How do general practitioners in Denmark promote physical activity?

Promotion of Physical Activity by Québec Primary Care Physicians: What Has Changed in the Last Decade?

OBJECTIVE

This study aimed to assess the changes in the frequency of physical activity (PA) counseling and in the predictors of primary care PA promotion in Québec primary care physicians (PCPs) between 2010 and 2020.

METHODS

In 2010, we conducted a survey among Québec PCPs. Questions included: frequency of promoting PA to patients, perceived barriers, needs to improve PA promotion practice, frequency of PCPs' PA practice, and sociodemographic information. In 2020, we took over the 2010 questionnaire to document the evolution of the PA promotion practice.

RESULTS

The proportion of PCPs discussing PA with their patients significantly increased (P < .05) in 2020 for the following health conditions: depression, low back pain, chronic obstructive pulmonary disease, and cancer; it declined (P < .05) for overweight patients, those with metabolic syndrome, and in primary prevention. Collaboration with PA professionals was the major need identified, and it increased in 2020. PCPs' own practice of PA was a predictor of PA promotion in 2010 (odds ratio = 6.679; P < .001) and in 2020 (odds ratio = 6.679; P < .001). In both 2010 and in 2020, older or more experienced PCPs were more likely to discuss PA with their patients without diagnosed diseases than younger ones or those with less experience.

CONCLUSIONS

Over the last 10 years, there has been a significant increase in PCPs promoting PA in Québec; however, it has been mainly oriented toward secondary prevention. It is concerning that PA counseling in primary prevention has declined, notably among younger PCPs. The stronger claim for closer collaboration with kinesiologists suggests that PCPs are in favor of an interprofessional strategy, namely collaboration with PA specialists.

Study design of 'Move More': Development and feasibility of a social-prescribing intervention to increase physical activity among inactive Danes

AIM

This paper describes the design of the 'Move More' study, which aims to develop and assess the feasibility of a social-prescribing intervention to increase physical activity among physically inactive Danes.

BACKGROUND

Physical inactivity constitutes a public-health challenge in Denmark. Social prescribing may be a promising tool to tackle physical inactivity by linking physical activity support from general practitioners with community-based activities in sports clubs, as this may help physically inactive citizens become more physically active. Given the range of stakeholders and behaviours required for social prescribing of physical activity, an intervention that harnesses this approach may constitute a complex intervention. The methods and decisions made in the stages of developing complex interventions are seldom reported. The present study enabled us to describe how co-creation can be used in a pragmatic development process for a complex intervention that considers the needs of stakeholders and the conditions of the delivery context.

METHODS

The study is based on the core elements of the development and feasibility phases of the Medical Research Council Framework for Developing and Evaluating Complex Interventions. Additionally, it is informed by a framework for the co-creation and prototyping of public-health interventions, drawing from a scoping review, stakeholder consultations and co-creation workshops. Ultimately, a feasibility study will be conducted to refine the programme theory by introducing the proposed intervention in case studies.

PERSPECTIVES

The study will result in a prototype intervention manual and recommendations for implementation of an adapted social-prescribing intervention targeting physical inactivity in Denmark.

Counselling on physical activity in Danish antenatal care: A qualitative study of experiences from both the pregnant woman's and the care provider's perspective

OBJECTIVES

Physical activity during pregnancy is beneficial to maternal and fetal health, but most pregnant women do not achieve the recommended level of physical activity. To investigate how antenatal care can promote physical activity during pregnancy, this study explores experiences of physical activity counselling from the perspectives of pregnant women and antenatal care providers.

METHODS

In a qualitative design with an inductive approach individual semi-structured interviews with 19 pregnant women and seven antenatal care providers were performed and analyzed using thematic analysis.

RESULTS

The themes "Experiencing inadequate counselling", "Benefiting from individualized guidance", and "Voicing a need for enhanced support" cover the perspectives from the participating pregnant women. They often experienced insufficient physical activity counselling that left them insecure about proper physical activity during pregnancy. The pregnant women desired individualized and concrete advice and early and continuous support. From antenatal care providers the themes "Providers' perceived barriers in counselling", "Balancing the act of counselling", and "Acknowledging potential for enhanced counselling" were identified. They perceived barriers towards counselling including time restraints, lack of interest, and doubts about certain physical activity during pregnancy but expressed trying to adjust the counselling to meet the woman's individual situation. They acknowledged that continuous support during pregnancy and updated knowledge and increased focus among providers might improve physical activity counselling.

