Practicing health promotion: the doctor's dilemma

The News on Health Behavior: Coverage of Diet, Activity, and Tobacco in Local Newspapers

News media are an important and influential part of the social environment, calling attention to certain issues by the amount and nature of their coverage. To better understand howhealth behaviors are covered, we examined more than 80, 000 stories in 1, 354 newspaper issues from four midsize Missouri communities. Health behavior stories were rare. Of 1, 373 stories (1. 7%) that addressed diet, physical activity, or tobacco, few were prominently located in the paper, and only half had a primary prevention focus. A large majority had no local angle, local quotes, or call to action for individuals or the community, and only 10% were generated by local reporters. Because the local newspaper can be especially influential in smaller communities, strategies are needed to help reporters and editors in these settings provide more and better coverage of health behavior-related stories.

Physician counseling of overweight patients about preventive health behaviors

BACKGROUND

Numerous studies show that many primary care physicians (PCPs) do not discuss preventive health behaviors related to diet and exercise with their overweight patients.

PURPOSE

To investigate whether certain counseling approaches by PCPs in their clinical encounters with patients are associated with improvements in care and resource utilization.

METHODS

A total of 2205 patients in a large HMO were surveyed, during November and December 2010, about their health behaviors and perceptions of their interactions with their PCPs. Survey responses from each patient were matched with 48 months of patient-specific medical claims data, from October 2008 through September 2012, capturing the frequency and monetary costs of health care utilization. A series of regression analyses, completed in June 2013, focused on four dependent variables: patients' intentions to improve diet and activity, patients' satisfaction with their physicians, visits to healthcare providers, and health plan spending on treatment.

RESULTS

For each finding, the degree of physician-patient discussion of preventive health behaviors was strengthened when (1) physicians expressed confidence in patients' ability to improve diet and exercise and (2) patients had confidence that their physician could facilitate improvement of these behaviors.

CONCLUSIONS

The associations between physician counseling and subsequent key improvements for overweight patients are strengthened by the physician's confidence in the patient's ability to engage in preventive health behaviors and the patient's confidence in the physician's ability to help in implementing these behaviors. Cultivating such mutual confidence is instrumental in optimizing physicians' influence on overweight patients' health behaviors.

Barriers in the Implementation of a Physical Activity Intervention in Primary Care Settings

Barriers encountered in implementing a physical activity intervention in primary health care settings, and ways to address them, are described in this paper. A randomized comparison trial was designed to examine the impact of health care providers’ written prescriptions for physical activity, with or without additional physical activity resources, to adult, nonpregnant patients on preventive care or chronic disease monitoring visits. Following abysmal recruitment outcomes, the research protocol was altered to make it more appealing to all the participants, i.e., health care providers, office personnel, and patients. Various barriers—financial, motivational, and executive—to the implementation of health promotion interventions in primary health care settings were experienced and identified. These barriers have been classified by the different participants in the research process, viz., healthcare providers, administrative personnel, researchers, and patients. Some of the barriers identified were lack of time and reimbursement for health promotion activities, and inadequate practice capacity, for health care providers; increased time and labor demands for administrative personnel; constrained access to participants, and limited funding, for researchers; and superseding commitments, and inaccurate comprehension of the research protocol, for patients. Solutions suggested to overcome these barriers include financial support, e.g., funding for researchers, remuneration for health care organization personnel, reimbursement for providers, payment for participants, and free or subsidized postage, and use of health facilities; motivational strategies such as inspirational leadership, and contests within health care organizations; and partnerships, with other expert technical and creative entities, to improve the quality, efficiency, and acceptability of health promotion interventions.

Perspectives of family physicians on computer-assisted health-risk assessments

Background

The firsthand experience of physicians using computer-assisted health-risk assessment is salient for designing practical eHealth solutions.

Objective

The aim of this study was to enhance understanding about computer-assisted health-risk assessments from physicians’ perspectives after completion of a trial at a Canadian, urban, multi-doctor, hospital-affiliated family practice clinic.

Methods

A qualitative approach of face-to-face, in-depth, semi-structured interviews was used. All interviews were audio recorded and field notes taken. Analytic induction and constant comparative techniques were used for coding and analyses. Interpretation was facilitated by peer audit and insights gained from the social exchange theoretical perspective.

