Attitude toward preventive counseling and healthy practices among medical students at a Colombian university

Abstract

Unhealthy behaviors of medical students influence their attitudes toward preventive counseling. The burden of chronic diseases is continually growing in developing countries, emphasizing the need for the increased role of general practitioners in preventive counseling. The objective of this study was to describe the effect of medical training on the risk profiles and attitudes of medical students toward preventive counseling in a Colombian university. Students in their first and fifth years of training were surveyed using the “Healthy Doctor= Healthy Patient” questionnaire to assess counseling attitudes; personal practices, such as risky drinking, smoking, inadequate nutrition, and non-compliance with physical activity recommendations; and the university environment. The association among these components was estimated, as well as the effect of the university environment. Risky drinking and smoking decreased from first to fifth year (59.3% vs. 37.1%, P = 0.021 and 31.5% vs. 25.9%, P = 0.51, respectively), whereas inadequate nutrition and non-compliance with physical activity recommendations increased. Physical activity (PA) was associated with positive counseling attitude (ORs: nutrition 7.6; alcohol 5.2; PA 10.6). Areas governed by institutional policies that are emphasized in the curriculum positively affected student practices. PA promoted preventive counseling and healthy lifestyles most effectively. Universities should therefore strengthen their preventive medicine curricula and modify social determinants.

Keywords

lifestyle / medical students / preventive medicine / counseling / universities / schools / medical

1 Introduction

For the past 30 years, the burden of chronic diseases has increased remarkably, particularly in low and middle income countries. In 2008, 63% of deaths worldwide were associated with non-communicable diseases; 48% of those deaths were caused by cardiovascular disease, and 1.3 million deaths were related to type 2 diabetes mellitus [1].

The modifiable risk factors that are most frequently associated with the occurrence of these diseases are smoking, at-risk drinking, inadequate dietary habits, and sedentarism [1]. Modifying these factors would reduce negative health outcomes [2−6], but such action requires intervention at different levels (political, social, community, individual) [7]. Behavioral interventions in clinical practice have been proven effective [8], and diverse models with which to implement these interventions have been established [9−12]. All these interventions include professional counseling, in which medical counseling plays a significant role [13].

Despite the positive effect of medical counseling on unhealthy habits, its success depends on motivated doctors and proper knowledge. Several studies indicate that health professionals who have received training in preventive medicine tend to have healthier lifestyles and better attitudes toward preventive counseling [14,15]. Furthermore, studies have observed that counseling has a higher level of impact and effectiveness if the provider is a model of the messages transmitted to the patients [2,16−19].

Similarly, various studies have established an association among poor prevention training, unhealthy behavior, and scant interest in non-pharmacological interventions among medical doctors [9,20,21]. Other data show that behavior modification is more plausible at the beginning of medical training and that medical students generally have favorable attitudes toward preventive counseling and academic programs [22−26].

Most of the available information on preventive medical training is derived from developed countries, and only a few studies on the subject have been conducted in developing nations. Hence, the objective of the present study is to identify the role of medical training and extracurricular interventions on the knowledge and attitudes toward preventive counseling among medical students from a Colombian university. This study aims to provide useful information that can assist in improving medical training in accordance with the major health needs of Colombia as a developing country.

2 Methods

We conducted surveys on a group of students on their first and fifth years of medical school (2007 − 2011) on a before-and-after observational basis. The project was approved by the Ethics Committee of the Faculty of Medicine at the Pontificia Universidad Javeriana in Bogotá, Colombia. The students were invited to participate voluntarily, the survey was conducted anonymously, and informed consent was obtained from all participants.

The exposures considered were medical education and the university environment (Healthy University Program or HUP). The specific academic curriculum content is available in the university website [27]. The topics of nutrition, physical activity, alcohol, and tobacco are included in various courses throughout the medical training (a total of 16 classroom-hours). Additionally, related health problems are studied in the corresponding courses, which have a therapeutic orientation but lack a preventive perspective.

