What are medical students learning about physical activity? Experiences from a
South African medical education programme: A cross-sectional study
Mark Stoutenberg
PhD, MSPH
1,2,3
Innocent Maposa
PhD
4
Georgia Torres
PhD
3,5✉ Phone(011)717 3374 Email
1 Wolfson Research Institute for Health and Wellbeing Durham University Durham UK
2 Department of Sport and Exercise Sciences Durham University Durham UK
3 Department of Exercise Science and Sports Medicine, School of Therapeutic Sciences University of the Witwatersrand Johannesburg South Africa
4 Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences Stellenbosch University Stellenbosch South Africa
5
A
Department of Exercise Science and Sports Medicine, School of Therapeutic Sciences, Faculty of Health Sciences University of Witwatersrand South Africa
Mark Stoutenberg1,2,3, PhD, MSPH, Innocent Maposa4, PhD, Georgia Torres3, PhD
1 - Wolfson Research Institute for Health and Wellbeing, Durham University, Durham, UK
2 - Department of Sport and Exercise Sciences, Durham University, Durham, UK
3 - Department of Exercise Science and Sports Medicine, School of Therapeutic Sciences, University of the Witwatersrand, Johannesburg, South Africa
4 - Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
Corresponding author:
Georgia Torres, PhD
Department of Exercise Science and Sports Medicine
School of Therapeutic Sciences
Faculty of Health Sciences
University of Witwatersrand, South Africa
Tel: (011) 717 3374
Email: georgia.torres@wits.ac.za
Abstract
Background
While previous work has examined physical activity (PA) training in medical schools in high income countries, little is known about practices in low-to-middle income countries (LMICs). This study examined the attitudes, preferences, and behaviours of medical students at a major South African medical school towards receiving PA training, as well as changes across each year of school, in their medical education.
Methods
A
A paper-based questionnaire was administered in-person to medical students across all four years of the Graduate Entry Medical Programme (GEMP) between April and September 2021. The questionnaire queried students about their personal PA practices, knowledge, and attitudes, as well as PA training received during medical school.
Results
Medical student PA levels were low (34.8% self-reported meeting WHO PA recommendations) and decreased with increasing year in medical school. Nearly all students recognised the importance of PA in disease prevention and treatment (98.1%) and as an important part of future patient consultations (95.0%), but lacked PA knowledge, with only 9.1% and 5.2% of all medical students correctly reporting WHO PA requirements and demonstrating knowledge of core principles for providing an exercise prescription, respectively. A majority of students (82.3%) desired more PA training and several other items assessing medical student attitudes towards PA improved significantly with increasing year in medical school.
Conclusions
This study adds to existing literature, from a LMIC perspective, that provides strong evidence that medical students are interested in receiving PA training, understand its importance in their future work as health professionals, and feel unprepared to counsel future patients.
Keywords:
attitudes
exercise
knowledge
medical school
physical activity
students
A
A
Background
Non-communicable diseases (NCDs) are the leading cause of death globally, accounting for 41 million or 74% of deaths in 2020 (1). The burden of NCDs is not shared equally across the world, as individuals in low- and middle-income countries (LMICs) have a 3.8 times higher rate of death due to cardiovascular disease than individuals in high-income countries (2). In Africa, NCDs are responsible for 42% of all deaths with the rates ranging by country from 27% (Chad, Nigeria) to 88% (Mauritius) (3). The increasing prevalence of NCDs in Africa is attributed to a myriad factors, including lifestyle choices, genetic and epigenetic influences, and healthcare availability (4, 5). NCDs cause an estimated 51% of all deaths in South Africa, most of which are due to cardiovascular disease and diabetes (6). If not adequately addressed, the continued rise of NCDs will continue to cost millions of lives and trillions of dollars in the world economy (7).
A
Given this growing crisis, the World Health Organization (WHO) set an overarching goal to reduce global mortality due to NCDs by 25% by the year 2025 (8). To aid in this effort, the WHO created a list of “best buys” for the prevention and management of NCDs (9), which include cost effective strategies for reducing tobacco and alcohol use, unhealthy dietary practices (e.g., sodium consumption), and physical inactivity. Globally, physical inactivity is estimated to be responsible for 7.2% and 7.6% of all-cause and cardiovascular deaths, respectively, with 28% of adults not achieving physical activity (PA) guidelines (10, 11). Levels of physical inactivity in adults vary widely throughout Africa (12); in South Africa, 57.4% of individuals are physically inactive (13) due to a variety of barriers, including vandalism of gyms and parks, personal safety fears, and sidewalks appropriated by vendors or homeowners (14).
To overcome these barriers to PA, guidelines suggest engaging individuals through multi-sectoral approaches involving improvements to the built environment and transportation systems, changes in public policy, and community wide campaigns (15). While a systems-based approach has the potential to influence change on a community level, complimentary individualized strategies, such as PA counselling in health settings have also proven to be effective (16, 17). Existing literature suggests that PA advice by health professionals has a small to moderate impact on increasing moderate-to-vigorous PA levels (17, 18), which, in turn, can have a significant impact on overall health outcomes. Despite the potential impact of providing PA counselling shown, physicians report feeling unprepared to counsel their patients due to inadequate knowledge and training (19, 20).
