Correspondence:
Dr. Mohamed Ghaith Al-Kuwari
Senior Specialist in Family Medicine
Primary Care- Hamad Medical Corporation
Doha- Qatar
P O Box 5054

As the patterns of disease in many societies have been shifted from communicable diseases to chronic disease, the importance of lifestyle has increasingly been addressed as an important determinant of health.¹ Certain behaviors have been identified as risky behaviors and linked to a range of chronic diseases (e.g. coronary heart disease, stroke, diabetes, and cancer. These behaviours include tobacco consumption, poor diet (high in fat and sugar), lack of physical exercise, use of recreational drugs (e.g. Cannabis, heroin), and use of alcohol.² Nowadays evidence is increasing about the role of healthy lifestyle choices such as eating a prudent diet, exercising regularly, managing weight, and not smoking, in reducing the risk of these chronic diseases.^3,4

Promoting healthy lifestyle to restore health and prevent disease has been considered as the new public health or "Health Promotion".¹ The World Health Organization (WHO) defines health promotion as "the process of enabling people to increase control over and improve their health".^5,6 At individual level, health promotion can be described as the application of methods that foster physical and emotional well-being and that increase length and quality of life.⁷ Primary health care and hospitals provide an important setting for health promotion because it offers an opportunity for health professionals to integrate health promotion into their practice.^2,8 However, primary care provides unique advantage of easy access compared to hospitals due to the high patient contact rates.⁹

Because of their perceived creditability by public, the primary care physician has been identified as an important and cost-effective contributor to promoting healthy lifestyle, such as smoking cessation, healthy diet, and physical activity.^2,8 Therefore disease prevention and health promotion became important tasks in the daily practice of all general practitioners (GPs).^10-12 And many health care organizations in developed countries have recommended clinical guidelines for promoting healthy lifestyles in primary care as a part of prevention and treatment of chronic diseases such as cardiovascular disease and diabetes.^13-14

In Qatar, chronic diseases related to unhealthy lifestyle are increasing, putting burden on health care services. As Family Medicine or General Practice becomes an attractive specialty among young physicians in Qatar, health care planners expect that primary care physicians can provide preventive health and health promotion services in their practice in order to tackle chronic disease. In this study we aim to describe the health promotion practices among primary care physicians' in Qatar.

State of Qatar, located in Arabian Gulf, one of the GCC countries with a population of more than 796, 000 estimated last census in 2005. Primary heath care in Qatar is provided through a network of 24 primary health care centers distributed all over the country. There are 253 physicians working at these centers. This cross-sectional survey has recruited primary care physicians working in primary health care centers in Qatar in the last 3 months. Sample size is calculated using 253 physicians.

These include family medicine board certified and other non-family medicine certified physicians. Assuming 10% losses due to refusal and other reasons, we arrived at 136 physicians. The following formula was used N= Nz²p (1-p) l [d²(N-1)+z²p (1-p).

In which; N= total population (253); z= value corresponding to the confidence level (1.96²=3.84); d=absolute precision (0.05²=2.5); p=proportion of the population with the studied characteristics (0.2). Subjects will be recruited by using "Simple random sampling Technique". A list of Primary Health Care physicians will be considered as the sampling frame and each physician will be considered as a unit. 136 physicians were randomly selected from the list.

A structured self-administered questionnaire was used to collect data from the primary care physicians. The questionnaire was in English and had covered the two parts: personal data which includes age, gender, position, last qualification and year of graduation, and health promotion practice over the last 3 months which includes 20 questions about screening, advice, and different ways of management (as a part of comorbidity management or prevention), referral, receiving training in promoting smoking cessation, healthy diet, and physical exercise. Answers were categorized into (always, sometimes, rarely, and not at all).Data were coded and entered into Statistical Package of Social Science, version 13.00 for windows (SPSS-13).

Of the 136 questionnaires distributed, 118 were returned; representing a response rate of 86.7 %. Table 1 presents the profile of GPs who participated in the survey. Mean age was 42.2 years (SD 7.2, range 30-59). Sixty four physicians were females (54.2 %) and 54 (45.8%) were males. Among these categories, only 28% were Qatari and 39 % were family board certified physicians. Regarding experience in clinical practice, 28 % had less than ten years and 26.3 % had more than 20 years. In terms of receiving health promotion training only 16 (13.6%) received training in obesity management counseling. While almost 90 % GPs reported that they had not received any training or education in promotion of smoking cessation, all GPs have not received any training in physical activity promotion counseling.

Table 2 presents the smoking cessation practice of physicians. About 15.2% of the GPs reported that they always ask their patient about their smoking habits and 25.4 % of them advise their smoker patient to quit on regular bases. While 43.2% of GPs reported that they tend to advise their smoker patients to quit if they present with illnesses related to smoking. Besides advising, only 13.6% of GPs said they gave out a leaflet about smoking cessation.

Only 11.9 % of GPs reported that they always provide personal smoking cessation counseling for their smoker patients, while 16.1% said that they always referred their patients to specialized smoking cessation clinics. Regarding smoking cessation medications, nicotine replacement therapy (NRT) was prescribed on regular bases by two physicians and there were no physicians prescribing bupropion for smoking cessation.

Table-3 shows that 23 of the 118 respondents (19.5%) stated that they always ask their patients about their physical activity status and 18.6 % GPs reported that they always advise patients about physical activity. This percentage is increased to 32.2 % if the patients presenting with diseases related to physical inactivity are included. Only 10 of the all surveyed GPs (8.5%) said that they gave out leaflets promoting physical activity on regular bases, while no one of the GPs reported regular referral to exercise practitioners.

