A Physical Activity Learning Module Improves Medical Students ’ Skills and Confidence for Advising Patients about Physical Activity

Physicians’ knowledge, confidence, and prior training will influence physical activity (PA) counselling in general practice. This study evaluated the effects of a PA learning module on knowledge, skills, and attitudes toward PA counselling in third-year medical students. Students (n=216; age: 21.1±2.2 years; 47% males; participation rate 91%) participated in a PA learning module that included tutorials, lectures, and experiential learning through providing health checks to adults. At baseline and four months after the intervention, students completed a paper questionnaire about their awareness of current PA guidelines, benefits of, and attitudes toward PA advising, perceived competence/importance of PA advising skills, and personal PA habits. Data were analysed using a t-test for dependent samples and Chi-square analysis. After the intervention, students reported a greater awareness of the PA guidelines (pre vs. post: 3.1±1.1 vs. 3.8±0.9), the national PA initiative (4.2±0.9 vs. 4.7±0.7), the importance of PA counselling in general practice (4.1±0.8 vs. 4.3±0.8), and their confidence (3.2±0.9 vs. 3.9±0.8), and perceived competence (3.1±0.8 vs. 3.8±0.8, all p<0.05) in providing PA advice compared to baseline. In conclusion, exposure to a PA learning module increased medical students’ awareness and knowledge of the current PA guidelines and improved their confidence and perceived competence in providing PA advice. However, even after the training, students on average perceived themselves to be only moderately competent in providing PA advice. Therefore, clinical training for medical students should be designed to improve students’ competence and skills in PA counselling.


Introduction
Lack of physical activity (PA) and sedentary lifestyles among all segments of the population represent global public health problems in both developed and developing countries (World Health Organization, 2004).According to the World Health Organization, physical inactivity (lack of PA) has been identified as the fourth leading risk factor for global mortality, causing an estimated 3.2 million deaths annually (World Health Organization, 2015).Global recommendations for PA have been developed for children and adolescents, adults, and older adults (World Health Organization, 2010).According to the current PA guidelines, adults should engage in at least 150 minutes of moderate-intensity PA or at least 75 minutes of vigorous-intensity PA throughout the week, or an equivalent combination of moderate-and vigorous-intensity PA and include muscle strengthening activities on at least two days per week (Haskell et al., 2007).Additional health benefits are achieved by increasing PA above the minimum recommended levels (Haskell et al., 2007;World Health Organization, 2010).However, only one in four adults and one in five adolescents globally meet minimum PA recommendations (World Health Organization, 2015).Reducing physical inactivity by 10% worldwide is one of the nine global targets for non-communicable disease prevention (World Health Organization, 2013).Increasing PA is a societal, not just an individual problem, and requires a population-based, multi-sectoral, multi-disciplinary, and culturally relevant approach (World Health Organization, 2004).Consequently, PA is becoming an integral part of health-related initiatives across all segments of the population and in various settings including communities, workplaces, and schools, as well as extending into the fields of urban design, transportation and policy development.Given the key role of physicians in the public health domain, it is important to train medical students to use PA as a medical therapeutic option and to provide individualized PA advice to their patients.
Medical students (Connaughton, Weiler & Connaughton, 2001;Vallance, Wylie & MacDonald, 2009) and residents (Rogers et al., 2002) have modest competence and confidence in providing PA advice.PA also has intrinsic benefits for students in terms of their own health and wellbeing (Dyrbye, Satele & Shanafelt, 2016).The authors of this paper recently reported that third year (pre-clinical) medical students in New Zealand were generally physically active and had a good understanding of the links between PA and health, but were lacking skills for PA advising and knowledge of specific PA guidelines for healthy individuals and clinical populations (Mandic, Wilson, Clark-Grill & O'Neill, 2017).In addition, regularly active medical students felt more confident in providing PA advice and perceived a greater impact of PA advising on patients' quality of life (Mandic et al., 2017).Since physicians' confidence in PA-advising skills was significantly influenced by prior training (Rogers et al., 2002), it is essential to provide opportunities for medical students to develop effective skills in PA advising as a part of their undergraduate training.A recent systematic review of PA counselling in medical education curriculums reported positive changes in students' attitude towards PA, their PA counselling knowledge and skills, and their self-efficacy to provide PA advice (Dacey, Kennedy, Polak & Phillips, 2014).The effective medical education programmes incorporated experiential learning, theoretically based frameworks, and students' personal PA habits (Dacey et al., 2014).The heterogeneity of the PA-related curriculum and weak study design of previous studies (Dacey et al., 2014) warrant further examination of the effects of the inclusion of curricula on PA advising in medical education.The current study examined the effects of an introductory learning module on PA on knowledge, skills, and attitudes toward PA advising in third-year medical students in New Zealand.

