COUNSELING STRATEGIES FOR PHYSICAL ACTIVITY USED BY THE EXPANDED NUCLEUS OF FAMILY HEALTH IN FLORIANÓPOLIS

ESTRATÉGIAS DE ACONSELHAMENTO PARA ATIVIDADE FÍSICA UTILIZADAS PELO NÚCLEO AMPLIADO DE SAÚDE DA FAMÍLIA EM FLORIANÓPOLIS

ABSTRACT

Counseling strategies, such as the 5A model, can provide important changes in physical activity. The objective of this study was to estimate the prevalence of physical activity counseling strategies used by professionals of the Expanded Nucleus of Family Health and Primary Health Care (ENFH-PHC) of Florianópolis according to the 5As model. A survey was conducted with ENFH-PHC professionals. The collection took place in the planning meetings of the Health Centers. There were 72 professionals, 40 employees and 32 residents. Most of the professionals reported some physical activity counseling in the last 12 months (97.2%). Among the professionals who reported some type of counseling, the most reported counseling strategies focus on "As" ask (94.1%), advise (98.5%) and assist (95.7%). The least reported strategy was arranging (25.7%). The most used resource was to indicate the participation in groups of physical activity of the Health Center. It is concluded that ENFH-PHC professionals perform physical activity counseling and use some strategies according to the 5A model, although they are not used in a systematic way. Therefore, it is recommended to invest in lifelong education in the use of tools for evaluation (assess) and in the improvement of strategies to follow up (effectiveness) to improve the practice of counseling.

Keywords:
Counseling; Motor activity; Primary health care; Life style; Health promotion

RESUMO

Estratégias de aconselhamento, como o modelo 5As, podem oportunizar importantes mudanças na atividade física. O objetivo deste estudo foi estimar a prevalência das estratégias de aconselhamento para atividade física utilizadas pelos profissionais do Núcleo Ampliado de Saúde da Família e Atenção Básica (NASF-AB) de Florianópolis de acordo com o modelo 5As. Foi realizado inquérito com profissionais do NASF-AB. A coleta ocorreu nas reuniões de planejamento dos Centros de Saúde. Participaram 72 profissionais, sendo 40 servidores e 32 residentes. A maioria dos profissionais reportaram realizar algum aconselhamento para atividade física nos últimos 12 meses (97,2%). Entre os profissionais que referiram realizar algum tipo de aconselhamento, as estratégias de aconselhamento mais reportadas concentram-se nos “As” ask (94,1%), advise (98,5%) e assist (95,7%). A estratégia menos reportada foi arrange (25,7%). O recurso mais utilizado foi indicar a participação em grupos de atividade física do Centro de saúde. Conclui-se que os profissionais NASF-AB realizam aconselhamento para atividade física e utilizam algumas estratégias conforme o modelo 5As, embora não sejam usadas de modo sistematizado. Portanto, recomenda-se o investimento em Educação Permanente no uso de ferramentas para avaliação (assess) e no aperfeiçoamento de estratégias de acompanhamento (arrange) da efetividade, para assim aprimorar a prática do aconselhamento.

Palavras-chave:
Aconselhamento; Atividade motora; Atenção primária à saúde; Estilo de vida; Promoção da saúde

Introduction

Physical inactivity is one of the main risk factors for the development of chronic non-communicable diseases (NCDs)¹. Against this background, Brazil has implemented coping actions, such as the National Health Promotion Policy (NHPP)², creation of the Family Health Support Center³ and the Strategic Action Plan to Combat NCDs (2011-2022)⁴. Most of the actions proposed in these documents and initiatives involve Primary Health Care (PHC), a context where the multidisciplinary teams of the Family Health Strategy (FHS) and the Family Health Support Center, currently called the Expanded Nucleus of Family Health and Primary Health Care (ENFH-PHC) can develop together, counseling for physical activity (PA), besides, of course, many other actions.