Results

Ten physicians (seven female and three male) participated in the interviews. Three overarching themes emerged in relation to computer-assisted health-risk assessments: (1) perceived benefits, (2) perceived concerns or challenges, and (3) feasibility. Physicians unanimously acknowledged the potential of computer-assisted health-risk assessments to open dialogue on psychosocial health risks. They also appreciated the general facilitative roles of the tool, such as improving time-efficiency by asking questions on health risks prior to the consultation and triggering patients’ self-reflections on the risks. However, in the context of ongoing physician-patient relationships, physicians expressed concerns about the impact of the computer-assisted health-risk assessment tool on visit time, patient readiness to talk about psychosocial issues when the purpose of the visit was different, and the suitability of such risk assessment for all visits to detect new risk information. In terms of feasibility, physicians displayed general acceptance of the risk assessment tool but considered it most feasible for periodic health exams and follow-up visits based on their perceived concerns or challenges and the resources needed to implement such programs. These included clinic level (staff training, space, confidentiality) and organizational level (time, commitment and finances) support.

Conclusions

Participants perceived computer-assisted health-risk assessment as a useful tool in family practice, particularly for identifying psychosocial issues. Physicians displayed a general acceptance of the computer tool and indicated its greater feasibility for periodic health exams and follow-up visits than all visits. Future physician training on psychosocial issues should address physicians’ concerns by emphasizing the varying forms of “clinical success” for the management of chronic psychosocial issues. Future research is needed to examine the best ways to implement this program in diverse clinical settings and patient populations.

Trial Registration

ClinicalTrials.gov NCT00385034; http://clinicaltrials.gov/ct2/show/NCT00385034 (Archived by WebCite at http://www.webcitation.org/5pV8AGRgt)

Educating physician assistants as agents in cancer control: issues and opportunities

BACKGROUND

Lifestyle factors (eg, smoking, diet) and compliance with screening recommendations play a role in cancer risk, and emerging technologies (eg, new vaccines, genetic testing) hold promise for improved risk management.

METHODS

However, optimal outcomes from cancer control efforts require better preparation of health professionals in risk assessment, risk communication, and implementing health behavioral change strategies that are vitally important to cancer control.

RESULTS AND CONCLUSION

Although physician assistants (PAs) are substantively engaged in cancer-related service delivery in primary care settings, few models exist to facilitate integration of cancer control learning experiences into the curricula used in intense, fast-paced, 24- to 30-month PA training programs.

Cervical Cancer: The Indian Perspective

Cancer of the uterine cervix is the commonest gynaecologic cancer in India, with most women presenting with disease extending beyond the cervix. The majority of women belong to the lower socioeconomic status, are rural, aged between 35 and 64 years and highly noncompliant for complete treatment and follow-up. Opportunistic screening with cytology, colposcopy and test for Human Papilloma Virus and appropriate treatment are available on payment at urban private medical centres but are not available at urban and rural government health centres that are accessed by women of the lower socioeconomic status. The Government's investment in health is 0.9% of the GDP. Thus cytology screening as a government health measure is not feasible. The 'social vaccine' of health empowerment along with visual inspection and appropriate referral by the rural and urban health personnel (Department of Health and Family Welfare); with an additional input of health awareness and motivation by Anganwadi Workers (Department of Women and Child Development), elected women representatives in the Panchayats (Department of Rural Development and Panchayati Raj) and non-governmental development agencies could be a collaborative effort towards "downstaging" cervical cancer. This could lay the foundation for the introduction of cytology screening when resources are available.

Effectiveness of individually tailored calendars in promoting childhood immunization in urban public health centers

OBJECTIVES

We examined the effectiveness of tailored calendars in increasing childhood immunization rates.

METHODS

Parents of babies aged birth to 1 year (n = 321) received individually tailored calendars promoting immunization from 2 urban public health centers. For each baby, an age- and sex-matched control was selected from the same center. Immunization status was tracked through age 24 months.

RESULTS

A higher proportion of intervention than of control babies were up to date at the end of a 9-month enrollment period (82% vs 65%, P <.001) and at age 24 months (66% vs 47%, P <.001). The younger the baby's age at enrollment in the program, the greater was the intervention effect.

CONCLUSIONS

Tailored immunization calendars can help increase child immunization rates.

Strengthening asthma education to enhance disease control

This article focuses on reducing the barriers to effectively applying what is known about asthma patient education. One barrier to effective asthma control in individuals and populations is failure to recognize the range of influences on patients trying to manage their disease, including actions of family, clinicians, friends and neighbors, work or school mates, and significant people and organizations in the wider social environment. Another deterrent is failing to assist patients in developing their self-regulation skills. Other barriers are the lack of attention to the patients' asthma management goals (as opposed to clinical objectives) and overlooking signs that indicate follow-up education is needed. Five actions taken by health-care professionals could significantly enhance the effectiveness of asthma education: (1) make messages to patients and core skills taught consistent with national asthma guidelines; (2) focus on developing the patient's ability to self-regulate; (3) develop comprehensive plans for treatment and education that assign clinicians to appropriate educative roles; (4) use clinician communication techniques demonstrated to enhance asthma management by patients; and (5) ensure that all providers of education are themselves trained to achieve actions 1 to 4.