Previous work has examined PA training in medical schools in Canada (21), the United States (22, 23), Australia (24), and Europe (25). However, little is known about PA training in medical schools in LMICs, particularly in sub-Saharan African. Given the low levels of PA in South, better understanding how PA can be optimally integrated into medical school curricula is a critical strategy in effectively addressing the growing NCD epidemic. Therefore, the purpose of this study was to examine the attitudes, preferences, and behaviours of South African medical students towards PA in their medical education and how those factors change in students across years in medical school.
Methods
Overview
This study was conducted between April and September 2021 with medical students enrolled across all four years of the Graduate Entry Medical Programme (GEMP) in the Faculty of Health Sciences at the University of Witwatersrand. A paper-based survey, which took less than ten minutes to complete, was administered in-person to all medical students during the first teaching block at the beginning of the year.
Questionnaire Development
A paper-based questionnaire was developed based on previous work conducted in medical schools based in the United States (22) and the United Kingdom (25). The questionnaire (see supplemental appendix 1) consisted of five sections: basic student demographic information (5 items), student personal PA practices (5 items), PA knowledge (4 items), attitudes towards PA (5 items), and PA training in medical school (4 items). Medical student self-reported PA levels were collected using the PA Vital Sign (26), a clinical tool that quickly and accurately determines whether an individual is meeting global PA guidelines (27), as well as single items about their weekly strength training practices and sedentary behaviour. Their PA knowledge was evaluated using short answer questions that asked about the aerobic and strength training components of the global PA guidelines (27), as well as the basic components of a PA prescription (frequency, intensity, time, type; FITT). Medical students’ attitudes towards PA were assessed using 5-point Likert scales that queried their perceived importance of PA in future patient interactions, their perceived knowledge of PA, and their ability to help patients to become more physically active. Lastly, 5-point Likert scales were used to query students about PA promotion on campus, the PA attitudes of their peers, and their general attitudes towards being active and fit. The questionnaire was piloted by ten 10 medical school faculty to ensure the tool's clarity and appropriateness before final administration to medical students.
Procedures for Survey Tool Completion
A hard copy of the questionnaire was completed by GEMP I (first year) students prior to a series of COVID-19 closures. Students were provided with the questionnaire and asked to complete it prior to a practical session at the Department of Exercise Science and Sports Medicine. The other medical students (GEMPs 2–4 or years 3–6 of SA medical school) completed the questionnaire during small group (8–10 students), in-person tutorial sessions in the early phases of campus re-opening in late 2020. The research team was provided with time at the beginning of one tutorial at which time students could choose to fill out the study questionnaire. The tutorials were not compulsory for the medical students to provide accommodations for those who preferred to study online during the uncertainty of health issues surrounding campus re-opening; thus, not all medical students in years 2–4 were present and able to complete the questionnaire (see Supplemental Table 2 for response rates).
Data Analysis
Data were captured in an Excel spreadsheet and exported to STATA version 17 (StataCorp. 2021. Stata Statistical Software: Release 17. College Station, TX: StataCorp LLC.) for preprocessing and analysis. Categorical variables were summarized using frequencies and percentages, while continuous variables were described using medians and interquartile range or mean and standard deviation. Fisher’s Exact tests were used to assess bivariate association between categorical variables. The independent Student’s T test was used to compare means from two groups for normally distributed scores, while the Mann-Whitney U test was used for non-normal continuous variables. For more than two groups, the analysis of variance (ANOVA) or Kruskal Wallis test were utilized depending on distribution. The univariate and multivariable logistic regression models were used to assess factors that are associated with the desire for more PA training.
Ethics
Ethical approval
A
was provided by the Human Research Ethics Committee (Medical) at the University of Witwatersrand [Ref. M191043] for all study materials and procedures.
Results
Demographic information of the medical students who participated in the study are found in Table 1. Response rates were highest with first year students (> 60%), and declined in GEMP years 2–4 (19.0%, 24.5%, and 28.4%, respectively). Across all GEMP years, approximately two thirds of respondents were female, with a large majority from South Africa.
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Slightly more than one third of all medical students reported meeting WHO PA recommendations; however, students in GEMP 2 and 3 were significantly less likely than their classmates to meet these guidelines (27.5% and 23.1%, respectively). Nearly half (45.7%) of the students reported sitting an average of 6–10 hours per day; however, this proportion decreased with increasing year of medical school with a greater proportion GEMP 3 and 4 students reporting only 0–5 hours of sitting time.
Table 1
Demographic characteristics of participating medical students.
 
