Artigos

Conteúdo (article):

Physical activity counseling in primary health care in Florianopolis, Brazil


Sheylane de Queiroz Moraes
Graduate Program in Physical Education. Sports Center. Federal University of Santa Catarina. Florianopolis, SC, Brazil.
Email: moraessheylane@gmail.com
ORCID: https://orcid.org/0000-0002-2389-7426

Ana Carolina Belther Santos
Graduate Program in Physical Education. Sports Center. Federal University of Santa Catarina. Florianopolis, SC, Brazil.
Email: anabelther.acbs@gmail.com
ORCID: https://orcid.org/0000-0003-2957-8255

Rogério César Fermino
Graduate Program in Physical Education. Federal Technological University of Paraná. Curitiba, PR, Brazil.
Email: rogeriofermino@utfpr.edu.br
ORCID: https://orcid.org/0000-0002-9028-4179

Cassiano Ricardo Rech
Graduate Program in Physical Education. Sports Center. Federal University of Santa Catarina. Florianopolis, SC, Brazil.
Email: cassiano.rech@ufsc.br
ORCID: https://orcid.org/0000-0002-9647-3448

Resumo
O objetivo deste estudo foi descrever a prevalência e analisar os fatores associados ao aconselhamento para a atividade física realizado por profissionais da Atenção Primária à Saúde (APS) de Florianópolis, Santa Catarina. Foi realizado inquérito com 587 profissionais de 49 centros de saúde. A realização de aconselhamento nos últimos 12 meses foi avaliada. Os fatores explorados na associação foram os sociodemográficos, de formação e atuação profissional, do conhecimento das recomendações de atividade física e do nível de atividade física. A proporção de profissionais que relataram aconselhar para atividade física foi 86,2% (IC95%: 83,2-88,8%). Os profissionais com maiores chances de aconselhar foram os com pós-graduação em Saúde Pública (OR: 3,71; IC95%: 1,69-9,37), que tiveram experiências acadêmicas na APS (OR: 2,68; IC95%:1,32-5,92), que pertenciam ao Núcleo Ampliado de Saúde da Família (OR: 4,52; IC95%: 1,31-28,50), que participavam de reuniões de matriciamento sobre atividade física (OR: 1,91; IC95%: 1,08-3,44) e eram fisicamente ativos (OR: 1,80; IC95%: 1,01-3,27). Os resultados sugerem que aspectos da formação e atuação profissional e o nível de atividade física dos profissionais contribuem positivamente nas ações de aconselhamento para atividade física na APS.

Palavras-chave: Aconselhamento; Atenção Primária à Saúde; Pessoal de Saúde; Atividade motora.

Abstract
The aim of this study was to determine the prevalence and examine the correlates of physical activity counseling by primary health care professionals in Florianopolis, state of Santa Catarina. A face-face survey was carried out with 587 professionals from 49 Health Centers. Physical activity counseling was evaluated in the last 12 months. The correlates explored in the association were sociodemographic, training and professional performance, knowledge of physical activity recommendations and physical activity level. The prevalence of physical activity counseling was 86.2% (95% CI = 83.2-88.8%). The professionals most likely to provide counseling were those with graduate degrees in Public Health (OR = 3.71; 95% CI: 1.69-9.37), who had academic experiences in primary health care (OR = 2.68; 95% CI: 1.32-5.92), who belonged to the Family Health Support Center (OR = 4.52; 95% CI: 1.31-28.50), who participated in meetings of physical activity (OR = 1.91; 95% CI: 1.08-3.44) and were physically active (OR = 1.80; 95% CI: 1.01-3.27). The results show that aspects of training and professional performance and the physical activity level of professionals contribute positively to counseling for physical activity in primary health care.

Keywords: Counseling; Primary Health Care; Health Personnel; Motor activity.

