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301 568 0097

 

LIBRARY

Michigan State
University

 

 

 

This is to certify that the

thesis entitled

Primary Care Providers' Practices
and Peceptions Regarding Exercise
Counseling for the Elderly

presented by

Amy Marie HaClunann

has been accepted towards fulﬁllment
of the requirements for

Masters degree in Nursing

 

 

(:JALiﬂl/LJ J4)&4H42 [fZA/;IO{QZ>

Major professor/

April 30, 1997

MS U is an Aﬂirmative Action/Equal Opportunity Institution

 

PRIMARY CARE PROVIDERS' PRACTICES AND
PERCEPTIONS REGARDING EXERCISE COUNSELING
FOR THE ELDERLY
By
Amy Marie Hackman

A THESIS

Submitted to

Michigan State University
in partial fulﬁllment of the requirements
for the degree of

MASTERS OF SCIENCE IN NURSING

College of Nursing
1997

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ABSTRACT

PRIMARY CARE PROVIDERS' PRACTICES AND
PERCEPTIONS REGARDING EXERCISE COUNSELING
FOR THE ELDERLY

By
Amy Marie Hackman ,

The elderly present primary care providers with a number of
challenges, the most important of which centers on the declining
physical activity and sedentary lifestyle associated with aging. There
are few studies referring to counseling by Advanced Practice Nurses or
Physicians Assistants. A quantitative study utilizing a questionnaire
was used to explore the relationship between primary care providers'
perceptions and practices regarding exercise counseling for the elderly.
The intent was to identify differences in counseling amongst different
provider types. The descriptive data obtained enabled the investigator
to identify the distributions of provider characteristics, barriers to
counseling and current sources of information used regarding exercise
guidelines for the elderly. Results indicated that provider type was
not related to counseling or their perceived success in counseling
regarding exercise. It was found that those who perceived themselves
as moderately to very successful in counseling actually did counsel the

elderly regarding exercise on a more consistent basis.

 

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ACKNOWLEDGMENTS

I would like to thank the faculty of my thesis committee: Joan
Wood, Sharon King and Linda Keilman. Thank you for all your
expert guidance, knowledge and encouragement.

I would also like to thank my family for supporting me in this
endeavor of graduate school. Thank you for your support,

encouragement and understanding, especially to Greg who was always

there for me. Thank you!

iii

 

LIST

CH2
INT

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DEF

TABLE OF CONTENTS

Page
LIST OF TABLES ............................................................... vii
LIST OF FIGURES ............................................................ viii
CHAPTER 1
INTRODUCTION .................................................................. 1
Purpose ............................................................................. 3
CHAPTER 2
DEFINITIONS: OPERATIONAL AND CONCEPTUAL... 5
Elderly .............................................................................. 5
Conceptual .................................................................... 5
Operational ................................................................... 5
Exercise ............................................................................ 6
Conceptual .................................................................... 6
Operational ................................................................... 6
Counseling ....................................................................... 6
Coceptual ...................................................................... 6
Operational ................................................................... 7
Primary Care Provider .................................................... 7
Conceptual ................................................................... 7
Operational ................................................................... 7
CHAPTER 3
REVIEW OF LITERATURE .............................................. 8
Exercise Beneﬁts ............................................................. 9
Cardiovascular Disease .................................................... 9
Osteoporosis ..................................................................... 10

iv

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Elderly and Exercise ....................................................... 10

Preventive Health Care and the Elderly ........................ 12
Primary Care Provider and Counseling ......................... 12
Barriers to Counseling .................................................... 16
Guidelines in Counseling ............................................... 16
CHAPTER 4
THEORETICAL FRAMEWORK ......................................... 19
Interaction Model of Client Health Behavior ................ 19
Professional Singularity ................................................... 23
CHAPTER 5
METHODS ........................................................................... 26
Design ............................................................................. 26
Sample ............................................................................ 28
Questionnaire .................................................................. 29
Proceedure ...................................................................... 30
Protection of Human Subjects ...................................... 31
CHAPTER 6
DATA PRESENTATION ................................................... 32
Demographics ................................................................ 33
Practice ........................................................................... 36
Barriers ........................................................................... 39
Sources of Information .................................................. 40
CHAPTER 7
DISCUSSION ....................................................................... 42
Practices and perceptions ................................................ 42
Interaction Model of Client Health Behavior ................ 45
Limitations ....................................................................... 46
General Implications ........................................................ 47
Education ...................................................................... 47
Practice .......................................................................... 48
Research ........................................................................ 49
APN Implications ........................................................... 49
Education ..................................................................... 49
Practice ......................................................................... 50
Research ....................................................................... 51

AP

AP

US

Conclusion .......................................................................
APPENDIX A: QUESTIONNAIRE ...................................
APPENDD( B: COVER LETTER .....................................
APPENDIX C: APPROVAL LETTER FROM UCRIHS..

LIST OF REFERENCES ....................................................

52

54

58

 

Tab

Tab

Tat,

Tat

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Ta]

Tal

LIST OF TABLES

Table 1 - Demographic Characteristics of the Respondents ....... 34
Table 2 - Primary Care Providers' Patients over 65 and

Practice Setting ............................................................. 35
Table 3 - Primary Care Providers' Responses Regarding

Exercise Counseling by % of Clients Asked ............ 36
Table 4 - Relationship of Provider Perceived Success and

'Actual Counseling ...................................................... 38
Table 5 - The Association Between Frequency of Counseling

and Provider Perceived Importance of Exercise in the

Elderly ......................................................................... 38
Table 6 - % of Response of Primary Care Providers' Perception

of Barriers to Exercise Counseling ........................... 39
Table 7 - % of Responses of Primary Care Providers' Sources of

Information Regarding Exercise in the Elderly .......... 4O

vii

LIST OF FIGURES

Figure 1 - Interaction Model of Client Health Behavior ......... 21

Figure 2 - Modiﬁed IMCHB: Element of Professional

Singularity: Background Variables ........................... 24

viii

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Chapter 1
INTRODUCTION

The 1990's have brought increased attention to aging, health care
and quality of life. The proportion of elderly persons in America is
growing quickly; individuals over the age of 65 currently account for
12% of all Americans. It is estimated that in the next 50 years this
ﬁgure will rise 20% (Healthy People 2000, 1990). According to the
1990 census, men and women are living on the average to the ages
of 79.7 and 83.6 years respectively (Barry & Eathome, 1994).

Health in the elderly is deﬁned as "the absence of disease, the
maintenance of optimal function, and the presence of an adequate
support system" (Klinkman, Zazove, Mehr & Ruffm, 1992, p. 205).
Although preventive health care and aging are not usually thought of
together there is a great need for preventive health care and
enhancement of positive health behaviors in the elderly.

Changes in attitudes of health care providers toward preventive
health care in the elderly can be seen in two national efforts. The

Department of Health and Human Services (1990) revised its Year

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2000 goals for the elderly to include more preventive health care
objectives and the Institute of Medicine (1990) commissioned a special
committee to investigate what is known about preventive health care in
the elderly (Ory & Cox, 1994). Both of these reports contain data
suggesting a change in attitude by health care providers regarding
preventive health care for the elderly.

One of the general goals of preventive health care in the elderly
is maximizing life span while minimizing morbidity and functional
disability (Gleich, 1995). Sources of morbidity and mortality in this
age group include hypertension and cardiovascular disease, diabetes,
arthritis, osteoporosis, neuropsychiatric disease, decreased social and
sensory stimulation and general functional decline (Barry & Eathome,
1994; Elward & Larson, 1992; Gorman & Posner, 1988). 1

Primary care providers for the elderly ﬁnd that functional
impairment from physical disability and maintenance of independence
are two of the most challenging management problems (Elia, 1991).
With increases in the average life span there should be more than
sufﬁcient time for interventions directed at preventive health care to
have an effect on improving the quality of life and functional status
of the elderly.

The US. Preventive Service Task Force (1989) recommendations

for the elderly include "clinicians should provide all patients with

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information on the role of physical activity in disease prevention and
assist in selecting an appropriate type of exercise" (p 7). Despite the
inclusion of exercise in these guidelines, few elderly actually receive
counseling regarding exercise or engage in any type of exercise
program (Sommers, 1988).

