European Journal of Public Health, Vol. 15, No.

6, 569–575
Ó The Author 2005. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/cki045 Advance Access published on July 28, 2005
............................................................................................................
Attitudes and practices of physicians and
nurses regarding physical activity promotion
in the Catalan primary health-care system
A. Puig Ribera1, J. McKenna2, C. Riddoch3

Background: In Catalonia a high percentage of the population remains inactive. General practices are an
ideal setting to advise on physical activity (PA). However, there is a lack of evidence regarding practices,
barriers and predictors of such promotion in the Catalan primary health-care system. This study set out to
establish descriptive baseline data for PA promotion in Catalan general practices, and to explore the
experiences of doctors/nurses in promoting PA in their day-to-day professional lives. Methods: A mixed-
method approach was adopted. A survey was conducted with 245 physicians/nurses (58% response rate).
Subsequently, focus groups (n ¼ 5) and semi-structured interviews (n ¼ 7) were conducted with 18
physicians and 15 nurses. After coding for important themes, the final interpretation was confirmed
by contributors. Results: Eighty-eight percent of physicians/nurses promoted PA at least infrequently.
However, work conditions were perceived as unfavourable, with the main barriers being lack of (i) time,
(ii) training and (iii) protocols. Qualitative data showed that PA promotion was opportunistic, focused on
selected patients, used generalized messages and was highly dependent on personal interests. Regular
promotion was encouraged by direct experiences of the benefits of regular exercising, knowing patients
well, being supported by medical colleagues and creating links with other community institutions.
PA promotion was especially hindered by seeing PA promotion as a secondary task, and patients ignoring
recommendations. Conclusions: PA promotion in Catalonia remains to be integrated into practice con-
sultations. Therefore, strategies should be developed within public health. Using a mixed-method
approach provided a broader range of evidence than most studies, which rely on quantitative methods.

Keywords: Catalonia, health promotion, physical activity, primary care, Spain

............................................................................................................

edentary behaviour is one of the strongest risk factors for the practices, barriers and personal behaviours that have been
S many chronic diseases and conditions, including coronary identified as predictors of promotional intensity in other
heart disease, hypertension, diabetes mellitus type 2, osteo- westernized public health services10–14 remain unexplored.
porosis, colon cancer, depression and anxiety.1 Despite these The purpose of this study was to establish descriptive baseline
benefits, 65% of adult Catalans are inactive.2 Inactivity is also data for PA promotion practices in the Catalan primary care
more prevalent in Spain than the rest of Europe.3 Furthermore, setting, and to explore physicians/nurses’ lives as they promote
obesity and diabetes mellitus are increasing in the Spanish and PA in their day-to-day professional life.
Catalan populations.4,5 In this context, a reduction in sedentary
lifestyles will have beneficial effects on sedentary-related diseases Methods
and will reduce future health-care expenditure.
With inactivity a major public health problem, the medical Clinical practice reflects elements of both the subjective experi-
community is searching for effective solutions to prevent ence of the individual in the context of the growing evidence
these costly and deleterious health consequences.6 Non- base provided by controlled experiments.15 Given that most
pharmacological, behavioural interventions may be more cost- evidence in medical sciences has traditionally been number-
effective and safer than the alternatives,7 and encouraging based,16 this has overriden essential elements of clinical inter-
primary care health professionals to promote physical activity action such as opinions and experiences.17 Therefore, there is a
(PA) is one feature of this approach.1 General practice in Cata- need for experience-evidence in day-to-day life of working with
lonia is an ideal setting to identify sedentary adults and advise patients. In this understanding, a mixed-method approach
on PA, as 87.8% of adults visit a physician at least once a year.8 allows researchers to unify both types of evidence.18 First, quant-
Official documentation also identified the primary care set- itative methods provided number-based information on current
ting as central to increasing PA levels. The Framework Document PA promotion practices and barriers. Subsequently, focus
for the Elaboration of the Health Plans of Catalonia emphasized groups and semi-structured interviews provided experience-
that ‘by the year 2000, 50% of physicians in primary care should based information. Throughout, priority is given to the qualit-
promote physical activity to patients’.9 However, there is a lack ative study, in the need to establish important daily concerns of
of evidence regarding the levels of PA promotion. Furthermore, staff (figure 1).

