Physical activity advice from general practitioners in Germany: Findings from a cross-sectional population survey of individuals with chronic ischemic heart disease (OptiCor study)

Physical activity advice from general practitioners in Germany: Findings from a cross-sectional population survey of individuals with chronic ischemic heart disease (OptiCor study) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Physical activity advice from general practitioners in Germany: Findings from a cross-sectional population survey of individuals with chronic ischemic heart disease (OptiCor study) Sabrina Hoppe, Alicia Prinz, Daniel Kotz, Ute Mons, Oliver Kuß, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6030336/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: The current German treatment guideline for chronic ischemic heart disease (IHD) recommends that general practitioners (GPs) deliver brief advice on physical activity (PA) to IHD patients. Such advice consists of at least three elements (i.e., 3As): (1) assessing the PA level, (2) advising on PA, and (3) assisting with recommendations. This study examined the extent to which individuals with IHD in Germany reported the receipt of such advice. Design: Cross-sectional population-based face-to-face survey (06/2023-08/2024). Setting: Germany. Participants: 1,004 individuals aged 35+ with self-reported IHD and GP contact. Outcome measures: Primary outcome: Self-reported proportions of receipt of GP-delivered PA advice according to the 3As. Main secondary outcome: Associations between person characteristics and the likelihood of receiving PA advice. Results: Among individuals with IHD, 36.4% (95% CI=33.4 to 39.4) received all 3As of PA advice, 42.1% (95% CI=39.1 to 45.2) received one or two elements, 9.9% (95% CI=8.1 to 11.8) received no advice at all, and 3.8% (95% CI=2.7 to 5.1) were advised to avoid PA (7.9% did not remember/refused to answer). Women (vs. men) were more likely to receive no advice (OR=1.74, 95% CI=1.11 to 2.72), while individuals with higher PA levels (OR=0.82, 95% CI=0.75 to 0.90, per hour/week) and those with higher (vs. lower) education were less likely to receive no advice (OR=0.39, 95% CI= 0.20 to 0.76). Individuals living in urban (vs. rural) areas were less likely to receive only one or two (vs. all) of the 3As (OR=0.65, 95% CI=0.46 to 0.88). Of those who received at least one element of advice (n=766), 72.5% reported they were more active afterwards, with a higher proportion when all 3As (vs. only some elements) were provided (86.8% vs. 59.6%). Conclusions: Only one-third of individuals with IHD in Germany received comprehensive PA advice. Specific person characteristics, such as female gender and lower education, were associated with lower proportions of received PA advice. Efforts are needed to improve GP-led PA guidance, particularly for underserved groups. Trial registration: German Clinical Trials Register (DRKS00031304) Chronic ischemic heart disease coronary heart disease physical activity primary care brief intervention brief advice Figures Figure 1 Figure 2 Strengths and limitations of this study A key strength of this study is that it represents the first nationwide population-based survey focussing on individuals with IHD and their receipt of GP-delivered PA advice, offering valuable insights into the implementation of clinical guideline recommendations. Data were collected from a large sample (1,000 individuals with IHD), with participants selected using a combination of random probability sampling (50%) and quota sampling (50%), and face-to-face data collection was employed to maximise representativeness. The IHD diagnosis was self-reported, which may not fully reflect a clinical diagnosis. Assessing whether individuals had ever received GP advice on PA is complex and may introduce recall bias. However, we sought to account for potential recall bias by adjusting for the ‘years since the last IHD event or diagnosis’ in a sensitivity analysis. Due to an opt-in question, the proportion of individuals with IHD in our study was somewhat lower than estimates from another national population survey, and individuals with lower education and income were overrepresented among non-responders. INTRODUCTION BACKGROUND Regular physical activity (PA) is an effective measure in the management of prevalent chronic ischemic heart disease (IHD) ( 1 , 2 ), as it reduces the risks of cardiovascular mortality, recurrent cardiac events as well as hospitalisation, and can improve the quality of life in individuals with IHD ( 2 ). However, only about 21% of the affected population in Germany is sufficiently physically active, when applying the current World Health Organization (WHO) recommendations on PA ( 3 ). About half of the population with IHD is physically inactive ( 4 ) and the same is true for the general population in Germany ( 5 ). IHD is one of the most commonly treated diseases in general practice ( 6 ). General practitioners (GPs) are well placed to offer advice on PA as they regularly see their patients with IHD ( 6 ), including elderly individuals who have a higher probability of being diagnosed with IHD ( 7 ) and more socially isolated and disadvantaged groups ( 8 ). GPs are also a trusted source of health information from the patients’ perspective ( 6 , 9 ). The German IHD treatment guideline recommends GPs and other health professionals (HPs) to offer advice on and support with PA to their patients with IHD ( 10 ). Previous systematic reviews suggest GP advice can effectively increase patients’ PA level ( 11 – 14 ) (with a number needed to treat of 12 (95% confidence interval (CI): 7 to 33) for long-term behaviour change ( 13 )). However, a recent meta-analysis ( 15 ) found no clear effect, potentially due to the inclusion of heterogeneous counselling approaches, including different modes of delivery, different number of follow-up contacts, and time-intensive motivational interviewing. While the German IHD guideline advocate motivational interviewing for advising on health behaviour, the UK’s NICE guideline recommends brief advice (or brief intervention), including “advice, discussion, negotiation or encouragement, with/without written or other support or follow-up” ( 16 ). A recent systematic review showed brief advice, as defined by NICE and delivered in healthcare settings, effectively increases self-reported and measured PA for at least six months ( 17 ). The WHO also endorses brief advice as a cost-effective intervention for managing and preventing noncommunicable diseases ( 18 ). The 3As approach (Ask/Assess: assessing the PA level, Advise: advising on PA, Assist: assisting with recommendations to increase PA) is a quick method for providing PA advice, commonly used for smoking cessation, but adaptable for PA ( 19 ). This approach, taking only a few minutes, is easier to integrate into routine primary care than longer interventions and focuses on tailored support based on patient's preferences, activity level, goals, and barriers ( 6 ). Population survey evidence shows delivering all 3As is more effective for behaviour change than providing single elements ( 20 ), with the Assist step seeming particularly associated with positive outcomes ( 21 ). However, international data show all elements are rarely implemented together, and GP consultations often focus only on Ask/Assess ( 20 , 21 ). German studies not focussing on individuals with IHD suggest that the implementation of GP advice on PA is insufficient ( 9 , 22 – 24 ). There is also little representative national data on how GP advice on PA is delivered to IHD patients or whether individual characteristics (e.g., age, gender, body mass index (BMI), or PA level) influence its receipt. Although the NICE guideline ( 16 ) advise against relying on visual cues like body weight for identifying patients to counsel, such factors may still influence GPs’ decisions in practice. Understanding the prevalence of and factors associated with GP-delivered PA advice could identify treatment gaps in primary care for individuals with IHD in Germany. STUDY AIM AND RESEARCH QUESTIONS This study aims to determine the proportion of individuals aged 35 + years in Germany with self-report IHD who report the receipt of GP advice on PA since their most recent IHD event or diagnosis. Our research questions are: What proportion of individuals report having received the 3As of GP-delivered PA advice, overall and by socio-demographic, socio-economic, and health-related characteristics of affected individuals (age, gender, education, income, urbanisation, migration background, BMI, PA level)? To what extent are these person characteristics associated with receiving no advice on PA vs. all 3As, or one/two elements of 3As vs. all 3As? Among those who report having received at least one 3As element, what proportion report being more or more regular physically active afterwards, stratified by the specific elements received? METHODS This study report is written in accordance with the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) Statement ( 25 ). STUDY DESIGN AND SETTING Data were collected using a cross-sectional population-based household survey of the German population. By means of computer-assisted personal interviews (CAPI), data has been collected between June 2023 and August 2024 from individuals aged 35 + living in private households (rented or owned) across Germany. The fieldwork was conducted as an omnibus survey by the market research institute ‘Oracle Life Science’. The study has been pre-registered at the German Clinical Trials Register ( https://www.drks.de/DRKS00031304 ). The study protocol including an analysis plan was developed together with a statistician (OK) and published prior to the analyses on the Open Science Framework (OSF): https://osf.io/7adf2 . The study questionnaire was developed in the multidisciplinary study team (with backgrounds in public health, psychology, sociology, epidemiology, and a GP) and pretested with voluntary IHD patients in a GP setting (n = 4, unintentionally only men, all aged 65 + years) and subsequently adapted. The questionnaire was published on OSF in the original German version and translated into English: https://osf.io/kvfnb . STUDY POPULATION Study participants were selected using a dual-frame design: a random probability sample (50%) and a quota sample (50%). Data were collected over nine survey waves, reaching approximately 1,800 individuals aged 35 + years per wave (N = 16,576). As the probability of IHD increases with age ( 7 ), individuals under the age of 35 were not included, while no upper age limit was set. About 80% of the individuals aged 35+ (n = 12,827) opted in to answer questions about heart health and PA, as required by our ethics committee. Self-reported IHD was identified using four established, plain-language questions on IHD-related events/interventions, commonly used in national health surveys (e.g., ( 7 ), see Supplementary table 1 ), resulting in a sample of n = 1,139. The final study population included participants aged 35 + with self-reported IHD who also reported at least one GP visit after their most recent IHD-related event (n = 1,004). OUTCOME MEASURES GP advice on PA (research question 1 and 2): Participants of the final study sample were asked two questions about the receipt of the GP-delivered PA advice according to the 3As (see Supplementary Table 1 ). For further analysis, we categorised the response patterns into: ‘Receipt of all three elements (Ask/Assess, Advise, Assist)’ [question 1: option b AND question 2: option a], ‘Receipt of one or two elements (only Ask/Assess or Advise, Ask/Assess and Advise, or Advise and Assist)’ [question 1: option a] OR [question 1: option b AND question 2: option b OR c OR d] OR [question 1: option c AND question 2: option a OR b OR c OR d]), ‘No PA advice received’ [question 1: options e OR f], and ‘Advised to avoid PA’ [question 1: option d]. ‘Unable to remember/refused to answer’ [question 1: option g] OR [question 1: option h] PA behaviour after the receipt of PA advice (research question 3): Individuals with IHD who reported receiving at least one element (categories A or B) were asked whether these conversations led to increased or more regular PA (see Supplementary Table 1 ). Responses were categorised as “more regularly active” (options a or b) or “not more active” (option c). EXPOSURE VARIABLES The following sociodemographic characteristics were used: Gender : female/male; age : as a continuous variable for regression analyses and in categories of 35–54/55–74/75 + years for descriptive analyses; level of education : low (no graduation or 9 years of education)/middle (≥ 10years)/high (≥ 12 years); monthly net household income per person in the household: as a continuous variable for regression analyses and in categories for descriptive analyses: low ( 80th income percentile income). These categories reflect the distribution of income in Germany ( 26 – 28 ). The calculation was based on an equalisation technique provided by the Organisation for Economic Cooperation and Development (OECD-modified equivalence scale) ( 29 ), adjusting total net household income (after tax and other deductions) for household size and composition. Migration background : yes/no. Applied if at least one parent of the study participant was not born in Germany. Degree of urbanisation : assessed by using the administrative municipality district size [“politische Gemeindegrößenklassen”] based on the population size consisting of seven categories which were summarised into three categories: rural ( 500,000 residents). BMI : as a continuous variable for regression analyses in categories for descriptive analyses: underweight (BMI < 18.5)/normal weight (BMI 18.5–24.9)/overweight (BMI 25.0-29.9)/obesity (BMI ≥ 30.0) ( 30 ). Calculation was based on weight (in kilograms) and height (in meters squared) of the target population using the formula weight in kg / height in m^2 ( 30 ). Self-reported PA level in minutes/week : assessed by a modified version of a single-item question of Milton et al. ( 31 ). The question does not involve intensity or muscle strength, and PA at work or housework is excluded. In approximation to the current WHO recommendation on weekly PA levels for adults with and without chronic conditions (75–300 minutes/week of intense PA or 150–300 minutes/week of moderate PA) ( 3 ), weekly PA level was categorised for descriptive analyses into 0/1–74/75–149/150–299/ ≥300 minutes/week. For regression analyses, PA level was converted into hours/week and used as a continuous variable. Years since the most recent IHD-related event or diagnosis : as a continuous variable for regression analyses (sensitivity analyses). Individuals were asked about the timing of their last event or diagnosis, and this information was used to calculate the variable. STATISTICAL ANALYSIS Analyses were performed with IBM SPSS Statistics for Windows, V.29.0 ( 32 ). Data were analysed and reported unweighted. To address research question 1 , we report proportions of individuals with IHD aged 35 + who report the receipt of GP advice on PA according to the 3As (categories A: all 3 As, B: one or two elements, C: no advice) overall and by person characteristics. Individuals who fell into categories D and E (did not remember/refused to answer) were excluded. Since particularly the third element Assist seems to be associated with behavioural change ( 21 ) the proportion of those who received Assist is presented separately for the total sample. Data are presented as absolute and relative frequencies with 95%CIs. To address research question 2 , we used univariate multinomial logistic regression models to analyse the associations between individual person characteristics (exposure variables: e.g., sex, BMI) and the receipt of the 3As (outcome variable) with the three categories: Receipt of no elements (category C) vs. receipt of all 3As (category A) [reference] and receipt of one or two elements (category B) vs. receipt of all 3As (category A) [reference]. Individuals who fell into categories D and E (did not remember/refused to answer) were excluded. To explore a potential influence of recall bias, we fitted analogous multinomial logistic regression models, however, adjusted for the ‘years since the last IHD event or diagnosis’ as a sensitivity analysis. To address research question 3 , we report proportions of individuals with IHD who reported being more active (temporarily or permanently) following GP advice; overall and stratified by received elements (one or two elements vs. all 3As). Data is presented as absolute and relative frequencies with 95%CIs. DEALING WITH MISSING DATA AND NON-RESPONSE A total of 22.6% (n = 3,749) of the market research survey participants beforehand decided to opt-out and not answering study questions on heart health and PA. By means of a non-response analysis, we compared distributions of person characteristics of responders and non-responders. Missing data on dependent and independent variables in responders were sparse: household income: 0.2%, migration background: 1.3%, BMI: 4.2%, PA level: 4.8%. We assumed that excluding cases with missing data would not have relevant effects on our results, and used complete cases for the final analysis. PATIENT AND PUBLIC INVOLVEMENT STATEMENT As described above, the study questionnaire was pretested with individuals with IHD. Their feedback was accommodated in the questionnaire design. Beyond this, patients or the public were not involved in the design, conduction, reporting, or dissemination plans of this research. RESULTS The final sample consisted of 1,004 individuals aged 35 + years with self-reported IHD, and a GP contact since the most recent IHD-related event or diagnosis. Sample characteristics are presented in Table 1 . The mean age of this group was 70.0 years (Standard derivation (SD) = 11), and 37.7% of the sample (n = 379) were female. Table 1 Characteristics of all individuals aged 35 + with self-reported IHD and at least one GP contact since the last remembered IHD-related event or diagnosis (N = 1,004) % (n) Total sample 100 (1,004) Gender Male Female 62.3 (625) 37.7 (379) Diverse 0.0 (0) Age group 35–54 years old 8.2 (82) 55–74 years old 53.1 (533) 75 + years old 38.7 (389) Educational qualification 1 Low 42.4 (426) Medium 33.5 (336) High 24.1 (242) Household income 2 Low 9.6 (96) Medium 67.9 (682) High 22.3 (242) Migration background No 88.5 (877) Yes 11.5 (114) Degree of urbanisation 3 Rural 31.5 (316) Urban 49.1 (493) Metropolitan 19.4 (195) BMI category 4 Underweight 0.7 ( 7 ) Normal weight 32.2 (323) Overweight 43.4 (436) Obese 19.5 (196) PA level category (minutes/week) 5 0 20.8 (209) 1–74 11.0 (110) 75–149 12.2 (122) 150–299 18.1 (182) 300+ 33.2 (333) IHD, chronic ischemic heart disease; GP, general practitioner; BMI, body mass index; PA, physical activity. Data are presented as column percentages (number). Variables with missing data: household income: 0.2%, migration background: 1.3%, body mass index: 4.2%, physical activity level: 4.8% 1 German educational qualification levels: low (9 years of education, or no graduation), medium (10 years of education), high (≥ 12 years of education). 2 Monthly net household income per individual in the household, based on the Organisation for Economic Co-operation and Development (OECD)-modified equivalence scale ( 30 ). The variable was categorised into three levels: low ( 80th income percentile), approx. describing the income distribution in the German population ( 26 – 28 ). 3 The variable was assessed by using the administrative municipality district size (“politische Gemeindegrößenklassen”), consisting of seven categories which were summarised into three categories: rural ( 500,000 residents). 4 BMI based on weight (in kilograms) and height (in meters squared) of the target population using the formula weight (in kg)/height^2 (in m^2) ( 30 ). The variable was categorised into four categories: underweight (BMI < 18.5), normal weight (BMI 18.0-24.9), overweight (BMI 25.0-29.9), obese (BMI ≥ 30.0). 5 The level of PA is based on the WHO recommendations for adults and adults with chronic conditions (75–300 minutes/week of intense PA or 150–300 minutes/week of moderate PA) ( 3 ), although for pragmatic reasons there was no assessment of intensity. Supplementary Table 2 shows the basic characteristics of the total sample of all respondents aged 35+ (N = 16,576) stratified by non-responders (n = 3,749; 22.6%) and responders (n = 12,827; 77.4%). Proportions of individuals with low educational qualification, low household income, and of individuals living in a rural area were higher, while proportions of individuals with a migration background were lower in the group of non-responders. No relevant differences in gender and age were found. RESEARCH QUESTION 1: GP ADVICE ON PA Among individuals aged 35 + with self-reported IHD, 36.4% (95% CI: 33.4 to 39.4) reported the receipt of all 3As, 42.1% (95% CI: 39.1 to 45.2) reported the receipt of one or two elements, and 9.9% (95% CI: 8.1 to 11.8) reported receiving no advice since their most recent IHD-related event or diagnosis. 3.8% (95%CI: 2.7 to 5.1) reported the advice to avoid PA (see Fig. 1 ), and 7.9% (95% CI: 6.3 to 9.7) could not remember or refused to answer. Among individuals who reported the receipt of at least one 3As element (n = 788), 53.3% (95% CI = 49.8 to 56.8, n = 420) reported the receipt of Assist. Proportions of receipt of GP advice stratified by person characteristics are presented in Table 2 . Men (vs. women), individuals with a migration background (vs. no), those living in an urban (vs. rural or metropolitan) region, with overweight or obesity (vs. normal weight), or who were ≥ 75 minutes/week (vs. 0 minutes or < 75 minutes/week) physically active relatively more often reported the receipt of all 3As. Table 2 Prevalence estimates on categories of self-reported receipt of GP advice on PA, based on de 3As method among the subsample of individuals with self-reported IHD and at least one GP contact since the last remembered IHD-related event or diagnosis, stratified by person characteristics (N = 887) No advice N = 99, % (n, 95% CI) One or two elements N = 423, % (n, 95% CI) All three elements N = 365, % (n, 95% CI) Gender Male 9.2 (52, 7.0 to 11.8) 48.3 (273, 44.2 to 52.4) 42.5 (240, 38.4 to 46.6) Female 14.6 (47, 11.1 to 18.8) 46.6 (150, 41.2 to 52.0) 38.8 (125, 33.6 to 44.2) Age group 35–54 years old 17.4 (12, 9.9 to 27.6) 42.0 (29, 30.9 to 53.8) 40.6 (28, 29.6 to 52.4) 55–74 years old 8.4 (41, 6.2 to 11.1) 49.3 (240, 44.9 to 53.7) 42.3 (206, 38.0 to 46.7) 75 + years old 13.9 (46, 10.5 to 17.9) 46.5 (154, 41.2 to 51.9) 39.6 (131, 34.4 to 44.9) Educational qualification 1 Low 14.9 (54, 11.5 to 18.9) 44.8 (162, 39.7 to 49.9) 40.3 (146, 35.4 to 45.4) Medium 10.4 (32, 7.4 to 14.2) 47.6 (146, 42.0 to 53.1) 42.0 (129, 36.6 to 47.6) High 6.0 (13, 3.4 to 9.7) 52.8 (115, 46.1 to 59.3) 41.3 (90, 34.9 to 47.9) Household income 2 Low 5.1 (4, 1.7 to 11.6) 54.4 (43, 43.5 to 65.1) 40.5 (32, 30.2 to 51.5) Medium 12.5 (76, 10.1 to 15.3) 45.6 (277, 41.7 to 49.6) 41.8 (254, 38.0 to 45.8) High 9.5 (19, 6.0 to 14.2) 50.8 (101, 43.8 to 57.6) 39.7 (79, 33.1 to 46.6) Migration background No 11.6 (90, 9.5 to 14.0) 47.7 (371, 44.2 to 51.2) 40.7 (317, 35.3 to 54.8) Yes 8.2 (8, 3.9 to 14.8) 46.9 (46, 37.3 to 56.8) 44.9 (44, 35.3 to 54.8) Degree of urbanisation 3 Rural 10.9 (29, 7.6 to 15.0) 53.6 (143, 47.6) 35.6 (95, 30.0 to 41.5) Urban 10.7 (47, 8.1 to 13.8) 43.6 (192, 39.1 to 48.3) 45.7 (201, 41.1 to 50.4) Metropolitan 12.8 (23, 8.5 to 18.2) 48.9 (88, 41.7 to 56.2) 38.3 (69, 31.5 to 45.6) BMI category 4 Underweight 16.7 (1, 1.9 to 55.8) 83.3 (5, 44.2 to 98.1) 0.0 (0) Normal weight 13.8 (40, 10.2 to 18.1) 47.9 (139, 42.2 to 53.7) 38.3 (111, 32.8 to 44.0) Overweight 9.6 (37, 7.0 to 12.8) 45.3 (175, 40.4 to 50.3) 45.1 (174, 40.2 to 50.1) Obese 9.5 (16, 5.7 to 14.6) 49.1 (83, 41.6 to 56.6) 41.4 (70, 34.2 to 48.9) PA level category (minutes/week) 5 0 27.7 (43, 21.2 to 35.2) 47.1 (73, 39.4 to 54.9) 25.2 (39, 18.8 to 32.4) 1–74 8.9 (9, 4.5 to 15.6) 53.5 (54, 43.8 to 63.0) 37.6 (38, 28.6 to 47.3) 75–149 7.0 (8, 3.4 to 12.8) 43.9 (50, 35.0 to 53.0) 49.1 (56, 40.1 to 58.2) 150–299 7.1 (12, 4.0 to 11.8) 43.5 (73, 36.1 to 51.0) 49.4 (83, 41.9 to 56.9) 300+ 6.1 (19, 3.8 to 9.1) 49.5 (155, 44.0 to 55.0) 44.4 (139, 39.0 to 49.9) IHD, chronic ischemic heart disease; GP, general practitioner; BMI, body mass index; PA, physical activity. Data are presented as row percentages (number). Variables with missing data (total sample): household income: 0.2%, migration background: 1.3%, body mass index: 4.2%, physical activity level: 4.8% 1 German educational qualification levels: low (9 years of education, or no graduation), medium (10 years of education), high (≥ 12 years of education). 2 Monthly net household income per individual in the household, based on the Organisation for Economic Co-operation and Development (OECD)-modified equivalence scale ( 29 ). The variable was categorised into three levels: low ( 80th income percentile), approx. describing the income distribution in the German population ( 26 – 28 ). 3 The variable was assessed by using the administrative municipality district size (“politische Gemeindegrößenklassen”), consisting of seven categories which were summarised into three categories: rural ( 500,000 residents). 4 BMI based on weight (in kilograms) and height (in meters squared) of the target population using the formula weight (in kg)/height^2 (in m^2) ( 30 ). The variable was categorised into four categories: underweight (BMI < 18.5), normal weight (BMI 18.0-24.9), overweight (BMI 25.0-29.9), obesity (BMI ≥ 30.0). 5 The level of PA is based on the WHO recommendations for adults and adults with chronic conditions (75–300 minutes/week of intense PA or 150–300 minutes/week of moderate PA) ( 3 ), although for pragmatic reasons there is no categorisation according to intensity. Women (vs. men), younger individuals (35–54 years) and older individuals (75 + years; vs. middle aged (55–74 years)), individuals with a low or medium (vs. high) level of education, a medium and high (vs. low) net household income, individuals with normal weight (BMI 18.0-24.9; compared with overweight (BMI 25.0-29.9), and obesity (BMI ≥ 30.0)), and individuals who are physically inactive (vs. being physically active) relatively more often reported receiving no GP advice on PA at all. RESEARCH QUESTION 2: ASSOCIATIONS BETWEEN PERSON CHARACTERISTICS AND THE RECEIPT OF PA ADVICE Results of the multinomial logistic regression analyses are presented in Table 3 . Table 3 Results of a multinomial logistic regression analysis: Associations between the receipt of GP advice on PA (no advice/ one or two elements/ three elements [reference]) and person characteristics (n = 788) (unweighted) OR (95% CI) No advice vs. all three elements One or two elements vs. all three elements Gender Male (reference) 1 1 Female 1.74 (1.11 to 2.72) 1.06 (0.79 to 1.42) Age in years 1.01 (0.99 to 1.04) 1.0 (0.99 to 1.01) Educational qualification 1 Low (ref.) 1 1 Medium 0.67 (0.41 to 1.10) 1.02 (0.74 to 1.41) High 0.39 (0.20 to 0.76) 1.15 (0.81 to 1.64) Household income 2 0.86 (0.65 to 1.13) 1.04 (0.88 to 1.23) Migration background No (ref.) 1 1 Yes 1.56 (0.71 to 3.44) 1.12 (0.72 to 1.74) Degree of urbanisation 3 Rural (ref.) 1 1 Urban 0.77 (0.45 to 1.29) 0.65 (0.46 to 0.88) Metropolitan 1.09 (0.58 to 2.05) 0.85 (0.56 to 1.27) BMI 4 0.95 (0.91 to 1.00) 0.98 (0.96 to 1.01) PA level (hours/week) 0.82 (0.75 to 0.90) 0.99 (0.97 to 1.02) IHD, chronic ischemic heart disease; GP, general practitioner; BMI, body mass index; PA, physical activity. Unadjusted analyses. Data are presented as odds ratios (ORs) together with a 95% confidence interval (95% CI). Age, household income, BMI and PA level were treated as continuous variables for regression analyses. 1 German educational qualification levels: low (9 years of education, or no graduation), medium (10 years of education), high (≥ 12 years of education). 2 Monthly net household income per individual in the household, based on the Organisation for Economic Co-operation and Development (OECD)-modified equivalence scale ( 29 ). 3 The variable was assessed by using the administrative municipality district size (“politische Gemeindegrößenklassen”), consisting of seven categories which were summarised into three categories: rural ( 500,000 residents). 