There are several understandings about counseling. According to studies⁵, counseling can be understood as a generic process of support to users, in which the health professional considers the biopsychosociocultural context of the individual and helps him to explain the conflicts that permeate his daily life, aiming to build joint strategies to face health problems. Although they need to be discussed in greater depth, definitions of counseling commonly involve: setting collaborative goals, solving active problems, stages of change, barriers to change and making decisions related to lifestyles⁶. Studies show that counseling for PA should be part of the practice of health professionals working in PHC; and when properly developed, it can be an effective resource for promoting active lifestyles at the population level^7-9. It is worth mentioning, right now, that behavior change is a complex issue and depends on many factors, including some that are not in the full domain of individuals and even aspects that go beyond the more “rational” issues¹⁰. Thus, it would be naive to imagine that counseling, in isolation, can have a major impact on behavior change, in this case, on the adoption of a more physically active lifestyle^10,11. On the other hand, we assume that adopting counseling in routine care is feasible and acceptable, and contributes to reaching a larger part of the inactive public^12,13.

It is believed that greater success with counseling actions can be achieved if more systematic and specific strategies are used. One of the best known models worldwide is the five As (5As) model, which is based on theories of behavior change, based on evidence, applied to various health behaviors and feasible in PHC^14-17. The structure of the 5As correspond to the acronym formed by five words in the English language: ask, assess, advise, assist and arrange, and work as a structure to support health professionals to ask about behavior (ask), assess readiness to change (assess), advise a change (advise), assist in setting goals (assist) and organize follow-up (arrange)^14,18-21.

Counseling interventions based on the 5As model have proven effective for smoking cessation¹⁷ and PA in PHC^20,22-25. Despite a growing international evidence base that supports the use of the 5As model, there are few studies in Brazil that address these strategies for PA, in addition to the lack of training and specific protocols to the reality of the Unified Health System (SUS), which makes it difficult the provision of counseling, at least in a more systematic way, by health professionals.

Thus, it is important to know whether ENFH-PHC health professionals carry out counseling for PA and what strategies they use according to the 5As model, including to better understand the practice of these professionals regarding counseling for PA and help in the development of more efficient strategies. Given this context, the objective of the study was to estimate the prevalence of counseling strategies for physical activity used by professionals from the Expanded Nucleus of Family Health and Primary Health Care (ENFH-PHC) in Florianópolis, according to the 5As model.

Methods

This observational, cross-sectional study is part of a larger project entitled "Counseling for physical activity in Primary Health Care - Counseling SUS".

Study location

The study was developed at the PHC in the city of Florianópolis, composed of 49 Health Centers (HC), which are distributed in four Health Districts (HD) (Center, Continent, North and South). The FHS teams work in these HC, supported by matrix professionals from ENFH-PHC.

Participants

The participants were health professionals (civil servants and residents) who work at the ENFH-PHC in Florianópolis. Each ENFH-PHC team is composed of: social worker, nutritionist, physiotherapist, psychologist, pharmacist and Physical Education Professional (PEP); in addition to the presence of residents of the Family Health Residency Programs at the Federal and State University of Santa Catarina in their respective areas of activity. Interns, resident professionals linked to Residency programs in other cities and volunteers did not participate in the survey. We opted for a census, in which all professionals who were on duty at the time of collection were invited to answer the survey instrument.

According to data from the National Register of Health Establishments (NRHE) passed on by the Municipal Health Secretariat (MHS) (April / 2018) and updated by the HC coordinators (October / 2018), the total number of health professionals assigned to ENFH-PHC was 67 (excluding doctors) and 47 residents.

Ethical aspects

This study was approved by the Health Research Projects Monitoring Committee (CAPPS) of the MHS Public School of Health and by the Ethics Committee for Research with Human Beings of the Federal University of Santa Catarina (UFSC) with opinion number: 2,693. 520. All participants signed a Free and Informed Consent Form.

Procedures

In order to organize the collection, the HD was asked to: number of professionals filled, dates of the planning meetings and contact of the coordinators of the HC; dissemination of the survey by email and at district coordinator meetings.

