Artigos

INTRODUCTION
Physical inactivity is a significant global health problem, and a large proportion of the population is exposed to a risk of chronic diseases1. It is estimated that 31% of the world's adult population does not meet the moderate-to-vigorous physical activity (MVPA) guidelines of the World Health Organization (WHO), with this prevalence even higher in Latin America (37%), especially in Brazil (41%)2. If there is no reduction in physical inactivity, around 500 million new cases of chronic diseases could occur by 2030, with 74% of these in low- and middle-income countries3. In addition to the burden on countries' public health systems, the economic impact could reach US$ 300 billion4,5.

Despite governments’ efforts and investments related to physical activity (PA) promotion, only 47% of countries have a specific policy, strategy, or action plan, and this proportion is lower in middle and high-income countries (?40%)4. The Brazilian National Policy on Health Promotion is an important strategy to confront the physical inactivity burden6. It guides PA promotion at the community level as Primary Health Care (PHC) of the Unified Health System (Sistema Único de Saúde – SUS)6. To reduce the impact of physical inactivity and direct actions to increase PA levels, in 2018, the WHO launched the Global Action Plan for PA, highlighting the need for an integrated community approach to reduce physical inactivity by 15% by 20307. Also, the WHO suggested promoting PA within PHC, and the counseling yielded encouraging results in behavioral change and is advocated as an integral element of integrated community interventions7–9. The International Society for Physical Activity and Health (ISPAH) also highlights the potential of health professionals in PA promotion and the need for investment in this area10.

The population's first contact and primary access to health services occur at the PHC11,12. The characteristics of PHC provide a favorable environment that can enhance PA counseling as a strategy to promote it on a large scale13,14. Counseling is an effective, low-cost, and easy-to-implement strategy already used by most PHC professionals9,15–17. However, there is considerable variability in counseling by health professionals, ranging from 12-95%18. The disparity in the prevalence of counseling between studies can be explained by the care practice of each city or state, in addition to the conduct or work process of the professional18,19.

Faced with its multiple determinants and the importance of health professionals in PA promotion20, it is necessary to understand the implementation process and the articulation of counseling for behavior change conducted by professionals from different cities21. The different characteristics of PHC services at the municipal level can make it challenging to use standardized PA counseling22. Health professionals generally recognize the importance of PA actions in promoting public health23,24. However, implementing effective strategies for adequate counseling also depends, among other factors, on in-depth knowledge and analysis of the possible perceived barriers to its implementation23–25. For example, the difficulty or the number of barriers may reduce the chance of professionals counseling PA during individual or group consultation22,24,26.

Lack of time, skill, knowledge or training, resources or educational materials, low priority or relevance, and lack of success in changing user behavior are the main barriers to PA counseling reported by PHC professionals18,19,23,24. In Latin American countries, evidence of barriers to counseling was identified from only two studies in Brazil26,27. Like the world literature, the lack of instructional material, professionals to advise, knowledge, time, and environmental/financial resources of users were the most reported barriers26,27. Knowing the prevalence and associated factors with PA counseling reported by professionals and your barriers can direct interventions to increase and improve counseling18,22,24,26,27. However, exploring and advancing the knowledge related to the micro and macro-level barriers in each context, region, or country is necessary19,24.

Based on the literature review, there is no evidence of potential individual predictors of specific barriers in PHC professionals. Exploring this association may help direct strategies to reduce or manage the barriers and support the actions to implement programs for PA counseling at PHC18,22,28. Therefore, this study aimed to verify the possible associations between sociodemographic and job characteristics, knowledge, PA level, counseling, city, and each barrier to PA counseling reported by PHC professionals in two cities in southern Brazil.

METHODS
Our report was based on the Strengthening the Reporting of Observational Studies in Epidemiology items29.

Design, locals’ contextualization, and ethical aspects
It is an observational study with a quantitative approach and a cross-sectional design. Data from two surveys conducted between 2018 and 2020 in Florianópolis-SC and São José dos Pinhais-PR, in the southern region of Brazil, were analyzed. These surveys were designed to identify the prevalence of PA counseling conducted by PHC professionals and its associated factors30,31. Although these cities are in the South region of Brazil, 300 km apart, they present differences in distinct domains, such as population, employed population, Gross Domestic Product, and urban area32,33.