Participants
All third-year medical students at the Dunedin School of Medicine, University of Otago, (Dunedin, New Zealand, n=237) were invited to participate in this study, and 216 students (91%) gave signed consent and participated.The study was approved by the University of Otago Human Ethics Committee.

Study design
Participants completed a baseline survey in April 2009, participated in the intervention (April-May 2009) and completed the post-intervention survey in October 2009.Baseline and post-intervention surveys, were 15-to 20-minutes long and were completed on paper during tutorial classroom time.

Intervention
The PA Learning Module (intervention) consisted of three tutorials and one lecture related to PA advising and experiential learning through providing health checks to local residents.As a part of the health checks, medical students assessed the PA habits of the city residents and provided PA advice.Health checks were organized as a part of the Healthy Education Lifestyle Programme ("HELP" Day) in May 2009.

Outcome Measures
Outcome measures and measurement procedures have been described in detail elsewhere (Mandic et al., 2017) and are briefly summarized below.Demographic characteristics.Basic demographic data collected included age, gender, ethnicity, country of origin, and self-reported height and weight.Body mass index was calculated as weight in kg divided by height in cm squared.
Assessment of knowledge, skills, and attitudes.Several questionnaires and items developed specifically for this study were used to assess knowledge, skills, and attitudes toward PA advising.Items were developed for this study to assess the awareness of current PA guidelines, publicly available resources on exercise prescription, the 'Green Prescription' initiative, and the benefits of exercise.These items were assessed using five-point Likert scales (1 [strongly disagree] to 5 [strongly agree]).The Green Prescription health initiative is a primary healthcare referral programme available in New Zealand since 1998 (Ministry of Health, 2016).Primary care physicians can refer inactive patients with stable medical conditions to local physical activity providers for free telephone follow-up, one on one, or group support to assist with lifestyle changes (Ministry of Health, 2016).In July 2009, the Green Prescription Initiative was transferred from Sport and Recreation New Zealand (SPARC) to the Ministry of Health New Zealand.
A validated Exercise and Physical Activity Competence Questionnaire (Connaughton et al., 2001) was used to assess students' perceived competence and importance of skills in PA advising.Specific skills included performing a physical examination, determining maximal heart rate, body mass index, and daily nutritional needs, calculating training heart rate and designing an exercise prescription.The questionnaire contained 12 statements using a six-point Likert-type scale (for competence: 1 [not competent] to 6 [very competent]; for importance: 1 [not important] to 6 [very important]).
Students were asked to put themselves in the role of a primary care physician and identify their potential motivations for advising patients about PA, demonstrate their knowledge of current PA recommendations, and identify other health professionals that could assist in providing PA advice (Mandic et al., 2017).

Statistical analysis
Demographic characteristics were described using descriptive statistics.Differences between baseline and follow-up assessments were examined using the paired t-test for continuous variables and Chi-square for categorical variables.Data are reported as mean ± SD or frequency (percentage).A P-value less than 0.05 was considered statistically significant.Data were analysed using SPSS statistical software.

Demographic characteristics
Third-year medical students (n=216; age 21±2 years; 47% male) participated in the intervention and completed both baseline and follow-up questionnaires (9% loss to follow-up) (Table 1).

Awareness and knowledge of PA guidelines
The exposure to the intervention increased students' awareness of the Green Prescription Initiative in New Zealand and the PA guidelines for New Zealand adults (Table 2).The awareness of the American College of Sports Medicine guidelines for exercise in individuals with chronic medical conditions improved but remained low after the intervention.Although the majority of students were aware of the various benefits of Note: *Some participants selected 2 or more ethnic groups; † Other countries of origin include England, Korea, Australia, Brunei, Taiwan, South Africa, Saudi Arabia, and others.Data were missing for 17 participants.
PA before the exposure to the intervention, at the follow-up assessment significantly more students reported awareness of the benefits of both aerobic and resistance training as well as the health benefits and safety of exercise in individuals with chronic medical conditions.

