STRENGTHS AND LIMITATIONS OF THIS STUDY

First study to investigate a sit–stand desk intervention among general practitioners (GPs).

Conducted in a ‘real-world’ setting, providing accurate and meaningful data from both GPs and patients.

Used device-assessed physical activity and sitting time variables.

Single-group pre–post design limits ability to determine causality.

Use of sit–stand desks was self-reported by GPs.

Introduction

Sedentary behaviour, time spent sitting during waking hours, is highly prevalent in adults, accounting for around 9–10 hours of their day.1–3 This is of concern because sitting for long periods is associated with higher risks of cardiovascular disease and mortality,4–7 poorer mental health8–13 and lower quality of life.12 14 Specifically, high levels of sedentary behaviour accumulated in occupational settings have been associated with an increased risk of musculoskeletal disorders,15 lower work-related engagement and higher levels of presenteeism.16 17

General practitioners (GPs) spend large proportions of their working day sitting, the majority sitting for over 7 hours per day, putting their health at risk.18 The health risks for GPs are expected to be similar to those already outlined; however, there is some evidence that GPs who spend more time in prolonged sitting (equally to or greater than 30 min) reported more musculoskeletal complaints.19 Therefore, it is important to investigate ways in which GPs might be provided with opportunities during their working day to sit less. Sit–stand desks allow the user to quickly alternate between a sitting and standing position. The use of sit–stand desks might also prompt GPs to routinely have conversations with patients about reducing the time they spend sitting and increasing their physical activity. This is important because, like GPs, patients typically spend long periods of time sitting, and many are insufficiently physically active.20 For most people, their GP is the first port of call for health advice, making it an ideal place in which to promote physical activity and reduced sitting time in the population. Interventions delivered within primary care settings are also effective in increasing physical activity.21

While standing to deliver healthcare is not new (eg, hospital rounds), this is not the case in general practice, where consultations historically have been conducted sitting. Introducing standing consultations would be a large cultural change for both patients and GPs. A nationwide survey of GPs in the UK (n=630) reported that GPs would be interested in having a sit–stand desk, and would be willing to try standing within consultations with their patients.22 Further, sit–stand desks have been shown to be effective at reducing sitting among office workers (not patient facing) within the National Health Service (NHS), as occupational sitting was over 80 min per day lower after 12 months compared with controls, with corresponding improvements in job performance, work engagement, occupational fatigue, sickness presenteeism, daily anxiety and quality of life.23 Further, a Cochrane review showed sit–stand desks can reduce sitting time by up to 100 minutes in the short term and up to around 60 minutes at longer follow-up.24 It should be noted that some evidence suggests standing for prolonged periods is also associated with lower back pain25 and fatigue/discomfort in the lower limbs.26

This study was part of a larger programme of work that aimed to investigate the feasibility and acceptability of GPs using sit–stand desks to facilitate standing during consultations.22 This study focused specifically on investigating GPs’ experiences of using the sit-stand desk within their everyday work, including during consultations with patients, and investigating the impact of the desk on GPs’ physical activity and sedentary behaviours. This information would be useful to design the methodology for a subsequent larger phase III trial to test effectiveness and cost-effectiveness. Secondary aims were to: assess the impact of sit–stand desks on the doctor–patient relationship when GPs stand during consultations; explore GPs’ and patients’ views of standing during their GP consultation; and to explore the potential of the intervention to reduce sitting time and increase physical activity in GPs.

MethodStudy design

This study followed a pre–post single-group experimental design (figure 1). The study commenced in May 2021 and was completed in May 2022, and the study needed to comply with COVID-19 restrictions in England that were in place at the time of this research. Participants included GPs and their patients. GPs were recruited through three clinical research networks (CRNs) within England. CRNs contacted GP practices within their geographical area and interested practices responded to the research team or to the CRN. When an expression of interests was received, the research team arranged a call with the practice manager to discuss the study in more detail. If the practice manager was still interested, they would circulate relevant information (eg, participant information sheet (PIS)) with their GPs. Interested GPs would then contact the study team, indicating their intent to take part. Screening and baseline appointments (held online) were scheduled with interested GPs no sooner than 24 hours following receipt of the PIS. GPs were asked to provide informed consent to participate (audio recorded). To be eligible for the study, GPs needed to work at least five sessions per week (on average) with no pre-existing condition that inhibited their ability to stand or to be physically active.

Figure 1

Study design. GPs, general practitioners.

Adult patients aged 18 years or more and able to understand English were recruited following their face-to-face GP standing consultation. At the end of consultation, GPs provided eligible patients with a PIS and explained the purpose of the study. GPs then asked the patient to provide written informed consent, complete the study consultation exit questionnaire and returned it to the practice reception.

