The Views of General Practitioners in Iran About Prevention and Health Promotion and Related Obstacles in Clinical Practice

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1 ORIGINAL ARTICLE The Views of General Practitioners in Iran About Prevention and Health Promotion and Related Obstacles in Clinical Practice Taraneh Dormohammadi Toosi, Amirreza Azizian, Nader Roushan, Zahra Khazaeipour, Maryam Soleimanzadeh Faculty of Medicine, University of Tehran, Tehran, Iran Correspondence mail to: ABSTRACT Aim: to explore the awareness and attitudes of Iranian GPs in implementing evidence-based health promotion and disease prevention recommendations in primary care and to describe GPs perceived barriers to implementing these recommendations. Methods: our survey was carried out in 2007 in a random sample of GPs listed from an educational symposiums held for general practitioners. We developed and pre-tested a questionnaire, it was piloted with 417 GPs in general practitioners educational symposiums attending all parts of Iran. Those who did not respond received follow-up mailings and/or telephone calls. Our data management center started data entry and analyzing as soon as the questionnaires were sent back. Discrete variables were expressed as percentages and were compared with the chi-square test or Fisher s exact test as appropriate. Continuous variables were compared by means of the unpaired, two-sided t test. All statistical analyses were performed using SPSS software Version 13. Statistical significance was accepted for P<0.05. Results: four hundred and seventeen GPs participated in the study. Although they believe they should advise preventive and health promotion activities, in practice, they are less likely to do so. The two most important barriers reported were weak patients interest in screening tests no reimbursement for GPs. Associations between personal health behaviour and attitudes to health promotion or activities in prevention were found. GPs who exercised felt that they were more effective in helping patients to practice regular physical exercise than sedentary GPs. (P<0.001). Conclusion: significant gaps between GP s knowledge and practices persist in the use of evidence-based recommendations for health promotion and disease prevention in primary care. Key words: attitudes, prevention, health promotion, clinical practice, general practice. INTRODUCTION Health care services always face the concern about indication for screening examinations and their safety. Besides, they also are challenging the matter that how they could maintain population healthcare with wise investment of limited budgets. The cornerstone for maintaining health and giving attitudes to general population are general physicians (GPs) and it is quite normal for a GP to hesitate and being uncertain about the treatment method that he/she chooses. Therefore, it emphasizes the role of GPs in Prevention, stating that the general practitioner involves with various aspects about the fields of prevention, diagnosis, cure, care and palliation, using and integrating the sciences of biomedicine, medical psychology and medical sociology. 1 General physicians are the best to give advice to their patients at visit time and this relation leads gradually to promoting health. Furthermore, the relation between physician and doctor, allows the doctor to determine the best way for his/her patient to maintain patient s health. These altogethers come from the point that we can realize that what is GP s idea about their patients and to prevent disease. The Canadian Task Force on the periodic health examination 2 and the US Preventive Services Task Force 3 are two organizations that have released one of the most comprehensive guideline for disease prevention. These two organizations suggest a few numbers of laboratory screening tests and some tests for patients who are at risk for specific diseases. Regarding surveys conducted in The United States, it has been shown that general physicians are not fully aware of screening tests, and they order great numbers of unnecessary laboratory test, which had not been proved to be effective for their patients

