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Open Access Highly Accessed Research article

Physical activity counseling in primary health care in Brazil: a national study on prevalence and associated factors

Alex Antonio Florindo1*, Gregore Iven Mielke2, Grace Angélica de Oliveira Gomes3, Luiz Roberto Ramos4, Mário Maia Bracco5, Diana C Parra6, Eduardo J Simoes7, Felipe Lobelo8 and Pedro Curi Hallal29

Author Affiliations

1 School of Arts, Sciences and Humanities, University of Sao Paulo, São Paulo, SP, Brazil

2 Postgraduate Program in Epidemiology, Federal University of Pelotas, Pelotas, RS, Brazil

3 Gerontology Department, Federal University of Sao Carlos, São Carlos, SP, Brazil

4 Department of Preventive Medicine, Federal University of Sao Paulo, São Paulo, SP, Brazil

5 Hospital Israelita Albert Einstein, São Paulo, SP, Brazil

6 Prevention Research Center in St. Louis, George Warren Brown School of Social Work, Washington University in St. Louis, St. Louis, Missouri, USA

7 School of Medicine, Department of Health Management and Informatics at University of Missouri, Columbia, Missouri, USA

8 Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, Centers For Disease Control and Prevention, Atlanta, GA, Georgia

9 School of Physical Education, Federal University of Pelotas, Pelotas, RS, Brazil

For all author emails, please log on.

BMC Public Health 2013, 13:794  doi:10.1186/1471-2458-13-794

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2458/13/794


Received:1 May 2013
Accepted:23 August 2013
Published:31 August 2013

© 2013 Florindo et al.; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background

The aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care in Brazil.

Methods

A phone survey was carried out in 2011 with professionals working in primary health care in Brazil. The target sample consisted of 1,600 randomly selected primary care units covering all regions of the country. We successfully interviewed 529 professionals within the sampled units; 182 physicians and 347 nurses. The overall response rate was 49.6%. Multivariable logistic regression was used to estimate correlates of counseling in the whole sample and separately for physicians and nurses.

Results

The prevalence of regular physical activity counseling for at least six months was 68.9% (95% CI 64.9; 72.8) and was significantly higher among physicians compared to nurses (p < 0.05). Most professionals (93.2%) interviewed were unfamiliar with current physical activity recommendations for health. In the adjusted analysis, physical activity counseling was more frequent among those who report assessing patient’s physical activity (OR = 2.16; 95% CI 1.41; 3.29), those reporting that lack of time was not a barrier for counseling (OR = 0.62 95% CI 0.42-0.93), those who felt prepared to provide physical activity counseling (OR = 2.34; 95% CI 1.50-3.66), and those working at primary care units offering physical activity programs for patients (OR = 2.06; 95% CI 1.33-3.20). In the stratified analysis, only assessing patient’s physical activity was a significant correlate among physicians whereas assessing patient’s physical activity, feeling prepared to provide counseling and working in units with physical activity interventions were significant correlates among nurses.

Conclusions

Physicians and nurses deemed physical activity counseling of great importance in primary health care in Brazil. However, in order to increase the quality of counseling and the number of professionals engaging in this activity, these health teams require greater knowledge about physical activity (global recommendations for health) as well as training on the application of instruments for assessing physical activity. Moreover, sufficient time must be allowed during consultations for the counseling process, and physical activity promotion programs should be implemented within the primary health care units.

Keywords:
Physical activity promotion; Physical activity counseling; Primary health care; Physicians; Nurses; Knowledge; Associated factors

Background

Physical activity counseling for patients in primary care settings is an important component of health promotion [1]. It represents a brief intervention that can be used by health professionals with patients, ranging from basic conversation to more personalized discussion focusing on behavioral changes [2]. Randomized controlled trials have shown that adults of both sexes can increase their physical activity and fitness after receiving counseling in primary health care [3-9]. In particular, office-based screening of activity levels and physical activity counseling coupled with regular follow-ups and community support and referrals for physical activity, have been proven effective in increasing physical activity levels [10,11]. In addition, the cost of integrating physical activity counseling and referral schemes into primary health care teams has been found feasible and cost-effective [12,13].

