Rev Chil Nutr Vol. 29, Nº3, Diciembre 2002

VOLUNTARY LIFESTYLE CHANGES AND KNOWLEDGE ABOUT
HEALTHY LIFESTYLES OF CHILEAN PRIMARY HEALTH CARE WORKERS

CAMBIOS DE ESTILO DE VIDA Y CONOCIMIENTOS
SOBRE ALIMENTACIÓN SALUDABLE Y ACTIVIDAD FÍSICA EN
PROFESIONALES DE ATENCIÓN PRIMARIA EN CHILE

Se evaluaron los cambios en los estilos de vida y conocimientos en alimentación saludable y actividad física en profesionales de atención primaria de salud. Se aplicó una encuesta a 194 profesionales (médicos, enfermeras, nutricionistas, matronas y asistentes sociales), de los cuales el 86% eran mujeres. Se observó que durante el último año, la mayoría de los profesionales modificó sus hábitos hacia estilos de vida mas saludables. Alrededor del 80% señalaron que consumen menos grasas y consumen mas verduras, dos tercios indicaron consumir menos azúcar, alrededor de la mitad menos alcohol y un 45% hacen más actividad física. La gente mas joven es la que ha hecho las mayores modificaciones, a pesar que aumentaron el consumo de bebidas gaseosas, alcohol y tabaco. Un 80% de los profesionales respondió correctamente las preguntas relacionadas con alimentación y actividad física. Se encontró diferencias estadísticamente significativas entre los diferentes grupos de profesionales. Se concluye que muchos profesionales han efectuado cambios hacia estilos de vida mas saludable, tienen un buen conocimiento de hábitos alimentarios y actividad física. Estos resultados indican la importancia del trabajo en equipo para contribuir a la prevención de las enfermedades crónicas no transmisibles.
Términos claves: profesionales de atención primaria, cambios en estilos de vida, conocimiento, alimentación saludable, actividad física.

Este trabajo fué recibido el 8 de Noviembre de 2002 y aceptado para ser publicado el 7 de Diciembre de 2002.

INTRODUCTION

In the past decades the Chilean public health care system has been very successful in improving maternal and child health as well as in diminishing infectious diseases through national programmes. National standard measures carried out among children entering school (6 years of age) and pregnant women, indicate a steep rise in obesity (compared to standard weight tables) in both population groups in the past decade: from 6.5% in 1987 to 14% in 1999 among 6 year olds and from 12% in 1987 to 27% in 1999 among pregnant women. Prevalence of obesity (body mass index (BMI) >30) among the general adult population in the metropolitan areas of Chile is increasing and is higher in low socio-economic neighborhoods (1). The risk factors for noncommunicable diseases (NCDs) have not been evaluated systematically, however the first nationally representative survey on quality of life among adults was carried out in 2000. It was found that 40% are daily smokers and 91% are physically inactive. Some 47% reported to eat fruits and vegetables every day and only 35% said to consume milk products every day (2).

In response to increasing risk for NCDs, Chile, in 1996, joined the CARMEN programme (Conjunto de Acciones para la Reducción Multifactorial de Enfermedades No Transmisibles) of the Pan American Health Organization (PAHO), modelled after the European/Canadian experience of CINDI (Countrywide Integrated Non Communicable Disease Intervention). CARMEN is an integrated programme with activities to date in the demonstration area of the health service in the city of Valparaíso (5th region). All of the health services in the 8th region joined in 2001 (Arauco, Bio-Bio, Concepción, Talcahuano and Ñuble) as did the health service of the south-east area of the capital city Santiago de Chile.

The present study aimed at assessing life style changes, beliefs and knowledge regarding healthy diet and physical activity of primary health care (PHC) professionals working in PHC centres in Valparaíso and Concepción. This study takes into consideration that has been reported elsewhere (3-5), that health professionals who lead healthy life styles themselves are more credible to patients when prescribing changes in lifestyle and/or that they are more likely to prescribe lifestyle changes.

SUBJECTS AND METHODS

The survey was undertaken during two workshops for PHC workers within the framework of the CARMEN programme. The workshops were held in the area of the health services of Concepción and Valparaíso. Medical doctors, nurses, nutritionists, midwives and social workers participated.

Out of a total of 300 questionnaires were distributed, 194 questionnaires were received back. From the former, 93 questionnaires were received from Valparaíso and 101 from Concepción cities. All questionnaires were valid for the analysis.

Participants came from the following professions: 42 medical doctors, 82 nurses, 59 nutritionists, and 11 others (midwives, social workers).

The questionnaire, in Spanish, included four items and was self-administered. It included questions to be answered with «yes» or «no» about positive as well as negative lifestyle changes over the last twelve months for health reasons, including diet, tobacco use and physical activity. For example they would be asked the question: «Have you smoked less?»