Out of 118 GPs who participated in this study, the majority gave their patients advice on dietary habits (82.2%) and physical activity (80.5%). Ninety nine of 118 GPs (83.9%) stated that they always offer weight control advice for patients with chronic illness e.g. DM or Dyslipidemia, as part of their management. About two third of GPs (67.8%) reported that they used at least one method of obesity screening methods. Twenty one physicians (17.8%) reported that they always refer their obese patients to others who specialize in obesity management. More than one quarter(28.8%) of the physicians stated that they always give their obese patient leaflets on weight reduction.

This survey provides insight into health promotion practice during clinical consultations among GPs working in Qatar. The practice in this study involves range of activities like providing advice, information, counseling, screening, and providing treatment or referral. The first striking finding in this study was the level health promotion training received by GPs in Qatar, as most of them are under trained in this area. Therefore, practicing little health promotion in their daily clinical practice compared to other GPs from different countries is expected outcome.

For instance in smoking cessation while only one fourth of GPs in Qatar offer smoking cessation advice regularly, two-third GPs in the UK¹⁵ and half of family physicians in the US do this.¹⁶ Compared to one third of GPs working in New Zealand¹⁷ asking about smoking status of their patients which is another important step in smoking cessation, only 17.8% of GPs in this study do. According to international guidelines, it has been well known that GPs should address smoking habits every time a smoker visits their practice.^18,19 Giving out leaflet about quit smoking is considered as another way of promoting smoking cessation, in this study this practice was reported by 13.6 % of GPs which is also lower than what reported by GPs in the UK (57%).²⁰

Moreover, this study has shown that level of providing smoking cessation counseling and therapies in Qatar is far low from the international level of practice. For instance only 11.9% of GPs provide smoking cessation their clinics compared to 41% of GPs in the UK.²⁰ On the other hand the rare prescription of NRT and bupropion by GPs in Qatar compared to in this study can be attributed to unavailability of theses dugs in primary health care centers although there is strong evidence showing that NRT can increase chances of successful quit smoking attempts and increase the rate of quitting by 50-70%.²¹

Promoting physical exercise for improving health and preventing diseases is another important issue in health promotion; and guidelines recommend GPs to ask about the physical activity status of their patients and advice them accordingly.^3,4,6 Number of trials confirm the acceptability and efficacy of advising patients to be active at least 30 minutes of at least moderate intensity physical activity, like brisk walking or digging the garden is accumulated on five or more days per week (PA30×5).^22-24 However our finding is in agreement with previous studies from different countries GPs are not promoting physical exercise sufficiently. Less than one fifth of GPs in Qatar are asking about the physical exercise status and advising for physical exercise which is less than what reported in the UK (31%).^25,26

In consistent with other literature, in physical exercise promotion among GP in this study is increased if the patient presenting with a disease related to physical inactivity.²⁷ This can be referred to the known behavioral observation in some primary care based surveys which have shown that GPs less likely to recommend all apparently health adult patients take moderate exercise as apart of their health promotion practice compared to other primary care professionals practice nurses and health visitors even though GPs were more likely to discuss physical activity if they perceived it as relevant to a patient's presenting condition especially if the patient obese or hypertensive.²⁷

One of the interesting finding in this survey was that there was no GP doing referral to exercise practitioners in Qatar. Such result was expected that the neither primary health care centers nor secondary care facilities provide physical exercise class. Although such services is growing in number of countries. For instance in England Since the late 1990s there has been a massive expansion of GP exercise referral schemes. In these schemes, GPs refer patients to exercise classes and specialist support outside the Practice.^28,29

Our findings in this survey suggest that GPs are giving advice on healthy diet (82%) more than health areas like smoking and physical activity. However, the high percentage of promoting healthy eating obtained in this survey remains lower than percentage reported in German and American GPs (92% & 97% respectively).^30,31 Previous researches revealed that GPs have a unique opportunity for promoting healthy diet the benefits of good nutrition to patients; advise them about desirable dietary practices as a part of obesity prevention or managing obesity comorbidities.^32,33 Such lifestyle modification advice can be a valuable source of motivation for the patient and considered as a suitable therapeutic choice in the GP management of obesity.³⁴

Consistent with the previous researches GPs participated in this study tend to give advice to those who are obese and have obesity-related comorbidities such as type 2 diabetes, high cholesterol, or arthritis as apart of their management for the chronic illness.^32,35

It has been previously thought that lack of time was a key factor in preventing GPs from routinely promoting health at their clinical practice. However number qualitative researches revealed that low level of health promotion activity in primary care clinics can be attributed to several factors such as lack of confidence in efficacy of health promotion in changing patient behavior which acts as a barrier to GPs practicing health promotion activity.^36-38 Lack of confidence can be related to lack knowledge and skill due to lack of training in health promotion counseling for GPs.³⁹ Also lack of reimbursement is considered as an important barrier to encourage GPs to practice health promotion regularly.^40-42 Lack of guidelines in promoting health is regarded as another barrier, as introduction of such guideline can enhance practice.^43,44 A part from lack of training which is reported in our results, All theses factors should be considered as barriers of promoting health in primary care clinics in Qatar, as there is no guidelines for promoting health in practice and no reimbursement policy for those whom prompting health in their clinics in addition to

In conclusion this survey indicate the of health promotion interventions practiced by GPs in Qatar and level of training received in this field are apparently lower than that reported in different countries. Strategies such as health promotion training, formulating guidelines for promoting health, and providing incentives are recommended to increase level of health promotion practice in primary care clinics.

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