Sit–stand desk intervention

The intervention consisted of each GP having a sit–stand desk (Opløft Sit-Stand Platform, Posturite, Berwick, UK) installed in their consultation room (figure 2). This study was a National Institute for Health Research portfolio-adopted study and as such, it was eligible for excess treatment costs to cover the costs of the desks and were therefore provided with no cost to the practice. Sit–stand desks allow users to switch, in a few seconds, between a sitting and standing position and vice versa, by adjusting the height of the desk. A member of the research team explained to GPs how to use the desk correctly. This included explaining the correct height of the desk when sitting and standing to ensure 90° elbow flexion, how to move the desk from a sitting to a standing position and vice versa. GPs used the desks for 4 working weeks. Practices were given a poster to display in the waiting/reception area to inform patients that their GP may be standing during their consultation. The intervention was designed specifically to mimic larger-scale implementation of sit–stand desks; therefore, the training given to GPs was very brief, as would be expected if this intervention was to be implemented more widely.

Figure 2

Example of a general practitioner using the sit–stand desk during a consultation with a patient.

MeasuresGeneral practitioners

Demographic and work-related data, and GPs’ pre-intervention views about using the sit–stand desks during a variety of work-related tasks were collected at baseline using a questionnaire. At follow-up (after 4 working weeks of the desk being implemented into consultation rooms), data were collected to understand use of the sit–stand desk by GPs during work-related tasks, including face-to-face consultations, telephone/online consultations and administration. At follow-up, data were also collected to assess the perceived impact of the sit–stand desk and the GPs’ post-intervention views about the use of sit–stand desks during their work, having used one for 4 weeks. Some questions were not asked if the GP reported not using the desk in a standing position during certain tasks. All questionnaire data (baseline and follow-up) were collected using online survey software.

Sedentary behaviour and physical activity

To measure sedentary behaviour and physical activity, GPs were asked to wear an activPAL3 micro-monitor (PAL Technologies, Glasgow, UK) on their thigh 24 hours a day for up to 8 days at two different time periods: during the baseline period (between day 0 and day 8) and for the last 8 days of the sit–stand desk intervention (follow-up).27 The activPAL device was waterproofed using a nitrile sleeve and Hypafix dressing and attached (Hypafix Transparent) to the thigh; GPs were asked to complete a log on each day that they were wearing the activPAL detailing the time they woke up and the time they fell asleep. GPs also recorded the time they started and finished work on a given day. activPAL data were processed and summarised using Processing PAL (University of Leicester, UK, https://github.com/UOL-COLS/ProcessingPAL), a free Java application which uses a validated algorithm to separate valid waking wear data from time in bed, prolonged non-wear and invalid data.28 Data were processed using default settings. Data for sitting time, prolonged sitting (bouts of 30 min or more), standing time and stepping time were generated. These data were generated for waking time and for working time.

Patients: standing consultation exit questionnaire

Patients completed an exit questionnaire following a face-to-face standing consultation with their GP. The questionnaire asked how they felt about their GP standing, whether they would prefer their GP to be sitting or standing during consultations, and whether they felt their GP standing impacted the consultation. Patients were asked whether their GP discussed physical activity, sitting time, standing time and sleep with them during their standing consultation. The questionnaire also asked patients to report the reason for their visit to the GP today. Demographic data (age group, gender, employment status and ethnicity) were also collected.

Sample size

As this was a feasibility trial, a formal sample size calculation was not conducted. The research was not designed or powered to detect a statistically significant difference in efficacy between time points. Sample sizes of between 24 and at least 70 participants (in this case, GPs) have been recommended for feasibility trials.29 30 A recruitment target of between 30 and 40 GPs was set. We anticipated that between 200 and 300 patients would complete the exit questionnaire as this was considered the likely number GPs could recruit in the time available for the study.

Statistical analysis

Data were analysed using IBM SPSS Statistics V.27. Data were summarised to describe the characteristics of participants (GPs and patients). Descriptive statistics summarised GPs’ views about the impact of the intervention and patients’ views of their GP standing during face-to-face consultations. Paired-samples t-tests were used to examine changes in the time GPs spent sitting (total and in prolonged bouts of 30 min or more), standing and stepping, during work time and across the whole day, from baseline to follow-up. Data that were missing were treated as missing at random. For descriptive statistics, denominators are provided to give context to percentages.

Patient and public involvement

This study was the second phase of a larger body of work. The first phase examined GPs’ views of the potential use of sit–stand desks within general practice with the explicit aim of informing this study.22 The results of this survey directly informed study design. No specific patient and public involvement activities were conducted for this study.

Results

A total of 42 GPs and 301 patients were recruited from 22 general practices across three CRNs in England (see figure 3 for participants’ flow through the study) between May 2021 and April 2022. Most GPs were male (n=24, 57.1%), of white ethnicity (n=28, 66.7%) and working as a GP partner (64.3%). Just over half of patients were female (53.2%) and most were of white ethnicity (82.1%) (see table 1). Recruitment was completed when the number of GPs exceeded our preplanned number. No adverse events were reported.

