Why teach health promotion and disease prevention?
Disease prevention begins with a threat to health--a disease or environmental hazard--and seeks to protect as many people as possible from the harmful consequences of that threat. Health promotion begins with people who are basically healthy and seeks the development of community and individual measures which can help them to develop lifestyles that can maintain and enhance their state of well being.
--US Public Health Service (1980)
Health care systems are focusing their attention on three key functions--reducing costs, improving health outcomes, and enhancing patient satisfaction--and increasingly will value and reward clinicians who focus on these functions. Because attention to health promotion and disease prevention can contribute greatly to all three functions, it will be essential for clinicians to be skilled at helping patients maximize their health and prevent illness. In the new systems, disease treatment obviously will remain an important goal; however, financial viability will depend as well on investments in prevention (Pew Health Professions Commission, 1995; Schlackman, 1994). Promoting health is essential in primary care, but secondary and tertiary care also are focusing more on wellness and function in the context of living with chronic disease. Disease management strategies attempt to improve quality of life and decrease morbidity and costs of care.
The health benefits of incorporating prevention in practice have become more apparent in the last several decades. Immunization has made infectious diseases such as polio, rubella, and pertussis rare, and early detection of diseases such as hypertension and cervical cancer has led to dramatic decreases in mortality and morbidity. Helping patients change personal health behaviors may be the next major challenge for clinicians, as it is becoming more evident that certain behaviors are linked to many leading causes of death and disability, such as heart disease, cancer, chronic obstructive pulmonary disease, osteoporosis, diabetes, and sexually transmitted diseases (US Preventive Services Task Force, 1996). Nearly half of all deaths that occurred in the United States in 1990 may be attributed to external factors such as tobacco, alcohol, and illicit drug use; diet and activity patterns; motor vehicles; and sexual behavior (McGinnis & Foege, 1993).
While clinical prevention activities traditionally have been directed at the individual patient, interventions aimed at clinical and community populations are becoming more important. Population-based care, which encompasses the concepts and methods of epidemiology and public health, is essential to effective management of health care. As clinicians become responsible for helping to maintain the health of a defined population, they will have to attend not only to those patients who appear in the clinic or office, but also to those people who do not appear (Greenlick, 1995).
Learning goals for health professions students
Despite the value of emphasizing prevention, many barriers exist to doing so, including inadequate reimbursement, insufficient time with patients, contradictory guidelines and recommendations, inadequate training, and lack of practitioner confidence in their abilities (Becker and Janz, 1990; US Preventive Services Task Force, 1996). Helping students gain skills to engage in this area can help to mitigate some of these barriers and insure that future practitioners are as comfortable with health promotion and disease prevention as they are with disease treatment. Students participating in clinical rotations in community practices will come with a wide range of learning objectives related to health promotion and disease prevention; however, most of these objectives will be encompassed by the goals that are listed here, which represent the achievement expected of graduating students. Students earlier in their training may be expected to address only a few of these goals or only subsets of them. The goals presented here begin at the individual patient level and proceed through the practice population and community population levels. Goals at the individual level focus on developing knowledge and skills in counseling, screening, and immunization and prophylaxis. Goals at the population level emphasize the growth of expertise in promoting health and preventing disease in the practice population and in the wider community.
1. Demonstrate effective, patient-centered counseling.
Interventions that address patientsí personal health behaviors and practices are vitally important (US Preventive Services Task Force, 1996). Clinicians can help individuals change their health-related behaviors by using efficient, patient-centered counseling strategies that are based on an understanding of how people change. Students should learn that patient-centered counseling is a multifaceted process involving dialogue--not one-way information transfer from clinician to patient--that helps patients (1) recognize and acknowledge their specific risk behaviors, (2) decide on a personalized plan of action, (3) put the plan into effect, and (4) deal with relapses (UNC Program on Health Promotion and Disease Prevention, 1996). Students also should know about and apply the widely used transtheoretical model of change (Prochaska & DiClemente, 1982), which incorporates the concept of degrees of readiness for change and describes the following stages of change: precontemplation (the person is not considering making a behavior change), contemplation (the person is considering a change), preparation (the person has made plans to change), action (the person has acted on the decision), and maintenance (the person has maintained the change for a substantial period of time).
