Community Views About the Role of General Practitioners in Disease Prevention

Transcription

1 Family Practice Oxford University Press 199 Vol. 6, No. 3 Printed in Great Britain Community Views About the Role of General Practitioners in Disease Prevention KAREN J SLAMA. SELJNA REDMAN, JILL COCKBURN* AND ROBERT W SANSON-RSHER Slama K J, Redman S, Cockburn J and Sanson Fisher R W. Community views about the role of general practitioners in disease prevention. Family Practice 199; 6: The role of preventive medicine in reducing mortality and morbidity is now widely recognized. Although general practitioners appear to be in an excellent position to offer preventive care, there is evidence that they currently do not detect or intervene for common risk behaviours. One reason for this may be the general practitioner's perception that patients do not expect such preventive activities to be a part of the doctor's role. A postal survey of 309 people randomly selected from the community was undertaken to examine perceptions about the general practitioner's role in detection and intervention for smoking, alcohol abuse, emotional and hyptertension. Responses to the survey from 264 usable questionnaires indicated that people in the community accepted the general practitioner's role in preventive care, with most respondents indicating that they would appreciate being asked about the risks examined, would like the offer of intervention and would try treatments in these areas offered by the doctor. Few respondents indicated that they would change doctors as a result of preventive activity. The role of preventive medicine in reducing mortality and morbidity in the community is now widely recognized. 1 Preventive medicine can include screening and early detection programmes as well as interventions designed to modify risk factors. Preventive programmes can be delivered within a variety of settings, including hospitals, worksites and schools or via the mass media or legislative systems, and particularly in primary care. It has been argued that general practice has the potential to be a particularly effective setting for delivering preventive care. 2 The general practitioner has ready access to a wide section of the community and can therefore deliver preventive care to the majority of the population. 3 The people who visit medical practitioners are relatively representative of the general population. 4 General practitioners see health promotion as an integral part of their role. A recent random sample of 309 Australian general practitioners found that 6.% felt they had time to spend on preventive medicine and 2.5% believed Discipline of Behavioural Science in Relation to Medidne, Faculty of Medicine, University of Newcastle, NSW, Australia. Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria, Australia. Correspondence to Professor R W Sanson-Fisher. 203 identification of modifiable risk factors such as smoking was a very important aspect of their job. 5 Recent policy statements on prevention by the Royal Australian College of General Practitioners and the Australian Medical Association have indicated that preventive medicine is a significant part of a doctor's role. 6 Another reason for using general practitioners as disease prevention agents is that patients are likely to be receptive to preventive messages from this source. Individuals who present to a doctor may feel physically vulnerable because of their illness and may therefore be more likely to be responsive to suggestions for health changes. 2 Medical practitioners are seen as knowledgeable and prestigious which may increase the effectiveness of their health message. Most importantly, there is evidence to suggest that medical practitioners can effect changes in their patients' health risk behaviours. For example, a recent intervention trial to reduce smoking in general practice in Australia showed an impressive 33% abstinence rate among counselled patients at six month follow-up and promising results have been reported by studies examining general practitioner based interventions for alcohol related. 9 While doctors agree in theory about the need for preventive medicine, research has tended to find that general practitioners rarely detect or interview for