4 BMI based on weight (in kilograms) and height (in meters squared) of the target population using the formula weight (in kg)/ height^2 (in m^2) ( 30 ). Compared to the receipt of all elements of the 3As, female gender was associated with higher odds of reporting no GP advice received (OR = 1.74, 95% CI = 1.11 to 2.72). A higher (vs. lower) educational qualification (OR = 0.39, 95% CI = 0.20 to 0.76) and a higher PA level (OR = 0.82, 95% CI = 0.75 to 0.90, per hour/week) were associated with lower odds of reporting no advice received. No relevant associations were found with age, income, migration background, degree of urbanisation and BMI in this regard. Compared to the receipt of all elements of the 3As, individuals living in an urban (vs. rural) region had lower odds of receiving only one or two elements of the 3As (OR = 0.65, 95% CI = 0.46–0.88%). For gender, age, level of education, income, migration background, BMI and PA level, no clear associations with the receipt of one or two elements were observed. The results of the sensitivity analysis (see Supplementary table 3 ) indicate that the associations become smaller after adjustment for the time between our survey and the most recent IHD-related event or diagnosis. However, the directions of the associations remain largely unchanged. RESEARCH QUESTION 3: PA LEVEL AFTER THE RECEIPT OF AT LEAST ONE ELEMENT OF PA ADVICE Among individuals who reported the receipt of at least one element of GP (n = 766), a total of 72.5% (n = 555) said that they were more active following the advice. The proportions in individuals who reported the receipt of all 3As were even higher (n = 315 (86.8%; 95% CI = 83.0 to 90.0)) compared to those who reported the receipt of one or two elements (n = 240 (59.6%; 95% CI = 54.7 to 64.3)) (see Fig. 2 ). DISCUSSION In our cross-sectional study of the German population among individuals aged 35 + with IHD, around 36% reported the receipt of all 3As elements of GP advice on PA (Ask/Assess, Advise, Assist). About 42% reported the receipt of one or two elements, and around 10% received no advice at all. Our findings also suggest, that women (vs. men), individuals with a lower (vs. higher) educational qualification, individuals living in a rural (vs. urban) area, and individuals who are less physically active seem to have a lower probability of receiving advice on PA including all 3As. This is the first nationwide study focussing on individuals with IHD and their receipt of GP-led PA advice, providing insights into the implementation of clinical guideline recommendations on the delivery of relevant elements of advising on PA. The few existing previous German studies did not focus on individuals with IHD. For example, one cross-sectional survey in GP practices of patients aged 70 + in Rhineland–Palatinate reported that approximately 48% received GP advice on PA, with 39% that received Assist ( 9 ). An analysis of time trends from two representative cross-sectional surveys of the general population in Germany found that between 2008 and 2011, less than 9% of individuals younger than 65 years received GP advice on PA within the last 12 month ( 22 ). A cross-sectional study of adults aged 18 + revealed that about one-third received GP advice on PA within a year ( 23 ). In our study, over 80% of respondents received at least one element of the 3As of GP advice on PA, which seems encouraging. However, several studies suggest that all elements combined, but especially Assist (concrete recommendation on increasing PA) seem to be decisive to health behaviour change ( 20 , 21 ). Our findings suggest that individuals with IHD receive PA advice more frequently than other groups in Germany. This aligns with a previous cross-sectional survey in GP practices from 2011 showing that individuals with (vs. without) IHD aged 65 + in Germany had 1.93 higher odds (unadjusted, 95% CI = 1.53 to 2.43) of reporting GP advice on PA within a year ( 24 ). One explanation could be that individuals with IHD more often visit their GP regularly (e.g., in disease management programmes). However, it remains unclear how GP advice was defined and which elements were included in the respective studies. Although women with IHD are generally less physically active than men ( 4 ), our findings revealed that women had higher odds of reporting PA was not discussed with them or at least not comprehensively. This aligns with national and international studies, showing that women – irrespective of age or chronic conditions – tend to receive less GP advice not only on PA ( 22 , 24 , 33 ) but also on other health behaviours like hazardous alcohol consumption ( 34 ) and smoking ( 35 ). Although exact reasons for this disparity warrant further investigation, one speculation on our side for this could be that women may feel ashamed or are afraid of being stigmatised for admitting a lack of PA to their GP. Another explanation could be that men generally have riskier health behaviour and are less likely to use preventive services ( 36 ), regardless of any medical condition. This could result in GPs being more likely to see the need to advise men. The results of our study suggest that individuals who are overweight or obese (vs. normal weight) are more likely to receive GP advice. One explanation for this could be that visual cues play a role in the delivery of advice. Individuals of normal weight may have the stigma of already being physically active or not needing PA, regardless of whether they actually engage in sufficient PA. Our study found that individuals with higher educational qualifications were less likely to receive no PA advice than those with lower qualifications, perhaps also due to societal norms or stigmatisation tendencies. Our findings contrasts with a previous German study from the year 2011 that observed no differences based on educational attainment ( 24 ). However, one reason could be that this study differs methodologically from our study. In terms of degree of urbanisation, urban (vs. rural) residents were less likely to report receiving only one or two elements (vs. all 3As). However, relative frequencies suggest that urban residents were more likely to report receiving all 3As (approximately 46%) compared to rural residents (around 36%). These findings align with other studies ( 22 , 37 , 38 ), suggesting that rural areas face challenges like limited exercise opportunities ( 22 ) and weaker networks with cardiovascular prevention services ( 38 ). Although less active individuals would theoretically have a greater need for GP advice on PA, our findings indicate that the odds of reporting no advice decrease as PA levels increase. Analyses of relative frequencies reveal that inactive individuals are more likely to report no advice (approximately 27%) compared to those who are at least somewhat active (less than 9%). One possible explanation is that active individuals may be more receptive to GP advice on PA and, therefore also more likely to recall such interventions. Another possibility is that inactive individuals may have received advice in the past and subsequently became more active as a consequence. Another explanation could be that GPs may avoid advising patients with severe impairments (e.g., comorbidities, mobility impairments), who are less physically active or not active at all. Due to the cross-sectional design, we cannot determine the direction of this association. As an additional result, our study found that over 70% of individuals with IHD who reported receiving at least one element of the 3As engaged in PA following their GP’s advice. This proportion was even higher among individuals who reported receiving all the 3As (86%). Similarly, a German study found that 85% of individuals aged 70 + reported that they had tried PA offers recommended by their GP ( 24 ). These findings align with other studies showing a positive association between GP advice and subsequent PA engagement ( 6 , 17 , 39 ). STRENGTH AND LIMITATIONS A key strength of this study is that it represents the first nationwide population-based survey focussing on individuals with IHD and their receipt of GP-delivered PA advice, offering valuable insights into the implementation of clinical guideline recommendations. A second strength is that data were collected from a large sample (> 1,000 individuals with IHD), with participants selected using a combination of random probability sampling (50%) and quota sampling (50%), and face-to-face data collection was employed to maximise representativeness. Our study has also several limitations. First, the IHD diagnosis was self-reported which may not fully align with clinical diagnoses, though, we used an established instrument also employed in large national health surveys (e.g., ( 7 )). Second, recall bias is a concern, as participants may not accurately remember receiving GP advice. However, we conducted a sensitivity analysis based on timing of the most recent IHD event or diagnosis, which showed little impact on the associations, although recall bias could still be present. Third, the proportion of individuals with IHD in our study was about 6%, lower than the 9% estimate from another national survey ( 7 ), possibly due to our opt-in question. Additionally, individuals with lower education and income, linked to higher IHD prevalence ( 40 ), were overrepresented among non-responders to the opt-in question, which may have influenced the proportion of IHD cases in our study. Our focus, however, was on the prevalence of GP advice on PA in individuals with IHD and its associations with individual characteristics, not on IHD prevalence. Fourth, the complexity of our main study outcome question could have led to comprehension difficulties, though the CAPI survey allowed interviewers to assist. Fifth, some person- and health-related characteristics (e.g., BMI and PA levels) were collected at the time of the survey, but may have changed since the last GP visit. Finally, the findings on BMI and PA levels following GP advice do not allow conclusions about causality, though they are consistent with other studies showing positive effects of brief interventions on PA ( 6 , 17 ), or other health behaviours such as smoking cessation ( 41 ). IMPLICATIONS Currently, only about one-third of individuals with IHD receive comprehensive PA advice including all three elements (Ask, Advise, Assist) that could support them to change their health behaviour ( 20 , 21 ). While this is an acceptable proportion, the PA-related guideline recommendation could be implemented more frequently in the care of individuals with IHD. A major barrier seems to be insufficient training for GPs in providing PA advice ( 42 – 45 ). To address this, international guidelines recommend training for HPs ( 16 , 46 ) to promote understanding of PA as a preventive measure in primary care, provide practical PA recommendations (e.g., local sports programs), and raise awareness of at-risk groups ( 16 ). However, in Germany such training is not adequately integrated into the medical curriculum and continuing medical education. To bridge this gap, training in brief PA counselling should be anchored in the medical curriculum, and tailored educational trainings for GPs should be developed and implemented. CONCLUSION Our results indicate that GP advice on PA in Germany is not sufficiently implemented in line with the clinical guideline recommendations on the treatment of individuals with IHD. Only one in three received all 3As, which appears critical for facilitating health behaviour change. Moreover, women, individuals with lower educational qualifications, those in rural areas, and physically inactive individuals are even less likely to receive PA advice. To enhance PA advice delivery in primary care, incorporating brief PA counselling knowledge and skills into medical curricula and developing tailored educational trainings for GPs, as well as for other HPs, could be effective strategies to consider. Declarations ACKNOWLEDGEMENTS We would like to thank Constanze Cholmakow-Bodechtel and Marvin Kraemer from the market research institute ‘Oracle Life Science’ for data collection. CONTRIBUTORS SH drafted the analysis protocol and the manuscript, and analysed and interpreted the data. SK conceived the study, acquired funding, co-wrote the manuscript, and supervised all preparatory work and the analyses. AP, DK, UM, OK, and RK provided advice on the study protocol and critically revised the analysis protocol and the manuscript. OK also advised on the statistical analysis. All named authors contributed substantially to the manuscript and agreed on its final version. FUNDING The cross-sectional population survey is part of the OptiCor study (https://www.opticor-study.info/). The OptiCor study has been funded as a junior research group in health services research by the German Ministry of Education and Research (BMBF) (funding period: 05/2022-04/2027, grant number: 01GY2103). COMPETING INTERESTS The authors have no competing interests to declare. PATIENT AND PUBLIC INVOLVEMENT The study questionnaire was pretested with individuals with IHD. Beyond this, patients or the public were not further involved in the design, or conduct, or reporting, or dissemination plans of this research. PATIENT CONSENT FOR PUBLICATION Not applicable. ETHICS APPROVAL This study involves human participants and was approved by the ethics committee of the Medical Faculty of the Heinrich-Heine-University Duesseldorf, Germany (2023-2321). Participants gave informed consent to participate in the study before taking part. DATA SHARING STATEMENT The data underlying this study are third-party data and are available to researchers on reasonable request from the corresponding author ( [email protected] ). All proposals requesting data access will need to specify how it is planned to use the data, and all proposals will need approval of the study team before data release. ORCID IDs Sabrina Hoppe https://orcid.org/0009-0002-1429-3978 Alicia Prinz https://orcid.org/0009-0008-8159-7414 Daniel Kotz https://orcid.org/0000-0002-9454-023X Ute Mons https://orcid.org/0000-0003-1764-6783 Oliver Kuß https://orcid.org/0000-0003-3301-5869 Rik Crutzen https://orcid.org/0000-0002-3731-6610 Sabrina Kastaun https://orcid.org/0000-0002-5590-1135 References European Heart Network Physical activity policies for cardiovascular health [Internet]. Brussels: European Heart Network; 2019 [cited 2024 Aug 17]. 