Students should learn which behaviors warrant counseling and should become familiar with resources available to support their counseling efforts. The Guide to Clinical Preventive Services (U.S. Preventive Services Task Force, 1996) targets eleven areas on which to focus counseling: tobacco use, physical activity, healthy diet, motor vehicle injuries, household and recreational injuries, youth violence, low back pain, dental and periodontal disease, HIV and other STDs, unintended pregnancy, and gynecologic cancers. This guide also provides recommendations for effective counseling in each area. Other resources that can support health promotion counseling include "Put Prevention into Practice," a program of the US Public Health Service (Department of Health and Human Services, 1994), and other publications, e.g., Woolf and colleagues (1995).
2. Understand the principles of and procedures for screening.
Another central health promotion/disease prevention strategy that students need to be skilled in is screening, or testing for health problems in the absence of symptoms or signs indicating the presence of such a problem. The Guide to Clinical Preventive Services (U.S. Preventive Task Force, 1996) targets nine areas in which clinicians should screen patients: neoplastic diseases; cardiovascular diseases; metabolic, nutritional, and environmental disorders; infectious diseases; vision and hearing disorders; prenatal disorders; congenital disorders; musculoskeletal disorders; and mental disorders and substance abuse. Students need to learn (1) when screening is appropriate, (2) what procedures to use and how to use them effectively, and (3) how to interpret and use the results of screening tests.
Learning when to screen involves learning about the diseases that cause a substantial burden of suffering, are common within various age groups, and have a pre-symptomatic phase during which the disease may be detected. It also involves knowing whether treatment for the disease will work better if initiated in the presymptomatic phase, whether an effective screening test is available, and whether the test itself will cause more good than harm. Students should learn about and become skilled in the use of various strategies and procedures used to screen for disease, including questioning (e.g., CAGE questions to screen for alcohol problems), physical examination (e.g., for breast cancer), laboratory tests (e.g., serum cholesterol), and imaging tests (e.g., mammography for breast cancer). Finally, students need to learn how to interpret the results of screening tests and what the results imply, including the need for further diagnosis in the case of a positive test result and the potential for and implications of false positives and false negatives (UNC Program on Health Promotion and Disease Prevention, 1996).
3. Describe the importance and use of immunization and prophylaxis.
Students should understand the important role that widespread childhood immunization has played in drastically reducing the incidence of many illnesses, including diphtheria, pertussis, tetanus, poliomyelitis, measles, mumps, and rubella. In addition, students should learn which childhood immunizations are essential, when and how to administer them, and potential risks. Knowledge of the appropriate use of adult immunizations is also necessary. The Guide to Clinical Preventive Services (U.S. Preventive Task Force, 1996) discusses recommendations for adult immunization against influenza; pneumococcal disease; tetanus and diphtheria; measles, mumps, and rubella; and hepatitis A and B.
Learning the rationale for, appropriate use of, and potential risks of the following types of chemoprophylaxis is also important (U.S. Preventive Task Force, 1996):
4. Implement strategies to promote the health of the practice population.
Although health care professionals traditionally have focused on individual patients who present themselves for care one at a time in the office or clinic, students preparing for practice in todayís health care system also must learn to focus on the care of populations of patients. New methods of reimbursement provide incentives for practitioners to attend to the health of the entire population of patients who are enrolled in a particular health plan (Greenlick, 1995; Shortell et al., 1994). This is especially true under systems that pay practitioners through capitation (i.e., that pay the practitioner a certain amount per patient member per month to provide comprehensive care). Finding ways to promote health and prevent disease in all of the enrolled patients--not just the ones who come in regularly for care--can assist practitioners in containing health care costs and producing better outcomes for patients.
Students need to learn how to "accumulate the experience of practice in an effort to monitor the state of their populationís health, the problems of health care, and the sources (biomedical or not) of disease, distress, disability, destitution, and untimely death which prevail" among their patients (Inui, 1992, p. 29). To do so requires learning to apply the principles of population-based care to a practice population, using population-based strategies within a clinical setting (a) as a source of information to determine the extent of a particular health problem and (b) to inform clinical decision-making, health education efforts, disease and disability prevention efforts, and continuing professional education.
5. Engage in public education and advocacy to prevent disease.
For some health problems, preventive interventions aimed at the wider community may be especially appropriate and effective. Such problems include unintended pregnancy in adolescents, youth violence, domestic violence, initiation of tobacco use, sexually transmitted diseases, healthy dietary practices, and unintentional injuries (U.S. Preventive Task Force, 1996). Cliniciansí involvement in public education and advocacy includes a wide range of activities, including writing newspaper articles or opinion columns; speaking to school, church, or other community groups; helping to develop community education curricula; and advocating changes in public policies, ordinances, or laws (UNC Program on Health Promotion and Disease Prevention, 1996). Students need to learn how to identify health problems in the local or regional community for which public education and advocacy could have an impact and then determine appropriate strategies to effect improved public knowledge, encourage healthier behaviors, or discourage unhealthy activities.
