Preventive Medicine 48 (2009) 164–166

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Preventive Medicine
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y p m e d

Medical students' self-perceived competence and prescription of patient-centered

physical activity
Jeff K. Vallance a,⁎, Mark Wylie b, Randy MacDonald c
a
Centre for Nursing and Health Studies, Athabasca University, 1 University Drive, Athabasca, AB, Canada T9S 3A3
b
Faculty of Medicine, University of Calgary, Canada
c
Department of Emergency Medicine, University of Alberta, Canada

a r t i c l e i n f o a b s t r a c t

Available online 16 December 2008

Objective. The primary objective of this study was to explore medical students' perceptions of their own
competence and the importance they assign to patient-centered physical activity (PA) prescription.
Keywords:
Methods. 246 undergraduate medical students (27% response rate) from two large universities in Western
Medical students
Physical activity prescription Canada completed an online survey designed to assess their perceived competence and importance related
Perceived competence to patient-centered PA prescription. Data collection took place in September and October of 2007.
Perceived importance Results. While medical students perceived PA-related prescription to be important (Mresponse = 26.6 out of
36, SD = 5.1), students perceived they had only moderate competence at conducting PA-related prescription
(Mresponse = 20.7 out of 36, SD = 6.8). Students achieving national PA guidelines perceived significantly higher
competence than students not achieving PA guidelines. Students in their first or second year of medical
school perceived PA-related prescription to be of higher importance than students in their third or fourth
years.
Conclusion. Medical students indicated that patient-centered PA prescription was important. However,
they indicated less than moderate competence at performing several fundamental PA prescription behaviors.
This study suggests that medical students may not be adequately prepared to dispense patient-centered PA
prescriptions with their patients.
© 2008 Elsevier Inc. All rights reserved.

Introduction Methods

Estimates indicate that only 11% of physicians counsel the majority
of their patients about physical activity (PA) (Kennedy and Meeuwisse,
2003). When PA advice is dispensed/prescribed, the majority are
simple ‘encouragements’ and do not contain a specific prescription
tailored to the patient (Williford et al., 1992). It is recommended that
physicians dispense a PA prescription that is specific, focused, and
provided as carefully as the prescription of the patient's medications
(Warburton et al., 2006). However, one of the most commonly cited
barriers to PA-related prescription among physicians is the lack of
education in medical school that directly pertains to PA-related
prescription (Forman-Hoffman et al., 2006).
The purpose of this study was to explore Canadian medical
students' perceptions of their competence and the importance they
assign to patient-centered PA prescription. We hypothesized that
medical students' would perceive PA prescription to be of importance.
We also expected that students' perceived competence for PA
prescription would be low.
⁎ Corresponding author. Fax: +1 403 488 7183.
E-mail address: jeffv@athabascau.ca (J.K. Vallance).
Participants and procedures
Participants were 246 medical students from two large universities
in Western Canada. Ethical clearance for this study was granted by
both institutions' respective review boards. Data were gathered via an
internet-based survey during the months of September and October,
2007. An e-mail (and one reminder e-mail) was sent via class
listserves to 914 medical students that invited them to complete the
online survey.
Measures
Demographic and behavioral information included age, gender,
medical school year, and previous course/elective in preventive
medicine.
Physical activity behavior was assessed using the Leisure Score
Index (LSI) from the Godin Leisure Time Exercise Questionnaire
(GLTEQ) (Godin and Shephard, 1985). Students indicated their average
weekly PA over the past month (both frequency and duration) that
was performed at least at a moderate degree of intensity (i.e.,
moderate and vigorous intensity).

0091-7435/$ – see front matter © 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.ypmed.2008.12.006
 J.K. Vallance et al. / Preventive Medicine 48 (2009) 164–166 165

Table 1
Perceived competence related to patient-centered physical activity prescription among medical students

Skills n Mean SD Minimally Moderately Competent

competent n (%) competent n (%) n (%)
1. Conducting a physical exam on a healthy adult to approve that person 246 2.82 1.51 111 (45.2) 99 (40.3) 36 (14.6)
to begin a PA program
2. Determining the maximum heart rate for a healthy adult 246 3.59 1.76 77 (31.3) 80 (32.5) 89 (36.2)
3. Determining the daily caloric and nutritional needs of a healthy adult 246 3.02 1.49 102 (41.4) 100 (40.6) 44 (17.9)
4. Determining the body mass index for a healthy adult 246 5.39 1.08 9 (3.7) 28 (11.4) 209 (84.9)
5. Calculating the aerobic training heart rate range for a healthy adult 246 3.11 1.71 112 (45.6) 69 (28.0) 65 (26.4)
6. Designing a PA prescription including frequency, duration, and intensity 246 2.76 1.56 122 (49.6) 85 (34.6) 39 (15.8)
for a healthy adult
Overall perceived competence scale mean 246 3.45 1.13

SD = Standard deviation.
PA = Physical activity.
All skills rated on a scale from 1 (minimally competent) to 6 (competent).
Minimally competent = b 2.0.
Moderately competent = 2.01–3.99.
Competent = ≥4.0.
Data collected September–October, 2007.
Note: Data were collected from two medical schools in Western Canada.