2 Taraneh D. Toosi Acta Med Indones-Indones J Intern Med There are documents that other courtiers have also established guidelines for their general practitioners to give more information about maintaining health care and disease prevention with simple, yet effective screening test to prevent disease. 5,6 We were in shortage for studies similar to our idea, but our goal was to conduct our study to get the idea that how GPs perceive risk of disease, and how this perception is influenced by the way the risk is presented, e.g., whether changes in risk are presented in absolute or relative terms and compare our results with other coutries. METHODS Our survey was carried out in 2007 in a random sample of GPs listed from an educational symposium held for general practitioners. We developed and pre-tested a questionnaire that included the following parts; the first with demographic and professional data (8 questions), the second one including a list about their personal life styles and habits (8 questions), a third part about different preventive and health promotion activities with 4 different columns for responses beliefs and attitudes in practice (9 questions), and the fourth part which included items of their perception personally about serial clinical exams for themselves. (9 questions), and the last part with items related with barriers and patients expectations in implementing preventive activities (9 questions). The questionnaire was piloted with 417 GPs in general practitioners educational symposiums attending all parts of Iran. The questionnaires (addressed and stamped return envelope) were mailed to all physicians in Those who did not respond received follow-up mailings and/or telephone calls. Statistical Analysis Our data management center started data entry and analyzing as soon as the questionnaires were sent back. Discrete variables were expressed as percentages and were compared with the chi-square test or Fisher s exact test as appropriate. Continuous variables were compared by means of the unpaired, two-sided t test. All statistical analyses were performed using SPSS software Ver.13. Statistical significance was accepted for P < RESULTS A total number of 417 Iranian general practitioners took part in this survey. The mean age was 37 years (SD±8.8) 46.6% (n=193) of them were female and 53.4% (n=221) were male GPs. Table 1 shows age and sex characteristics of respondents. Professional characteristics requested in the first part of the questionnaire are shown in Table 2. Table 1. Demographic characteristics of GP participants (N = 417) Gender Female Male Variables Percentage (%) Marital status Single Married Widowed Divorced Place of work Private clinic Primary health care Hospital Other 46.6% 53.4% 29.4% 69.6% 0.5% 0.5% 33.2% 14.9% 13.9% 38% Table 2. Professional characteristics of GP participants (N = 417) Variables Percentage (%) Smoking status Non smoker Smoker Quitted Physical activity Never 1-3 times in a month > 3 times in a month Knowledge of Blood pressure Good Fair Knowledge of cholesterol Good Fair Knowldege of blood glucose Good Fair 88.9% 7.9% 3.2% 27.7% 20.7% 51.6% 89.6% 10.4% 73.3% 26.7% 78.2% 21.8% One of the parts of the questionnaire included questions about GPs perception of carrying out prevention and health promotion activities and of barriers in implementation about themselves, and its results is shown in Table 3. Table 4 reflects perception of general practitioners regarding the efficacy of prevention and health promotion in clinical practice. Table 5 shows the barriers perceived by GPs and patients prospect to implement health promotion and preventive activities by them. 116

3 Vol 41 Number 3 July 2009 The Views of General Practitioners in Iran Table 3. Perception of general practitioners regarding the efficacy of prevention and health promotion activities about themselves Variables No Not Percentage Slightly Very Blood pressure screening 2% 11.3% 35.7% 51% Measuring serum cholesterol level 7.5% 14.3% 33.2% 45% Screening for diabetes 5.5% 14.9% 33.2% 48.6% Quitting smoking habit 6% 6.6% 12.9% 74.4% Controlling ideal BMI 2.8% 6.1% 34.9% 56.2% Screening mammography 22.1% 19.6% 30.2% 28.1% Screening for colorectal cancer (OB, colonoscopy or rectosigmoidoscopy by 29.5% 25.1% 27.9% 18.5% indication) Screening for cervix cancer (pap smear) 26% 13.9% 27.4% 32.7% Screening for prostate cancer (PSA) 25.5% 18.3% 24.5% 31.7% Table 4. Perception of general practitioners regarding the efficacy of prevention and health promotion in clinical practice Percentages Variables No Not Slightly Very Blood pressure screening 0.2% 1% 12.8% 86% Measuring serum cholesterol level 0.2% 0.7% 23.8% 75.2% Screening for diabetes 0.2% 1.4% 13% 85.3% Quitting smoking habit 1.2% 5.8% 17.1% 76% Controlling ideal BMI 0.5% 3.6% 27.3% 56.2% Screening mammography 0.7% 5.3% 29% 65% Screening for colorectal cancer (OB, colonoscopy, or rectosigmoidoscopy by 1.2% 12% 34.9% 51.8% indication) Screening for cervix cancer (pap smear) 1% 3.1% 21% 74.9% Screening for prostate cancer (PSA) 0.7% 6.5% 36.1% 61.2% Younger GPs had more trends to carry out screening exams about themselves were more successful to advise the same matters to their patients than their older colleagues. (P=0.002 r=0.22) Similarly, younger GPs believed that they should take more active part in disease prevention and health promotion according to questions in Table 5 (P<0.001 r=0.21). Both males and females had the same points of view about applying disease prevention and health promotion according as either about them or in clinical practice. Moreover, both groups believed in the same character as a GP in health promotion according to Table 5. We detected the same relationship between marital status and items mentioned above. Sedentary GPs advised sedentary patients to perform regular physical exercise less often than GPs who exercised regularly. (P<0.001) In addition, GPs who exercised more than 1to 3 times as in month felt that they were more effective in helping patients to practice regular physical exercise than sedentary GPs (P<0.001). A GP s awareness of his/her serum fasting blood sugar(fbs) and cholesterol plays a significant role in advising their patients to keep their lipid profile and FBS in Ideal levels. (P=0.019 and P=0.003, consecutively) 117

