Cross-sectional and longitudinal analyses of nutrition guidance by primary care physicians.

OBJECTIVE: To investigate in primary care physicians (PCPs) the determinants of a nutrition guidance practice ('noticing patients' overweight and guidance of treatment'), as well as their mechanism of action, in a cross-sectional and a longitudinal approach. DESIGN: Mixed longitudinal design. Five years follow up study of a previous cross-sectional study in October 1992. SUBJECTS: A representative sample of 675 Dutch PCPs, in practice for 5 up to 20y. INTERVENTIONS: A shortened version of the Wageningen PCPs Nutritional Practices Questionnaire was mailed to the subjects in August 1997. MAIN OUTCOME MEASURE: To obtain with the LISREL-program a model of the mechanism of action of determinants of the dependent variable 'noticing patients' overweight and guidance of treatment' with an adequate fit of the empirical data, both in the cross-sectional and in the longitudinal approach. RESULTS: The same set of predisposing factors and intermediary factors explains the dependent variable both in two different representative cross-sectional study populations of PCPs, and in a cohort cross-sectional study at two points in time. Two dynamic LISREL-models were developed (the 'determinant-longitudinal approach' and the 'early behaviour longitudinal approach') which explain the dependent variable. The latter model has, as added value, a gain in explained variance. In 5 y time, the dependent variable decreased significantly (P < 0.001). CONCLUSIONS: This study reconfirms that PCPs' nutritional guidance practices are determined partly directly by predisposing factors, and indirectly via driving forces and barriers. However this study also reveals that an important nutrition guidance practice of PCPs, 'noticing patients' overweight and guidance of treatment', shows a significant decrease over the last 5 y. At the same time, two of the four predisposing factors and two of the three driving factors also decreased significantly. As research findings indicate that the role of diet in health and disease becomes of greater influence PCPs need to be activated to apply their responsibility in this field within a multi-faceted approach.

Consumers' expectations about nutrition guidance: the importance of primary care physicians.

To clarify the role of the primary care physician (PCP) in providing nutrition information to the public, we investigated in a random sample of Dutch consumers their referral to 11 nutrition information sources including the PCP, their perceived expertise of these sources, their interest in nutrition information, and their nutritional attitudes and beliefs. Factor analysis over these 11 sources of nutrition information resulted in two factors: noncommercial sources (alpha = 0.70) and commercial sources (alpha = 0.78). Respondents' referral to and perceived expertise on a five-point scale of noncommercial sources was higher than for commercial sources [respectively, 54% compared with 21%, P < 0.0001, and 3.9 +/- 0.6 compared with 2.7 +/- 0.6 (mean +/- SD), P < 0.01]. The individual Spearman correlation coefficient between referral scores and perceived expertise was p = 0.35 +/- 0.36 (mean +/- SD). For most sources, referral to that source was dependent on a higher interest in information about a healthy diet and on perceived expertise of the source. There were three leading noncommercial sources: the PCP, the dietitian, and the Netherlands Food and Nutrition Education Bureau (FNEB). Careful analysis revealed that because of their high referral scores, high perceived expertise, and reach to nearly all segments of the population, PCPs are in a unique position compared with dietitians and the FNEB.

Information sources and strategies of nutrition guidance used by primary care physicians.

We studied the nutrition information seeking behavior of primary care physicians (PCPs) and also PCPs' implementation of different strategies of nutrition guidance of patients. This was done by means of a questionnaire mailed to a nationwide random sample of 1000 PCPs in the Netherlands. The net response rate was 64%. The two most important nutrition information sources for PCPs were a dietitian (72% of respondents) and the literature (34% of respondents). Eighty-five percent of PCPs reported that they were actively involved in seeking nutrition information. For nutrition education of patients, PCPs gave personal information to patients, referred patients to a dietitian, and made publications available in the surgery. As preferred methods of obtaining nutrition information themselves, PCPs listed scientific journals, postgraduate nutrition education, congresses and study days, and publications. Determinants of nutrition information seeking behavior of PCPs as well as their implementation of different strategies of patient nutrition education were identified and discussed. PCPs were familiar with the body mass index, which is encouraging because treatment of overweight and obesity starts with a valid assessment. The findings in this study lead to a prudent positive conclusion about PCPs and nutrition information in practice. From this study and others it can be concluded that there are growing opportunities, challenges, and tools for PCPs to become more actively involved in nutrition guidance of patients.

Nutrition guidance by primary-care physicians: LISREL analysis improves understanding.

BACKGROUND: When determinants of nutrition guidance practices for primary care physicians (PCPs) are identified, the key question remains: what is the mechanism of action? This knowledge is essential in order to understand how PCPs practice nutrition guidance. METHODS: Mail questionnaires (result of focus-group discussions and in-depth interviews) were sent to a nationwide random sample of 1,000 PCPs in the Netherlands, who had been in practice for between 5 and 15 years (633 respondents). The mechanism of action of determinants of nutrition guidance practices of PCPs was identified by means of linear structural relationship analysis (LISREL) using a postulated model. RESULTS: The postulated model on the mechanism of action was confirmed. The model demonstrates that nutrition guidance practices of PCPs are directly and significantly based on a few predisposing factors; driving forces and perceived barriers may act as significant intermediary variables. The predisposing factors, driving forces, and perceived barriers were identified. CONCLUSION: Policies to improve nutrition guidance practices of PCPs may, in the future, benefit from a LISREL model analysis of determinants of these practices to become more effective. Using multiple regression analysis to ascertain the determinants of these practices could result in missing important predisposing factors and "hidden" intermediary factors and lead, therefore, to an incomplete understanding of the mechanism of action.

Nutrition guidance by primary-care physicians: perceived barriers and low involvement.

OBJECTIVE: To investigate the activities of general practitioners (GPs) in nutritional matters and the factors that influence their attitudes, knowledge and behaviour, especially perceived barriers. DESIGN: Postal questionnaires (result of focus group discussions and in-depth interviews) were sent to a nationwide random sample of GPs in the Netherlands. SUBJECTS: 1000 GPs, in practice for between 5 and 15 years. MAIN OUTCOME MEASURES: The identification of GPs' perceived barriers to nutritional guidance of their patients, their nutritional attitudes and behaviours. RESULTS: Net response rate was 64% (633/990). GPs perceived smoking to be the greatest health hazard, followed by dietary pattern and genome. 70% expressed considerable interest in the role of nutrition in health. In daily practice nutrition plays a minor role in the work of the GP. 28% of GPs gave daily nutrition information to about 10% of their patients and 48% to about 5% of their patients. It is found that GPs do perceive strong barriers of being involved in nutrition issues during their practice. The most important barriers expressed were: not being trained in nutrition, lack of time to address nutrition issues and the perception that patients lack motivation to change lifestyle and/or dietary patterns. CONCLUSIONS: The involvement of GPs in nutritional matters is very low. The fact that lack of training is considered as the most important barrier is, however, unexpected. This finding offers possibilities for improvement in which in-service courses and inter-active distant-learning programmes on nutrition for GPs should get special attention.