The collection took place between August and November 2018 at the HC planning meetings and ENFH-PHC district meetings and was carried out by a team composed of four researchers from the Aconselha SUS project. Each researcher was responsible for a HD and made: contact with HD and coordinators of the HC; dissemination of research by e-mail; distribution, collection and organization of questionnaires. The researchers were resident PEPs, master’s or masters, and participated in the entire process of outlining the research logistics, preparing the instruments and collecting guidance. To minimize losses, a second visit was made to collect questionnaires from professionals who for some reason did not attend the meeting / collection. For greater data reliability, all questionnaires were checked by two researchers at different times.

Instrument

The instrument was developed by the project's research team, and followed the steps: thorough reading of the literature and survey of protocols on the topic; selection and definition of questions; evaluation by two specialists in the field of Physical Education with expertise in PHC; test with graduate students; test in an HC and approval. The selection of questions about performing counseling for PA was based on data from a systematic review on the prevalence of counseling for PA²⁶; and for questions about strategies used according to the 5As model, the studies^{14,16,18,24,27}.

The instrument used consisted of a self-administered questionnaire composed of 49 objective questions distributed in five blocks, respectively: block 1 - counseling for PA; block 2 - knowledge about PA recommendations; block 3 - PA level at leisure; block 4 - professional training and performance and block 5 - sociodemographic information. For this research, questions related to blocks 1, 4 and 5 were selected.

Counseling for PA was assessed using the question: “During your visits, in the last 12 months, did you provide counseling for PA to users?”, With a dichotomous answer option (no or yes). This question was used in several cross-sectional studies on counseling, according to a systematic review²⁶.

The counseling strategies for PA according to model 5As were assessed using the question: “When do you advise PA which strategies do you use?”, Which was subdivided into nine questions, each corresponding to an “A”, all with a choice of dichotomous response (no or yes). The nine questions were: “Do you ask about PA level / practice?” (A1 - ask); "Do you assess the user's level of PA or stage of behavior change?" (A2 - assess); "Do you comment on the benefits of regular PA practice?" (A3 - advise); “Do you comment on the recommendations of PA for health?” (A3 - advise); "Do you advise based on individual characteristics (age, sex, clinical condition), recommending specific frequency and intensity of PA?" (A3 - advise); "Do you identify the reasons that hinder or prevent the user from not performing PA?" (A4 - assist); "Do you offer any solution to help the user with these difficulties?" (A4 - assist); “Do you use any strategy (eg visits, calls, text messages) to find out if the user has started to perform PA?” and "Do you use any strategy (eg visits, calls, text messages) to find out if the user is performing PA?" (A5 - arrange). The classification followed the 5As model: ask, assess, advise, assist, arrange, according to the studies^{14,16,18,20,24,27}.

The resources used by the professionals were evaluated using the question: “During counseling, what do you use to help the user to practice PA?”, With answer options: provide educational materials about PA, establish goals with the user, write prescription exercise, recommends PA group from HC, recommends a specific location to perform PA. The marked responses were categorized as performed.

To characterize the sample, age group, gender, skin color, postgraduate, postgraduate in Public Health, time working in PHC, category and professional relationship were evaluated. He was also asked about knowledge about PA health recommendations.

The postgraduate variables were assessed using the question: “Have you completed any postgraduate courses?”, With a dichotomous answer option (no or yes), in the case of an affirmative answer, the question was used: “The postgraduate course did you graduate in Public Health, or Family and Community Health or Collective Health?”, also with a dichotomous answer option (no or yes).

The working time at PHC was evaluated by the question: “How long have you been working in Primary Health Care?”, The answer should be answered in years and / or months. The identification of professionals was based on the question: “What is your professional category?”. The type of employment relationship was assessed based on the question: "What type of employment relationship do you currently have in Primary Health Care?", With response options: commissioned position, informal contract, temporary contract, cooperative, effective civil servant, health resident (Uni or Multiprofessional Residency Program). Knowledge about PA recommendations for health was assessed through the question: "Do you know what are the PA recommendations for apparently healthy adult people, in relation to moderate or vigorous PA?", With a dichotomous response option (no or yes).