Given the benefits of physical activity counseling for public health, an increasing number of surveys have been conducted, mostly in high-income countries, to evaluate its prevalence and correlates in primary health care settings [14-19]. These studies showed that the prevalence of counseling ranged from 19% to 76% [14,16-18]. Factors found to be consistently associated with physical activity counseling include feeling prepared to advise patients on physical activity, having sufficient time during consultation to provide counseling and the presence of physical inactivity related co-morbidities among patients [14-17]. In addition, a systematic review showed that the two main barriers to physical activity counseling perceived by primary care professionals were lack of time and limited knowledge [20].

There is currently a dearth of studies exploring the prevalence of physical activity counseling and its correlates in representative samples of primary care providers from low and middle income countries such as Brazil. This is particularly important because 80% of deaths from non-communicable diseases occurs in low and middle income countries [21]. The situation in Brazil is particularly interesting for studies of this type. The country has a universal health care system, on which 70% to 75% of the national population depends [22]. Therefore, the potential health and economic impact of universal, standardized physical activity counseling and referral systems is substantial. Hence, the aim of this study was to determine the prevalence and correlates of physical activity counseling among physicians and nurses working in primary health care settings in Brazil.

Methods

This cross-sectional study was conducted as part of the second cycle of Project GUIA (Guide for Useful Interventions for Activity in Brazil and Latin America). The main goal of Project GUIA is to examine and promote evidence-based strategies to increase physical activity in Brazil and Latin America [23]. Further information can be found at http://www.projectguia.org/ webcite.

A telephone survey was carried out to assess knowledge, opinions and practices regarding promotion of physical activity among health care professionals working in primary health care units in Brazil. In the survey, interviewees included units’ coordinators, physicians, nurses and community health workers. The primary sampling units comprised the 42,486 primary health care facilities of the country, based on the Ministry of Health registry. Within these units, we systematically sampled 1,600 for the survey; these units covered all regions of the country. Within each sampled primary health care unit, we interviewed the coordinator and one health professional (physician, nurse or community health worker). In order to do so, we targeted the coordinator and the physician in unit 1, the coordinator and the nurse in unit 2 and the coordinator and the community health worker in unit 3, for example, so that the total target sample included 1,600 coordinators, 534 physicians, 533 nurses and 533 community health workers. The last sampling unit was the specific health professional to be interviewed, because some units would have more than one physician, nurse or community health worker. In such cases, we asked the coordinator to list all physicians (nurses or community health workers) working in that unit and sampled one of them using a table with random numbers.

The present analysis was based on data from physicians and nurses only, for a total of 529 professionals (182 physicians and 347 nurses) interviewed. The overall response rate was 49.6% across all professionals eligible (34.1% for physicians and 65.1% for nurses). We opted not to use data from community health workers because the nature of their work is different from the other professionals, particularly due to the fact that instead of staying at the unit, community health workers spend most of their days visiting patients in their homes and prompting them to visit the unit whenever needed.

Data collection was carried out between January and July 2011. The questionnaires were administered over the telephone by a team of six previously trained interviewers. Calls were made to the coordinator of each unit. If he/she was unavailable, we tried to schedule the call for another hour or day. After interviewing the coordinator, we then sampled one health professional for his/her interview. Interviews lasted, on average, 40 minutes. The Ministry of Health sent a letter to the sampled units in order to encourage their participation in the survey.