Introduction
Physical activity is an important factor for human development, and it has been related to sociability, learning quality of life and health maintenance1; furthermore, physical activity has recognized benefits for the prevention of non-communicable chronic diseases2. An estimated three million deaths a year worldwide are related to physical inactivity, which imposes a challenge to health systems to incorporate actions to promote physical activity to the population2.
In this sense, counseling has been proposed as an effective strategy to increase physical activity levels3,4 and its practice is strongly recommended5,6. The practice of counseling in health services has been shown to be important, as it is a low-cost health education technology that can be applied by various health professionals7. In addition, it is estimated that 62.6% Brazilian population is served by the Family Health Strategy8. This high capillarity and scope can favor the use of counseling as a health care strategy.
Studies reinforce the importance of health counseling9,10. A systematic review with 21 studies showed that 60% health professionals provided counseling for physical activity9. In Brazil, this prevalence ranged from 46.2 to 88.9%9,11-15. However, most studies investigated the practice of counseling among physicians, nurses and community health agents11,12,14,15, not considering professionals from other Primary Health Care (PHC) teams. The Family Health Strategy organizes its work based on multidisciplinary actions16. Thus, in addition to including general practitioners, nurses, nursing assistants, community health agents, dental surgeons and oral health technicians, this model can count on the Family Health Support Centers (NASF-AP), a multiprofessional team working to expand the scope of care provision to users17. This model has produced favorable results for the health of the population16,17, constituting an important context for counseling promotion. Thus, identifying the prevalence and factors associated with physical activity counseling in the PHC reality, in Brazil, can broaden the discussion on the role of this strategy in the current context of the Sistema Único de Saúde (SUS) or Unified Health System.
Regarding association studies, most of them have tested the relationship between physical activity counseling and professional category, sociodemographic variables or barriers to counseling12,14,15,18,19. These studies show that personal characteristics, such as considering effective counseling for lifestyle changes15,20 and being prepared to counsel11,15,20 were associated with greater chances of counseling for physical activity. Additionally, regarding attitudes, having a lower body weight18, having a positive self-rated health15 and practicing physical activity12,14,18,19 were also associated with counseling practice. On the other hand, the isolated and simultaneous presence of barriers such as lack of time11,21, knowledge and guidance negatively contributed to the practice of counseling for physical activity21. Still, little has been explored about the characteristics of training and professional performance. A study that analyzed working time, daily number of consultations, participation in physical activity courses and support from a multidisciplinary team, did not find an association with counseling15. However, these data are not conclusive, requiring further analysis to better investigate these variables. In this sense, the present study sought to advance the state of the art, including in the analysis of variables of training and action strategy of health professionals as possible elements that may be related to physical activity counseling.
Thus, the aim of the study was to describe the prevalence and examine the correlates to physical activity counseling by primary health care professionals in Florianopolis, state of Santa Catarina.

Method
This was an observational, cross-sectional, quantitative study, carried out in 2018. PHC professionals from the municipality of Florianopolis, capital of the state of Santa Catarina, Southern Brazil, with an estimated population of 516,524 inhabitants, were evaluated. Florianopolis has the third-highest Municipal Human Develop Index in Brazil (0.847) and a high urbanization rate22.
The municipality’s PHC is organized based on the model of the Family Health Strategy, according to SUS guidelines23 and stands out in the national scenario for presenting high levels of coverage8. It is composed of 49 Basic Health Units (UBS), called Health Centers, distributed in four Health Districts (Center, Continent, North, and South) which have the “Family Health”, “Oral Health” and “NASF-AP” teams. This study included the 49 Health Centers.
All procedures were approved by the Ethics Committee in Research with Human Beings of the Federal University of Santa Catarina (opinion 2,693,520). Participants were informed about their willingness to participate in the research, upon consent and signing the Free and Informed Consent Term, in accordance with Resolution 466/2012.

Participants
Participants were health professionals working in the PHC in Florianopolis, and the Family Health Team was composed of a community health agent, a nurse, a physician and a nursing technician; the Oral Health Team consisted of an assistant/technician in oral health and a dental surgeon; and the NASF-AP multiprofessional team was composed of a social worker, nutritionist, physical therapist, psychologist, pharmacist and physical education professional.
The study included resident professionals from Programs in Family Health at the Federal University of Santa Catarina and the University of the State of Santa Catarina. Interns and volunteers did not participate in the survey.
According to data from the National Registry of Health Establishments furnished by the Municipal Health Department and updated by the Health Districts, the total number of professionals in 2018 corresponded to 1,056.