.............................................................
1 Departament de Ciències i Ciències Socials, Universitat de Vic, Survey
Catalonia, Spain The survey aimed to describe (i) current self-reported pro-
2 Carnegie Research Institute, Leeds Metropolitan University, motion practices, (ii) the perceived priority of this promotion,
Leeds, UK (iii) the perceived compatibility of work conditions within gen-
3 London Institute for Sport and Exercise, Middlesex University,
eral practices, (iv) perceived barriers, and (v) physicians/nurses’
London, UK
Correspondence: Anna Puig Ribera, University of Vic, Departament
stages of change for personal PA behaviour.
de Ciències i Ciències Socials. Carrer de la Sagrada Familia, A 23-item questionnaire was developed, based on published
7, 08500 Vic (Barcelona), Catalonia, Spain, tel: þ34 93 88612 22, literature.19–22 To establish content validity, expert researchers
fax: þ34 93 889 10 63, e-mail: [email protected] scrutinized the questionnaire items, which were based on
570 European Journal of Public Health

Mixed-methods methodology

Design Measurement Analysis

Dimension Dimension Dimension

Tools Validity Sampling

& Reliability

Phase I: Quantitative

Preliminary study: Quant Questionnaires Pilot study Cluster random Descriptive

sampling: Mean+SD
Physicians/nurses
Inferential:
Statistical
differences
+ ----------------------------------------------------------------------------

Phase II: Qualitative

Principal study: Focus groups Pilot study Purposive & Converting

QUAL snowball sampling: raw data into
physicians + nurses processed data

Interviews Pilot study physicians + nurses Coding

(for in-depth
Information) Developing
Emerging
Themes

Peer-debriefting

Figure 1 Flowchart of the research design

previous findings.23 Finally, doctors not involved in the study corroborated data from the focus groups and provided more
confirmed that the device was understandable, readable and of in-depth personalized information.
manageable length.24 Test–retest reliability (n ¼ 10) over 7 days A common guide, based on the Stages of Change theory and
ranged from r ¼ 0.40 to 0.75. Response options were Likert the Decisional Balance concept,25 was developed to structure
scales (range 1–5), where 1 ¼ completely unfavourable and the focus groups and interviews. In this literature, individuals
5 ¼ extremely favourable. change through stages (precontemplation, not changing and
The study population were physicians/nurses of primary care no intention of doing so; contemplation, thinking seriously
medical teams working in general practices managed by the about changing soon; preparation, infrequent changes in
Catalan Institute of Health (ICS). These teams were stratified behaviour; action, regular changes that were started only
according to the seven Health Regions of the Catalan Health recently; and maintenance, regularly and frequently change
System. At least two teams were randomly selected from each behaviour for >6 months). Changing reflects the balance of
region, giving a final pool of 19 teams. A cluster sample of two dimensions of decision-making: the benefits (pros) and
medical teams was obtained from each stratum. A sample of costs (cons) of changing. This approach has been adapted to
300 physicians and nurses was considered adequate to provide a address professional PA promotion behaviour of doctors and
sampling error of 2% to most research questions. A response nurses in the UK.12,21
rate of 70% was the target, allowing for a dropout of 30%, giving First, the guide was used to identify participants’ current
a final sample size of 420. practice. Then, active promoters were asked about what made
The Director of the primary health-care system of the ICS them start promoting PA or what could make them stop. Non-
endorsed the study. Questionnaires were sent to Directors of promoters were asked about what was stopping them from
each primary care medical team, requesting circulation of the promoting PA, even when they were interested in doing so.
confidential questionnaires to all team members. Using a theoretical sampling strategy,26 information-rich par-
Frequency and x2-tests were conducted to assess percentages ticipants were selected from different general practices, based
responses, differences in proportions between physicians and on four criteria: (i) geographical area (urban versus rural versus
nurses, and associations between the different stages of change suburban), (ii) private versus public management, (iii) practices
for PA and each variable. embodied within the ‘new’ model of primary care versus the
‘old’ model, and (iv) practices adhered to preventive activities
programmes versus non-adherers.
Qualitative study Five directors of primary care teams were contacted on behalf
Focus groups were conducted with physicians and nurses of the Catalan Society for Family and Community Medicine,
to understand the framework for PA promotion in primary which supported the study. This enhanced access to ‘key infor-
care and generate relevant insights, hypotheses and ideas that mants’. Verbal consent was obtained from each director for
were perceived to be important. Semi-structured interviews conducting focus groups and interviews with physicians/nurses
 Attitudes and practices of physicians and nurses 571