CONCLUSIONS

Pregnant women received scarce counselling on physical activity in antenatal care, while care providers described several barriers towards counselling on physical activity. Both pregnant women and antenatal care providers recognized opportunities for enhanced physical activity counselling.

Physical activity through social prescribing: An interview-based study of Danish general practitioners' opinions

Previous research suggested that regular physical activity (PA) is beneficial in both prevention and treatment of physical and mental conditions. Danish general practitioners' (GPs) have an ideal position to motivate inactive patients to increase their PA. Social prescribing (SP) enables GPs and other healthcare professionals in primary care to link patients to community-based activities of support provided by the community and the voluntary sector. This interview-based study aimed to explore viewpoints among Danish GPs regarding the advantages and disadvantages of applying SP to promote PA. The GPs were recruited through snowball sampling. Semi-structured interviews with nine Danish GPs were held via telephone or via Skype video conference. All interviews were audio-recorded and transcribed. Data were managed using the program NVivo 12 and analysed using the Framework Method procedure for analysis. The findings highlighted the need for tools to support GPs in providing an overview of patient-tailored options for PA in the local community. Advantages of applying SP to promote PA were related to the social aspect, the non-medical approach to a healthier lifestyle and the GPs' opportunity to signpost patients to PA in their local community. A supporting link-worker facilitating a bridge between general practice and community-based activities was identified as a pivotal component, specifically among patients with complex needs. Disadvantages of applying SP to promote PA were related to patients' expectations to general practice, stigmatising attitudes of society and lack of financial resources in patients. This study is the first to explore SP to promote PA in a Danish context. There is a need for an easy-to-use tool to support GPs in providing specific PA counselling. On this basis, SP appears as a promising tool for GPs to promote PA.

Delivering brief physical activity interventions in primary care: a systematic review

BACKGROUND

Physical activity (PA) brief interventions (BIs) involving screening and/or advice are recommended in primary care but frequency of delivery is unknown.

AIM

To examine the extent to which PA BIs are delivered in primary care, and explore factors associated with delivery, receipt, and patient receptivity.

DESIGN AND SETTING

A mixed-methods systematic review of studies conducted worldwide, with a narrative synthesis of results.

METHOD

CINAHL, EMBASE, MEDLINE, and APA PsycINFO index databases were searched for qualitative and quantitative studies, dating from January 2012 to June 2020, that reported the level of delivery and/or receipt of PA BIs in primary care, and/or factors affecting delivery, receipt, and patient receptivity. Quality was assessed using the Mixed Methods Appraisal Tool. Attitudes towards and barriers to delivery were coded into the Theoretical Domains Framework and the Capability, Opportunity, and Motivation Behaviour model.

RESULTS

After screening a total of 13 066 records, 66 articles were included in the review. The extent of PA screening and advice in primary care varied widely (2.4%-100% and 0.6%-100%, respectively). PA advice was delivered more often to patients with a higher body mass index, lower PA levels, and/or more comorbidities. Barriers - including a lack of time and training/guidelines - remain, despite recommendations from the World Health Organization and National Institute for Health and Care Excellence that PA advice should be provided in primary care. Few studies explored patients' receptivity to advice.

CONCLUSION

PA BIs are not delivered frequently or consistently in primary care. Addressing barriers to delivery through system-level changes and training programmes could improve and increase the advice given. Understanding when patients are receptive to PA interventions could enhance health professionals' confidence in their delivery.

Promoting physical activity and physical function in people with long-term conditions in primary care: the Function First realist synthesis with co-design

Background

As people age and accumulate long-term conditions, their physical activity and physical function declines, resulting in disability and loss of independence. Primary care is well placed to empower individuals and communities to reduce this decline; however, the best approach is uncertain.

Objectives

To develop a programme theory to explain the mechanisms through which interventions improve physical activity and physical function in people with long-term conditions in different primary care contexts, and to co-design a prototype intervention.

Data sources

Systematic literature searches of relevant databases with forwards and backwards citation tracking, grey literature searches and further purposive searches were conducted. Qualitative data were collected through workshops and interviews.

Design

Realist evidence synthesis and co-design for primary care service innovation.

Setting

Primary care in Wales and England.

Participants

Stakeholders included people with long-term conditions, primary care professionals, people working in relevant community roles and researchers.