Overall
(n = 536)
GEMP Year 1
(n = 274)
GEMP Year 2
(n = 80)
GEMP Year 3
(n = 91)
GEMP Year 4
(n = 91)
p-value
Age, Median (IQR)
22 (21–24)
21 (20–22)
22 (21–23)
23 (22–24)
25 (24–26)
< 0.001+
Gender
0.95£
Male
175 (32.8%)
92 (33.7%)
24 (30.0%)
30 (33.3%)
29 (32.2%)
  
Female
358 (67.2%)
181 (66.3%)
56 (70.0%)
60 (66.7%)
61 (67.8%)
  
Country of Origin
0.039¥
Non-South African
32 (6.1%)
17 (6.3%)
9 (11.5%)
5 (5.7%)
1 (1.1%)
  
South African
493 (93.9%)
254 (93.7%)
69 (88.5%)
82 (94.3%)
88 (98.9%)
  
Ethnicity
0.626¥
Caucasian
179 (33.5%)
100 (36.6%)
24 (30.0%)
27 (29.7%)
28 (30.8%)
  
African
219 (40.9%)
109 (39.9%)
32 (40.0%)
36 (39.6%)
42 (46.2%)
  
Indian
107 (20.0%)
47 (17.2%)
21 (26.3%)
21 (23.1%)
18 (19.8%)
  
Colored
22 (4.1%)
11 (4.0%)
2 (2.5%)
6 (6.6%)
3 (3.3%)
  
Other
8 (1.5%)
6 (2.2%)
1 (1.2%)
1 (1.1%)
0 (0.0%)
  
Meeting WHO PA recommendations
      
0.011£
No
349 (65.2%)
168 (61.5%)
58 (72.5%)
70 (76.9%)
53 (58.2%)
  
Yes
186 (34.8%)
105 (38.5%)
22 (27.5%)
21 (23.1%)
38 (41.8%)
  
Time spent seated per day
< 0.001¥
0–5 hours
53 (10.1%)
15 (5.5%)
1 (1.3%)
16 (17.8%)
21 (23.1%)
  
6–10 hours
241 (45.7%)
135 (49.8%)
37 (49.3%)
36 (40.0%)
33 (36.3%)
  
11–15 hours
123 (23.3%)
80 (29.5%)
16 (21.3%)
11 (12.2%)
16 (17.6%)
  
16–20 hours
37 (7.0%)
11 (4.1%)
9 (12.0%)
5 (5.6%)
12 (13.2%)
  
Unsure
73 (13.9%)
30 (11.1%)
12 (16.0%)
22 (24.4%)
9 (9.9%)
  
