GPs

1
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

• INTRODUCTION
• General 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.
•  
• AIM
• This qualitative study aims to explore recently
  trained GPs concepts of and attitudes to health
  promotion.
•  
• METHODS
• GPs 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 NUDIST (N5) software.

RESULTS Four 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 patients
  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 theres your holiday to Florida.
  (female, age 29, two years as GP)
• Positive attitude
• Health 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.

2. Roles within health promotion Primary 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 GPs
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)

• Barriers and opportunities
• Time
• Lack 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 relationship
• Concern 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 advice
• These GPs liked to give advice that was relevant
  to the presenting complaint

 
 
 
4. Characteristics and values. Characteristics Gen
der, 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 peoples 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 wouldnt be as easy for me to mention
alcohol because I like drinking. It is easier for
me to mention smoking because I dont smoke
(female, age 40, one year as GP) Moral
Obligation to advise These 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
advice They 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)
  women lt 14 units/week, men lt 21 units/week.
exercisegt20min x3 per week
judged by interviewee
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.
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
References 1. McAvoy BR, Kaner EFS, Lock CA,
Heather N, Gilvarry E. Our Healthier Nation are
general practitioners willing and able to
deliver? A survey of attitudes to and involvement
in health promotion and lifestyle counselling. Br
J Gen Pract 1999 49 187-190. 2. West R, McNeil
A, Raw M. Smoking cessation guidelines for
health professionals an update. Thorax 2000 55
987-999. 3. McAvoy BR. A scandal of inaction how
to help GPs implement evidence-based health
promotion. Br J Gen Pract 2000 50 180-1. 4.
Coleman T, Murphy E, Cheater F. Factors
influencing discussion of smoking between general
practitioners and patients who smoke a
qualitative study. Br J Gen Pract 2000 50
207-210. 5. Bruce N, Burnett S. Prevention of
lifestyle related disease general practitioners
views about their role, effectiveness and
resources. Fam Pract 1991 8(4) 373-377. 6.
Williams SJ, Calnan M. Perspectives on
prevention the views of general practitioners.
Sociol Health Illness 1994 16 372-393. 7.
Steptoe A, Doherty S, Kendrick T, Rink E, Hilton
S. Attitudes to cardiovascular health promotion
among GPs and practice nurses. Fam Pract 1999 16
(2) 158-163. 8. Strauss A, Corbin J. Basics of
qualitative research grounded theory procedures
and techniques. Newbury Park, California Sage
Publications Inc, 1998 197-223. 9. Summerskill
WSM, Pope C. I saw the panic rise in her eyes
and evidence-based medicine went out of the
door. An exploratory qualitative study of the
barriers to secondary prevention in the
management of coronary heart disease. Fam Pract
2002 19(6) 605-610. 10. Tomlin Z, Humphrey C,
Rogers S. General practitioners perceptions of
effective health care. BMJ 1999 318
1532-1535. 11. McKenna J, Naylor P-J, McDowell N.
Barriers to physical activity promotion by
general practitioners and practice nurses. Br J
Sports Med 1998 32 242-247. 12. Anderson P.
Managing alcohol problems in general practice.
BMJ 1985 290 1873-1875. 13. Deehan A, Marshall
EJ, Strang J. Tackling alcohol misuse
opportunities and obstacles in primary care. Br J
Gen Pract 1998 48 1779-1782. 14. Coleman T,
Wilson A. Anti-smoking advice in general practice
consultations general practitioners attitudes,
reported practice and perceived problems. Br J
Gen. Pract 1996 46 87-91.