Methods

The realist evidence synthesis combined evidence from varied sources of literature with the views, experiences and ideas of stakeholders. The resulting context, mechanism and outcome statements informed three co-design workshops and a knowledge mobilisation workshop for primary care service innovation.

Results

Five context, mechanism and outcome statements were developed. (1) Improving physical activity and function is not prioritised in primary care (context). If the practice team culture is aligned to the elements of physical literacy (mechanism), then physical activity promotion will become routine and embedded in usual care (outcome). (2) Physical activity promotion is inconsistent and unco-ordinated (context). If specific resources are allocated to physical activity promotion (in combination with a supportive practice culture) (mechanism), then this will improve opportunities to change behaviour (outcome). (3) People with long-term conditions have varying levels of physical function and physical activity, varying attitudes to physical activity and differing access to local resources that enable physical activity (context). If physical activity promotion is adapted to individual needs, preferences and local resources (mechanism), then this will facilitate a sustained improvement in physical activity (outcome). (4) Many primary care practice staff lack the knowledge and confidence to promote physical activity (context). If staff develop an improved sense of capability through education and training (mechanism), then they will increase their engagement with physical activity promotion (outcome). (5) If a programme is credible with patients and professionals (context), then trust and confidence in the programme will develop (mechanism) and more patients and professionals will engage with the programme (outcome). A prototype multicomponent intervention was developed. This consisted of resources to nurture a culture of physical literacy, materials to develop the role of a credible professional who can promote physical activity using a directory of local opportunities and resources to assist with individual behaviour change.

Limitations

Realist synthesis and co-design is about what works in which contexts, so these resources and practice implications will need to be modified for different primary care contexts.

Conclusions

We developed a programme theory to explain how physical activity could be promoted in primary care in people with long-term conditions, which informed a prototype intervention.

Future work

A future research programme could further develop the prototype multicomponent intervention and assess its acceptability in practice alongside existing schemes before it is tested in a feasibility study to inform a future randomised controlled trial.

Study registration

This study is registered as PROSPERO CRD42018103027.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 16. See the NIHR Journals Library website for further project information.

'Function First': how to promote physical activity and physical function in people with long-term conditions managed in primary care? A study combining realist and co-design methods

OBJECTIVES

To develop a taxonomy of interventions and a programme theory explaining how interventions improve physical activity and function in people with long-term conditions managed in primary care. To co-design a prototype intervention informed by the programme theory.

DESIGN

Realist synthesis combining evidence from a wide range of rich and relevant literature with stakeholder views. Resulting context, mechanism and outcome statements informed co-design and knowledge mobilisation workshops with stakeholders to develop a primary care service innovation.

RESULTS

A taxonomy was produced, including 13 categories of physical activity interventions for people with long-term conditions.

ABRIDGED REALIST PROGRAMME THEORY

Routinely addressing physical activity within consultations is dependent on a reinforcing practice culture, and targeted resources, with better coordination, will generate more opportunities to address low physical activity. The adaptation of physical activity promotion to individual needs and preferences of people with long-term conditions helps affect positive patient behaviour change. Training can improve knowledge, confidence and capability of practice staff to better promote physical activity. Engagement in any physical activity promotion programme will depend on the degree to which it makes sense to patients and professions, and is seen as trustworthy.

CO-DESIGN

The programme theory informed the co-design of a prototype intervention to: improve physical literacy among practice staff; describe/develop the role of a physical activity advisor who can encourage the use of local opportunities to be more active; and provide materials to support behaviour change.

CONCLUSIONS

Previous physical activity interventions in primary care have had limited effect. This may be because they have only partially addressed factors emerging in our programme theory. The co-designed prototype intervention aims to address all elements of this emergent theory, but needs further development and consideration alongside current schemes and contexts (including implications relevant to COVID-19), and testing in a future study. The integration of realist and co-design methods strengthened this study.