Evidence is mounting that exercise can maximize functional
capacity in the elderly population and that individuals who engage in
regular exercise tend to maintain a higher level of functioning (Elward
& Larson, 1992). Given the increased life expectancy and increased
number of health risks in the elderly, providing preventive health care
must be made a major concern of the primary care provider (Price,
Desmond, Losh & Krol, 1988). The challenge for health care
providers is to enhance a "disability free" life by increasing the quality
of life through guidance of preventive health care for the elderly.
PM;

There is more evidence in the past decade that supports the
beneﬁts of exercise in the elderly. Despite the positive consequences
of exercise, there tends to be a marked reduction in physical activity
with increasing age. The role of the primary care provider and
his/her counseling regarding exercise and its beneﬁts to the elderly has
received little attention in the literature. There are few studies that

evaluate the effectiveness of exercise counseling by the primary care

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provider. Therefore, the purpose of this study is to examine the
relationship between characteristics of primary care providers and the
perceptions and practices of these providers regarding exercise
counseling for the elderly.

Several questions are to be answered in this study. What are
the characteristics (age, gender, provider type) of primary care
providers in rural Southwestern Michigan? How often do primary care
providers ask and counsel their elderly clients about exercise? How
successful do primary care providers perceive themselves as exercise
counselors for the elderly? Are there any associations between the
characteristics of the providers and how often they ask and counsel
regarding exercise? Is there any association between perception of
success and actual counseling of the elderly regarding exercise? Are

there any differences in counseling practices amongst provider types?

Chapter 2
DEFINITIONS: OPERATIONAL AND CONCEPTUAL

Sci—6L1!

Conceptual

Most people do not consider themselves to be old or elderly
until they become sick or dependent upon others. In most of the
literature the term "elderly" refers to a group of individuals over the
age of 65 (Elia, 1991). Some researchers have further developed the
deﬁnition of elderly by placing them into more distinct groups which
include the young-old (age 65 to 75) and the old-old (85 and above)
(Elia, 1991).

Operational

The operational deﬁnition of elderly for this study will be those
individuals who are aged 65 and older. This deﬁnition was chosen
based upon the fact that it is used most frequently in national health

statistics and in Medicare regulations.

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Conceptual

Physical activity and exercise are used interchangeably
throughout the literature. The beneﬁts of geriatric exercise include
improvement of physical well—being, cognition, and self-image;
decreased cholesterol levels; positive approach to life; and potentially
indirect positive effect on caregivers (Zazove, Mehr, Rufﬁn, Klinkman,
Peggs, & Davies, 1992). Most researchers deﬁne people as sedentary
if they exercise less than three twenty minute sessions a week
(Busby-Whitehead, 1995; Woolf, Kamerow, Lawrence, Medalie, &
Estes, 1990; Zazove, et a1, 1992). The Public Health Service (1980)
deﬁned physical activity in the elderly as "exercise which involves
large muscle groups in dynamic movement for periods of 20 minutes
or longer, three or more days per week, and which is performed at an
intensity of 60% or greater of an individual's cardiorespiratory
capacity" (p. 30).

erational

For this study exercise will be deﬁned as an increase in
physical activity as perceived by the primary care provider.
Counseling

Conceptual

Much of the literature refers to the interaction between client

 

and
CDC
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infor

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and provider as the communication that goes on during health
encounters (Harris, Caspersen, DeFriese, & Estes, 1989; Makoul,
Amtson, & Schoﬁeld, 1995; Price, Desmond, Losh, & Krol, 1988;
Sherman & Hershman, 1993). Counseling involves education and
teaching by the primary care provider to the client at a routine ofﬁce
visit. Counseling regarding exercise refers to the exchange of
information about health beneﬁts of regular exercise and guidance in
selecting an appropriate exercise program (Woolf, et a1, 1990).

Mational

For the purpose of this study counseling refers to the
communication regarding exercise between primary care provider and
client at a routine ofﬁce visit as perceived by the provider.
_Pri_mary Care Provider

Conceptual

In general the research literature focused on physicians as
providers (Price, Desmond, Losh, & Krol, 1988; Sherman &
Hershman, 1993). There were no studies reviewed that referred to
counseling by advanced practice nurses or physician assistants.

Operational

A primary care provider in this study is a physician, advanced
practice nurse (APN) or physician assistant in family practice providing

general family health management to elderly clients.

 

 

1 980
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and

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Chapter 3
REVIEW of LITERATURE

The literature review included research studies published between
1980 and 1996 on exercise in the elderly, counseling the elderly in
primary care and guidelines for exercise counseling for the elderly.

An online search using CINAHL, Medline and Eric was conducted
with keywords, (exercise, elderly, primary care provider, communication
I and counseling). Research utilized was readily available from a large
university library. Doctoral dissertations, masters thesis, conference
proceedings and unpublished works were not easily accessible and
therefore not reviewed.

The literature review is organized into the following sections:
exercise beneﬁts, cardiovascular disease, osteoporosis, elderly and
exercise, preventive health care and the elderly, primary care provider
and counseling, barriers to counseling and guidelines in counseling.
These topics reﬂect the current related issues in the literature including
exercise beneﬁts and the most common related diseases. The other

topics are areas of interest relevant to this study and are an important
8

 

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part of the review.
Exercise Beneﬁts

Many of the most recent publications share a common theme
relating to the positive beneﬁts that exercise can bring. Positive
beneﬁts include improved health, increased quality of life, reduction of
risk for various diseases, i.e., cardiovascular, altered glucose
metabolism and diabetes, neuropsychological function and osteoporosis
(Elward & Larson, 1992; McPhillips, Pellettera, Barrett-Conner,
Wingard & Criqui, 1989; Zazove, et al., 1992). Decreased exercise
has been associated with many medical conditions that contribute to
geriatric morbidity and mortality (Barry & Eathome, 1994; Zazove, et
al., 1992). A variety of physiological changes and a slow progressive
decline in function occur naturally with aging (Carethers, 1992).
Cardiovascular Disease

The role exercise plays in cardiovascular disease is of particular
importance. The preventive effect on heart disease is as important as
smoking cessation and lowering blood pressure (Harris, Caspersen,
DeFriese, & Estes, 1989). Posner, Gorman, and Gitlin (1990) found
that regular exercise, even when started late in life, can delay the
onset of symptomatic cardiovascular disease. Paffenbarger, Hyde,
Wing, and Hsieh (1986) examined the lifestyles of almost 1700

Harvard alumni aged 35 to 74. During the follow-up period of 12 to

 

l6

inn

0%
(El
tha
ml
ex

w

inc

10

16 years nearly two thirds of the alumni died. Paffenberger, et a1
(1986) found that death rates declined as energy expended in exercise

increased and by the age of 80, exercise lead to an increase of 1 to 2
years additional life.
Osteop_orosis

In the United States over 24 million people have osteoporosis
(Elward & Larson, 1992). Dalsky, Stocke and Ehsani (1988) reported
that weight bearing exercises led to signiﬁcant increases in bone
mineral content in older, previously sedentary women and that
exercise needed to be continuous in order to sustain this beneﬁt.
Weight bearing exercises have been shown to decrease bone loss and
increase bone mineral content (Kavanaugh & Shephard, 1990).
Exercise may play a role in the prevention of osteoporosis as well.
Smith, Reddan and Smith's (1981) research demonstrated that even a
low level exercise program increases bone mineralization in older
women.
Elderly and Exercise

Little research was found about the actual extent to which older
adults engage in exercise. McPhillips, Pellettera, Barrett-Conner,
Wingard, and Criqui (1989) determined that while the amounts of
moderate and heavy exercise decreased with age, rates of participation

in and duration of light exercise actually increased. Walking was the

 

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gen:

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11

most common form of exercise reported. McPhillips et a1 (1989)
found that of those who walked, nearly 60% did so three times a
week for at least 20 minutes at a time.

The National Center for Health Statistics Survey regarding the
elderlys' lifestyles revealed: 16% smoke, 12% drink 10-12 alcoholic
beverages every two weeks, 20% are overweight and 71% are
sedentary. In addition further analysis of this data by Caspersen,
Christensen & Pollard (1986) found that regular exercise is uncommon
among those aged 65 years and older. Recommendations and
guidelines for preventive health care counseling, especially exercise
counseling, remains insufﬁcient at this time (Alto, 1995).

Exercise has infrequently been incorporated into the health
promoting behaviors of the elderly. Only 30% (244) of those over 65
report exercising regularly (McPhillips, Pelleterra, & Barrett-Conner,
1989). More than 40% age 65 years and older report no leisure time
physical activity and less than 10% participate in regular aerobic
exercise (Healthy People 2000, 1990). The goals of exercise depend
on the needs and desires of the individual. Elward and Larson (1992)
generalized goals to include improvement in cardiopulmonary and
muscular ﬁtness, preservation of functional ability, and
participation and maintenance of an exercise program so that beneﬁts

result.

