Promoting physical activity for health. A survey of knowledge,confidence and role-perception in final-year UK physiotherapy students

Abstract

BACKGROUND:

Physical inactivity is the fourth leading cause of global mortality and is a significant independent risk factor for a range of chronic conditions. Advice from a healthcare professional can increase activity levels in adults. Current literature does not identify whether UK physiotherapy undergraduate students are prepared to promote physical activity (PA) for health.

PURPOSE:

The aim of this study was to determine the knowledge, confidence and role perception of final-year UK Physiotherapy undergraduate students to promote physical activity for health.

METHODS:

An online cross-sectional survey was used. 19 UK undergraduate Physiotherapy courses participated. Descriptive statistics explored knowledge, confidence and role-perception. Inferential statistics tested the relationships between variables.

RESULTS:

Response rate was 16.6% (n = 158). The majority of respondents (82% n = 129) had received training in promoting PA for health. 66% (n = 73) of this group correctly specified a duration, frequency and intensity for current UK PA recommendations for 19–64 year olds. Role perception was extremely high (99%) in the surveyed population. Students reported being confident in giving general PA advice (92%, n = 144). Confidence scores were significantly correlated with training in the promotion of PA for health (β= 0.38 p < 0.001).

CONCLUSION:

Final-year UK Physiotherapy students perceive a professional role in promoting physical activity for health; and demonstrate good but variable knowledge of this subject. Confidence domain scores were best predicted by training in the promotion of PA for health.

Keywords

Physiotherapy physical activity health physiotherapy students

1 Introduction

Preventable illnesses are now formally recognised as a worsening global crisis affecting all groups, in all countries, regardless of income [1]. The World Health Organisation [2] estimates that 65% of total global mortality is due to non-communicable diseases (NCDs), amounting to 38 million deaths annually. This figure is expected to rise by 15% in the next decade to 44 million deaths globally each year [3]. The chronic nature of NCDs means that they are also one of the leading causes of preventable morbidity and disability [4]. Many NCDs are thought to be preventable and linked to lifestyle. Reduced regular physical activity is established globally as a significant independent risk factor for a range of chronic conditions including coronary heart disease, type-2 diabetes, and some cancers. Sedentary lifestyles are set to contribute to one of the most significant public health problems of the 21st Century [5].

Current UK recommendations on physical activity state that adults (aged 19–65) should participate in at least 150 minutes of moderate-intensity aerobic activity or 75 minutes of vigorous-intensity aerobic activity per week, or equivalent combinations [6]. Self-reported leisure and occupational physical activity showed that in 2012, 67% of men and 55% of women aged 16 and over met the current guidelines [6]. If all people in the UK met the minimum recommendations for physical activity this would prevent an estimated 35 000 deaths annually [7]. These estimations make physical inactivity similar to the established risk factors of smoking and obesity [8]. Increased levels of PA to 300 minutes moderate-intensity per week have been shown to reduce CHD risk by 20% (RR 0.80; 95% CI 0.74–0.88) [9]. In addition to aerobic activity, muscle strengthening activity is recognised for its role in reducing blood pressure, improving glucose metabolism, and reducing cardiovascular disease risk [10].

It has been identified that all health care staff have a role to play in improving the health and wellbeing of our population. Making Every Contact Count (MECC) is an approach to behaviour change in England that promotes positive mental and physical wellbeing during the millions of day-to-day interactions in health and social care [11]. Advice from health professionals is reported to encourage greater physical activity behaviours [12, 13]. Physiotherapists have been identified as ‘well-placed in the fight against the major health threat of chronic diseases’ [14]. Physiotherapist confidence, knowledge and perceptions related to promoting PA for health are not well known in the United Kingdom but have been explored elsewhere. A survey of physical therapists in three American states identified that increasing PA was their main area of focus for health promotion [15]. Confidence in prescribing ‘non-treatment’ physical activity was the best predictor of whether or not PA would be prescribed. Despite this, US Physical Therapist knowledge on activity recommendations is variable [16].

