Knowledge, attitudes, practices, and perceived barriers of physicians in promoting physical activity in Urban Odisha, India

ABSTRACT

Introduction:

Physical inactivity is a major risk factor for noncommunicable diseases and poses a significant challenge to healthcare systems. Regular physical activity (PA) is crucial for health, and physicians play a key role in motivating patients to adopt an active lifestyle. However, they have been criticized for not adequately discussing, counselling, or prescribing exercise. Physicians are expected to possess skills in ‘exercise prescription’ akin to ‘drug prescription.’ This study explores healthcare physicians’ knowledge, attitudes, practices, and perceived barriers (KAPPB) regarding promoting PA.

Methods:

Data were collected through an anonymous, self-reported questionnaire from physicians to assess their KAPPB on promoting PA. Association with the years of experience, qualification, work setting, gender, personal health status, and so on were evaluated using Chi-square test in SPSS 20.0v.

Results:

A total of 102 physicians responded. 29.4% rated their knowledge of PA promotion as ‘adequate’, while 81.4% indicated the need for further training on PA recommendations. Despite recommending exercise, only 7.8% provided written PA prescriptions. Physicians’ experience, practice setting, and personal exercise habits were associated with more effective PA counseling.

Conclusion:

Physicians generally have limited knowledge about PA recommendations and may require additional training to improve their understanding and ability to prescribe various forms of physical activity.

Introduction

Most deaths from noncommunicable diseases (NCDs) occur in low- and middle-income countries, with half of these deaths preventable.[1] Physical inactivity is the fourth leading risk factor for NCDs and a challenge for health systems.[2] Health systems are seen as having two arms: health promotion (focused on disease prevention) and health care (focused on personal health services). Both arms are involved in promoting physical activity (PA).[3] Public health systems should promote PA at the population level, while healthcare professionals (HCPs) should encourage PA at the individual level. Regular PA is well documented as a beneficial lifestyle change[4] with guidelines recommending 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity PA per week for adults between 18 and 64 years of age.[5]

Asians, particularly Indians, face a higher risk for abdominal obesity, diabetes, and cardiovascular diseases, linked to poor diet, inactivity, and genetic factors.[6,7,8] Literature shows that Indians are more sedentary than Caucasians,[9] with over 50% of the population inactive and less than 10% engaging in leisure-time PA. Even those who do exercise often do so at insufficient intensities.[10]

Research also reveals that many individuals, especially in urban areas like Odisha, exercise without professional guidance or prescription, and exercise prescriptions, when provided, are vague.[11] Similar issues occur in obstetrics and cancer care, where PA is rarely prescribed[12,13] and physicians have been criticized for not enquiring about physical activity in their patients.[14] This is in contrast to the popular evidence-based notion that PA counseling should be incorporated as a part of routine practice in primary care settings.[15]

HCPs play a crucial role in promoting PA,[16,17] yet many fail to do so effectively.[18] Endorsement by clinicians can motivate patients to become more active, but studies show that even HCPs often neglect PA promotion. There is a growing call for HCPs to incorporate exercise prescriptions into routine practice, akin to drug prescriptions.[19] However, there is limited research on how HCPs promote PA. This study aims to explore the knowledge, attitudes, and practices (KAP) of HCPs in prescribing PA to their patients.

Methods

This cross-sectional study was conducted in Bhubaneswar, Odisha, India, from June to December 2019, with ethical approval from the S‘O’A Institute Ethical Committee. Bhubaneswar has 38 government healthcare facilities, three private medical colleges, and various privately managed healthcare centers. The study targeted HCPs offering first-contact consultation, excluding dentists and alternative medicine practitioners. The study population consisted of approximately 1100 doctors registered with the Indian Medical Association, Odisha branch.

An email was sent to all registered doctors with a cover letter explaining the study, and those interested were contacted by phone for further details. Of the 332 valid email addresses, 118 responses were received. After excluding 16 incomplete responses, the final analysis included 102 participants.

