Family Practice, 2014, Vol. 31, No. 3, 325–332 doi:10.1093/fampra/cmu007 Advance Access publication 17 March 2014
Dietary counselling for cardiovascular disease prevention in primary care settings: results from a German physician survey Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, bInternistic Group Practice Dr. med. Manfred Mayer und Dr. med. Angela Schmid, Mannheim and cÄrztenetz Qu@linet e.V., Mannheim, Germany. a
*Correspondence to Tatiana Görig, Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Ludolf-Krehl-Straße 7-11, D-68167 Mannheim, Germany; E-mail: [email protected] Received September 10 2013; revised February 10 2014; Accepted February 12 2014.
Abstract Background. Primary care physicians (PCPs) play an important role in the promotion of healthy dietary behaviour. However, little is known about the practice of and factors associated with the provision of dietary counselling in primary health care in Germany. Objectives. To explore the attitudes towards and factors associated with the routine provision of dietary counselling in Germany using data from the nationwide, representative sample of the Physician Survey on Cardiovascular Disease Prevention. Methods. A total of 4074 randomly selected PCPs (response rate: 33.9%) provided data on dietary counselling for prevention of cardiovascular disease (CVD) based on the 5 A’s (Assess, Advise, Agree, Assist, Arrange), attitudes towards dietary counselling and patients’ and practice characteristics. Results. While the majority of PCPs (86%) reported having high levels of competence in providing dietary advice, only 49% felt they had been successful in counselling their patients on nutrition. PCPs routinely asked (68%) and advised patients to change their dietary habits more frequently (77%) compared to other counselling techniques based on the 5 A’s. Female physicians and those with a higher percentage of privately insured patients and patients at higher risk of CVD were more likely to use the 5 A’s to routinely counsel their patients on nutrition. Conclusions. The data showed high levels of involvement by German PCPs in CVD prevention and dietary counselling. The rather low perceived success of dietary intervention and differences with respect to patients’ health insurance status indicate a need to address both communication skills in medical training and appropriate reimbursement of preventive services. Key words: Cardiovascular diseases, counselling, health behaviour, physicians, prevention, primary health care.
Introduction Since they are in regular contact with their patients, they have the opportunity to encourage patients to change potentially unhealthy dietary habits (2). A recent study on patients’ attitudes towards lifestyle counselling showed that the majority of
A poor diet is one of the main preventable risk factors for many chronic diseases, including, among others, cardiovascular disease (CVD) (1). Primary care physicians (PCPs) have the potential to promote healthy dietary behaviour by providing dietary advice (2).
© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
325
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on March 3, 2015
Tatiana Göriga,*, Manfred Mayerb,c, Christina Bocka, Katharina Diehla, Jennifer Hilgera, Raphael M Herra and Sven Schneidera
Family Practice, 2014, Vol. 31, No. 3
326
Methods Study design and sample The ÄSP-kardio Study is a nationwide cross-sectional survey conducted from October 2011 to March 2012 in a random sample of PCPs in Germany. The primary aim of the ÄSP-kardio Study was to investigate the implementation of health promotion and prevention of CVDs in primary care in Germany. As there is no comprehensive register containing data on all PCPs residing in Germany, the sample was drawn from the database
provided by ArztData GmbH, Hamburg, Germany. This database contains comprehensive data on physicians from all of the 16 federal states in Germany and was therefore considered to provide the highest coverage of PCPs and thus be the most suitable for forming a national sample pool. The sample PCPs, which included general practitioners, medical practitioners and internists working as general practitioners who were resident in a medical practice, were selected using random stratification by sex, medical specialty and the federal state. One month prior to the initial contact with PCPs, the ÄSPkardio Study was announced in several medical journals. In accordance with the Total Design Method (11), the selected PCPs were contacted four times by mail. One week after sending out an invitation letter, all physicians received the standardized four-page questionnaire by post, together with a cover letter containing further information on the study’s aims, information on data protection and a self-addressed, pre-stamped envelope. One week later, physicians received a reminder postcard, followed by the second survey mailing 1 month later. Responses were obtained from 4074 PCPs who met the inclusion criteria. Nearly all of the physicians (96%) who did not complete the survey were contacted by phone or by email to investigate the reasons for non-participation. Furthermore, nonrespondents who were contacted by email were asked to fill in the web-based survey questionnaire. In this way, responses from 51 additional PCPs were obtained and included in the final sample. These responses represented a response rate of 33.9%, calculated according the RR3 standard provided by the American Association for Public Opinion Research (12). There were no significant differences between the study sample and the overall population of German PCPs regarding the distribution of sex, medical specialty and federal region (all P > 0.05). The study participation was voluntary. All participants were informed in writing about the study’s aims, data protection and data handling procedures. Respondents who provided their bank account details were paid 20 Euro as reimbursement. Those who provided their email addresses were sent a short summary of the descriptive study results after the end of the field phase. The study was conducted according to the principles stated in the Declaration of Helsinki. Its design and procedure were approved by the Medical Ethics Committee of the Medical Faculty Mannheim, Heidelberg University (2008-272E-MA).
