An Investigation into GP’s Promotion, Prescription and Referral of Physical Activity for Obesity

Title: Ethics Supplementary Information

Table of Contents

Section A: Detailed study rationale………………………………………………..3

Section B: study aims and hypothesis……………………………………….…….5

Section C: Detailed Testing Protocol…………………………………….….…….6

Participant Information Sheet……………………………………….…….………9

Participant Informed Consent …………….………………………………….…..10

Participant Recruitment Email……………………………………………..….….13

Bibliography …………………………………………………………….….……14

Section A: Detailed study rationale

General practitioners (GP’s) are crucial influencers of patient behaviour and important initiators in the prevention of non-communicable disease. Therefore, they can inspire large amounts of the general population (NERF,2016, p.10). Patients identify GP’s as credible sources of information (Haddad et al, 2000). This is evident when it comes to the adoption of healthy lifestyle decisions as patients report their GP as their primary source of information in regards to healthier behaviours and PA (Oberg and Frank, 2009., Lobelo and De Quvodo,2016). A major predictor of whether GPs promote healthy lifestyle behaviours to their patients is whether they engage in a healthy lifestyle themselves (Oberg and Frank, 2009) This can be attributed to general practitioners’ reluctance and/or difficulty in recommending strategies that they themselves do not adhere to (McKenna, Naylor and McDowell, 1998). This is evident in a study by Keohane et al (2018) where it was discovered that 50% of Irish GP’s currently fail to reach the recommended physical activity levels (30 min per day, preferably 7 days a week). According to Fraser et al (2013) Patient’s perceptions of the health advice received during consultations are heavily influenced by the perceived health status of the GP. However, evidence suggests that promotion of PA in primary care can significantly increase PA levels in physically inactive populations. (Orrow et al., 2012., NICE,2006). However, In Ireland, there is a lack of information on the current status of physical activity promotion for obesity specifically in relation to General Practitioners.

There is mixed evidence on whether referral to community-based exercise programmes improves the rate of physical activity/Exercise participation (Orrow et al 2012., Murphy et al, 2012., Campbell et al, 2015., Williams et al,2007). However, In regards to obesity, community-based exercise programmes have been proven to produce reductions in weight (Clark et al, 2010). As stated above GP’s are vital influencers of patient behaviour and their referral to community-based programmes would be a crucial step to decrease the rates of obesity in Ireland (NERF,2016, p.10).

Obesity can be defined as excessive or abnormal fat accumulation that presents a risk to life, whereby a person with a BMI (Body mass index) of ≥30 is considered obese (WHO, 2018). Obesity is a major risk factor for depression (Roberts et al., 2003; Kasen et al., 2007; Luppino et al., 2010), and chronic diseases, including cardiovascular diseases (Poirier et al., 2006), diabetes (Algoblan, Alalfi and Khan, 2014) and cancer (Bhaskaran et al., 2014).  As a result, obesity is a significant contributing factor to mortality and morbidity (Pi-Sunyer, 2002., Lenz, Richter and Mühlhauser, 2009., Abdelaal, le Roux and Docherty, 2017). The increased rates of obesity associated with the last 100 years can be attributed to shifts in nutritional norms and patterns of sedentary behaviour (Popkin, Adair and Ng, 2012., Owen et al., 2010). According to Wiklund, (2016) PA has the potential to be a solution for this ever-growing crisis.

Physical inactivity accounts for approximately 5.3 million (9%) deaths globally per year and it is estimated that if physical inactivity was reduced 25%, more than 1.3 million deaths could be prevented annually (Lee et al., 2012). Physical activity can be defined as any bodily movement produced by skeletal muscles that require energy use (Alricsson, 2013). Many studies have shown a positive correlation between increased levels of physical activity and a reduction in obesity and related symptoms (Swift et al, 2014; Wiklund, 2016; Strasser, 2012). Along with a reduction of obesity related comorbidities physical activity also has been linked to a lessoning of depression symptoms and an increase in quality of life (Gill et al., 2013). The American College of Sports Medicine in a 2009 recommendation’ outlined strategies for weight loss and the prevention of weight gains. In which they stated that:

“Moderate-intensity PA of 150 to 250 min-wk. with an energy equivalent of 1200 to 2000 kcal-wk. seems sufficient to prevent weight gain greater than 3% in most adults” (Donnelly et al, 2009).

and for people suffering from obesity:

“PA that approximates 250 to 300 min-wk. (approximately 2000 kcal-wk.) of moderate intensity PA” (Donnelly et al, 2009).

This study hopes to identify if GP’s prescription of physical activity meets the guidelines set out be the ACSM.

