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General Practice, Chapter 10

Chapter 10 - Health promotion and patient

education
Never believe what a patient tells you his doctor
said. Sir William Jenner (1815-98)

Health promotion

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 education
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 methods
to avoid disease, e.g. sexually transmitted disease.

Illness education
A 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 practice

General 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. 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 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 promotion

The classic model by Stott and Davis ( Table 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 ( Fig 10.1 ). 4

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12/15/11

General Practice, Chapter 10

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.

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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 Fig 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 counselling
co-ordination 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

Health 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 ( Table 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 disease
the death rate from stroke
the prevalence of smokers (15% or less)
the proportion of adults who persistently have a diastolic blood pressure of greater than 90
millimetres of mercury
the prevalence of plasma cholesterol levels of 6.5 millimoles per litre or more in people aged
25- 64 years
the mean fasting plasma cholesterol level from 5.6 millimoles per litre to 4.8 millimoles per
litre or less in people aged 25-64 years
the prevalence of overweight and obesity in people aged 25-64
years the contribution of fat to dietary energy
dietary 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 equipment
the incidence of poisoning severe enough to require hospitalisation
the incidence of burns and scalds that are severe enough to require
hospitalisation the incidence of injury severe enough to require medical attention
death and injury due to motor vehicle accidents in children aged 0-4 years
the incidence of motor vehicle injury, including whiplash, due to rear-end collisions involving
passenger cars
illness 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

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Goals

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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 promotion

The 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 education
Evidence 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. 6
Patient 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. 9

There 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. 10
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. 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 back ( Fig 10.2 )
backache ( Fig 10.3 )
exercises for your
neck your painful neck
exercises for your
knee
breast-feeding and milk
supply how to lower
cholesterol
breast self-examination
testicular selfexamination vaginal
thrush
menopause
anxiety
coping 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 and
bending

Summary
Recommended target areas for health promotion in general practice include:
nutrition
weight
control
substance abuse and
control smoking
alcohol
other
drugs
exercise practices
appropriate sleep, rest and recreation
safe sexual practices
promotion of self-esteem and personal growth
stress management
Important health promotion recommendations are to encourage patients: 12
to cease smoking
to reduce alcohol intake to safe levels
women no more than two standard drinks per day
men no more than three standard drinks per day
three alcohol-free days per week
to limit cafeine intake to three drinks per day
to increase regular physical activity
30 minutes per day for 3 days per week, suficient to produce a sweat
to reduce fasting plasma cholesterol to 4.8 mmol per litre
to have a diastolic BP of less than 90 mm of mercury
to 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 food
to increase dietary fibre to 30 grams per day
to build up their circle of friends who ofer emotional support
to express their feelings rather than suppress them
to discuss their problems regularly with some other person
to work continuously to improve their relationships with people
not to drive a car when angry, upset or after drinking

to have a 2-yearly Pap smear

to avoid casual sex
to practise safe sex
to have an HIV antibody check before entering a relationship

References
1. 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.