Instrumentation In collaboration with the GESIS Leibnitz-Institute for Social Sciences in Mannheim, Germany, the questionnaire administered in the ÄSP-kardio Study was validated using cognitive interviewing techniques with a sample of 10 PCPs. To recruit the physicians for these in depth interviews, we were supported by Ärztenetz Qu@linet, Mannheim. Additionally, the questionnaire
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on March 3, 2015
responders would like to receive more support regarding nutrition from their physicians (3). If delivered correctly, such interventions by physicians are known to bring beneficial changes in patients’ dietary habits and thus lower cardiovascular risk factors, such as high blood pressure and high cholesterol levels (4,5). Therefore, the German Society of General Practice and Family Medicine recommends that PCPs advise all patients at risk of CVD on maintaining a healthy diet (2). In Germany, there is lack of representative data regarding the provision of dietary counselling in primary care settings. Previous studies from the USA and other nations have explored the provision of dietary advice in primary care as well as physicians’ attitudes towards nutritional counselling. In general, PCPs have been shown to hold positive opinions on the importance of diet for the prevention of CVD. The majority of the physicians was convinced of the high importance of nutritional counselling for the prevention of CVD and regarded it as one of their central responsibilities to offer such advice (6,7). However, dietary counselling was only provided in 24−35% of patient encounters (8,9). Different obstacles to the provision of dietary counselling have been revealed in several studies, with lack of time, insufficient reimbursement and lack of patients’ motivation being the most important barriers (6). However, since the majority of the above-mentioned surveys were conducted in the USA, these findings cannot be generalized to German health care system. Thus, to date, the prevalence of dietary counselling offered for the purpose of health promotion and disease prevention in primary health care here still remains unclear. Our aim was therefore to explore the routine provision of dietary advice and factors associated with dietary counselling based on the 5 A’s, using data provided by the German ÄSPkardio Study (Ärzte-Survey zur Prävention kardiovaskulärer Erkrankungen; German for: Physician Survey on Cardiovascular Disease Prevention), the largest representative physician survey on this topic to date. The 5 A’s counselling framework, initially developed to counsel patients on smoking cessation, has also been proposed as an approach for physicians to provide advice regarding diet (4,10). We further aimed to examine the attitudes of German PCPs towards dietary counselling for the prevention of CVD.
Dietary counselling in primary care settings
was pretested and used in a regional study, which included 260 PCPs in Baden-Wuerttemberg, Germany (13).