4 Taraneh D. Toosi Acta Med Indones-Indones J Intern Med Table 5. GPs point of view regarding barriers in implementing health promotion and preventive activities Patients believe that health promotion must be a part of clinical practice by GPs Patients expect the physician to carry out the same health advice which he/she gives to patients Patients believe that GPs not only must cure diseases, but also gives health advice to his/her patients You have high motivation for prevention and health promotion activities as well as curing diseases You are known as a GP and an activist about health promotion activities as well by your patients It is easy for you to do your daily job in addition to prevention and health promotion activities You are a well trained and skillful GP about prevention and health promotion activities You perform the same advice about disease prevention and health promotion about yourself as well It seems to be hard to prevent diseases and health promotion activities Agree Disagree No opinion 82.4% 8.3% 9.3% 92.3% 2.9% 4.8% 92.5% 4.1% 3.4% 79.0% 8.8% 12.2% 92.2% 2.7% 5.1% 70.8% 22% 7.2% 47.8% 34.9% 17.3% 83% 7.6% 9.3% 34% 52.8% 13.3% Obese GPs (BMI =30 g/m) 2 and non-obese GPs played the same role in advising overweight patients to reduce weight and in the perception of effectiveness in helping patients to achieve or maintain normal weight. No differences were found regarding the carrying out of mammography between female GPs having undergone mammography and those who have not. Likewise, female GPs having undergone cervical cytology carried out cytological tests on their patients the same as women GPs who have not undergone cervical cytology. GPs who smoked felt less effective in helping patients to reduce tobacco consumption than non-smoking GPs, but results are not statistically significant. General physicians of all age ranges approved the efficacy of prevention and health promotion in clinical practice, so we found no meaningful difference between age and age and GPs beliefs about the matter. DISCUSSION Although our data were gathered in GPs symposium from all over Iran, we still believe that these data do not necessarily give us a scheme from all Iranian GPs and we think that this study should be done with cooperation of universities and medical colleges in all states in larger scales. It is not easy to compare our results with the ones obtained in other surveys because of variations in their methods. In brief, we found out that it seems time taking for general physicians to ask their patients about various aspects of their patient s lifestyles. In such conditions, physicians are less intense to play their role as health matter advisors and health promoters and tend to ask for laboratory tests in order to advise their patients. There are similar studies done on GPs in other parts of the world, and points out the matter that GPs tend to play their treatment role and they are less keen to act as health promoter or disease preventor. 7, 8 Surprisingly, we realized that measuring weight, height and BMI was at the bottom of the tasks that every GP should perform, and they did not focus on to the point that obese patients are at risk for many diseases, while these patients could get the best benefits by reducing their weight by simple dietary advice as a disease prevention task. On the contrary, about 40% of GPs showed tendency for some disease screening, which are not yet mandatory to be performed in our national prevention program, (such as screening for lung cancer) nor other countries have enrolled them in their screening programs. Hence, the efficacy of such tests is not completely proved. Even The Canadian Task Force on the Periodic health Examination 2 and the US Preventive Services Task Force 3 which have released one of the most comprehensive guideline for disease prevention, have not advised these tests for smoker population. Moreover, it 118