12

Preventive Health Care and the Elderly

Regular exercise is now recognized as a critical element in
preventive health care in adults (Ory & Cox, 1994). Although
preventive health care and aging are not usually thought of together
there is a great need for preventive health care and enhancement of
positive health behaviors in the elderly. Freid, Rosenberg and Lipsitz
(1995) measured knowledge of various health promotion and disease
prevention topics with the elderly. They found ahnost all of the
population studied were aware of the topics and had some discussion
with their physician regarding them. Freid, Rosenberg and Lipsitz
(1995) found that 93% of the elderly knew about exercise and 78%
thought it was important. Most elderly who exercised attributed their
activity to self-initiation rather than to physician referral (Freid,
Rosenberg & Lipsitz, 1995).
Mare Provider and Counseling

To foster preventive health care in the elderly, providers need to

 

be knowledgeable about recommended prevention measures and
combine these with effective communication skills (Black & Kapoor,
1990). Interest in the role of the primary care provider in reducing
modiﬁable risks to health has given rise to surveys regarding the
education and counseling activities of primary care providers (Mullen

& Tabak, 1989). A study of physicians and their tasks in client

 

 

:-

13

education revealed that they consider client education as a central task,
but the range of methods they were willing to use was limited
(Spronk & Warmerhoven, 1985). Spronk and Warmerhoven (1985)
interviewed 52 physicians using an open-ended questionnaire. The
questions elicited information regarding: 1) their role as providers of
information to their clients, 2) what they thought about the different
aspects of client education and 3) the problems or limitations they
experienced related to client education. Almost every physician
believed he/she was the most important person to provide client
education. Most of the physicians were only willing to do counseling
and education in their setting and did not become involved in group
methods of education. The most frequently mentioned problems in
client education were 1) translating medical terms into understandable
language, 2) dealing with the ideas and images clients have of the
human body and its functioning and 3) getting little or no response
from clients on the information and explanation given.

Kottke, Brekke, and Solberg (1993) found that health education
can be effectively incorporated into routine ofﬁce visits with minimal
additional time. The increased frequency of visits by the elderly
creates a signiﬁcant opportunity for providers to disseminate health
information and advice to their elderly clients. Education should begin

with the initial visit and be reinforced at each subsequent visit (Barry

l4

& Eathome, 1994). A client visit for a current health problem allows
the primary care provider an opportunity to include preventive services
and anticipate future development of health problems (Radecki &
Cowell, 1990; Warshaw, 1986). The challenge to the provider is to
present and emphasize a variety of health related behaviors in the
context of a routine medical visit (Radecki & Cowell, 1990).

As stated earlier, few studies have evaluated exercise counseling
by primary care providers. Studies surveying physicians' preventive
health care activity prescriptions for the elderly, found that the most
commonly prescribed practices were related to smoking cessation,
yearly stool for occult blood testing, monthly breast exams and yearly
prostrate exams. Engaging in regular exercise was seventh on the list
(Price, Desmond, Losh & Krol, 1988; Radecki & Swofford, 1986).
Logsdon, Rosen, and Demak (1982) studied the effect of brief training
sessions for physicians to administer various preventive health care
interventions, including exercise counseling. Preliminary data indicated
that 35.9% of clients that had exercise counseling began a program of
regular exercise whereas 28.2% of the clients without exercise
counseling at the control site had began a program of regular exercise.
The health of the client prior to the study was not addressed. Only
one other study suggested that primary care providers who counsel

their clients to exercise actually demonstrated improved exercise habits

 

in
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15

in their clients (Harris, Caspersen, DeFriese & Estes, 1989). Most of
the studies showing the effectiveness of exercise counseling were in
cardiac rehabilitation programs (Harris, Caspersen, DeFriese & Estes,
1989).

Only a few studies assessed the perception of or actual
counseling done by providers. It was found that physicians with good
personal health habits counsel their clients more about all health
preventive activities regardless of their clinical specialties (Wells,
Lewis, Leake & Ware, 1984). Price, Desmond, Losh and Krol (1988)
surveyed the perceptions and practices of physicians regarding health
promotion in the elderly. He found that: a) 88% of providers
believed that counseling is of value to clients of all ages, b) 69% of
providers thought medical schools should put more emphasis on
counseling and c) 25% of providers believed that the elderly are
interested in preventive health care issues.

Many of the research reports found that clients perceive
providers of health care as the most important source of health
information (Becker & J anz, 1990; Freidman, Brownson, Peterson &
Wilkerson, 1994; Harris, Caspersen, DeFries & Estes, 1986).

Despite these ﬁndings, providers have been remiss in the provision of
basic preventive care and particularly counseling regarding exercise for

the elderly (Lurie, Manning, Peterson, Goldberg, Phelps & Lillard

 

 

198

 

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16

1987; Morris & Morris, 1988).
Barriers to Counseling

Primary care providers have an opportunity to encourage
preventive health care and maintenance at every age level and at each
level of functional ability. Providers of primary care repeatedly report
that the reason for not providing preventive services is that they do
not have "time" (Kottke, Brekke & Solberg, 1993).

Treatment of multiple diseases and problems are characteristic of
the elderly population. While clients 65 and older are more likely to
require more time regardless of the reason for the visit, it is
interesting to note that general and family physicians spend equal or
less time with this population compared to clients 45 to 64 years old
(Radecki, Kane, Solomon, Mendenhall & Beck, 1988). Radecki and
Swofford (1986) found that the lowest rates of counseling by primary
care providers was for surgical clients followed by preventive care
counseling in all age groups. The 65 and older age group was
signiﬁcantly lower in patient education and counseling than any other
age group (Radecki and Swofford, 1986) .

Guidelines in Counseling

Primary care providers appreciate the importance of preventive

health care in the elderly, yet recommendations and guidelines for

preventive health care counseling remains insufﬁcient (Alto, 1995).

17

Primary care providers should routinely assess their clients' exercise
practices and counsel them in engaging in a program of regular
exercise that is tailored to their health status and lifestyle. While lists
of preventive recommendations for the elderly have been formulated,
the debate continues as to which preventive services are important and
which should be the focus of counseling by the primary care provider
(Black & Kapoor, 1990).

The American College of Sports Medicine (1991) issued
guidelines for different types of exercise including general exercise and
organized exercise. National public health policy directives recognize
that physiological and psychological conditions of aging can be
prevented or delayed in asymptomatic persons with increased exercise
(Klingman & Pepin, 1992). The US. Preventive Services Task Force
and the American Academy of Family Physicians recommend that all
clients should receive counseling on the role of exercise in preventive
health care (US. Preventive Services Task Force, 1989).

Health care providers are being urged to reduce the prevalency
of sedentary lifestyles by counseling their clients to exercise (Harris,
Caspersen, DeFriese & Estes, 1989).

With the state of knowledge that is available in preventive
health care and health screening, there remains a differential between

the primary care providers intellectual acceptance, awareness of these

18

guidelines and the actual use of these guidelines on a regular,

consistent basis.

Chapter 4
THEORETICAL FRAMEWORK
Interaction Model of Client Health Behavior

The Interaction Model of Client Health Behavior (IMCHB)
framework provides a basis for exploring the relationship between the
concepts of interest, (i.e. the research question), and describing study
ﬁndings. The IMCHB (Cox, 1982) was developed to satisfy the
need for a client focused theoretical framework to guide nursing
research and practice.

After reviewing and critiquing nursing and non-nursing
perspectives on client health behavior, Cox (1982) concluded that these
various models failed to demonstrate their "practical value and
relevancy to the practicing clinician, who must decide how to proceed
given the multidirnensionality and variability of a client's behaviors"
(p. 44). Cox also addressed the failure of these models to attend to
the role of the provider in effecting client behavior. Previous models
assumed that clients behave in a given manner with no emphasis

placed on provider characteristics. Additionally these models fail to

10

20

attend to the role of the professional in effecting client behavior. Cox
(1982) believes that because the client-professional relationship has
shown a consistent impact on positive health behavior, the relationship
is essential in the model.

