockene et al, , 1997(Ockene et al, , 1999Whitlock et al, 2002). Unfortunately, utilization of such a framework appears to be minimal, as health care professionals infrequently assess patient readiness to change PA and rarely discuss PA guidelines (Carroll et al, 2011).…”

The effectiveness of motivational interviewing for health behaviour change in primary care settings: a systematic review

“…In the addiction field, practitioners typically have much greater contact time to deliver MI interventions, which contrasts with primary care setting where most encounters are brief. Furthermore, within primary care settings, patients are not necessarily expecting any type of health intervention within the consultation (which contrasts with the addiction field, whereby patients will often expect intervention) and are often ambivalent about change for health-enhancing behaviours such as PA (Carroll, Antognoli, & Flocke, 2011). In fact, within primary care settings, patients may be unaware that they are at high risk of disease associated with their health-related behaviours until this consultation.…”

Primary Care Residents' Knowledge, Attitudes, Self-Efficacy, and Perceived Professional Norms Regarding Obesity, Nutrition, and Physical Activity Counseling

“…[6][7][8][9][10][11] Although several guidelines exist for this counseling, 8,9,[12][13][14] and mounting evidence shows physician advice can encourage weight loss among patients, [15][16][17] weight-related counseling during ambulatory visits occurs at modest rates and is infrequently aligned with recommended methods shown to support behavior change. [18][19][20][21][22][23] Studies examining barriers to weight counseling in primary care practice suggest physicians feel inadequately trained, and report a lack of time and poor selfefficacy to counsel on weight management. [24][25][26][27][28] Additionally, physicians may hold negative attitudes toward overweight and obese patients and their ability to sustain change, which may inhibit counseling.…”