Provision of physical activity advice for patients with chronic diseases in Shenzhen, China

Chronic diseases are the leading causes of death worldwide [1]. In 1990, > 28 million global deaths were due to chronic disease [2], which increased to 39.5 million deaths in 2016 [3]. Furthermore, three quarters of all deaths attributed to chronic diseases occurred in low- and middle-income countries [4]. For instance, China, a middle-income country, chronic diseases accounted for 86.6% of mortality in 2015 [5]. This chronic disease pandemic imposes a great burden to the healthcare system and effective interventions are imperative to alleviate the current situation [6].

Physical activity (PA) reduces the incidence and complications of chronic diseases among adults and offers other multiple health benefits including the prevention and treatment of psychiatric diseases, neurological diseases, pulmonary diseases, diabetes, musculoskeletal disorders, and cancer [7, 8]. In contrast, physical inactivity is responsible for almost one sixth of the direct (medical) and indirect (non-medical) yearly costs for the management of chronic diseases [9]. Despite its health and economic benefits, participation in PA among Chinese adults remains low [10].

Physicians are influential sources of health information [11]. The Exercise is Medicine (EIM) initiative, developed by the American College of Sports Medicine (ACSM) and the American Medical Association (AMA), calls upon physicians to address the physical inactivity pandemic in patients with chronic diseases by assessing PA levels, providing PA counselling and referring patients to PA resources [12]. Numerous studies have evaluated PA promotion (i.e., prescription and referral) in primary health care setting, concluding that PA promotion delivered via healthcare providers in clinical settings is effective to increase patients’ PA levels and improve their health outcomes [13‐15].

Although PA promotion in clinical settings is effective, only a small number of patients received PA advice from their healthcare providers in western countries. It was reported that only 18.0, 32.8, and 56.0% of patients received PA advice from healthcare providers in Australia, Germany, and United States (U.S.), respectively [16‐18]. Reasons for not recommending PA to patients are often related to limited consultation time and insufficient education in EIM, competing priorities during clinical consultations, and perceiving a lack of motivation in patients [19]. Other studies examined patients’ characteristics associated with the receipt of PA advice. In Australia, patients with a lower physical and mental health-related quality of life score and/or with chronic diseases were more likely to receive PA advice [16]. Similarly, in U.S., patients who were male, non-married, lower-educated, Spanish-speaking, and with no chronic conditions were less likely to receive PA advice [20].

The prevalence of PA advice and its associated patients’ characteristics are understudied in Eastern countries like China. Furthermore, only a few studies investigated the contents of PA advice being provided to patients [16, 21, 22]. Specific contents of PA advice should contain exercise type, intensity, frequency and duration of activities. PA advice lacking specific contents may limit the health impact to patients [16]. Therefore, the present study aimed to: 1) investigate the prevalence of PA advice in patients with chronic diseases in China (primary outcome); 2) describe the content of PA advice that patients with chronic disease receive and examine whether such PA advice was adequate as defined by the current PA guideline (secondary outcome) [23]; and 3) identify patients’ factors that were associated with the receipt of PA advice (secondary outcome).

Out of 670 patients contacted, 187 patients were excluded due to not meeting inclusion criteria, not have sufficient time for completing the questionnaire, or not interested in the survey (Fig. 1). Out of the 483 patients who completed the survey, 29 were further excluded for incomplete information, resulting in a final sample size of 454 for analysis (response rate = 67.8%).

The mean age of the respondents (N = 454) was 47.0 ± 14.4 years-old. A majority of respondents were women (51.3%, n = 229) and were employed (69.0%, n = 298). Those who completed post-secondary education accounted for 47.7% (n = 215) whereas secondary school 32.6% (n = 147). A total of 19.4% (n = 88) and 26.2% (n = 119) of the respondents were classified as overweight and obese, respectively. Furthermore, 18.3% (n = 76) of the respondents met PA guidelines within the last 6 months (Table 1).

The present study investigated the prevalence of PA advice received by patients with chronic diseases, and key factors associated with the provision of this advice. To address limitations in previous studies, we also report on the content of the PA advice being given by physicians, which, to our knowledge, has not been previously examined in China.

A main finding of our study is that less than one-fifth of the patients (19.2%) reported receiving PA advice from their physician. Among them, only two patients received full-details of PA advice from their physicians. This prevalence of PA advice is lower than that reported in other countries, where a total of 31.0%, 32.8%, and 57.7% of patients reported receiving PA advice in United Kingdom (UK), Germany and U.S., respectively [17, 36, 37]. The heterogeneous questions used in these studies to quantify the level of PA advice may be responsible for these varying outcomes. In several studies, participants were commonly asked ‘has a healthcare provider advised you to exercise within the past 12 months’ [11, 38, 39]; whereas in the current study, patients were asked whether they were advised to exercise by their physicians. It is possible that other healthcare providers (e.g., nurses) may have provided our patients with PA advice during their hospital visits. Moreover, the low prevalence of giving PA advice may reflect the fact that exercise prescription in clinical setting has not yet receive much attention in China. Unlike the Green Prescription (GRx) project of New Zealand and the National Physical Activity Plan of U.S. [40, 41], which were well-promoted since 1998 and 2007, respectively, the importance of exercise advice in clinical setting was recently being emphasized in the “Healthy China 2030 Plan” [42].