The studies were approved by the Research Ethics Committees of the Federal University of Santa Catarina (#2,693,520) and the Pontifical Catholic University of Paraná (#2,882,260). Participants were consulted, informed about voluntariness, and agreed to participate in the research by signing an informed consent form following the recommendations of the National Commission for Ethics in Research of the National Health Council.

Participants
The PHC professionals who worked in the SUS at the health units [Basic Health Units, or Unidades Básicas de Saúde (UBS) – in Portuguese] were invited to participate30,31. The UBS are public clinics strategically distributed within a city, with free access for PHC provided by physicians, nurses, pharmacists, physiotherapists, nutritionists, psychologists, and community health workers. In some Brazilian cities, some UBS also include physical education professionals. In Florianópolis-SC, a census was conducted with professionals, and those absent on interview day (vacation, licenses) were considered losses, and the professionals on training were excluded. In São José dos Pinhais-PR, all nurses and physicians participated in the study. However, 59 of 176 community health workers were randomly sampled to represent these professionals (34%). We excluded those with some physical limitations to PA practice (e.g., wheelchair and crutch users) (n=1). Thus, the total sample consisted of 497 health professionals (220 community health workers [44.2%], 146 nurses [29.4%], and 131 physicians [26.4%]) who worked in all the 64 UBS of the urban areas in two cities30,31.

Data collection
In Florianópolis-SC, data were collected by applying a self-administered questionnaire in planning meetings held at the UBS between August and November 201831. In São José dos Pinhais-PR, data collection took place with individual interviews conducted by a trained researcher between December 2019 and January 202030. The questionnaires were adapted from similar studies, paired, adapted to the local context, tested in a pilot study, and adequate concerning the clarity of the questions and adequacy of the protocols, according to the manual of instructions designed to assist in data collection.

Data selection and pairing
The literature review found that the health professionals who most frequently provided PA counseling were physicians, nurses, and community health workers. Since the project aim was to identify the barriers reported by professionals who provided counseling most frequently, and due to the logistics involved in data collection in São José dos Pinhais-PR, professionals from other health areas were not evaluated. Furthermore, the data were restricted to these three professional categories to enable comparison with other studies. As a result, data from other professional categories were suppressed in the Florianópolis-SC database to enable combination with data from physicians, nurses, and community health workers collected in São José dos Pinhais-PR. The pairing of research and merging of data was carried out to enable comparability between different contexts, increase the number of participants in the sample, and reduce the estimation errors in the association analyses between the possible predictors explored and the prevalence of each barrier to PA counseling.

Outcome variable: Barriers to PA counseling
The perception of barriers was evaluated using a questionnaire developed for Brazilian PHC professionals27 and adapted from other studies24,26. The kappa values ranged from 0.56 to 0.83 (p<0.001)26. Participants answered: “What reasons prevent or make it difficult for you to carry out PA counseling during your consultations or attendance?”. Seven barriers were evaluated based on the most frequently mentioned in the literature24: 1) “lack of time in consultations”, 2) “lack of knowledge or training about counseling”, 3) “does not consider its function”, 4) “does not considers important”, 5) “lack of evidence on the benefits of PA for health”, 6) “lack of educational materials” and 7) “lack of success in changing the behavior of users”. A dichotomy scale was available for each barrier (no, yes). For analysis purposes, the number of barriers was operationalized by the sum of the seven barriers, ranging from zero to seven. The number of barriers was categorized into “0”, “1”, or “? 2”26,27,34.

Possible predictor variables
Based on the literature review, the possible predictor variables included sociodemographic and job characteristics, knowledge, PA level, counseling, and city22,24,26–28. These variables are described below.


Sociodemographic characteristics
Sex was observed or self-reported, age was grouped into two categories (18-39; ?40 years old), a university degree was classified into “incomplete” or “complete”, and postgraduate (specialization degree) in public health (no, yes).

