10. Health Promotion

12/15/11 General Practice, Chapter 10

file:///E:/Downloads/murtagh/GP_Murtagh/html/GP- 1

Chapter 10 - Health promotion and patient educationNever believe what a patient tells you his doctor

said. Sir William Jenner (1815-98)

Health promotion 1

Health promotion is the motivation and encouragement of individuals and the community to see good health as a desirable state that should be maintained by the adoption of healthy practices. It is also the process of helping people obtain their optimal health.For those who feel healthy, the message may have little meaning, but it is reinforced by contact with others who become ill, particularly within the family.

Health educationHealth education is the provision of information about how to maintain or attain good health.There are many methods including the advertising of health practices; the provision of written information, e.g. about diet and exercise, immunisation, accident prevention and the symptoms of disease; and methods to avoid disease, e.g. sexually transmitted disease.

Illness educationA great deal of so-called 'health' education is in reality information about the cause of particular illnesses. Clearly the medical practitioner is in a pre-eminent position to provide his or her patients with specific information about the cause of an illness at the time either individually or to the family. This educative strategy has a preventive objective that is often the modification of help-seeking behaviour.Every consultation is an opportunity to provide information about the condition under care and this can be reinforced in written, diagrammatic or printed form. Patients' own X-rays can be similarly used to illustrate the nature of the problem.

Health promotion in general practiceGeneral practitioners are ideally placed to undertake health promotion and prevention, mainly due to opportunity.There are several reasons for this health promotion role:

Population access: over 80% of the population visit a GP at least once a year. 2On average, people visit a GP about five times each year.GPs have a knowledge of the patient's personal and family health history.The GP can act as leader or co-ordinator of preventive health services in his or her local area. The GP can participate in community education programs.GPs should undertake opportunistic health promotion-the ordinary consultation can be used not just to treat the presenting problem, but also to manage ongoing problems, co-ordinate care with other health professionals, check whether health services are being used appropriately and undertake preventive health activities. 2

Opportunistic health promotionThe classic model by Stott and Davis ( T ab l e 3 . 1 ) highlights the opportunities for health promotion in each consultation. 3 Since the consultation is patient-initiated, it is the doctor who needs to be the initiator of preventive health care. The potential in the consultation involves reactive and proactive behaviour by the doctor ( F i g 10 . 1 ). 4Reactive professional behaviour deals only with the presenting complaint. It may be performed with skill but if the practitioner is only trained to perform reactively then the opportunity for preventive and promotive health care will be lost.



Proactive behaviour is defined as professional behaviour that is necessary for the patient's wellbeing, but it is performed not merely as a response to the presenting problem and it is initiated by the doctor. 4 It includes health promotion, preventive care and screening and the early detection of disease before it becomes symptomatic. Other aspects of proactive care are seen in F i g 10 . 1 .

Fig. 10.1 The potential in every general practice consultation

Proactive behaviour also includes: 4

continuing care of a previously treated problem, e.g. rechecking blood pressure, checking diabetic control, follow-up bereavement counsellingco-ordination of care by organising referral to appropriate agencies or specialists and maintaining adequate medical recordsThe modification of abnormal or inappropriate help-seeking behaviour: e.g. the person who never attends is at risk from 'silent disease'; the too frequent attender wastes resources and serious illness may be overlooked

This mix of reactive and proactive behaviour is not appropriate in every consultation. It requires counselling skills and training in the delivery of quality general practice.

Methods

Being informed and updated by maintaining continuing medical education, especially in preventive roles.Using health promotional material for patient education:

handoutswaiting room posterswaiting room video systems.

Having an efficient medical record system. Operating a patient register and recall system.Encouraging regular health checks for at-risk groups. Providing regular advice on:

nutrition exercisestress management weight control.

Providing personal health records to the parents of newborn babies.

Health goals and targetsHealth goals and targets as determined by the Health Targets and Implementation Committee 5 were set in three areas-population groups, major causes of illness and death, and risk factors ( T ab l e 10 . 1 ). The targets are to achieve significant results by the year 2000 and are expanded under the following headings. The four prime targets are cardiovascular disease, cancer, accident prevention and mental health.



1. Population groups 2 5

The socioeconomically disadvantaged

Goal

To reduce significantly differences in death rates, illness and the prevalence of health risk factors between socioeconomically advantaged and disadvantaged Australians.

Table 10.1 Health promotion areas in which goals and targets have been set

Population groups

The socioeconomically disadvantaged, Aborigines, migrants, women, men, older people, children and adolescents.

Major causes of illness and death

Heart disease and stroke, cancers (including lung, breast, cervical and skin cancer), injury, communicable diseases, musculoskeletal disease, diabetes, disability, dental disease, mental illness, asthma.