The IMCHB emphasizes the process by which the singular
position of each client is translated into health care behavior. "The
object of the model is to identify and suggest explanatory relationships
between client singularity, the client-provider relationship, and
subsequent client health care behavior" (Cox, 1982, p. 46).
Assumptions of the model are: a) clients are capable of making
informed, independent, and competent choices regarding their health
care behavior and b) clients should be given a maximum amount of
control in determining the quality of their health and actions taken to
preserve that state of health. "Self care by no means implies or
negates a decreased role for the health care professionals; on the
contrary, it demands that they be even more skilled in the
identiﬁcation of the client's holistic needs" (Cox, 1982, p. 54).

The model's usefulness is greatest in situations of client
responsibility and control of a health problem or health promotion
effort (Cox, 1982). In these situations the role of the primary care

provider becomes more of a teacher and counselor. Figure 1 presents

21

the IMCHB model and identiﬁes the major elements and factors that

mediate relationships among these elements.

 

Elements of Client Singularityl

 

 

 

Background Variables

_, 1. Demographic
V Characteristics
I

e 2. Social Inﬂuence
l

L 3. Previous Health
Care Experience

 

 

L L 4. Environmental
Resources

 

Vl’

 

 

 

 

if Elements of

Professional Interaction

 

 

 

Intrinsic
Motivation

 

 

l

T”?

 

 

Cognitive
Appraisal

 

 

l

 

 

Affective
Response

 

 

 

Nonrecursive Block

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Elements of

Health Outcomes

A

/

 

We " 1. Utilization of health
Support care services
2. Clinical Health
Health status indicators
Information 3. Severity of health
care problem

Decisional 4. Adherence to
Control recommended

» care regrmem
Professional/ 5. Satisfaction with
Technical care
Competemcies

 

 

 

 

 

 

 

Figure l. The Interaction Model of Client Health Behavior

(Cox 1932).

The IMCHB model consists of three major elements: 1) client

singularity, 2) client-professional interaction and 3) client health

outcomes.

Client sipgplarig describes the client's background

variables, intrinsic motivation, cognitive appraisal of the health care

concern, and the affective response to that concern. The background

22

variables include the client's demographic characteristics, social
inﬂuences, previous health care experiences, and environmental
resources (Cox, 1982). "The concepts and constructs represented
within the elements of the model must be transformed into speciﬁc
variables that represent a speciﬁc health care issue" (Cox, 1986, p.
42). The combination of the elements of client singularity help primary
care providers determine an interactional approach and plan of
intervention (Cox, 1986).

Elements of client professional interaction is viewed as a major
inﬂuence on health care behavior by Cox (1982). The model suggests
four components that deﬁne this interaction; these include: a) provision
of health information to the client regarding details about what can
and cannot be done, b) affective support that attends to the client's
level of emotional arousal, c) decisional control of the client to make
his/her own decisions and d) professional-technical competencies
needed by the client from the provider (Cox, 1982).

The elements of heﬂgoumomgp include ﬁve variables: 1)
utilization of health care services, 2) clinical health status indicators,
3) severity of health care problem, 4) adherence to the recommended
care regimen and 5) satisfaction with care.

The IMCHB has been useful in explaining risk related health

behaviors. The model‘s structure and utility have been documented

23

extensively (Brown, 1992; Cox, 1986; Marion & Cox, 1996; Hill-Rice,
Fox, Lepczyk, Sieggreen, Mullin, J arosz, & Templin, 1994; Troumbley
& Lenz, 1992). Marion and Cox (1996) investigated condom use and
fertility among divorced and separated women. Brown (1992) tested
the IMCHB in her research to see if Advanced Practice Nurses (APN)
tailored their care based on individual clients. According to Cox
(1982) the APN tailors health care based on the clients singularity and
allows that singularity to determine the interactional approach. Cox
and Roghmann (1984) tested the IMCHB to show that both the
individuality of the client and the client professional interaction were
signiﬁcant determinants of health decisions and subsequent health
behavior. Hill, et a1 (1994) used Cox's model to organize the
numerous factors thought to affect smoking behavior. Troumbley and
Lenz (1992) utilized only portions of the model and emphasized client
singularity.
Professional Singularity

The IMCHB does not address the contribution of professional
singularity. However, Harris (1978) suggests that clients are inclined
to change health behaviors when their provider counsels them to do
so. A new conceptual dimension of the model, professional
singularig, has been developed and was used to guide the current
study. Figure 2 depicts the variables identiﬁed thru the literature

24

search which appeared to contribute to the providers role in prevention
and counseling. The background variables of the provider, the
demographic characteristics, age, gender, years in practice and type of
provider (APN, D.O., M. D. and P.A.), experience (the type of
training as well as the source of health information as well as social
and environmental baniers to providing health information to clients.
Figure 2 depicts these variables as elements of Professional
Singularity. The element of Professional Singularity would ﬁt into the
IMCHB model under Client Singularity and would contribute to the
Elements of Client -Professional Interaction and ultimately Elements of
Health Outcomes. The area of background variables of the provider
has been shaded gray to help distinguish the part of the model under

current investigation.

 

Elements of Professional -
Singularity

 

Background Variables

1. DemOgraphic _
1 Characteristics ML
, ’ - age, gender, provider Elements of Elements of
V' ' type * .——-—) Client-Professional ---> Health Outcomes
2. Experience ‘ ‘ Interaction
'- type of training ~
3. Social Inﬂuence ., [
T ‘- barriers to counseling
4. Environmental Resources
, ~ -, health information '

 

--W-pﬂ—

 

 

 

 

 

 

 

 

 

 

Figure 2. Modiﬁed IMCHB: Element of Professional Singularity.

25

It is important to include Professional Singularity in this model
due to the impact of the described background variables on the
client-professional interaction and ultimately the health outcomes.

What the professional brings to the interaction is just as important as
what the client brings and it is the combination of these variables that
play a role in the interaction and the determinant of the outcome.

Information imparts knowledge; without knowledge clients cannot
make informed health decisions. If the information provided is
sufﬁcient and has meaning to the client, adaptation should follow
(Cox, 1982). "This model acknowledges that information and
knowledge are necessary conditions which effect positive health
behaviors" (Cox 1982, p. 52).

In summary the IMCHB is an appropriate framework for this
study because it addresses the importance of the interaction that occurs
between client and professional. The proposed modiﬁcation of the
IMCHB: elements of Professional Singularity focuses on the
background characteristics the the professional (primary care provider)

brings to the client-professional interaction.

Chapter 5
METHODS
298.ng

A quantitative study utilizing a descriptive questionnaire was
used to explore the relationship between primary care providers'
characteristics and their perceptions and practices regarding exercise
counseling for the elderly. An advantage of using a descriptive
research design is that large amounts of data can be collected and a
large number of interrelationships can be discovered in a short period
of time (Polit & Hungler, 1985). A limitation of this type of design
is that it doesn't allow any cause and effect inferences to be made by
the investigator.

Most of the data obtained from the questionnaire was descriptive
data. Measures of central tendency and frequency distribution tables
were used. Frequency distribution tables allowed the investigator to
analyze provider characteristics, as in questions 1-6. After entering
the data, the responses to these questions were grouped into smaller

categories for ease in interpretation. Measures of central tendency

26

27

(mean, median and mode) were used for questions 7 and 8 that ask
the subject to choose a given response. Polit and Hungler (1985)
state "to describe a distribution adequately, there is a need for a
measure of variability that expresses the extent to which scores deviate
from one another" (p. 383).

Cross tabulations were used to examine the interrelationships
between the provider characteristics (age, gender, provider type) and 1)
how often they ask the elderly about exercise (questions 9-12), 2) how
often they counsel the elderly about exercise (questions 14-17) and 3)
how successful they perceive themselves as exercise counselors for the
elderly (questions 21-23). Cross tabulations allowed the investigator to
study the relationship between the variables of interest (Polit and
Hungler, 1985).

The Phi coefﬁcient and/or Cramer's V were used to measure the
extent of association between the selected variables; Pearson's chi
square was used to test the hypothesis that there was no association
between the variables. To test the relationship between the provider
type and his/her perception of success in exercise counseling in the
elderly, an independent T-test was used. This test detects the
difference in means between two populations regardless of the

direction (Polit and Hungler, 1985). In this study the population will

28

be divided into subgroups of advanced practice nurses, physicians,
and physician assistants.
mm;

A study population of APNs, physicians and physician assistants
currently practicing in South West Michigan was identiﬁed. Inclusion
criteria were: 1) board certiﬁcation in family medicine for the
physicians, or certiﬁcation as an APN or physician assistant, 2)
currently practicing primary care medicine and 3) currently practicing
in one or more of the following Michigan counties: Allegan, Barrien,
Barry, Branch, Calhoun, Cass, Eaton, Kalamazoo, St. Joseph and Van
Burren. Professionals reﬂecting these criteria totaled 82 APNs 112
physicians, 90 physician assistants for the designated geographic area.

Potential participants for this study were selected from various
lists: 1) Physicians listed in the Yellow Pag_e_s. as family practice
physicians of the selected counties, 2) physician assistants listed in the
Michigan Academy of Physician Assistants (1995) 1995-1996 Respurce
Directogy whose address was one of the listed Michigan counties and
3) the APNs identiﬁed on a list from the Michigan Nurses Association
who resided in the selected counties and were certiﬁed in adult,

family, pediatric, and/or gerontology.

29

Questionnaire

After review of the literature and an extensive search it was
found by this investigator that few questionnaires regarding the
perceptions of health care providers and exercise counseling were
available. The questionnaires which were available lacked evidence of
reliability and validity.

A questionnaire developed by Sherman and Hershman (1993)
was utilized to assess providers' perceptions and practices in regards to
counseling elderly clients about exercise. This was a paper and pencil
questionnaire composed of 38 questions utilizing various rating scales.
The internal reliability/validity of Sherman and Hershman's (1993)
questionnaire was not measured by the authors.

These questions ask the provider to rate his/her frequency of
asking and counseling regarding exercise on a Lickert scale of 1
(0-25%), 2 (26.50%), 3 (51-75%), and 4 (76-100%). Perceived
counseling is rated on a 4 point scale ranging from "Not Successful"
to "Very Successful". A ﬁve point scale, ranging from "Not
Important" to "Extremely Important" assesses the perceived importance
of exercise and barriers to counseling. Questions six thru 22 and
number 25 were used for the questionnaire in this study (questions
9-25).

An additional question (#26 in this study) of an instrument

30

developed by Price, Desmond, Losh and Krol (1988) was added to
assess the source of the provider's information regarding exercise.
Their questionnaire in it's entirety has an internal reliability, utilizing
Cronbach's alpha, of .84. However there was no information available
regarding the reliability of the individual question selected.

The questionnaire used in this study (Appendix A) includes
provider characteristics (questions 1-8), counseling practices (questions
9-12 and 15-17), knowledge of exercise guidelines (questions 13-14),
perceived success in exercise counseling (questions 21-23), barriers to
exercise counseling (question 25) and sources of exercise information
(question 26). This survey questionnaire takes approximately 10-15
minutes to complete.

Procedure

The questionnaire was mailed to the 284 selected providers with
a cover letter; the cover letter (Appendix B) included a summary
explanation of the research, an estimate of the amount of time to
complete the questionnaire and a consent statement that indicated their
voluntary agreement to participate upon the completion and return of
the questionnaire. A self-addressed, stamped envelope was enclosed
with the questionnaire and cover letter. The questionnaire was color
coded for investigator information use and follow up. A second

mailing consisting of the same material was mailed two weeks later to

31

non-respondents. It was anticipated that 30 percent of each
professional group would respond.
Protection of Hum_an Subjects

To assure that the rights of the study participants were not
violated, speciﬁc procedures were followed. Consent for participation
in the study was explained in the cover letter (see Appendix B). By
completing and returning the questionnaire the participants indicated
voluntary consent.

In accordance with the Michigan State University College of
Nursing requirements, application was be made to and approval was
received from the University Committee on Research Involving Human

Subjects (Appendix C).

Chapter 6
DATA PRESENTATION

The goal of this study was to identify the characteristics and the
perceptions and practices of primary care providers regarding exercise
counseling for the elderly. The questions to be answered included: 1)
What are the characteristics (age, gender, years in practice, provider
type) of primary care providers in rural Southwestern Michigan, 2)
How often do primary care providers ask and counsel their elderly
clients about exercise, 3) How successful do primary care providers
perceive themselves as exercise counselors for the elderly, 4) Are there
any associations between the characteristics of the providers and how
often they ask and counsel regarding exercise, 5) Is there any
association between perception of success and actual counseling of the
elderly regarding exercise and ﬁnally, 6) Are there any differences in
counseling practices amongst provider types?

There were 284 questionnaires mailed to primary care providers
in the ﬁrst mailing and 189 questionnaires mailed in the second. In

the ﬁrst mailing there were 60 returned answered questionnaires and
32

33

36 returned for incorrect address or no forwarding address; there were
65 returned answered questionnaires from the second mailing; a total
of 125 answered questionnaires yielded only 98 suitable for data
analysis. Reasons for exclusion included: working in another speciality
area (21), retired (3), teaching (2) and refused (1).

The original distribution of provider types in the mailing was:
34% (97) medical doctors, 5% (15) doctors of osteopathy, 28% (82)
APNs and 31% (90) physician assistants. The returned survey
distribution was: 39.8% (39) medical doctors, 6.1% (6) doctors of
osteopathy, 25.5% (25) APNs and 28.4% (28) physician assistants.
This result was a close replication of the original distribution. A 30%
return rate was expected and a 43 % return rate was achieved for this
study. Lower return rates may have been due to the way in which
addresses were obtained. The directory of physician assistants was
from 1995 and many of the addresses were school addresses and the
individuals have since moved. Fourteen of the returned physician
assistants surveys were returned with no forwarding address.
Demogrpphics

Demographic information about the respondents is presented in
Table 1. The category of age was divided into sections of 10 years

so that it could be compared more closely with the other categories in

34

Table 1. Demographic Characteristics of the Respondents

 

 

n %
Provider Type
Advanced Practice Nurse 25 25.5
Doctor of Osteopathy 6 6.1
Medical Doctor 39 39.8
Physician Assistant 28 28.6
Age
<30 10 8.2
31-40 24 24.7
41-50 36 37.3
51-60 16 16.5
61-70 9 9.2
>70 2 2.0
Gender
Male 51 52.0
Female 47 48.0
Years In Practice
0-5 27 27.8
6-10 18 16.5
11-15 15 15.5
16-20 14 14.4
21-25 9 9.3
>26 16 16.5
Number of patients seen/week
<30 7 7.3
31-50 13 13.5
51-70 5 5.2
71-90 19 19.8
91-110 24 25.0
111-130 7 7.3
131-150 13 13.5
>150 8 8.3
Minutes scheduled for new patients
<10 2 2.1
11-20 26 27.1
21-30 40 41.7
31-40 6 6.3
41-50 11 11.5
51-60 11 11.6
Minutes scheduled for follow up patients
<5 4 4.2
6-10 23 24.2
11-15 58 61.1
16-20 5 5.3
21-25 0 0.0
26-30 5 5.3

35

the demographic section. The median age grouping of the respondents
was 41-50 years, 52% of the population were male and the number of
years in practice varied from 1-25 years with 1-5 years being the
most frequent. The respondents reported seeing an average of 80-100
clients per week, scheduled 21-30 minutes with new clients and 11-15
minutes for follow-up clients. This amount of time is consistent with
the literature and reports of actual practice (Radecki, Kane, Solomon,
Mendenhall and Beck, 1988).

Measures of central tendency (mean, median and mode) are
shown in Table 2 for questions 7 and 8 where the respondents were
asked to indicate which category best described their practice.
Seventy-four percent, or 72 of the 98, respondents reported that less

than 40% of their cheats were over age 65. Practices in

Table 2. Primary Care Providers' Patients Over 65 and Practice

Setting. (Questions 7 and 8)

 

 

Choice 11 % mean median mode SD
Percentage of patients over 65

(1) 0-20% 32 33.0

(2) 21-40% 40 41.2

(3) 41-60% 21 21.6 1.99 2.0 2.0 .909

(4) 61-80% 2 2.1

(5) 81-10096 2 2.1
Setting

(1) Urban 14 14.4

(2) Suburban 20 20.6 2.5 3.0 3.0 .738

(3) Rural 63 64.9

36

rural settings accounted for 65% of the respondents.

Practice

The study's ﬁndings regarding the counseling practices of the
elderly were consistent with the ﬁndings of Sherman and Hershman
(1993), i.e., only 22.9% (22) of the respondents reported that they
counsel more than 75% of their elderly patients about exercise, while
25% (24) report they counsel less than 25% of their patients (see
Table 3).

Table 3. Primary Care Providers' Responses Regarding Exercise
Counseling by % of Clients Asked.

 

Exercise Counseling 0-25% 26-50% 51-75% 76- 100%
Qrestions

 

1. Percentage of healthy

elderly asked about exercise 21.4 29.6 18.4 30.6
habits: (Question 9) n=98 (21) (29) (18) (30)
2. Percentage of patients

with CHD asked about 13.3 16.3 24.5 45.9
exercise habits: (Question 10) (13) (16) (24) (45)
ii: 98

3. Percentage of healthy

elderly counseled about 25.0 28.1 24.0 22.9
exercise: (Qiestion 15) (24) (27) (23) (22)
ii: 96

4. Percentage of patients

with CHD counseled 22.7 24.2 17.9 35.8
about exercise: (Question 16) (21) (23) (17) (34)
ii: 98

Table 3, Primary Care Providers' Responses Regarding Exercise

Counseling, suggests that primary care providers asked and counseled

37

more about exercise in the elderly when the client was diagnosed with
coronary heart disease.

A comparison of providers' perceived success at counseling about
exercise and frequency of counseling was made using Pearson's Chi
Square. Pearson's Chi Square is used to test the hypothesis that there
is no association between the selected variables. A value of less than
.05 rejects the null hypothesis and shows a relationship between the
stated variables. Based on a Lickert scale of "not at all" to "slightly"
to "moderately" to "very", providers who felt at least moderately
successful at getting patients to start exercising were more likely to
counsel their patients (Pearson's chi square 0.00629). A similar
association was found between perceived success at getting the patient
to continue exercising and the frequency of counseling (Pearson's Chi
Square 0.03764).

Further analysis of the relationship of perceived success at
getting clients to start exercising and the practice of counseling was
done using a T-test for independent samples. The perceived success
in getting elderly clients to start and continue exercise was divided
into those who felt "moderately to very successful" and those who felt
"not at all to slightly successful". Table 4 shows a signiﬁcant
association between perceived success at counseling and actual

counseling by the providers.

38

Table 4. Relationship of Providers Perceived Success and Actual

Counseling. (Questions 21-23 compared with questions 15-16)

 

 

Levene's T-test for equality *P 2-tail

value signiﬁcance
Perceived level of success at getting patients to start exercising .022 .002
Perceived level of success at getting patients to continue .017 .027

* P value of < .05 shows association between variables.

Survey question 20 asked the provider to indicate how important
exercise in the elderly was based on a Likert scale from "not
important" to "extremely important". Those who reported exercise
as being "important" were more likely to counsel clients regarding
exercise. This tended to be consistent across the categories whether
the patient was 65, 75 or 85 years old or whether they had coronary

heart disease.

Table 5. The Association Between Frequency of Counseling and

Providers Perceived Importance of Exercise in Client Types.

 

 

123.111.9131 erl
1. Client age 65 years .00534*
2. Client age 75 years .01097
3. Client age 85 years .00666
4. Client with CHD .02515

* < .05 shows signiﬁcant relationship between variables.

39

Balm

Table 6 reﬂects an analysis of providers' perceptions regarding
possible barriers to counseling about exercise (question 25), revealed
that 54.5% (54) of providers reported "not having enough time" as a
barrier. Fifty percent (50) reported their "elderly patients would not
be interested in exercise", whereas, 38.4% (38) reported that
"counseling would not lead to a change in patient behavior". These
percentages are based on providers reporting each barrier as at least
"moderately important" to counseling for the elderly.
Table 6. % of Responses of Primary Care Providers' Perception of

Barriers to Exercise Counseling.

 

M
W

E31nod'lanoeinbehavlor

% .2notenoughtime
o macIIentnotlnteresred
f E34notbeneﬂelal

lspomnttleholoe

6 norelmburaement
El 7 noskilllncouneeltng
E36 lmportantaspects
9 counselothertoplea

OmHO'OmOI-n

 

 

 

cameo-omen

40

Sources of Information

Finally, primary care providers' sources of information on
exercise (question 26) for the elderly are described in Table 7. While
86% (85) of the providers claimed they received information on
exercise from personal experience and professional journals, more than
half of the respondents reported they received information from
workshops or seminars (66.7%, n=66) and mass media (54.5%, n=54).

Response categories less than 50% included "received information from

Table 7. % of Responses of Primary Care Providers' Sources of

Information Regarding Exercise in the Elderly.

 

8

 

 

D2 professionaljomnala

U4resldency
[:JSOthercolleguea
[36mm
{:17maasmedta
Dateﬁbooks

 

 

 

 

 

 

 

 

 

 

 

41

other colleagues" (43.1%, n=43), textbooks (40.4%, n=40), residency or
training (35.4%, n=35) and medical school (23.2%, n=23). The
signiﬁcance of the ﬁndings presented are discussed in the following

chapter entitled "Discussion".

Chapter 7
DISCUSSION

This study examined the relationship between characteristics of
primary care providers and the perceptions and practices of these
providers regarding exercise counseling of the elderly. It was found
through this survey that primary care providers who were most likely
to counsel were those who perceived themselves as successful at
getting their elderly clients to start exercising and continue exercising.
those who felt exercise was important for the elderly were also more
likely to counsel.

The geriatric population is very much aware of preventive health
care topics, including exercise (Freid, 1995). In order to foster
preventive health care for the elderly, providers need to be
knowledgeable about recommended preventive measures (Black and
Kapoor, 1990).

Practices and Perceptions

As stated earlier practice type and background characteristics

were not found to be unrelated to counseling practice; this is

consistent with other recent studies. This ﬁnding shows a lack of
42

43

association between background characteristics and attitudes toward
prevention (Maheux, Pineault and Beland, 1987) and counseling
practices (Wells, Lewis and Leake, 1986). Although not hypothesized
this investigator anticipated an association between provider type and
counseling practice based upon personal experience and observation of
health providers. Since health promotion and disease prevention are
being taught in nursing educational programs, undergraduate and
graduate, this could have been demonstrated thru the responses of the
APNs. The age of the respondents (an average of 45 years) and
years in practice (29% less than ﬁve years) for all respondents may
have contributed to the similarity of responses across respondents.
Newer educational models in current health education programs may
be including more preventive health care in their curricula and thus
replication with providers earlier in their practice career could yield
different responses.

This study found that most of the respondents were
knowledgeable about certain aspects of exercise in the elderly. The
components of exercise education evaluated included the number of
times per week recommended to exercise, how long each exercise
session should be and what the target heart rate in the elderly should
be during exercise (question 13). There were similarities found in the

knowledge regarding number of times per week to exercise, the

recommended length of the exercise session and the recommended
target heart rate.

In this study, sources of information (question 26) regarding
exercise in the elderly were obtained from personal experience and
professional journals. There are no standards or frames of reference
associated with personal experience. It would be preferable if
providers received more information in professional health educational
programs. As society changes, by focusing on preventive health care
and taking into account the increased number of aging, it is hoped
that professional health care curricula will change to meet these needs
on a more consistent basis.

Few studies have evaluated the effectiveness of exercise
counseling in any population by primary care providers. Although
most primary care providers consider client counseling to be an
integral part of providing quality health care, time and money tend to
limit the use of counseling in personal practice (Radecki and
Swofford, 1986). Physicians are more likely to counsel their clients
about physical activity if three conditions are met: 1) they are able to
use low-level screening techniques to judge appropriateness, 2) they
can counsel within the context of a client's regular visit and 3) they
can easily monitor the client's adherence (Harris, Caspersen, DeFriese

and Estes, 1989). These same conditions could also apply to PAs and

45

APNs. Based on current literature, the issue of client adherence with
exercise counseling as a primary preventive intervention by primary
care providers is largely unstudied.

Interaction Model of Client Health Behavior

The Interaction Model of Client Health Behavior (Cox, 1982) is
based on the assumption that the role of the client is to assume
responsibility for his/her own care. It suggests that client singularity
is based on background variables that make each person unique. It is
this uniqueness that contributes to the client-professional interaction and
ultimately the outcomes of their health. It is believed by the
investigator that this same belief is true of the professional. Each
professional brings with him/her their individual background variables
that ultimately effect the client-professional interaction and health
outcomes as well.

In this study background variables identiﬁed in the literature as
impacting provider practice were examined. However, no signiﬁcant
relationships were found between the selected provider demographic
variables and the provider counseling practices. What the
professional brings to the client-professional interaction is important.
In this study there were no data which allowed the analysis of
whether or not provider background variables effect health outcomes.

Further research on the outcomes of health, based on professional

46

characteristics, may show a signiﬁcant relationship.
Limitations

This study had several limitations. First, the sample was a
small sample from southwest Michigan and may not be representative
of primary care providers elsewhere in this state or country.
However, this study did include a variety of providers from a mix of
practice settings. This sample was limited to providers practicing
family health care management. It would be difﬁcult to discern
whether the results are valid for providers in other speciality practices.
It may be that those who are most interested and active in health
promotion may have been more likely to participate in this study.

Another limitation of this study was that it utilized a self-report
questionnaire of practice patterns and perceptions, and thereby results
are subject subject to reporting bias. In self-report, providers tend to
overestimate their perceived good behavior. Thus, there may be some
exaggeration, but the 53% of the respondents who reported counseling
less than 50% of their clients undoubtedly seldom counsel about
exercise. Also, despite the survey's anonymous nature, respondents
may have presented their activities in what they perceived as the most
favorable light, especially those providers who knew the investigator
through professional contact. These factors would together create a

"best case" bias, limiting generalizability. Only through chart review

47

or patient interview could one discern the extent of this bias.

Another limitation would be the questionnaire itself. Sherman
and Hershman's (1993) questionnaire did not have any reliability or
validity testing. If this questionnaire were to be used again the
investigator would have a small group of clinical cohorts answer the
questionnaire and make suggestions to further clarify the questions and
their content. After data collection reliability of the questionnaire
could be assessed.

General Irmlications

This study revealed that providers may be counseling about
exercise more frequently than ten years ago, there still remains a
substantial number of primary care providers who do not counsel their
elderly clients about it. It was found that the frequency
of provider counseling of elderly clients about exercise is strongly
associated with their perceived success at getting clients to start and to
continue to exercise as well as the providers' perceptions of the
importance of exercise. The results suggest that education is needed
so that more providers become aware of the beneﬁts of exercise in
the elderly.

Education

This investigator believes there was a lack of educational

preparation in all health care curricula regarding health promotion and

48

disease prevention issues in the elderly. This was evident in the
responses regarding where exercise information was obtained with 32%
receiving information from residency and training programs and 23%
from medical schools. From the literature review it was evident that
health promotion and disease prevention are being integrated into
professional health care curricula. What is not clear is whether or not
this information and education are being applied to the elderly
population, e.g.. preventive health care strategies in counseling
regarding exercise.

.Era_c_ti_02

Offering medicare reimbursement for routine health promotion
and disease prevention in the elderly as seen as a need by those who
deliver health care. With out this reimbursement, health care costs for
older adults (over age 65) are unlikely to change. If reimbursement
were available, two of the largest barriers to exercise counseling could
be diminished. In this study, "limited time" was a seen as a large
barrier in counseling for the elderly. Limited time for health
promotion is a reality. Yet, withholding effective treatments or
counseling because of time limits ultimately places a greater burden on
the health-care system through in chronic illness and its implications.
Those barriers of "not enough time" and "no reimbursement for

counseling" could be diminished through a fee for service incentive for

49

health promotion issues not only in the elderly but in all age groups.
Health promotion services to the elderly could meaningfully change
their health risks and behaviors.

Research

Throughout the literature the terms "physical activity and
"exercise" are used interchangeably. This same interchangeability has
also seen observed throughout the guidelines about exercise counseling.
It is this lack of a clear deﬁnition that leads to the confusion of
what is appropriate for elderly exercise guidelines. Each term needs
to have a concrete deﬁnition and associated guidelines based on the
deﬁnition. This same lack of clarity of terms holds true for deﬁning
"elderly". Although some deﬁnitions divide the elderly into young-old
and old-old subgroups, current guidelines for prevention and health
promotion do not.
APN Implications

Education

To encourage a greater use of health promotion counseling at
routine ofﬁce visits, incorporation of current health promotion age
appropriate issues into the general management plan is needed. To
implement this suggestion further development of health promotion
counseling is needed in the APN educational curricula. Perhaps with

each disease management problem there could be a health promotion

50

counseling component which is explored and incorporated into the
management plan.

hem

Advance Practice Nurses (APN) are in a position to assist other
primary care providers in becoming knowledgeable about the beneﬁts
associated with increased physical activity or exercise in the elderly
population. Clients may stop smoking after just a brief statement by
the provider, however, special training of providers in counseling about
smoking appears to greatly increase their success in getting clients to
quit (Cummings, Coates and Richard, 1989). A similar program
regarding exercise, developed by an APN, might lead to more frequent
counseling and increased exercise in the elderly. APNs could take the
initiative to adapt specialized interventions to the time constraints and
visit patterns of primary care and develop written guidelines for
elderly preventive care. These guidelines could be made as simple as
check lists for each age group. On these check lists are those health
promotion and disease prevention issues that are appropriate for that
age group. If exercise is a health promotion topic that needs to be
addressed at each visit a reminder sheet could be attached to each
client chart. The availability of such teaching and counseling sheets
could be developed by APNs. This counseling sheet could cover

"asking", "assessing" and "advising" regarding exercise at the moment

51

of the provider-client interaction. With the knowledge APNs have
regarding client care, communication skills and health promotion,
development of these guidelines would not be a difﬁcult task.

As seen through the literature review and this study, there is no
proven clinical approach to preventive care in the elderly. The use of
"opportunity" screening, in which performance of health promotion and
prevention measures are done during routine client contact, needs to be
adopted by all health professionals. Perhaps through APN modeling
other health care providers will recognize the importance of screening
for potential health risks.

Research

This study represents an important ﬁrst step. The ﬁndings are
presented as a baseline against which further research may be
compared. It is important to continue to examine the impact of
"background characteristics" (i.e., years in practice, practice setting,
provider type, and educational training) as these are variables that
potentially affect the elements of "client-professional interaction" and
the elements of "health outcomes" in the primary care setting. These
then are three areas for further research. The expansion of the
IMCHB of "professional singularity" and the expanded
comprehensiveness of the model can provide further opportunity for

research and the effect it has on health outcomes. Further research

52

questions may include what effect do provider backgrounds (age,
gender, provider type) have on health outcomes in health promotion
issues? Variables such as the provider's own health status and use of
health promotion behaviors need to be assessed as well as their
contribution to the client-professional interaction.

Conclusion

Prevention in the elderly is a complex issue. The complexities
begin with deﬁning "the elderly", "health" and "exercise" and continue
through assessing the effectiveness of approaches which enhance
preventive health care in the elderly. An expanded deﬁnition of
health is needed to fully address those issues important to the elderly
population. This deﬁnition needs to include: 1) quality of life, 2)
satisfaction with life and 3) productivity.

Preventive health care for the elderly continues to be under
increased scrutiny as the US population grows older; todays Americans
are living longer than ever before. This increase in life span has
increased the numbers of the elderly in our population; it also
contributes to the number of individuals who suffer from numerous
chronic conditions. Attempts to develop comprehensive programs of
preventive care have been greatly hampered by the absence of a
consistent set of values on which to base the assessment of preventive

services. Perhaps beginning health promotion counseling at a younger

53

age on a consistent basis would increase the clients' awareness of the
importance of health promotion. This in turn would create a public
awareness of these issues. Further research on the development and
effectiveness of screening tools, preventive health care guidelines in
the elderly, and the effectiveness of exercise counseling for the elderly

are greatly needed.

APPENDD( A

54

APPENDIX A

Exercise Questionnaire

Instructions- Please select responses that best reﬂect your current practice and beliefs regarding
exercise in the elderly.

l0.

What year were you born? l9

What is your gender? Male [3 Female D
How many years have you been ill practice?

Approximately how many patients do you see in your oﬂice in a week? patients
How many minutes do you schedule for a new patients? minutes
How many minutes do you schedule for a typical follow-up patient? minutes

What percentage of your ofliee patients are over age 65?

0-20% 2 1-40% 41-60% 61-30% 8l-100%

El Cl CI 1:] C]

Now would you describe the setting where you practice? (Choose one)

Urban [3
Suburban E]
Rural C]

What percentage of your healthy elderly patients do you 15k at some point about their
exercise habits?

0-25% 26-50% 51-75% 76- l 00%

D D D [3

What percentage of your elderly patients with coronary heart disease do you is}; as some
point about their exercise habits?