With the current Irish health care system under significant pressure, physical activity would be an uncomplicated intervention with a strong evidence base that is easily accessible, free and non-discriminatory. In Ireland, the recommended levels of physical activity are 30 minutes of moderate activity 5 days per week (or 150mins/wk.) (Department of Health,2015, p.8). The Healthy Ireland Survey (2015) outlined that 32% of the Irish population are considered to be highly active with men being more (40%) active than women (24%), Thereby resulting in a physical inactivity rate of 68%. This high level of inactivity highlights the question of physical activity promotion and prescription within the Irish context and whether it meets the guidelines set by the ACSM.

section b: study aims and hypothesis

Study Aims:

The aim of this study is to examine what GP’s know about exercise promotion, prescription and referral of physical activity in relation to obesity in Ireland

Research Questions

Research questions are more applicable to this study. These include:

•Is the current level of physical activity promotion provided by GP’s’ sufficient for the prevention of obesity?

•Upon examination, do Irish GP’s prescribe physical activity in accordance with the most recent physical activity levels recommended by the American College of Sports Medicine? (2009 recommendations)

•Is referral of physical activity utilised as a tool to tackle obesity? If so, how?

•Do barriers exist when promoting, prescribing or referring physical activity to patients? If so what are they?

Section C: Detailed Testing Protocol

Testing Protocol Overview

Study design:

This study will be a cross-sectional analysis carried out via questionnaire. It will cover the topics of GP’s promotion, prescription and referral of physical activity for obesity in Ireland. Within will be a series of statements for which participants will agree or disagree along with some open-ended question based around promotion and prescription of PA.

Participants and setting:

The participants for this study will be general practitioners of all ages and gender who work and are located in Ireland with inclusion and exclusion criteria as follows:

Inclusion of participants:

Criteria for inclusion:

• General practitioners located in Ireland will be allowed to participate

Exclusion of participants:

Criteria for exclusion:

• General practitioners located outside of Ireland
• General practitioners who no longer work
• General practitioners in training

Recruitment:

Recruitment will be different for the electronic-based and paper-based questionnaire. The ICGP (Irish College of General Practitioners) is a national organisation that has access to many GP’s and general practices across the country. In order to recruit for the paper-based questionnaire, I will get in contact and request to attend some of their annual meetings. The ICGP also has contact details of many GP’s and general practitioners across the country. I will request that my questionnaire be distributed. Along with this, I will contact general practices in my local region and formally request their participation.

Questionnaire development:

The questionnaire will be both an electronically based (Created on survey monkey) and paper-based which will maximise the population size. Principles for the creation of the online survey will be inspired from Dillan et al, (1998), Edwards et al, (2009) and Kelly (2003) in regards to maximising response rates. The questionnaire will consist of multiple-choice, open-ended and statement-based questions and will take influence from questionnaires acquired from (Cantwell et al, 2017., O’Hanlon and Kennedy, 2014., Chatterjee et al., 2017,. Wheeler et al., 2017). The official questionnaire will take considerable time to create and will not be available for the ethics form. However, below are examples of questionnaire formats and style of questions that will be adapted to fit the purpose of this study:

• How familiar or unfamiliar are you with the 2015 physical activity recommendations provided by the department of health.

□Very Familiar

□Familiar

□Unfamiliar

□Very unfamiliar

• How do you promote physical activity to obese patients (Tick any that apply)?

□Verbal advice

□Pamphlets/ information sheets

□Refer onto physiotherapist or specialised exercise professionals

□Not applicable (I do not give advice)

□Other (Give description below)

• When prescribing physical activity to obese patients what are your general recommendations in terms of the following:

-Frequency (Number of sessions per week)

-Intensity (Light, moderate or vigorous)        

-Time (Minutes per session)                            

-Type (Aerobic or resistance training)            

-Not applicable (I do not give advice based off these headings). If so please state what recommendations you provide

• Discussing physical activity with obese patients is part of my role as a general practitioner.

□ Strongly agree

□ Agree

□ Neither agree nor disagree

□ Disagree

□ Strongly disagree

• Are there any perceived barriers that limit GP’s from discussing physical activity with their patients (Tick whichever apply)?

□Insufficient time

□Insufficient resources

□Lack of Knowledge of physical activity

□Patients are unlikely to adhere to advice

□Not my professional role

Statistical analysis:

When the questionnaires are received they will be quantitatively analysed using descriptive statistical methods as described by Elo and Kyngäs (2008). This will be analysed using the Crosstabs procedure within the Statistical Package for the Social Sciences (SPSS).