Risk factors

Drugs (including tobacco smoking, alcohol misuse, pharmaceutical misuse or abuse, illicit drugs and substance abuse), nutrition, physical inactivity, high blood pressure, high blood cholesterol, occupational health hazards, unprotected sexual activity, environmental health hazards.

Source: Health Targets and Implementation Committee 5

Aborigines

Goal

To reduce significantly the gap in health status between Aborigines and the rest of the Australian population.

Migrants

Goals

To ensure that the health advantage of migrants on arrival in Australia is not eroded by the adoption of less healthy lifestyles or environments.To ensure that the special health needs of refugees on arrival in Australia are met.

Women

Goal

To improve the overall health and well-being of Australian women.

Target

To be determined as part of the National Women's Health Policy.

Men

Goals



To improve the overall health and well-being of Australian men.To reduce the incidence of premature death among Australian men, especially in lower socioeconomic groups.

Older people

Goal

To reduce the percentage of older Australians with health problems that preclude their independence.

Children and adolescents

Goal

To reduce preventable illness, injury and death among Australian children and adolescents.

2. Major causes of sickness and death

Heart disease and stroke

Goal

To reduce avoidable illness and premature death from heart disease and stroke.

Targets

By the year 2000 to achieve a significant reduction in: the death rate from heart diseasethe death rate from strokethe prevalence of smokers (15% or less)the proportion of adults who persistently have a diastolic blood pressure of greater than 90 millimetres of mercurythe prevalence of plasma cholesterol levels of 6.5 millimoles per litre or more in people aged 25- 64 yearsthe mean fasting plasma cholesterol level from 5.6 millimoles per litre to 4.8 millimoles per litre or less in people aged 25-64 yearsthe prevalence of overweight and obesity in people aged 25-64 years the contribution of fat to dietary energydietary sodium intake to 100 millimoles (2.3 grams) or less per day.

To increase participation in sufficient activity to achieve and maintain physical fitness and health.

Lung cancer

Goal

To reduce the incidence of death from lung cancer.

Breast cancer

Goal

To reduce illness and death from breast cancer.

Target

To increase participation in breast cancer screening to 70% or more of eligible women.



Cervical cancer

Goal

To reduce the incidence of death from cervical cancer.

Targets

To increase triennial participation in Pap smear screening of women aged 18-69 years.To establish organised population-based cervical neoplasia screening programs in each state and territory.

Skin cancer

Goals

To reduce illness and death from melanoma and other skin cancers through early detection.To reduce the incidence of all forms of skin cancer through protection against ultraviolet exposure.

Targets

To reduce exposure to ultraviolet radiation.To reduce exposure to ultraviolet radiation for people at high risk of skin cancer.

Injury

Goal

To reduce preventable death and disability from injury and poisoning.

Targets

To reduce:the death rate from drowning to 2 per 100 000 per annum or less in children aged 1-4 years fractures related to playground equipmentthe incidence of poisoning severe enough to require hospitalisationthe incidence of burns and scalds that are severe enough to require hospitalisation the incidence of injury severe enough to require medical attentiondeath and injury due to motor vehicle accidents in children aged 0-4 yearsthe incidence of motor vehicle injury, including whiplash, due to rear-end collisions involving passenger carsillness and death due to alcohol-related motor vehicle accidents

Communicable diseases

Goals

To reduce the incidence of death and disability caused by communicable diseases for which immunisation is available.To eradicate measles, hepatitis B and rubella embryopathy.To minimise illness due to communicable diseases not preventable through immunisation by promoting accurate diagnosis and effective infection control procedures.

Targets



To ensure that evidence of a completed immunisation schedule is used as a condition of primary school enrolment, with exemptions being granted for defined medical, personal or religious reasons. To eradicate indigenous measles.To ensure use of a combined measles/mumps/rubella (MMR) vaccine in all immunisation programs for children.To increase immunity against rubella to 90% or more of women aged 15 to 34 years.To increase participation in screening for hepatitis B surface antigen just before childbirth, of individuals at a high risk of being infected.To ensure that hepatitis B immunoglobulin and a complete course of vaccination is given to all newborn infants of women identified as carriers.To increase vaccination against hepatitis B of newborn infants in populations which have 10% or more of their individuals identified as carriers.To ensure that a contingency plan for the control of epidemics of Australian encephalitis and other mosquito-transmitted diseases is developed.To ensure that maps of the mosquito breeding sites associated with the spread of viral diseases are prepared.To ensure that knowledge of the avoidance of sexually transmitted diseases is gained by adolescents aged 15 years.

Musculoskeletal diseases

Goal

To reduce the prevalence of musculoskeletal diseases.

Diabetes

Goal

To reduce preventable illness, handicap and premature death due to diabetes.

Targets

To establish a national database to record the incidence of diabetes and its complications. To slow down the increase in the prevalence of diabetes in Australia.