Perhaps one encouraging result from this study, was that nearly 60% of respondents (57.5%, n = 50/87, Fig. 2) indicated willingness to follow the physician’s PA advice if provided, versus only 9.2% (n = 8/87) indicated not willing to follow physician’s PA advice. Such a large gap suggested that physician’s PA advice is a powerful channel to motivate PA participation among patients. Similar to previous ACSM survey reported that 65% of American who visited doctors indicated willingness to follow PA advice [43], which was considered much higher than most other exercise promotion campaigns. However, the finding need to be interpreted with cautious, as there may be social desirability bias. It is unfortunate that only 19.2% of the physicians in China prescribed PA advice, there may be a high chance of success (i.e. increase PA practice) if more physicians in China learned and are willing to prescribe PA to their patients.

The present study revealed that patients who were male were more likely to receive PA advice from their physician. This finding is consistent with previous studies involving adults of different ages [17, 30, 44]. It was reported that the prevalence of mortality from chronic diseases and obesity in Chinese men was much higher than women, it is logical that physicians in China tended to provide more suggestions, such as PA advice, to men more than women [45, 46]. Another large scale PA survey on Chinese community age 35–74 years revealed that the prevalence of leisure time PA in Chinese men, both from rural and urban areas, were much higher than women (OR = 1.16 to 2.26, p < .001 to .05, across various age groups) [47], hence physicians may have stronger confidence and motivation to prescribe PA for male patients due to the higher readiness in male patients.

Association between employment status and receiving PA advice was not found in American patients [18, 21, 48]. In contrast, unemployed patients in the current study were less likely to receive PA advice from their physicians. Reason for the impact of employment status in Chinese patients on receiving PA advice is unclear, however, it may be related to the income status. A recent review suggests that higher income is likely to induce Chinese individuals to utilize healthcare services including access to PA facilities (e.g., health club membership) [49], unemployed Chinese may have limited resource to access PA due to lower social economic status (SES). Physicians may therefore hesitate to provide PA advice to patients with lower SES. Further study is needed to verify the association between SES and physician’s advice on PA.

Lastly, the present study revealed that meeting PA guidelines within the last 6 months was negatively associated with receiving PA advice. This result is consistent with several other studies, that suggest sedentary patients are more likely to receive PA advice [38, 50, 51]. These findings suggest that physicians are promoting PA to patients who may benefit most from the recommendation [37, 52]. Conversely, in Brazil, patients reported having leisure-time PA were more likely to receive PA advice [53, 54]. Similarly, patients with higher PA levels tend to initiate more conversations with their providers about PA compared to those with poorer lifestyle habits [55].

We found that only 9.2% patients reported receiving complete PA advice (including frequency, intensity, duration and type) from their physicians. The lack of completed PA guidance may suggest that Chinese physicians do not receive sufficient training on exercise prescription. Previous studies suggest that healthcare providers may feel uncomfortable or lack confidence in giving specific rather than general advice [56, 57]. Other barriers to providing specific advice may include limited consultations time, lacking resources, or negative attitude toward the effectiveness of PA promotion [16]. Given the greater effectiveness of detailed PA recommendations, frequency, intensity, duration, and type should be incorporated into PA promotion practices [58].

Findings from the present study showed that a majority of patients (25.0%) were advised to participate in walking, which is generally consistent with previous studies [22, 29]. This finding may be related to the time constraints of the physicians. In China, physicians typically see up to 40 patients per day, necessitating that PA advice be quick and easily understood [59]. Instruction on walking can be given fairly quickly without much explanation in a busy clinical setting [21]. Besides walking, physicians should also learn other effective types of physical activities for patients such as resistance training and aquatic exercise.

This is the first study to investigate the prevalence of PA advice provision for patients with chronic diseases in China. The receipt of PA advice was captured at the completion of the clinic visit, reducing the risk of recall bias. Furthermore, the individual components of the PA advice were examined in this study, providing a glimpse into the type and quality of PA advice being provided to patients by their physicians.

However, there are some limitations with this study that deserve mention. The results of the study are based on self-reported data, which may lead to an overestimation of the prevalence rates of PA advice due to social desirability bias. Additionally, there may be other factors, not captured by this survey, that influence the receipt of PA advice, such as characteristics of the healthcare providers or the self-rated health status of the patients [30]. Only the provision of physicians’ advice collected from the out-patient clinics of the three major hospitals in Shenzhen China were involved, the total number of physicians involved was not known and was estimated at around 76 physicians according to the hospitals’ website. Cautious should be made as results we discussed only applied to these out-patient physicians. Another limitation is that the medical condition (i.e., acute or severe health issues) of the patients may make PA advice inappropriate, leading to an underestimation of correctly provided PA advice. Further, only three general hospitals in Shenzhen were selected may limit the external validity of our results. However, the included hospitals were major hospitals that provide services to majority of patients with various health conditions. The health services provided were similar to other general hospitals in Shenzhen, China. It is important to note that the objective of the study was to explore the provision of PA advice given by physicians from the perspective of patients, the actual practice and attitude of providing PA advice from the physician’s perspective is unknown and separate investigation is needed.

Only a small proportion of patients are receiving PA advice and guidance from their physicians in healthcare settings in Shenzhen, China. In patients who received PA advice, frequency, intensity, duration, and type of activity were not commonly provided. Although patients who are most likely to benefit from PA reported receiving advice at a greater rate, there is still much room for improvement [18]. Comprehensive initiatives, such as EIM, can provide reference and guidance to improve the PA counselling practices of physicians in healthcare settings.