Data are presented as median (IQR) for continuous measures, and n (%) for categorical measures. PA: physical activity; WHO: World Health Organization. GEMP: Graduate Entry Medical Programme.
+ p-value computed using Kruskal Wallis test to assess differences in age distribution across year of medical school.
£ p-value computed using Pearson’s χ2 test to assess association between year of medical school and the characteristic.
¥ p-value computed using Fishers’ Exact test to assess association between year of medical school and the characteristic.
[Insert Table 1]
Medical student attitudes towards PA and promoting it with their future patients is found in Tables 2 (overall) and 3 (by year in medical school). Students expressed a high level of awareness on the importance of promoting PA for disease prevention and treatment (mean = 4.7), promoting it with their future patients (mean = 4.5), and desired more PA training in their curriculum (mean = 4.1). Conversely, medical students did not feel that their medical school (2.7/5.0) or their classmates (2.9/5.0) encouraged them to be physically active. Medical students in their final years of medical school reported being significantly more confident in being able to effectively counsel patients to increase their PA levels (p = 0.019).
Table 2
Overall level of medical student agreement towards physical activity training and promotion with patients.
Item
Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree
Importance of PA as a treatment and prevention tool for disease
385 (71.8%)
141 (26.3%)
6 (1.1%)
0 (0%)
4 (0.7%)
Promoting PA is an important part of their future patients consults
301 (56.2%)
208 (38.8%)
23 (4.3%)
1 (0.2%)
3 (0.6%)
Students have sufficient knowledge to properly advise PA
40 (7.5%)
164 (30.6%)
204 (38.1%)
110 (20.5%)
18 (3.4%)
Provide more effective counseling if I exercise and stay fit
132 (24.8%)
308 (57.9%)
73 (13.7%)
15 (2.8%)
4 (0.8%)
Prevention is less interesting than treatment
32 (6.0%)
39 (7.4%)
58 (10.9%)
173 (32.6%)
228 (43.0%)
Belief they can effectively help patients increase PA levels
57 (10.6%)
254 (47.4%)
181 (33.8%)
43 (8.0%)
1 (0.2%)
Would like more training in PA
172 (32.1%)
269 (50.2%)
70 (13.1%)
15 (2.8%)
10 (1.9%)
Medical school encourages us to exercise
18 (3.4%)
98 (18.5%)
189 (35.6%)
151 (28.4%)
75 (14.1%)
Classmates encourage each other to exercise
19 (3.6%)
121 (22.7%)
227 (42.7%)
127 (23.9%)
38 (7.1%)
[Insert Tables 2 and 3]
Table 3
Medical student attitudes towards physical activity training and promotion with patients by year in medical school.
 
Overall
(n = 536)
Year 1
(n = 274)
Year 2
(n = 80)
Year 3
(n = 91)
Year 4
(n = 91)
p-value
Confidence in changing own personal exercise habits in next 6 months*
6.65 (2.21)
6.80 (2.10)
6.73 (2.04)
5.90 (2.47)
6.90 (2.28)
0.010
Prevention is less interesting than treatment
2.01 (1.17)
2.01 (1.20)
2.13 (1.17)
2.02 (1.13)
1.87 (1.14)
0.54
Importance of PA as a treatment and prevention tool for disease
4.68 (0.57)
4.65 (0.52)
4.81 (0.39)
4.69 (0.69)
4.67 (0.70)
0.17
Promoting PA is an important part of their future patients consults
4.49 (0.64)
4.45 (0.61)
4.63 (0.54)
4.56 (0.76)
4.48 (0.69)
0.12
Students have sufficient knowledge to properly advise PA
3.18 (0.96)
3.14 (0.98)
2.91 (0.93)
3.37 (0.91)
3.36 (0.86)
0.003
Belief they can effectively help patients increase PA levels
3.60 (0.79)
3.54 (0.79)
3.51 (0.75)
3.82 (0.75)
3.63 (0.84)
0.019
Would like more training in PA
4.08 (0.85)
4.06 (0.88)
4.18 (0.81)
4.07 (0.90)
4.07 (0.74)
0.75
Medical school encourages us to exercise
2.69 (1.04)
2.68 (1.07)
2.53 (1.06)
2.81 (1.03)
2.70 (0.89)
0.38
Classmates encourage each other to exercise
2.92 (0.94)
2.85 (0.93)
2.62 (0.91)
3.00 (0.95)
3.30 (0.92)
< 0.001
Provide more effective counseling if students exercise and stay fit
4.03 (0.75)
3.99 (0.78)
4.10 (0.71)
4.06 (0.80)
4.08 (0.66)
0.58
* Mean (standard deviation) from items using a 1–10 scale with 1 indicating ‘very confident’ and 10 indicating ‘not confident at all’. All other items are presented as [Mean (standard deviation)] from items using a 5-point Likert scales in which 1 = strongly disagree and 5 = strongly agree.
p-value denotes significant differences between medical students across year of medical school.
PA: physical activity.
A
A
Similar to the belief that they would be more credible and effective providing PA counselling if they exercised and stayed fit, a large majority (Table 4; 87.5%) of all medical students reported a desire to change their own exercise habits (Table 4). While medical students reported having an average level of knowledge to properly advise future patients on PA (Table 2; 3.2/5.0), those in GEMP years 3 and 4 reported having significantly higher knowledge to properly provide PA advise (p = 0.003). However, only 9.1% and 5.2% of all medical students correctly reported WHO PA requirements and demonstrated knowledge of core FITT principles for providing an exercise prescription, respectively.
Table 4
Medical student physical activity knowledge.
 