Physical Activity Promotion: A Systematic Review of The Perceptions of Healthcare Professionals

Physical activity (PA) is a cost-effective and non-pharmacological foundation for the prevention and management of chronic and complex diseases. Healthcare professionals could be viable conduits for PA promotion. However, the evidence regarding the effectiveness and benefits of the current forms of PA promotion are inconclusive. Healthcare professionals' perceptions on key determinants impact on the optimum promotion of PA were explored in this review. Thirty-four (34) studies were identified after systematically searching seven databases for peer-reviewed articles published within the last decade. PA advice or counselling was the most recorded form of PA promotion, limited counselling time was the most reported obstacle while providing incentives was viewed as a key facilitator. There is widespread consensus among healthcare professionals (HCPs) on some aspects of PA promotion. Utilisation of all PA promotional pathways to their full potential could be an essential turning point towards the optimal success of PA promotional goals. Hence, strategies are required to broaden chronic disease treatment methods to include preventive and integrative PA promotion approaches particularly, between frontline HCPs (e.g., GPs) and PA specialists (e.g., EPs). Future studies could explore the functionality of GP to EP referral pathways to determining what currently works and areas requiring further development.

Health Care Providers' Advice on Lifestyle Modification for Older Adults

OBJECTIVES

To describe the pattern of health care providers' advice on lifestyle modification to older adults, and identify correlates of receiving such advice.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

Data from the National Health and Nutrition Examination Survey study from 2007-2016 on adults ≥65 years (n = 3758) were analyzed.

METHODS

We estimated the weighted prevalence and correlates of receiving advice on the following lifestyle modifications: (1) increase physical activity, (2) reduce fat/calories, (3) control/lose weight, and (4) a combination of control/lose weight and physical activity. Data were analyzed according to level of comorbidity (number of chronic conditions including high blood pressure, high blood cholesterol, type 2 diabetes mellitus, coronary heart disease, and arthritis) and body mass index (BMI).

RESULTS

Physical activity was the most widely prescribed lifestyle modification, reported by 15.7% of older adults free of chronic conditions and 28.9%, 35.4%, and 52.6% of older adults with 1, 2, and ≥3 comorbidities. Advice on reducing fat/calories was reported by 9.2%, 18.5%, 26.3%, and 40.9% of older adults with 0, 1, 2, and ≥3 comorbidities, respectively, and advice on weight loss/control was reported by 6.5%, 19.1%, 20.8%, and 37.5%, respectively. The combination of advice on weight loss/control and physical activity was least commonly reported: 5.1%, 13.5%, 16.6%, and 32.0%, respectively. Overall, lifestyle modifications were more frequently advised to older adults who were overweight, obese, or Hispanic.

CONCLUSIONS AND IMPLICATIONS

In the United States, lifestyle modifications are not routinely recommended to older adults, particularly those free of chronic conditions, presenting a missed opportunity for chronic disease prevention and management. Among those advised to lose or manage weight, concurrent advice to increase physical activity is not consistently provided.

Should sports and exercise medicine be taught in the Swiss undergraduate medical curricula? A survey among 1764 Swiss medical students

OBJECTIVES

The global lack of sports and exercise medicine (SEM) teaching at medical schools contrasts with evidence that physical activity (PA) plays a major role in preventing and treating non-communicable diseases (NCDs). The aims of this study were to (a) examine whether Swiss medical students are expected to acquire SEM-related skills and knowledge, (b) systematically reviewed SEM teaching in the Swiss undergraduate medical curricula, (c) assess if Swiss medical students are aware of SEM and (d) whether they would like SEM to be included in their curricula.

METHODS

Two authors independently screened the 'Principal Relevant Objectives and Framework for Integrative Learning and Education in Switzerland' (PROFILES) for SEM-related learning objectives and reviewed the curricula. 7708 Swiss medical students were invited to participate in an online survey.

RESULTS

32 SEM-related learning objectives were identified in PROFILES with 20 of them linked to PA. Four of eight Swiss medical schools display limited mandatory SEM teachings. 1764 students participated in the survey (482.0% of the necessary sample size, 22.9% of all Swiss medical students). One in two students knew that SEM includes preventing and treating NCDs. Almost 95% of the participants would like SEM to be included in the curricula.

CONCLUSION

Despite its inclusion in PROFILES and comprehensive evidence that SEM should be taught at medical schools, this is scarcely the case in Switzerland. Swiss medical students have limited understanding of SEM, but are keen to have it included in the curricula. This study highlights the need for more comprehensive SEM teaching at Swiss medical schools.

The effects of previous educational training on physical activity counselling and exercise prescription practices among physicians across Nova Scotia: a cross-sectional study

BACKGROUND

Physicians (MDs) report difficulty including physical activity (PA) and exercise (PAE) as part of routine care. MDs who report previous educational training in PAE may prescribe exercise more frequently. We evaluated the effects of previous training on perceptions and practices of PA counselling and exercise prescriptions among MDs in Nova Scotia.