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Syst Reviews 12(1):104 Green A, Engstrom C, Friis P (2018) Exercise: an essential evidence-based medicine. Med J Aust 208(6):242–243 Lambe B, Collins C (2010) A qualitative study of lifestyle counselling in general practice in Ireland. Fam Pract 27(2):219–223 Silva CS, Godinho C, Encantado J, Rodrigues B, Carraça EV, Teixeira PJ et al (2023) Implementation determinants of physical activity interventions in primary health care settings using the TICD framework: a systematic review. BMC Health Serv Res 23(1):1082 World Health Organization. Global action plan on physical activity 2018–2030: more active people for a healthier world [Internet]. Geneva: World health Organization (2018) [cited 2024 Aug 17]. Available from: https://iris.who.int/bitstream/handle/10665/272722/9789241514187-eng.pdf?sequence=1. Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryTable1.pdf Supplementary Table 1. Measures of assessing self-reported IHD, the receipt of GP advice on PA, and PA behaviour after received GP advice SupplementaryTable2.pdf Supplementary Table 2. Sample characteristics of the full sample of people aged 35+ years SupplementaryTable3.pdf Supplementary table 3. Results of a multinomial logistic regression analysis, adjusted by years since the last remembered IHD-related event or diagnosis Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Kastaun","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-5590-1135","institution":"Institute of General Practice (ifam), Patient-Physician-Communication Research Unit, Centre for Health and Society (chs), Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Germany","correspondingAuthor":true,"prefix":"","firstName":"Sabrina","middleName":"","lastName":"Kastaun","suffix":""}],"badges":[],"createdAt":"2025-02-14 11:45:35","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-6030336/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6030336/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":76583132,"identity":"70484747-0ac5-4250-9cd3-082115359186","added_by":"auto","created_at":"2025-02-18 15:13:57","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":39105,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"FIGURE1PrevalenceestimatesonthevariouslevelsofGPadvice.png","url":"https://assets-eu.researchsquare.com/files/rs-6030336/v1/057a84d82a076f3cfc2e1f3b.png"},{"id":76581477,"identity":"6dde01fc-edf7-460f-b07b-4f7391563456","added_by":"auto","created_at":"2025-02-18 15:05:57","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":56492,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"FIGURE2ProportionofindividualswithselfreportedIHDwhoreportedtheeffectsofthereceiptofatleastoneelementregardingthePAlevel.png","url":"https://assets-eu.researchsquare.com/files/rs-6030336/v1/b5edffa34c6bc1c5bf3bcdb8.png"},{"id":76583447,"identity":"43fdb31b-b0fb-4b55-b144-e78f8f9d956d","added_by":"auto","created_at":"2025-02-18 15:21:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1636945,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6030336/v1/1c6fd6e7-5bae-43c4-8858-a1214a352c20.pdf"},{"id":76581480,"identity":"aeb522b2-8230-477a-abae-d9a352e62c2d","added_by":"auto","created_at":"2025-02-18 15:05:57","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":157229,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 1. Measures of assessing self-reported IHD, the receipt of GP advice on PA, and PA behaviour after received GP advice\u003c/p\u003e","description":"","filename":"SupplementaryTable1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6030336/v1/b623bdc11823e200f0466e82.pdf"},{"id":76581485,"identity":"0a2e0e0f-e393-44e3-a449-647e496c5e31","added_by":"auto","created_at":"2025-02-18 15:05:57","extension":"pdf","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":140691,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary Table 2. Sample characteristics of the full sample of people aged 35+ years\u003c/p\u003e","description":"","filename":"SupplementaryTable2.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6030336/v1/fee133361a4aabb1a86f3731.pdf"},{"id":76583133,"identity":"665a9191-e61b-4f13-9246-6dd70660cf6d","added_by":"auto","created_at":"2025-02-18 15:13:57","extension":"pdf","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":132305,"visible":true,"origin":"","legend":"\u003cp\u003eSupplementary table 3. Results of a multinomial logistic regression analysis, adjusted by years since the last remembered IHD-related event or diagnosis\u003c/p\u003e","description":"","filename":"SupplementaryTable3.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6030336/v1/2665d2af7c96b6b461b695f2.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003ePhysical activity advice from general practitioners in Germany: Findings from a cross-sectional population survey of individuals with chronic ischemic heart disease (OptiCor study)\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"Strengths and limitations of this study","content":"\u003cul\u003e\n \u003cli\u003eA key strength of this study is that it represents the first nationwide population-based survey focussing on individuals with IHD and their receipt of GP-delivered PA advice, offering valuable insights into the implementation of clinical guideline recommendations.\u003c/li\u003e\n \u003cli\u003eData were collected from a large sample (1,000 individuals with IHD), with participants selected using a combination of random probability sampling (50%) and quota sampling (50%), and face-to-face data collection was employed to maximise representativeness.\u003c/li\u003e\n \u003cli\u003eThe IHD diagnosis was self-reported, which may not fully reflect a clinical diagnosis.\u003c/li\u003e\n \u003cli\u003eAssessing whether individuals had ever received GP advice on PA is complex and may introduce recall bias. However, we sought to account for potential recall bias by adjusting for the \u0026lsquo;years since the last IHD event or diagnosis\u0026rsquo; in a sensitivity analysis.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eDue to an opt-in question, the proportion of individuals with IHD in our study was somewhat lower than estimates from another national population survey, and individuals with lower education and income were overrepresented among non-responders.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"INTRODUCTION","content":"\u003ch3\u003eBACKGROUND\u003c/h3\u003e\n\u003cp\u003eRegular physical activity (PA) is an effective measure in the management of prevalent chronic ischemic heart disease (IHD) (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), as it reduces the risks of cardiovascular mortality, recurrent cardiac events as well as hospitalisation, and can improve the quality of life in individuals with IHD (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, only about 21% of the affected population in Germany is sufficiently physically active, when applying the current World Health Organization (WHO) recommendations on PA (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). About half of the population with IHD is physically inactive (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) and the same is true for the general population in Germany (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIHD is one of the most commonly treated diseases in general practice (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). General practitioners (GPs) are well placed to offer advice on PA as they regularly see their patients with IHD (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), including elderly individuals who have a higher probability of being diagnosed with IHD (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) and more socially isolated and disadvantaged groups (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). GPs are also a trusted source of health information from the patients’ perspective (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The German IHD treatment guideline recommends GPs and other health professionals (HPs) to offer advice on and support with PA to their patients with IHD (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious systematic reviews suggest GP advice can effectively increase patients’ PA level (\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e–\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) (with a number needed to treat of 12 (95% confidence interval (CI): 7 to 33) for long-term behaviour change (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)). However, a recent meta-analysis (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) found no clear effect, potentially due to the inclusion of heterogeneous counselling approaches, including different modes of delivery, different number of follow-up contacts, and time-intensive motivational interviewing. While the German IHD guideline advocate motivational interviewing for advising on health behaviour, the UK’s NICE guideline recommends brief advice (or brief intervention), including “advice, discussion, negotiation or encouragement, with/without written or other support or follow-up” (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). A recent systematic review showed brief advice, as defined by NICE and delivered in healthcare settings, effectively increases self-reported and measured PA for at least six months (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The WHO also endorses brief advice as a cost-effective intervention for managing and preventing noncommunicable diseases (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe 3As approach (Ask/Assess: assessing the PA level, Advise: advising on PA, Assist: assisting with recommendations to increase PA) is a quick method for providing PA advice, commonly used for smoking cessation, but adaptable for PA (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This approach, taking only a few minutes, is easier to integrate into routine primary care than longer interventions and focuses on tailored support based on patient's preferences, activity level, goals, and barriers (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Population survey evidence shows delivering all 3As is more effective for behaviour change than providing single elements (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), with the Assist step seeming particularly associated with positive outcomes (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, international data show all elements are rarely implemented together, and GP consultations often focus only on Ask/Assess (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eGerman studies not focussing on individuals with IHD suggest that the implementation of GP advice on PA is insufficient (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e–\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). There is also little representative national data on how GP advice on PA is delivered to IHD patients or whether individual characteristics (e.g., age, gender, body mass index (BMI), or PA level) influence its receipt. Although the NICE guideline (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) advise against relying on visual cues like body weight for identifying patients to counsel, such factors may still influence GPs’ decisions in practice. Understanding the prevalence of and factors associated with GP-delivered PA advice could identify treatment gaps in primary care for individuals with IHD in Germany.\u003c/p\u003e\n\u003ch3\u003eSTUDY AIM AND RESEARCH QUESTIONS\u003c/h3\u003e\n\u003cp\u003eThis study aims to determine the proportion of individuals aged 35 + years in Germany with self-report IHD who report the receipt of GP advice on PA since their most recent IHD event or diagnosis. Our research questions are:\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat proportion of individuals report having received the 3As of GP-delivered PA advice, overall and by socio-demographic, socio-economic, and health-related characteristics of affected individuals (age, gender, education, income, urbanisation, migration background, BMI, PA level)?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo what extent are these person characteristics associated with receiving no advice on PA vs. all 3As, or one/two elements of 3As vs. all 3As?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eAmong those who report having received at least one 3As element, what proportion report being more or more regular physically active afterwards, stratified by the specific elements received?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003cp\u003e\u003c/p\u003e "},{"header":"METHODS","content":"\u003cp\u003eThis study report is written in accordance with the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ (STROBE) Statement (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eSTUDY DESIGN AND SETTING\u003c/h3\u003e\n\u003cp\u003eData were collected using a cross-sectional population-based household survey of the German population. By means of computer-assisted personal interviews (CAPI), data has been collected between June 2023 and August 2024 from individuals aged 35\u0026thinsp;+\u0026thinsp;living in private households (rented or owned) across Germany. The fieldwork was conducted as an omnibus survey by the market research institute \u0026lsquo;Oracle Life Science\u0026rsquo;. The study has been pre-registered at the German Clinical Trials Register (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.drks.de/DRKS00031304\u003c/span\u003e\u003cspan address=\"https://www.drks.de/DRKS00031304\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The study protocol including an analysis plan was developed together with a statistician (OK) and published prior to the analyses on the Open Science Framework (OSF): \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/7adf2\u003c/span\u003e\u003cspan address=\"https://osf.io/7adf2\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eThe study questionnaire was developed in the multidisciplinary study team (with backgrounds in public health, psychology, sociology, epidemiology, and a GP) and pretested with voluntary IHD patients in a GP setting (n\u0026thinsp;=\u0026thinsp;4, unintentionally only men, all aged 65\u0026thinsp;+\u0026thinsp;years) and subsequently adapted. The questionnaire was published on OSF in the original German version and translated into English: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://osf.io/kvfnb\u003c/span\u003e\u003cspan address=\"https://osf.io/kvfnb\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/p\u003e\n\u003ch3\u003eSTUDY POPULATION\u003c/h3\u003e\n\u003cp\u003eStudy participants were selected using a dual-frame design: a random probability sample (50%) and a quota sample (50%). Data were collected over nine survey waves, reaching approximately 1,800 individuals aged 35\u0026thinsp;+\u0026thinsp;years per wave (N\u0026thinsp;=\u0026thinsp;16,576). As the probability of IHD increases with age (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), individuals under the age of 35 were not included, while no upper age limit was set. About 80% of the individuals aged 35+ (n\u0026thinsp;=\u0026thinsp;12,827) opted in to answer questions about heart health and PA, as required by our ethics committee. Self-reported IHD was identified using four established, plain-language questions on IHD-related events/interventions, commonly used in national health surveys (e.g., (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), see \u003cb\u003eSupplementary table 1\u003c/b\u003e), resulting in a sample of n\u0026thinsp;=\u0026thinsp;1,139. The final study population included participants aged 35\u0026thinsp;+\u0026thinsp;with self-reported IHD who also reported at least one GP visit after their most recent IHD-related event (n\u0026thinsp;=\u0026thinsp;1,004).