Determinants of Counseling in Primary Care Pediatric Practice: Title and subTitle BreakPhysician Attitudes About Time, Money, and Health Issues FREE

INCREASING RECOGNITION of the growing role of psychosocial and behavioral issues affecting health has brought renewed attention to primary care counseling and prevention. The American Academy of Pediatrics (AAP) has emphasized the role of the pediatrician in the prevention, early detection, and management of various behavioral, developmental, and social functioning problems encountered in pediatric practice (often called "the new morbidity").¹ The publication of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents² and the updated AAP Guidelines for Health Supervision III³ have reemphasized the goals of preventive health care for children. The ultimate effect of new guidelines is dependent on diffusion into patient care. Numerous studies have documented this shortcoming.^{4 - 6} In this era of practice guidelines and recommendations, it is important to assess current practice and implementation issues in primary care counseling. Whether and how guidelines and recommendations are integrated into primary care practice and what motivates practitioners are critically important.

The literature has described the unique opportunity in primary care to influence patient behavior and the effectiveness of brief preventive health counseling interventions.^{7 - 10} Clinicians have been challenged to address numerous issues in practice, from smoke exposure and dietary issues to firearms and family substance abuse. Nonetheless, surveys of physicians have reported low levels of counseling on many preventive issues.^{11 - 18} Green et al¹⁹ and Lawrence²⁰ have conceptualized predisposing, enabling, and reinforcing factors influencing physician behavior in preventive care. These authors and others have suggested that lack of time and money contribute to low levels of counseling and preventive services.^{17 - 18 ,21 - 25} Few studies, however, have assessed the effect of physicians' attitudes about time, reimbursement, and health issues in relationship to their counseling practice. Most studies have looked at specific counseling issues without a broader perspective of physician behavior across issues.

This study assesses pediatricians' attitudes about health issues in pediatric anticipatory guidance and concerns about time and reimbursement in preventive counseling. Social learning theory has been recognized as a predictor of health-related behavior change and maintenance and acknowledges the relationship among behavioral, personal, and environmental influences.^{26 - 30} The theory postulates that behavior is determined by expectancies and incentives. Expectancies include self-efficacy (one's own competence to perform the behavior needed to influence outcomes) and outcome expectation (opinion about how one's behavior is likely to influence outcomes). Incentive is defined as the value or importance of a particular outcome. Describing physician counseling in the context of this model affords a deeper understanding of physician behavior and avenues for enhancing physician counseling practices.

This study was part of the periodic surveys of fellows conducted by the Division of Child Health Research of the AAP. These surveys of AAP membership are performed 4 times a year and include a random sample of US members. About 73.5% of US board-certified pediatricians are members of the AAP (AAP Department of Membership, written communication, 1996).

The questionnaire was an 8-page, self-administered, forced-choice survey mailed to 1620 AAP members. After pretesting, an original mailing and 4 follow-up mailings were sent. The survey was accompanied by a cover letter from the executive director of the AAP and a postage-paid return envelope. Pediatricians were asked their opinion on the frequency of preventive child health supervision visits recommended by the AAP and goals related to 6 areas of health supervision: biomedical, development, behavior, family functioning, safety education, and supportive interpersonal interaction. These areas were chosen from current preventive care recommendations and effectiveness studies in the pediatric literature.^{2 - 3}

Physicians were also asked about the prevalence of counseling on 15 specific topics. Additional questions using social learning theory to understand physician counseling were asked. For each topic, physicians were asked about their self-efficacy ("What is your level of confidence in providing guidance on the topic?"), outcome expectation ("How much can you do to prevent these problems?"), and the value or importance of the particular issue ("How important is the topic to the health of children in general?"). Environmental issues that may influence general counseling behavior were addressed. They were asked to indicate their level of agreement with a statement about time issues ("I usually do not have enough time to provide counseling to parents about changing health-related behaviors.") and reimbursement ("I get adequate reimbursement for my preventive efforts.").

Demographic information including sex, age, practice type and location, and proportion of managed care patients was also obtained. The survey instrument was developed with the help of the AAP Committee on Psychosocial Aspects of Child and Family Health and the AAP Council on Pediatric Research.

Characteristics of the sample were summarized using descriptive statistics. Multivariate stepwise analyses were performed with counseling practice as the independent variable. Hypothesis testing focused on the predictive significance of the 5 social learning theory constructs with inclusion (P≤.10) and exclusion (P≥.15) criteria for variables to enter and be removed from the model. All dependent variables were measured on a Likert scale; because of skewness, responses were logarithmically transformed.