PA advising: Attitudes, competence, and future intentions
The exposure to the intervention increased students' appreciation of the importance of PA advising in general practice and the impact of PA advising on quality of life (Table 2).After the intervention, students also reported higher levels of confidence in their ability to provide PA advice (Table 3).At baseline, most medical students perceived PA advising to be important, and this perception was not significantly changed  as a result of the intervention (Table 3).Although still only moderately competent, after the intervention students perceived increased competence in performing a physical examination, determining maximal heart rate and daily nutritional needs, calculating training heart rate, and designing an exercise programme, in comparison to the baseline (Table 3).
When students were asked to imagine themselves working as primary care physicians five years in the future, the main reasons for future PA advising in general practice (improved fitness, disease prevention, weight control and psychological benefits) remained unchanged between the baseline and follow-up assessments (Table 4).However, a greater proportion of students reported that they were more likely to provide PA advice for musculoskeletal health, physical appearance and social interaction at the follow-up assessment in comparison to the baseline (Table 4).After the intervention, a greater proportion of students reported that they would refer patients to a Green Prescription support (38% increase) and physiotherapist (7% increase), and a smaller proportion would refer patients to a personal trainer (11% decrease) or exercise physiologist (5% decrease) for more specific PA advice compared to the baseline (Table 4).

Discussion
In the present study, the exposure to the PA learning module increased medical students' awareness and knowledge of the PA guidelines and improved their confidence and self-perceived competence in providing PA advice in future.However, even after the intervention, students still perceived themselves to be only moderately competent in providing PA advice.The exposure to the PA learning module broadened students' understanding of different reasons for providing PA advice in general practice and the awareness of other health professionals, particularly Green Prescription support personnel in New Zealand, for further PA advice for their patients.Background knowledge and confidence for PA advising provide a foundation for successful PA advising in general practice.These findings suggest the importance of incorporating PA advising-related curriculum in undergraduate medical degrees.
The present study shows that the exposure to the PA learning module significantly increased medical students' awareness of the PA guidelines, national PA-related programmes (i.e. Green Prescription Initiative in New Zealand), understanding of specific benefits of exercise such as the safety of exercise in clinical populations and the awareness of the other health professionals who can assist in providing further PA advice.These findings are consistent with the results of recent studies and findings from a recent systematic review on PA counselling in medical school education (Dacey et al., 2014;Jones, Brooks & Wylie, 2013).The authors of the present study previously reported that New Zealand medical students had a good understanding of the links between exercise and health and positive attitudes towards PA advising in general practice (Mandic et al., 2017) and those outcomes were not changed considerably after the intervention in the present study.Although the intervention increased students' awareness of the PA guidelines for individuals with chronic medical conditions, students' self-perceived awareness of these guidelines remained low even after the intervention in this study.This finding is not surprising given the brief nature of this intervention, as well as the complexity of and background knowledge required for prescribing exercise for individuals with different medical conditions.
Due to the comprehensive background knowledge required for designing exercise prescription and the time constraints for PA advising in primary care practices, it is therefore essential to raise medical students' awareness of the other health professionals who could assist them in providing comprehensive PA advice for their patients, especially for patients with chronic medical conditions.In the present study, after the intervention, over 80% of New Zealand medical students reported that they would refer their patients to the Green Prescription support (38% increase from baseline) and approximately half of the students would refer their patients to the physiotherapist (7% increase from baseline) compared to the baseline assessment whereas there was a reduction in proportion of students who would refer their patients to a personal trainer.These findings indicate that the exposure to the PA Learning Module in the undergraduate curriculum significantly increased medical students' awareness of the other competent health professionals who could assist in proving specific PA advice for their patients.As suggested previously (Mandic et al., 2017), offering medical students an opportunity to interact with different exercise professionals during their medical training may be an effective way of raising students' awareness of the role of those professionals and the support they can provide.
Although the exposure to the PA learning module increased students' self-perceived competence in providing PA advice, on average students perceived themselves to be only moderately competent in providing such advice.Several previous studies reported that medical students (Connaughton et al., 2001;Vallance et al., 2009) and resident physicians (Rogers et al., 2002) lacked competence for prescribing exercise.Since physicians' confidence in PA-advising skills was significantly influenced by prior training (Rogers et al., 2002), it is essential to provide opportunities for medical students to develop effective skills in PA advising as a part of their undergraduate training.A recent systematic review found that the inclusion of PA advising in medical school curriculum increased students' knowledge, skills, and self-efficacy to conduct PA counselling (Dacey et al., 2014).The results of the present study show that exposure to a short PA learning module consisting of one lecture, three tutorials, and one-day experiential learning increased students' self-perceived competence in providing PA advice and this increase was maintained for four months after the exposure to the intervention.However, even after the intervention, on average pre-clinical medical students perceived themselves to be only moderately competent in providing such advice.Therefore, more extensive training in PA advising may be necessary as a part of the undergraduate medical curriculum to develop medical students' skills, knowledge and confidence for providing effective PA advice in future.As suggested previously, improving medical students' knowledge of and confidence regarding PA promotion is a step forward and may increase the rates and effectiveness of physicians' PA counselling in the future (Jones et al., 2013).
The findings of this study have significant implication for future undergraduate medical curriculums.Given the effectiveness of the PA advising in general practice (Elley et al., 2003;Harsha et al., 1996;Swinburn et al., 1998), the multiple benefits of PA in healthy individuals and clinical populations (Warburton, Nicol & Bredin, 2006), and global efforts to reduce physical inactivity by 10% worldwide (World Health Organization, 2013), it is essential to equip future physicians with the skills, and knowledge for PA advising.The present study shows that the inclusion of the PA Learning Module in undergraduate medical curriculum increases medical students' awareness of the PA guidelines, their self-perceived competence for providing PA advice to patients and awareness of the existence of other health professionals.Since increasing PA levels has multiple health benefits, taking an PA history should be a standard feature of routine medical assessment.Therefore, undergraduate medical training should include a comprehensively planned and delivered the curriculum related to PA assessment and advising.Our findings suggest that future tutorials on PA advising for medical students need to be designed to provide specific training for advising and focus on improving students' competence in providing patient-oriented exercise prescription.