Figure 3

Participants’ flow through the study. GPs, general practitioners.

Table 1

GP and patient characteristics

GPs’ use of the sit–stand desk

Most GPs reported using their sit–stand desk daily (n=28, 75.7%). Only three (7.3%) GPs reported never using it and one (2.7%) reported using it less than once a week. 16 GPs (44.4%) reported using their sit–stand desk during face-to-face consultations every day. Only two (5.6%) GPs who used the desk for other tasks (eg, telephone consultations and administration) reported not using it for face-to-face consultations. Of GPs who used the sit–stand desk during face-to-face consultations, the average time the desk was used in a standing position was 20 min (SD=19.6). Almost all (n=38, 97.4%) GPs would recommend a sit–stand desk to other GPs.

At baseline, most GPs thought that using a sit–stand desk to enable them to stand during face-to-face consultations was a good idea (n=31), and this view remained at follow-up (n=31) after using the desk for 4 weeks. GPs’ preference for sitting or standing during face-to-face consultations was largely unchanged from baseline to follow-up. Overall, if the patient was standing, GPs also preferred to stand (baseline: n=27, 64.3%; follow-up: n=30, 76.9%), and if the patient was sitting, GPs preferred to sit (baseline: n=27, 64.3%; follow-up: n=20, 51.3.%) (see table 2).

Table 2

GPs’ views about the potential use of sit–stand desks during a variety of work-related tasks and preference of posture during face-to-face consultations

Impact of GPs’ standing during face-to-face consultations

Most GPs and patients did not think that GPs’ standing during face-to-face consultations impacted the doctor–patient relationship, GPs’ ability to listen to patients’ concerns or patients’ ability to understand the issues discussed (table 3). Patients generally expressed less impact than GPs. Of those GPs and patients who did think GPs’ standing impacted key elements of the consultation, most thought it had a positive impact on the doctor–patient relationship and GPs’ ability to listen and patients’ ability to understand the issues discussed. Some GPs and patients felt GPs’ standing had a negative impact on the doctor–patient relationship, GPs’ ability to listen to patients’ concerns or patients’ ability to understand the issues discussed (table 3). Only 10.8% (n=32) of patients reported disliking GPs’ standing during their consultation. Most patients reported that they had no preference as to whether their GP was sitting or standing during consultations.

Table 3

Impact of GP standing on interaction with patients

Impact of sit–stand desks on discussion of lifestyle behaviours with patients

Patients reported GPs discussed physical activity in 30% of consultations, sitting time in 10% and standing time in 9%. GPs indicated that the sit–stand desk prompted some conversations with patients about physical activity (73.5%), standing (79.4%) and sitting (64.7%) (see online supplemental tables 1 and 2). GPs reported discussing physical activity regularly at baseline and at follow-up, with no change in frequency following the intervention.

GPs’ sedentary behaviour and physical activity

At baseline, GPs spent 77.2% and 62.7% of their work time and of the time they are awake each day sitting. Compared with baseline, sitting time was lower at follow-up for their whole day and during working hours by 1.04 hours (95% CI: −1.52 to −0.56) and 2.02 hours (–2.75 to −1.29), respectively. This equates to 62 and 121 min, respectively. Standing time was higher by similar amounts: 0.91 hours (0.52 to 1.30) during waking time and 1.82 hours (1.16 to 2.47) during work time at follow-up compared with baseline. There was no change in physical activity between baseline and follow-up for the whole day or the working day (table 4).

Table 4

Difference in sitting, standing and stepping time from baseline to follow-up in work and across the whole waking day

Discussion

This pre-to-post feasibility trial found that sit–stand desks were acceptable to GPs and patients. GPs frequently used their sit–stand desk to stand for work-related tasks, including face-to-face consultations. Overall, neither GPs or patients reported that GPs’ standing during face-to-face consultations impacted consultations, including the doctor–patient relationship, GPs’ ability to listen to patients’ concerns or patients’ ability to understand the issues discussed. Among GPs and patients who thought standing impacted the consultations, most perceived this impact as positive. However, a small proportion of patients (6%) and GPs (9%) thought that standing during face-to-face consultations negatively impacted the doctor–patient relationship. Prior to the intervention, GPs generally thought using a sit–stand desk was a good idea for all work-related tasks. This was broadly similar to GPs’ views reported previously.22 This view remained following the 4-week sit–stand desk intervention. GPs mostly preferred to match patients’ posture during consultations, meaning if the patient was sitting, the GPs would also usually prefer to sit. Likewise, if patients were standing for their consultation, GPs also mostly preferred to stand.