2 204 FAMILY PRACTICE AN INTERNATIONAL JOURNAL common risk behaviours. The Newcastle primary care research group, in a study of 56 randomly selected general practitioners and 2301 of their patients found that only 2% of heavy drinkers 10 and 6% of emotionally disturbed patients were correctly identified as being at risk by their practitioners. Similar low detection rates for health risk behaviours have been reported in numerous other studies. 12 " 14 The reasons for the failure of general practitioners to engage in preventive medicine are likely to be complex. Disincentives to health promotion include financial disadvantages, a perception that interventions to change lifestyle factors are not effective and inadequacy of personal skills in behavioural interventions. 2 ' One reason which seems likely to be of particular importance is the general practitioner's belief that patients do not see lifestyle issues as part of the doctor's role. General practitioners may be uncertain of their patients' potential reactions to the detection of and intervention for factors such as smoking or alcohol abuse. They may fear actually losing patients from their practice if they initiate such discussions. There is currently little information available about patients' attitudes towards the role of general practitioners in preventive care or about the type of preventive interventions which patients would consider to be most acceptable. A study in the United Kingdom indicated that between 4 and 6% of patients believed that their general practitioners should be interested in their lifestyle. 12 In Australia, the Royal Australian College of General Practitioners investigated patients' perceptions of the services which should be provided by general practitioners. While 100% of the selected sample of patients indicated that general practitioners should provide preventive care and be involved in promoting good health, more than 30% of patients did not believe that general practitioners should provide treatment for drug and alcohol abuse or the management of psychosocial. 6 However, the questions included in this study were too broad to provide detailed information which would encourage general practitioners to alter their behaviour in the area of prevention. The aim of the present study was to provide detailed information about community attitudes towards the general practitioner's role in detection and intervention in four areas of preventive medicine: smoking, alcohol abuse, hypertension and emotional. These four areas were selected because each is common, 16 " 19 each has a major impact on morbidity and mortality " 22 and in each case there is some evidence that general practitioner interventions can be effective. ' 9-23 In addition, the areas were selected to fall along a continuum from those which patients were likely to view as most appropriate for the general practitioner (for example, hypertension) to those which may be less acceptable (for example, alcohol and psychological disturbance). METHOD Subjects and Procedure Telephone numbers were selected at random from the 196 Newcastle area telephone directory. Three hundred and seventy four respondents were asked to participate in a survey about prevention in primary care. People who were blind, deaf or too frail to complete a questionnaire, or who did not speak or read English were excluded. Of the original sample 309 (3%) agreed to participate. Questionnaires and reply paid envelopes were sent to those who consented to take part in the study. Three weeks after the questionnaire was sent out a follow-up call was made to those who had not replied and this was repeated two weeks later where necessary. These procedures yielded 29 questionnaires or a return rate of 90%. Five per cent of the questionnaires were incorrectly completed, and the analyses were therefore based on a sample of 264. Questionnaire Before the study the questionnaire was developed and piloted on samples of patients. The reading age of the questionnaire, calculated using the Flesch formula, indicated that 5% of the population could understand the material. Respondents were asked four sets of questions. Information on basic demographic characteristics was collected from all respondents. Individuals were also asked if they were smokers, if they were having related to their drinking, if they were having emotional or if they had ever been diagnosed as having hypertension. Attitudes towards general practitioner detection of the four risk behaviours was assessed. Respondents were asked to indicate how they would respond if their general practitioner took their blood, or asked about smoking, drinking or emotional. For each question respondents indicated: 'Yes definitely', 'Yes, probably', 'I don't know', 'No, probably not' or 'No, not at all'. For each of the four risk behaviours, respondents were asked to indicate how they would respond to a range of possible general practitioner intervention strategies. The strategies varied slightly between the risk behaviours and were constructed to fall along a continuum from minimal to intensive intervention. Respondents again used a five point scale from 'Yes, definitely' to 'No, not at all'. It should be noted that non-smokers were not asked to answer questions about smoking interventions. The other risk behaviours could all potentially be taken up by respondents, but adult non-smokers appear unlikely to have similar reactions, as smoking uptake generally occurs in adolescence. For each behaviour, respondents' attitudes towards

3 ROLE OF GENERAL PRACTITIONERS IN DISEASE PREVENTION 205 attempting to comply with strategies proposed by the doctor were assessed and they were asked whether they would attend a programme offered by another general practitioner for each of the risk behaviours. Respondents were asked to indicate using a five point scale from 'Yes, definitely' to 'No, definitely not'. Analysis For each health risk, those individuals with the risk behaviour were compared with those without the risk, using a Yates' adjusted chi-square test on their responses to each of the questions. changing general practitioners between at-risk and not at-risk respondents. However, when respondents were asked about how much they would appreciate the doctor's screening for high blood, there were significant differences between those with and without hypertension. Those with hypertension were more likely to be appreciative of screening on each visit than those without hypertension (x 2 = 4.9, df=l; P<0.05). There were no signigcant differences between the responses of smokers and non-smokers, those who reported alcohol related and those who had long-term emotional distress. RESULTS Sample Characteristics Table 1 shows the demographic characteristics and risk factors of the sample compared with the Newcastle 191 census, and data from participants in a recent study in general practice, the Newcastle primary care study. 10 The study sample was reasonably similar to the Newcastle census data, except that it contained a higher proportion of women. The characteristics of the study sample were very similar to those of the general practice population observed in the Newcastle primary care study. Of the study sample, 93% reported visiting their general practitioner in the preceding six months. Taken together, it would appear that the study sample was reasonably representive of the Newcastle population and very similar to attenders at general practice. The self-reported prevalence of the risk factors were as follows: 34% were smokers; 6% reported having alcohol-related ; 31% considered themselves to have emotional that would last six months and 30% reported that they had at any time been diagnosed as having high blood. Attitudes Towards General Practitioner Detection of Risk Behaviours Total sample. It is evident from Table 2 that the majority of respondents would appreciate screening for each of the four risks factors examined. However, the proportion of patients who would appreciate screening for smoking, alcohol and emotional on each visit was substantially reduced with less than half of the sample indicating positive responses. In contrast, a high proportion of the population (4%) indicated that hypertension ought to be screened for on all visits. Very few patients would change general practitioners if the general practitioner asked them about smoking, alcohol consumption or emotional, or took their blood (Table 2). The number who would leave the general practitioner if asked on each occasion increased a little for alcohol, emotional and smoking. At-risk sub-sample There were no significant differences in responses to the questions about Attitudes Towards General Practitioners' Interventions for Health Risk Behaviours Total sample. Only a small proportion of the respondents reported that they would dislike the general practitioner talking about health risk dangers or advising them to change their health behaviour (Table 3). Although only a small proportion of patients reported that they would dislike the general practitioner suggesting other mechanisms to help reduce the problem, a larger percentage would dislike being offered drug treatments or extra sessions for the health behaviours examined. Nonetheless, it is of note that the majority of the sample (around 0%) would not dislike being offered any of the treatment TABLE 1 Characteristics of the study sample compared with the 191 Newcastle census and the Newcastle primary care study Sex Female Male Marital status Married Single Widowed Divorced/ separated Education High school Above high school Age (years) ^t Percentage of sample population Study sample Newcastle census Primary care study " (n=2301)