A random sample of 1620 AAP fellows was surveyed. A total of 1163 completed surveys were returned, for a response rate of 72%. Residents (n=188), those stating that they spend no time in preventive care (n=360), and those with 0 patient visits per week (n=121) were eliminated. The 556 pediatricians who had finished training and currently performed child health supervision were included in the analysis.

Respondents had a mean age of 44 years, with 58% female and 42% male. Overall, 29% of respondents were in a solo or 2-physician practice, 43% were in group practice, 10% were in staff model health maintenance organizations, and the remainder were in other practice settings. Thirteen percent described their practice location as rural, 47% suburban, and 38% urban. Respondents reported seeing an average of 111 patients per week. Most respondents had some managed care patients, with a mean of 53% (SD, 32.7%) managed care patients among insured patients in their practice.

Physicians were asked how many preventive care visits they recommend for patients aged birth to 12 years, including visits to a physician and/or nurse practitioner. Respondents reported an average of 9.1 visits in the first 2 years (excluding prenatal or hospital nursery visits) and 7.8 visits after the 2-year visit through age 12 years. Most believed that the AAP periodicity schedule for preventive care (physician visits at ages 2-4 weeks; 2, 4, 6, 12, 15, 18, and 24 months; and 3, 4, 5, 6, 8, 10, and 12 years) was appropriate for their patient population and children in general. For children aged 0 to 2 years, 78% believed there were an appropriate number of recommended visits, 12% stated there were too many, and 11% stated there were too few. For children aged 3 to 12 years, 68% stated that the number of visits was appropriate, 15% stated there were too many, and 17% stated there were too few. When asked about the effect on their patients' health if preventive visits at ages 0 to 2 years were twice as often, 54% believed there would be no effect, 27% predicted a positive effect, and 20% predicted a negative effect. For children aged 3 to 12 years, 50% believed more frequent visits would have no effect, 33% predicted a positive effect, and 17% predicted a negative effect. If preventive visits were half as often, 91% and 80% believed there would be a negative effect on patient health for the age groups 0 to 2 years and 3 to 12 years, respectively. When asked how often they vary the content and emphasis of preventive care visits, most (81%) said occasionally or often. When asked how often they vary the number of preventive care visits, 23% stated that they did so rarely, 44% occasionally, and 24% often.

Physicians were asked, "During preventive care visits, who usually asks most of the questions and determines the topics of discussion?" Eighty-two percent stated that this was done predominantly by the physician and 18% stated that it was predominantly the parent. When physicians were asked, "Who would you prefer to ask the questions and determine the topics of discussion?" 52% stated the physician and 48% stated the parent.

Physicians were asked about their goals for preventive care visits in 6 areas of health supervision: biomedical, development, behavior, family functioning, safety education, and supportive interpersonal interaction. They were asked to assess the importance of these goals in preventive care visits and rate how well they think they achieve these goals (Table 1). All goals were individually rated as very important. Ensuring physical health of children ranked the highest among the 6 goals. Most respondents thought they were good to excellent at achieving these goals, especially in areas of physical health, development, and developing a supportive relationship. Lower proportions of respondents felt they were good to excellent at ensuring a healthy family environment (50%), ensuring emotional health and dealing with behavior problems (70%), and educating about safety issues (73%).

Fifty-three percent of respondents agreed that they do "have enough time to provide counseling to parents about changing health-related behaviors," with 29% disagreeing and 18% neutral. Fifty-seven percent agreed that, "In general, I get adequate respect for my preventive efforts" (20% disagreeing, 23% neutral). Only 17% agreed that, "I get adequate reimbursement for my preventive efforts" (62% disagreeing, 21% neutral). There were no significant relationships between percentage of patients in managed care and concerns about time or reimbursement for preventive efforts (time, r=0.07; xdreimbursement,r=0.12).

An overall counseling score was computed for each physician that was a sum of all responses on prevalence of counseling in the 15 areas. Those more concerned about time for preventive counseling reported less overall counseling (r=−0.28, P<.001). There was no significant relationship between overall counseling and concern about reimbursement (r=− 0.03). Concern about time and reimbursement were somewhat related (r=− 0.11, P<.01).