Questionnaire

A short questionnaire was designed to be completed by HCPs which took about 5–10 minutes. The items were adapted from previous studies examining HCPs’ KAP regarding PA promotion.[20,21,22] The final questionnaire consisted of 28 items: 7 on knowledge, 8 on attitude, 8 on practice, 3 on the relevance of PA, and 2 on barriers to exercise prescription. Demographic data, including gender, qualifications, years of practice, work setting, service level, and personal health status, were also collected. The questionnaire was pretested on 10 randomly selected HCPs, whose responses were not included in the final sample. The Cronbach’s alpha for the questionnaire was 0.8, indicating high reliability.

Data management and analysis

Data analysis was conducted using SPSS version 20.0. Incomplete forms were excluded, and both quantitative and descriptive methods were used to describe the current situation. The relationship between categories was analyzed using Pearson’s Chi-squared test, with significance set at P < 0.05.

Experience was categorized into two groups: those with ≤10 years of experience and those with >10 years. Work setup was classified as government, private, or mixed (both government and private). Service delivery level was categorized into three groups: primary, secondary, and tertiary healthcare units, with self-employed HCPs considered part of primary care for this study.

HCPs were classified based on their responses: those correctly answering 4 out of 7 knowledge questions were deemed to have ‘adequate knowledge’, those answering 5 out of 8 attitude questions correctly were categorized as having a ‘favorable attitude’, and those answering 4 out of 7 practice-related questions correctly were considered to have ‘well-oriented practice’ toward PA recommendations for health.

Coding used

In the questionnaire, responses in the knowledge section (B) were coded as ‘0’ for incorrect answers and ‘1’ for correct answers. In the attitude section (C), responses such as ‘disagree/undecided’, ‘none/casual’, ‘no/undecided’, ‘no role/undecided’, and ‘non-exercise-based professionals/undecided’ were coded as ‘0’. Responses like ‘agree’, ‘strong/emphatic’, ‘yes’, ‘role as a leader’, and ‘exercise-based health professionals’ were coded as ‘1’. For the practice section (D), answers such as ‘no’, ‘no/undecided’, ‘no or inadequate’, and ‘rarely or never’ were coded as ‘0’, while responses like ‘yes’, ‘both’, ‘more often than not’, and ‘adequate and more than enough’ were coded as ‘1’.

Results

The overall response rate was 35.5%. The demographic details of the HCPs are provided in Table 1.

Table 1.

Characteristics of physicians who participated in the study (n=102)

Characteristics	Number (%)
Gender
Female	26 (25.5%)
Male	76 (74.5%)
Qualification
DM/MCh (Super specialty)	10 (9.8%)
Master degree/Postgraduate (Specialist)	53 (52%)
Medical graduate	39 (38.2%)
Experience
Equal to or less than 10 years	56 (54.9%)
More than 10 years	46 (45.1%)
Working sector
Government	42 (41.2%)
Private	44 (43.1%)
Both Government and private	16 (15.7%)
Set up level
Primary health care unit	30 (29.4%)
Secondary health care unit	13 (12.7%)
Tertiary healthcare unit	59 (57.8%)
Self-declared status on doing regular exercise
Yes	72 (70.6%)
No	30 (29.4%)
Self-reported health status regarding having NCD
Yes	30 (29.4%)
No	72 (70.6%)

Knowledge about current PA recommendations for health within the current healthcare system

A significant majority of HCPs recognized the importance of community PA programs in the current healthcare system, with 69.6% agreeing that these programs are essential. Moreover, 72.5% believed these programs could be viable at the primary healthcare level, and 83.3% felt that PA should be a priority in health units. However, only 29.4% of HCPs rated their knowledge of current PA recommendations for health as ‘adequate’. Knowledge gaps were evident, with only 8.8% and 21.6% providing correct answers regarding the recommended frequency of moderate and vigorous intensity exercises, respectively. Additionally, 73.5% of participants knew the minimum duration for moderate intensity exercise, but none knew the correct duration for vigorous intensity exercise. Only 44.1% could correctly identify whether moderate and vigorous intensity exercises should be combined to meet PA guidelines. None of the participants correctly identified the shortest PA screening tool that can be used in busy clinics.