4 206 FAMILY PRACTICE AN INTERNATIONAL JOURNAL options. As shown in Table 4, very few patients indicated they would change general practitioners as a result of being offered any of the intervention strategies. It should also be noted that of the four respondents were somewhat more resistant to interventions for emotional. At-risk sub-sample. Significantly fewer at-risk respondents (3%) would dislike being offered behavioural strategies for controlling hypertension than respondents at-risk (10%) (x 2 = 4.3, df = 1, P<0.05) and fewer at-risk respondents (13%) would dislike being asked to attend extra sessions to control drinking than non at-risk respondents (33%) (X 2 = 4.6, df = 1, P<0.05). There were no other differences in attitudes towards interventions between those at-risk and those who were not. Willingness to Try Proposed Interventions Total sample. Hypertension was the problem which respondents were most likely to try intervention for (Table 5). For alcohol-related and emotional, a high proportion indicated a willingness to attempt behaviour change, with medication being the least popular strategy offered. Between 30% and 5% of trie sample said they would be willing to attend a special programme offered by another general practitioner for any of the risk behaviours. For each of the intervention strategies, smoking was the risk behaviour for which respondents were least willing to try interventions proposed by the general practitioner. Nonetheless, it is of interest that 59% of smokers indicated a willingness to attempt change if asked by their general practitioner, and between 30-6% would attempt the interventions speciged. TABLE 2 At-risk sub-sample. There was no difference between those at-risk and not at-risk, except in relation to the questions about alcohol. A significantly greater proportion of those at-risk (1%) than those not atrisk (40%) indicated that they would try to attend the extra sessions to help control their drinking (x 2 = 6.5, df = 1 P<0.05). Similarly, a greater proportion of those at-risk (60%) than those not at-risk (25%) would attend a programme offered by another doctor to control drinking (x 2 = 6.6, df = 1 P<0.05). DISCUSSION The present study indicates that the community accepts the general practitioner's role in screening and intervening for smoking, alcohol-related, emotional and hypertension. The majority of respondents reported that they would appreciate screening for all of the behaviours and would not change general practitioners even if asked about the risk on every visit. A very small proportion of respondents would change doctors if offered any of the intervention strategies included in the present study. Moreover, with the exception of smoking, respondents indicated that they would be willing to try most of the intervention strategies if these were suggested by their doctors. Overall, these data suggested that general practitioners ought not to be discouraged from preventive care by fear of negative patient reactions. There are several other aspects of responses to the questionnaire which are of interest. First, only about half of the respondents indicated that they would appreciate screening for smoking, alcohol related or emotional on each visit. Since these behaviours may fluctuate over time, it might be expected that general practitioners would monitor these behaviours on each visit if they are providing Respondents' attitudes towards general practitioner detection of risk behaviours Percentage answering 'Yes, definitely' or 'Yes, probably' Asking about smoking Asking about alcohol related Asking about emotional Taking your blood Would you appreciate your GP doing this? On each visit? Would you change to another doctor if your GP did this? On each visit? n= total number of respondents