Next, participants were asked about what they perceive to be the most important reason for a high prevalence of NCD related deaths in Chile. The last part tested knowledge of PHC workers about healthy diet and physical activity. The participants were asked to state if given phrases about healthy diet and physical activity were true or false (see annex).

All questionnaires were coded on MS Excel 1997 and subsequently analysed using the same programme and SPSS. Mann-Whitney tests for significance were made taking p<0.05 as the cut-off point.

RESULTS

Of the 194 PHC professionals 86% were women. Forty two percent were nurses. Of the physicians, fewer than half were men, and of all other health professions, such as nurses, nutritionists, and others (midwives, social workers), more than 90% were women. Physicians were, on average, younger than the other professional groups (Table I).

When asked about changes in their lifestyle habits during the last 12 months, more than 80% reported that they consumed less fat and ate more vegetables. Two-thirds said they ate less sugar. Half of them asserted that they drank less alcohol. Forty-four percents of the PHC professionals claimed to do more physical activity, whereas one third of respondents admitted that they reduced their physical activity. Nearly 25% stated that they ate a higher amount of high energy foods and just as many reported to have gained weight.

Comparing the changes in diet and other lifestyle habits among the different PHC professional groups, a significant difference exist in the change of the type of fat used, the decrease of sugar intake, as well as the increase of high energy food consumption. The percentage of nutritionists who changed the type of fat they consumed is significantly higher (p < 0.05) than the percentage of nurses who reported such a change. The percentage of physicians who said that they ate less sugar is significantly lower than the percentage of nurses (p < 0.01) and the percentage of nutritionists (p < 0.05) mentioning a reduction of sugar intake. A significantly higher percentage (p < 0.001) of nurses eat more high energy foods compared to the percentage of nutritionists who eat high energy foods (Table II).

Comparing the changes in diet and other lifestyle habits over the last 12 months among the different age groups, a significant difference exists regarding the consumption of soft drinks, alcohol and tobacco.The percentage of respondents who reported an increase in the consumption of soft drinks of the age group <30 years is significantly higher than the age group 40-49 years (p<0.05) as well as the age group 50+ years (p< 0.05). The percentage of the youngest age group who admitted to smoking more is significantly higher than all the other age groups (30 - 39 years: p<0.01; 40 - 49 years: p<0.05; 50+ years: p< 0.01). A significantly higher percentage of the youngest age group admitted, drank more alcohol compared to the 40-49 year olds (Table III).

The PHC professionals were also asked their personal opinion of what the most important causes are for the high prevalence of NCDs in Chile today. Participants mentioned unhealthy diet, obesity, the lack of physical activity and smoking respectively as the most important causes.

Looking at the answers to the knowledge questions, 80% or more of the participants answered each question correctly. Comparing the knowledge among professional groups regarding healthy diet, significant differences in the knowledge about healthy diet can be identified. The percentage of correct answers nutritionists gave to the first question about the food pyramid was 100%, it was 76% among nurses and 67% among physicians. The fraction of correct answers of the nutritionists was significantly higher (p<0.001) compared to the other two groups. All professions had >90% of correct answers to the second question about the type of fat, and no significant difference could be found. A significant difference (p<0.01) exists between percentage of correct answers the nutritionists and physicians gave to the third question asking about the amount of fat in pizza. The nutritionists had 92% correct answers whereas the physicians had 7%. The nutritionists also had a significantly higher percentage of correct answers given to the fourth question about soluble dietetic fibre intake compared to both the physicians (p<0.01) and nurses (p<0.05). Ninety-three percents of the nutritionists, 77% of the nurses, and 74% of the physicians answered correctly. The fifth question, testing knowledge concerning physical activity, shows that >80% of correct answers were given from all PHC professionals, and no significant difference could be identified among them (figure 1).

FIGURE I Percentage of primary health care workers correctly answering knowledge questions about heathy diet and physical activity

DISCUSSION

NCDs are, more and more, becoming a major cause of death. It is, therefore, of high importance to tackle the risk factors such as unhealthy diet, physical inactivity, smoking and alcohol consumption. PHC professionals play a key role in the prevention of NCDs and the reduction of risk factors by passing on their knowledge and advice to patients and the public at large (6). The knowledge, attitudes and beliefs of PHC professionals are an important aspect. The approach and composition of the present study is unique. Comparable studies could not be found.

The majority of the sample was female with the major subgroup (36%) being nurses, 40 to 49 years of age. Men were mainly represented in the professional group of physicians and the physicians were younger, on average, than the other professional groups. Due to these unequal distributions of the sample, it must be understood that this sample is not representative for PHC professionals in Chile in general.

The data show that the PHC workers believe that wrong diet, obesity, lack of physical activity and smoking are the main risk factors for NCDs in Chile today, which demonstrates that they are aware of the major risk factors. It can be assumed that workshops on prevention of NCDs previously offered within the CARMEN programme provoked this awareness because these subjects were discussed. Data from the general population confirm the responses from the PHC workers about the main risk factors. For example, the baseline survey for the CARMEN programme shows that 85% of a random sample in the CARMEN pilot area in the city of Valparaíso were physically inactive, 41% were smokers and 20% had a BMI over 30 (7).

