Physical Activity Counseling in Primary Care in Germany—An Integrative Review

Physical activity counseling in primary health care is regarded as a useful complementary preventive and therapeutic measure and is advocated by leading public health institutions. This integrative review summarizes the available data on physical activity counseling in primary care in Germany. A systematic literature search in various databases (peer reviewed and grey literature) was carried out for quantitative and qualitative studies on physical activity counseling and use of “Exercise on Prescription”. The 25 studies included show a very high methodological diversity and, in some cases, considerable risks of bias, with limited comparability across studies. Counseling was provided in all studies by physicians. They report frequent physical activity counseling, which is partly confirmed and partly refuted by patient data. The use of “Exercise on Prescription” is at a very low level. Information on the frequency of physical activity counseling in Germany varies depending on data source and is sometimes contradictory. Our review provides a synthesis of various perspectives on routine physical activity counseling in primary care in Germany. Future studies using standardized and validated instruments in representative samples are needed to further knowledge on counseling and to be able to establish trends in prevalence. Strengthening the topics of physical activity and health and physical activity counseling in medical curriculum is strongly recommended.


Introduction
The evidence on the wide-ranging health benefits of regular physical activity (PA) is overwhelming [1,2]. PA reduces mortality risk, the risk of chronic diseases with the highest disease burden, such as cardiovascular and metabolic diseases, cancers, and diseases of the musculoskeletal system, and is also an effective (complementary) therapeutic measure for these clinical conditions [2]. Nevertheless, PA levels remain low worldwide [3] and in Germany [4].
The relevance attributed to routine PA promotion in primary care is based on two further aspects in addition to the health effects of PA. Through universal access to health care in most Western countries, physicians can reach practically all social-economic groups, and physicians are considered the most important source of health information. Because of this high public health potential, PA counseling in health care has been advocated by a number of public health institutions, including the World Health Organization [5]. In Germany, the Annual Meeting of German Physicians has also recently confirmed the importance of PA counseling as a part of physicians' routine [6].
In international practice, two general approaches in PA promotion in health care are established: PA counseling, where counseling is provided by physicians and/or other health care professionals and patients implement the recommendations on their own; and exercise referral (also called exercise on prescription, green prescription), where physicians refer patients to an existing group offer, usually in

Risk of Bias
According to Hoy et al. [15] Representative data on health of the general population. Health services utilization Prevalence of physicians' PA 1 counseling in the 12 previous months; time trends and regional differences

Risk of Bias
According to Hoy et al. [27] Regional differences in physicians' (1) attitudes to lifestyle counseling,  None of the physicians use the exercise on prescription in the intended sense; physicians attribute high to very high significance of routine PA counseling in both healthy and diseased patients, the perceived effectiveness of the counseling is either very high or very low.
The risk of bias was assessed using the 10-item instrument developed by Hoy and colleagues [40] for quantitative studies. The instrument addresses four domains of bias and provides a summary risk-of-bias assessment. The overall interrater agreement is 91% with a Kappa statistic of 0.82 [40]. Risk of bias in qualitative studies was assessed using the 10-item Critical Appraisal Skills Programme (CASP) checklist [41].

Results
The search yielded 626 records. After deduplication, we screened 587 titles and abstracts and reviewed 92 full texts subsequently. After applying the inclusion and exclusion criteria, 25 articles from 20 studies were included in the descriptive analysis , cf. also Figure 1.
The risk of bias was assessed using the 10-item instrument developed by Hoy and colleagues [40] for quantitative studies. The instrument addresses four domains of bias and provides a summary risk-of-bias assessment. The overall interrater agreement is 91% with a Kappa statistic of 0.82 [40]. Risk of bias in qualitative studies was assessed using the 10-item Critical Appraisal Skills Programme (CASP) checklist [41].