Disability

Goal

To reduce the proportion of handicapped people having insufficient social, emotional and physical support to maintain independence.

Dental disease

Goals

To reduce the incidence of dental disease.To reduce inequalities in dental health status.

Mental illness

Goal

To reduce the levels of psychiatric illness and psychosocial problems.



Asthma

Goal

To reduce illness and death from asthma.

3. Risk factors

Drugs

Goal

To minimise the harmful effects of drugs.

Tobacco smoking

Goals

To prevent the onset of smoking in nonsmokers, especially children. To reduce the number of smokers.To reduce the exposure of smokers to tobaccoderived carcinogens. To reduce involuntary exposure to tobacco smoke.

Targets

To reduce the prevalence of smokers to 15% or less.To reduce the difference in the prevalence of smokers between upper white and lower blue collar men. To reduce the prevalence of regular smokers in adolescents aged 15 years.To introduce regulations to prohibit the sale of tobacco products to minors in all states and territories. To introduce legislation or regulations to prohibit smoking on government controlled or regulated public transport and associated buildings in all states and territories.To ensure that all government buildings are smoke-free.To ensure that all enclosed public spaces are smoke-free.

Alcohol misuse

Goals

To reduce the incidence and prevalence of alcohol dependence and other alcohol-related problems. To reduce consumption of alcohol per capita.

Pharmaceutical misuse or abuse

Goals

To reduce the incidence of misuse of pharmaceuticals. To ensure appropriate use of pharmaceutical drugs.

Target

To develop a comprehensive medicinal drug policy pursuant to the recommendations of the World Health Organisation Conference of Experts on the Rational Use of Drugs.

Illicit drugs and substance abuse



Goal



To reduce the use of illicit drugs and substance abuse.

Nutrition

Goal

To reduce the incidence and prevalence of diet-related health disorders.

Targets

To reduce the prevalence of overweight and obesity in people aged 25-64 years. To reduce the contribution of fat to dietary energy.To reduce the contribution of refined sugars to dietary energy.To reduce dietary sodium intake to 100 millimoles (2.3 grams) per day or less. To reduce the contribution of alcoholic beverages to dietary energy.To increase dietary fibre intake to 30 grams per day or more. To increase the level of breast-feeding at 3 months of life.

Physical inactivity

Goal

To increase participation by adults in sufficient activity to achieve and maintain physical fitness and health.

Target

To increase participation in sufficient activity to achieve and maintain physical fitness and health.

High blood pressure

Goal

To reduce the incidence and prevalence of high blood pressure.

Targets

To reduce the proportion of adults who persistently have a diastolic blood pressure greater than 90 millimetres of mercury.To increase the proportion of adults who have had their blood pressure accurately measured within the last 2 years.

High blood cholesterol

Goal

To reduce the incidence and prevalence of high blood cholesterol levels.

Targets

These targets are based on the work of the Better Health Commission Cardiovascular Taskforce.

Occupational health hazards



Goals



To reduce the incidence of occupational illness, injury and death. To provide all workers with a safe and healthy working environment.

Unprotected sexual activity

Goal

To reduce the number of unwanted pregnancies among teenagers.

Target

To reduce both the birth rate and total pregnancy rate for females aged 15 years or less.

Environmental health hazards

Goal

To increase protection against and reduce exposure to environmental hazards posing a threat to health.

Targets

To ensure an adequate supply of good quality drinking water to the whole population.To reduce the number of deaths and injuries caused by the use of hazardous chemicals in the home. To safely dispose of the intractable chemical wastes at present stored in Australia.

Psychosocial health promotionThe preceding health goals and targets focus mainly on physical illness and do not emphasise mental health. However, this area represents an enormous opportunity for anticipatory guidance. It includes the important problems of stress and anxiety, chronic pain, depression, crisis and bereavement, sexual problems, adolescent problems, child behavioural problems, psychotic disorders and several other psychosocial problems.Time spent in counselling, giving advice, stressing ways of coping with potential problems such as suicide and deterioration in relationships is rewarding. GPs need to pay more attention to promoting health in this area, which at times can be quite complex.

Patient educationEvidence has shown that intervention by general practitioners can have a significant effect on patients' attitudes to a change to a healthier lifestyle. If we are to make an impact on improving the health of the community, we must encourage our patients to take responsibility for their own health and thus change to a healthier lifestyle. They must be supported, however, by a caring doctor who follows the same guidelines and maintains a continuing interest. Examples include modifying diet, cessation of smoking, reduction of alcohol intake and undertaking exercise.In an American survey of 360 patients, 90% reported wanting a pamphlet at some or all of their office visits. Overall, 67% reported reading or looking through and saving pamphlets received, 30% read or looked through them and then threw them away, and only 2% threw them away without review. Only 11% of males and 26% of females reported ever asking a doctor for pamphlets. More patients desire pamphlets than are receiving them. 6Patient educational materials have been shown to have a beneficial effect. Giving patients a handout about tetanus increased the rate of immunisation against tetanus among adults threefold. 7 An educational booklet on back pain for patients reduced the number of consultations made by patients over the following year and 84% said that they found it useful. 8 The provision of systematic patient education on cough significantly changed the behaviour of patients to follow practice guidelines and did not result in patients delaying consultation when they had a cough lasting longer than 3 weeks or one with 'serious' symptoms. 9There is no evidence that patient education has a harmful effect. Patient education about drug side effects has been shown not to have any detectable adverse effects. 1 0