Statistical analysis

The data were tabulated in the EpiData software previously prepared for data insertion. For data analysis, descriptive statistics (averages and absolute and relative frequencies) were presented using graphs and tables. For the purpose of analyzing the prevalence of counseling in the last 12 months, all 72 respondents were considered. In the following analyzes, we chose to analyze only those who reported carrying out some type of counseling using Stata version 13.0.

Results

The proportion of ENFH-PHC professionals who participated in the survey in relation to the number allocated in MHS is equivalent to the response rate equal to 62.0%. The losses occurred due to leave reasons, such as vacations, leave and internships (in the case of residents) or the absence of the professional on the day of data collection. The refusal rate was 6.9% (n = 5).

Thus, 72 professionals working at the ENFH-PHC in Florianópolis participated in 2018. Of these, 40 (55.5%) were effective civil servants and 32 (45.5%) residents. The largest proportion of respondents were female (88.9%), were between 30 and 49 years old (54.3%), declared themselves to be white (77.8%), had at least one graduate degree (64.7%), with 56.5% in the Public Health area. As for the length of service at PHC, half of the professionals had more than three years (54.1%), the professional categories nutritionist and PEP were those with the highest participation, being just over 20%, and half of the professionals did not know the recommendations PA for health (53.7%) (Table 1).

Table 1
Characteristics of the sample of professionals from the Expanded Nucleus of Family Health and Primary Health Care in Florianópolis, 2018 (n = 72)

Variables	Category	n(%)
Sex	Male	8 (11.1)
	Female	64 (88.9)
Age range	20 to 29	30 (42.9)
	30 to 49	38 (54.3)
	50 or more	2 (2.9) *
Skin color	White	56 (77.8)
	Non-white	16 (22.2)
Postgraduate studies	No	24 (35.3)
	Yes	44 (64.7)*
Post-Graduation in PHa	No	20 (43.5)
	Yes	26 (56.5)*
Working time at PHCb	( 3 years ( 3 years	33 (45.8) 39 (54.1)
Professional category	Social Worker Pharmaceutical Physiotherapist Nutritionist PEPc	9 (12.5) 10 (13.9) 13 (18.0) 17 (23.6) 16 (22.2)
	Psychologist	7 (9.7)
Employment Bond at PHCb	Effective Public Servant Resident in FHd	40 (55.6) 32 (44.4)
Know the recommendations of PAe for health	No Yes	36 (53.7) 31 (46.3)*

• Note: ^aPublic health; ^bPrimary Health Care; ^cPhysical Education Professional; ^dFamily Health; ^ePhysical activity; *Frequencies did not correspond to the total due to missings (omission of respondents in the survey)
• Source: Authors

The prevalence of counseling for PA performed by ENFH-PHC professionals in the last 12 months was 97.2% (n = 70). In general, the main strategies used during counseling permeate the action of the professional to comment on the benefits of PA to improve health (97.1%), identify barriers to be physically active (97.1%), offer solutions to remove / reduce barriers (94.2%), ask about PA level / practice (94.1%) and comment on PA recommendations (87.1%). On the other hand, it is observed that a smaller proportion of professionals assess the level of PA of individuals (60.1%), advise according to individual characteristics (54.4%) and only one fifth of professionals use strategies to verify whether counseling had the expected result (21.7%) or whether that counseling brought about lasting changes over time (24.6%) (Figure 1).

Figure 1
Prevalence of strategies used by professionals from the Expanded Nucleus of Family Health and Primary Health Care in Florianópolis who reported performing counseling for physical activity. Florianópolis, Santa Catarina, 2018 (n = 70)

When analyzed according to the 5As model, it is observed that ENFH-PHC professionals who reported performing some type of counseling, actively use four of the 5As, three of which had more than 90% prevalence: ask (94.1%), advise (98.5%) and assist (95.7%). Arrangement was the least used strategy (25.7%) (Table 2).