Results
The search yielded 626 records. After deduplication, we screened 587 titles and abstracts and reviewed 92 full texts subsequently. After applying the inclusion and exclusion criteria, 25 articles from 20 studies were included in the descriptive analysis , cf. also Figure 1. Nineteen studies were quantitative, eight of which were conducted with patients, ten with physicians, and one study was based on patient records. Of the six qualitative studies, three were conducted with physicians and one with patients. In two studies, physician-patient discussions formed the data basis, cf. also Tables 1 and 2. Four studies are grey literature [33,[37][38][39].
PA counseling [17,23,24] and the use of EoP per se [18,25,39] were primary research questions in three studies each. The remaining publications represent secondary research questions of other, usually more comprehensive studies, such as cardiovascular disease prevention in primary care [26] or the National Health Survey [15,16,20].
Due to the great methodological diversity of the included studies, a meta-analysis was not feasible.

Study Quality
The results of the methodological assessment are presented in Tables 3 and 4. Nineteen studies were quantitative, eight of which were conducted with patients, ten with physicians, and one study was based on patient records. Of the six qualitative studies, three were conducted with physicians and one with patients. In two studies, physician-patient discussions formed the data basis, cf. also Tables 1 and 2. Four studies are grey literature [33,[37][38][39].
PA counseling [17,23,24] and the use of EoP per se [18,25,39] were primary research questions in three studies each. The remaining publications represent secondary research questions of other, usually more comprehensive studies, such as cardiovascular disease prevention in primary care [26] or the National Health Survey [15,16,20].
Due to the great methodological diversity of the included studies, a meta-analysis was not feasible.

Study Quality
The results of the methodological assessment are presented in Tables 3 and 4. [15] low high low high low high high low high low 5/10 [16] low high low high low high high low high low 5/10 [17] high high high low low high high low high low 4/10 [18] high high high high low high high low low low 4/10 [19] high low high low low high high low high low 5/10 [20] low high low high low high high low high low 5/10 [21] high high high high low high high low high low 3/10 [22] high high high high low high high low high low 3/10 No study has given a formal definition of "physical activity" or "physical activity counseling"; various terms and periphrases were used instead. All quantitative studies that did not evaluate data in patient records used self-developed survey instruments (questionnaires), with one or more items for PA counseling or use of EoP. Physicians were typically invited to provide information on the prevalence of counseling using different level Likert scales. The overall sample of patients to whom the counseling prevalence refers varied and was not explicitly mentioned in every study. None of the physician surveys provided information on how inactive or insufficiently active patients were defined and identified. Patient surveys included questions on PA counseling and prescribing exercise in different past time-periods.

Content of PA Counseling
Beyond data on prevalence, some studies provide information on the content and methods of counseling, such as recommendations for specific types of PA [23,37]; general information on the health benefits of PA [18,23]; recommendation on the frequency and intensity of PA (Kroll 2014); patients' preferences [35]; and disease-related, individual exercise capacity [23]; use of written materials [24,29]; referral to group offers or to therapists [17,24,29,32]; written agreement on goals and follow-up [27,29], and motivational counseling [29].

Self-Assessed Competences and Knowledge, Ability to Motivate
Two studies [26,29] and [24] have assessed physicians' self-rated counseling competence and knowledge. The physicians report high to very high competences and at the same time express doubts that they can actually bring about behavior change in patients [23,24,26,29]. Similar views are also voiced in qualitative studies [34,39].

Barriers
Some studies have assessed barriers to routine PA counseling [23][24][25]39]. These included lack of remuneration, lack of time, patients' disinterest and lack of compliance, lack of information, and lack of networking with partners outside the health care system [17,25,39].

Effects of Counseling
The effects of counseling or prescription of PA were assessed in three studies using non-validated self-reports with different follow-up periods [17,18,20]. No study has used objective measurement methods. Kroll documented the effects of counseling in her qualitative study [37].