Overall
(n = 536)
Year 1
(n = 274)
Year 2
(n = 80)
Year 3
(n = 91)
Year 4
(n = 91)
p-value*
Desire to change own exercise habits
          
0.92
Yes
468 (87.5%)
238 (86.9%)
71 (89.9%)
79 (86.8%)
80 (87.9%)
  
No
67 (12.5%)
36 (13.1%)
8 (10.1%)
12 (13.2%)
11 (12.1%)
  
Knowledge of WHO PA Requirements
          
< 0.001
Yes
49 (9.1%)
43 (15.7%)
0 (0.0%)
6 (6.6%)
0 (0.0%)
  
No
487 (90.9%)
231 (84.3%)
80 (100.0%)
85 (93.4%)
91 (100.0%)
  
Knowledge of all Principles of an Exercise Rx**
          
< 0.001
Yes
28 (5.2%)
4 (1.5%)
1 (1.3%)
21 (23.1%)
2 (2.2%)
  
No
508 (94.8%)
270 (98.5%)
79 (98.8%)
70 (76.9%)
89 (97.8%)
  
PA: physical activity; Rx: prescription; WHO: World Health Organization
* All p-values represent Fishers’ Exact test of association.
** correctly identifying the core concepts of an exercise prescription as frequency, intensity, time, and type (FITT).
[Insert Table 4]
When analysing data across the student cohorts (GEMP 1–4; see Table 1), there was a significant decrease in PA levels (p = 0.011) between students in GEMP 1 (38.5% meeting PA recommendations) and GEMP 3 (23.1% meeting PA recommendations), before a spike with students in GEMP 4 students (41.8% meeting recommendations). At the same time, there was a significant increase in the patterns of time spent seated with increasing year in medical school (p < 0.001). Contrary to these changes in lifestyle behaviours, multiple improvements in student attitudes towards PA across cohorts were observed (Table 3). There were significant increases in medical student confidence in changing their personal exercise habits in the future (8.6%), reporting that they have sufficient knowledge to properly advise future patients on PA (7.0%), belief that they can effectively help patients increase their PA levels (2.5%), and the perspective that their classmates encourage each other to exercise (15.8%).
The univariate logistic regression analyses identified several characteristics significantly associated with the belief that medical students could effectively help patients increase their PA levels. When entered into a multivariate logistic regression model (see Table 5), only medical students in GEMP 3 (p = 0.011), those who reported meeting WHO PA recommendations (p = 0.016), as well as those that believed in the importance of PA as treatment (p = 0.014), had sufficient PA knowledge (p < 0.001), and believed they would be more credible and effective counselling if they exercised and stayed fit (p = 0.03) remained significant. Similarly, the factors significantly associated with medical student desiring more PA training (see Table 6) from the multivariate logistic regression model were students that believed in the importance of PA as treatment (p = 0.002) and had sufficient PA knowledge (p < 0.026).
Table 5
Factors associated with student belief that they can effectively help patients increase their physical activity.
 
Univariate logistic regression
Multivariable logistic regression*
Characteristics
OR [95% CI]
p-value
aOR [95% CI]
p-value
Gender
        
Male
1
      
Female
1.602 [1.101–2.331]
0.014
1.381[0.856–2.228]
0.186
Year in Medical School
        
1
1
  
1
  
2
1.150 [0.699–1.894]
0.581
1.180 [0.641–2.172]
0.594
3
0.458 [0.273–0.769]
0.003
0.434 [0.229–0.823]
0.011
4
0.829 [0.512–1.341]
0.445
1.036 [0.570–1.883]
0.908
Meeting WHO PA regulations
        
No
1
      
Yes
0.384 [0.262–0.565]
< 0.001
0.538 [0.325–0.892]
0.016
Desire to change PA habits
        