\u003c/p\u003e\n\u003ch3\u003eOUTCOME MEASURES\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eGP advice on PA (research question 1 and 2):\u003c/h2\u003e \u003cp\u003eParticipants of the final study sample were asked two questions about the receipt of the GP-delivered PA advice according to the 3As (see \u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e). For further analysis, we categorised the response patterns into:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e\u0026lsquo;Receipt of all three elements (Ask/Assess, Advise, Assist)\u0026rsquo; [question 1: option b AND question 2: option a],\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e\u0026lsquo;Receipt of one or two elements (only Ask/Assess or Advise, Ask/Assess and Advise, or Advise and Assist)\u0026rsquo; [question 1: option a] OR [question 1: option b AND question 2: option b OR c OR d] OR [question 1: option c AND question 2: option a OR b OR c OR d]),\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e\u0026lsquo;No PA advice received\u0026rsquo; [question 1: options e OR f], and\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e\u0026lsquo;Advised to avoid PA\u0026rsquo; [question 1: option d].\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e\u0026lsquo;Unable to remember/refused to answer\u0026rsquo; [question 1: option g] OR [question 1: option h]\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003ePA behaviour after the receipt of PA advice (research question 3):\u003c/h2\u003e \u003cp\u003eIndividuals with IHD who reported receiving at least one element (categories A or B) were asked whether these conversations led to increased or more regular PA (see \u003cb\u003eSupplementary Table\u0026nbsp;1\u003c/b\u003e). Responses were categorised as \u0026ldquo;more regularly active\u0026rdquo; (options a or b) or \u0026ldquo;not more active\u0026rdquo; (option c).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEXPOSURE VARIABLES\u003c/h3\u003e\n\u003cp\u003eThe following sociodemographic characteristics were used: \u003cb\u003eGender\u003c/b\u003e: female/male; \u003cb\u003eage\u003c/b\u003e: as a continuous variable for regression analyses and in categories of 35\u0026ndash;54/55\u0026ndash;74/75\u0026thinsp;+\u0026thinsp;years for descriptive analyses; \u003cb\u003elevel of education\u003c/b\u003e: low (no graduation or 9 years of education)/middle (\u0026ge;\u0026thinsp;10years)/high (\u0026ge;\u0026thinsp;12 years); \u003cb\u003emonthly net household income\u003c/b\u003e per person in the household: as a continuous variable for regression analyses and in categories for descriptive analyses: low (\u0026lt;\u0026thinsp;20th income percentile)/middle (20th to 80th income percentiles)/high (\u0026gt;\u0026thinsp;80th income percentile income). These categories reflect the distribution of income in Germany (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). The calculation was based on an equalisation technique provided by the Organisation for Economic Cooperation and Development (OECD-modified equivalence scale) (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), adjusting total net household income (after tax and other deductions) for household size and composition. \u003cb\u003eMigration background\u003c/b\u003e: yes/no. Applied if at least one parent of the study participant was not born in Germany. \u003cb\u003eDegree of urbanisation\u003c/b\u003e: assessed by using the administrative municipality district size [\u0026ldquo;politische Gemeindegr\u0026ouml;\u0026szlig;enklassen\u0026rdquo;] based on the population size consisting of seven categories which were summarised into three categories: rural (\u0026lt;\u0026thinsp;20,000 residents)/urban (20,000 to 500,000 residents)/ metropolitan (\u0026gt;\u0026thinsp;500,000 residents). \u003cb\u003eBMI\u003c/b\u003e: as a continuous variable for regression analyses in categories for descriptive analyses: underweight (BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5)/normal weight (BMI 18.5\u0026ndash;24.9)/overweight (BMI 25.0-29.9)/obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30.0) (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Calculation was based on weight (in kilograms) and height (in meters squared) of the target population using the formula \u003cem\u003eweight in kg / height in m^2\u003c/em\u003e (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e). Self-reported \u003cb\u003ePA level in minutes/week\u003c/b\u003e: assessed by a modified version of a single-item question of Milton et al. (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The question does not involve intensity or muscle strength, and PA at work or housework is excluded. In approximation to the current WHO recommendation on weekly PA levels for adults with and without chronic conditions (75\u0026ndash;300 minutes/week of intense PA or 150\u0026ndash;300 minutes/week of moderate PA) (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e), weekly PA level was categorised for descriptive analyses into 0/1\u0026ndash;74/75\u0026ndash;149/150\u0026ndash;299/ \u0026ge;300 minutes/week. For regression analyses, PA level was converted into hours/week and used as a continuous variable. \u003cb\u003eYears since the most recent IHD-related event or diagnosis\u003c/b\u003e: as a continuous variable for regression analyses (sensitivity analyses). Individuals were asked about the timing of their last event or diagnosis, and this information was used to calculate the variable.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSTATISTICAL ANALYSIS\u003c/h2\u003e \u003cp\u003eAnalyses were performed with IBM SPSS Statistics for Windows, V.29.0 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e). Data were analysed and reported unweighted.\u003c/p\u003e \u003cp\u003eTo address \u003cb\u003eresearch question 1\u003c/b\u003e, we report proportions of individuals with IHD aged 35\u0026thinsp;+\u0026thinsp;who report the receipt of GP advice on PA according to the 3As (categories A: all 3 As, B: one or two elements, C: no advice) overall and by person characteristics. Individuals who fell into categories D and E (did not remember/refused to answer) were excluded. Since particularly the third element Assist seems to be associated with behavioural change (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) the proportion of those who received Assist is presented separately for the total sample. Data are presented as absolute and relative frequencies with 95%CIs.\u003c/p\u003e \u003cp\u003eTo address \u003cb\u003eresearch question 2\u003c/b\u003e, we used univariate multinomial logistic regression models to analyse the associations between individual person characteristics (exposure variables: e.g., sex, BMI) and the receipt of the 3As (outcome variable) with the three categories: Receipt of no elements (category C) vs. receipt of all 3As (category A) [reference] and receipt of one or two elements (category B) vs. receipt of all 3As (category A) [reference]. Individuals who fell into categories D and E (did not remember/refused to answer) were excluded.\u003c/p\u003e \u003cp\u003eTo explore a potential influence of recall bias, we fitted analogous multinomial logistic regression models, however, adjusted for the \u0026lsquo;years since the last IHD event or diagnosis\u0026rsquo; as a sensitivity analysis.\u003c/p\u003e \u003cp\u003eTo address \u003cb\u003eresearch question 3\u003c/b\u003e, we report proportions of individuals with IHD who reported being more active (temporarily or permanently) following GP advice; overall and stratified by received elements (one or two elements vs. all 3As). Data is presented as absolute and relative frequencies with 95%CIs.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDEALING WITH MISSING DATA AND NON-RESPONSE\u003c/h2\u003e \u003cp\u003eA total of 22.6% (n\u0026thinsp;=\u0026thinsp;3,749) of the market research survey participants beforehand decided to opt-out and not answering study questions on heart health and PA. By means of a non-response analysis, we compared distributions of person characteristics of responders and non-responders.\u003c/p\u003e \u003cp\u003eMissing data on dependent and independent variables in responders were sparse: household income: 0.2%, migration background: 1.3%, BMI: 4.2%, PA level: 4.8%. We assumed that excluding cases with missing data would not have relevant effects on our results, and used complete cases for the final analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003ePATIENT AND PUBLIC INVOLVEMENT STATEMENT\u003c/h2\u003e \u003cp\u003eAs described above, the study questionnaire was pretested with individuals with IHD. Their feedback was accommodated in the questionnaire design. Beyond this, patients or the public were not involved in the design, conduction, reporting, or dissemination plans of this research.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe final sample consisted of 1,004 individuals aged 35\u0026thinsp;+\u0026thinsp;years with self-reported IHD, and a GP contact since the most recent IHD-related event or diagnosis. Sample characteristics are presented in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The mean age of this group was 70.0 years (Standard derivation (SD)\u0026thinsp;=\u0026thinsp;11), and 37.7% of the sample (n\u0026thinsp;=\u0026thinsp;379) were female.\u003c/p\u003e\n\u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eCharacteristics of all individuals aged 35\u0026thinsp;+\u0026thinsp;with self-reported IHD and at least one GP contact since the last remembered IHD-related event or diagnosis (N\u0026thinsp;=\u0026thinsp;1,004)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003e% (n)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal sample\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100 (1,004)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62.3 (625)\u003c/p\u003e\n \u003cp\u003e37.7 (379)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eDiverse\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e35\u0026ndash;54 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2 (82)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e55\u0026ndash;74 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.1 (533)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e75\u0026thinsp;+\u0026thinsp;years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.7 (389)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational qualification\u003c/strong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.4 (426)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.5 (336)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e24.1 (242)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income\u003c/strong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.6 (96)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67.9 (682)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e22.3 (242)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMigration background\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e88.5 (877)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.5 (114)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree of urbanisation\u003c/strong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e31.5 (316)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.1 (493)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMetropolitan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.4 (195)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI category\u003c/strong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUnderweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.7 (\u003cspan class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNormal weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e32.2 (323)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOverweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.4 (436)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eObese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19.5 (196)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePA level category (minutes/week)\u003c/strong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20.8 (209)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1\u0026ndash;74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.0 (110)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e75\u0026ndash;149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.2 (122)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e150\u0026ndash;299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18.1 (182)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e300+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e33.2 (333)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eIHD, chronic ischemic heart disease; GP, general practitioner; BMI, body mass index; PA, physical activity.