METHODS

MDs (n=174) across Nova Scotia completed an online self-reflection survey regarding their current PAE practices. MDs who reported previous training (n=41) were compared to those who reported no training (n=133).

RESULTS

Trained-MDs were 22% more confident performing PA counselling than untrained-MDs (p<0.005). In patient appointments, trained-MDs included PAE more often (51% vs 39%; p=0.03) but trained-MDs and untrained-MDs had similar rates of exercise prescriptions (12%; p>0.05). The most impactful barriers (on a scale of 1 to 4) were lack of time (2.5) and perceived patient interest (2.4), which were unaffected by previous training (p>0.05).

CONCLUSION

Previous training was associated with a higher confidence to include PAE discussions with patients by MDs in Nova Scotia, but had minimal influence on their many barriers that prevent exercise prescription. Although some training supports MDs inclusion of PAE into their practice, there is a need for greater, more intensive educational training to assist MDs in prescribing exercise.

Exercise is Medicine Canada physical activity counselling and exercise prescription training improves counselling, prescription, and referral practices among physicians across Canada

Exercise is Medicine Canada (EIMC) is an initiative that promotes physical activity (PA) counselling and exercise prescription within health care. The purpose of this study was to compare physicians' perceptions and practices around PA counselling and exercise prescription following EIMC training. Physicians (n = 46) from 7 different provinces completed questionnaires initially and 3 months following an EIMC workshop. Three months after intervention, physicians reported greater confidence compared with baseline for providing physical activity and exercise (PAE) information to patients (79% vs 55%; p < 0.001), assessing patients' PAE (69% vs 44%, p = 0.005), answering patients' PAE questions (78% vs 54%, p < 0.001), providing PAE advice (71% vs 43%, p < 0.001), and identifying which patients would benefit from referral to qualified exercise professionals (77% vs 52%, p = 0.002). At follow-up, physicians reported PA prescription barriers as less impactful (out of 4; all p < 0.05), including perceived patients' lack of interest (2.75 to 2.25), lack of available resources (2.59 to 2.00), and lack of time (2.41 to 2.14). The proportion of physicians providing written exercise prescriptions increased from 20% to 74%. This study suggests that the completion of a 1-day EIMC workshop increases physicians' confidence, knowledge, and counselling behaviours of physicians in prescribing PAE.

Health care provider confidence and exercise prescription practices of Exercise is Medicine Canada workshop attendees

The Exercise is Medicine Canada (EIMC) initiative promotes physical activity counselling and exercise prescription within health care. The purpose of this study was to evaluate perceptions and practices around physical activity counselling and exercise prescription in health care professionals before and after EIMC training. Prior to and directly following EIMC workshops, 209 participants (physicians (n = 113); allied health professionals (AHPs) (n = 54), including primarily nurses (n = 36) and others; and exercise professionals (EPs) (n = 23), including kinesiologists (n = 16), physiotherapists (n = 5), and personal trainers (n = 2)) from 7 provinces completed self-reflection questionnaires. Compared with AHPs, physicians saw more patients (78% > 15 patients/day vs 93% < 15 patients/day; p < 0.001) and reported lower frequencies of exercise counselling during routine client encounters (48% vs 72% in most sessions; p < 0.001). EPs had higher confidence providing physical activity information (92 ± 11%) compared with both physicians (52 ± 25%; p < 0.001) and AHPs (56 ± 24%; p < 0.001). Physicians indicated that they experienced greater difficulty including physical activity and exercise counselling into sessions (2.74 ± 0.71, out of 5) compared with AHPs (2.17 ± 0.94; p = 0.001) and EPs (1.43 ± 0.66; p < 0.001). Physicians rated the most impactful barriers to exercise prescription as lack of patient interest (2.77 ± 0.85 out of 4), resources (2.65 ± 0.82 out of 4), and time (2.62 ± 0.71 out of 4). The majority of physicians (85%) provided a written prescription for exercise in <10% of appointments. Following the workshop, 87% of physician attendees proposed at least one change to practice; 47% intended on changing their practice by prescribing exercise routinely, and 33% planned on increasing physical activity and exercise counselling, measured through open-ended responses.