No
1
      
Yes
2.140 [1.210–3.785]
0.009
-
-
Prevention less interesting
1.008 [0.870–1.167]
0.920
-
-
Importance of PA as treatment
0.451 [0.319–0.638]
< 0.001
0.621 [0.392–0.984]
0.014
Students have sufficient PA knowledge
0.324 [0.255–0.410]
< 0.001
0.378 [0.287–0.496]
< 0.001
Medical School encourages PA
0.796 [0.672–0.943]
0.008
0.895 [0.722–1.108]
0.310
Classmates encourages each other to exercise
0.813 [0.676–0.978]
0.028
1.053 [0.824–1.346]
0.679
Provide more credible counselling if fit
0.566 [0.443–0.724]
< 0.001
0.711 [0.523–0.967]
0.03
Confident can change exercise habit in 6 months
0.865 [0.794–0.943]
0.001
0.950 [0.850–1.061]
0.362
*Backward stepwise variable selection using nominal p-value of 0.20. PA: physical activity; WHO: World Health Organisation.
Table 6
Factors associated with medical students desiring more training in physical activity.
 
Univariate logistic regression
Multivariable logistic regression*
Characteristics
OR [95% CI]
p-value
aOR [95% CI]
p-value
Gender
        
Male
1
      
Female
0.936 [0.584–1.499]
0.783
-
-
Year in Medical School
        
1
1
      
2
0.521 [0.252–1.072]
0.077
0.661 [0.287–1.520]
0.330
3
0.607 [0.315–1.168]
0.135
0.542 [0.243–1.208]
0.134
4
0.607 [0.316–1.168]
0.135
0.646 [0.298–1.398]
0.267
Meeting WHO PA regulations
        