Perceived competence and importance related to patient-centered PA
prescription was assessed using the Exercise and Physical Activity
Competence Questionnaire (EPACQ) (Connaughton et al., 2001). On
the EPACQ, students rate their competence of six fundamental skills
(see Tables 1 and 2 for list of skills) related to patient-centered PA
prescription (Part A). Students indicated their responses on a six-point
Likert scale (1 = not competent to 6 = very competent). In Part B,
students rate the importance they place on being able to perform the
six fundamental skills. Students indicated their responses on a six-
point Likert scale (1 = not important to 6 = very important).
Statistical analyses
Descriptive statistics were used to examine the demographic and
behavioral profiles of the students. Multivariate analysis of variance
(MANOVA) procedures were conducted for those independent
variables that were significantly associated (i.e., Pearson correlations)
with perceived competence and perceived importance composite
scale scores. Effect size d (ES) was computed by dividing the difference
in means between groups by the pooled SD (Cohen, 1992).
Results
Participants
Participants were 246 medical students (i.e., 27% response rate) in
their first (n = 76), second (n = 102), third (n = 49), or fourth (n = 19) year
of training. 53% of the sample were female and the mean age of the
sample was 25 (SD = 4.01). Only 46% (n = 113) of the sample had
previously taken a course/elective in preventive medicine in their
medical school training. Only 40% (n = 99) of our sample were
achieving the current Public Health Agency of Canada (PHAC)
recommendations for PA.
Perceived importance and competence related to patient-centered
PA prescription
Descriptive statistics for both perceived importance and perceived
competence related to patient-centered PA prescription are shown in
Tables 1 and 2. Overall, medical students perceived PA-related
prescription to be important (Mresponse = 26.6 out of 36, SD = 5.1), yet
perceived themselves to be only moderately competent in conducting
PA-related prescriptions (Mresponse = 20.7 out of 36, SD = 6.8).
Perceived competence was positively correlated with meeting
PHAC guidelines (r = 0.22, p b .001) and being in years 3 and 4 of
medical school (r = 0.20, p b 0.01). Being in years 3 and 4 was negatively
associated with perceived importance (r = −0.14, p b 0.05). Having
taken a previous unit or elective in preventive medicine was positively
associated with perceived competence (r = 0.15, p b 0.05). These
variables were entered into the multivariate model with perceived
importance and competence functioning as the dependent variables.
The overall MANOVA was significant for meeting PHAC guidelines
[Wilks' λ = 0.965, F(2,237) = 4.287, p = 0.015] and medical school year
(i.e., years 1 and 2 vs. 3 and 4) [Wilks' λ = 0.939, F(2,243) = 7.639,

Table 2
Perceived importance related to patient-centered physical activity prescription among medical students

Skills n Mean SD Minimally Moderately Important

important n (%) important n (%) n (%)
1. Conducting a physical exam on a healthy adult to approve that person 246 4.54 1.28 16 (6.5) 88 (35.8) 142 (57.7)
to begin a PA program
2. Determining the maximum heart rate for a healthy adult 246 3.98 1.28 28 (11.4) 135 (54.9) 83 (33.7)
3. Determining the daily caloric and nutritional needs of a healthy adult 246 4.77 1.06 8 (3.2) 70 (28.5) 168 (68.3)
4. Determining the body mass index for a healthy adult 246 4.47 1.27 18 (7.3) 101 (41.1) 127 (51.6)
5. Calculating the aerobic training heart rate range for a healthy adult 246 4.15 1.18 20 (8.1) 127 (51.6) 99 (40.2)
6. Designing a PA prescription including frequency, duration, and intensity 246 4.69 1.29 16 (6.5) 81 (32.9) 149 (60.6)
for a healthy adult
Overall perceived importance scale mean 246 4.43 0.85