from general practices in their divisions. Further ‘differential’ reported promoting PA in practice consultations (table 2).
cases were identified through the data gathering process and More nurses (93.5%) than physicians (84.1%) reported
were included in the sampling structure. doing this. Table 2 shows that most staff were, at best, infre-
Interviews and focus groups were tape-recorded, fully tran- quently active in their personal lives. Over 70% of physicians
scribed and coded using the sensitizing themes of stage of change and nurses perceived physical activity promotion as ‘very
for PA promotion21 and the decision balance concepts of pros important’.
and cons of changing.25 Findings and interpretations were sent Physicians (55%) and nurses (46.1%) felt that work condi-
back to selected participants for verification (see figure 1 for a tions in general practices were ‘unfavourable’ for promoting PA.
flowchart of the design). Several strategies were used to ensure The way the medical team was organized was also perceived to
rigour in the qualitative section of the study. These variously be unfavourable for promotion (62.5%), while PA promotion
addressed the credibility, confirmability, dependability and was viewed as unimportant within the current political climate
transferrability of both analysis and interpretation:26 (69%). Not having a protocol was an important inconvenience
(55%). In addition, physicians/nurses reported having ‘very
(i) Piloting focus groups and interviews. little’ time (60.5%) and ‘very limited’ training in counselling
(ii) Data gathering was based on different participants, at skills for PA promotion (64%).
different times and at different places to ensure diverse Stage of change for personal PA was significantly associated
experiences and levels of conformity. with current practices and perception of barriers (x2 ¼ 15.16,
(iii) Using a comparative method established interactions, P < 0.05). ‘Personally active’ staff (action or maintenance stages,
which were assessed in successive focus groups and inter- 24.3%) reported promoting PA to ‘all’ patients (table 2). In
views. contrast, the majority of ‘personally inactive’ staff (precontem-
(iv) Searching for deviant cases helped to test ‘discoveries’. plation or contemplation stages, 49.8%) reported promoting
(v) Member checking. PA with ‘few’ of their patients (table 2). More of the ‘personally
(vi) Integrating different cases and contexts to analyse the active’ staff reported a higher importance of PA promotion and
relations under study and improve generalizability. for having a higher theoretical knowledge for doing this than the
‘personally inactive’ staff (table 2).

Results Qualitative study

Eighteen physicians and 15 nurses volunteered to participate.
Survey Each gave informed consent verbally for the tape recording
A response rate of 58% (n ¼ 245), 145 physicians and 92 nurses, contributions. Confidentiality was promised. Seven semi-
was obtained. Table 1 shows the mean ages, and percentage by standardized interviews were carried out in venues chosen by
gender and occupation. A majority of staff (88%, n ¼ 214) individual contributors. These lasted 30–120 min. The five focus
groups ranged from five to 12 participants and were conducted
until the moderator could predict how the participants were
Table 1 Sample occupation, age and gender going to respond.27
Physicians/nurses identified different themes that described
Mean age, n (%) the current situation of PA promotion in the Catalan primary
years (SD) care system. Current practice was described as (table 3):
Males Females Missing