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eData are presented as column percentages (number).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eVariables with missing data: household income: 0.2%, migration background: 1.3%, body mass index: 4.2%, physical activity level: 4.8%\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e1\u003c/sup\u003eGerman educational qualification levels: low (9 years of education, or no graduation), medium (10 years of education), high (\u0026ge;\u0026thinsp;12 years of education).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e2\u003c/sup\u003eMonthly net household income per individual in the household, based on the Organisation for Economic Co-operation and Development (OECD)-modified equivalence scale (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). The variable was categorised into three levels: low (\u0026lt;\u0026thinsp;20th income percentile), medium (20th\u0026ndash;80th income percentiles) and high (\u0026gt;\u0026thinsp;80th income percentile), approx. describing the income distribution in the German population (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e3\u003c/sup\u003eThe variable was assessed by using the administrative municipality district size (\u0026ldquo;politische Gemeindegr\u0026ouml;\u0026szlig;enklassen\u0026rdquo;), consisting of seven categories which were summarised into three categories: rural (\u0026lt;\u0026thinsp;20,000 residents), urban (20,000 to 500,000 residents), metropolitan (\u0026gt;\u0026thinsp;500,000 residents).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e4\u003c/sup\u003eBMI based on weight (in kilograms) and height (in meters squared) of the target population using the formula weight (in kg)/height^2 (in m^2) (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). The variable was categorised into four categories: underweight (BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5), normal weight (BMI 18.0-24.9), overweight (BMI 25.0-29.9), obese (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30.0).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003e\u003csup\u003e5\u003c/sup\u003eThe level of PA is based on the WHO recommendations for adults and adults with chronic conditions (75\u0026ndash;300 minutes/week of intense PA or 150\u0026ndash;300 minutes/week of moderate PA) (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e), although for pragmatic reasons there was no assessment of intensity.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\n \u003ch2\u003e\u003cbr\u003e\u003c/h2\u003e\n \u003cp\u003e\u003cstrong\u003eSupplementary Table\u0026nbsp;2\u003c/strong\u003e shows the basic characteristics of the total sample of all respondents aged 35+ (N\u0026thinsp;=\u0026thinsp;16,576) stratified by non-responders (n\u0026thinsp;=\u0026thinsp;3,749; 22.6%) and responders (n\u0026thinsp;=\u0026thinsp;12,827; 77.4%).\u003c/p\u003e\n \u003cp\u003eProportions of individuals with low educational qualification, low household income, and of individuals living in a rural area were higher, while proportions of individuals with a migration background were lower in the group of non-responders. No relevant differences in gender and age were found.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\n \u003ch2\u003eRESEARCH QUESTION 1: GP ADVICE ON PA\u003c/h2\u003e\n \u003cp\u003eAmong individuals aged 35\u0026thinsp;+\u0026thinsp;with self-reported IHD, 36.4% (95% CI: 33.4 to 39.4) reported the receipt of all 3As, 42.1% (95% CI: 39.1 to 45.2) reported the receipt of one or two elements, and 9.9% (95% CI: 8.1 to 11.8) reported receiving no advice since their most recent IHD-related event or diagnosis. 3.8% (95%CI: 2.7 to 5.1) reported the advice to avoid PA (see \u003cstrong\u003eFig.\u0026nbsp;1\u003c/strong\u003e), and 7.9% (95% CI: 6.3 to 9.7) could not remember or refused to answer.\u003c/p\u003e\n \u003cp\u003eAmong individuals who reported the receipt of at least one 3As element (n\u0026thinsp;=\u0026thinsp;788), 53.3% (95% CI\u0026thinsp;=\u0026thinsp;49.8 to 56.8, n\u0026thinsp;=\u0026thinsp;420) reported the receipt of Assist.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\n \u003cp\u003eProportions of receipt of GP advice stratified by person characteristics are presented in Table \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Men (vs. women), individuals with a migration background (vs. no), those living in an urban (vs. rural or metropolitan) region, with overweight or obesity (vs. normal weight), or who were \u0026ge;\u0026thinsp;75 minutes/week (vs. 0 minutes or \u0026lt;\u0026thinsp;75 minutes/week) physically active relatively more often reported the receipt of all 3As.\u003c/p\u003e\n \u003cp\u003e\u003c/p\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003ePrevalence estimates on categories of self-reported receipt of GP advice on PA, based on de 3As method among the subsample of individuals with self-reported IHD and at least one GP contact since the last remembered IHD-related event or diagnosis, stratified by person characteristics (N\u0026thinsp;=\u0026thinsp;887)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNo advice\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;99, % (n, 95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eOne or two elements\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;423, % (n, 95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eAll three elements\u003c/p\u003e\n \u003cp\u003eN\u0026thinsp;=\u0026thinsp;365, % (n, 95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eGender\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.2 (52, 7.0 to 11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.3 (273, 44.2 to 52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.5 (240, 38.4 to 46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.6 (47, 11.1 to 18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.6 (150, 41.2 to 52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.8 (125, 33.6 to 44.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e35\u0026ndash;54 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17.4 (12, 9.9 to 27.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.0 (29, 30.9 to 53.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.6 (28, 29.6 to 52.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e55\u0026ndash;74 years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.4 (41, 6.2 to 11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.3 (240, 44.9 to 53.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.3 (206, 38.0 to 46.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e75\u0026thinsp;+\u0026thinsp;years old\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.9 (46, 10.5 to 17.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.5 (154, 41.2 to 51.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.6 (131, 34.4 to 44.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational qualification\u003c/strong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14.9 (54, 11.5 to 18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.8 (162, 39.7 to 49.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.3 (146, 35.4 to 45.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.4 (32, 7.4 to 14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.6 (146, 42.0 to 53.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42.0 (129, 36.6 to 47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.0 (13, 3.4 to 9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52.8 (115, 46.1 to 59.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.3 (90, 34.9 to 47.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income\u003c/strong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.1 (4, 1.7 to 11.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54.4 (43, 43.5 to 65.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.5 (32, 30.2 to 51.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.5 (76, 10.1 to 15.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.6 (277, 41.7 to 49.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.8 (254, 38.0 to 45.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5 (19, 6.0 to 14.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50.8 (101, 43.8 to 57.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39.7 (79, 33.1 to 46.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMigration background\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e11.6 (90, 9.5 to 14.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.7 (371, 44.2 to 51.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e40.7 (317, 35.3 to 54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.2 (8, 3.9 to 14.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46.9 (46, 37.3 to 56.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.9 (44, 35.3 to 54.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree of urbanisation\u003c/strong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRural\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.9 (29, 7.6 to 15.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.6 (143, 47.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e35.6 (95, 30.0 to 41.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10.7 (47, 8.1 to 13.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.6 (192, 39.1 to 48.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.7 (201, 41.1 to 50.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMetropolitan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12.8 (23, 8.5 to 18.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e48.9 (88, 41.7 to 56.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.3 (69, 31.5 to 45.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI category\u003c/strong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUnderweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e16.7 (1, 1.9 to 55.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e83.3 (5, 44.2 to 98.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNormal weight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13.8 (40, 10.2 to 18.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.9 (139, 42.2 to 53.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38.3 (111, 32.8 to 44.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOverweight\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.6 (37, 7.0 to 12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.3 (175, 40.4 to 50.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e45.1 (174, 40.2 to 50.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eObese\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e9.5 (16, 5.7 to 14.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.1 (83, 41.6 to 56.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41.4 (70, 34.2 to 48.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003ePA level category (minutes/week)\u003c/strong\u003e\u003csup\u003e5\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e27.7 (43, 21.2 to 35.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e47.1 (73, 39.4 to 54.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25.2 (39, 18.8 to 32.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e1\u0026ndash;74\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8.9 (9, 4.5 to 15.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e53.5 (54, 43.8 to 63.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e37.6 (38, 28.6 to 47.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e75\u0026ndash;149\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.0 (8, 3.4 to 12.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.9 (50, 35.0 to 53.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.1 (56, 40.1 to 58.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e150\u0026ndash;299\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7.1 (12, 4.0 to 11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e43.5 (73, 36.1 to 51.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.4 (83, 41.9 to 56.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e300+\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e6.1 (19, 3.8 to 9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e49.5 (155, 44.0 to 55.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44.4 (139, 39.0 to 49.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eIHD, chronic ischemic heart disease; GP, general practitioner; BMI, body mass index; PA, physical activity.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eData are presented as row percentages (number).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003eVariables with missing data (total sample): household income: 0.2%, migration background: 1.3%, body mass index: 4.2%, physical activity level: 4.8%\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003e1\u003c/sup\u003eGerman educational qualification levels: low (9 years of education, or no graduation), medium (10 years of education), high (\u0026ge;\u0026thinsp;12 years of education).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003e2\u003c/sup\u003eMonthly net household income per individual in the household, based on the Organisation for Economic Co-operation and Development (OECD)-modified equivalence scale (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e). The variable was categorised into three levels: low (\u0026lt;\u0026thinsp;20th income percentile), medium (20th\u0026ndash;80th income percentiles) and high (\u0026gt;\u0026thinsp;80th income percentile), approx. describing the income distribution in the German population (\u003cspan class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003e3\u003c/sup\u003eThe variable was assessed by using the administrative municipality district size (\u0026ldquo;politische Gemeindegr\u0026ouml;\u0026szlig;enklassen\u0026rdquo;), consisting of seven categories which were summarised into three categories: rural (\u0026lt;\u0026thinsp;20,000 residents), urban (20,000 to 500,000 residents), metropolitan (\u0026gt;\u0026thinsp;500,000 residents).