SD = Standard deviation.
PA = Physical activity.
All skills rated on a scale from 1 (minimally important) to 6 (highly important).
Minimally important = ≤2.0.
Moderately important = 2.01–3.99.
Important = ≥ 4.0.
Data collected September–October, 2007.
Note: Data were collected from two medical schools in Western Canada.
166 J.K. Vallance et al. / Preventive Medicine 48 (2009) 164–166
p = 0.001]. Pairwise follow-up univariate F-statistics indicated signifi-
cant differences in perceived competence between students achieving
and not achieving PHAC guidelines. Follow-up F-statistics also
indicated significant differences for both perceived competence and
perceived importance between students in years 1 and 2 and students
in years 3 and 4. Linear independent pairwise comparisons indicated
that students achieving PHAC recommendations for PA indicated
significantly higher perceived competence related to PA prescription
than students not achieving the recommendations (Mdiff = 2.95,
p b 0.01, ES = 0.44). Students in years 3 and 4 indicated significantly
higher perceived competence than students in years 1 and 2 of
medical school (Mdiff = 3.1, p b 0.01, ES = 0.46) while students in years 1
and 2 indicated significantly higher perceived importance than
students in years 3 and 4 (Mdiff = 1.52, p b 0.05, ES = 0.30).
Discussion
We confirmed our hypothesis that medical students' perceived PA
prescription skills to be of importance. However, students indicated
only moderate competence at conducting several PA-related prescrip-
tion skills. We reported that students perceived it was important to
perform skills related to prescribing PA (Mitem response = 4.43, SD = 0.85).
Frank et al. (2004) found similar findings in that 79% of freshmen
medical students believed that it would be highly relevant to their
future practices to counsel patients about PA. We reported that
students in years 1 and 2 indicated significantly higher perceived
importance than students in years 3 and 4. It is plausible to speculate
that students in years 3 and 4 focus on very specific rotations that are
typically not conducive or relevant to PA prescription (e.g., neo-natal
intensive care, urology, neurology, surgery). Furthermore, years 1 and
2 students may perceive PA prescription to be of greater importance
given that PA prescription may be more relevant and appropriate to
the general patient population that these students have experience
with.
Students indicated that they were only moderately competent at
utilizing skills related to PA prescription (Mitem response = 3.45,
SD = 1.13). Rogers et al. (2002) reported that only 28% of residents
felt confident in their skills to prescribe PA. There are other
competencies besides those assessed that could be used by medical
students/physicians in their PA discussions with patients. For
example, the EPACQ asks students about their perceived importance
and competence related to prescribing heart rate training zones.
However, using the simpler rating of perceived exertion (RPE) method
to monitor PA intensity is also a well-accepted (and more familiar)
method in which to monitor PA intensity.
The finding that students in years 3 and 4 indicated lower
perceived importance of these skills is concerning. Indeed, most
subspecialties of internal medicine have multiple disease processes
that are directly impacted by health behaviors. Therefore, one
explanation for the lower perceived importance may be that medical
students are being trained to immediately rely on pharmacotherapies
to mitigate and control disease processes. Indeed this approach is
often considered standard practice. Given emerging evidence indicat-
ing that multiple disease processes may be best approached with
pharmacotherapies in combination with behavior modification (e.g.,
Gaede et al., 2003; Wadden et al., 2005), there is an increasingly
relevant role for lifestyle behavior modification in the context of
pharmacotherapy.
Study limitations
First, the response rate of 27% is low. Unfortunately, this may be
indicative of a general disinterest in the topic. However, research has
indicated that interest level in a topic is not associated with response
rate (e.g., Woodward and McKelvie, 1985). Nonetheless, our low
response rate does limit the conclusions that can be drawn with
reference to the ‘average’ medical student. It is possible that students
who did not respond to the survey may have perceived PA prescription
as less important. However, Table 2 indicates that across the six skills
assessed, ∼ 50% of students still indicated that these skills were only
minimally or moderately important. A selection bias may have existed
given the transparent purpose of our study. However, this is unlikely
given that the PA prevalence rate among the medical students in this
study (i.e., 40%) was similar to that of the general Canadian population
(i.e., 41%) (Craig et al., 2004). Regardless, it is difficult to establish
whether the 27% of students participating in this study are
representative of medical students in general, particularly given the
lack of background information elicited from students in this study.
Finally, the clinical relevance of curriculum content related to
students' competence in PA-related prescription is unknown. Future
research should survey residents nearing the end of their residencies
regarding how often they prescribe PA. Specifically, students in family,
pediatric, renal, rheumatology, orthopedic, and cardiology programs
may receive instruction on PA prescription in their residency given the
relevance of PA and PA-related conditions (e.g., obesity, diabetes,
arthritis, and osteoporosis) in their specialties.
Conclusion
Medical students in this sample indicated they felt moderately
competent at performing PA prescription behaviors. Creating a
patient-centered PA prescription curriculum component may equip
future physicians for the changing medical care environment that
includes a dramatic rise in the prevalence of physical inactivity and the
consequent adverse health conditions associated with inactivity (e.g.,
obesity, diabetes, cancer).
Conflict of interest
None declared.
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