opportunistic owing to a perceived ‘shortage’ of time and
Physicians 41.94 (8.46) 76 (52.4) 64 (44.2) 5 (3.4) ‘rushing to fit everything into practice consultations’;
(n ¼ 145, 59.2%)
.............................................................
having different levels of delivery (non-promoters, sporadic-
Nurses 41.91 (7.31) 10 (10.9) 81 (88) 1 (1.1) promoters and regular-promoters), which were subject to
(n ¼ 92, 37.6%) personal interest in PA;

Table 2 Responses by stage of change for personal PA behaviour

Stage for personal Currently Low priority Incompatibility Lack of Lack of Lack of Lack of
behaviour (n) no PA of PA of work time (%)d theoretical training in standard
promotion promotion conditions knowledge counselling protocols
(%)a (%)b (%)c (%)e (%)f (%)g

Precontemplation (45) 12 48* 70 65 58 75 42

..............................................................................................................................
Contemplation (71) 9 38* 65 63 46 70 40
..............................................................................................................................
Preparation (60) 6 15 60 60 35 56 50
..............................................................................................................................
Action (27) 1* 8 63 55 46* 65 58
..............................................................................................................................
Maintenance (32) 0* 18 50 55 36* 42 39
..............................................................................................................................
Missing (10)
a: Currently do not promote PA
b: Scores of 1 (completely unimportant) or 2 (unimportant)
c: Scores of 1 (completely unfavourable) or 2 (unfavourable)
d: Scores of 1 (no time at all) or 2 (not enough time)
e: Scores of 1 (no knowledge at all) or 2 (not enough knowledge)
f: Scores of 1 (no training at all) or 2 (not enough training)
g: Scores of 1 (extremely important inconvenience) or 2 (very important inconvenience)
*x2 differences, P < 0.05
572 European Journal of Public Health

Table 3 Quotes describing current promotion practices

Opportunistic
..............................................................................................................................
‘To promote physical activity has a lot to do with the capacity of the doctor to prioritize what is the most important,
will I do this or that. This is not possible with other things.’
..............................................................................................................................
Subject to personal interest of staff
‘In my case, its something personal [attending exercise classes]. I believe in exercising, and I like it, I say this to myself a lot.
I also say it quite frequently and in different moments when I am in the clinics.’
..............................................................................................................................
Non-priority task
‘When you give a series of treatments you say: no smoking, watch fat and cholesterol, take your medicine and
do some exercise, and maybe we should be conscious that to do exercise should be put at the top of the list.’
..............................................................................................................................
Physical inactivity never regarded as a health problem in its own right
‘I recommend doing exercises for specific treatments, such as obesity, hyperlipidaemia, high cholesterol, diabetes and
above all for elderly people that are lonely, or live alone. The action of going out and walking is useful for them to meet
people and spend sometime outside in the sun, this action alone motivates them.’
..............................................................................................................................
Absence of structured and common criteria
‘Only small programmes exist including in the protocols, exercises for diabetics or patients with heart problems, exist,
but its not a common project, but in part. This means, that you read it and they are sentences, right? Exercise should be done,
should but it doesn’t say what type of exercise. Anyway, it’s there like an invitation or an indication but there is no
determined structured project on how to do it.’
..............................................................................................................................
Over-generalized, over-simplified, repetitive and non-individualized messages
‘Let’s see if part of the treatment for diabetics is exercise, very well. You do exercise, right? You have to walk more
because you are overweight! Okay! Next!’
..............................................................................................................................
‘The prescription isn’t an individual prescription. We don’t ask the patients: What do you like? Have you ever done
any exercise? Do you exercise regularly? What exercises do you do?’
..............................................................................................................................
Isolated from other agencies in the community
‘There is no need to organize anything, but if we had access, the same as when you direct the patient to a digestive specialist,
when you have a problem that we could . . . If you think that that person will benefit from that program [of physical activity].’