Table 2
Frequency of use of 5As by professionals from the Expanded Nucleus of Family Health and Primary Health Care in Florianópolis who reported performing some type of counseling for physical activity, 2018 (n = 70)

Model 5As	Total (n = 70) n(%)
Ask	64 (94.1)
Assess	42 (60.1)
Advise	69 (98.5)
Assist	67 (95.7)
Arrange	18 (25.7)

• Source: Authors

As for the resources used by professionals, it is observed that the main recommendation is to participate in PA groups developed in HC (97.1%). About half of the professionals reported recommending places in the neighborhood to practice PA (50.7%), 44.9% establish goals with the individual, 30.4% provide educational material and 20.3% prescribe physical exercises (Figure 2).

Figure 2
Types of resources used by the professionals of the Expanded Nucleus of Family Health and Primary Health Care in Florianópolis who reported carrying out some counseling for physical activity. Florianópolis, Santa Catarina, 2018 (n = 70)

Discussion

The results of the study show that counseling has been used as an assistance strategy to promote PA in PHC in Florianópolis-SC. The most reported counseling strategies by ENFH-PHC professionals focus on “As” ask, advise and assist. The least reported strategy was arrange. The most used resource was to indicate the participation in PA groups, from HC.

The prevalence of counseling for PA performed by ENFH-PHC professionals in the last 12 months was high (97.2%). This is a high prevalence when compared to national and international studies presented in a systematic review that showed an average of 60% of counseling among health professionals such as doctors and nurses²⁶. In national studies^5,26 the prevalence ranged from 50 to 88.9%, but involved only FHS professionals (doctor, nurse and Community Health Agent. Thus, the high prevalence may be related to the professional categories surveyed, as the professionals who are part of the ENFH-PHC must seek to guide their performance in an interdisciplinary way, including the theme body practices and PA³, in order to encourage the adoption of ways of life healthier at the population level²⁸.

It can also be explained by the organization of PHC in Florianópolis and the FHS coverage, which since 2010 has ENFH-PHC teams distributed in all Health Districts²⁹. Although PA should be a theme worked by health teams regardless of their composition, the presence of PEP in all ENFH-PHC teams may have contributed to reinforce the provision of counseling, since one of their functions is to carry out permanent education of the FHS / ENFH-PHC on guidance for PA practice and supporting the FHS in health promotion and behavior change actions³⁰.

It can also be considered that the constant investment in permanent education and health training, such as the presence of the Multiprofessional Residence, the Education through Work for Health Program (PET-Saúde / Interprofessionality) and extension projects, can contribute to the quality of the Florianópolis PHC and consequently to carry out counseling³¹. In addition to the fact that more than half of the ENFH-PHC professionals who work in the system already have completed Postgraduate Studies in Public Health and have worked at PHC for over three years, which generates more knowledge of public policies and greater experience in PHC context. In addition to that Florianópolis is one of the capitals with more active population of Brazil, what makes PA a subject present in the daily one and of easier approach³².

The high prevalence of counseling suggests that PHC in Florianópolis is incorporating PA into its routine. Considering that high levels of PA in the population are related to decreased risk of early mortality and reduction of NCDs: diabetes, hypertension, osteoporosis, depression and various types of cancer¹, ENFH-PHC professionals are sensitized to address the issue of PA in calls.

As for the use of strategies according to the 5As model, the ENFH-PHC professionals reported actively using four of the 5As to advise PA. This finding demonstrates PHC Florianópolis' awareness of public policies aimed at promoting PA and preventing NCDs, and the efforts of ENFH-PHC professionals to assist patients in changing their behavior, since counseling using the 5As is a totally acceptable approach and valid for PA^33-34. However, although ENFH-PHC professionals perform strategic actions that refer to the 5As model, it is quite possible that they do not know it as an organizational construct and do not use it as a functional tool in their care practice²⁷.