Can a 3-hour educational workshop and the provision of practical tools encourage family physicians to prescribe physical activity as medicine? A pre-post study

OBJECTIVES

To increase, in our sample, the proportion of family physicians who provided their patients with written physical activity prescriptions after the delivery of a 3-hour educational workshop with the provision of practical tools to facilitate behaviour change.

DESIGN

A pre-post study.

SETTING

Abbotsford and Mission, British Columbia.

PARTICIPANTS

All 158 physicians registered with the Abbotsford (121) or Mission (37) Divisions of Family Practice were invited to participate.

INTERVENTION

A 3-hour educational workshop combined with practical tools. Educational content of the workshop included (1) assessing patients' physical activity levels, (2) using motivational interviewing techniques to encourage physical activity and (3) providing written physical activity prescriptions when appropriate. Practical tools to facilitate physician behaviour changes included a 'physical activity vital sign', and copies of the Exercise is Medicine Canada Prescription Pad. Participating physicians completed a bespoke questionnaire before and 4 weeks after their attendance at the workshop.

OUTCOME MEASURES

The primary outcome was the change in the proportion of family physicians who reported providing written physical activity prescriptions. Exploratory outcomes included changes in other physical activity prescription behaviours, the perceived importance of various barriers to prescription, and knowledge and confidence in regards to physical activity prescription. McNemar's test evaluated changes in proportions before and after the workshop, while Wilcoxon signed-rank tests evaluated changes in Likert data.

RESULTS

25 family physicians completed the baseline questionnaire and attended the workshop, with 100% follow-up response rate. The proportion of family physicians who reported providing written physical activity prescriptions in their clinical practice increased significantly (p<0.05), from 10 (40%) at baseline to 17 (68%) 4 weeks after the intervention.

CONCLUSIONS

Educational workshops combined with practical tools appear to be a promising method to encourage the use of written physical activity prescriptions among family physicians in this setting, over the short term.

Physician awareness of knee and hip pain in the context of coronary heart disease treatment

Background. The benefit of physical activity for the prevention and treatment of cardiovascular disease (CVD) has been well documented. The aim of the present study was to determine the level of awareness among general practitioners (GPs) of knee and hip problems in patients with CVD or CVD risk. Design. Cross-sectional questionnaire survey. Setting and Subjects. Thirty-five Austrian GPs and 1,118 patients were included. The GPs completed an extraction form about the presence or absence of documented evidence of problems related to the knee and/or hip joint within the patient medical data. Patients, in turn, were asked to complete a questionnaire that included the Oxford Knee/Hip Score and the cardiovascular risk-chart established by the European Society of Cardiology. Results. In 748 patients' data from medical records and questionnaires were available. 40.9% of these patients suffered from serious knee pain and 32.1% from hip pain. However, in the medical records, in only 51.3% (knee) and 48.1% (hip) of these pain-patients the problems were documented. Conclusion. Joint disorders of the knee and hip problems are considerable barriers to effective physical activity and can therefore contribute to the development of CVD. Our data showed that GP awareness of such knee/hip disorders should be improved.

Physical activity promotion in the health care system

Physical activity (PA) and exercise training (ET) have great potential in the prevention, management, and rehabilitation of a variety of diseases, but this potential has not been fully realized in clinical practice. The health care system (HCS) could do much more to support patients in increasing their PA and ET. However, counseling on ET is not used widely by the HCS owing partly to attitudes but mainly to practical obstacles. Extensive searches of MEDLINE, the Cochrane Library, the Database of Abstracts of Reviews of Effects, and ScienceDirect for literature published between January 1, 2000, and January 31, 2013, provided data to assess the critical characteristics of ET counseling. The evidence reveals that especially brief ET counseling is an efficient, effective, and cost-effective means to increase PA and ET and to bring considerable clinical benefits to various patient groups. Furthermore, it can be practiced as part of the routine work of the HCS. However, there is a need and feasible means to increase the use and improve the quality of ET counseling. To include PA and ET promotion as important means of comprehensive health care and disease management, a fundamental change is needed. Because exercise is medicine, it should be seen and dealt with in the same ways as pharmaceuticals and other medical interventions regarding the basic and continuing education and training of health care personnel and processes to assess its needs and to prescribe and deliver it, to reimburse the services related to it, and to fund research on its efficacy, effectiveness, feasibility, and interactions and comparability with other preventive, therapeutic, and rehabilitative modalities. This change requires credible, strong, and skillful advocacy inside the medical community and the HCS.