Shirley, van der Ploeg, and Bauman [17] surveyed Australian physiotherapists and physiotherapy students on their knowledge, confidence, role perception, and feasibility with regard to promoting physical activity for health. Their cross-sectional survey found that both groups believed PA promotion for health should be part of their role. Both groups reported feeling confident in promoting PA for health, and this was attributed to training in exercise prescription. These findings support a relationship between training in PA and confidence to promote this within the role of physiotherapist. The situation within the UK remains unknown.

The aim of this study was to determine the knowledge, confidence and role perception of final-year UK Physiotherapy undergraduate students to promote physical activity for health. This study proposed the following research questions:

Do final-year UK Physiotherapy students perceive a professional role in promoting physical activity for health?

Do final-year UK Physiotherapy students have the knowledge and confidence to promote physical activity for health?

Is there a relationship between knowledge, confidence and role-perception in the promotion of PA for health by final-year UK Physiotherapy students?

2 Methodology

The study design was observational. Sampling was attempted from all eligible UK physiotherapy courses with a final-year cohort in a sufficient number to exceed the sample size calculation. The sampling frame for this study included the 33 UK Physiotherapy courses with a final year cohort [18] in 2012–2013 [19]. All 33 undergraduate course leaders were approached by email with an informed invitation to participate in the study. If a course leader or equivalent agreed to distribute the survey link, the research ethics committee for each course institution was contacted to ascertain whether further ethical approval was necessary.

A response rate of 19 courses was achieved through this process. All courses that agreed to a link-person and gave ethical approval were included in the sample. This decision was made to increase representativeness of the sample for external validity of results and to minimise sampling error [20, 21]. A sample size of 200 was set to detect a significant correlation of 0.2 or greater (power = 0.8; significance = 0.05) [20] between variables. This was calculated on sampling Physiotherapy courses with an average final-year cohort of fifty students and a response rate of 30% based on the work of others [17]. Other studies have reported response rates to questionnaire as low as 12% [15]. Power was set at 0.8, and the probability (α) was set at 0.05 [20].

Ethical approval for this study was granted. Informed consent was asked of participants. All potential participants were granted autonomy, made clear in the informed consent document. Full disclosure of the nature of the study and its potential risks and benefits were also detailed in the informed consent document, along with an extended opportunity to ask further questions about the study [22].

Privacy and confidentiality were protected from unauthorised observation by the secure Bristol Online Surveys (BOS) tool. The survey was anonymous at the point of submission. Where a UK Physiotherapy undergraduate course had agreed to participate and there had been confirmation of ethical approval all of their final year students were targeted with the online survey. This study could not guarantee that all potential participants would have equal access to the survey as it was dependent on distribution by the link university tutor. Descriptive data analysis was performed within the BOS software.

A paper-based copy of the questionnaire can be found in the appendix. The survey was adapted from a study of physical activity promotion in Australian physiotherapists and physiotherapy students [17]. Permission was granted to adapt and use the survey by the correspondence author. Following peer-review for face validity of the modified questionnaire the pilot survey was administered using the online format to a convenience sample of ten final-year physiotherapy students in a target UK institution.

A standardised email was sent to course leaders and contained an informed consent document and a direct internet link to the online survey. Initial email distribution took place in January 2013. It was requested that the distribution process be standardised to email. The online collection and analysis facilities in BOS were used to track progress. Reminder emails were sent out to the course leaders at three weeks and five weeks after launch of the survey to maximise sample size and response rate [15, 17]. The study closed data collection through BOS eight weeks after initial launch.

For each question the frequency of responses for each Likert value were tabulated allowing for analysis of raw frequency, relative frequency, and cumulative relative frequency. For the nominal level demographic variables a table of raw and relative frequency was created.

Box-plots were used to show medians, quartiles and extremes of response to each subset of questions for knowledge, confidence and role perception. Data were analysed directly using the BOS software or in SPSS (version 21). Quantitative descriptive analysis of demographics was performed to assess sample representativeness. Descriptive analysis of the nominal data included the mode. The median, rather than the mean, was used as the measure of central tendency in ordinal data. Range and quartiles were used to measure the dispersion of the ordinal data [21].

