Case 2
Fred needs a repeat script…
This
48-year old man illustrates many of the concepts central to health promotion.
Health promotion is the process of enabling people to increase control over,
and to improve, their health. Patients such as Fred challenge us to think about
the steps we will need to take in order to improve the health and wellbeing of
our population.
Learning Objectives
· Understand and respond to the special needs and characteristics of your practice population, including:
§ Disease prevention and health promotion (medical, lifestyle and community development and how you can play a role in all three)
§ Access and equity issues
· Take into account a patient’s socio-political, economic, work, spiritual and cultural background and needs, and their relationship with family and significant others in relation to their health needs.
· Apply this knowledge of a patient’s background in determining their health needs, health care and health outcomes.
· Familiarize yourself with key references that underpin health promotion practice
· Increase your knowledge of the theories of behaviour change
· Increase your awareness of the social determinants of health
· Understand the concept of the community as an empowered partner
· Understand the principles of advocacy and how you can expand your role as an advocate for the health needs of your patients
Fred’s Clinical Summary
Past Medical
History:
Chronic mechanical back pain
(lumbosacral)
Hypertension
Hypercholesterolaemia
Past
Surgical History:
Nil
Allergies:
Nil known
Meds:
Panadeine forte ii qid prn
Tritace 5 mg daily
Lipitor 10 mg daily
Aspirin 100 mg daily
Social
History:
Smokes cigarettes – 25 pack year
history
Drinks alcohol – 6 – 8 standard
drinks daily
Occupational
History:
Unemployed
labourer
Case Notes:
Fred comes in for a repeat prescription for Panadeine Forte for his chronic back pain. He mentions that he is not sleeping well and asks if there is something you can give him.
You have known Fred for some time now. He is 48 years old, is unemployed and living on a disability pension. He lives in the caravan park down the road from your practice. He used to work as a builders labourer before he injured his back on a construction site lifting bricks a few years ago. He hasn’t worked since, although he’s tried to find work a couple of times and did a retraining course through Centrelink 2 years ago. It didn’t lead to a job though.
Defining Health:
The
World Health Organisation (WHO) definition of health is of ‘a complete state of
physical, mental and social well-being, and not merely the absence of disease
or infirmity’.
According to the still
current World Health Organisation Ottawa Charter (1986) health promotion is
defined as ‘the process of enabling people to increase control over, and to
improve, their health. To reach a state of complete physical, mental and social
wellbeing, an individual or group must be able to identify and to realize
aspirations, to satisfy needs, and to change or cope with the environment.
Health is, therefore, seen as a resource for everyday life, not the objective
of living. Health is a positive concept emphasizing social and personal
resources, as well as physical capacities’.
Issues to Consider:
a) Using the WHO
concept of health, what do you consider to be Fred’s ‘health’ problems?
b) How would you manage
Fred’s sleeping problem in a way that is consistent with the WHO definition of
health promotion? What wouldn’t be management consistent with this definition?
Case Notes:
Fred lives alone. He spends most of his time surfing the internet and watching cable TV. He goes to the pub with his mates whenever he has the money. He smokes a fair bit and drinks daily. Fred finds the caravan park a bit depressing. Everyone there is poor and living on pensions. There is a fair bit of crime in the park and he worries about getting broken into.
The Social
Determinants of Health:
Social determinants are
key aspects of people’s living and working circumstances, and their lifestyles,
which impact on their health and wellbeing. Most social factors seem to affect
health by affecting the degree to which people are able to control their
actions in different spheres of life (work / home / leisure), how many physical
hazards they are exposed to, and the degree of social support they enjoy.
Social factors seem to affect the human body through biological pathways. For
example, people who are unemployed are less able to afford adequate housing,
which may in turn expose them to cold, which in turn is a potent risk factor
for cardiac events. A poor social environment also makes it more likely that
people will smoke, drink alcohol excessively, and eat to excess.
In 1997, at the 4th
International Conference on Health Promotion in Jakarta, the WHO highlighted
the importance of social determinants to health, noting that even in the most
affluent of countries people who are not as well off have shorter life
expectancies and poorer quality of health than the rich.
The most important aspects of social determinants are
outlined in the WHO document: Social Determinants – the Solid Facts. This
document summarizes current knowledge about the impact of the social gradient,
social exclusion, lack of social support, high levels of stress, poor living
conditions in childhood, employment and unemployment, addiction, food and
transportation systems on health and well-being.