Job characteristics
The professional category was classified into community health workers, nurses, physicians, working time at the UBS (?36 and >36 months), and the number of users attended per week (?50, 51-99, ?100).

Knowledge and PA level
A single question identified the perception of knowledge about PA guidelines for health: “Do you know what the PA recommendations are for apparently healthy adults regarding MVPA?” (no, yes).

Leisure-time PA (LTPA) in a habitual week was measured by the long version of the International Physical Activity Questionnaire (IPAQ)35. Participants reported weekly frequency and average walking duration, as well as MVPA. Each activity/intensity score was identified in minutes per week (min/wk) by multiplying the weekly frequency by the average daily volume. Total LTPA was obtained by summing min/wk of walking + min/wk of moderate PA + (min/wk of vigorous PA*2). Total LTPA was classified according to WHO guidelines (? 150 min/wk)36.

PA counseling
The counseling was identified by asking, “During your consultations or home visits, do you counsel users on PA”? (advice, tips, or guidance to move as exercise, sports, or commuting) (no, yes).


City
The barriers were analyzed by the city (Florianópolis-SC and São José dos Pinhais-PR).

Data Analysis
Data were explored and analyzed using the qualitative variables' absolute and relative frequency distribution. The prevalence of each barrier was determined between the categories of predictor variables, and the association was analyzed using the chi-square tests (?2) for heterogeneity and linear trend or Fisher's exact test. The barriers were explored by sociodemographic and job characteristics, knowledge, PA level, counseling, city, and prevalence of each barrier to PA counseling34. Analyzes were conducted using the SPSS 26 software, and the significance level was kept at 5%.

RESULTS
Health professionals had an average age of 41±9 years old. The sample was predominantly composed of women (83.0%), people aged ?40 years (51.5%), graduates (61.4%), and no postgraduate in public health (72.8%) (Table 1). Regarding professional categories, we observed a higher frequency of community health workers (44.2%), people who worked at the UBS for >36 months (57.9%) and attended ?100 users per week (43.3%) (Table 1). The proportion of sex, age group, postgraduate, and number of users attended per week differed between the cities (p<0.05).

Around 49% of professionals reported knowing the PA guidelines, and 60.8% did not reach the ?150 min/wk in LTPA. PA counseling was reported by 82.9% of professionals, and the highest proportion of them related ?1 barrier to counseling (89.0%) (Table 1). All variables showed significant differences between the cities (p<0.05).

INSERT TABLE 1

The most barriers reported were “lack of time” (54%), “lack of educational material” (47%), and “lack of knowledge or training” (45%) (Figure 1). The proportion of the barriers “lack of knowledge or training”, “does not consider its role”, “does not consider important”, and “lack of evidence of the PA benefits” was highest in Florianópolis-SC (p<0.05) (Table 2).

INSERT FIGURE 1

The barrier “lack of time” was most common among the physicians (p<0.05). Except for the barrier of “lack of educational material”, all the others were higher for the community health workers (p<0.05). The professional category was not associated with the number of barriers to PA counseling (p>0.05) (Figure 2).

INSERT FIGURE 2

The only common and proportionally equal barrier among the possible predictors explored was the “lack of educational material” (p>0.05). The barrier “lack of evidence of the PA benefits” was significantly associated with eight (73%) of the 11 predictors explored (1: sex, 2: age group, 3: university degree, 4: professional category, 5: working time at the UBS, 6: number of users attended per week, 7: knowledge of PA guidelines, and 8: city) (p<0.05) (Table 2). “Lack of time” was proportionally highest among health professionals aged 18-39 years (62.5% vs. 42.4%), those with a university degree (64.9% vs. 29.7%), physicians (71.1% vs. 62.9%, and 29.7%), and those working at the UBS ?36 months (68.0% vs. 44.8%) (p<0.05) (Table 2).

INSERT TABLE 2

Despite an 8-9 percentage point reduction in the prevalence of counseling, the number of barriers was not associated with the counseling provided (p=0.390) (Figure 3).