No
1
      
Yes
0.943 [0.591–1.507]
0.807
-
-
Desire to change PA habits
        
No
1
      
Yes
0.315 [0.180–0.552]
< 0.001
-
-
Prevention less interesting
1.247 [1.044–1.489]
0.015
1.211 [0.980–1.497]
0.077
Importance of PA as treatment
0.593 [0.421–0.834]
0.003
0.513 [0.334–0.789]
0.002
Students have sufficient PA knowledge
1.162 [0.919–1.469]
0.208
1.426 [1.043–1.951]
0.026
Medical school encourages PA
0.905 [0.728–1.126]
0.372
-
-
Classmates encourages each other to exercise
0.912 [0.719–1.156]
0.445
-
-
Provide more credible counselling if fit
0.624 [0.470–0.828]
0.001
0.731 [0.509–1.050]
0.090
Confident can change exercise habit in 6 months
0.891 [0.798–0.996]
0.042
0.908 [0.806–1.022]
0.109
*Backward stepwise variable selection using nominal p-value of 0.20. PA: physical activity; WHO: World Health Organisation.
[Insert Tables 5 and 6]
Discussion
This study examined the attitudes, preferences, and practices of South African medical students towards the inclusion of PA in their medical education and how these factors change across their year in medical school. To our knowledge, the inclusion of PA in medical schools in Africa, or other LMICs in general, has not been rigorously examined previously and few studies have examined medical student attitudes, preferences, and practices of medical students across cohorts in each year of training. This training is particularly valuable given the rise in NCDs in Sub-Saharan African, combined with resource constraints and health system realities, which make PA a low-cost prevention strategy.
A
Our work found that medical students had a strong awareness of the importance of PA, possess a strong desire for PA training to be included in their training, yet lacked knowledge of PA guidelines and exercise prescription and desired an enhanced learning environment around promoting PA and healthy lifestyles. We observed few significant differences in medical student attitudes, preferences, or practices across the different medical student cohorts.
Medical Student Physical Activity Knowledge & Training Received in Medical School
Similar to several previous studies in high income countries, such as the United States (23, 28), Australia (24), and the United Kingdom (29), there continues to be a persistent lack of PA training in medical schools, despite general medical student awareness of the importance of PA in the overall health of their patients and in non-communicable disease prevention (30, 31). These findings are not specific to medical schools; a greater desire for more PA training has been identified in the training of future nurse practitioners (32), physiotherapists (33), and pharmacists (34). This lack of PA training is often accompanied by an overall lack of PA knowledge. While students in a Brazilian medical school scored 88% on a PA knowledge questionnaire, only 22% knew the WHO recommendation for weekly aerobic activity (35), and less than 1% of students (1 of 134) at a U.S. osteopathic medical school provided a correct definition of national PA recommendations (36).
A
In the current study, just over a third of medical students felt they had a sufficient level of PA knowledge, with an even lower proportion correctly stating WHO PA guidelines and the core principles of developing an exercise prescription (9.1% and 5.2%, respectively).
The importance of PA, and lack of training in medical school curricula, is reflected in most studies as medical students feel PA is important in the treatment and prevention of NCDs and that they desire greater training on PA in their curriculum (36, 37). In the current study, 82.3% of students agreed or strongly agreed that they desired more PA training as part of their program. This aligns with results from studies in Brazil (35), Scotland (38), and the United States (28), in which 74.5%, > 80%, and 84.7% of students desired greater PA training in their medical school curriculum, respectively. Moreover, medical student PA knowledge and attitudes (e.g., desire for greater training) are inextricably linked; in our study, valuing the importance of PA as important in the treatment of disease was a significant predictor of students desiring more PA training in their curriculum.
Individual PA Habits & the Medical School Environment
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The individual lifestyle habits of medical students also plays an essential role in their holistic health and future counselling patterns. Maintaining an active lifestyle during medical training is associated with academic success and achievement (39, 40), as well as improved levels of physical and mental health (22, 41, 42). Despite the heavy demands of their academic programme of study, several studies report that the proportion of medical students meeting PA recommendations exceeds that of the general population (21, 22, 36, 43). U.S. medical students meeting PA recommendations were more likely to recognize that physician PA levels influence patient PA levels and that they will be able to provide more credible and effective counselling if physically fit (22). Active students have better attitudes (21) and are more likely to report counselling patients on PA (22).
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In the current study, the self-reported PA levels of the medical students was significantly lower than population averages with only 34.8% meeting PA guidelines for aerobic activity. These findings correlate with a similar study at the same medical school in which only 30% of students met WHO PA requirements and were below population cardiorespiratory fitness norms (44). When looking across each year of medical school (GEMP 1 through 4), decreases in PA levels were observed with increasing year in medical school from year 1 to years 3 (38.5% to 23.1%), before a spike in year 4 (41.8%). The decreases observed from the first to the third year are similar to Frank et al. (22) who found that students perceived PA counselling to be more relevant to their intended practices upon entry to medical school compared to their final year. This may be explained by the fact that the latter years of medical school are spent in clinical rotations, often with supervisors who are not trained nor feel competent themselves to provide PA counselling with patients (45).
One explanation for the low levels of self-reported PA observed in the current study may be the medical school environment itself. The medical school environment plays an important role, not only in the instruction of PA content, but in the formation of positive lifestyle habits. Medical students believe that faculty should set a good example by practicing healthy lifestyles themselves and that encouragement from their classmates and medical school faculty members increased the relevance of PA counselling (22). Yet, in the current study, only 21.9% and 26.3% of the medical students felt that the school and their classmates, respectively, encouraged them to be active. While we see a positive increase in these perceptions from the first to the fourth year cohorts, this data suggest that there could be improvements to the environment in valuing and supporting student PA. Beyond changes to curricular content, ensuring that there are sufficient extracurricular opportunities, appropriate facilities (28), and an overall supportive environment all appear to be important factors in the development of positive attitudes (e.g., self-efficacy) and healthy lifestyle habits in medical school students (28, 45).