The predominance of ask, advise, assist and assess strategies partly agree with the literature, which generally indicates that ask and advise are the concepts of the "As" most frequent in clinical practice^14,35. This result is important because it demonstrates that ENFH-PHC professionals have used varied strategies and according to the 5As model to advise PA at Florianópolis' PHC. The use of ask, points out that ENFH-PHC professionals use the strategy that initiates counseling, having its importance for being a principle of motivational interview that allows the patient to be heard²¹.

The use of advise, which includes commenting on the benefits and recommendations of PA for improving health, is a significant result because it favors greater motivation and confidence of the patient to change behaviors^14,19. Advise is the most commonly documented practice in research^19,27,35, its use is of direct relevance to the patient, and therefore requires professionals to have up-to-date access to studies in the field and knowledge about PA recommendations for health. However, although they report advising on PA recommendations for health, ENFH-PHC professionals reported not knowing them (53.7%). This result points to an important issue that needs to be further explored, as counseling must be based on scientific evidence that allows users a greater chance of incorporating PA practice into their daily lives. It is evident the need for greater training of ENFH-PHC professionals on the recommendations and also provide means and strategies for patients to achieve the recommendations. However, it is worth mentioning that the practice of PA is associated with several health outcomes, and it is not so simple to establish a notion of “dose-response”, also because the “minimum dose” to influence one outcome may not be sufficient in another. , while a practice lower than the “minimum dose” can influence other aspects of the subjects' lives³⁶. In this sense, not only focusing on quantitative aspects related, for example, to volume, intensity and frequency, but also giving importance to other aspects, such as the meaning of practices and people's satisfaction can be of great importance³⁶.

The assist strategy was also one of the “As” most mentioned by ENFH-PHC professionals. This finding differed from the patterns of use of the 5As indicated in most studies of counseling on tobacco, weight loss, diet and exercise^{16,19,27,37,35}, which point to the very limited use of assist. This disagreement may be related to the professional categories researched in these studies, generally doctors and / or nurses, who have a different configuration of clinical practice when compared to ENFH-PHC professionals. When using “assist” (helping patients to identify barriers and approach facilitators for PA practice) ENFH-PHC professionals from Florianópolis demonstrate knowledge about the territory in which they are inserted, and that when advising PA they take into account the context of patients and the main environmental, social, medical, emotional and economic barriers to being active. This assistance provided by professionals is relevant because it contributes to driving behavior change in a more realistic and patient-centered way, and with a greater probability of success²⁴.

Another assistance frequently mentioned by ENFH-PHC was to offer solutions to assist patients in the identification and search for reliable resources for adherence to PA. Among the solutions or resources used, the main recommendation is the participation in groups of PA, of the HC, followed by recommending a specific place for PA in the neighborhood. It is observed that “conducting PA promotion groups for adults” is one of the minimum activities specific to the PEP of the ENFH-PHC advocated in the PHC Florianópolis service portfolio³⁰. The high reference in indicating them demonstrates that the majority of the HC have working groups. PA groups are an important resource to support the adoption of healthier life habits, but they should not be the only health education resources for PA, since the opening hours of these groups can restrict participation to a certain portion of the population (elderly and / or retired people). Still, about give assistance (assist), the resources mentioned by the professionals indicate little use of educational materials and prescription of physical exercises, which leads to the understanding that the assistance offered is limited to verbal guidelines. According to Meriwether et al.²⁴ printed materials and written prescriptions appear to increase the effectiveness of health behavior interventions, and Smith et al.²⁰ recommends the use of tools to encourage self-monitoring in PA, such as pedometers or activity diaries. However, it should be noted that the use of certain resources involves high costs, and their feasibility and applicability on a large scale in the context of SUS should be evaluated. It should also be considered that the prescription of physical exercise is the exclusive competence of the PEP, which explains the low percentage presented, as it refers to the practice of professionals from different backgrounds.