not being a priority compared with other consultation tasks; the pharmaceutical industry. There was no rival advocate for
where it did occur, patients had chronic and specific health PA promotion (table 4).
problems, especially diabetes and obesity;

not recognizing inactivity as a health problem in its own right; Episodic promoters: preparers

lacking a structured approach and common criteria to guide
Episodic promoters felt competent and self-confident in
delivery;
promoting PA. They described having ‘basic knowledge of PA

based on using over-generalized, over-simplified, repetitive
and health benefits’, and having appropriate training/skills.
and non-individualized messages;
These skills often developed through personal involvement in

isolated from other PA agencies in the community such as
exercising. Promotion often began tentatively and with selected
sports/fitness centres, community centres and neighbour-
patients who were well known to the staff, or who staff predicted
hood associations.
would react favourably. ‘Seeing patients over several sequential
Physicians and nurses held distinctive attitudes toward appointments’ helped to establish the readiness of the patient
PA promotion. Two stage clusters were distinguished: ‘Non- for PA promotion. Support from medical colleagues helped to
promoters’, which included contemplators, and ‘promoters’, initiate PA promotion within patient consultations (table 4).
which included episodic (i.e. in the preparation stage) and Several cons discouraged staff from moving to more regular
regular (action and maintenance) promoters. and frequent promotion. Not having the ‘right’ answer to the
two most common barriers that patients reported for being
Non-promoters: contemplators more active (lack of time and money) was a problem. All staff
felt they lacked knowledge and training in ‘PA for pathologies’,
Staff reported that they would promote PA if it was a ‘non-time-
‘PA prescription’ and ‘behaviour change strategies’. In the
consuming task’; they felt they had to fit it into already time-
absence of formal training, staff typically developed only a
pressed conditions. PA would be promoted when staff could see
modest range of PA messages. Few of these messages had direct
a clear link to specific body diseases. Recent, first-hand experi-
relevance to patient health status and circumstances. This made
ences of the positive health benefits of regular PA encouraged
it difficult for staff to make the PA recommendation directly
staff to consider it for their patients (table 4).
relevant to the patients and led to patients ignoring PA recom-
Several factors (cons) undermined personal enthusiasm for
mendations. Lack of information further discouraged staff when
taking the first steps in promoting PA. PA was rarely seen as a
they wished to help specific patients, especially obese people
priority within 5-min consultations. This placed all preventive
wanting to lose weight (table 4).
activities in a ‘second division’ of optional approaches. Lack
of official support and being under-resourced supported
these beliefs. Lack of consensus statements and official protocols Active promoters
were cited as further evidence for this argument. There was also a Active promoters were proactive in creating links with other
sense that patients did not want PA promotion; they preferred community institutions, including neighbourhood associations,
cure approaches. Furthermore, any energy for changing profes- fitness centres, community centres, schools and city councils.
sional practice was absorbed by coping with the attentions of This capitalized on the pre-existing, specialist physical resources
 Attitudes and practices of physicians and nurses 573

Table 4 Quotes from Non-Promoters, Episodic And Active Promoters of physical activity