Measures
Statistical analysis Factors associated with the provision of dietary advice were explored using chi-square tests and multiple logistic regression analyses. Separate regression models were run for each of the A’s, in order to explore the provision of dietary counselling in
depth. The regression models included variables that were significant in bivariate analyses and were adjusted for the confounding effect of PCPs’ sex and age. Data were analysed using IBM SPSS 21.0 (Somers, NY). In all of the tests, P-values 30%
Male Female ≤50 years >50 years General medicine/ general practitioner General internal medicine
1.00 [Ref.] 0.84 [0.73–0.98]* 0.64 [0.23–1.71] – – – – – n = 3518
– – – – – – – – n = 3665
1.00 [Ref.] 1.45 [1.23–1.72]*** 1.00 [Ref.] 1.55 [1.31–1.85]*** 1.00 [Ref.] 1.24 [1.03–1.49]*
–
1.27 [1.06–1.52]**
1.00 [Ref.] 1.72 [1.47–2.01]*** 1.00 [Ref.] 1.33 [1.14–1.56]*** 1.00 [Ref.] 1.25 [1.05–1.48]*
1.00 [Ref.] 1.41 [1.19–1.66]*** – – –
1.00 [Ref.] 1.51 [1.29–1.76]*** 1.00 [Ref.] 1.18 [1.02–1.37]* 1.00 [Ref.]
Advise
– – – 1.00 [Ref.] 1.29 [1.06–1.57]* – – – n = 3576
1.00 [Ref.] 1.57 [1.29–1.91]*** – – 1.00 [Ref.] 1.48 [1.19–1.82]***
–
– – – – –
Agree
Arrange
1.00 [Ref.] 1.16 [1.02–1.33]* – – – –
1.00 [Ref.] 1.45 [1.26–1.66]*** 1.00 [Ref.] 1.22 [1.06–1.40]** 1.00 [Ref.] 1.31 [1.13–1.52]*** – – – – – – – – n = 3717
Assista
1.00 [Ref.] 1.49 [1.27–1.76]*** – – – –
1.00 [Ref.] 1.41 [1.19–1.67]*** 1.00 [Ref.] 1.26 [1.07–1.49]* – – – – – – – 1.00 [Ref.] 0.81 [0.68–0.95]* 0.79 [0.64–0.98]* n = 3545
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on March 3, 2015
95% CI, 95% confidence interval; Ref., reference category. Metrically scaled variables were dichotomized by the median split; models included variables significant in bivariate analyses and were adjusted for the confounding effect of PCPs’ sex and age; only significant associations are shown; ***P
Dietary counselling for cardiovascular disease prevention in primary care settings: results from a German physician survey Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Mannheim, bInternistic Group Practice Dr. med. Manfred Mayer und Dr. med. Angela Schmid, Mannheim and cÄrztenetz Qu@linet e.V., Mannheim, Germany. a
*Correspondence to Tatiana Görig, Mannheim Institute of Public Health, Social and Preventive Medicine, Medical Faculty Mannheim, Heidelberg University, Ludolf-Krehl-Straße 7-11, D-68167 Mannheim, Germany; E-mail: [email protected] Received September 10 2013; revised February 10 2014; Accepted February 12 2014.
Abstract Background. Primary care physicians (PCPs) play an important role in the promotion of healthy dietary behaviour. However, little is known about the practice of and factors associated with the provision of dietary counselling in primary health care in Germany. Objectives. To explore the attitudes towards and factors associated with the routine provision of dietary counselling in Germany using data from the nationwide, representative sample of the Physician Survey on Cardiovascular Disease Prevention. Methods. A total of 4074 randomly selected PCPs (response rate: 33.9%) provided data on dietary counselling for prevention of cardiovascular disease (CVD) based on the 5 A’s (Assess, Advise, Agree, Assist, Arrange), attitudes towards dietary counselling and patients’ and practice characteristics. Results. While the majority of PCPs (86%) reported having high levels of competence in providing dietary advice, only 49% felt they had been successful in counselling their patients on nutrition. PCPs routinely asked (68%) and advised patients to change their dietary habits more frequently (77%) compared to other counselling techniques based on the 5 A’s. Female physicians and those with a higher percentage of privately insured patients and patients at higher risk of CVD were more likely to use the 5 A’s to routinely counsel their patients on nutrition. Conclusions. The data showed high levels of involvement by German PCPs in CVD prevention and dietary counselling. The rather low perceived success of dietary intervention and differences with respect to patients’ health insurance status indicate a need to address both communication skills in medical training and appropriate reimbursement of preventive services. Key words: Cardiovascular diseases, counselling, health behaviour, physicians, prevention, primary health care.