Discussion
The first aim of this review was to present data on the prevalence of routine PA promotion in health care in Germany as comprehensively as possible. Our approach was that of an integrative review to "enhance a holistic understanding" of this topic [13]. The second aim was to offer and discuss findings on contents of and barriers to PA counseling. The great methodological diversity, which is inherent in the method of integrative reviews, and the substantial methodological limitations of the studies included make it difficult to draw a conclusive summary. Since to date no review on PA counseling in primary care in Germany has been published, we adopted an approach that allows for the synthesis of different perspectives on the topic. Thus, e.g., the juxtaposition of contrasting physician and patient reports adds a further dimension relative to presenting just "one side" [13].

Prevalence of Counseling
Physician-reported prevalence of counseling is high. The largest nationwide study, with over 4000 respondents, found that 71.8% of primary care physicians offered PA counseling to more than half of their patients [26]. Furthermore, more than 80% of neurologists surveyed in a nationwide study stated that they "frequently" counseled their patients on PA [23]. Moreover, 90% of the general practitioners surveyed in Berlin report offering PA counseling always or frequently if it is indicated [31]. General practitioners in and around the city of Würzburg also give recommendations on PA physical activity to 53.5% of older patients [24]. However, knowledge and use of EoP is limited: less than 8% of the physicians surveyed use it as part of their PA counseling [25] or do not use it in the intended sense [39].
Some, but not all, of the patient-reported data seem to contradict those of the physicians. The representative data of the National Health Surveys show a considerably lower prevalence: 8.6% of patients between 18 and 64 years of age report having received PA counseling in the past 12 months [16]. According to the 1998 National Health Survey, the prevalence of counseling in the 18-79 age group was as low as 6.85% [20]. However, two smaller studies documented an almost fourfold (32.8%) [19] and sevenfold (48%) [17] prevalence of counseling, respectively, in older patients. In a sub-sample of the Leipzig Life Study, 21.5% of patients reported having received PA counseling from their primary care physician [22].
The only study based on patient records found a counseling prevalence of 21.4% [33].
Counseling prevalence seems to be higher in patients with diabetes [16,19] coronary heart disease [16,19], myocardial infarction, osteoarthritis, multi-medication [19], and hypertension [16] than in people without these conditions. These patient-reported data are consistent with those of physicians: physicians with a high proportion of high-risk patients seem to offer counseling more frequently [29]. These results are also in line with data from Sweden [42], the U.S. [43,44], and a systematic review [45].

Contents of Counseling
Current data from Germany provide little insight into how PA counseling is offered. It remains largely unknown whether counseling is based on a theory of behavior change, whether physicians use motivational techniques and, if so, which ones, how they define "inactivity", for which patients they consider counseling to be indicated, how often follow-ups take place. These data would be of major interest when it comes to effectiveness, since though the specific intervention components associated with best result cannot be clearly defined, interventions that include multiple behavioral change strategies such as goal setting, written prescriptions, providing feedback, and follow up, seem to yield better outcomes [12].

Barriers
Primary care physicians' attitudes and perceptions on PA counseling is very similar to those reported from other countries [45]. Physicians typically regard lifestyle counseling in general [26] and PA counseling in particular [25,39] as an important part of their routine as medical professionals, but face a number of barriers. Besides lack of time [23,24,39], patient-related factors such as disinterest, lack of motivation, and lack of compliance [23][24][25]39] are often reported to be important barriers to routine counseling.
There seems to be a disconnect between physicians' and patients' perception of success in behavior change, which is very similar across countries. While physicians in Germany [23][24][25]34,39] and elsewhere [45] cite patients' disinterest and reluctance to act upon advice as one of the major barriers to counseling, patients' reports seem to at least to some extent contradict these relatively widespread assumptions. Indeed, several German studies show that patients value physicians' advice. More than three-quarters of older patients stated that they had decided to keep up with an exercise course recommended by their family doctor, and 82% were generally more interested in a course if their family doctor recommended it [17]. More than half of the patients who received an EoP from their physician reported that they did more exercise and were more active in their everyday life [18]. In the National Health Survey, compliance rate upon counseling was 52% [20]. Appreciation of physicians' support in increasing PA has been found in various countries and patient groups [46][47][48].
Lack of remuneration for counseling is mentioned in every study that identified the barriers [23][24][25][26]29], but interestingly, it is not always considered the most important factor.