Questionnaires

Physical activity counseling was assessed by one question containing six response categories: “(1) I do not recommend physical activity and do not intend to start doing so; (2) I do not recommend physical activity, but I am thinking about starting to do so; (3) I sometimes recommend physical activity but do not do so on a regular basis; (4) I regularly recommend physical activity, but have started doing so only recently; (5) I’ve been regularly recommending physical activity for over 6 months; (6) I used to recommend physical activity, but no longer do so”. The questions used to assess professionals’ opinions regarding counseling, instruments used for patient’s physical activity assessment and knowledge about physical activity are presented in (Table 1).

Table 1. Questionnaire used for data collection

Data concerning the availability of free physical activity classes or physical activity programs for patients in the primary health care units’ catching area was obtained by administering a separate questionnaire to unit coordinators. Social and demographic characteristics of respondents were assessed including age, skin color, sex, educational level and variables related to professional practice at the health unit (number of hours per day spent on the unit, number of patients seen per week, and time working at the specific unit).

Data analysis

We initially describe the counseling practices of health professionals using the six categories of response. For the analysis of correlates, providers who reported having regularly recommended physical activity for over six months were considered to provide counseling to patients. The prevalence of physical activity counseling was compared across categories of the independent variables using chi-square tests. Correlates found to be significantly associated (p < 0.05) with physical activity counseling in the unadjusted analyses were included in logistic regression models. Adjustment variables used were sex, age, duration of employment health professional (Physicians or Nurses) and number of patients seen per week. We then repeated the analyses separately for physicians and nurses. All analyses were run using SPSS 15.0.

Human subjects

The project was approved by the Research Ethics Committee of the Physical Education School of the Federal University of Pelotas.

Results

Nursing professionals (N = 347) were predominantly women (84.7%), had white skin color (62.0%) and a mean age of 32.6 years (SD 8.5). Most of them (88.5%) held no degree in public health. In terms of work experience, 93.3% graduated less than 10 years ago, and 81.8% worked for fewer than five years in primary health care units. Most nurses (77.2%) had a working week of 40 hours or longer. Physicians (N = 182) were predominantly men (56.6%), white (67.6%) and with a mean age of 40.5 years (SD 12.8). Again, most (90.7%) had no degree in public health. In terms of work experience, 65.2% graduated less than 10 years ago, and 81.7% worked for fewer than five years in primary health care units. Just over half (54.4%) had a working week of 40 hours or longer (Table 2).

Table 2. Socio-demographic characteristics of the physicians and nurses interviewed

Very few professionals (0.3% of the nurses and none physicians) reported not recommending physical activity at all and having no plan to start doing so. Exactly the same proportions were true for the category “I do not recommend physical activity, but plan to start doing so”. The proportion of health professionals reporting to recommend physical activity sometimes, but not on a regular basis, was 21.8% in the whole sample, 12.2% among physicians and 26.9% among nurses. The proportions reporting to have started to recommend physical activity recently were 8.5% in the whole sample, 6.1% among physicians and 9.8% among nurses. The prevalence of regular physical activity counseling for at least six months were 68.9% (95%CI 64.9; 72.8) in the entire sample, 81.2% among physicians and 62.4% among nurses (Table 3). Only 0.4% of the professionals reported recommending physical activity regularly in the past, but not currently.

Table 3. Prevalence, knowledge and opinions of health professionals with regards to physical activity counseling, Brazil, 2011

The majority of professionals reported assessing the physical activity of patients and considered the promotion of physical activity at the health units to be both feasible and a priority. Regarding the methods used for assessing physical activity of patients, most (77.4%) reported using general questions, while only 10.7% employed standardized questionnaires. Lack of time and of facilities for patient’s to engage in physical activity were the main barriers reported for providing physical activity counseling. Despite feeling prepared to provide counseling on physical activity, few primary care professionals answered correctly questions on physical activity recommendations for health (Table 3).

All the variables significantly associated with physical activity counseling in the bivariate analyses (Table 3) remained significant in the logistic regression models (Table 4), including conducting physical activity assessment on patients, feeling prepared to advise about physical activity, reporting lack of time as a barrier, and working on units offering physical activity programs for patients.