Physicians were asked about 15 specific preventive care topics. Table 2 presents data on how often they address each of the issues as part of age-appropriate routine well-child visits. Biomedical, developmental, and some behavioral issues were often or always discussed. Safety and family issues were less frequently addressed. Many respondents never or only occasionally discussed family substance abuse, gun safety, or television.

Physicians were asked about each of these topics within the context of social learning theory constructs of importance, self-efficacy, and outcome expectation. Physician ratings for each topic are presented in Table 3. All of the 15 health topics were believed to be issues of great importance by most respondents. Most had a high degree of confidence in counseling in these areas, with lower confidence on issues of gun safety, family stress, and substance abuse. Fewer respondents believed they were able to prevent problems (outcome expectation), especially those related to gun injuries, family problems, passive smoke, and television.

Multiple regression analyses were performed to ascertain if social learning theory constructs on importance of the topic, self-efficacy, outcome expectation, and general attitudes about time and reimbursement could predict physician responses regarding counseling practice. Social learning theory predictors explained 25% to 47% of the variability, depending on the topic (Table 4). In all areas, importance of the issue and physician confidence in counseling were the most significant predictors of physician practice. Attitudes about time and reimbursement were not primary predictors and often did not enter the model.

Physicians were additionally asked about factors that determine the content and emphasis of their preventive care visits (Table 5). Experience as a physician, comfort and knowledge in topics of discussion, and perception of their effectiveness in counseling were felt to be most important among the 12 factors queried.

As morbidity and mortality in pediatrics have shifted and guidelines for preventive practice have evolved, it is critical to monitor change in practice and obstacles to change. This study evaluated physician goals and counseling practices in child health supervision. Previous studies have largely focused on physician attitudes and practice regarding single prevention issues and have rarely addressed issues of time and reimbursement. We present a social learning theory approach to understanding physician priorities. This approach provides insight into physician attitudes regarding health promotion topics and a theoretical foundation for improving primary care practice.

Physician goals in child health supervision were primarily biomedical, with psychosocial and safety issues of lesser importance. Studies have found that mothers expect a biomedical orientation in child health supervision visits but often have more psychosocial concerns.³¹ In this study, physicians stated that they usually ask most of the questions and determine the topics of discussion, although many prefer parents to be more involved. According to physicians, a parent's interest in topics was very important in determining the content and emphasis of preventive visits. If providers wish to increase involvement of parents and address psychosocial concerns, physicians must raise pertinent issues or allow parents to take the lead. It must be made clear that psychosocial as well as biomedical issues are part of the visit and that parental questions are the focus. Use of tools like previsit patient checklists or questionnaires may aid in identifying concerns of parents in an efficient manner. In addition to provider encouragement, a broader campaign to change and expand public expectations about health supervision visits may be needed to address the new morbidity.

We found that discussion of some issues was related to physician factors, including self-efficacy, importance of the health issue, and expectation of effectiveness. Social learning theory has been found to have high predictive validity in explaining behavior and explained 25% to 47% of the variability in counseling practice. The issues of family stress and substance abuse, gun safety, and television were less frequently discussed and were associated with lower health importance, self-efficacy, and outcome expectation.

It is encouraging that despite the pressures on physicians today, these data suggest that issues of time and money were not the primary factors affecting prevention counseling. Although there was a relationship between time and overall counseling, in multiple regression analysis the influence of general attitudes about time and reimbursement for prevention were not as strong in explaining counseling practice as issue importance and physician self-efficacy. Other studies have found that adequate reimbursement for preventive services does not ensure physician provision of these services, which confirms the importance of other motivators.³² Nonetheless, concerns about time were associated with rate of overall counseling. Clearly, time and reimbursement must be sufficient to allow for or maintain current levels of preventive counseling. It is possible that with continuing changes in the health care delivery system and growing penetration of capitated managed care, time and reimbursement issues may play a greater role in influencing preventive care practice.

Self-efficacy is a central concept in social learning theory and was found to be a strong predictor of physician behavior in all 15 topic areas studied. When asked generally about factors that determine the content and emphasis of their preventive care visits, experience as a physician and comfort and knowledge about a topic were most important. Other research has found that many physicians lack confidence in their ability to motivate behavior change.^{22 ,33 - 34} Building physician self-efficacy in preventive counseling must be a priority. According to social learning theory, efficacy expectations are derived from 4 sources: personal experience (the most powerful), vicarious experience or observing models, verbal persuasion through didactic learning, and emotional arousal.³⁵ These educational strategies can be incorporated into interventions for physicians and patients alike.