Introduction Since they are in regular contact with their patients, they have the opportunity to encourage patients to change potentially unhealthy dietary habits (2). A recent study on patients’ attitudes towards lifestyle counselling showed that the majority of
A poor diet is one of the main preventable risk factors for many chronic diseases, including, among others, cardiovascular disease (CVD) (1). Primary care physicians (PCPs) have the potential to promote healthy dietary behaviour by providing dietary advice (2).
© The Author 2014. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: [email protected].
325
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on March 3, 2015
Tatiana Göriga,*, Manfred Mayerb,c, Christina Bocka, Katharina Diehla, Jennifer Hilgera, Raphael M Herra and Sven Schneidera
Family Practice, 2014, Vol. 31, No. 3
326
Methods Study design and sample The ÄSP-kardio Study is a nationwide cross-sectional survey conducted from October 2011 to March 2012 in a random sample of PCPs in Germany. The primary aim of the ÄSP-kardio Study was to investigate the implementation of health promotion and prevention of CVDs in primary care in Germany. As there is no comprehensive register containing data on all PCPs residing in Germany, the sample was drawn from the database
provided by ArztData GmbH, Hamburg, Germany. This database contains comprehensive data on physicians from all of the 16 federal states in Germany and was therefore considered to provide the highest coverage of PCPs and thus be the most suitable for forming a national sample pool. The sample PCPs, which included general practitioners, medical practitioners and internists working as general practitioners who were resident in a medical practice, were selected using random stratification by sex, medical specialty and the federal state. One month prior to the initial contact with PCPs, the ÄSPkardio Study was announced in several medical journals. In accordance with the Total Design Method (11), the selected PCPs were contacted four times by mail. One week after sending out an invitation letter, all physicians received the standardized four-page questionnaire by post, together with a cover letter containing further information on the study’s aims, information on data protection and a self-addressed, pre-stamped envelope. One week later, physicians received a reminder postcard, followed by the second survey mailing 1 month later. Responses were obtained from 4074 PCPs who met the inclusion criteria. Nearly all of the physicians (96%) who did not complete the survey were contacted by phone or by email to investigate the reasons for non-participation. Furthermore, nonrespondents who were contacted by email were asked to fill in the web-based survey questionnaire. In this way, responses from 51 additional PCPs were obtained and included in the final sample. These responses represented a response rate of 33.9%, calculated according the RR3 standard provided by the American Association for Public Opinion Research (12). There were no significant differences between the study sample and the overall population of German PCPs regarding the distribution of sex, medical specialty and federal region (all P > 0.05). The study participation was voluntary. All participants were informed in writing about the study’s aims, data protection and data handling procedures. Respondents who provided their bank account details were paid 20 Euro as reimbursement. Those who provided their email addresses were sent a short summary of the descriptive study results after the end of the field phase. The study was conducted according to the principles stated in the Declaration of Helsinki. Its design and procedure were approved by the Medical Ethics Committee of the Medical Faculty Mannheim, Heidelberg University (2008-272E-MA).