Table 4. Variables associated with regular counseling for physical activity among health professionals, Brazil, 2011

In Table 4, we present the statistically significant results of physical activity counseling associations of with variables selected in Table 3 for three groups of respondents: the combined responses of physicians and nurses (health professionals) and stratified for professional group. Physical activity assessment was a significant correlate among health professionals, physicians and nurses. Feeling prepared to advise about physical activity, and working in health care units offering physical activity programs for patients were significant predictors of physical activity counseling among health professionals and nurses. Stating that lack of time was a barrier for physical activity counseling decreased the odds of physical activity counseling among health professionals and nurses.

Finally, the higher the number of patients attended weekly, the higher the prevalence of reported lack of time as a barrier for physical activity counseling (Figure 1).

thumbnailFigure 1. Prevalence of the report of lack of time as a barrier for physical activity counseling according to the number of patients seen by health professionals on a weekly basis.

Discussion

Health professionals who reported assessing patients’ physical activity levels, who did not feel that lack of time was a barrier for them to counsel, those who felt well prepared to advise patients about physical activity, and who worked in health units offering physical activity programs for patients, had a greater likelihood of providing physical activity counseling in primary health care settings in Brazil. Assessing physical activity of patients was a significant correlate among health professionals, physicians and nurses. In addition, overall rates of physical activity counseling were high, with 8 out of 10 physicians and 6 out of 10 nurses reporting regular physical activity counseling to patients. However, in spite of these high counseling rates, their knowledge about physical activity recommendations was found to be relatively low.

In our sample, physicians were more likely than nurses to advice patients about physical activity, differently from a survey involving primary health care physicians and nurses in Scotland [14]. The Scottish study, although reporting a similar overall prevalence of physical activity counseling (76%), found rates of 62% among physicians and 90% among nurses. Another study with a sample of physicians in Estonia found that 94% reported advising patients with chronic diseases about physical activity [24]. Another survey among North-American nurses [25] found a prevalence of regular physical activity counseling of 57%. The prevalence of physical activity counseling reported here, in Scotland and Estonia were greater than the rates reported in both the U.S. and South Korea [17].

Our results are extremely important for the Brazilian scenario. The universal public health system in Brazil is the source of health care for 70 to 75% of the population. Therefore, physical activity promotion in this setting is highly viable, since health professionals can act as advocates for the promotion of healthy behaviors. Although there are no written specific Brazilian physical activity guidelines focused on health promotion, physical activity current recommendations have been met in other guidelines of chronic diseases published by the Ministry of Health. This situation is different from other places. For example, in the United States, physical activity counseling by primary health care providers constitutes a national public health objective [10].

Mirroring the results of the present study, a South Korean study showed that physicians who felt better prepared were more likely to promote physical activity [17]. However, this finding should be interpreted with caution, because out of the health professionals who felt prepared to provide physical activity counseling in the present study, most failed to correctly identify current guidelines for physical activity recommendations. In addition, no association was found between feeling prepared to counsel on physical activity and correctly identifying recommendations for physical activity. Similarly, the Scottish study also showed that few professionals had adequate knowledge to counsel about physical activity with regard to intensity and duration of exercise [14]. This highlights an urgent need for training of primary care professionals around the world in an effort to improve their level of knowledge regarding physical activity guidelines.

In this study, routine assessment of patient’s physical activity was associated with a greater likelihood of providing physical activity counseling. Although we found no other studies reporting this association, it is clear that such assessment reflects a more organized and concerted effort towards regular physical activity counseling. Nevertheless, a large proportion of primary health care professionals have not been adequately trained to assess physical activity. A survey conducted in the U.S. showed that most physicians used general questions to assess physical activity, while only 7% applied standardized questionnaires [18]. A similar result was found in the present study, where only 10.7% of health professionals reported using standardized instruments. A qualitative study carried out among primary care professionals in Australia showed that physical activity assessment is only routinely conducted in the presence of disease or risk factors [26]. This is important because it suggests that the implementation of a comprehensive program of physical activity counseling, including a standard initial assessment for all users is likely to have a significant impact on the promotion of physical activity. For example, physical activity “vital signs” in electronic medical records have been validated in clinical settings [27].