INSERT FIGURE 3

DISCUSSION
This is the first study to evaluate the possible associations between sociodemographic and job characteristics, knowledge, PA level, counseling, city, and each barrier to PA counseling reported by professionals in PHC. Additionally, it is the third study in Latin America to analyze barriers to counseling in this population. The quantitative approach and standardized methodology, designed to avoid selection bias, allowed us to explore the barriers in a representative sample from two cities in Brazil. Our study expands the knowledge about PA counseling and provides new insights for designing interventions to reduce specific barriers among healthcare professionals. These are the strengths and innovations of our study.

It is well known that counseling has an association and effect on increasing PA9,15–17. Identifying the prevalence and associated factors with barriers to counseling is important to promote PA in PHC. Counseling rates are high, ranging between 12-95%18; however, it is relevant to identify ways to increase its effectiveness in different PHC contexts, especially in Latin America13,37. From an international perspective, knowledge and exploration of these variables are essential so that policymakers can develop public policies and plan actions to improve the quality of counseling to promote PA at the population level in countries with a public health system like Brazil, which can reduce the burden of risk factors for noncommunicable diseases3–5,12.

The “lack of time” in attendance was the barrier most frequently reported by professionals (54%). These results are similar to those found in other studies13,18,24,26,27. These barriers were reported more frequently by younger professionals (18-39 years old) and with less time working at the UBS (?36 months). In Brazil, the PHC in the SUS is based on comprehensive care for users12. However, services must be quick and agile due to users' high daily demand. In this study, 43% of professionals reported serving ?100 people per week (? 20 per day), an increased demand without considering other care needs at the PHC. This characteristic can compromise the work of professionals and the quality of information delivery to users, such as PA counseling24,27.

Counseling strategies should be tailored to the local work context. In this sense, models and brief counseling protocols consider the time the health professional has available17. For example, some authors suggest that the lack of time can be alleviated by using the 5A's model in conjunction with organizational changes, such as having the patient fill out PA questionnaires in the waiting room, limiting the counseling session to 2–4 min, and providing written material to supplement the counseling efforts38. However, many countries have counseling protocols for PHC (e.g., Exercise is Medicine®, NICE)25. The WHO also has a PA promotion guide in PHC8. Stakeholders, managers, and health professionals can combine and adapt two or more approaches to the local context8,25,39.

As “lack of time” was mostly reported by physicians and nurses, community health workers are essential for PA counseling in the population. The working characteristic provides a significant interaction with the community, which results in more knowledge of demands and needs40. However, there are reports that community health workers are directed to many daily demands of the PHC, such as welcoming users, scheduling appointments, and other bureaucratic activities41. The work overload can distance these professionals from PHC. However, as the function of community workers does not require a university degree in health, it is necessary to direct actions to teach them about “PA and public health” so that it is possible to deliver good counseling during home visits. For example, it is important to train them about their role in promoting health in the community through PA to make them aware of the efficacy or effectiveness of counseling and its benefits to public health6,40. These actions could reduce the frequent barriers to counseling reported by community health workers in this study.

“Lack of educational material” (47%) and “lack of knowledge or training” (45%) were the other barriers most reported, as in other studies18,19,24,26. The “lack of educational material” was not associated with any possible predictors, showing that the reason is common to all, regardless of sociodemographic and work characteristics. However, the “lack of knowledge or training” was higher among women, professionals with incomplete university degrees, some community health workers, and those who reported not knowing about PA guidelines. These results can be explained by training characteristics and the absence of content on “PA and public health” in health colleges13,25. For example, only 27% of the professionals interviewed completed postgraduate studies in public health. Experience and public health training can increase the odds of PA counseling for PHC users by four times28. Similarly, presenting academic experiences at PHC and attending multidisciplinary meetings at the UBS are also significantly and positively associated with PA counseling22,28.

