GPs’ concepts of Health Promotion: a qualitative study.

Katherine MacLurg, MSc MRCGP, Mairead Corrigan, PhD, Margaret Cupples, MD, FRCGP, Keith Steele, MD FRCGP.

Department of General Practice, Queens University Belfast

  

      

 

 

   

    

 

    

     

 

General Practitioners Recently completed vocational training More Experienced

  Focus Group Interviews Interviews

Number 6 6 4

Age (years) 27 - 36 28 - 40 37 – 38

Sex: male(M) / female(F) 2M, 4F 3M, 3F 1M, 3F

Experience in General Practice (years) 1 1 - 2 10 – 11

Urban (U) / Rural (R) 3U, 3R 5U, 1R 2U, 2R

Practice profile: young(Y) / mixed(M) / elderly(E) 2Y, 2M, 2E 2Y, 2M, 2E 3M, 1E

Training Practice: yes (Y) / no (N) 6Y 6Y 2Y, 2N

Work: full time (FT) / part time (PT) 6FT 6FT 2FT, 2PT

Smoking: ex-smokers (EX) / non-smokers (NS) 1EX, 5NS 6NS 4NS

Regular alcohol*: yes (Y) / no (N) 2N, 4Y 6Y 4Y

Regular exercise†: yes (Y) / no (N) 3N, 3Y 3N, 3Y 4Y

Healthy diet‡: yes (Y) / no (N) 6Y 2N, 4Y 4Y * women < 14 units/week, men < 21 units/week. † exercise>20min x3 per week ‡ judged by interviewee

INTRODUCTIONGeneral Practitioners (GPs) are ideally placed to provide professional advice on healthy living1. However suggestions that GPs should offer such advice routinely may overlook the particular circumstances of NHS primary care.2,3 For example it has been shown that decision to offer antismoking advice is multi-factorial and complex.4 Earlier studies reported that GPs had positive attitudes towards health promotion in principle but reservations about it in practice.1,5,6,7 Younger GPs were more positive about health promotion than their senior colleagues.5 There is little current knowledge about what GPs concept of health promotion involves. Information relating to GPs’ attitudes to health promotion is of relevance to its future planning and provision.  

AIMThis qualitative study aims to explore recently trained GPs’ concepts of and attitudes to health promotion. 

METHODSGPs were purposefully selected on the basis of gender, experience and practice characteristics. Six took part in a focus group; ten others were interviewed. Interviews were flexible, allowing in-depth exploration of issues as they emerged. Data collection occurred between June 2001 and January 2002.Primary questions explored: • GPs’ understanding of and attitudes to health promotion• difficulties in implementing health promotion within the consultation,• participants’ views about responsibilities for health • participants' own health behaviours. Secondary questions, developed from analysis of initial transcripts, explored areas such as participants’ views on the media and health promotion guidelines.  

Interviews audiotaped with participants’ consent and tapes were transcribed verbatim

Transcripts were analysed independently by two researchers using a constant comparative method .8

Data was coded using NUD*IST (N5) software.

Codes were developed into broader categories

Categories were refined into four major themes.

Interviewing was discontinued when all the authors agreed that no new themes were emerging. 

PARTICIPANTSThe table below summarises the personal characteristics, health behaviours and practice details of the sixteen general practitioners who participated in the study.

DISCUSSION These GPs had a broad concept of health promotion. They embrace it as an enjoyable part of their professional role and integrate it into every aspect of the consultation. Their sixth sense about when patients are receptive to advice reflects the complex art of general practice. Concern for the doctor patient relationship is an important influence on deciding when to give health promotion advice and has previously been shown to influence other areas of practice.9,10

In this study gender seemed to be relevant to participants; male respondents were more comfortable with male issues and vice versa and our results concur with studies which reported that doctors’ exercise habits11 and alcohol consumption12 influenced their health promotion activity. Our participants found it difficult to advise about alcohol consumption because of its social context13 and because most of them enjoyed drinking alcohol. These doctors felt a moral obligation to give health promotion advice and also felt that they ought to take the advice themselves. This double-sided moral imperative has not been identified previously and demonstrates the extent to which these GPs have internalised health promotion messages from their training into their professional and personal lives. As this is a qualitative study the views of these GPs cannot be generalised to all GPs and what participants say may not be what they do. However, this method allowed us to explore in depth the overall concept of health promotion held by these doctors rather than documenting attitudes to predetermined areas as previous studies have done.1, 5, 6, 7, 14 Our participants were possibly more positive about health promotion than their older colleagues, however they are the future workforce and subsequent presentation of our study to two more generalised groups of GPs confirmed our interpretation of our findings.