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003e4\u003c/sup\u003eBMI based on weight (in kilograms) and height (in meters squared) of the target population using the formula weight (in kg)/height^2 (in m^2) (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e). The variable was categorised into four categories: underweight (BMI\u0026thinsp;\u0026lt;\u0026thinsp;18.5), normal weight (BMI 18.0-24.9), overweight (BMI 25.0-29.9), obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30.0).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"6\"\u003e\u003csup\u003e5\u003c/sup\u003eThe level of PA is based on the WHO recommendations for adults and adults with chronic conditions (75\u0026ndash;300 minutes/week of intense PA or 150\u0026ndash;300 minutes/week of moderate PA) (\u003cspan class=\"CitationRef\"\u003e3\u003c/span\u003e), although for pragmatic reasons there is no categorisation according to intensity.\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003cp\u003e\u003c/p\u003e\n \u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n \u003cp\u003eWomen (vs. men), younger individuals (35\u0026ndash;54 years) and older individuals (75\u0026thinsp;+\u0026thinsp;years; vs. middle aged (55\u0026ndash;74 years)), individuals with a low or medium (vs. high) level of education, a medium and high (vs. low) net household income, individuals with normal weight (BMI 18.0-24.9; compared with overweight (BMI 25.0-29.9), and obesity (BMI\u0026thinsp;\u0026ge;\u0026thinsp;30.0)), and individuals who are physically inactive (vs. being physically active) relatively more often reported receiving no GP advice on PA at all.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\n \u003ch2\u003eRESEARCH QUESTION 2: ASSOCIATIONS BETWEEN PERSON CHARACTERISTICS AND THE RECEIPT OF PA ADVICE\u003c/h2\u003e\n \u003cdiv id=\"Sec18\" class=\"Section3\"\u003e\n \u003cp\u003eResults of the multinomial logistic regression analyses are presented in Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eResults of a multinomial logistic regression analysis: Associations between the receipt of GP advice on PA (no advice/ one or two elements/ three elements [reference]) and person characteristics (n\u0026thinsp;=\u0026thinsp;788) (unweighted)\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eOR (95% CI)\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"3\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo advice\u003c/strong\u003e vs. all three elements\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e\u003cstrong\u003eOne or two elements\u003c/strong\u003e vs. all three elements\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMale (reference)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.74 (1.11 to 2.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.06 (0.79 to 1.42)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge in years\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.01 (0.99 to 1.04)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.0 (0.99 to 1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducational qualification\u003c/strong\u003e\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eLow (ref.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMedium\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.67 (0.41 to 1.10)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.02 (0.74 to 1.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eHigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.39 (0.20 to 0.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.15 (0.81 to 1.64)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eHousehold income\u003c/strong\u003e\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.86 (0.65 to 1.13)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.04 (0.88 to 1.23)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMigration background\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eNo (ref.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.56 (0.71 to 3.44)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.12 (0.72 to 1.74)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eDegree of urbanisation\u003c/strong\u003e\u003csup\u003e3\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eRural (ref.)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eUrban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.77 (0.45 to 1.29)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.65 (0.46 to 0.88)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003eMetropolitan\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1.09 (0.58 to 2.05)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.85 (0.56 to 1.27)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eBMI\u003c/strong\u003e\u003csup\u003e4\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.95 (0.91 to 1.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.98 (0.96 to 1.01)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePA level (hours/week)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.82 (0.75 to 0.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0.99 (0.97 to 1.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eIHD, chronic ischemic heart disease; GP, general practitioner; BMI, body mass index; PA, physical activity.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003eUnadjusted analyses. Data are presented as odds ratios (ORs) together with a 95% confidence interval (95% CI). Age, household income, BMI and PA level were treated as continuous variables for regression analyses.\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003e1\u003c/sup\u003eGerman educational qualification levels: low (9 years of education, or no graduation), medium (10 years of education), high (\u0026ge;\u0026thinsp;12 years of education).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003e2\u003c/sup\u003eMonthly net household income per individual in the household, based on the Organisation for Economic Co-operation and Development (OECD)-modified equivalence scale (\u003cspan class=\"CitationRef\"\u003e29\u003c/span\u003e).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003e3\u003c/sup\u003eThe variable was assessed by using the administrative municipality district size (\u0026ldquo;politische Gemeindegr\u0026ouml;\u0026szlig;enklassen\u0026rdquo;), consisting of seven categories which were summarised into three categories: rural (\u0026lt;\u0026thinsp;20,000 residents), urban (20,000 to 500,000 residents), metropolitan (\u0026gt;\u0026thinsp;500,000 residents).\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\"\u003e\u003csup\u003e4\u003c/sup\u003eBMI based on weight (in kilograms) and height (in meters squared) of the target population using the formula weight (in kg)/ height^2 (in m^2) (\u003cspan class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eCompared to the receipt of all elements of the 3As, female gender was associated with higher odds of reporting no GP advice received (OR\u0026thinsp;=\u0026thinsp;1.74, 95% CI\u0026thinsp;=\u0026thinsp;1.11 to 2.72). A higher (vs. lower) educational qualification (OR\u0026thinsp;=\u0026thinsp;0.39, 95% CI\u0026thinsp;=\u0026thinsp;0.20 to 0.76) and a higher PA level (OR\u0026thinsp;=\u0026thinsp;0.82, 95% CI\u0026thinsp;=\u0026thinsp;0.75 to 0.90, per hour/week) were associated with lower odds of reporting no advice received. No relevant associations were found with age, income, migration background, degree of urbanisation and BMI in this regard.\u003c/p\u003e\n \u003cp\u003eCompared to the receipt of all elements of the 3As, individuals living in an urban (vs. rural) region had lower odds of receiving only one or two elements of the 3As (OR\u0026thinsp;=\u0026thinsp;0.65, 95% CI\u0026thinsp;=\u0026thinsp;0.46\u0026ndash;0.88%). For gender, age, level of education, income, migration background, BMI and PA level, no clear associations with the receipt of one or two elements were observed.\u003c/p\u003e\n \u003cp\u003eThe results of the sensitivity analysis (see \u003cstrong\u003eSupplementary table 3\u003c/strong\u003e) indicate that the associations become smaller after adjustment for the time between our survey and the most recent IHD-related event or diagnosis. However, the directions of the associations remain largely unchanged.\u003c/p\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\n \u003cp\u003eRESEARCH QUESTION 3: PA LEVEL AFTER THE RECEIPT OF AT LEAST ONE ELEMENT OF PA ADVICE\u003c/p\u003e\n \u003cp\u003eAmong individuals who reported the receipt of at least one element of GP (n\u0026thinsp;=\u0026thinsp;766), a total of 72.5% (n\u0026thinsp;=\u0026thinsp;555) said that they were more active following the advice. The proportions in individuals who reported the receipt of all 3As were even higher (n\u0026thinsp;=\u0026thinsp;315 (86.8%; 95% CI\u0026thinsp;=\u0026thinsp;83.0 to 90.0)) compared to those who reported the receipt of one or two elements (n\u0026thinsp;=\u0026thinsp;240 (59.6%; 95% CI\u0026thinsp;=\u0026thinsp;54.7 to 64.3)) (see \u003cstrong\u003eFig.\u0026nbsp;2\u003c/strong\u003e).\u003c/p\u003e\n\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn our cross-sectional study of the German population among individuals aged 35\u0026thinsp;+\u0026thinsp;with IHD, around 36% reported the receipt of all 3As elements of GP advice on PA (Ask/Assess, Advise, Assist). About 42% reported the receipt of one or two elements, and around 10% received no advice at all. Our findings also suggest, that women (vs. men), individuals with a lower (vs. higher) educational qualification, individuals living in a rural (vs. urban) area, and individuals who are less physically active seem to have a lower probability of receiving advice on PA including all 3As.\u003c/p\u003e \u003cp\u003e This is the first nationwide study focussing on individuals with IHD and their receipt of GP-led PA advice, providing insights into the implementation of clinical guideline recommendations on the delivery of relevant elements of advising on PA. The few existing previous German studies did not focus on individuals with IHD. For example, one cross-sectional survey in GP practices of patients aged 70\u0026thinsp;+\u0026thinsp;in Rhineland\u0026ndash;Palatinate reported that approximately 48% received GP advice on PA, with 39% that received Assist (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). An analysis of time trends from two representative cross-sectional surveys of the general population in Germany found that between 2008 and 2011, less than 9% of individuals younger than 65 years received GP advice on PA within the last 12 month (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). A cross-sectional study of adults aged 18\u0026thinsp;+\u0026thinsp;revealed that about one-third received GP advice on PA within a year (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn our study, over 80% of respondents received at least one element of the 3As of GP advice on PA, which seems encouraging. However, several studies suggest that all elements combined, but especially Assist (concrete recommendation on increasing PA) seem to be decisive to health behaviour change (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Our findings suggest that individuals with IHD receive PA advice more frequently than other groups in Germany. This aligns with a previous cross-sectional survey in GP practices from 2011 showing that individuals with (vs. without) IHD aged 65\u0026thinsp;+\u0026thinsp;in Germany had 1.93 higher odds (unadjusted, 95% CI\u0026thinsp;=\u0026thinsp;1.53 to 2.43) of reporting GP advice on PA within a year (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). One explanation could be that individuals with IHD more often visit their GP regularly (e.g., in disease management programmes). However, it remains unclear how GP advice was defined and which elements were included in the respective studies.\u003c/p\u003e \u003cp\u003eAlthough women with IHD are generally less physically active than men (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), our findings revealed that women had higher odds of reporting PA was not discussed with them or at least not comprehensively. This aligns with national and international studies, showing that women \u0026ndash; irrespective of age or chronic conditions \u0026ndash; tend to receive less GP advice not only on PA (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e) but also on other health behaviours like hazardous alcohol consumption (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and smoking (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). Although exact reasons for this disparity warrant further investigation, one speculation on our side for this could be that women may feel ashamed or are afraid of being stigmatised for admitting a lack of PA to their GP. Another explanation could be that men generally have riskier health behaviour and are less likely to use preventive services (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), regardless of any medical condition. This could result in GPs being more likely to see the need to advise men.\u003c/p\u003e \u003cp\u003eThe results of our study suggest that individuals who are overweight or obese (vs. normal weight) are more likely to receive GP advice. One explanation for this could be that visual cues play a role in the delivery of advice. Individuals of normal weight may have the stigma of already being physically active or not needing PA, regardless of whether they actually engage in sufficient PA.\u003c/p\u003e \u003cp\u003eOur study found that individuals with higher educational qualifications were less likely to receive no PA advice than those with lower qualifications, perhaps also due to societal norms or stigmatisation tendencies. Our findings contrasts with a previous German study from the year 2011 that observed no differences based on educational attainment (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). However, one reason could be that this study differs methodologically from our study.