The HUP is based on an institutional policy that discourages alcohol and tobacco consumption and promotes healthy diet and physical activity. The program banned the sales and consumption of cigarettes and alcohol within the campus, increased the supply of fruits and vegetables and healthy menus in food services, built a sports training center, and used outdoor spaces for physical activity. The HUP also promoted the inclusion of physical activities into the academic curriculum and established extracurricular activities to encourage healthy behaviors. Finally, the HUP developed clinical preventive services for the University community [28].

The effects evaluated in this study were the knowledge and attitudes of students toward preventive counseling regarding smoking, alcohol consumption, diet, and physical activity. Considering that personal practices might play a dual role, that is, as a factor that influences the attitude toward preventive counseling and as a result of medical training and other university programs, such practices were analyzed using both aspects as bases.

We used the “Healthy Doctor= Healthy Patient” questionnaire, which includes questions on socio-demographic characteristics, general health status, dietary habits, physical activity, smoking, alcohol consumption, knowledge of preventive medicine, overall perceptions of the role of the university environment and the academic program on the subject, and attitudes toward preventive counseling. The questionnaire was translated into Spanish and was culturally adapted in accordance with international rules [24,26]. All the information was captured electronically to a database to preserve fidelity and quality.

Inadequate dietary habits were defined as the consumption of less than five servings of fruit and vegetables per day. Smoking was defined as the consumption of more than 100 cigarettes during the lifetime of the participant and having smoked during the last month. Non-compliance with physical activity recommendations was defined as engaging in less than 75 min of intense physical activity or less than 150 min of moderate physical activity per week. Lastly, at-risk drinking was defined as the intake of more than three drinks per occasion for women and four drinks for men.

The opinions of students on medical training and the university environment, and their attitudes toward preventive counseling were assessed using a Likert-type scale with five options that were subsequently grouped into three categories (favorable, unfavorable, and indifferent). Questions regarding perceived barriers for healthy behavior were also included in the survey.

Two separate surveys were conducted involving 82 first year students and 67 fifth year students. Subsequently, a descriptive analysis of socio-demographic characteristics, body mass index (BMI), and self-perception of health status was performed.

2.1 Statistical analysis

The prevalence of risk factors and categorical variables (perceived barriers and other opinions) were presented as percentages. The level of preventive medical knowledge was rated on a scale from 0 to 100, and results were expressed as the proportion of correct answers by category (diet, alcohol, smoking, and physical activity). For the multivariate analysis, a dichotomous variable was used based on the assumption that adequate knowledge is equal or greater than 60%.

The Xi [2], exact statistics test, and the Mann-Whitney tests were used for non-parametric values to compare the basic characteristics of first and fifth year participants and to assess the changes in the prevalence of risk factors and the level of preventive medical knowledge between the two periods.

Student perception of the university environment, curriculum, and the role of preventive counseling was analyzed only for students on their fifth year, considering that at this stage, they should have acquired adequate experience with these parameters. Percentages were estimated with confidence intervals (95%). A multivariate logistic regression model adjusted for potential confounders was used to investigate the association between the length of training and risk factor prevalence, socio-demographic characteristics, student perceptions, and knowledge of preventive medicine. Specific variables are listed in Table 4.

Similarly, we investigated the association between the attitudes of students toward preventive counseling in different areas (diet, alcohol, smoking, and physical activity) and their personal characteristics, perceptions of the role of university and curriculum, level of preventive medical knowledge, and unhealthy practices (inadequate dietary habits, smoking, at-risk drinking, and non-compliance with physical activity recommendations). Given the presence of zero values, unadjusted associations were estimated through bivariate logistic regression. Data were processed using Stata^® version 11.2 [29].

3 Results

Fifty four students were surveyed in 2007 and 2011, yielding answer rates of 65.8% and 80.6%, respectively. The percentage of female respondents was 51.9% and 57.4%, respectively and the average age was 18.3 (SD 0.86) and 22.2 (SD 1.16), respectively. The socio-economic group with the largest percentage was middle class, followed by the upper socio-economic bracket (Table 1).