Clinical preventive medicine in primary care: background and practice: 1. Rationale and current preventive practices

Impressive evidence supports the value of clinical preventive medicine, defined as the maintenance and promotion of health and the reduction of risk factors that result in injury and disease. Primary prevention activities deter the occurrence of a disease or adverse event, e.g., smoking cessation. Secondary prevention (screening) is early detection of a disease or condition in an asymptomatic stage so treatment delays or blocks occurrence of symptoms, e.g., mammographic detection of breast cancer. Tertiary prevention attempts to not allow adverse consequences of existing clinical disease, e.g., cardiac rehabilitation to prevent the recurrence of a myocardial infarction. Preventive services have decreased morbidity and mortality from both acute and chronic conditions. However, these services are underutilized for numerous reasons. Barriers to their use include physician, patient, and health system factors. The traditional disease/treatment model should be modified to incorporate more preventive services. The subsequent 2 parts of this review will discuss suggestions for integrating primary preventive services and screening into primary care practice.

An exploratory study of nursing and medical students health promotion counselling self-efficacy

Self-efficacy of nursing and medical students for client health promotion counselling was examined in an exploratory study using Bandura's (1977) self-efficacy theoretical perspective. Third-year nursing students (n = 41) and fourth-year medical students (n = 60) were compared on their self-efficacy for engaging in clients health promotion activities within 5 areas: smoking, exercise, nutrition, sexually-transmitted diseases and injuries. Their self-efficacy about their knowledge levels in the same 5 areas of health was also compared along with their perceptions of the relative impact of various curricular learning experiences on building health promotion counselling self efficacy. Self-efficacy scores were high for both groups. Nursing students scored significantly higher on both knowledge and ability to counsel patients in the areas of exercise, nutrition and injury prevention. In both groups, confidence in knowledge for health promotion activities was higher than ability to counsel patients. Learning specific health promotion strategies in class and actual practice were strongly associated with nursing students' self-efficacy while practice, feedback on performance, and role modelling were strongest for medical students.

Physician recommendations for diet and physical activity: which patients get advised to change?

BACKGROUND

National objectives and guidelines call upon physicians to help reduce the population burden of chronic diseases by advising patients to eat less fat and get more physical activity. However, studies show physicians are most likely to provide behavioral recommendations to patients who are already sick. Understanding factors that influence physicians' advising decisions can help broaden the reach of these activities.

METHODS

Subjects were 915 adult patients and 27 physicians from four community-based family medicine clinics in southeastern Missouri. To participate, patients completed a self-administered behavioral and health questionnaire while waiting to see their doctor.

RESULTS

Having a high body mass index was the strongest predictor of receiving advice to increase physical activity (OR = 1.6; 95% CI 1.3, 2.0), and having a high cholesterol level was the strongest predictor of receiving advice to eat less fat (OR = 1.9; 95% CI 1.5, 2.4). Neither the actual content of patients' diets nor their levels of physical activity were associated with receiving advice.

CONCLUSIONS

Physicians' advising may be guided by quick but fallible heuristics that systematically exclude patients whose needs are not easily visible. This pattern misses the opportunity to reduce future needs for therapeutic counseling by taking preventive action now.

An adolescent tobacco-use prevention trial in orthodontic offices

OBJECTIVES

This study examined the effect of an orthodontist-delivered tobacco-use prevention program for adolescents.

METHODS

Southern California orthodontic offices were randomly assigned to experimental (n = 77) and control (n = 77) groups. Randomly selected adolescents were interviewed at baseline and 2 years later (n = 15,644). Experimental offices received tobacco prevention training, anti-tobacco materials, and 50 cents for each anti-tobacco "prescription" written.

RESULTS

The 30-day tobacco use 2-year incidence rates for the control and experimental groups were 12.6% and 12.0%, respectively; incidence rates for using tobacco more than 100 times were 7.6% and 6.8%. Differences between the groups did not reach significance. Mean prescription compliance was 64.4%. A multivariate logistic model, showed a significant dose response: patients who received more prescriptions had lower incidence rates than those who received few or none (10% vs 14%).

CONCLUSIONS

Training, payment, and support did not ensure clinician compliance with prevention services. The dose effect suggests that replication under conditions that would ensure clinician compliance and statistical power would more thoroughly test clinicians' ability to prevent tobacco use.