Respondents were individually scored on their responses to the statements on knowledge, role-perception, and confidence to promote PA for health. These scores were then summed to give a domain total for knowledge, role-perception, and confidence, allowing mean and standard deviation to be calculated on the interval data. Pearson product moment correlation (r) was used to test the relationship between the interval scores for knowledge, role-perception, and confidence.

Test-retest reliability of the survey was assessed using the Spearman correlation coefficient (r_s) of Likert-type scale rankings. Item-to-item correlation was used. Wider analysis was also considered on the relationship between the domain scores and self-perceived PA level, training in PA for health, and knowledge of current UK guidelines for PA using the Spearman correlation coefficient (r_s). A significance level (α) of≤0.05 was set and a two tailed test was used as standard practice [23]. Multiple linear regression was used to test whether an outcome can be predicted from several predictor variables [24].

3 Results

The online survey was conducted between 19th January 2013 and 20th March 2013. Of the 19 UK Physiotherapy undergraduate programmes surveyed the approximate study population was 950 final-year physiotherapy students. The response rate was 16.6% (n = 158).

The demographic and educational characteristics of respondents are shown in Tables 1 and 2.

Table 1
Demographic Characteristics of Respondents

Characteristic / Variable n %

Sex (n = 158)

∘ Female 113 71.5

∘ Male 45 28.5

Age group in years (n = 158)

∘ 18–24 112 70.9

∘ 25–30 33 20.9

∘ 31–39 10 6.3

∘ 40+ 3 1.9

Perceived physical activity level compared with other members of the UK public of your sex and age (n = 158)

∘ Much more active 52 32.9

∘ Slightly more active 59 37.3

∘ About the same 36 22.8

∘ Slightly less active 11 7.0

∘ Much less active 0 0.0

Characteristic / Variable	n	%
Sex (n = 158)
∘ Female	113	71.5
∘ Male	45	28.5
Age group in years (n = 158)
∘ 18–24	112	70.9
∘ 25–30	33	20.9
∘ 31–39	10	6.3
∘ 40+	3	1.9
Perceived physical activity level compared with other members of the UK public of your sex and age (n = 158)
∘ Much more active	52	32.9
∘ Slightly more active	59	37.3
∘ About the same	36	22.8
∘ Slightly less active	11	7.0
∘ Much less active	0	0.0

Table 2

Educational and Professional Characteristics of Respondents

Characteristic / Variable		n	%
Preferred area of Physiotherapy practice (n = 158)
∘ Musculoskeletal		68	43.0
∘ Neurological		24	15.2
∘ Cardio-Respiratory		15	9.5
∘ Paediatrics		23	14.5
∘ Care of the elderly		4	2.5
∘ Occupational health and safety		1	0.6
∘ Amputees		1	0.6
∘ Palliative care		2	1.2
∘ Health promotion		1	0.6
∘ Management consultancy in healthcare		1	0.6
∘ Animal		1	0.6
∘ Not sure yet		17	10.8
Length of Physiotherapy degree course in years (n = 158)
∘ Two Years		1	0.6
∘ Three Years		143	90.5
∘ Four Years		14	8.9
Received training in the promotion of physical activity / exercise for maintaining or improving health as part of Physiotherapy course (n = 158)
∘ No		29	18.4
∘ Yes		129	81.6
If yes above (n = 129), this was:	University	54	41.9
	Clinical placement	6	4.7
	Both	69	53.5
Knowledge of the current UK recommended physical activity levels for adults (aged 19–64 years)
∘ No		47	29.7
∘ Yes		111	70.3

Table 2 shows that a majority of surveyed physiotherapy students (n = 111, 70%) perceived themselves to be more physically active than other members of the public for their age and sex. When asked whether they had received training in PA promotion for health 18% (n = 29) reported that they had not. Of the 82% (n = 129) who stated having received PA training the majority (54%, n = 69) reported this as a combination of both university and clinical placement based education. The majority of respondents (70%, n = 111) reported being knowledgeable about current UK recommendations for PA levels for 19–64 year olds. Of the 111 respondents who reported being knowledgeable 66% (n = 73) correctly specified a duration, frequency and intensity.

