Our results show that when clinicians addressed physical activity, their efforts were characterized by an emphasis on two As-- Asking and Advising -- with relatively little Agreement (i.e., collaborative goal-setting), Assistance (i.e., with identifying and overcoming barriers) or Arrangements to help the patient follow through with a physical activity program. There were seldom assessments of patients’ willingness to change behavior, and few recommendations were given regarding community resources. These findings are similar to patterns of use of the 5A’s in tobacco counseling 17–19
and in other studies of diet and exercise counseling in underserved populations.
The finding that the topic of physical activity was raised 41% of the time was somewhat higher than previously reported in studies of underserved populations. Yet the question of how much counseling is sufficient—and by whom— is an area of active debate. If we consider that the majority of our participants (78%) were not meeting recommended levels of activity and/or were either overweight or obese (75%), then one could argue that the observed rate of counseling was inadequate to achieve national goals. In all likelihood, a wide variety of strategies in the health care, mass media, policy, and school settings are needed. Yet intervention studies are also needed to identify efficacy of the 5As in physical activity, followed by large practical clinical trials test the effects of the As on physical activity change in primary care settings.
Although primary care clinicians are in a key position to promote physical activity, this task is challenging in a time-pressured environment with competing priorities, systems barriers, and limited resources.10
These issues are magnified for clinicians working with underserved populations. Nevertheless, we found no evidence that discussion of a large number of concerns diminished the likelihood of physical activity counseling; in fact, the reverse may be true. Although visits in which activity was discussed were longer, they also included nearly twice as many patient concerns. A larger study would be needed to assess the relative contribution of number of concerns, demographics, obesity, and race to the likelihood of discussing physical activity.
Previous work has shown that primary care physicians spend an average of about 55 seconds per visit – though the time varies widely- providing diet and/or exercise advice to patients. Not surprisingly, less than half of patients receiving such advice were able to recall what their physician had said. In one study, an extra minute in the encounter discussing these issues was associated with a 2.5-fold increase in patient recall.20
Perhaps, if more emphasis were placed on strategies or systems to support mutual agreement, goal setting, and specific assistance, clinicians could make better use of their limited time and see improved recall and/or positive behavioral changes in their patients.
Little is known about how the 5As model changes patient motivation for physical activity, but based on specific features of the 5As— providing assistance, intra-treatment support, access to information about available community resources, and establishing a clear plan for follow-up—seem likely to motivate patients or result in change of physical activity behaviors 21, 22
. Some of the As (albeit the least frequently observed ones—Agree, Assist, and Arrange) aim to set goals collaboratively based on the patient’s willingness to change. If patients do not want to change, emphasis may be more appropriately placed on helping the patient connect their behavior to their health; in this way, Asking or Advising may reinforce patients’ responsibility for changing their activity if they believe it will preserve their health. This overlaps conceptually with other behavioral models23–26
that promote patient activation to become self-managers more explicitly by providing them with assistance in problem-solving skills.
Despite the multiple barriers to the delivery of high quality counseling, several lines of evidence support a role for expanded physician counseling for physical activity. Randomized clinical trials have shown that intensive 27
and brief 21
physician counseling have been shown to increase physical activity levels in patients, though data on long term outcomes are lacking. The Activity Counseling Trial found that when physicians were taught how to Ask and Advise patients to promote physical activity and were supported by ancillary staff and office-based systems to provide the other As, they were able to use the model efficiently and achieve a high level of satisfaction from providing it.21
The tobacco literature has determined that the 5As counseling is three times more likely to occur if clinics have support systems to remind physicians to do the counseling.28, 29
Implementation of office systems to identify sedentary individuals and facilitate the provision of support materials (e.g, chart note templates, identification systems for those at risk, and/or community resources lists) might increase 5As counseling for physical activity.
Primary care physicians have access to a large portion of the US population; 80% of adults visit a physician during a one-year period, and most of these visits are with primary care physicians.30
Patients are often more vulnerable or concerned about their health when visiting a physician and as such are more likely to be receptive and responsive to the information they receive.31
Patients find physician counseling useful and associated with higher satisfaction with clinical care.32
Patients who are advised by a physician to lose weight, quit smoking, eat less fat, and/or become physically active are significantly more likely to attempt to change these behaviors than those who are not advised. 33–35
Although data from underserved populations are lacking, one study showed that low-income patients with whom physical activity was discussed were significantly more likely to attempt behavior change than high-income patients.36
Some data suggest that the last two As—Assist and Arrange—may be better achieved by collaboration with allied health educators, community programs, or other health care staff resources, given the competing demands that primary care clinicians face.6,15
Because strong empirical data to support this —especially for underserved populations— are lacking, studies should address the role of ancillary professionals in delivery of counseling and the effect on activity outcomes.
Interestingly, only one audiorecorded discussion with four of the 5As was patient-initiated. While very preliminary, this observation suggests that patient-initiated discussion about physical activity may be more likely to lead to in-depth conversation (defined as more As covered); thus, clinician training plus patient activation may yield more discussion about physical activity.
Our study has several limitations. First, this study was designed to collect a preliminary set of observations to show how the 5As occur and was conducted at two community health centers. We thus had a small sample size in a narrowly defined underserved population which limits generalizability. Because we used a cross-sectional design, we were unable to assess clinician-patient communication about physical activity over time. We attempted to address this short-coming by incorporating questions about previous communication in the post-visit patient survey, but recall may be biased, especially given the discordance we saw in patient recall compared with actual observed communication. It is possible that the three least commonly observed As (Agree, Assist, and or Arrange) require more patient involvement and dialogue and thus are more time- and effort-intensive for the clinician; therefore we would not have captured these as frequently. We did not include the clinician’s perspective on recall or adequacy of communication about physical activity.
Future studies should compare the effects of physician counseling, involvement of other health professionals, and patient activation or prompting of the topic on physical activity outcomes in underserved populations. Only longitudinal studies can measure communication interventions in the “real-world setting” over time, the dose-response effect of physical activity discussions, the effect of continuity of care on the 5As, and to test whether 5A-derived communication interventions result in improved patient behaviors and/or health status.