Pros Cons

Non-time-consuming task Preventive activities perceived as a second division of

optional approaches
..............................................................................................................................
‘It’s no effort for me to take a minute and say: it will do ‘The doctor in general is more concerned with whether
you good to do a bit of exercise, it doesn’t take a lot of the patient smokes or has high cholesterol than if the
effort and its two seconds.’ patient does any exercise.’
..............................................................................................................................
Clearly linked to specific diseases Lack of official support
..............................................................................................................................
0
‘I really think that professionals attitudes towards this [PA] ‘If there is someone who voluntarily prescribes a little exercise
depends on what has been said in the programmes for its because they want to, and on their own initiative.’
diabetics and obesity.’
..............................................................................................................................
Personal benefits from regular physical activity Lack of demand from patients
..............................................................................................................................
‘but if you do physical activity and feel good then you will ‘. . . the patient who comes here wants you to give a treatment
recommend it to others. What’s important is that they or to diagnose something, they are not open to the promotion
have lived it . . . exactly, who has lived it, even if it was in of exercising, it has to be you who insists on this.’
their childhood.’
..............................................................................................................................
Having developed basic knowledge and training skills Pharmaceutical industry competes with physical activity
promotion
..............................................................................................................................
‘If there is a doctor that has some knowledge of this is, because ‘. . . because we are all motivated through the pharmaceutical
they have taken an interest in something, because as such, industry to give prescriptions . . . because there is no interest,
there is no subject of exercising for health.’ from any industry to obtain any benefits [from promoting
physical activity], you have to look for it, if you are interested.’
..............................................................................................................................
Promoting to selected patients Deficient knowledge and training
..............................................................................................................................
‘I take time to explain the advantages of exercising to people ‘I think the doctor, except with few exceptions, don’t
who really listen and the people that think I am a stupid, sufficiently know the benefits of physical activity, or the
I don’t tell them to do exercises . . .’ disadvantages, nor do they know how to prescribe it
regularly.’
..............................................................................................................................
Support from medical colleagues and working in consensus Irrelevance of our messages to patients
..............................................................................................................................
‘The three assistants and the three directors of the team and I, ‘In general, it’s OK to say walk as much as you are able, OK?
while I was there, I was the person who tried to maintain But this is not enough. I think that we are trying to change
the common idea and all the history [of promoting activity].’ this idea but, we aren’t worried enough about promoting
physical activity.’
..............................................................................................................................
Creating links with other community institutions Patients ignore recommendations
..............................................................................................................................
‘Social security prescribes a lot of things but doesn’t promote ‘A lot of people when you tell them to exercise daily,
gyms. And that could be watched over by social security they say you must be joking, they have to work,
doctors, specialized exercise staffs, and doctors who and nowadays working full time is very tiring.’
liked the subject.’
..............................................................................................................................
Development and implementation of own structures for Difficulties in accessing to physical activity promotion training
delivery
..............................................................................................................................
‘I have dealt with time constraints, I have made this protocol ‘There are few conferences and workshops and you have
clear, I have believed 100% in it, and I met a nurse in my team to pay to attend them. So, if you want something
who shared my ideas. You have to choose people who believe you have to fight for it.’
in exercising.’
..............................................................................................................................
Difficulties overcoming patients’ barriers
..............................................................................................................................
‘Yes, because they say that they do enough exercise at home or
at work, and that the problem is that they have no time.’

and was based on an acceptance that community-based special- Discussion

ists have more appropriate skills in PA promotion. Active
promoters felt highly trained to promote PA. This resulted This study explored the current situation of PA promotion in
from self-teaching, which helped to achieve a better delivery. the Catalan primary health-care system. The study is the first to:
Delivery was individualistic and developed to satisfy personal (i) target randomly selected general practices independently of
models for ‘successful’ interventions (table 4). any preventive programme, not only in Catalonia, but through-
The main cons for active promoters were the perceived out Spain; (ii) use a qualitative approach to explore the concerns
difficulties in accessing PA promotion training. Not having and practices of professionals through an established model of
enough space to address the PA problems of individual patients, behaviour change; and (iii) adopt a mixed-method approach.
such as organizing PA programmes, was a further concern This has provided a broader range of evidence than most studies,
(table 4). which typically rely on quantitative methods. These issues relate
574 European Journal of Public Health