5 Vol 41 Number 3 July 2009 is still controversial that prescribing laboratory tests for early detection of prostate cancer could be of great help for asymptomatic general population. 9,10 The reason that other GPs did not request for screening test, may be the fact that the general population are not fully aware of its benefits. Concisely, clinicians have various ideas about screening tests: some confirm the idea that early detection of some disease is obtainable only by screening tests in normal population, while others mention the fact that a national screening test should be not only clinically proved, but also highly benefited to prescribe. We also noticed that GPs were relatively successful in advising their patients to loose their weight, avoid smoking, reduce their weight and physical exercise. There are other surveys that approve our results. The results from a study on 200 GPs in Quebec, Canada showed that general physicians felt they could be effective to change their patients behaviors. The results from another study done in Denmark revealed that general physicians claimed changing impaired lifestyle was a part of their responsibility. 11,12 Amazingly, we found the relation between the general practitioners health attitudes and their activity as health promoter and disease preventor. GPs with less healthy lifestyle were less intense to give advice to their patients about improving their attitudes. Some other studies approve the mentioned result that the health care personnel with less healthier lifestyle, are less effective to change normal population life style. 13,14 We found some other studies that did not approve of the results from later studies, and the author rejected the relation between general practitioners health attitude and their effectiveness to change their patients life style. However, one probable reason for failing to find a significant relation was due to small participants in this study. 15 On the contrary, the study on female American general physicians showed that those who felt more responsible about disease prevention and health promotion in their patients, they themselves had healthier life attitudes than other GPs. 16 CONCLUSION Our study on 417 Iranian GPs provided us better concepts about their point of view about disease prevention and health promotion and related obstacles about health services performance. We also could realize that results from personnel s health attitude and their concepts about disease prevention, with no doubt, have great effect on their patients as the target The Views of General Practitioners in Iran population. Furthermore, we understood the gap between GPS knowledge and their routine errors in their office work. To mention the last point, it is importance to consider our GPs as the specific members of our society which their life habits and concepts about healthy life style would directly affect their task as disease preventer or health promoter. ACKNOWLEDGMENT The authors would like to thank Farzan Institute for Research and Technology for technical assistance. REFERENCES 1. Olesen F, Dickinson J, Hjortdahl P. General practice Time for a new definition. Br Med J. 2000; 320: Canadian Task Force on the Periodic Health Examination. Clinical preventive health care. Ottawa, Ontario Canada Communications Group; US Preventive Task Force. US preventive services task force. Guide to C. Brotons et al. Preventive Medicine. 2005;40: Six hundred clinical preventive services. second ed. Baltimore, MD7: Williams and Wilkins; Prochazka AV, Lundahl K, Pearson W, Oboler SK, Anderson RJ. Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers. Arch Intern Med. 2005;165: Hogg W, Lemelin J, Moroz I, Russell G. Improving prevention in primary care: Evaluating the sustainability of outreach facilitation. Can Fam Physician. 2008;54: Margolis P, Lannon CM, Stuart JM, Fried B, Keyes-Elstein L, Moore D. Practice based education to improve delivery systems for prevention in primary care: randomized trial. BMJ. 2004;14: Lopez-de-Mountain J, Torcal J, Lopez V, Garay J. Prevention in routine general practice: activity patterns and potential promoting factors. Prev Med. 2001;32: Holmboe ES, Wang Y, Tate JP, Meehan TP. The effects of patient volume on the quality of diabetic care for Medicare beneficiaries. Med Care. 2006; 44: Haggerty J, Tudiver F, Brown JB, Herbert C, Ciampi A, Guibert R. Patients anxiety and expectations: How they influence family physicians decisions to order cancer screening tests. Can Fam Physician. 2005;51: Bunting PS, Goel V, Williams JI, Iscoe NA. 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6 Taraneh D. Toosi Acta Med Indones-Indones J Intern Med 14. Sherman SE, Hershman WY. Exercise counselling: how do general internists do? J Gen Intern Med. 1993;8: Steptoe A, Doherty S, Kendrick T, Rink E, Hilton S. Attitudes to cardiovascular health promotion among GPs and practice nurses. Fam Pract. 1999;16: Frank E, Rothenberg R, Lewis C, Belodoff BF. Correlates of physicians Prevention-related practices. Findings from the women physicians health study. Arch Fam Med. 2000; 9: