What influences general practitioners’ use of exercise for patients with chronic knee pain? Results from a national survey
Exercise is a recommended ‘core’ treatment for chronic knee pain (CKP), however it appears to be underused by general practitioners (GPs). While behavioural theories suggest that attitudes and beliefs influence behaviours, no single theory reliably predicts GPs’ behaviours. An underpinning theoretical model based on sociocognitive theories was developed to investigate the key factors associated with GPs’ use of exercise for patients with CKP.
A cross-sectional postal questionnaire survey investigated GPs’ use of exercise based on a patient case vignette. Factors influencing GPs’ behaviour were examined using attitude statements, free text questions or multiple response option questions related to factors within the underpinning model. Unadjusted logistic regression analyses explored the associations between GPs’ attitudes and beliefs and their behaviour.
From a total sample of 5000 GPs, 58 were ineligible, and 835 (17%) returned a questionnaire. Most respondents (n=729, 87%) reported that they would use exercise for CKP. Factors significantly associated with exercise use (OR (95% CI)) included GPs’ beliefs about their role (belief that GPs should give information on type, duration and frequency of exercise (30.71 (5.02,188.01)), beliefs about consequences (agreement that knee problems are improved by local (3.23 (1.94,5.39)) and general exercise (2.63 (1.38,5.02))), moral norm (agreement that all patients should be prescribed local (3.08 (1.96,4.83)) and general exercise (2.63 (1.45,4.76))), and beliefs about their skills (prior experience of having insufficient expertise to give detailed exercise information (0.50 (0.33,0.76)). Whilst perceived time limitations were not associated with exercise use (1.00 (0.33,3.01)), GPs who disagreed they experienced time limitations were more likely to suggest general (2.17 (1.04, 4.55)) or demonstrate local (2.16 (1.06,4.42)) exercises. Few GP characteristics were associated with, and no patient- or service-related factors seemed to influence, GPs’ use of exercise. Some factors within the underpinning model were not associated with behaviour as expected, for example a significantly increased use of exercise among those who agreed with attitude statements was not accompanied by a reduced use of exercise among those who disagreed (or vice versa). Further, similar use of exercise was observed among GPs who were positive and negative about its safety or efficacy, and the lowest use of exercise was often seen among GPs who neither disagreed nor agreed with attitude statements.
GPs’ attitudes and beliefs are associated with their use of exercise for patients with CKP. While the low response risks response bias, these results can inform future interventions by highlighting the particular factors which seem to be most associated with GPs’ behaviour, which include their beliefs about their role, consequences, moral norm, and skills. The role of GP uncertainty and influences on clinical decision-making need further exploration. An amended model is suggested, which should be tested in future research