Health care professionals interviewed in the present study who did not report lack of time as a barrier were more likely to regularly counsel patients about physical activity. Physicians and nurses from both Scotland and South Africa cited lack of time as a barrier to providing advice on physical activity [14,15], and similar results were obtained in a recent systematic review of perceptions of physical activity counseling in clinical settings [20]. One of the most notable findings of the present study was that, as the weekly patient case load rose, the prevalence of reporting lack of time for regular physical activity counseling as a barrier also increased, particularly among physicians. This finding suggests that seeing an excessive number of patients per week may jeopardize health professionals’ work in Brazil’s primary health care system.

A greater likelihood of providing physical activity counseling was observed among health professionals from units that offered physical activity classes or physical activity programs for users. Therefore, it is important to discuss the implementation of an integrated network for the promotion of physical activity in the public health system. A study in elderly individuals from a low socioeconomic community in São Paulo showed that their perception of having primary health care units in their immediate neighborhood was associated with a greater likelihood of participation in leisure-time physical activity [28]. A qualitative study on factors influencing physicians and nurses in their management of risk factors for chronic disease, identified the importance of having infrastructure available to engage in physical activity, given that the advice is generally accompanied by encouragement to join structured exercise programs at gyms, clubs and health units [26]. Therefore, actions promoting physical activity interlinked with primary health care are essential. The ‘Academia da Cidade’ program implemented in the cities of Recife and Aracaju exemplifies this integration whereby centers and facilities to engage in physical activity had direct links with primary health care units [29,30].

A potential limitation of this study may have been overestimation of reported physical activity counseling by Brazilian health professionals, given that levels were higher than those obtained for primary care physicians in both the U.S. (30-50%) [19] and South Korea (51.1%)[17]. However, prevalence levels were similar to those of a cohort of physicians and nurses in Scotland (76% prevalence)[14] and the family physicians in Estonia (94% prevalence) [24]. In a recently published study among patients attending primary health care units of Southern and Northeastern Brazil, 28.9% of adults and 38.9% of older adults reported having received counseling for physical activity [31]. Another survey among German older adults showed that 32.8% of patients interviewed had been given advice on physical activity by physician and nurse practitioners [32]. These data indicate that the prevalence of physical activity counseling reported by health professionals differs from those reported by patients. However, it is important to take into account that patients’ self-reports can be affected by their understanding on the meaning of physical activity advice given by health professionals, leading to potential underestimates [33]. A population-based epidemiological survey of an adult urban population in Southern Brazil showed that the prevalence of physical activity counseling was 56.2%, but counseling was mostly done by physicians (92.5%) [34]. It is important to highlight that physical activity promotion is a governmental priority in Brazil. Since the implementation of the Health Promotion Policy in 2006, cities have been funded to develop physical activity interventions.

Another limitation of our study is the low response rate for physicians, which does reduce our statistical power for the analyses stratified by occupation. The study with South Korean physicians had a similar response rate (38.0%) [17] but other surveys on physical activity counseling among physicians from the U. S. and Scotland had higher response rates [14,18]. Notably however, some of the characteristics of the physicians interviewed in the present study were similar to those of physicians working within the primary health care in Brazil. A survey carried out on physicians working under the Family Health Strategy showed that the majority of health professionals were 40 years of age or younger (60%), predominantly male (56%), had not undertaken a specialized training course after graduating (70%) and had graduated within the last 15 years (63%) [35]. A final limitation is the definition of regular counseling for the practice of physical activity. While physicians and nurses may have talked about physical activity with patients, some of these activities might not be structured, planned and repeated [2].