Improving residents' confidence in using psychosocial skills

OBJECTIVE

To evaluate an intensive training program's effects on residents' confidence in their ability in, anticipation of positive outcomes from, and personal commitment to psychosocial behaviors.

DESIGN

Controlled randomized study.

SETTING

A university- and community-based primary care residency training program.

PARTICIPANTS

26 first-year residents in internal medicine and family practice.

INTERVENTION

The residents were randomly assigned to a control group or to one-month intensive training centered on psychosocial skills needed in primary care.

MEASUREMENTS

Questionnaires measuring knowledge of psychosocial medicine, and self-confidence in, anticipation of positive outcomes from, and personal commitment to five skill areas: psychological sensitivity, emotional sensitivity, management of somatization, and directive and nondirective facilitation of patient communication.

RESULTS

The trained residents expressed higher self-confidence in all five areas of psychosocial skill (p < 0.03 for all tests), anticipated more positive outcomes for emotional sensitivity (p = 0.05), managing somatization (p = 0.03), and nondirectively facilitating patient communication (p = 0.02), and were more strongly committed to being emotionally sensitive (p = 0.055) and managing somatization (p = 0.056), compared with the untrained residents. The trained residents also evidenced more knowledge of psychosocial medicine than did the untrained residents (p < 0.001).

CONCLUSIONS

Intensive psychosocial training improves residents' self-confidence in their ability regarding key psychosocial behaviors and increases their knowledge of psychosocial medicine. Training also increases anticipation of positive outcomes from and personal commitment to some, but not all, psychosocial skills.

Processing narratives of self-destructive behavior in routine medical encounters: health promotion, disease prevention, and the discourse of health care

This study asked how patients and doctors process self-destructive behaviors that warrant preventive action, such as smoking, substance use, and sexual practices. Although many suggestions have appeared about how physicians should encourage health promotion and disease prevention by counseling patients about self-destructive personal habits, few studies have examined actual encounters to assess how patients and doctors communicate about these matters, and prior research rarely has considered the social context of self-destructive habits. The present research has been influenced by a growing recognition of narratives, embedded in the sociocultural context of medical encounters, as an important analytic focus in the study of patient-doctor communication. Our conceptual work extended perspectives from literary criticism, critical theory, and narrative analysis in the humanities and social sciences to focus on elements of sociocultural context, ideology, social control, underlying structure, and superficially marginal features of discourse in medical encounters. Based on a critical review of both quantitative and qualitative techniques in research on patient-doctor communication, we developed an interpretive method with systematic criteria to guide the sampling of encounters, transcription of recordings, interpretation of transcripts, and presentation of findings. We applied the interpretive method to 50 encounters selected randomly from a stratified random sample of 336 audiotaped encounters involving patients and primary care internists. As shown by two illustrative encounters, the discourse of health care reinforces ideologic principles of professional surveillance and individual control in dealing with patients' self-destructive tendencies. Contextual issues remain largely marginal features of the discourse, despite their pertinence to the goal of prevention. Narrative analysis provides a useful method to study the processing of self-destructive behavior in medical encounters. Future studies should continue to assess the variability of discourse in dealing with self-destructive behavior and should begin interventions to test the efficacy of differing discourse styles. Meaningful improvements in health-care discourse depend partly on difficult changes in the social context of medicine, including policies that address social conditions contributing to substance abuse and other forms of self-destructive behavior.

Community responsive medicine: defining an academic discipline

Academic medicine is entering a period of introspection created by changing patterns of health and disease and changing patterns in reimbursement and health policy. To respond to existing health challenges, innovative strategies for health care delivery and education must be devised. The migration of medical education and health care delivery into centralized and frequently difficult-to-access campuses is being reviewed by payors, policy analysts, and purchasers of care. One proposed solution to this problem responds to the identified shortcomings in medical education and some of the failures of our health care delivery system. Community Oriented Primary Care (COPC) and the related discipline of Community Responsive Medicine define health-oriented strategies that blend traditional primary care and public health. The classroom in Community Responsive Medicine is the community. The curriculum is defined by the elements and skills necessary to improve the health status of the target community. The model allows the student and resident to appreciate and experience the entire spectrum of health and disease and to understand the sequence of events that may lead to illness. Tertiary care is a critical curriculum component, but in Community Responsive Medicine the curriculum is balanced between the ambulatory and tertiary care settings. Community Responsive Medicine defines a role for new leadership that can create responsive educational and health care delivery systems accountable to the communities they serve.