Chapter 7: Health promotion and patient education

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 to increase control over and improve their health (WHO definition 2009).

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.

The Lalonde report¹ highlighted the notion that all causes of death and disease had four contributing elements:

• inadequacies of the existing health care system

• environmental hazards

• behavioural factors and unhealthy lifestyles

• human biological factors

Health 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 information about methods to avoid disease (e.g. sexually transmitted infection).

A lot 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.

GPs 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 visits a GP at least once a year.²

• On 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 coordinator 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, coordinate care with other health professionals, check whether health services are being used appropriately and undertake preventive health activities.²

The classic model by Stott and Davis (see TABLE 3.1 in CHAPTER 3) 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 (see FIG. 7.1).⁴

Reactive 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 well-being, 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 FIGURE 7.1.

Proactive behaviour also includes:⁴

• continuing care of a previously treated problem (e.g. rechecking blood pressure, checking diabetic control, follow-up bereavement counselling)

• coordination of care by organising referral to appropriate agencies or specialists and maintaining adequate medical records

• the 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:

  • — handouts

  • — waiting room posters

  • — waiting 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

  • — exercise

  • — stress management

  • — weight control

• Providing personal health records to the parents of newborn babies.

Health goals and targets as determined by the Health Targets and Implementation Committee⁵ were set in three areas—population groups, major causes of illness and death, and risk factors (see TABLE 7.1).

The seven priority health areas for Australians are:⁵

• asthma

• cancer control

• cardiovascular health

• obesity control

• diabetes mellitus

• injury prevention and control

• mental health

GPs can provide a simple framework to encourage patients to adopt a healthy lifestyle whether they have a particular disorder or not. The acronyms act as a good aide-mémoire for practitioners for opportunistic health promotion.

The SNAP guide⁶

The SNAP guide was developed by the Royal Australian College of General Practitioners to address important risk factors with patients with a view to encouraging change if appropriate. The guide comes as a comprehensive booklet and includes the ‘Estimation of absolute 5-year risk of cardiovascular events’ tables.

The SNAP guide can be summarised by the following risk factors.

• S = Smoking

• N = Nutrition

• A = Alcohol

• P = Physical activity

The guide emphasises that there are health inequalities in the community because the risk factors are far more prevalent in people from low-socioeconomic-status backgrounds and Indigenous Australians.

The guide focuses on the ‘5 As’ as stages of change theory to promote change on lifestyle where appropriate (see TABLE 7.2).

This information can be accessed at http://www.racgp.org.au/guidelines/snap.

The NEAT guide

The NEAT guide (see TABLE 7.3) is similar to the SNAP guide, but with a greater emphasis on counselling the patient about lifestyle and the importance of stress management.

There is a tendency for health goals and targets to focus mainly on physical illness and 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, bullying, domestic abuse, child behavioural problems, psychotic disorders and several other psychosocial problems.

Time spent in counselling, giving advice and 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.

Evidence has shown that intervention by GPs can have a significant effect on patients’ attitudes to a change to a healthier lifestyle. If we are to have 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 desired pamphlets than received them.⁷

Patient education materials have been shown to have a beneficial effect. Giving patients a hand-out about tetanus increased the rate of immunisation against tetanus among adults threefold.⁸ An education 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.⁹ Providing 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.¹⁰

One form of patient education is giving hand-outs (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 hand-out.

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 345 common medical conditions.¹¹ 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 lower back (see FIG. 7.2)

• backache

• exercises for your neck

• your painful neck

• exercises for your knee

• breastfeeding and milk supply

• how to lower cholesterol

• breast self-examination

• testicular self-examination

• vaginal thrush

• menopause

• anxiety

• coping with stress

• depression

• bereavement