Conclusions

In conclusion, the results of this study showed that physicians and nurses deemed physical activity promotion and counseling of great importance in primary health care in Brazil. However, these health teams would benefit from continued education programs to improve their knowledge regarding physical activity since few demonstrated familiarity with current physical activity recommendations or applied standardized instruments for assessing physical activity of patients. Standardized education strategies are therefore needed [22], similarly to what happens in other developed countries that have universal health care system [11,13,36]. Finally, because physical activity levels are not increasing in Brazil [37], interventions are urgently needed to promote more physical activity counseling in primary health care. These interventions must be linked to the recently launched ‘Academia da Saúde’ program [38], a nationwide policy that will fund over 4,000 cities to build capacity for physical activity promotion by the year 2015.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

AAF, GIM, GAOG, LRR and PCH contributed to the idea this study. AAF, GIM and PCH contributed for data analysis, interpretation and drafted the manuscript. GAOG, LRR, MMB, DCP, EJS and FL contributed to drafting and critically revising the manuscript. All authors have read and approved the final manuscript.

Disclaimer

The findings and conclusions in this article are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Acknowledgments

The authors wish to thank all members of the GUIA team. This study was funded through the Centers for Disease Control and Prevention’s Prevention Research Centers Program special interest project U48/DP001903 (Applying Evidence-Physical Activity Recommendations in Brazil).

References

  1. Jacobson DM, Strohecker L, Compton MT, Katz DL: Physical activity counseling in the adult primary care setting: position statement of the American College of Preventive Medicine.

    Am J Prev Med 2005, 29(2):158-162. PubMed Abstract | Publisher Full Text OpenURL

  2. National Institute for Health and Care Excellence:

    Four commonly use methods to increase physical activity.

    http://guidance.nice.org.uk/ph2; webcite March 2006

    OpenURL

  3. Hirvensalo M, Heikkinen E, Lintunen T, Rantanen T: The effect of advice by health care professionals on increasing physical activity of older people.

    Scand J Med Sci Sports 2003, 13(4):231-236. PubMed Abstract | Publisher Full Text OpenURL

  4. The Activity Counseling Trial Research Group: Effects of physical activity counseling in primary care: the Activity Counseling Trial: a randomized controlled trial.

    JAMA 2001, 286(6):677-687. PubMed Abstract | Publisher Full Text OpenURL

  5. Petrella RJ, Koval JJ, Cunningham DA, Paterson DH: Can primary care doctors prescribe exercise to improve fitness? The Step Test Exercise Prescription (STEP) project.

    Am J Prev Med 2003, 24(4):316-322. PubMed Abstract | Publisher Full Text OpenURL

  6. Calfas KJ, Long BJ, Sallis JF, Wooten WJ, Pratt M, Patrick K: A controlled trial of physician counseling to promote the adoption of physical activity.

    Prev Med 1996, 25(3):225-233. PubMed Abstract | Publisher Full Text OpenURL

  7. Marcus BH, Goldstein MG, Jette A, Simkin-Silverman L, Pinto BM, Milan F, Washburn R, Smith K, Rakowski W, Dube CE: Training physicians to conduct physical activity counseling.

    Prev Med 1997, 26(3):382-388. PubMed Abstract | Publisher Full Text OpenURL

  8. Sabti Z, Handschin M, Joss MK, Allenspach EC, Nuscheler M, Grize L, Braun-Fahrlander C: Evaluation of a physical activity promotion program in primary care.

    Fam Pract 2010, 27(3):279-284. PubMed Abstract | Publisher Full Text OpenURL

  9. Orrow G, Kinmonth AL, Sanderson S, Sutton S: Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials.

    BMJ 2012, 344:e1389. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  10. Patrick K, Pratt M, Sallis RE: The healthcare sector's role in the U.S. national physical activity plan.

    J Phys Activity and Health 2009, 6:Suppl 2:S211-219. OpenURL

  11. Williams NH, Hendry M, France B, Lewis R, Wilkinson C: Effectiveness of exercise-referral schemes to promote physical activity in adults: systematic review.

