Physical inactivity is a global health concern and the fourth leading cause of global death ¹. Annually, physical inactivity is responsible for more than five million deaths worldwide, with an overall healthcare cost estimated at 53.8 billion U.S dollars ². To continue ongoing efforts to address this public health concern, in 2018, the Department of Health and Human Services issued the Physical Activity Guidelines for Americans to promote life-long health benefits. These science-based guidelines were proposed to provide policymakers, clinicians, public health practitioners and the general public with comprehensive information regarding achievable physical activity (PA) goals to manage chronic conditions, including hypertension, type 2 diabetes, obesity, heart disease, stroke, dementia, selected cancers, and depression ^3–5.

National guidelines recommend that adults perform at least 150 minutes of moderate aerobic activity, or 75 minutes of vigorous aerobic activity, or a combination of moderate and vigorous activity weekly ⁵. Despite the long-term health benefits of PA, many Americans across the lifespan do not meet the recommended levels ⁵. The global initiative “Exercise is Medicine” was developed in 2007 by the American Medical Association and the American College of Sports Medicine ⁶. The principal goal of the initiative calls for healthcare providers to include PA assessments and promotion as a standard in clinical care, connecting health care with evidence-based PA resources for people everywhere and of all abilities ⁶. Since then, the U.S. Department of Health and Human Services’ Healthy People 2020 Initiative established their goal for 85% of healthcare providers to counsel patients on the importance of regular PA. Yet, according to U.S. national sample surveys, only 33% of adults received counseling on PA activity from their healthcare provider ⁷.

PA discussions in the clinic setting may actually hold promise because the majority of adults visit their health care providers (HCPs) annually ^8–11. The HCPs’ role in delivering PA counseling has been advocated in various reports with established recommendations, and it is well documented that patients want PA advice from their HCPs ^9,12–14. While the role of the HCP in promoting PA reflects an upward trend since 2010, there is much work to be done to meet Healthy People 2030 goals. A vast amount of evidence confirms that counseling on regular PA is one of the most powerful recommendations HCPs can offer their patients ^4,14,15. In fact, the healthcare system and clinicians have an important role promoting regular PA. The beliefs and attitudes of clinicians are significantly influential when discussing health related issues such as PA as a lifestyle behavior ¹⁶. Moreover, HCPs at healthcare clinics have frequent contact with large numbers of patients who are older, have a lower social economic status, and/or have multiple comorbidities; these groups would benefit the greatest from lifestyle discussions to improve health outcomes ^16,17.

Although PA is an effective strategy to manage and prevent many chronic illnesses, research suggests that there are barriers and facilitators to offering PA discussions with patients ^18–20. Clinicians with a positive attitude towards regular PA are more likely to provide PA counseling to their patients ¹⁸. However, HCPs cite barriers to physical activity counseling, such as inadequate time and lack of training and reimbursement ²¹. Establishing policies within a healthcare organization is a promising strategy to encourage HCPs to promote physical activity participation at each clinic encounter, which could subsequently improve overall health among vulnerable adults. The purpose of this pilot study was to understand HCPs’ beliefs and practices regarding PA discussions as part of patients’ healthcare regime.

The University of Alabama at Birmingham Institutional Review Board approved this study. Cooper Green Mercy Health Services (CGMHS) was the study site. CGMHS is an ambulatory safety-net clinic located in Jefferson County, Alabama, that serves residents regardless of their ability to pay and provides services including primary and specialty care, urgent care, and occupational and speech therapy. Researchers developed a PA policy study that encouraged HCPs to discuss PA with their patients during clinic visits. Post intervention, we obtained evaluative feedback and perspectives about the PA policy from the HCPs. The overall pilot study had three collection periods ²². Period 1 included identifying policies (or the lack thereof) that promote PA discussions during patients’ clinical visits with HCPs to assess baseline data from African American (AA) patients about whether physical activities were discussed during their visit. We achieved this by first reviewing policy manuals of the clinic. We also conducted baseline assessments of patients’ perceptions of PA discussions during their clinic visit. We accomplished this by administering surveys to patients immediately after their clinic visit to assess if PA discussions occurred. Period 2 involved the development and implementation of the policy to promote PA discussion during patients’ clinical visits with their HCPs. Modifications to the clinic’s electronic medical record (EMR) were made to facilitate documentation and HCPs were provided an educational PA brochure to help facilitate their discussions ²³. The final period, which is the focus of this paper, was to conduct a qualitative descriptive pilot study to explore HCPs’ perceptions and feedback about discussing PA with patients after the conclusion of the PA policy intervention.