\u003c/p\u003e \u003cp\u003eIn terms of degree of urbanisation, urban (vs. rural) residents were less likely to report receiving only one or two elements (vs. all 3As). However, relative frequencies suggest that urban residents were more likely to report receiving all 3As (approximately 46%) compared to rural residents (around 36%). These findings align with other studies (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e), suggesting that rural areas face challenges like limited exercise opportunities (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and weaker networks with cardiovascular prevention services (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough less active individuals would theoretically have a greater need for GP advice on PA, our findings indicate that the odds of reporting no advice decrease as PA levels increase. Analyses of relative frequencies reveal that inactive individuals are more likely to report no advice (approximately 27%) compared to those who are at least somewhat active (less than 9%). One possible explanation is that active individuals may be more receptive to GP advice on PA and, therefore also more likely to recall such interventions. Another possibility is that inactive individuals may have received advice in the past and subsequently became more active as a consequence. Another explanation could be that GPs may avoid advising patients with severe impairments (e.g., comorbidities, mobility impairments), who are less physically active or not active at all. Due to the cross-sectional design, we cannot determine the direction of this association.\u003c/p\u003e \u003cp\u003eAs an additional result, our study found that over 70% of individuals with IHD who reported receiving at least one element of the 3As engaged in PA following their GP\u0026rsquo;s advice. This proportion was even higher among individuals who reported receiving all the 3As (86%). Similarly, a German study found that 85% of individuals aged 70\u0026thinsp;+\u0026thinsp;reported that they had tried PA offers recommended by their GP (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). These findings align with other studies showing a positive association between GP advice and subsequent PA engagement (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eSTRENGTH AND LIMITATIONS\u003c/h2\u003e \u003cp\u003eA key strength of this study is that it represents the first nationwide population-based survey focussing on individuals with IHD and their receipt of GP-delivered PA advice, offering valuable insights into the implementation of clinical guideline recommendations. A second strength is that data were collected from a large sample (\u0026gt;\u0026thinsp;1,000 individuals with IHD), with participants selected using a combination of random probability sampling (50%) and quota sampling (50%), and face-to-face data collection was employed to maximise representativeness.\u003c/p\u003e \u003cp\u003eOur study has also several limitations. First, the IHD diagnosis was self-reported which may not fully align with clinical diagnoses, though, we used an established instrument also employed in large national health surveys (e.g., (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)). Second, recall bias is a concern, as participants may not accurately remember receiving GP advice. However, we conducted a sensitivity analysis based on timing of the most recent IHD event or diagnosis, which showed little impact on the associations, although recall bias could still be present. Third, the proportion of individuals with IHD in our study was about 6%, lower than the 9% estimate from another national survey (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), possibly due to our opt-in question. Additionally, individuals with lower education and income, linked to higher IHD prevalence (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e), were overrepresented among non-responders to the opt-in question, which may have influenced the proportion of IHD cases in our study. Our focus, however, was on the prevalence of GP advice on PA in individuals with IHD and its associations with individual characteristics, not on IHD prevalence. Fourth, the complexity of our main study outcome question could have led to comprehension difficulties, though the CAPI survey allowed interviewers to assist. Fifth, some person- and health-related characteristics (e.g., BMI and PA levels) were collected at the time of the survey, but may have changed since the last GP visit.\u003c/p\u003e \u003cp\u003eFinally, the findings on BMI and PA levels following GP advice do not allow conclusions about causality, though they are consistent with other studies showing positive effects of brief interventions on PA (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e), or other health behaviours such as smoking cessation (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003eIMPLICATIONS\u003c/h2\u003e \u003cp\u003eCurrently, only about one-third of individuals with IHD receive comprehensive PA advice including all three elements (Ask, Advise, Assist) that could support them to change their health behaviour (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). While this is an acceptable proportion, the PA-related guideline recommendation could be implemented more frequently in the care of individuals with IHD.\u003c/p\u003e \u003cp\u003eA major barrier seems to be insufficient training for GPs in providing PA advice (\u003cspan additionalcitationids=\"CR43 CR44\" citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e). To address this, international guidelines recommend training for HPs (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e) to promote understanding of PA as a preventive measure in primary care, provide practical PA recommendations (e.g., local sports programs), and raise awareness of at-risk groups (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). However, in Germany such training is not adequately integrated into the medical curriculum and continuing medical education. To bridge this gap, training in brief PA counselling should be anchored in the medical curriculum, and tailored educational trainings for GPs should be developed and implemented.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003e Our results indicate that GP advice on PA in Germany is not sufficiently implemented in line with the clinical guideline recommendations on the treatment of individuals with IHD. Only one in three received all 3As, which appears critical for facilitating health behaviour change. Moreover, women, individuals with lower educational qualifications, those in rural areas, and physically inactive individuals are even less likely to receive PA advice. To enhance PA advice delivery in primary care, incorporating brief PA counselling knowledge and skills into medical curricula and developing tailored educational trainings for GPs, as well as for other HPs, could be effective strategies to consider.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eACKNOWLEDGEMENTS\u003c/h2\u003e\n\u003cp\u003eWe would like to thank Constanze Cholmakow-Bodechtel and Marvin Kraemer from the market research institute \u0026lsquo;Oracle Life Science\u0026rsquo; for data collection.\u003c/p\u003e\n\u003ch2\u003eCONTRIBUTORS\u003c/h2\u003e\n\u003cp\u003eSH drafted the analysis protocol and the manuscript, and analysed and interpreted the data. SK conceived the study, acquired funding, co-wrote the manuscript, and supervised all preparatory work and the analyses. AP, DK, UM, OK, and RK provided advice on the study protocol and critically revised the analysis protocol and the manuscript. OK also advised on the statistical analysis. All named authors contributed substantially to the manuscript and agreed on its final version.\u003c/p\u003e\n\u003ch2\u003eFUNDING\u003c/h2\u003e\n\u003cp\u003eThe cross-sectional population survey is part of the OptiCor study (https://www.opticor-study.info/). The OptiCor study has been funded as a junior research group in health services research by the German Ministry of Education and Research (BMBF) (funding period: 05/2022-04/2027, grant number: 01GY2103).\u003c/p\u003e\n\u003ch2\u003eCOMPETING INTERESTS\u003c/h2\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e\n\u003ch2\u003ePATIENT AND PUBLIC INVOLVEMENT\u003c/h2\u003e\n\u003cp\u003eThe study questionnaire was pretested with individuals with IHD. Beyond this, patients or the public were not further involved in the design, or conduct, or reporting, or dissemination plans of this research.\u003c/p\u003e\n\u003ch2\u003ePATIENT CONSENT FOR PUBLICATION\u003c/h2\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch2\u003eETHICS APPROVAL\u003c/h2\u003e\n\u003cp\u003eThis study involves human participants and was approved by the ethics committee of the Medical Faculty of the Heinrich-Heine-University Duesseldorf, Germany (2023-2321). Participants gave informed consent to participate in the study before taking part.\u003c/p\u003e\n\u003ch2\u003eDATA SHARING STATEMENT\u003c/h2\u003e\n\u003cp\u003eThe data underlying this study are third-party data and are available to researchers on reasonable request from the corresponding author ([email protected]). All proposals requesting data access will need to specify how it is planned to use the data, and all proposals will need approval of the study team before data release.\u003c/p\u003e\n\u003ch2\u003eORCID IDs\u003c/h2\u003e\n\u003cp\u003eSabrina Hoppe https://orcid.org/0009-0002-1429-3978\u003cbr\u003eAlicia Prinz https://orcid.org/0009-0008-8159-7414\u003cbr\u003eDaniel Kotz https://orcid.org/0000-0002-9454-023X\u003cbr\u003eUte Mons https://orcid.org/0000-0003-1764-6783\u003cbr\u003eOliver Ku\u0026szlig; https://orcid.org/0000-0003-3301-5869\u003cbr\u003eRik Crutzen https://orcid.org/0000-0002-3731-6610\u003cbr\u003eSabrina Kastaun https://orcid.org/0000-0002-5590-1135\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEuropean Heart Network Physical activity policies for cardiovascular health [Internet]. Brussels: European Heart Network; 2019 [cited 2024 Aug 17]. 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Fam Pract 27(2):219\u0026ndash;223\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSilva CS, Godinho C, Encantado J, Rodrigues B, Carra\u0026ccedil;a EV, Teixeira PJ et al (2023) Implementation determinants of physical activity interventions in primary health care settings using the TICD framework: a systematic review. BMC Health Serv Res 23(1):1082\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. Global action plan on physical activity 2018\u0026ndash;2030: more active people for a healthier world [Internet]. Geneva: World health Organization (2018) [cited 2024 Aug 17]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://iris.who.int/bitstream/handle/10665/272722/9789241514187-eng.pdf?sequence=1.\u003c/span\u003e\u003cspan address=\"https://iris.who.int/bitstream/handle/10665/272722/9789241514187-eng.pdf?sequence=1.\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Federal Ministry of Education and Research","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Chronic ischemic heart disease, coronary heart disease, physical activity, primary care, brief intervention, brief advice","lastPublishedDoi":"10.21203/rs.3.rs-6030336/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6030336/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e The current German treatment guideline for chronic ischemic heart disease (IHD) recommends that general practitioners (GPs) deliver brief advice on physical activity (PA) to IHD patients. Such advice consists of at least three elements (i.e., 3As): (1) assessing the PA level, (2) advising on PA, and (3) assisting with recommendations. This study examined the extent to which individuals with IHD in Germany reported the receipt of such advice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDesign:\u003c/strong\u003e Cross-sectional population-based face-to-face survey (06/2023-08/2024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting:\u003c/strong\u003e Germany.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants:\u003c/strong\u003e 1,004 individuals aged 35+ with self-reported IHD and GP contact.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOutcome measures:\u003c/strong\u003e Primary outcome: Self-reported proportions of receipt of GP-delivered PA advice according to the 3As. Main secondary outcome: Associations between person characteristics and the likelihood of receiving PA advice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among individuals with IHD, 36.4% (95% CI=33.4 to 39.4) received all 3As of PA advice, 42.1% (95% CI=39.1 to 45.2) received one or two elements, 9.9% (95% CI=8.1 to 11.8) received no advice at all, and 3.8% (95% CI=2.7 to 5.1) were advised to avoid PA (7.9% did not remember/refused to answer). Women (vs. men) were more likely to receive no advice (OR=1.74, 95% CI=1.11 to 2.72), while individuals with higher PA levels (OR=0.82, 95% CI=0.75 to 0.90, per hour/week) and those with higher (vs. lower) education were less likely to receive no advice (OR=0.39, 95% CI= 0.20 to 0.76). Individuals living in urban (vs. rural) areas were less likely to receive only one or two (vs. all) of the 3As (OR=0.65, 95% CI=0.46 to 0.88). Of those who received at least one element of advice (n=766), 72.5% reported they were more active afterwards, with a higher proportion when all 3As (vs. only some elements) were provided (86.8% vs. 59.6%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Only one-third of individuals with IHD in Germany received comprehensive PA advice. Specific person characteristics, such as female gender and lower education, were associated with lower proportions of received PA advice. Efforts are needed to improve GP-led PA guidance, particularly for underserved groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTrial registration:\u003c/strong\u003e German Clinical Trials Register (DRKS00031304)\u003c/p\u003e","manuscriptTitle":"Physical activity advice from general practitioners in Germany: Findings from a cross-sectional population survey of individuals with chronic ischemic heart disease (OptiCor study)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-18 15:05:52","doi":"10.21203/rs.3.rs-6030336/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"456a4c63-13d0-4372-8b49-2d7510e9bb39","owner":[],"postedDate":"February 18th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-02-18T15:05:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-18 15:05:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6030336","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6030336","identity":"rs-6030336","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}