    Br J Gen Pract 2007, 57(545):979-986. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  12. Hogg WE, Zhao X, Angus D, Fortier M, Zhong J, O'Sullivan T, Sigal RJ, Blanchard C: The cost of integrating a physical activity counselor in the primary health care team.

    J Am Board Fam Med 2012, 25(2):250-252. PubMed Abstract | Publisher Full Text OpenURL

  13. Murphy SM, Edwards RT, Williams N, Raisanen L, Moore G, Linck P, Hounsome N, Din NU, Moore L: An evaluation of the effectiveness and cost effectiveness of the National Exercise Referral Scheme in Wales, UK: a randomised controlled trial of a public health policy initiative.

    J Epidemiology Community Health 2012, 66(8):745-753. Publisher Full Text OpenURL

  14. Douglas F, Torrance N, van Teijlingen E, Meloni S, Kerr A: Primary care staff's views and experiences related to routinely advising patients about physical activity. A questionnaire survey.

    BMC Public Health 2006, 6:138. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  15. Parker WA, Steyn NP, Levitt NS, Lombard CJ: They think they know but do they? misalignment of perceptions of lifestyle modification knowledge among health professionals.

    Public Health Nutr 2010, 14(8):1429-1438. PubMed Abstract | Publisher Full Text OpenURL

  16. Peek ME, Tang H, Alexander GC, Chin MH: National prevalence of lifestyle counseling or referral among African-Americans and whites with diabetes.

    J Gen Intern Med 2008, 23(11):1858-1864. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  17. Cho HJ, Sunwoo S, Song YM: Attitudes and reported practices of Korean primary care physicians for health promotion.

    J Korean Med Sci 2003, 18(6):783-790. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  18. Smith AW, Borowski LA, Liu B, Galuska DA, Signore C, Klabunde C, Huang TT, Krebs-Smith SM, Frank E, Pronk N, et al.: U.S. primary care physicians' diet-, physical activity-, and weight-related care of adult patients.

    Am J Prev Med 2011, 41(1):33-42. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  19. Barnes PM, Schoenborn CA: Trends in adults receiving a recommendation for exercise or other physical activity from a physician or other health professional.

    NCHS data brief 2012, 86:1-8. PubMed Abstract OpenURL

  20. Hebert ET, Caughy MO, Shuval K: Primary care providers' perceptions of physical activity counselling in a clinical setting: a systematic review.

    Br J Sports Med 2012, 46(9):625-631. PubMed Abstract | Publisher Full Text OpenURL

  21. Lee IM, Shiroma EJ, Lobelo F, Puska P, Blair SN, Katzmarzyk PT, Lancet Physical Activity Series Working G: Effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy.

    Lancet 2012, 380(9838):219-229. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  22. Paim J, Travassos C, Almeida C, Bahia L, Macinko J: The Brazilian health system: history, advances, and challenges.

    Lancet 2011, 377(9779):1778-1797. PubMed Abstract | Publisher Full Text OpenURL

  23. Pratt M, Brownson RC, Ramos LR, Malta DC, Hallal PC, Reis RS, Parra DC, Simoes EJ: Project GUIA: A model for understanding and promoting physical activity in Brazil and Latin America.

    J Phys Activity and Health 2010, 7(2):S131-134. OpenURL

  24. Suija K, Pechter U, Maaroos J, Kalda R, Ratsep A, Oona M, Maaroos HI: Physical activity of Estonian family doctors and their counselling for a healthy lifestyle: a cross-sectional study.

    BMC Fam Pract 2010, 11:48. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  25. Burns KJ, Camaione DN, Chatterton CT: Prescription of physical activity by adult Nurse practitioners: a national survey.