Among the first and fifth year students surveyed, 85.2% and 79.6%, respectively reported a normal BMI range, and 98.2% of students in their first year and 94.4% in their fifth year perceived their health status as good (Table 1).

Levels of at-risk drinking and smoking dropped from first year to fifth year, but no significant differences were observed for smoking (59.3% vs. 37.1%, P = 0.021 and 31.5% vs. 25.9%, P = 0.51). By contrast, both inadequate dietary habits and non-compliance with physical activity recommendations increased significantly (42.6% vs. 100%, P<0.001 and 53.7% vs. 74.1%, P = 0.014) (Table 2).

The main perceived barriers to physical activity in the first and fifth years were lack of time (87% and 85.2%, respectively) and lack of energy (55.6% and 68.5%, respectively). The main barrier to fruit and vegetable consumption was cultural background (dislike of vegetables: 29.6% and 22.2% for the first and fifth years, respectively), without significant differences between the two periods (Table 2).

More than 50% of students in their fifth year (57.4%; 95% CI 43.6 − 70.2) indicated a favorable perception of the role of the university in discouraging smoking. On the contrary, 46.3% of students in the fifth year (95% CI 33.2 − 60.0) reported an unfavorable opinion regarding the role of the university in promoting healthy dietary habits, and 59.3% (95% CI 45.4 − 71.8) expressed unfavorable opinions on the role of the university in encouraging physical activity (Table 3).

Moreover, 75.9% and 53.7% of students in their fifth year reported favorable perceptions regarding their training on smoking and at-risk drinking, respectively, whereas 59.3% indicated an unfavorable opinion on their training on nutrition (Table 3).

Most fifth year students (77.8%; 95% CI 64.3 − 87.2) perceived a higher chance for patients to adopt healthy behaviors if their doctor advises them to do so, and 88.9% (95% CI 76.8 − 95.1) believed that preventive counseling is important. Only 9.3% (95% CI 3.8 − 20.9) of students conferred higher relevance to the preventive component than to the therapeutic component of medical care (Table 3).

Overall medical knowledge on healthy practices was higher in the fifth year than in the first year (58.5% vs. 42.6% of correct answers; P<0.001), and similar results were observed for smoking (72.7% vs. 44.7%, P = 0.022) and physical activity (46.8% vs. 34.7%, P = 0.001). On the contrary, no significant differences were observed for knowledge of either alcohol consumption (62.3% vs. 58.9%, P = 0.33) or nutrition (33.6% vs. 29.1%, P = 0.26).

Male sex was associated with at-risk drinking (OR 5.0; 95% CI 1.9 − 13.0) and smoking (OR 3.9; 95% CI 1.2 − 12.2). Similarly, older age was independently associated with inadequate dietary habits and smoking (OR 1.7 and 2.2, respectively), and overweight − obesity (BMI>25) was associated with smoking (OR 11.9; 95% CI 1.5 − 96.1) (Table 4).

Congruent with lower prevalence, the risk of smoking and high alcohol consumption was lower in the fifth year (OR 0.1 and 0.3, respectively). An indifferent or unfavorable opinion on the role of the university environment was inversely associated with smoking (OR 0.2; 95% CI 0.5 − 0.8), but a similar opinion toward physicians as role models for patients was associated with increased risk of high alcohol consumption and smoking (OR 2.2; 95% CI 1.2 − 4.2 and OR 2.6; 95% CI 1.2 −5.6, respectively) (Table 4).

Among fifth year students, compliance with recommendations on physical activity was associated with a positive attitude toward counseling on diet (OR 7.6; 95% CI 1.2 − 47.6), alcohol (OR 5.2; 95% CI 1.3 − 21.6), and physical activity (OR 10.6; 95% CI 1.0 − 112.6). On the contrary, a negative attitude toward counseling on smoking was associated with an indifferent or unfavorable opinion regarding the academic program on this subject (OR 0.4; 95% CI 0.2 − 0.9). No other associations regarding attitude toward preventive counseling were observed.