Attitude toward PA counseling, PA referral, and learning more on PA

The majority (79.4%) of HCPs saw themselves as leaders in promoting PA, though only 35.3% considered referring patients to exercise-based healthcare professionals for PA guidance. A strong majority, 85.3%, agreed that exercise can replace medication, and 88.2% supported screening for safety against adverse exercise reactions. Additionally, 86.3% wanted to improve their skills in PA assessment, and 81.4% felt they needed further training to provide appropriate PA recommendations.

Practices regarding PA prescription [Table 2]

Table 2.

Practices regarding PA prescription

Counseling practices (in routine clinical practice)	Frequency (%)
Asking questions about physical activity (wherever applicable)	95 (93.1%)
Assessing level of physical activity of patient (wherever applicable)	81 (79.4%)
Prescribing exercise to your patients (either verbal or written)	96 (94.1%)
Written prescription for physical activity	8 (7.8%)
Prescribing yoga to your patients as a form of physical activity	50 (49.0%)
Spending adequate time in physical activity counseling	72 (70.6%)
Do you convince your patients to do regular exercise?	77 (75.5%)
Do you promote physical activity in community settings?	31 (30.4%)

Most HCPs (79.4%) assessed PA levels, and 94.1% provided PA counseling. However, only 49.0% offered yoga as part of health promotion. Two-thirds of HCPs (66.0%) reported success in convincing patients to engage in regular exercise, and 30.4% were involved in promoting exercise or yoga in community settings.

Personal and clinical characteristics associated with HCPs’ PA counseling behavior [Table 3]

Table 3.

Relationship between personal characteristics and PA counseling behavior (n=102)

Variable	Total subjects	Not well-oriented practice	Well-oriented practice	Chi-Squared	P
Gender
Male	76 (74.50%)	20 (26.3%)	56 (48.7%)	3.541	0.060
Female	26 (25.50%)	12 (46.2%)	14 (53.8%)
Qualification
Medical graduate	39 (38.23%)	13 (33.3%)	26 (66.7%)	0.683	0.711
Master degree/Postgraduate (Specialist)	53 (51.96%)	17 (32.1%)	36 (67.9%)
DM/MCh (Super specialist)	10 (9.80%)	2 (20.0%)	8 (80.0%)
Experience
<10 years	56 (54.9%)	22 (39.3%)	34 (60.7%)	3.611	0.047
>10 years	46 (45.1%)	10 (21.7%)	36 (78.3%)
Work set up
Government	42 (41.2%)	18 (42.9%)	24 (57.1%)	8.598	0.014
Private	44 (43.1%)	7 (15.9%)	37 (84.1%)
Both Government and private	16 (15.7%)	7 (43.8%)	9 (56.2%)
Service delivery level
Primary health care	30 (29.4%)	11 (36.7%)	19 (63.3%)	2.680	0. 262
Secondary health care	13 (12.7%)	6 (46.2%)	7 (53.8%)
Tertiary healthcare	59 (57.8%)	15 (25.4%)	44 (74.6%)
Habit of regular exercise
No	30 (29.42%)	20 (66.7%)	10 (33.3%)	24.589	0.000
Yes	72 (70.58%)	12 (16.7%)	60 (83.3%)
Having NCD
Yes	30 (29.42%)	12 (40.0%)	18 (60.0%)	1.469	0.225
No	72 (70.58%)	20 (27.8%)	52 (72.2%)
Knowledge
Inadequate knowledge	90 (88.2%)	31 (34.4%)	59 (65.6%)	3.353	0.048
Adequate knowledge	12 (11.8%)	1 (8.3%)	11 (91.7%)
Attitude
Poor attitude	18 (17.7%)	9 (50.0%)	9 (50.0%)	3.523	0.031
Good attitude	84 (82.3%)	23 (27.4%)	61 (72.6%)

Working in certain healthcare settings and having a personal exercise routine were significantly associated with better PA counselling practices (P < 0.05). Female HCPs were slightly more likely to provide effective PA counseling than their male counterparts (53.8% vs 48.7%). Although the relationship between education level and counseling practice was not significant, superspecialists (80.0%) were more likely to engage in well-oriented PA counseling compared to those with lower qualifications.