Data collection
A census was carried out and all the professionals in service at the time of data collection were invited to respond to the survey instrument. Data were collected by a team consisting of four researchers during the planning meetings of the Health Centers and NASF-AP meetings from August to November 2018. They participated in the whole process of research design, elaboration of instruments and data collection.
The researchers contacted the Districts and Health Center coordinators to schedule the date and time for data collection. Also, they carried out the dissemination of the survey via email, in addition to the application, data collection and organization of the questionnaires. The collection was preceded by a brief explanation about the research and instructions for self-completion of the questionnaire. To minimize losses in data collection, a second visit was made to collect questionnaires from professionals who were not present or were unable to complete at the time of the meeting. For higher data reliability, all questionnaires were checked by two researchers at different times.

Instrument and variables
A self-administered questionnaire composed of 49 objective questions was applied. These questions were distributed in five blocks: 1 - counseling for physical activity; 2 - knowledge about physical activity recommendations; 3 - level of physical activity during leisure time; 4 - training and professional performance and block 5 - sociodemographic information.
The instrument was developed by the research team based on a systematic review9. Subsequently, the questionnaire was evaluated and approved by two specialists in the field of Physical Education with expertise in PHC and tested with undergraduate students and health professionals.

Counseling for physical activity
Physical activity counseling was evaluated through the recall question: “during your consultations, in the last 12 months, did you provide physical activity counseling to users?”, with a dichotomous answer option (“no”, “yes”). This question was based on other studies on counseling9,24.

Sociodemographic variables
The sociodemographic variables were sex (“male”, “female”), age group (“20 to 29 years old”, “30 to 49 years old” and “≥ 50 years old”) and marital status (“single”, “married/common-law marriage” and “divorced/widowed”)25. In addition, education was initially assessed in five categories (“incomplete elementary”, “complete elementary/incomplete elementary/secondary school”, “complete elementary/incomplete high school”, “complete high school/incomplete higher education” and “complete higher education”)25. Schooling was grouped with the question of having a graduate degree (“no” and “yes”) and, thus, recategorized into “no undergraduate degree”, “undergraduate degree” and “graduate degree”.

Professional qualification
In relation to Graduate Studies in Public Health, the question used was: “Was the graduate program you completed in Public Health, or Family and Community Health or Collective Health?”, with a dichotomous answer option (“no”, “yes”).
Academic experiences in PHC were evaluated by the question: “During the undergraduate course, did you participate in academic programs or activities related to professional intervention in Primary Care (PC)?”, with answer options: mandatory curricular internship at PC, PET-Saúde (Program of Education through Work for Health), scientific initiation project related to PC, extension project related to PC, PRÓ-Saúde (National Program for Reorientation of Professional Training in Health), no other programs were offered. The answers were dichotomized (“no”, “yes”).
Participation in a course on physical activity was evaluated through the question: “In the last 12 months, have you participated in any training course offered by the Municipal Health Department that addressed the topic of physical activity and health?”, with a dichotomous answer option (“no”, “yes”).

Professional performance
To evaluate the professional team, professionals were grouped into two categories: 1) Family Health and Oral Health “eSF/eSB” (community health agent, nurse, physician, nursing technician, oral health assistant/technician and dental surgeon); 2) “NASF-AP” (social worker, nutritionist, physical therapist, psychologist, pharmacist and physical education professional).
The type of employment relationship was evaluated through the question: “What type of employment relationship do you currently have in Primary Care?”. The answers were recategorized into “temporary” (commissioned position, temporary contract, cooperative and health resident) and “public service” (effective public servant).
Participation in health support on physical activity was evaluated by the question: “In the last 12 months, how often have you received or carried out support from the NASF-AP team on the topic of physical activity and health, such as: performing technical actions-assistance (discussion of clinical cases) and/or technical-pedagogical (continuing education on topics relevant to the teams)?”. Responses were recategorized into “no” (the “never” response) and “yes” (the “rarely”, “often” and “always” responses).
The working time (in years and/or months) in PHC was evaluated by the question: “How long have you worked in Primary Care?”. The answers were dichotomized into: “≤ 3 years” and “3 years”. The weekly workload was evaluated in five categories and later dichotomized into “≤ 30h” and “≥ 40h”.