CONCLUSIONS These GPs have accepted health promotion as a fundamental part of their professional role and believe in it. Their concept of it is inter-woven throughout their work. The wide scope of the concept identified and the finding that these doctors select relevant areas of health promotion to tackle at appropriate times demonstrate the unique role of general practice in the interpretation of national guidelines for the individual patient and their circumstances. These doctors combine their knowledge of the evidence with their knowledge of patients and a “sixth sense” in their decision-making. This study suggests that recognition should be given for wholehearted involvement of practitioners in health promotion in a holistic sense rather than merely setting targets for specific areas of health promotion. Suggestions that GPs should offer advice routinely undervalue the art of general practice.

RESULTSFour major themes relating to health promotion were identified:

1. Concepts of health promotion Broad Concept•“primary and secondary prevention”•“promoting health and well-being”•“taking a holistic approach to the patient”•cardiovascular risk identification particularly antismoking advice•vaccination; sexual health; antenatal care; cancer screening•advice on stress management, medication use and management of chronic disease.

“Empowering” patients to make health related decisions.Some limited this to providing advice and information: “I think that we are in an advisory role. It is our responsibility to give them the information, to interpret it for them. If the patients want to make the wrong decisions then that is up to them.” (female, age 38, ten years as GP)

Others linked the information to the patient’s social and economic context:“I do find that the more socially deprived they are, the harder it is for them to do it. A good way into it there is to ask, “How much are you spending on cigarettes? Put that money on the fridge and there’s your holiday to Florida.” (female, age 29, two years as GP)

Positive attitudeHealth promotion is seen as an intrinsic part of the normal consultation: “It is automatic. It is part of the general normal consultation. It is integral to the whole thing.” (female, age 37, eleven years as GP)

Most of the participants viewed it as something positive, intrinsically valuable and enjoyable. “I think that is what we should be doing as general practitioners. I think if we could improve health promotion that would save more lives than anything else we do.” (female, age 29, two years as GP)

2. Roles within health promotionPrimary care team. These GPs regarded health promotion as part of their professional responsibility and saw themselves as having a central role in instigating health promotion. “What we use the practice nurse for sometimes is to follow up. Things like monitoring blood pressures and checking cholesterol and giving dietary advice. Some people would possibly listen more to the nurse… it depends on their relationship with her. On the whole, if the GP says it they would take it a lot more seriously.” (female, age 38, ten years as GP)

The Media.The role of the media was seen as complementary to the GP’s personalised approach. “You need the media to increase awareness but you need doctors to provide the professional one to one advice afterwards, to individualise it to the patient.” (female, age 28, one year as GP)

The media is seen as the biggest source of influence for good or bad: “The media has a big role to play. They can raise the profile of health promotion. Even scare stories in the media can be a help.” (female, age 40, one year as GP)

Information disseminated through newspapers, magazines, radio and television had a role in raising the profile of health related issues and taking health promotion to a wider audience: particularly important for those who rarely consult and are therefore less likely to receive opportunistic advice.