Strengths & Limitations
There are several limitations with this study. First, there was a significant decline in the medical student response rate between the GEMP 1 and GEMP 2–4 cohorts. This limitation arose from GEMP 1 students being able to complete the survey prior to COVID-19 closures and a decrease of in-person educational activities, where surveys were collected with other cohorts, after resuming classes. Second, this study presents data from a cross-sectional sample of students across four years of medical school. While initial conclusions may be drawn regarding differences between cohorts of students as they progress through medical school, these findings would be strengthened by longitudinally following cohorts of students through their medical school journey. Lastly, this study was conducted at a single medical school limiting its generalizability to medical schools in South Africa. At the same time, these limitations are offset by several strengths. This study is the first to comprehensively examine the PA knowledge, attitudes, and habits of medical students in a medical school in sub-Saharan Africa. Additionally, there have been a limited number of studies that have intentionally compared PA attitudes, knowledge, and preferences of medical students across each of the years of their programme.
Future Recommendations
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Several studies have provided guidance for the training of medical students and health professionals that can be used as a model for increasing PA in medical school curricula (46–49). There are also multiple examples from around the world on how PA can be integrated into medical education programmes that lack content matter expertise or the proper facilities and resources, including broad, health promotion or lifestyle medicine interventions (50), PA-specific curricular interventions (51), and self-directed educational tools (52). Non-curricular strategies may include the formation of cross-disciplinary partnership with other health disciplines (e.g., exercise science/kinesiology programs) to provide expert guidance to PA and exercise topics (45), required rotations in PA laboratories, fitness centres, or ‘hubs’ (53), or having students to teach PA classes to the local community as part of a service-learning experiences (54). Ultimately, for PA to gain a permanent and widespread foothold in medical education, progress must be made towards its inclusion in national licensing examinations (45, 55).
Conclusions
This study, which provides medical student preferences, attitudes, and behaviours at a major medical school in a LMIC, adds to the growing body of literature from around the world supporting the inclusion of PA training in the medical school curriculum. Similarly to numerous studies conducted in higher income countries, our work demonstrates that medical students are interested in receiving PA training and understand its importance in their future work as health professionals, yet feel unprepared to counsel future patients. Our examination of medical students’ attitudes and behaviours across all four years of training provides a unique finding that medical students awareness and perception of PA improves with increasing years in medical school. Our findings also points to the potential importance of the medical school environment, beyond curricular changes, in providing the proper resources and support to encourage medical students to engage in healthy lifestyle habits during their program of study. We hope that our contribution to this work adds greater urgency in the call to action to increase the emphasis on adding PA training to medical school curricula and licensing exams around the world.
List of Abbreviations
GEMP
Graduate Entry Medical Programme
LMICs
low- and middle-income countries
NCDs
non-communicable diseases
PA
physical activity
WHO
World Health Organization
DECLARATIONS
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Acknowledgement
The authors would like to acknowledge Fathima Jeewa, Fathima Jeewa, a medical student who led the data collection process, as well as the University of Witwatersrand Department of Family Medicine for accommodating our data collection efforts during a difficult period of dealing with COVID-19 restrictions.
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Funding
Not applicable.
Author Information
Wolfson Research Institute for Health and Wellbeing, Durham University, Durham, UK; Mark Stoutenberg
Department of Sport and Exercise Sciences, Durham University, Durham, UK; Mark Stoutenberg
Department of Exercise Science and Sports Medicine, School of Therapeutic Sciences, University of the Witwatersrand, Johannesburg, South Africa; Mark Stoutenberg, Georgia Torres
Division of Epidemiology and Biostatistics, Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa; Innocent Maposa
Contributions
MS and GT conceptualized the study and contributed to the study design and methodology. GT conducted participant recruitment and data collection. IM analysed and interpreted the data.
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MS drafted the original manuscript and GT and IM provided critical revisions and contributed to reviewing and editing the final manuscript. All authors read and approved the final version of the manuscript.
Ethics approval and consent to participate
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Medical students were only included in the study if they agreed to participate and provide their written informed consent.
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Ethical approval was provided by the Human Research Ethics Committee (Medical) at the University of Witwatersrand [Ref. M191043] for all study materials and procedures.
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All procedures performed in this study involving human participants were conducted in accordance with the Helsinki Declaration.
Consent for publication
Not applicable.
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Data Availability
The dataset(s) supporting the conclusions of this article is(are) available upon request from the corresponding author.
Competing Interests
Mark Stoutenberg is a paid consultant for the American College of Sports Medicine for his work with the Exercise is Medicine® initiative.
Clinical trial number
Not applicable.
Electronic Supplementary Material
Below is the link to the electronic supplementary material
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Author Contribution
MS and GT conceptualized the study and contributed to the study design and methodology. GT conducted participant recruitment and data collection. IM analysed and interpreted the data. MS drafted the original manuscript and GT and IM provided critical revisions and contributed to reviewing and editing the final manuscript. All authors read and approved the final version of the manuscript.
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Yes
Total words in MS: 5158
Total words in Title: 11
Total words in Abstract: 252
Total Keyword count: 6
Total Images in MS: 0
Total Tables in MS: 6
Total Reference count: 55