Physical activity recommendations knowledge
Knowledge of moderate and vigorous physical activity recommendations for adults was assessed using self-reported and described knowledge questions. Self-reported knowledge was assessed by the question: “Do you know the recommendations for physical activity for apparently healthy adults, regarding moderate or vigorous physical activity?”, with a dichotomous answer option (“no”, “yes”). For the knowledge described, professionals reported the minimum weekly frequency and the minimum time (in minutes) recommended for physical activity for adults to achieve health benefits, according to the World Health Organization26. The score of minutes per week (min/week) of recommended physical activity was the result of the product of the weekly frequency and the minimum time, with knowledge categorized as “correctly described the physical activity recommendations” for values between “150 - 300 min /week” of moderate physical activity, and “75 - 150 min/week” of vigorous physical activity, and “did not correctly describe physical activity recommendations” values below or above these references26.

Level of physical activity during leisure time
Leisure-time physical activity was assessed using the long version of the International Physical Activity Questionnaire (IPAQ) instrument27. It was calculated from the sum of the products of the weekly frequency and the time in minutes of moderate, vigorous physical activity and leisurely hiking in a typical week, and the time in physical activities of vigorous intensity was multiplied by two. Thus, for data analysis, the score of minutes per week was categorized into “< 150 min/week” and “≥ 150 min/week” according to international recommendations26.
Data analysis
Information was entered using EpiData® version 3.1 software (The EpiData Association, Odense, Denmark). Data were reviewed with exploratory analysis to identify possible typing errors, which were manually corrected. An initial analysis was run with descriptive statistics, absolute and relative frequency distribution. The prevalence of counseling was described among the categories of independent variables using the Chi-Square test. The association was analyzed using bivariate binary logistic regression analysis and adjusted for all covariates. After the bivariate analysis, all variables from the same level or higher level, which presented p-value < 0.20, were selected for adjustment in the final model, according to the backward method. Analyses were performed using the R software version 3.5.3 and the significance level was kept at 5%.
Results
A total of 1,056 professionals from the 49 Health Centers were invited to the survey. The refusal rate was 25.8% (n = 273) and the loss was 18.5% (n = 196). The losses occurred due to incomplete filling of data (n = 23; 3.7%) and due to absence from work (vacation and leaves) during the data collection period (n = 173, 16.4%). Thus, the final sample consisted of 587 professionals (85.4% women).
There was a predominance of professionals of 30-49 years old (68.8%), with graduate degrees (44.2%). As for professional practice, most professionals belonged to the Family Health and Oral Health teams (87.7%), were public service providers (61.8%), worked in PHC for more than three years (77.1%) and with a workload equal to or greater than 40 hours per week (80.6%) (Table 1).

< INSERT TABLE 1 >

The proportion of physical activity counseling was 86.2% (95% CI = 83.2; 88.8%). In the bivariate analysis, there was a greater chance of counseling among those with undergraduate degree, with a graduate degree, with a graduate degree in Public Health, with academic experience in PHC who belonged to the NASF-AP, who participated in matrix meetings on physical activity and were physically active (Table 2).
After adjustment for all covariates, the analysis showed that professionals with a graduate degree in Public Health remained associated with a higher chance of counseling (OR = 3.71; 95% CI:1.69; 9.37), who had academic experiences in PHC during initial training (OR = 2.68; 95% CI: 1.32; 5.92), who belonged to the NASF-AP team (OR = 4.52; 95% CI:1.31; 28.50), who participated in physical activity matrix meetings (OR = 1.91; 95% CI: 1.08; 3.44) and were physically active (OR = 1.80; 95% CI: 1.01;3.27) when compared to their peers (Table 2).