In Brazil, the knowledge of PHC professionals needs to be improved and is low about PA guidelines42. Around 85-90% of physicians, nurses, and community health workers reported the need to improve their knowledge of PA guidelines42. The recommended weekly amount of moderate-to-vigorous PA reported accurately was 9% for nurses, 8% for physicians, and 4% for community health workers. The “hit” rate for guidelines to vigorous PA was non-existent: 0% for physicians and <1% for nurses and community health workers42. Insufficient knowledge of the elementary base about PA and public health, which are the weekly volume guidelines, can lead to incorrect information delivery during the counseling offered8,36.

All barriers identified in this study can be partially or wholly overcome by the access of PHC professionals to materials recently prepared by the Brazilian Ministry of Health in partnership with researchers: The “PA Guidelines for the Brazilian Population”43 and “Guide of Brief Guidance on PA Counseling at PHC in SUS”39. The PA guidelines present simple information about the concept and contextualization of PA and guidelines for children, adolescents, adults, and older adults, in addition to pregnant and women in postpartum and for people with disabilities43. The guide also presents a set of recommendations for PHC stakeholders, managers, and professionals to help them understand how information can assist in professional practice. Similarly, the “Guide of Brief Guidance on PA Counseling”39 contains information on application, planning, realization, content, and suggestions for implementing counseling in individual and group attendance. Also, The Brazilian National Policy on Health Promotion should be used together for action6. These documents must be widely disclosed to facilitate access to information and implementation of counseling at PHC.

In addition to the documents above, the Brazilian National Policy on Continuing Health Education emphasizes the importance of constantly updating professionals44. The Ministry of Health documents should be used to design and conduct PA counseling workshops to increase PHC professionals' competence. An educational intervention can significantly increase about 92% of health professionals' knowledge about PA counseling for pregnant women45. Also, the women cared for by the intervention group were more likely to receive counseling46. The intervention with counseling was effective, increasing the odds of PA increase about three times47,48.

Another action that should be implemented in the PHC is hiring a physical education professional for the health team49,50. Thereby, people whom other health professionals had instructed to start or increase PA could seek a specialist during their consultations at the UBS, thus receiving detailed information on other possible activities to be performed (e.g., domains and types of PA, frequency, intensity, daily or weekly volume, progression)51. Florianópolis-SC has multidisciplinary teams structured with physical education professionals52. In addition to organizing, conducting, and supervising PA classes50, these professionals should help the health team (physicians, nurses, community health workers, pharmacists, physiotherapists, nutritionists, and psychologists) with information and discussion about PA, as well as interpreting and using documents from the Ministry of Health52–54.

At least four limitations must be considered to interpret the results adequately. First, the data reflect the reality of the PHC according to the management and public policies in force at the local level. Second, the sample was limited to only three professional categories from two cities in Southern Brazil. Our results should be analyzed with parsimony for extrapolation to other professionals and regions of Latin America. Third, the quantitative approach using a short and standardized questionnaire to evaluate barriers did not allow for in-depth exploration of relevant information to implement professional training programs for counseling. Therefore, capturing contextual information that could explain or signify the feelings toward barriers was impossible. This would only have been possible through a qualitative or mixed-method approach. Finally, as the data are restricted to physicians, nurses, and community health workers, caution is recommended when extrapolating the results to other health professionals working in the SUS (e.g., physical education professionals, pharmacists, physiotherapists, nutritionists, psychologists).

CONCLUSION
The most reported barriers were the lack of time, educational material, and knowledge or training. The “lack of time” barrier was most common among physicians and nurses. “Lack of knowledge or training” was the most common barrier among community health workers. Except for the “lack of educational material”, all the others were associated with at least three analyzed predictors. The barrier “lack of evidence of PA benefits” was associated with 73% of predictors explored.

The results of this study could be used to guide ongoing training at the PHC on PA counseling. Health managers can base their strategic actions on emphasizing specific content to overcome barriers to counseling by sociodemographics, job characteristics, knowledge, and PA level of health professionals. PHC actions in Latin America should be expanded, with health professionals’ training towards promoting PA, emphasizing epidemiology, public health, and PA, and developing counseling methods in routine service, with valid and valuable protocols to evaluate actions’ effectiveness. Future studies could assess the efficacy and effectiveness of different formats of permanent educational training in competence to reduce barriers to counseling in this population.

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