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Health promotion and lifestyle advice in a general practice: what do patients think?

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Journal of Advanced Nursing
Health promotion and lifestyle advice in a general practice: what do patients think?
Author(s):

Duaso, Maria Jose BSc MA RGN; Cheung, Philip BA MA Ed PhD

Issue:
Volume 39(5), September 2002, p 472–479
Publication Type:
[Issues and innovations in nursing practice]
Publisher:
© 2002 Blackwell Science Ltd.
Institution(s):
Lecturer, School of Nursing, University of Navarra, Pamplona, Spain (Duaso)
Director of the Centre for Comparative Public Health, School for Health, University of Durham, Durham, UK (Cheung)
Correspondence: Maria J. Duaso, Escuela Universitaria de Enfermería, Universidad de Navarra, c/Irunlarrea, s/n, 31008 Pamplona (Navarra), Spain. E-mail: mjduaso@unav.es
Submitted for publication 4 October 2001
Accepted for publication 31 May 2002
Keywords: health promotion, lifestyle advice, risk factors, practice nurses, primary care, postal questionnaire, patient's needs, mass media
Abstract

Background/rationale: Since 1990 health promotion and lifestyle advice has been integrated in general practice and has been mainly undertaken by practice nurses. However little is known about patients' views of the service provided.

Aims of the study: To examine patients' recall and perceptions of lifestyle counselling received from practice nurses in a general practice in the North-east of England. To investigate the extent to which patients' needs are met. To assess the main sources of health information sought by patients.

Design/methods: Cross-sectional descriptive survey. A total of 512 patients were sent a postal questionnaire about current lifestyle, recall of lifestyle advice received and perceptions of the advice provided.

Findings: A response rate of 64% was achieved. Questionnaire analysis revealed unhealthy lifestyles among the population studied that could be addressed through health promotion, e.g. 25% were smokers; 44% exercised occasionally; 40% had a body mass index >25 kg/m2. Advice received on diet was reported by 6% of patients; on exercise by 4%; on smoking by 4% and on alcohol consumption by 2%. Patients were willing to receive more health promotion in areas such as stress, exercise and weight reduction. Magazines (67%) and TV (47%) were selected as the main sources for health promotion information.

Conclusions: Health needs to be promoted. The low rate of lifestyle advice reported by the patients implies that more preventive advice should be provided in primary care settings. More effective health promotion should be planned according to the needs of the practice population.



Introduction

The term health promotion encompasses a range of component activities contributing to health. Health promotion has been conceived as: ‘a multifactorial process operating on communities, through education, prevention and protecting measures’ (Tannahill 1985, p. 167); ‘the process of enabling people to increase control over, and to improve, their health’ (World Health Organisation [WHO] 1986: http://www.who.int ); and as ‘an umbrella term that includes all those activities intended to prevent disease, improve health and enhance well-being’ (Naidoo & Wills 1998, p. 3).

The statement of principles known as the Ottawa Charter for Health Promotion, developed by the WHO, is internationally accepted as the guiding framework for health promotion activity. This charter identified five priority areas of action: building healthy public policy; creating supportive environments; strengthening community action; developing personal skills and reorienting health services (WHO 1986). Yet, it has been criticised for producing a ‘catch-all framework for health promotion in which priorities are unclear’ (Jones 1997, p. 7). The definition of health promotion indicated in the Ottawa Charter is extremely broad, encompassing health education, public policy change, environmentalism and community action.

Health promotion is underpinned by a strong emphasis on healthy public policy. In other words, it is based on the potential to achieve social change via economic, environmental and legal measures. Health promotion is also concerned with helping to raise awareness in the individual on how to prevent illness. However, as Delaney suggests, it would appear unfair to expect any group or individual to operate at all levels in health promotion (Delaney 1994). Therefore, it seems necessary to identify the limits and extent of nurses' contribution to health promotion at a primary care level. In practice, clinical health promotion has been defined as ‘health education and patient counselling aimed at behaviour change in patients at risk for lifestyle related illnesses, or who have diseases for which lifestyle modification can improve function or outcome’ (Herbert 1995, p. 278). According to Herbert's definition, health promotion is related to the provision of help support for people to change lifestyles which are either causing them problems or are potentially harmful.

Townsend in 1982 and Whitehead in 1987, pointed out the link between poverty and health and that the gap in health between the rich and the poor had widened (Townsend & Davidson 1982, Whitehead 1987). Politicians are changing their policies, acknowledging that health and wealth are inextricably linked. It is the responsibility of health professionals to equip individuals with the appropriate knowledge and support and to work with them to provide them with the facilities they need in order to lead a healthier lifestyle.