Association of HCPs’ knowledge and attitude with a well-oriented PA counseling practice [Table 3]

Knowledge and attitude also played a role; HCPs with adequate knowledge (91.7%) and a positive attitude (72.6%) were more likely to provide well-oriented PA counseling than their counterparts (P < 0.05).

Perceived barriers to PA counseling and physician’s own barrier to exercise (table not presented)

The majority of participants (71.6% of healthcare professionals) considered themselves ‘undecided’ about the reasons for not providing physical activity counseling. Meanwhile, 12.7% attributed it to personal factors, and 15.7% cited perceived patient or workplace factors. Regarding their own lack of regular exercise, 74.5% of healthcare professionals were unsure of the cause, while 16.7% reported personal barriers, 5.9% struggled with motivational issues, and 2.9% faced a combination of both personal barriers and motivational challenges.

Discussion

To our knowledge, this is the first study conducted in India that examines healthcare providers’ KAP regarding promotion of PA and factors associated with it. Previous studies have demonstrated a linear relationship between PA and health status, meaning that an increase in PA leads to further improvements in health outcomes.[23] A systematic review also concluded that PA has a positive long-term impact on NCDs.[24] Despite this evidence, only half of the HCPs in our study were engaged in well-oriented PA practices. This limited engagement in PA promotion is surprising, given the consensus among participants that PA should be integrated into the current healthcare delivery system.

The study revealed significant knowledge gaps regarding current PA recommendations and PA assessment tools used clinically, which aligns with findings from Bock et al.[25] and Florindo et al.[22] In our study, 29.4% of HCPs rated their knowledge of PA counseling as inadequate, slightly higher than 26.9% reported by Bock et al.[25] Similarly, a study in the UK found that 26% of physicians were unaware of any PA assessment tools.[26] While HCPs in our study were aware of PA tools, their knowledge of the shortest and most effective PA assessment tools for a busy outpatient departments was limited. Notably, 93.1% of physicians in our study routinely took a PA history before making PA recommendations, significantly higher than the 48% reported by Williford et al.[19] This suggests that while our participants are keen on gathering PA history, they may lack knowledge about standardized practices, such as the Physical Activity Vital Sign. This could be due to gaps in their training curricula. A significant proportion of HCPs expressed interest in learning more about PA assessment tools, with 86.3% of participants eager to improve their knowledge in this area. Roos[27] similarly found that, despite lacking familiarity with the principles of safe and effective exercise prescription, HCPs believed PA prescription was within their scope of practice. In our study, most HCPs supported patient screening for safety before recommending exercise, highlighting their awareness of its importance.

Many HCPs also expressed a strong attitude toward improving their PA knowledge related to PA recommendation and assessment tools. This is consistent with previous studies where physicians have shown a desire to learn more about PA prescriptions.[22,28,29] Most participants saw themselves as ‘leaders’ in PA promotion, a sentiment echoed in previous studies, where HCPs recognized the importance of promoting PA in their patients’ health.[18,30,31] However, only one-third of participants in our study referred patients to exercise-based healthcare professionals for PA guidance similar to the finding by Olutende et al.,[32] which reported that 33.9% of physicians referred patients to such professionals. This limited referral rate may be due to perceived overlap between HCPs’ and exercise-based professionals’ roles or a lack of awareness about available referral schemes. There is a clear need for education on the role of exercise professionals in PA promotion. Regarding Yoga as a PA tool, more than 60% of HCPs had a positive attitude toward its inclusion in PA recommendations, and nearly 50% of HCPs advised their patients to try Yoga for health benefits.