5 ROLE OF GENERAL PRACTITIONERS IN DISEASE PREVENTION TABLE 3 Respondents' attitudes towards general practitioner interventions 20 Percentage answering 'Yes definitely' or 'Yes probably' Smoking («=91) Alcohol related Emotional (/i=264) High blood Would you dislike your GP: Talking about health dangers of the problem? 5 - Advising you to stop, reduce or seek help? Would you dislike your GP recommending: Medication for the problem? Other ways to help you reduce the problem? That you attend extra sessions to help you stop or deal with the problem? Not asked TABLE 4 Respondents' attitudes towards general practitioner interventions Would you change doctors if your GP: Told you about the dangers of the problem? 2 Advised you to stop, reduce, seek help? 3 Would you change doctors if your GP recommended: Medication for the problem? 0 Other ways to help you reduce the problem? 6 That you attend extra sessions to help you stop or deal with the problem? 6 Not asked optimal care. It may be that there is a need to educate patients about the advantages of repeated screening in these areas. Secondly, there was some evidence that the general practitioner's preventive role was perceived more positively in relation to hypertension than for- the other behaviours studied. Screening for hypertension on each visit was more acceptable to patients than the other behaviours and patients were more willing to try preferred treatments. It seems likely that this may be attributable to public education about the dangers of Percentage answering 'Yes definitely' or 'Yes probably' Smoking Alcohol Emotional High related blood (/i=91) high blood as well as a patient perception that this is more strongly related to the physical domains of care than the other risks examined, and is therefore more clearly a part of the general practitioner's role. Thirdly, although it is often argued that the community seeks a 'magic bullet' approach to preventive action, 24 there was little evidence in the present study that respondents were looking for an easy approach to behaviour change. Drug treatments were not the preferred option particularly in

6 20 FAMILY PRACTICE AN INTERNATIONAL JOURNAL TABLE 5 Respondents' willingness to try proposed interventions Percentage answering 'Yes definitely' or 'Yes probably' If my doctor suggested it, I would: Try to change my behaviour Try medication to change my behaviour Try other ways to change my behaviour Come to extra sessions Smoking ("=91) Alcohol Emotional High blood (/i=264) If another GP offered a special programme to help me change my behaviour, I would attend Not asked relation to emotional, where 23% indicated that they would dislike the general practitioner recommending a drug treatment and only 59% indicated they would try drug treatment if suggested by their doctor. Moreover, with the exception of smoking, a reasonable proportion of the sample indicated that they would be prepared to attend four to eight extra sessions with their general practitioner to help with the problem. It would therefore appear that doctors may be able to introduce somewhat more intensive behavioural or counselling programmes than are usually attempted and that these will be acceptable to their patient group. Finally, it would appear that respondents were able to clearly differentiate between general practitioners' behaviours which they did not like and the need to change doctors. The data suggest that even when patients do not like preventive attempts by the doctor, they will not change general practitioners as a result. A comparison of Tables 3 and 4 indicates that while patients disliked some of the treatment options, few would change doctors if they were offered. Similarly, while some respondents were not appreciative of detection questions on each visit, relatively few indicated that this behaviour would cause them to change doctors. These data suggest that general practitioners can be reasonably confident about providing preventive care in the areas studied without losing patients as a result. In the interpretation of the present findings, it should be rememberd that they reflect patients' attitudes or perceptions. Given research which indicates some divergence between attitudes and behaviour, 25 it should not be concluded that if detection, advice and treatment for the nominated health risk behaviours were offered, patients would behave in concordance with their attitudes. It seems likely that patient acceptance of preventive care will be influenced to a considerable extent by the skill with which general practitioners introduce the topic and the programmes they use to deal with any problem. Consequently, there is a continuing need for skill training for the doctor in detecting risk behaviours in an acceptable manner. There is also a need to develop effective interventions that can be implemented by general practitioners and are acceptable to patients. The data reported here reinforce these needs since there is a clear community perception that prevention is part of the general practitioner's role. REFERENCES 1 Goldstein G. Goals and priorities in prevention: The challenge of chronic disease and disability. Community Health Stud 193; : Nutting P A. Health promotion in primary medical care: and potential. Prev Med 196; 15: Australian Bureau of Statistics. Australian Health Survey 19-. Doctor consultations. ABS Catalogue no Canberra: Australian Bureau of Statistics, Australian Bureau of Statistics. 191 Census of population and housing. Small area summary data. ABS catalogue no Canberra: Australian Bureau of Statistics, 192. 'Cockbum J, Killer D, Campbell E, Sanson-Fisher R. Measuring general practitioners' attitudes towards medical care. Fam Pract 19; 4: Royal Australian College of General Practitioners. Survey on general practice "The standards and practices' summary results: January, 195. Sydney: RACGP, 195. Horvath N, Howat P. Towards health education. Med J Aust 193; 13: _,

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