0-25% 26-50% S l -75% 76- l 00%

D D D D

For your elderly patients who already exercise which, if any, of the following aspects do

you ask routinely?
Ask Don’t Ask
What type of exercise the patient does

llow strenuous is the patients exercise

Duration of exercise

How often the patient exercises

Whether the patient warms up before exercising

DDDDD
DDUUD

12.

l3.

I4.

55

I: or your patients who you believe do M exercise adequately, which of the aspects do
you ask routinely?
Ask Don’t Ask
Why they do not exercise
What previous types of exercise they have done
What their attitude is towards exercise
What their beliefs are about exercise
What type of exercise their friends or family get

DENIED
DEUCE

What is your exercise recommendation for an average healthy patient to obtain an optimal
benefit?

Number of times per week they |_—2 3-4 5-6 7
should exercise? Ll El El Cl
How long should each session be ill l0-20 21-30 31-40 41-50 51-60

minutes? E] Cl E] E] El

What should their heart rate be (as a 506033 61-70% 71-80% 81-90% 91-100%
°/o of their maximum heart rate) 1:] Cl C] E] E]

Do you routinely advise your patients not to exercise in any of the following

situations?
DON’T Exercise

Exercise Is Okay Uncertain

3 months after an uncomplicated myocardial infarction [:l [:l 1:]
Patient has unstable angina pectoris Cl C] D
Patient with moderately severe COI’D E] C] C]

What percentage of your healthy eldcg'ly patients do you counsel at some point about
their exercise habits?

 

0-25% 26-50% 5 l-75% 76- 100%

C] [:1 [3 Cl

What percentage of your elderly patients with coronary heart disease do you counsel at
some point about their exercise habits?

0-25% 26-50% S l-75% 76- l 00%

Cl El Cl El

When you counsel a healthy elderly patient about exercise for the first time, how much
time do you spend on average?

Less than 2 minutes [:l
2 - 5 minutes C]
More than 5 minutes E]

20.

2I.

22.

23.

24.

56

Do you ever refer patients to someone else for counseling about exercise?

Yes D No [:1

If there were people available who specialized in counseling about exercise (analogous to
dietitians), would you refer any of your elderly patients there?

Yes E] N0 l:l

Please answer the following questions about the importance ofexercise.

Not Slightly Moderately Very Extremely
How important is exercise for Important Important Important Important Important
a healthy 65 year old D D E] Cl C]
a healthy 75 year Old El D El El El
a healthy 35 year old E] E] El El Cl
someone with coronary heart disease [:1 D [3 El [:1

How successful do you feel you are at getting your elderly patients to start
exercising?

Notat all C] Slightly 1:] Moderately [3 Very [:l

Ilow successful do you feel you are at getting your elderly patients to continue
exercising on a regular basis?

 

Not at all C] Slightly E] Moderately [3 Very E]

Of the elderly patients who you do counsel about exercise, how successful do you feel that
you are at impacting on their quality of life?

Not at all C] Slightly [:J Moderately E] Very [:1

Do you believe exercise is helpful in...
No No

Opinion

-<
O
U)

...decreasing overall mortality?

...decreasing coronary heart disease?
...decreasing nrortality in COI’D?

...improving overall blood sugar control ill DM?
...inrproving in overall lipoprotein pr‘olile?
...preventing hip fractures in the elderly?

DECIDED
DECIDED
DECIDED

57

25. Below is a list of pp_ssible barrigs that might keep you from counseling elderly patients
about exercise. Please circle how important you feel each of them is in our practice.

 

 

 

Not Slightly Moderately Very Extremely
Important =l Important =2 Important =3 Important =4 Important
I believe that counseling about exercise will not lead to a change ill patients
behavior 1 2 3 4
I do not have enough time to adequately counsel patients about exercise ill
a typical ollicc visit. I 2 3 4
Ill most situations, I am not convinced that exercise is beneficial. I 2 3 4
Lifestyle is a matter of personal choice, and I would thus be overstepping
my bounds as a provider. I 2 3 4
My reimbursement is not sullicient for the time it takes to counsel patients. I 2 3 4
I need more practice with my counseling skills with respect to exercise. I 2 3 4
I am unsure what is most important ill counseling patients about exercise I 2 3 4
My time is better utilized ill counseling about other lifestyle changes. I 2 3 4
My patients are not interested irl exercise. I 2 3 4
Other (please specify)
I 2 3 4
26. Below is a list of possible sources of information on exercise counseling for the elderly.

Choose all that apply.

Personal experience .................
Professional journals ................
Workshops and/or seminars ......
Residency or training program ..
Other colleagues .......................
Medical school ........................
Mass media ............................
Textbooks ............................
Other

EMBEDDED

 

Thank you for completing this questionnaire. A summary oftlle results will be forwarded as soon

as possible.

APPENDIX B

58

APPENDIX B

Michigan State University
College of Nursing
A230 Life Science Building
East Lansing, Michigan 48824-1317

Dear Colleague,

In the past decade there has been an increasing amount of evidence
supporting the beneﬁts of exercise in the elderly. However, few studies evaluated
the role of the primary care provider in exercise counseling for the elderly.. This
letter describes a study about this issue and is being conducted to complete the
research component of my graduate program.

The purpose of this study is to examine the relationship between family
practice providers' characteristics and their perceptions and practices regarding
exercise counseling for the elderly. Family practice providers who are currently
practicing in primary care are invited to participate in exploring this important
topic.

Enclosed is a brief questionnaire that will take approximately 10-15
minutes of your time to complete. All results will be treated with strict
conﬁdence and all participants will remain anonymous in any report of research
ﬁndings. Coding of the surveys will allow only the investigator the ability to
identify the participant. A summary of the results will be sent to all participants

at the conclusion of the study.

Participation in this study is voluntary and you may withdraw at any time
or refuse to answer any question without penalty. You indicate that you are
currently practicing and voluntarily agree to participate by completing and
returning this questionnaire. Please complete the questionnaire by March 17, 1997
and return it to me in the enclosed stamped envelope.

If you are not currently practicing and would like a summary of the
results please return the unanswered questionnaire. Please contact me or my
faculty advisor, Dr. Joan Wood, at (517) 355-6523 with questions you may have.

Thank you for your time and assistance in furthering the research of health
care prevention in the elderly.

Sincerely,

Amy M. Hackman, RN
Family Nurse Practitioner Graduate Student

APPENDIX C

59

MICHIGAN STATE APPENDIX C
u N I v E R s l T Y

February 10, 1997

 

TO: Joan E. Wood .
A-230 Life SCiences Bldg.

RE: IRB#: 97-052 .
TITLE: PRIMARY CARE PROVIDERS' PERCEPTION AND PRACTICES

REGARDING EXERCISE COUNSELING FOR THE ELDERLY
REVISION REQUESTED: N/A
CATEGORY: l-C
APPROVAL DATE: 02/10/97

The University Committee on Research Involving Human Subjects'(UCRIHS)
review of this project is complete. I am pleased to adVise that the
rights and welfare of the human subjects appear to be adequately
protected and methods to obtain informed consent are appropriate.
Therefore, the UCRIHS approved this preject and any reVisiOns listed
above.

RENEWAL: UCRIHS approval is valid for one calendar year, beginning with
the approval date shown above. Investigators planning to
continue a project beyond one year must use the green renewal
form (enclosed with t e original approval letter or when a
project is renewed) to seek u date certification. There is a
maXimum of four such expedite renewals ossible. Investigators
wishing to continue a prOJect beyond tha time need to submit it
again or complete reView.

REVISIONS: UCRIHS must review any changes in procedures involving human
subjects, rior to initiation of t e change. If this is done at
the time o renewal, please use the green renewal form. To
revise an approved protocol at any other time during the year,
send your written request to the CRIHS Chair, requesting reVised
approval and referencing the project's IRB # and title. Include
in your request a description of the change and any revised
instruments, consent forms or advertisements that are applicable.

PROBLEMS/ .
CHANGES: Should either of the follow1ng arise during the course of the

work, investigators must noti y UCRIHS promptly: (1) roblems
(unexpected Slde effects, comp aints, e c.) involving uman
subjects or (2) changes in the research environment or new
information indicating greater risk to the human sub'ects than
existed when the protocol was previously reviewed an approved.

If we can be of any future hel , please do not hesitate to contact us
at (517)355-2180 or FAX (517)4 2-1171.

Sincerely,

   
 
  

   

avid E. Wrig
UCRIHS Chair

DEW:bed

cc: my M. Hackman

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(Black & Kapoor, 1990)

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