Since 1990, several measures have been taken in the United Kingdom (UK) to encourage health promotion in primary care settings. The government national health strategy, Saving Lives: Our Healthier Nation, targets heart disease and stroke, accidents, cancer and mental health and identifies professional advice on healthier living as a key component of its national contract for health (Department of Health [DoH] 1999). Nurses and doctors working in primary care have been identified as key figures to promote health. Because of their close relationships with patients registered with GP practice, primary health care teams are more likely to identify health issues and needs of the population and provide health promotion and education accordingly.

However, a decade after the introduction of the 1990 GP contract, how successful has the DoH's intervention been? What contribution have practice nurses been able to make in health promotion terms? Two major randomized controlled trials took place in England to assess the effectiveness of health checks by nurses in reducing risk factors for cardiovascular diseases (Family Heart Study 1994, Imperial Cancer Research Fund OXCHECK Study Group 1995). Although the reports of these studies called into question the efficacy of general population interventions in general practice, they do demonstrate positive effects on health promotion activity in terms of promoting dietary change and reducing cholesterol levels (O'Neill 1994). Qualitative research conducted about nurses' health promotion role, suggest that nurses have a positive attitude to health promotion although their understanding of the concept is more centred on ill-health than well-being (Davis 1995, Le Touze 1996, Sourtzi et al. 1996, Steptoe et al. 1999). Most of the studies have focused on surveying the nurses but there are few that have considered the patients' perceptions of the role of nurses in health promotion (Poulton 1990, Silagy et al. 1992, Eggleston et al. 1995).

The successful implementation of health promotion and health education activities will depend on numerous factors such as resources, expertise, and more importantly the extent to which the practice population is involved in the process of planning. Merely providing the necessary health information does not necessarily result in the modification of the patient's health related behaviour (Whitehead 2001). Health promotion should be tailored to patients' needs. In this study, the current and future health needs of a practice population were identified by means of a postal questionnaire.

The study

The objectives of this study are:

* to examine patients' recall and perceptions of lifestyle advice received from practice nurses in a particular GP practice in the Northeast of England;
* to investigate whether the advice provided in this GP practice meets the needs of the practice population;
* to assess the main sources of health information sought by the patients.
Methods
Setting

The practice is a five-doctor partnership located in a residential area in a town in the Northeast of England. The ancillary staff comprised the practice manager, receptionists, two practice nurses, two health visitors, secretary and computing staff. They also had two midwives, three district nurses and a counsellor who attended the surgery. The surgery provides a range of medical services, including maternity care, cervical smears, family planning, minor surgery, childhood and adult immunizations, healthy heart, asthma and diabetes clinics.

The practice provides primary health care to 9200 patients. The boundary embraces the town area and nine villages around. The ranks of the Indices of Deprivation of the electoral wards served by the practice ranged from 519 to 7713 (with rank 1 being the most deprived ward in England out of a total of 8414 English wards (National Statistics Great Britain 2000).

Sample size calculation (for [alpha] = 0·05)

For the sample size calculation the following requirement was made: the probability that the estimated proportion is within 0·05 of the actual value is at least 0·95 (1–[alpha]). In other words, a 95% confidence interval for the proportion will have a maximum width of 0·10. This requirement is met if the sample size is 384. However literature reviews from previous studies that have used postal questionnaires to patients from a GP practice showed response rates ranging from 60% to 80% (Silagy et al. 1992, Ruta et al. 1997). Assuming a response rate of around 75%, the required sample size was 512 to achieve 384 responses.

Instrument: questionnaire

A structured questionnaire was developed by the researchers. It contained three sets of questions. The first section was designed to obtain data on socio-demographic characteristics including age, gender, marital status and occupation. The second part, measured lifestyle and health status of the sample, using both positive and negative indicators of health, e.g. exercise and fitness vs. presence of illness. Smokers were classified as light smokers (fewer than 15 cigarettes per day), moderate smokers (15–19 cigarettes per day) and heavy smokers (20 or more cigarettes per day) (United States Department of Health and Human Services [USDHHS] 1986). Alcohol consumption was graded according to reported weekly intake of standard units of alcohol. Excessive drinking was defined as 21 or more units for men and 14 or more units for women (DoH 1995). In order to identify the prevalence of obesity and overweight, the WHO's classification on Body Mass Index (kg/m2) was used (WHO 1996). Patients were defined as underweight (if they were under 20 kg/m2), desirable weight (20–25 kg/m2), overweight (25–30 kg/m2) and obese (over 30 kg/m2).

The third part of the questionnaire was concerned with health promotion issues. Patients were asked whether they had received preventive advice about specific aspects of health behaviour from a practice nurse during the preceding 12 months, how useful they had found it and whether they would like to receive any additional lifestyle advice. They were also asked about their main sources of health promotion information.