    Nurs Outlook 2000, 48:28-33. PubMed Abstract | Publisher Full Text OpenURL

  26. Ampt AJ, Amoroso C, Harris MF, Mackenzie SH, Rose VK, Taggart JR: Attitudes, norms and controls influencing lifestyle risk factor management in general practice.

    BMC Fam Pract 2009, 10(59):1-8. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  27. Coleman KJ, Ngor E, Reynolds K, Quinn VP, Koebnick C, Young DR, Sternfeld B, Sallis RE: Initial validation of an exercise “vital sign” in electronic medical records.

    Med Sci Sports Exerc 2012, 44(11):2071-2076. PubMed Abstract | Publisher Full Text OpenURL

  28. Salvador EP, Florindo AA, Reis RS, Costa EF: Perception of the environment and leisure-time physical activity in the elderly.

    Revista de saude publica 2009, 43(6):972-980. PubMed Abstract | Publisher Full Text OpenURL

  29. Simoes EJ, Hallal P, Pratt M, Ramos L, Munk M, Damascena W, Perez DP, Hoehner CM, Gilbertz D, Malta DC, et al.: Effects of a community-based, professionally supervised intervention on physical activity levels among residents of Recife, Brazil.

    Am J Public Health 2009, 99(1):68-75. PubMed Abstract | Publisher Full Text | PubMed Central Full Text OpenURL

  30. Mendonca BC, Oliveira AC, Toscano JJO, Knuth AG, Borges TT, Malta DC, Cruz DK, Hallal PC: Exposure to a community-wide physical activity promotion program and leisure-time physical activity in Aracaju, Brazil.

    J of Physl Activity and Health 2010, 7:Suppl 2:S223-228. OpenURL

  31. Siqueira FV, Nahas MV, Facchini LA, Silveira DS, Piccini RX, Tomasi E, Thume E, Hallal PC: Counseling for physical activity as a health education strategy.

    Cadernos de saude publica 2009, 25(1):203-213. PubMed Abstract | Publisher Full Text OpenURL

  32. Hinrichs T, Moschny A, Klaassen-Mielke R, Trampisch U, Thiem U, Platen P: General practitioner advice on physical activity: analyses in a cohort of older primary health care patients (getABI).

    BMC Fam Pract 2011, 12:26. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  33. U. S. Preventive Task Force: Behavioral counseling in primary care to promote physical activity: recommendation and rationale.

    Ann Intern Med 2002, 137(3):205-207. PubMed Abstract | Publisher Full Text OpenURL

  34. Hallal PC, Machado PT, Del Duca GF, Silva IC, Amorim TC, Borges TT, Rombaldi AJ, Azevedo MR, Knuth AG: Physical activity advice: short report from a population-based study in Brazil.

    J Phys Activity and Health 2010, 7(3):352-354. OpenURL

  35. Ministério da Saúde do Brasil:

    In Observatório de recursos humanos em saúde no Brasil: estudos e análises. Rio de Janeiro. Edited by Fiocruz. 2003, 460.

    in portuguese

    PubMed Abstract OpenURL

  36. Leijon ME, Bendtsen P, Nilsen P, Ekberg K, Stahle A: Physical activity referrals in Swedish primary health care - prescriber and patient characteristics, reasons for prescriptions, and prescribed activities.

    BMC Health Serv Res 2008, 8:201. PubMed Abstract | BioMed Central Full Text | PubMed Central Full Text OpenURL

  37. Hallal PC, Knuth AG, Reis RS, Rombaldi AJ, Malta DC, Iser BP, Bernal RT, Florindo AA: Time trends of physical activity in Brazil (2006–2009).

    Revista brasileira de epidemiologia 2011, 14:Suppl 1:53-60. OpenURL

  38. Malta DC, Barbosa Da Silva J: Policies to promote physical activity in Brazil.

    Lancet 380(9838):195-196. OpenURL

Pre-publication history

The pre-publication history for this paper can be accessed here:

http://www.biomedcentral.com/1471-2458/13/794/prepub