Strategies related to health promotion/disease prevention in individual patients
Because it has been difficult for clinicians to incorporate prevention into their everyday routine, it is becoming increasingly common for them to organize their practices so that preventive care becomes an automatic part of each patient visit, regardless of the purpose of the visit. Some clinicians instruct staff members to check the immunization status of all appropriate patients to make sure it is up to date. Others have preventive care flow sheets kept in a special place in the medical record or maintain computerized databases that keep track of which patients are due for various preventive care procedures.
Preceptors may help students become aware of opportunities to build prevention into patient care efficiently by (1) assigning students to analyze the practice to see what systems have been developed to ensure that preventive care is done automatically; (2) as an extension of that activity, encouraging students to suggest additional measures the practice could take to build prevention into patient care; and (3) guiding students to identify places in the medical interview where questions about risk factors could be incorporated and to develop questions and appropriate responses to use in that context.
In teaching students to counsel patients for behavior change, the first step is for students to learn how to explore the context of the behavioral risk factors in a patientís life and to begin to understand the process of empowering patients who desire a change. The 5 Aís model for patient-centered behavioral change counseling, originally developed for smoking cessation counseling, may be used effectively to guide students through the counseling process. Like Prochaska and DiClementeís stages of change model (see p. 3), it emphasizes that behavior change is a process determined by the patientís readiness to change; thus counseling must be viewed as more than a one-time event. The two approaches complement each other and may be used together.
Briefly stated, the 5 Aís approach directs the student to:
(1) address agenda: that is, deal first with the patientís agenda for the visit, and then introduce the topic of the at-risk behavior ("Iíd like to talk to you about...");
(2) assess the patientís knowledge of the risks and his/her readiness to change ("What do you know about...?" "What are you willing to do about...?");
(3) advise ("I strongly encourage you to...");
(4) assist patients ready to make changes by answering questions, suggesting strategies, and collaborating on a plan ("Here are some specific things you could do..." "What ways can you think of that would allow you to change?"); for patients not yet ready to change, assist by providing information and support and addressing barriers to change ("I know itís hard to change, but I think you can do it");
(5) arrange follow-up to reinforce the effort ("What worked--or didnít work--and why?") (UNC Program on Health Promotion and Disease Prevention, 1996).
Including health promotion and disease prevention issues in the "One-Minute Preceptor" or microskills approach to clinical teaching (Neher et al., 1992) may be an effective way to help students learn about these issues. This approach was presented in greater detail in Module Two: Effective Teaching in the Community Practice. Microskills 1 and 2 involve getting a commitment from the student about his or her conception of a patientís problem and probing for supporting evidence. To add a health promotion/disease prevention focus, ask the student the following questions (UNC Program on Health Promotion and Disease Prevention, 1996):
How did the patient come to have this problem at this time, and what could have been done to prevent it?
What problems is this person likely to have in the future, and what can be done to prevent them?
After the student has explained his or her thinking on these issues, the preceptor can turn to Microskill 3, teaching general rules. The answers given to the two questions above can help the preceptor determine learning needs and choose one or two rules or principles that can help the student deal more effectively with the current or future cases. Microskills 4 and 5, reinforcing what was right and correcting mistakes, are important as well in that they encourage and reinforce attention to health promotion and disease prevention and correct any misconceptions that the student may have.
Strategies related to health promotion/disease prevention in populations
To help students learn practice-level strategies, first help them learn about the practice population: What ages are represented in the practice population? For various age groups, what are the most common illnesses? Which of them are preventable? What is the immunization rate for children? What screening protocols are in place for patients of various ages? How many patients do not regularly come to the office for care? What outreach efforts are made to ensure that all patients receive appropriate preventive care? Students may be asked to identify a practice-level issue to investigate and then to develop an intervention to improve preventive care, such as a reminder system to insure universal immunization or an educational pamphlet for patients.
Students may learn about the communityís health problems by investigating questions such as the following: What are the leading causes of mortality and morbidity in this community? Are some of these preventable? If so, which could be prevented through public education? Through public advocacy (i.e., legislative change)? The preceptor then can help the student choose a strategy for addressing one of these problems. Should the student campaign for a traffic light at a dangerous intersection? Write a letter to the editor? Meet with a congressional representative? Organize a diabetes support group at a local church? Preceptors also may invite students to accompany them in any community activities in which they routinely engage.
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