The questionnaire was piloted with 20 patients who did not take part in the final sample. On the basis of the comments made the questionnaire was revised. No major changes were made. The final sample consisted of 516 subjects selected from the 3612 patients aged from 17 to 45 registered in this practice. A computer generated list ordered by age was obtained and every seventh patient was selected. This would ensure a representative proportion of every age-group. Two mailings were undertaken between February and March 1999. The questionnaire was sent together with a covering letter signed by one of the doctors of the practice explaining the aims of the survey and asking for collaboration. A stamped self-addressed envelope was also provided.

Data analysis

SPSS was used for quantitative analysis. Open questions were codified into groups by content analysis technique and introduced into the data base as categorical variables. Means were compared using Student's t-test. Chi-square test or Fisher's exact test were used in analyses that entailed comparisons of proportions. The missing data were excluded from the analysis. All tests were performed at a two-tailed significance level (P) set at 0·05.

Ethical considerations

The covering letter sent with the questionnaire emphasized that the responses would be confidential. During the data analysis confidentiality was maintained by data coding to eliminate identifying data with personal information.

Results
Survey response

Of the 516 questionnaires initially sent, 21 were returned by the Post Office because of ‘addressee has gone away’ or ‘addressee unknown’. Out of 495 patients, 228 (46%) replied within a month. Then a reminder was sent to nonrespondents. The final response rate was 316 (64%).

In order to assess the representativeness of the results, the response rate by gender, age and post code was studied. According to the Office of Population Censuses and Surveys (OPCS), post code areas can be used as a proxy for social classes (OPCS 1994). Respondents were more likely to be female (P < class="fulltext-IT">P <>

Socio-demographic characteristics

Participants in the study were 34-year-old on average, most of them were married with an average family size of 1·2 children and working full time. Tables 1a and b show socio-demographic characteristics by gender.



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Table 1 Socio-demographic characteristics of participants by gender

Health status and lifestyles

Questionnaire analysis revealed unhealthy lifestyles that could be addressed through health promotion. For example, 25% (95% CI = 21–31) were smokers, from which 63% (95% CI = 51–74) wanted to receive help to quit the habit; 44% (95% CI = 39–50) exercised occasionally; 39% (95% CI = 34–45) had a BMI > 25 kg/m2 (see Table 2). There were significant differences in some lifestyles between male and female. Men drink more than women, and the percentage of overweight was higher among men. However, obesity was more prevalent among women and they seem to become anxious more often.



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Table 2 Prevalence of risk factors among participants by gender

Lifestyle advice rates

The overall reported rate of advice was 6% (95% CI = 3–10) for diet, 4% (95% CI = 2–7) for exercise, 4% (95% CI = 2–7) for smoking, and 4% (95% CI = 2–7) for weight reduction (Figure 1). As expected, those with unhealthy behaviour profiles seem to have received more advice. For instance, 11% of smokers had received advice on smoking or 8% of those with BMI higher than 25 kg/m2 had received advice on weight reduction.



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Figure 1 Lifestyle advice received vs. expected (n = 316). Symbol Percentage of patients who recalled receiving lifestyle advice; [square with 75% upper left to lower right fill] percentage of patients who would like to receive more health promotion.



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Symbol. No caption available.

There appears to be a discrepancy between patients' expectations of lifestyle advice from the practice nurses and the receipt of such advice. Patients were willing to receive more advice on healthier living in areas such as stress, exercise and weight reduction. Figure 1 indicates whether there was a difference between the lifestyle advice received and expected.

As shown in Figure 2, those who had received lifestyle advice from practice nurses (n = 102) found it, on average, very/fairly helpful. However, there were significant differences between male and female perceptions of the advice received from the practice nurses. Most of the female patients found the health promotion provided by nurses in the practice very/fairly helpful while male patients were more dubious about it.



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Figure 2 Patients' evaluation of the lifestyle advice received (n = 102). [chi]2 = 9.84; d.f. 3; P < linkindex="106" class="fulltext-GX" href="http://ovidsp.uk.ovid.com/spa/ovidweb.cgi#FSM1">Symbol Women.

Sources of health information

When asked about the main sources of health promotion information, magazines (67%; 95% CI = 62–73) and television (47%; 95% CI = 41–53) rated the highest. Health professionals had lower rates: 22% (95% CI = 18–28) cited the doctor, 14% (95% CI = 10–19) the chemist and only 5% (95% CI = 3–8) of them referred to the practice nurse. As can be seen in Figure 3, while significantly more women than men chose magazines as the main source (P < class="fulltext-IT">P <>


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Figure 3 Main sources of health information (n = 316) (participants could indicate more than one source of information). [square with 75% upper left to lower right fill] Men; Symbol Women.