Discussion
This study shows that approximately eight out of ten PHC professionals in Florianopolis reported performing some type of physical activity counseling in the last 12 months. Higher counseling was observed among professionals with a graduate degree in Public Health who had academic experience in PHC, who belonged to the NASF-AP, who participated in support meetings on physical activity and were physically active.
The practice of physical activity counseling reported by professionals was 86.2%. Similar results were found in other studies13. A systematic review9 identified that the average prevalence of counseling reported by health professionals was 60.2 ± 22.7%. In studies carried out in Brazil with medical professionals, nurses, nursing technicians and community health agents, the prevalence ranged from 46.2 to 88.9%11-15. The high prevalence in the present study can be explained by the characteristics of PHC in Florianopolis as it is recognized for its innovative practices, constant investment in permanent health education, and for being a national reference in population coverage of the Family Health Strategy (above 70%)28-30. In addition, it relies on multidisciplinary teams throughout the territory, and has 14 Physical Education professionals, which may have contributed to the dissemination of content on physical activity to other professionals and, consequently, to the increase in the practice of counseling. Still, this high prevalence has an innovative character, since in addition to including professionals from the Family Health team, NASF-AP and Oral Health professionals were also considered. In fact, experimental evidence in different countries has identified that counseling is an effective strategy for increasing the level of physical activity in adults treated in PHC5,31. From this perspective, the SUS in Brazil presents a promising scenario with great potential for the practice of counseling, due to the scope of PHC, above all, due to the participation of multidisciplinary teams32. However, physical activity counseling is a construct far beyond recommending physical activity and requires a foundation in theories about behavior change. For this reason, it is necessary to check the quality of this counseling, in other words, it is necessary to verify if the strategies used to advise are based on solid theoretical models that promote behavior change33. Therefore, the prevalence-related findings are novel even though challenges related to the quality of counseling need to be further investigated.
Health professionals who reported having a graduate degree in Public Health were 3.7 times more likely to provide counseling compared to professionals who do not have this training (no undergraduate degree or with a graduate degree in another area). No studies were found that tested this specific association9. However, a specialization degree in Public Health can favor the opening of the professional to address the issue of physical activity, since this field intends to break with the traditional paradigm of health care, allowing a broader look at the various factors involved in the genesis of the disease, in health promotion, and a more communicative, horizontal and transdisciplinary practice34,35. Additionally, the incentive for graduate studies in Public Health strengthens the SUS, since the guiding principles of this policy involve welcoming and comprehensively looking at the individual, in addition to supporting counseling actions for physical activity, as health professionals are important mediators of reflections on behavior change.
Another important result was that health professionals with academic experience in PHC were more likely to perform physical activity counseling than professionals who did not have this experience during the initial training process. Although no studies have tested this association, the literature identifies experiences during the initial training process are decisive for knowledge about the reality of PHC36 and are closely related to the strengthening of professional identity37. Also, the experience in the SUS reality provides the opportunity for interaction in multidisciplinary teams and dialogue between different professions, which drives transdisciplinary exchange of knowledge38,39. These experiences are essential to transform work organization modes and qualify health care practices40 as they prepare future professionals for a more collaborative and humanized practice, not focused on disease, but on health promotion. In this way, promotion of these experiences can have a positive impact on consolidating the practice of counseling for physical activity during consultations. An example of this are the programs in the SUS that allow students to experience PHC through curricular internships, extension projects, and programs, such as the Education Program for Work for Health (PET-Saúde) and experiences and internship in the reality of the Unified Health System (VER-SUS). Despite this, it is necessary to strengthen the teaching-service partnership and strategies that improve training for the various professional categories to work in PHC, since each has its own challenges related to initial training36,40. Also, it is necessary to think about the inclusion of physical activity counseling in the syllabus of undergraduate health programs, since this is an interdisciplinary, promising topic that requires knowledge and skills from professionals41,42.
Participating in support health meetings on physical activity and belonging to the multidisciplinary team of the NASF-AP were related to greater chances of physical activity counseling. Only one study tested the association between counseling and participating in the support health meeting on physical activity, but did not evidence an association and was carried out with professionals from the Family Health team15. Therefore, the present study is pioneer in investigating counseling for physical activity among various professionals of the Family Health, Oral Health and NASF-AP teams. Furthermore, this result highlights the importance and applicability of PHC policies, such as the implementation of support health meeting and actions focused on integrality, transdisciplinary and overcoming the disease-centered health model43,44. The essential role NASF-AP has played through matrix support17 signals the need for these teams to be upheld, given that recent political changes in the way Brazilian PHC is financed may contribute to weakening this strategy45,46. Furthermore, it is essential that health units can count on the NASF-AP as a support team, creating space on the agenda for holding support health meetings. Still, it is worth highlighting the role of the Physical Education professional in these teams43. The sharing of knowledge about physical activities by the Physical Education professional seems to influence counseling not only through the health education component, such as the offer of physical activity groups11, but also through the provision of permanent education and expanded clinical actions, as conversation circles, directed studies, case discussions and consultation, which can contribute to the propagation of the topic about physical activity among other specialties44. Although this professional plays a key role in support meetings on physical activity, it is necessary to consider that many still demonstrate difficulties in working in the context of PHC, possibly due to the lack of approximation of the Physical Education syllabus of Brazilian higher education institutions on topics related to Public Health47,48. Therefore, the support of the NASF-AP team (especially the Physical Education professional) and holding matrix meetings are essential for promoting physical activity counseling in PHC.
Physically active professionals were more likely to provide physical activity counseling. Similar results were found in studies with community health workers in Brazil12,14. Studies conducted with physicians in the United States and Japan have also shown a relationship between the habit of practicing physical activities and counseling to promote this behavior18,19. Another study identified that support policies to increase physical activity levels in undergraduate health students have been considered important for developing a training program in physical activity counseling42. These findings reinforce how essential it is to involve health professionals in healthy behaviors and occupational programs encourage the practice of physical activities. Thus, the positive and affective experience with the practice of physical activities, in addition to contributing to improving the quality of life of professionals, can be a motivating element to encourage and advise patients to change their behavior towards an active lifestyle13,14.
As a strength, this is a pioneering study for investigating physical activity counseling to professionals from different health teams, including the NASF-AP and Oral Health teams9. The representative sample of PHC professionals in a Brazilian capital is also a strength of the study. Also, as a strong point, the search for investigating the association of aspects related to training and professional performance in the practice of counseling for physical activity is highlighted. Some limitations must be considered. The counseling measure used may have overestimated the results, since in a single question, it was not possible to encompass the complexity and polysemy permeating the term “health counseling”. Professionals may have had divergent understandings of the term, which would require a refinement of the concept for future research through the objective identification of strategies that have been used. There may also have been a “social desirability” bias, depending on the context in which the respondents were inserted.