4 Discussion

Medical counseling plays an essential role in changing unhealthy lifestyles, particularly among patients with chronic diseases [13]. Previous studies have established that doctors with healthy behaviors and adequate knowledge of preventive medicine are more motivated to work with their patients in this area and that their interventions are more credible and effective than those without healthy behaviors and adequate knowledge [14−19]. Therefore, emphasizing these aspects during medical training reduces the burden of non-communicable diseases [14−21]. Our study provides useful information on the factors associated with unhealthy practices and their relationship with preventive counseling attitudes in a developing country, where both the influence of tobacco companies and unhealthy behaviors are on the rise.

Changes in the habits of students did not exhibit consistent modification over time: some decreased, whereas others increased. Tobacco and alcohol consumption were relatively high in both the first and fifth years, but decreased toward the end of medical training. However, smoking did not decline significantly despite the favorable student perceptions of the role of the university environment in discouraging smoking (57.4%). Furthermore, the students gained higher awareness of the problem throughout medical training (44.7% and 72.7% for the first and fifth years, respectively).

Smoking prevalence among the Colombian adult population decreased from 18.9% in 1999 to 12.8% in 2007 [30,31]. Unlike most developing countries, Colombia has achieved considerable progress on smoking control, mainly as a result of the enactment of a comprehensive anti-smoking law in 2009, which totally bans advertising and sponsorship of smoking products, protects smoke-free environments, and enforces warnings on smoking-related health conditions [32]. Although distinguishing the influence of social determinants versus that of university interventions is difficult, the slight decline in smoking prevalence appears to be associated with university interventions, particularly the HUP. This hypothesis is reinforced by the fact that fifth year students demonstrated a trend toward lower smoking prevalence (non-significant) despite the higher risk of smoking for older ages (Table 4). In addition, the enactment of the anti-smoking law would not have affected the knowledge of students. During the implementation of this study, only a few years have passed since the law was implemented and as such the level of implementation was low.

The study shows an inverse association between smoking and an indifferent or unfavorable attitude toward the role of the university environment and inadequate knowledge on smoking (Table 4). However, to increase the observations, these results include data gathered from first year students, who likely had minimal knowledge on the topic and were unlikely to have formed an opinion on the university environment. Furthermore, the HUP had not been fully implemented when the survey was conducted to students in their first year of training.

At-risk drinking decreased from the first to the fifth year in accordance with a favorable perception derived from their training about this issue (53.7%). However, the lack of significant differences in the knowledge on risky alcohol consumption between first and fifth year students contradicts the favorable perception of the curriculum. Therefore, the perception may be influenced by the academic training on health problems related to alcohol consumption rather than the training on preventing alcoholism.

Contrary to our results, the prevalence of at-risk drinking has remained constant among the Colombian population during the past decade (61.6% in 1996 vs. 61.2% in 2008) [33,34]. Comparing the interventions for the reduction of smoking prevalence, only limited regulations that ban alcohol sales in the vicinity of educational centers have been established by law in the country. However, the HUP has developed educational programs concerning the matter and promoted alcohol-free recreational and entertainment activities on campus [28].

Findings on diet and physical activity revealed that unhealthy practices declined between the first and fifth years (Tables 2 and 4) and that the perception of the role of the university in managing these risk factors was negative, as opposed to that for alcohol and tobacco (Table 3). These results indicate the less significant role of university interventions on both the prevalence and the attitude toward preventive actions on these topics, which could be a reflection of the absence of interventions at the population level during the study period. The results are also consistent with previous reports that show unhealthy diets and low physical activity among physicians from different regions [25,35,36], and with local reports that show a low prevalence of daily fiber intake among the Colombian population (33.2% of the population do not eat fruits and 71.9% do not eat vegetables). Similarly, a high prevalence of non-compliance with physical activity recommendations during free time has been observed among the Colombian population (86.2% for women and 71.8% for men) [37].