Discussion

This study explored patients' recall and perceptions of lifestyle counselling received from practice nurses in a general practice in the North-east of England. The results reflect the situation in a particular practice, therefore wider generalizations cannot be established. In spite of these limitations, this study provides some evidence that can enable practice nurses to plan future services according to the client's needs.

Although the accuracy of our estimate is limited by the restricted response rate, results of this study suggest that there is still considerable room for improvement in preventive activity. The questionnaire sent to 516 patients of the practice, reveals unhealthy lifestyles among the population that can and should be addressed through health promotion. Obesity, or being overweight, together with smoking, stressful environment, excessive alcohol consumption and lack of physical activity were prevalent among the population studied and form a group of lifestyle risk factors associated with increased morbidity and mortality from noncommunicable diseases (WHO 1996).

Smoking, for instance, is the single greatest cause of avoidable illness and preventable ill health in UK (DoH 1998a). In the present study, one in four respondents was a smoker; 63% of smokers wanted to receive help to quit the habit. However, only 11% of the smokers who visited the surgery during the previous year had received health promotion advice from the nurses, encouraging them to give up smoking. The findings suggest that more emphasis should be placed on regular smoking screening and smoking cessation clinics which would be welcomed by the patients.

According to recent accounts, obesity leads to much suffering in the UK by contributing to chronic disease and premature mortality (Great Britain Parliament House of Commons Committee of Public Accounts 2002). The increase in obesity reflects changes in lifestyle, people being more sedentary and a diet richer in energy dense foods (DoH 1998b). In the present survey, 44% of the men and 15% of the women were overweight and 8% of men and 15% of women were obese. However, general practices are uniquely placed in the management of obesity, as they are often the first port of call to those seeking help. Practice nurses can play a valuable role identifying patients with weight problems and in providing advice and support on weight control.

Mental health was also shown to be an important issue among this practice population. Anxiety, also appeared to be a common problem: one in two women and one in three men reported becoming anxious about things often/very often. Stress management was the most selected topic (33%) when asked about the kind of health promotion information they were willing to receive. However, only 1% patients recalled having received advice in this area. This is consistent with recent reports that claim that in England, on average, family doctors identify only about half of the people who come to them with depression and anxiety (DoH 1999).

Because of their close relationships with patients registered with the surgery, practice nurses would appear to be in an ideal position to identify the health issues and needs of the population and provide health promotion accordingly. However our results suggest that the frequency with which patients recall having received lifestyle advice was low. This rate is consistent with previously reported studies (Silagy et al. 1992, Deehan et al. 1998, Little et al. 1999). Therefore, more emphasis should be placed on health promotion, particularly through the use of screening instruments and brief interventions.

Part of the explanation for the low advice rates observed inthis study may be because of the reporting bias. Underreporting by patients might be either because they forgot that advice was offered or because they failed to recognize that advice was given. Lack of training in lifestyle counselling has also been perceived as a problem. Steptoe et al. (1999) found that the majority of the nurses felt that lifestyle counselling was difficult and thought that the influence on their patients was limited. Additional training for health professionals especially those who are closely involved in health promotion should be provided. A further explanation of the low advice rates maybe the lack of time. Previous studies have shown that nurses have a positive attitude to health promotion although they identified problems with administration and data collection (Le Touze 1996, Broadbent 1998) Appropriate resources are required for lifestyle surveillance in each practice so that future actions can be planned and implemented based on research evidence.

Mass media resources have an enormous potential to influence health-related behaviour (Flyn et al. 1994, Finnegan et al. 1999). Patients in this practice have reported TV and magazines to be the main sources of health information. It has been claimed that the incorporation of health-related mass media initiatives into nursing's health promotional role can increase the overall effectiveness in a very interesting and empowering way (Whitehead 2000). Nurses in primary care could incorporate effective mass media resources into their practices, improving current levels of health promotion advice.

Although our results suggest that the frequency with which patients recall having received lifestyle advice is not very high, patients in this practice were interested in receiving more health education and on average, patients found the advice received from the practice nurses very/fairly helpful. This should encourage nurses working in primary care to continuing developing and improve their practice providing patients with the ability and opportunity and power to change.

Conclusion

This study raises a number of preventive and public health issues. First, there is a need for regular and planned health surveillance in each GP practice, so that preventive health strategies are updated and that those who carry a number of health risks can be targeted. The lack of human and financial resources places severe constraints on primary health services. Nurses working in primary care should review their practices and be innovative in their approach to health promotion. It would appear that media, particularly magazines and TV have a major role to play in providing counselling and advice.

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Keywords: health promotion; lifestyle advice; risk factors; practice nurses; primary care; postal questionnaire; patient's needs; mass media


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