Study limitations
Study limitations include the non-experimental pre-test/post-test study design without a control group and the assessment of students in one medical school.In addition, the newly developed PA Learning Module was designed to introduce PA advising to medical students and did not specifically aim to increase students' overall competence in providing comprehensive PA advice.Finally, the long-term effects of the exposure to the PA Learning Module as a part of the medical education curriculum on subsequent rates of PA advising by future physicians remain unknown.Despite these limitations, the current study was conducted on a large sample of pre-clinical medical students with a high participation rate (91% of the total sample).In addition to the lectures and tutorials, PA learning module in this study included an experiential learning through providing health checks and assessing PA habits of the city residents.Future studies need to examine the effects of comprehensive medical curriculum interventions focused on PA and health and PA advising on short-term outcomes (students' attitudes, knowledge, and confidence in providing patient-oriented exercise prescriptions) and long-term outcomes (the influence of undergraduate medical training on the subsequent rates of PA advising by future physicians in specialist and general practice).Future studies should use objective measures of the medical students' knowledge, skills, and competencies for PA advising and objective measures of students' PA.

Conclusion
The exposure to the PA learning module increased medical students' awareness and knowledge of the current PA guidelines and improved their confidence and perceived competence in providing PA advice.However, even after the training on average students perceived themselves to be only moderately competent in providing PA advice.Therefore, future clinical training on PA advising for medical students should be DOI 10.26773/mjssm.180304MEDICAL STUDENTS CONFIDENCE | S. MANDIC ET AL.

TABLE 1
Demographic Characteristics

TABLE 2
The effects of the intervention on students' knowledge of physical activity guidelines, initiatives, and benefits and attitudes towards PA advising

TABLE 3
The effects of the intervention on students' self-perceived competence in providing PA advice and importance of PA advising

TABLE 4
The effects of the intervention on the reasons for providing PA advice in future and utilization of specialists for further advice