Guidelines Mentioned by most participants: many were critical of the large number of guidelines currently in circulation, which were often inappropriate for routine general practice. “I think there are too many guidelines; far, far too many of them. Too many of the same thing from different agencies. Hospital based guidelines from a hospital perspective, which does not lie well with what you get in run of the mill general practice. Unrealistic a lot of them: totally, totally unrealistic.” (female, age 37 eleven years as GP)

Participants applied guidelines pragmatically and adapted them to the context of the consultation. “ I think a guideline is useful, it is condensed evidence based information….that can be fitted in around the patient. It is an optimum management, an ideal management, but general practice isn't an ideal world so a guideline must remain just that.” (female, age 40, one year as GP)

3. Barriers and opportunitiesTimeLack of time was the major barrier to doing more health

promotion: “If I had time I would love to mention it to everybody …but I

must say that unless I'm really well ahead of time it would be well down my list.” (female, age 27, one year as GP)

Doctor /Patient relationshipConcern that unwelcome advice might damage this relationship

was another significant barrier. Nurturing this relationship encouraged GPs to address patients’ complaints first.

“You've got to do something about the problem they have come in with, or they aren't going to be happy.” (male, age 28, one year as GP)

They avoided “nagging” patients and relied on a “sixth sense” about when patients were receptive to health promotion.

“Patients can feel that they are being preached to which is inappropriate.” (male, age 38, eleven years as GP)

“If they don't want the advice then you pick up the non-verbal cues and you know that you're not on to a winner.” (female, age28, one

year as GP)

“Pecking Order”To get around time constraints these doctors developed a

“pecking order” of advice: “I would say if you were to have a pecking order of topics that

you were trying to promote, alcohol would be well down the list” (male, age 29, two years as GP)

They were more inclined to do things that they thought were effective and about which they felt knowledgeable. Anecdotal positive feedback from patients also influenced them.

Opportunistic, tailored adviceThese GPs liked to give advice that was relevant to the

presenting complaint:“If they have a problem that you can pull round it is very easy.

It gives you something to latch on to.” (female, age 29, two years as GP)

“For the vast majority of busy people it probably works better when there is immediate relevance to them. They take it much more seriously if it is connected to something that is happening to them right there and then.” (female, age 37, eleven years as GP)

and tailored for the individual patient: “I mean it has to be geared towards the individual. It's getting

it into the context of their lifestyle. You have to tailor it to everybody individually.” (female, age 40, one year as GP)

“Pivot Points”Advice was given at a “pivot point” (when a patient has been

triggered to consult because of some concern and therefore may be ready to accept advice).

“People come to you when they are worried about themselves and that is often a pivot point for change.” (female, age 37, eleven years as GP)

“It has suddenly become very real in their lives so they are going to be very receptive to that information.”(male, age 38, eleven years as

GP)

Adolescents and young men were seen as a difficult group to reach, as they tended to be healthy, visited the doctor relatively infrequently and had fewer “pivot points”.

4. Characteristics and values.CharacteristicsGender, professional interests and lifestyle influenced what aspects of health promotion they prioritised within their work whereas age, time spent in general practice or practice profile did not. “Well because of being a female I would probably tend to ask most women “have you had your smear?” And because I've done a bit of cardiology I would tend to check people’s blood pressures, lipids, that sort of thing”. (female, age 40, one year as GP)

Giving advice on alcohol consumption was particularly problematic for our respondents possibly because in their culture drinking alcohol is a normal social activity. “I find it quite difficult to take an alcohol history. They look at me and say, you're a rugby player; you have a few drinks... It is a social thing as well.” (male, age 29, two years as GP)

“It wouldn’t be as easy for me to mention alcohol because I like drinking. It is easier for me to mention smoking because I don’t smoke” (female, age 40, one year as GP)

Moral Obligation to adviseThese doctors believed that they had a moral obligation to tackle health promotion in the consultation and felt that withholding relevant advice could be interpreted as condoning unhealthy behaviour“If you have got the power to help somebody and the education base then you do have the moral duty to help them.” (female, age 28, one year as GP)

“I have a duty of care; it is part of my responsibility to provide them with information.” (male, age 28, one year as GP)

Moral obligation to take own adviceThey also described an obligation to make healthy choices themselves: those with less healthy lifestyles were apologetic about it. “I would find it very difficult if I had smoke on my breath and was overweight. The immediate reaction is "well what about yourself?" I mean there is no answer to that.” (male, age 29,

two years as GP)

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