Regarding the use of the assess strategy, although performed by more than half of the ENFH-PHC professionals, it presented a reasonable value when compared to the other “As” (ask, advise and assist). Assessing the level of PA and stage of behavior change requires specific tools. Several assessment tools have already been designed and tested in order to facilitate counseling in care practice such as Physical Activity Assessment Tool (PAAT) and Patient-Centered Assessment and Counseling for Exercise and Nutrition (PACE), some of which are available in print version and even in clinical software programs^20,22,24. Currently, there is no knowledge of the systematic use of any tool or software for assessing the level of PA and the stage of behavior change or counseling in the practice of ENFH-PHC professionals in Florianópolis.

Finally, regarding arrange (organizing/monitoring), on average two out of ten ENFH-PHC professionals use strategies to monitor the results of counseling, which classifies this “A” as the least frequent. This data is similar to several studies that indicate that arrange is the least mentioned of the 5As^15,19,27,35. Arrange consists of making follow-up contacts (in person, by phone or email) to provide assistance, continuous support and / or to adjust the action plan as needed, including referral for specialized treatment²². The literature suggests that this “A” is extremely essential to produce significant and lasting behavior change^38-39. Additional research has shown that its use by doctors was related to improved eating habits, weight loss and that about half of patients wish to receive continuous support from a health professional^14,19. It is considered necessary that ENFH-PHC professionals can have access to mechanisms (strategies and tools) for monitoring and recording the results of counseling, otherwise there will be no way to evaluate effectiveness, scope and continuity, elements that are indispensable to evaluate/effect public policy. This result reinforces the need to broaden the understanding that counseling for PA applied in PHC cannot be confused with a generic and meaningless and objective orientation, within the Health Care networks. As can be seen, the prevalence of counseling was high, however, the low number of professionals who reported monitoring the results obtained from this practice can compromise the effectiveness of this type of intervention.

This study aimed to evaluate the use of the 5As model as counseling strategies for PA by ENFH-PHC professionals, and has strengths. The professional categories surveyed stand out as a strong point since most of the studies carried out in Brazil sought counseling for PA only from a uniprofessional perspective or involving only professionals who make up the FHS (doctor, nurse, and/or community health agent). The identification of strategies according to the 5As model also broadens the understanding of their use by professionals, contributing to the future planning of more concrete actions to improve this practice in PHC services. In addition, this study proposed to conduct a survey with all professionals working in ENFH-PHC in a Brazilian capital, achieving a high response rate when compared to other studies.

Among the study's limitations, it is possible to list the cross-sectional design, the lack of sample calculation, the use of non-inferential statistical analyzes and a self-administered questionnaire (memory bias). Although most studies use direct observation of consultations (audio recording) to assess the use of 5As, the self-administered questionnaire was chosen due to the nature of the research (cost and complexity and the absence of an observational coding system for 5As). The instrument was also not applied to patients, circumscribing the report only to professionals, which may overestimate the performance of counseling. Another limitation may have been the period specified in the survey regarding the provision of counseling in the past 12 months, which may generate recall bias. However, a recent systematic review²⁶ noted that most counseling studies use this recall time.

Conclusion

In conclusion, the results showed a high prevalence of counseling for PA reported by ENFH-PHC professionals in Florianópolis. The strategies used to advise are related to the 5As model, although they are not used in a systematic way. Among the most mentioned strategies are ask, advise and assist. Arrange was the least mentioned strategy.

Counseling structured according to the strategies of the 5As model provides guidelines for a better approach to change behavior in PA, with lower cost and greater effectiveness for PHC services. Therefore, it is essential that the ENFH-PHC in Florianópolis observes the gaps that permeate the use of these strategies in order to improve the practice of counseling that has already been proven.

Thinking about practical implications, it is necessary to invest in permanent education specific to the thematic counseling for PA. In addition, to use efforts in intervention research for the development and insertion of resources to support counseling according to the 5As model, as practical tools to assess the level of PA and stage of behavior change, and of follow-up schemes using new technologies and software to organize the records of this practice in PHC services.

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Publication Dates

• Publication in this collection
  05 May 2021
• Date of issue
  2021

History

• Received
  06 Sept 2019
• Reviewed
  05 Mar 2020
• Accepted
  30 Apr 2020