The four knowledge statements in Table 3 were converted from a 5-point Likert scale to a 3-point scale (correct response, incorrect response, or answered unsure) in line with other methods [17]. An overwhelming majority (94%, n = 146) responded correctly according to current UK recommendations for 19–64 year olds. An almost equal split correctly identified the requirements of moderate to vigorous intensity (47.4%, n = 74), versus those who were incorrect in their response (46.8%, n = 73).

Table 3

Knowledge Statement Responses for UK PA Guidelines

Statement (respondents)	Correct		Incorrect		Not sure
	n	%	n	%	n	%
Muscle strengthening physical activity does not contribute to improved health (n = 156)	146	93.6	5	3.2	5	3.2
Half an hour of walking on most days is not sufficient exercise for good health (n = 158)	92	58.2	57	36.1	9	5.7
Exercise that is good for health must be moderate to vigorous in intensity (n = 156)	74	47.4	73	46.8	9	5.8
Several short walks of 10 minutes each on most days is better than one round of golf per week for good health (n = 157)	105	66.9	13	8.3	39	24.8

Numbers in agreement with the role-perception statements are outlined in Table 4. An overwhelming majority of survey respondents agreed that discussing the benefits of a physically active lifestyle (99%, n = 156) and suggesting to patients ways to increase daily PA (99%, n = 154) were part of a physiotherapist’s role. Over half of respondents (57%, n = 90) agreed that physiotherapists should use every patient contact to promote PA for health while a quarter of respondents (n = 39) disagreed.

Table 4

Role-Perception Statement Choices^a

Statements (respondents)	Agree		Not sure		Disagree
	n	%	n	%	n	%
Discussing the benefits of a physically active lifestyle with patients is not part of the Physiotherapist’s role (n = 158)	1	0.6	1	0.6	156	98.7
Suggesting to patients ways to increase daily physical activity is not part of the Physiotherapist’s role (n = 156)	1	0.6	1	0.6	154	98.8
Physiotherapists should be physically active to act as a role model for their patients (n = 158)	136	86	10	6.3	12	7.6
Physiotherapists should use every patient contact to promote physical activity for health (n = 158)	90	57	29	18.4	39	24.7

^aagree includes ‘strongly agree’, disagree includes ‘strongly disagree’.

Final-year physiotherapy students reported being confident in giving general PA advice to patients (92%, n = 144) and also in giving specific PA programs to patients (85%, n = 133) (Table 5).

Table 5

Confidence Statement Choices^a

Statements (respondents)	Agree		Not sure		Disagree
	n	%	n	%	n	%
I feel confident in giving general advice to patients on a physically active lifestyle (n = 156)	144	92.3	6	3.8	6	3.8
I feel confident in suggesting specific physical activity programs for my patients (n = 157)	133	84.7	11	7	13	8.3

^aagree includes ‘strongly agree’, disagree includes ‘strongly disagree’.

All respondents were individually scored on their responses to the statements on knowledge, role-perception, and confidence to promote PA for health (Table not included). The maximum domain score was four for knowledge. Four points was the maximum score for role-perception statements if all responses were positive. The same method was used for the two confidence statements, giving a score range of 0–2 in this domain. Mean score for the knowledge domain was 2.63 (SD = 0.85, range 0–4). The median score was 3. The quartile ranges are shown by boxplot in Fig. 1 where the range of the top and bottom 25% of scores is the same. The two respondents scoring zero are treated as outliers. Figure 1 also depicts the median score boxplot for the role-perception domain. The data for this domain is heavily skewed, with a median score of 4; which is the maximum score available. The bottom quartile ranges to a score of two, while two outliers scored 1 and 0 respectively. The mean score for the role-perception domain was 3.39 (SD = 0.75). The mean confidence domain score was 1.75 (SD = 0.54, range 0–2), while the median score was 2. As this was also the maximum score available the data was heavily skewed, and a boxplot (not included) could not give quartile ranges.