One form of patient education is giving handouts (either prepared or printed from a computer at the time of the



consultation) to the patient as an adjunct to the verbal explanation which, it must be emphasised, is more important than the printed handout.The patient education leaflets should be in non-technical language and focus on the key points of the illness or problem. The objectives are to improve the quality of care, reduce costs and encourage a greater input by patients in the management of their own illness. In modern society where informed consent and better education about health and disease is expected, this information is very helpful from a medicolegal viewpoint. The author has produced a book called Patient Education, which has a one-page summary of each of 197 common medical conditions. 1 1 The concept is to photocopy the relevant problem or preventive advice and hand it to the patient or relative. Over the years the greatest demand (following a survey of requests for prints of the sheets) has been for the following (in order):

exercises for your back ( F i g 10 . 2 ) backache ( F i g 10 . 3 )exercises for your neck your painful neck exercises for your kneebreast-feeding and milk supply how to lower cholesterolbreast self-examination testicular self-examination vaginal thrushmenopause anxietycoping with stress depression bereavement

Fig. 10.2 Patient education leaflet (diagrammatic part only): exercises for your lower back



Fig. 10.3 Patient education leaflet on back ache (diagrammatic part only): rules of care for sitting, lying andbending

SummaryRecommended target areas for health promotion in general practice include:

nutrition weight controlsubstance abuse and

control smokingalcohol other drugs

exercise practicesappropriate sleep, rest and recreationsafe sexual practicespromotion of self-esteem and personal growthstress management

Important health promotion recommendations are to encourage patients: 1 2

to cease smokingto reduce alcohol intake to safe levels

women no more than two standard drinks per daymen no more than three standard drinks per daythree alcohol-free days per week

to limit caffeine intake to three drinks per dayto increase regular physical activity

30 minutes per day for 3 days per week, sufficient to produce a sweatto reduce fasting plasma cholesterol to 4.8 mmol per litreto have a diastolic BP of less than 90 mm of mercuryto have a body mass index of between 20 and 25

BMI = (weight in kg) � (height in metres)2

to reduce fat, refined sugar and salt intake in all foodto increase dietary fibre to 30 grams per dayto build up their circle of friends who offer emotional supportto express their feelings rather than suppress themto discuss their problems regularly with some other personto work continuously to improve their relationships with peoplenot to drive a car when angry, upset or after drinking



to have a 2-yearly Pap smear to avoid casual sexto practise safe sexto have an HIV antibody check before entering a relationship

References1. Piterman L, Sommer SJ. Preventive care. Melbourne: Monash University, Department of

Community Medicine, Final Year Handbook, 1993; 75-85.2. National Health Strategy. The future of general practice. Issues paper No 3. Canberra: AGPS,

1992; 54-169.3. Stott N, Davis R. The exceptional potential in each primary care consultation. JR Coll Gen

Pract, 1979; 29: 201-5.4. Sales M. Health promotion and prevention. Aust Fam Physician, 1989; 18:18-21.5. Health Targets and Implementation (Health for All) Committee. Health for all Australians.

Canberra: AGPS, 1988.6. Shank JC, Murphy M, Schulte-Mowry L. Patient preferences regarding educational pamphlets in

the family practice center. Fam Med, 1991; 23(6):429-32.7. Cates CJ. A handout about tetanus immunisation: Influence on immunisation rate in general practice.

BMJ, 1990; 300(6727):789-90.8. Roland M, Dixon M. Randomised controlled trial of an educational booklet for patients presenting

with back pain in general practice. JR Coll Gen Pract, 1989; 39(323):244-6.9. Rutten G, Van Eijk J, Beek M, Van der Velden H. Patient education about cough: Effect on

the consulting behaviour of general practice patients. Br J Gen Pract, 1991; 41(348):289-92.10. Howland JS, Baker MG, Poe T. Does patient education cause side effects? A controlled trial. J

Fam Pract, 1990; 31(1): 62-4.11. Murtagh J. Patient education (2nd edn). Sydney: McGraw-Hill, 1996.12. Fisher E. The botch of Egypt: Prevention better than cure. Aust Fam Physician, 1987; 16:187.

Documents

10. Health Promotion