Findings from our analyses support the need for more detailed and more frequent exercise counseling (including follow-up) by rural primary care physicians. In our study, physicians’ counsel was most effective when presented as a plan or prescription that was followed up with periodic inquiries. Patients’ initiation and maintenance of physical activity were significantly associated with physicians’ follow-up of exercise plans. Those who were merely “advised” to exercise more were less likely to meet physical activity recommendations. This illustrates the importance of detailed physician counseling over simple advice to exercise more.
Over 80% of normal-weight individuals, who comprised more than 40% of the sample, reported that their physician had not suggested they exercise more. There are many possible explanations for these reports. Rural populations are relatively isolated and slow to adopt changes. Thus patients may be unaware of new recommendations for physical activity and their significant benefit for disease prevention, and therefore unlikely to discuss such matters with their physician. Physicians also may perceive normal-weight individuals as healthy regardless of their actual health behaviors. On the other hand, 1 study showed that patients with disease risk factors (eg, high cholesterol, elevated BMI) were more likely to be counseled on preventive health behaviors.37
With overweight patients, who are at increased risk of developing chronic diseases, physician counseling strengthened their resolve significantly. Overweight individuals who received directives from their physician (a plan to increase exercise and subsequent follow-up) were 5½ times more likely to be physically active than those who received less counseling.
Obese patients did not receive counseling as often as overweight patients, or benefit from it as much when given, perhaps due to the presence of comorbidities. However, many studies show that regardless of BMI status, physical activity reduces all-cause mortality.38-41
Interestingly, our results showed that seeing a doctor less than once a year was associated with increases in physical activity. Patients who see their physician once a year may be going for annual wellness exams, providing more opportunity to discuss health behavior.
Overall, patients are counseled less often/thoroughly than needed. Our findings agree with those of a previous statewide study that used Missouri BRFSS data to assess the extent to which overweight or physically inactive people received advice from their physicians concerning these risk factors.42 Although most Missouri residents who were overweight or inactive reported seeing their physician within the past year, less than half said their doctors advised them to alter their risk behavior(s).42 Our findings are also consistent with a recent nationwide study by Ma and colleagues that focused on adults with obesity, diabetes, or other related conditions.43 Participants from across the United States reported receiving counseling for physical activity in <30% of visits to private physician offices and hospital outpatient departments.43
Our study was unique in that it examined a tri-state sample of the nation’s rural population for both evidence and effectiveness of physician counseling. It is one of very few studies using a longitudinal design, strengthening the associations found. Causality is limited, however, due to the multifaceted design of the intervention program from which the data were obtained. Future research should evaluate varying degrees of physician counseling and other indirect measures of its impact.
Limitations of the study
Our observational cohort design and the large, randomly selected sample resulted in fewer limitations than were seen with previous similar studies. However, our study had several limitations.
- Recall bias may be present. We assessed counseling with patient memory alone; we made no attempts to interview physicians or audit charts.
- Self-reported height and weight data tend to underestimate the prevalence of obesity.44,45 Resultant misclassification of overweight subjects as being at normal weight could have skewed the stratified analysis.
- The external validity of the physician-counseling questions we used has not been formally confirmed. Given the demographics of the analytic sample (ie, mostly female, white, low income), it would be appropriate to generalize our findings only to similar, rural populations.
Barriers to counseling, and means of removing them
Primary care physicians—rural or urban—are no doubt aware of the health risks associated with physical inactivity. However, the barriers physicians face in counseling at-risk patients overwhelm most efforts. These barriers include lack of time, inadequate provider counseling skills and training, perceived ineffectiveness and nonadherence, patient comorbidities, and lack of organizational support and reimbursement.46-48