Purposeful and snowball sampling strategies were used to recruit HCPs who provided direct patient care within CGMHS. Ten HCPs expressed interest and were screened to ensure that they provided direct patient care to AA patients in primary care ^24–26. Once participants were entered into the study, informed written consent was obtained, and each participant was compensated $50.00 for their time.

PA advice from HCPs can be a powerful catalyst to start and sustain PA ^10,14, and many vulnerable populations need healthy lifestyle behavior advice the most ¹⁶. The majority of participants in our study believed that PA counseling is an important part of a patient’s plan of care. This finding supports the current literature because most HCPs have a positive attitude towards PA counseling and believe that PA is an important provision for patients ¹⁸. However, it was interesting that most of our providers immediately quoted the national PA recommendations during their interviews, but when pressed to talk about their own PA behavior, their reality was complicated and challenging, even with having access to additional resources such as wearable activity monitors such as FitBits or living in a high resource (e.g., golfing) community.

Even though all the HCPs acknowledged that PA is an important component to manage and prevent chronic diseases, many providers voiced factors that would hinder their ability to provide regular PA counseling to this population. Our HCPs mentioned barriers such as time restraints, limited resources, and the perceptions that vulnerable and marginalized populations would not adhere to PA advice, confirming many barriers identified in the literature ^16,18.

Although HCPs in our study cited “a lack of time” as a barrier, some researchers have found that PA counseling did not increase the length of the appointment and, in fact, was an asset to their practice because their patient’s health benefited ³⁵. One solution towards vulnerable populations adhering to PA counseling might incorporate more personalized recommendations centered on the patient’s health needs. Tailored healthy lifestyle counseling is more acceptable and more effective in motivating behavior change ^36,37. Several of the HCPs in our study mentioned time restraints or expressed the need for someone else to provide the PA counseling. Another strategy may be to implement guidelines to assist clinicians and health care systems with how to adopt the exercise is medicine (EIM) initiative into busy primary care clinics ³⁸.

Consistent with our findings, HCPs should not make pre-conceived perceptions about PA counseling to vulnerable and marginalized populations. Moreover, HCPs should not solely use their judgement and underestimate the importance of collaborating with patients to include their preferences when prescribing treatment plans ³⁹. Routine and consistent PA counseling with each health care visit should be offered to improve health care outcomes, and HCPs are well positioned to positively influence behavior change, such as increased PA. Implementing policies to encourage HCPs to counsel their patients on PA at each encounter could increase the likelihood of sustaining healthy behavioral changes for patients. The promotion of PA by HCPs should become integrated into routine health care practice and be tailored to the needs of patients.

Given the important role HCPs have in the lives of patients, PA counseling at every clinic visit regardless of barriers is a promising strategy for all HCPs to utilize to improve health outcomes. The goal of this pilot study was to assess the HCP’s perceptions and to understand HCPs’ beliefs and practices regarding PA discussions as part of patients’ healthcare regime. This study also sought input from HCPs to inform future strategies that might help safety-net facilities or any clinical setting that serves vulnerable populations provide PA discussions at every visits. Further research is needed in larger sample sizes to test interventions that encourage meaningful PA discussions and to assess the impact on patient health outcomes. Results of this study also suggests that HCPs may need additional resources and training on how to integrate PA counseling into their clinical practices ^38,40. Institutional policies that support HCPs in the delivery of PA counseling may improve patient motivation and sustainability to engage in regular PA.