Fig.1

Boxplots of Knowledge and Role-Perception Domain Scores of Final Year UK Physiotherapy Students.

The mean confidence domain scores showed a weak statistically significant positive correlation (r = 0.227, p < 0.01, two-tailed) with mean role-perception scores. Respondents who perceived themselves to be more physically active (n = 111, 70%) than other members of the public of their age and sex were found to have a weak statistically significant positive correlation (r_s = 0.176, p < 0.05, two-tailed) with their confidence domain scores. Confidence domain scores were also found to have a medium positive correlation (r_s = 0.391, p < 0.05, two-tailed) with training in the promotion of PA for health. The Pearson correlation coefficient also showed a weak statistically significant positive correlation (r = 0.163, p < 0.05, two-tailed) between mean confidence domain scores and mean knowledge domain scores. No other significant correlations were found between the variables.

Results of the multiple linear regression analysis showed that when the two domain scores and relative PA scores are controlled for, training in PA promotion for health is the best predictor of student physiotherapy confidence to promote PA for health (β= 0.38). Higher domain scores in role-perception and knowledge were less significant predictors of confidence domain scores. A modified coefficients table is presented in Table 6.

Table 6

Multiple regression analysis of several independent variables to predict confidence domain scores

	B	SE B	β
Step 1
Constant	0.39	0.25	_______
Role-perception domain score	0.12	0.05	0.16**
Knowledge domain score	0.10	0.05	0.16**
Relative PA score	0.07	0.04	0.12
Training in PA promotion	0.53	0.10	0.38*

Note. R² = 0.25. *p < 0.001. **p < 0.05. Dependent variable: Confidence domain scores.

4 Discussion

Results from the present study suggest that surveyed final-year UK physiotherapy students believe that promoting PA for health is part of their role and that they are confident to perform this role. These results are comparable with a similar study of Australian physiotherapists and physiotherapy students [17]. Survey respondents were representative of the study population based on student demographic data from the Chartered Society of Physiotherapy [25].

UK undergraduate student knowledge of PA guidelines was found to be better regarding intensity of exercise required for health compared with Australian fourth year undergraduates (47% compared with 28%). There were however differences between the two studies in the wording of the intensity statement. Highly comparable results were found regarding the benefits of 10 minute bouts of activity (67% agreement compared with 69% in 4th year Australian undergraduates). The statement was worded identically in both the UK and Australian study, which may account for the high similarity. The ability of physiotherapy students to correctly state national PA recommendations for health is positive for UK undergraduates, with 46% of respondents identifying their national PA guidelines compared with a third of Australian respondents [17]. The Australian study grouped their data for qualified and student physiotherapists on knowledge of national PA guidelines, whereas the present study reports only on a student population.

Training in the promotion of PA for health as part of their physiotherapy programme was reported by four-fifths of survey respondents. While no study appears to have examined the specific content of UK Physiotherapy curricula, present findings suggest that current undergraduate training is in line with WCPT [14] and CSP [26] recommendations for entry-level training on PA and exercise for health. It is unclear from this study whether the remaining 18.4% of surveyed students have incorrectly recalled or interpreted their training experiences or whether one fifth of undergraduate providers are failing to deliver adequate training in this area. A recommendation from this study would be content analysis of UK Physiotherapy curricula. This study also found that 59% of respondents were exposed to PA promotion training during clinical placement. Another recommendation of this study would be to survey UK clinical educators as a majority (66%) of Irish [clinical] practice tutors [27] reported a lack of knowledge, and / or confidence to educate students in contemporary health recommendations.

Role-perception statement responses between this and an Australian study [17] were highly comparable suggesting high validity for these survey statements. Nearly all respondents in the present study agreed that their role should include discussing the benefits of PA (99%) and suggesting physical activity to patients (99%). Australian final-year counterparts reported 94% agreement to both statements [17]. The majority (86%) of UK respondents agreed with the statement that physiotherapists should be physically active role models, which again was comparable with Australian final-year undergraduates (91%). In the present study 70% of final year UK physiotherapy students perceived themselves to be more active than members of the public of their age and sex.

The statement ‘Physiotherapists should use every patient contact to promote physical activity for health’ had the lowest level of agreement (57%) in the role-perception domain. There was a more even split between unsure (18%) and disagree (24%) responses. The statement was included in line with the UK agenda for Making Every Contact Count (MECC). This statement was examined further through cross-tabulation with training in PA for health and perhaps surprisingly it was found that those not reporting training in PA actually disagreed with this statement less than those having received training (17% versus 26%). These results suggest that even where PA promotion curricula exists there is more emphasis required on implementation. Self-reported levels of confidence to promote PA for health were high in responding final-year UK physiotherapy students. The vast majority were confident to give both general (92%) and specific (85%) PA guidance. This was highly comparable with the findings of Shirley, van der Ploeg, and Bauman [17].

Inferential statistical analysis showed that confidence domain scores had a weak statistically significant correlation with role-perception scores; a weak statistically significant correlation with a perception of being more physically active than members of the public of their age and sex; and a weak statistically significant correlation with knowledge domain scores. Confidence domain scores were also found to have a medium correlation with training in the promotion of PA for health. Multiple linear regression analysis showed that training in PA promotion for health is the best predictor of student physiotherapy confidence to promote PA for health. This finding supports the recommendation to include PA promotion in undergraduate physiotherapy curricula to develop confidence to promote PA for health in patient populations.

A sample size of 200 was set to detect a significant correlation of 0.2 or greater between the variables. The number of respondents was 158 which equated to 16.6% of the estimated accessible study population. Survey response rates in physiotherapy populations have been reported as low as 12% [15] and the small sample size in the present study may have been insufficient to detect significant correlations between some variables. Results should therefore be interpreted with caution. The small sample size may compromise the external validity of the study findings.

Strengths of this study included the representative demographic characteristics of respondents, and also the breadth of UK Physiotherapy providers targeted and recruited for the study. Despite this, and considering the general implications of a cross-sectional design, it is acknowledged that a large sample with low response rate reduces the generalisability of findings. Factors responsible for the low response rate may include the barrier of not having direct access to student populations, ‘survey fatigue’ [28] in final-year university students, and students on clinical placement during the survey period. Reporting bias may have influenced internal validity of results as responses such as training in PA promotion for health may be underestimated, whilst self-reported levels of PA may be overestimated. Like postal surveys it is also acknowledged that online questionnaires may be poor at avoiding response bias, use closed questions, cannot control question answering sequence, and cannot motivate subjects to answer uninteresting questions [29]. Most question responses totalled 158/158 and the lowest question response totalled 156/158.

5 Conclusion

This study identifies the potential for next-generation UK physiotherapists to promote health through PA in a health service set to emphasise wellness and the prevention of illness. Surveyed UK Physiotherapy students identify strongly with this role and demonstrate the confidence to give non-treatment PA advice to their patients. Knowledge of national PA guidelines for adults has been found to be good but variable in surveyed UK final-year physiotherapy students. These results were comparable with Australian counterparts in a similar study.

It is acknowledged that when using a cross-sectional design to generalise results a large sample with low response rate is less preferable. The small sample size may have been insufficient to detect significant correlations between some variables and so results should be interpreted with caution. A strength of the method was the strong statistically significant correlation between test-retest results for reliability over time for the survey tool.

Conflict of interest

The author reports no declaration of interest.

Footnotes

Appendix

Acknowledgments

The author thanks Dr Marjorie L Wilson (Teesside University) for her support and feedback on this project. Thanks also to the undergraduate Physiotherapy course leaders who distributed the survey, and to the students who took the time to complete the survey.

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