Instrumentation In collaboration with the GESIS Leibnitz-Institute for Social Sciences in Mannheim, Germany, the questionnaire administered in the ÄSP-kardio Study was validated using cognitive interviewing techniques with a sample of 10 PCPs. To recruit the physicians for these in depth interviews, we were supported by Ärztenetz Qu@linet, Mannheim. Additionally, the questionnaire
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on March 3, 2015
responders would like to receive more support regarding nutrition from their physicians (3). If delivered correctly, such interventions by physicians are known to bring beneficial changes in patients’ dietary habits and thus lower cardiovascular risk factors, such as high blood pressure and high cholesterol levels (4,5). Therefore, the German Society of General Practice and Family Medicine recommends that PCPs advise all patients at risk of CVD on maintaining a healthy diet (2). In Germany, there is lack of representative data regarding the provision of dietary counselling in primary care settings. Previous studies from the USA and other nations have explored the provision of dietary advice in primary care as well as physicians’ attitudes towards nutritional counselling. In general, PCPs have been shown to hold positive opinions on the importance of diet for the prevention of CVD. The majority of the physicians was convinced of the high importance of nutritional counselling for the prevention of CVD and regarded it as one of their central responsibilities to offer such advice (6,7). However, dietary counselling was only provided in 24−35% of patient encounters (8,9). Different obstacles to the provision of dietary counselling have been revealed in several studies, with lack of time, insufficient reimbursement and lack of patients’ motivation being the most important barriers (6). However, since the majority of the above-mentioned surveys were conducted in the USA, these findings cannot be generalized to German health care system. Thus, to date, the prevalence of dietary counselling offered for the purpose of health promotion and disease prevention in primary health care here still remains unclear. Our aim was therefore to explore the routine provision of dietary advice and factors associated with dietary counselling based on the 5 A’s, using data provided by the German ÄSPkardio Study (Ärzte-Survey zur Prävention kardiovaskulärer Erkrankungen; German for: Physician Survey on Cardiovascular Disease Prevention), the largest representative physician survey on this topic to date. The 5 A’s counselling framework, initially developed to counsel patients on smoking cessation, has also been proposed as an approach for physicians to provide advice regarding diet (4,10). We further aimed to examine the attitudes of German PCPs towards dietary counselling for the prevention of CVD.
Dietary counselling in primary care settings
was pretested and used in a regional study, which included 260 PCPs in Baden-Wuerttemberg, Germany (13).
Measures
Statistical analysis Factors associated with the provision of dietary advice were explored using chi-square tests and multiple logistic regression analyses. Separate regression models were run for each of the A’s, in order to explore the provision of dietary counselling in
depth. The regression models included variables that were significant in bivariate analyses and were adjusted for the confounding effect of PCPs’ sex and age. Data were analysed using IBM SPSS 21.0 (Somers, NY). In all of the tests, P-values 30%
Male Female ≤50 years >50 years General medicine/ general practitioner General internal medicine
1.00 [Ref.] 0.84 [0.73–0.98]* 0.64 [0.23–1.71] – – – – – n = 3518
– – – – – – – – n = 3665
1.00 [Ref.] 1.45 [1.23–1.72]*** 1.00 [Ref.] 1.55 [1.31–1.85]*** 1.00 [Ref.] 1.24 [1.03–1.49]*
–
1.27 [1.06–1.52]**
1.00 [Ref.] 1.72 [1.47–2.01]*** 1.00 [Ref.] 1.33 [1.14–1.56]*** 1.00 [Ref.] 1.25 [1.05–1.48]*
1.00 [Ref.] 1.41 [1.19–1.66]*** – – –
1.00 [Ref.] 1.51 [1.29–1.76]*** 1.00 [Ref.] 1.18 [1.02–1.37]* 1.00 [Ref.]
Advise
– – – 1.00 [Ref.] 1.29 [1.06–1.57]* – – – n = 3576
1.00 [Ref.] 1.57 [1.29–1.91]*** – – 1.00 [Ref.] 1.48 [1.19–1.82]***
–
– – – – –
Agree
Arrange
1.00 [Ref.] 1.16 [1.02–1.33]* – – – –
1.00 [Ref.] 1.45 [1.26–1.66]*** 1.00 [Ref.] 1.22 [1.06–1.40]** 1.00 [Ref.] 1.31 [1.13–1.52]*** – – – – – – – – n = 3717
Assista
1.00 [Ref.] 1.49 [1.27–1.76]*** – – – –
1.00 [Ref.] 1.41 [1.19–1.67]*** 1.00 [Ref.] 1.26 [1.07–1.49]* – – – – – – – 1.00 [Ref.] 0.81 [0.68–0.95]* 0.79 [0.64–0.98]* n = 3545
Downloaded from http://fampra.oxfordjournals.org/ at University of California, San Francisco on March 3, 2015
95% CI, 95% confidence interval; Ref., reference category. Metrically scaled variables were dichotomized by the median split; models included variables significant in bivariate analyses and were adjusted for the confounding effect of PCPs’ sex and age; only significant associations are shown; ***P