Findings in Relation to Other Countries
The widespread call and advocacy for routine PA promotion in primary care notwithstanding there seems to be a paucity of current representative data on PA counseling prevalence. Representative patient-reported data indicate that in 2010 about one third of all U.S. patients who had seen a physician or other health professional in the previous 12 months had received advice on PA [43]. In a national sample, which was representative in some but not all relevant terms, 18.2% Australian adults reported having received PA counseling from their physician in the previous 12 months [49].
In a nationwide Brazilian study, over 80% of physicians reported regularly providing PA counseling [50]. A nationally representative survey of primary care physicians in the United States found that 93.9% and 86% provide guidance on PA "often" or "always" to patients with and without chronic diseases respectively [44]. In a national survey among Canadian primary care physicians, 85% of respondents reported asking their patients about PA, whereas only 15.8% provided written advice [51]. Similar rates have been reported from Ireland [52]; 88% of survey participants reported asking about PA, but the vast majority (82.6%) did not provide written prescription [52]. These findings collectively suggest considerably higher physician-reported prevalences than patient-reported ones.
Based on electronic patient records, an EoP was issued to 3% of all patients in primary and secondary care in a Swedish County Council [42].
Involving allied health care professionals, such as nurses, physiotherapists, or exercise scientists, into PA counseling in primary care is practice in some countries [53]. This interdisciplinary model has been shown to produce better result than physician-only approaches [53]. We could identify no study in Germany where professions other than physicians were involved. The less than optimal cooperation between professions and sectors was cited as a barrier in various studies [17,18,25,34,39].
We see improved interdisciplinary work as a key element to enhance the prevalence of PA counseling in primary care.
Direct comparison between countries is challenging for various reasons. Assessment methods (self-report vs. patients' records), data sources (patients vs. physicians), patient and physician characteristics differ in different countries. Interestingly, data showing that physicians tend to offer advice on PA more readily to already diseased populations than to currently healthy participants seems to be consistent across countries, data sources, and assessment methods [16,42,45,49]. Encouraging patients with chronic diseases and compromised health to be more physically active is very welcome. On the flipside, PA counseling seems to be underutilized as a preventive tool.

Strengths and Limitations
To the best of our knowledge, this is the first study to give an overview of PA counseling in primary care in Germany. We have followed the strict criteria of the PRISMA recommendations. In order to provide the most comprehensive overview possible, we have included both quantitative and qualitative studies from peer reviewed and grey literature. At the same time, our review must be seen in the light of the limitations of the studies included.
There are no widely accepted reporting schemes for survey studies, which leads to inconsistent reporting [54]. In the included studies, with a few exceptions, response rates were low, and most studies did not provide information on item non-response (complete vs. partial answers to the questions). We cannot exclude the possibility that the data presented here contain a positive bias. Self-selectivity may have played a role for both physicians and patients, and physicians may have indicated more frequent counseling activity (social desirability). Overall, the methodological limitations greatly reduce the generalizability of the results.

Conclusions
Data on the prevalence of PA counseling in Germany vary according to data source and are sometimes contradictory. Direct comparison with other countries is challenging due to methodological issues. Perceived barriers to routine PA counseling in primary care seem to be very similar to those reported from other countries. To improve comparability among studies and to improve overall methodological quality, standardized instruments should be developed and validated. Surveys in representative samples using such instruments are needed to further knowledge on counseling and to be able to establish prevalence trends. Conducting studies on counseling methods and contents can add valuable information beyond prevalence. Strengthening the topics of physical activity and health and physical activity counseling in medical curriculum is strongly recommended.