to the practicalities of promoting PA in everyday primary care, The study has several limitations. First, we can not ensure
to the theoretical relevance of the stages of change perspective to that all themes were identified. Secondly, although analytical
professional practice, and also to more generalizable issues approaches were adopted to suspend the researchers’ views,
regarding the promotion of PA within general practice. The no criteria can confirm this. Thirdly, only volunteers were rep-
process generated three specific main findings. resented. Therefore, the study does not claim to have achieved
The first finding was that a high percentage of staff reported completeness; it is likely to express the ‘best it is’.
promoting PA and felt that this was an important task. These Future research on PA promotion in primary care can profit
rates are higher than reported in previous research.10,19,28–30 from mixing experiential with numerical evidence. This may
This may be due to sampling bias, where the most active pro- identify the best approach for promotional effectiveness.
moters completed the questionnaire. The uneven response rates PA promotion should target not only physicians/nurses, but
from within individual medical teams (ranging from 10% to also patients and community figures, with a clear specialized
80%, and groups of from 10 to 50 staff) generated higher than role. Further research on PA promotion in Catalonia should
expected standard sampling errors for some questionnaire (i) develop standardized structured protocols to guide delivery,
responses. Further studies should explore the frequency of pro- (ii) co-ordinate primary care with already existing community
moting PA, since the focus groups and interviews suggested institutions and specialists, including exercise specialists,
the dominance of episodic and opportunistic approaches. Con- and (iii) study the effectiveness of such protocols through
sistent with McKenna and Vernon (2004),12 these studies should intervention studies.
also define the specific style and messages within PA promotion.
Second, ‘personally active’ staff promoted PA more frequently
and perceived it to be more important than sedentary staff. As Acknowledgements
with UK doctors and nurses,21 physical inactivity behaviour was We wish to thank all the volunteers who altruistically contrib-
an important factor in supporting decisions regarding PA pro- uted in the study. We also thank the following for their support
motion in practice consultations. Many ‘traditional’ barriers of the study: the Exercise and Health group of the Catalan
were identified, which have been reported in many countries. Society for Family and Community Medicine, the Advisory
These include lack of time, short consultation time, lack of Council on Physical Activity and Health Promotion of the
education, training and lack of institutional support.19,31–33 Department of Sanity and Social Security of Catalonia, the Gen-
With such consistency, there appears to be a generic perception eral Subdirection of Health Promotion of the Department of
of a hostile context for promoting PA in primary care settings. Sanity and Social Security of Catalonia, and the ICS.
The third main finding was that PA promotion was not fully
integrated into daily consultation routines. Focus groups and
interviews identified several reasons. First, physical inactivity
only became a concern for most staff when it was clearly linked
Key points
to a ‘medical’ health hazard. This is consistent with a recent US
We established descriptive baseline data for physical
study, which showed that recall is heightened when behaviour activity promotion and, explored doctors/nurses’
change recommendations are linked to health states.34 However, experiences in such promotion in Catalan general
many Catalan staff felt they knew too little about how PA practices.
influences most health states, suggesting their training needs.
Work conditions were perceived as unfavourable with
Secondly, the lack of patient-initiated PA discussion matches the main barriers being lack of (a) time, (b) training and
US evidence showing that almost two out of three of directly (c) protocols.
observed lifestyle interventions were doctor-initiated.35 Patients
Physical activity promotion was opportunistic, focused
who were unwilling to communicate about health behaviour on selected patients, based on generalised messages and
incurred 22% higher annual medical care costs than those was highly dependent on personal activity interests.
who were,36 suggesting the need to prioritize the least enthusi-
Physical activity promotion in Catalonia remains to be
astic patients. In Spain these people are more common among integrated into practice consultations. Existing promo-
the over 65-year-olds, people who are separated or widowed or tional approaches were considered relatively ineffective
who have BMI values exceeding 25.3
Health policy should focus on integrating physical
Thirdly, the lack of a protocol that overcomes system barriers activity promotion into more practice consultations
prevented many staff from changing the content of their con- and search for evidence of effectiveness.
sultations. Thus, most professionals were in the contemplation
stage for PA promotion, and were still looking for ways to help
them to move into the more active stages. However, regular PA References
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UK would require the development and evaluation of PA pro-
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