On the practice side, the prevalence of PA counseling and green prescriptions (written PA prescriptions) in urban settings was 94.1% and 7.8%, respectively. These rates are substantially higher than those reported in international studies, but they may reflect self-reporting bias. Written prescriptions are a clear reminder to patients that PA is part of their treatment plan, as important as medications.[27] A written exercise prescription from the HCPs’ reminds the patient that PA is part of their treatment plan and it should be adhered to with the same diligence as medication.[32] However, the proportion of written PA prescriptions in our study (7.8%) was much lower than 26% reported by Pojednic et al.[33] This finding aligns with Keats et al.,[20] who also found that while most clinicians provided verbal PA counseling, fewer issued written prescriptions.

Two-thirds of HCPs in our study exhibited a well-oriented PA practice, reflecting their belief in the importance of PA as part of treatment. This was supported by the majority of HCPs agreeing that ‘exercise can replace many drugs, but no drug can replace exercise’, a sentiment echoed in Teferi et al.,[31] who found that many healthcare professionals viewed exercise as equally effective as medication. A large proportion of HCPs in this study also exhibited a positive attitude toward PA, with three-quarters showing well-oriented PA practices. In lieu of above discussion, it could therefore be generalized that the limited knowledge about PA may not prevent HCPs about having a positive attitude and practice towards PA and vice versa.

Patients often view their physician’s lifestyle as a model to emulate, meaning that a physician’s own PA habits can significantly influence patients’ choices to adopt healthier behaviors.[31,34] Additionally, a physician’s PA counseling has been linked to their personal engagement with PA.[33] The results of our study identified two key factors associated with a well-oriented PA counseling practice: the HCP’s own involvement in physical activities and their work environment. Moreover, less experienced HCPs were less likely to adopt a well-oriented PA counseling approach. This may be due to their perception that promoting PA is not a core aspect of their role, with a focus instead on immediate health concerns, prognosis, and treatment options taking precedence.[35,36]

Regarding barriers to promoting PA, physicians identified personal factors, such as lack of time, as the primary reason for not recommending PA to patients. These findings align with previous research.[28] A similar number of physicians also cited patient-related factors, including patient expectations, and workplace issues, such as inadequate staff support, as obstacles to PA promotion. Additionally, healthcare professionals reported personal barriers, such as a busy lifestyle and lack of motivation, or a combination of these factors, as reasons for not engaging in regular exercise themselves. This may explain why only one-third of physicians are actively involved in PA promotion in community settings.

A key limitation of this study is that responses may be influenced by the specific patient populations that HCPs consult, depending on their specialty and the type of service they provide. The study was conducted among HCPs in a particular urban geographic area, so the results may not be generalizable to other settings. Additionally, self-reporting biases, such as recall inaccuracies or personal biases, could have influenced the study’s outcomes.

Conclusion

Our study highlighted several gaps in HCPs’ knowledge of PA, as evidenced by the relatively low frequency of correct responses to certain questions. The limited understanding of current PA recommendations underscores the need for enhanced training to update HCPs on the various forms and dosages of PA. To address this, more physicians should be encouraged to prescribe ‘green prescriptions’ for their patients, promoting PA as part of routine care. Furthermore, HCPs should be encouraged to actively engage in physical activity themselves as this could help increase community participation and serve as a role model for patients. Additionally, HCPs may consider referring patients to exercise specialists or other professionals who are better equipped to promote PA. Given the persistently low global rates of PA engagement, there is a clear need for large-scale interventions at both the public health and healthcare levels to foster broader participation in physical activity.

What is already know on this topic

• Physicians are a vital source of motivation and encouragement for their clients to be physically active.

• Physicians are not living up to their potential with regard to PA promotion.

What this study adds

• Physicians in this sample have inadequate knowledge on current recommendations regarding PA.

• Perceived personal, patient, and workplace factors may prevent physicians from PA prescriptions.

Authors’ contributions

Concept, design: EVR, SP

Definition of intellectual content: EVR, SG, SP

Literature search and data acquisition: SM

Manuscript preparation: SM

Data analysis: SM, EVR

Manuscript editing and manuscript review: EVR, SG, SP

All authors read and approved the final manuscript

The manuscript has been read and approved by all the authors, and the requirements for authorship as stated earlier in this document have been met, and that each author believes that the manuscript represents honest work.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.