The results of the knowledge questions demonstrate a very high knowledge level in both topics questioned: healthy diet and physical activity. Looking at the knowledge level of the different professions, the nutritionists show the highest level of expertise in healthy diet and physicians the lowest. This result is not surprising when taking into account that nutritional issues are only briefly touch upon in medical curricula. The nurses, too, know slightly more than the physicians about nutrition. This finding can be related to the higher average age of the nurses compared to the physicians, which is presumably linked to a higher average of work experience. A study carried out in the United Kingdom also featured substantially higher nutritional knowledge of practice nurses (PN) compared to general practitioners (GP). Fifty percents of the PN answered a nutritional knowledge questionnaire correctly, compared to only 20% of the GP (8).

The knowledge about the healthier fat type is high in all professional groups and there is no relevant difference among them. All professional groups, show the same high knowledge level in physical activity. It can be assumed that they attended workshops discussing this topic, which were previously offered in the area, thus leading to a higher knowledge level.

The changes in diet and other lifestyle habits demonstrate an overall positive and healthy attitude of the PHC workers. The majority of the PHC professionals reported that, in the 12 months prior to the study, they incorporated more vegetables into their diet, reduced the amount of fat in their diet and changed to a healthier fat type. Compared to these positive modifications, the negative changes in diet and other lifestyle habits are rather low.

Comparing the different PHC professions, nutritionists show a «healthier» attitude in their diet and other lifestyle habits. Significantly more nutritionists said that they reduced their sugar intake compared to the nurses or the physicians. Their increased intake of high energy foods is lower than the nurses', and, compared to the physicians, not as many nutritionists have increased their alcohol consumption.

The youngest group differs from the older age groups because they not only show a significantly higher increase in the consumption of soft drinks and alcohol, but also more of them reported to have increased their smoking habit. The consumption of soft drinks, alcohol and tobacco is presumably more integrated into social life and more accepted among young adults than among older adults because of different social interactions. These differences could also be due to varying accessibility and exposure to advertisements and peer influences. The CARMEN baseline survey (7) reports the prevalence of smokers by age. The highest percentage of smokers is found in the age group 25-34 years and the percentage of smokers decreases with increasing age. In a population study in Santiago de Chile the highest alcohol consumption of females was observed in the age group 25-34 (9).

Due to the way questions were asked, it was not possible to distinguish between, for example, smokers augmenting their tobacco consumption and non-smokers starting to smoke, or likewise between alcohol consumers reducing their intake and participants who never drank alcohol in the first place.

CONCLUSION

The PHC team plays a major role in tackling NCD risk factors. This analysis highlights the contribution nutritionists can give to a PHC team, which should not be overlooked. The role of nutritionists in a PHC team should be enlarged and their advisory function strengthened. Good teamwork among nutritionists, physicians, nurses and other PHC workers is a necessity and should be emphasized. These measures can be a great step to improve the effectiveness of a heath care team especially dealing with NCD prevention.

ABSTRACT

This study aimed at assessing life style changes and knowledge regarding healthy diet and physical activity among Chilean primary health care (PHC) professionals. The sample of 194 PHC workers was composed of physicians, nurses, nutritionists, midwives and social workers, of which 86% were women.The majority reported to have made positive changes in their lifestyle: more than 80% stated that they consumed less fat and ate more vegetables; two-thirds said they ate less sugar; around half reported that they drank less alcohol and 45% that they were more physically active. Negative changes like increasing the consumption of soft drinks, alcohol and tobacco were highest in the youngest of all the age groups. Eighty percents correctly answered the knowledge questions about healthy diet and physical activity. Significant differences among the professionals could be identified. Most of the PHC professionals show a positive change in their lifestyle and have a high knowledge level about healthy diet and physical activity. It has to be emphasized that good teamwork among nutritionists, physicians, nurses and other PHC workers is a necessary pre-condition to improve the effectiveness of a heath care team dealing with non-communicable disease prevention.
Keywords: primary health care professionals, lifestyle changes, knowledge, healthy diet, physical activity.

Acknowledgements: The authors would like to express our appreciation and gratefulness to Dr. B. Legetic, Pan American Health Organization / World Health Organization, Santiago de Chile, Dr. M. C. Escobar, Ministry of Health, Santiago de Chile and Dr. I. Salas, for their advice and support of this study.

Author to whom correspondence should be addressed: Isabel Zacarías
Instituto de Nutrición y Tecnología de los Alimentos
Universidad de Chile
Santiago de Chile
Tel.: (56-2) 678 1429
Fax: (56-2) 221 4030
izacaria@uec.inta.uchile.cl

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