In addition, specific information on unhealthy behaviors among Colombian doctors is scarce. In contrast with our results, a study of 11 universities found a 27.9% smoking prevalence among medical students, with no differences observed between the first and fifth years [38]. Another study of eight Colombian universities reported an increase in both smokers and heavy drinkers between the first and fifth years of medical training (tobacco: 17% vs. 28%, P = 0.02; alcohol: 12% vs. 18%, P = 0.08) [24]. Reporting aggregated data from different universities is expected to show high variability because of the considerable differences among universities in terms of social determinants (family income, cultural backgrounds) and in the emphasis on preventive medicine and the existence of university programs that promote healthy lifestyles. Therefore, despite the small and non-representative sample of university activity in the country, our results allow for better assessment of the role of universities in risk factor prevention as these provide data from a specific intervention and characterize students at the beginning and at the end of their training. In addition, the execution of this study in an academic setting with a well-established “Healthy University Program” indicates that the synergistic effect of environmental interventions, as noted, could be assessed.

Most students believe that preventive counseling is relevant and that doctors are role models for patients (Table 3). Similarly, several studies from North America have found that receiving training in medical schools that emphasize healthy personal practices predicts preventive counseling in clinical practice [21,23,26,39]. Despite the perceived relevance of preventive counseling, participants in the study exhibited a strong therapeutic orientation (79.6%). Apart from the influence of the academic curriculum, this finding may also reflect the effect of the health system orientation and of the opportunities in the labor market. The essential tension between curative and preventive approaches has been consistently present in medical training, but such discussions scarcely addressed the needs of developing countries. Some authors claim that better skills for primary care indicate that general practitioners in non-industrialized nations are required to concentrate on preventive programs [40]. Unfortunately, our results show a different trend as observed in the weak preventive curriculum content and the lack of association between university interventions and student attitudes toward preventive counseling. This finding suggests that general changes toward proactive attitudes on preventive medicine are unlikely in the near future. Therefore, the university should strengthen its role as a transformational agent in producing the knowledge required to modify social determinants and promote preventive attitudes and healthier lifestyles. Particularly, an association was observed between physical activity and a positive attitude toward preventive counseling, which indicates that interventions in this field may have broader impacts on the topics under study.

Regardless of the comparison between populations in both periods (Table 1), student participation in the first year was low (65.8%), which indicates limited representation of the student universe. This finding differed in the fifth year and could therefore affect some results. However, no differences between respondents and non-respondents regarding basic socio-demographic characteristics were observed in either period. In addition, prevalence was obtained by self-reporting without biological verification. However, the results show different patterns among risk factors, therefore suggesting the absence of bias or unidirectional answers.

Unhealthy practices did not change consistently throughout medical training; yet, the areas that were perceived as the strongest in the curriculum and those backed by institutional policies demonstrated the best results. Therefore, beyond the role of social determinants, stronger interventions in both the curriculum and the university environment could produce a larger and more sustained impact, particularly if the observation that only smoking has compelling effects at the population level is taken into account.

Despite the study limitations on distinguishing the effects of social determinants or public policies versus institutional interventions, the abovementioned results (better for risk factors with stronger university actions), highlights the significant role of university programs. In future studies, the inclusion of questions on student exposure to specific population interventions such as smoke-free environments, banning of cigarette and alcohol sales, and so on, might help clarify the effects of each level of action in the same manner as with other international surveys [41].

Considering the increasing burden and economic impact of chronic diseases in developing countries, improving curriculum design and implementing comprehensive healthy university programs should be a priority in any scenario with or without interventions at the population level. For the former, university interventions would accelerate and heighten impact, as in the case of tobacco use; and for the latter, university interventions would promote better attitudes, as shown to some extent for alcohol consumption. Furthermore, both would likely increase research activity and produce knowledge for fundamental input on changing public policies.

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