Importance of the health problem was another factor determining the content and emphasis of preventive visits. Most physicians believed that all the 15 topics were issues of great importance. Education on the importance of specific health problems affecting children may influence physician priorities. Though not as strong a predictor as self-efficacy, perception of the effectiveness of counseling (outcome expectation) was very important in several of the topic areas. Research must continue on the effectiveness of specific preventive strategies and results must be disseminated to practitioners.

This study provides a wealth of information about individual topics in health promotion. For example, most physicians (67%) reported often or always discussing parental smoking in child health supervision. Parental smoking was believed to be an important health problem by 86%, and 81% were confident in counseling on this issue. Only 44%, however, believed they were able to prevent problems related to parental smoking. Social learning theory constructs explained 47% of the variability in physician practice, and perceived self-efficacy and health importance were significant factors. This analysis suggests that emphasizing the importance of the passive smoke problem and enhancing physician skills and confidence in parental smoking cessation may increase physician counseling.

These findings have important implications for undergraduate, postgraduate, and continuing medical education. Although personal experience as a physician or as a parent were rated higher, 63% of physicians stated that residency training was an important factor in determining the content and emphasis of health supervision visits. Preventive medicine training at all levels which improves counseling skills and self-efficacy are needed for physicians to attempt counseling and gain experience and confidence.

Potential study limitations should be addressed. This national survey of pediatricians had a high response rate (72%); however, its generalizability to other disciplines and other preventive issues is unclear. Nonetheless, it is likely that the social learning theory framework and general findings may apply. In addition, social desirability bias may have overestimated the counseling behavior of physicians and self-report of counseling behavior may be different from actual practice. Reporting of factors that influence counseling may be less subject to bias.

Finally, this study did not address all the facilitators and barriers to health promotion in primary care. Pathman et al³⁶ have identified the cognitive and behavioral steps physicians must take to comply with clinical guidelines, including awareness of guidelines, agreement, adoption in patient care, and regular adherence at appropriate times. Incentives and disincentives are present at each step. Green et al¹⁹ and Lawrence²⁰ have conceptualized predisposing (knowledge, attitudes, beliefs, values, perceptions), enabling (skills, reimbursement, time, office systems, coherent guidelines), and reinforcing (visible results, colleague support, feedback, physician self-efficacy) factors that influence physician behavior in preventive care. Others have emphasized that favorable attitudes alone are not sufficient to increase preventive care but that other facilitators, including supportive office systems, reminder systems, feedback, incorporation into managed care guidelines, and skills training, must be addressed.^{37 - 43} Collaborative efforts to identify needs, capabilities, and concerns of involved individuals with active participation of practitioners may enhance effectiveness.^{43 - 45} The patients' perspectives and their receptiveness to preventive counseling must also be addressed.^{46 - 48}

In this era of practice guidelines and challenges to physicians to address the medical and social ills of their patients, understanding what motivates practitioners to accept and embrace these challenges is of critical importance. It is not enough to simply disseminate guidelines or write recommendations to change physician behavior, but understanding and addressing facilitators and barriers to implementation are needed. This study begins to explore some key implementation issues and provides insight into the knowledge, skills, and support necessary to enhance preventive care counseling.

Accepted for publication October 21, 1998.

This study was supported by the American Academy of Pediatrics, Elk Grove Village, Ill. Dr Cheng is a Robert Wood Johnson Generalist Physician Faculty Scholar.

Presented at the Pediatric Academic Societies Annual Meeting, Washington, DC, May 10, 1996.

The views expressed in this article are those of the authors.

We thank the Committee on Psychosocial Aspects of Child and Family Health, Council on Pediatric Research, American Academy of Pediatrics Department of Research, and the pediatrician participants.

Corresponding author: Tina L. Cheng, MD, MPH, Department of General Pediatrics, Children's National Medical Center, 111 Michigan Ave NW, Washington, DC 20010 (e-mail: tcheng@cnmc.org).

Editor's Note: We should feel good that concerns about time and reimbursement were secondary predictors of pediatrician counseling. However, counseling about psychosocial and safety issues was also of secondary importance. Is there a connect/disconnect?—Catherine D. DeAngelis, MD