Click here to
view the Jakarta Declaration
Click
here to view WHO Social Determinants: The Solid Facts
Issues to Consider:
a) What are the social
determinants affecting Fred’s health?
b) What are the likely
impacts of these determinants on Fred’s life expectancy?
c) What kinds of
actions would increase Fred’s life expectancy? Whose ‘job’ is it to address
these issues?
Case Notes:
Fred has high blood pressure, high cholesterol and obesity. You have talked to him in the past about medications and lifestyle change to treat him. He tried really hard to change his diet and get a little exercise but didn’t stick with it for long. You also prescribed him Tritace and Lipitor at one stage. Fred decided he didn’t want to be paying for pills though and soon stopped taking them. Even on his health care card, he found the cost of the tablets a bit of a stretch.
Should we attempt to change Fred’s behaviour?
Interventions directed at
changing behaviour are a mainstay of population health and of clinical
practice. There is a great deal of evidence supporting the effectiveness of
behavioural approaches to health promotion.
In a democratic system
individuals have the right to behave in any way they choose – providing it does
not have negative consequences for others. There are two key concepts to be
aware of in relation to behavioural change:
-
Victim
blaming
-
Voluntarism
Victim blaming describes
the process by which patients who adopt health-damaging behaviours (for
example, smoking) are blamed for their behaviour. In fact, they are the victims
of social and environmental pressures that, to a large extent, force them into
a position of adopting such behaviours. If health campaigns focus on individual
responsibility for behavioural change, rather than addressing the underlying
determinants of the health-damaging behaviour (for example, poverty,
unemployment, poor educational attainment) the patient may feel blamed and
alienated, and attempts to change behaviour will be unsuccessful.
Voluntarism is concerned
with ensuring that patients are willing and active participants in their
attempts to change behaviour. Behaviour change that is sustainable occurs when
there is a partnership between health care provider and patient. Patients should
not to be coerced, nor should there be covert manipulation of their behaviour,
even if it is deemed to be ‘for the best’ by their health professional.
Theories of Behaviour
Change:
Theories of behaviour
change are derived largely from the field of psychology. There are a number of
significant theories and models that underpin the practice of health promotion.
Health Belief Model
This model suggests that,
when faced with the possibility of changing health behaviour, individuals
consider the advantages and disadvantages of change and then make a rational
decision. Their decision depends on their view of their susceptibility to the
illness or danger, the perceived seriousness of the illness, and the relative
costs and benefits of the possible change.
Theory of Reasoned Action
According to the theory, the most
important determinant of a person's behaviour is behaviour intent. If a
person perceives that the outcome from performing certain behaviour is
positive, she/he will have a positive attitude toward performing that
behaviour. The opposite can also be stated if the behaviour is thought to be
negative. If relevant others see performing the behaviour as positive and the
individual is motivated to meet the exceptions of relevant others, then a
positive subjective norm is expected. If relevant others see the
behaviour as negative and the individual wants to meet the expectations of
these "others", then the experience is likely to be a negative
subjective norm for the individual.
Transtheoretical Model
This model of behaviour
change has been applied in the RACGP SNAP Guide. In this model, behaviour
change has been conceptualized as a five-stage process or continuum related to
a person's readiness to change: pre-contemplation, contemplation, preparation,
action, and maintenance. People are thought to progress through these stages at
varying rates, often moving back and forth along the continuum a number of
times before attaining the goal of maintenance. Therefore, the stages of change
are better described as spiralling or cyclical rather than linear. In this
model, people use different processes of change as they move from one stage of
change to another. Efficient self-change thus depends on doing the right thing
(processes) at the right time (stages). According to this theory, tailoring
interventions to match a person's readiness or stage of change is essential.
For example, for people who are not yet contemplating becoming more active,
encouraging a step-by-step movement along the continuum of change may be more
effective than encouraging them to move directly into action.
Limitations of the
Behavioural Approach:
These various models of
individual behaviour change conceptualise health behaviour as based on reason
and rational choice. The assumption is that once people are provided with
sufficient information and support for their decision, then they will change
their behaviour. The obvious flaw in the logic is that people will actively
choose their behaviours according to what they believe is good for their
health. This is clearly not the case.
Behaviour change doesn’t
happen in a vacuum. It is related to the social context in which people live,
and ‘in order to change behaviour it is often necessary to change more than
behaviour’. Behavioural strategies need to be complemented with social,
economic, environmental, policy, legislative and community development
approaches that facilitate and enable behaviour change.
Issues
to Consider:
a) What influence does Fred’s social situation have on the likelihood that he will be able to change his lifestyle?
b) How would you assess Fred’s readiness to change his lifestyle?
c) How would you go about exploring the reasons Fred may be unwilling to change?