The activPAL data suggest that the sit–stand desks have the potential to reduce sitting time, particularly during working hours. Average sitting time during working hours was 2 hours per day lower following the introduction of the sit–stand desk intervention compared with baseline. This reduction in sitting time is broadly in line with previous recommendations.31 Sitting time was almost entirely replaced with standing time. Although the energy expenditure is only slightly higher for standing compared with sitting,32 the potential benefit of this reduction in sitting time is expected to be more evident in work-related and well-being outcomes. For example, previous evidence has shown that a 1-hour reduction in sitting at 12 months resulted in improvements in stress, well-being and vigour,33 as well job performance, work engagement, occupational fatigue, sickness presenteeism, daily anxiety and quality of life.23

This study contributes new evidence about the use of sit–stand desks within general practice, and changes to the context in which GPs might work. It is known from a previous survey of GPs across the UK that most GPs were in favour of the implementation of sit–stand desks within general practice, with 60% of GPs reporting that they wanted a sit–stand desk within their consultation room to enable them to alternate their postures between sitting and standing.22 In this previous survey, when GPs were asked hypothetical questions about potentially using sit–stand desks to facilitate standing during face-to-face consultations, they were less certain about implementation and the potential effects. In this study, standing during face-to-face consultations was acceptable to GPs and their patients, with minimal negative effects on the doctor–patient relationship. However, with ~10% of patients reporting disliking GPs standing for consultations, it should be recognised standing will not be appropriate for all patients and GPs should make this determination during the consultation.

Strengths and limitations

This is the first study to investigate the use of a sit–stand desk intervention among GPs, and to simultaneously collect data from both GPs and patients. This study was conducted during COVID-19, a time when there was substantial pressure on the NHS, particularly in primary care. This is important given current concerns around the health, well-being and retention of GPs. We also conducted this study in a ‘real-world’ environment within general practice to provide accurate and meaningful data about GPs’ and patients’ direct experiences of standing during consultations. The collection of device-assessed physical activity and sitting time is also a particular strength given that self-reported data of these outcomes are prone to reporting and recall bias.

Our findings should also be considered in the context of some limitations. To maximise data, this study used a single-group pre-to-post trial design. This limits our ability to determine the effect of the intervention on sitting time, physical activity, health and well-being, although the focus of this initial study was on understanding GPs’ and patients’ experiences of using a sit–stand desk during consultations. Future research should look to determine efficacy of this intervention for reducing sitting time, as well as for improving health and well-being. GPs’ use of the sit–stand desks was self-reported which may be susceptible to recall or social desirability bias, although the device-measured data using the activPAL provide reassurance that these data are plausible. Patients were recruited to take part in the consultation exit questionnaires by their GP who was taking part in the study, which opens the possibility of desirability and selection bias. However, patients were asked to complete the questionnaire after they had seen their GP and the questionnaire was returned to the practice reception, not directly to the GP. Prolonged standing can contribute to some negative health outcomes which were not examined here. Future research should examine both the potential benefits and negatives, as well as how to minimise these potential negatives. Lastly, the follow-up period of 4 working weeks was relatively short and it may be that over time, GPs’ use of the desk reduces. Future research to investigate longer-term impacts of a sit–stand desk intervention among GPs, as well as other health professionals in primary care, would be worthwhile.

Conclusion

We have demonstrated that implementing sit–stand desks is feasible and acceptable within general practice and future research should now determine their long-term impact on GPs’ health and work-related outcomes, as well as whether they encourage GPs to raise the topic of sitting time and physical activity more frequently within consultations. Future research should also look to identify key facilitators and barriers to successful implementation of sit–stand desks within primary care. This study suggests that GPs’ sitting time may be reduced through use of sit–stand desks, potentially improving the health and well-being of GPs if these behaviours are adhered to over time. Furthermore, sit–stand desks could be part of a suite of strategies to promote and prompt GPs to have conversations with patients who would benefit from being more physically active, as GPs can be effective in encouraging health behaviour change among patients.21

Data availability statement

Data are available upon reasonable request. Data from the upstanding GP study or the study materials are available from the corresponding author at gjhb2@leicester.ac.uk. All individual participant data will be available on request 1 year after publication of trial outcomes. The study protocol is available on request. All requests for data access will need to specify the planned use of data and will require approval from the trial investigator team and the sponsor prior to release.

Ethics statementsPatient consent for publication

Consent obtained directly from patient(s).

Ethics approval

This study involves human participants and was approved by the Wales Research Ethics Committee 2 (21/WA/0082). Participants gave informed consent to participate in the study before taking part.

Acknowledgments

We would like to thank all the GPs and patients who took part in the study. Also, our thanks go to the West Midlands CRN and East Midlands CRN who helped identify participating GP practices. This study was conducted in partnership with the Royal College of General Practitioners.