Conclusion
The prevalence of physical activity counseling reported by PHC professionals was high (approximately 86%). Furthermore, the highest chances of counseling for the practice of physical activity were identified among professionals with a graduate degree in Public Health, academic experience in PHC, who belonged to the multidisciplinary team of the NASF-AP, participated in support health meetings about physical activity and were physically active compared to their peers. It is suggested that future studies explore the strategies, barriers, and knowledge necessary for counseling in PHC by professionals to better understand the physical activity counseling scenario in Brazil.

Practical implications
The results found in the present study reinforce the importance of investing in educational strategies to guide PHC professionals on behavioral counseling and physical activity. These should be encouraged both during initial training, with experiences in the SUS, as well as in permanent and continuing education, with incentives for specializations in Public Health, guaranteeing conditions for carrying out support health and programs to promote physical activity for academics and professionals in service. Additionally, the presence of the NASF-AP, and especially of the Physical Education professional, must be maintained and valued in the Brazilian PHC policies, since the performance of this team is related to the provision of counseling for physical activity and has been essential to expand population health care.

Acknowledgement
The authors thank the team of researchers, managers and professionals participating in the research. This work was carried out with the support from the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001 and the Fundação de Amparo à Pesquisa e Inovação do Estado de Santa Catarina (FAPESC).

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