(It may be helpful for you to review the RACGP SNAP Guide in considering your response to these questions)
The factors
affecting health and wellbeing:
The setting within which he lives influences Fred’s health. His friends and family, local community and broader social environment – which includes factors such as income, education, employment, poverty, housing, transportation, social networks and social capital - all impact on his health.
Fred has many risk factors for poor health, as the
following diagram shows. These are not only physiological, but are also
behavioural, psychosocial and situational. However, there are also a range of
protective factors that could help Fred to improve his health and wellbeing.
As a General Practitioner, you are an important
member of your local community. Your presence in that community, and the work that
you do, contributes to the ‘social capital’ within your community. Social
capital can be defined as the quality of interactions between people in
specific situations and places. Greater
social capital within a community is better for everyone’s health.
The RACGP has formally acknowledged that GPs play
a pivotal role in identifying and addressing inequalities in health care and
improving social capital. Health inequalities are unjust, unfair and
avoidable differences in health status or health care based on social position
or economic circumstances. If Fred’s social position and economic circumstances
were better, not only would he have better access to health care, but he would
also live in surroundings that were health promoting rather than health damaging.
The health
of the Australian population improved markedly during the twentieth century.
For example: the toll of infectious disease was reduced sharply; life
expectancy at birth continued to increase; since the late 1960s, death rates
from coronary heart disease and stroke have declined; and in more recent years,
we have witnessed a downward trend in deaths from lung, colorectal and breast
cancer.
Despite
this, health gains have not been equally shared across all sections of the
population, and at the end of the century,
The causes
of health inequalities are complex, and mostly lie in the broader environmental
and economic conditions of society. Nevertheless evidence supports a role for
health care systems in addressing health inequalities, particularly through
removing barriers to accessing care, and potentially through advocating for
changes to upstream policies to reduce their inequitable impact on
disadvantaged communities.
General
Practice has a role, supported by some evidence, in reducing barriers to
accessing care. This role is discussed further in the RACGP Policy Statement on action on health inequalities
through general practice.
A range of strategies can be used in clinical practice
to support the health and wellbeing of people like Fred.
·
Develop a
knowledge of local people, their environment and their needs
·
Develop
partnerships with other people in the community that have a role in promoting
health
·
Involve
yourself in advocacy and provide a public voice for the health of your local
community
Examples of effective partnerships and advocacy
include:
·
Raising
awareness of the issue of childhood obesity with a local school and having
input into ways to combat the problem – e.g. allowing water bottles on desks in
the classroom, healthy canteens etc.
·
Supporting
the initiatives of organisations such as Diabetes
·
Lobbying by
neurosurgeons for safer road design with the aim of preventing brain injury
·
International
Physicians Against Nuclear War
·
Lobbying by
local GPs against pollution of waterways because of the threat to health in the
local community
Issues
to consider:
(It may be helpful for you to review the attached article on communities as empowered partners to give you ideas about ways to respond to these questions)
Epilogue:
It is now 12 months later. From what you hear, the environment in the caravan park has changed quite a bit!
Over a number of consultations, you talked with Fred about many of the challenges he was facing in his life. As a result, he started to talk more with his beer-drinking buddies about life in the caravan park and some of the challenges they were all facing. His friends also felt that changes in the park were needed.
They got together with management to discuss the problems as they saw them. Management, who could also identify with their concerns, arranged a number of meetings with residents to talk about the issues and solutions to the problems they were facing. Some of the changes included:
- Building a covered playground area for the kids
- Providing barbeque facilities for residents to use for social gatherings
- Every weekend a family-friendly social is run in the park; people come along to the gathering for a barbeque and friendly games such as cricket or ball games
- Regular walking groups have been set up by residents to get more people active
- Getting in touch with the local police station about the crime problem. They sent a constable to visit and help the residents set up a neighbourhood watch program
- Stopping the sale of tobacco at the caravan park shop and making the public areas in the park no-smoking zones
- Getting the local shop to stock juices and mineral water instead of soft drinks
This case
illustrates many of the concepts central to health promotion. Health promotion
is the process of enabling people to increase control over, and to improve,
their health. Patients such as Fred challenge us to think about how we provide
health care for our population. They help us to realize that provision of
health care is much broader than the actions of the health system alone. Health
promotion action will also have to occur both within and outside the health
system if the health of the population is to improve.
- Baum F. The New Public Health. 2nd Edition.
- Kemm J and Close A. Health Promotion: Theory and Practice. Palgrave
Publishers.
- Achhra,
Amit . Health Promotion in Australian general Practice. Australian Family
Physician 38( 8) 605-610 2009