Prevention and health promotion in primary care: Baseline results on physicians from the INSURE project on lifecycle preventive health services

doi:10.1016/0091-7435(84)90022-7

Preventive Medicine

Volume 13, Issue 5, September 1984, Pages 535-548

https://doi.org/10.1016/0091-7435(84)90022-7 Get rights and content

Abstract

The insure Project on Lifecycle Preventive Health Services is a 3-year feasibility study to develop and test a clinical model of preventive health services, including patient education, in primary medical care as an insurance benefit. Seventy-four primary care physicians in group practices were surveyed regarding their baseline attitudes toward, and practice of, preventive services. Physicians report that they tend to be conscientious in educating their patients about their health risks, although they spend little time in patient education. Physicians are not sanguine about their success in getting their patients to follow their recommendations and tend to harbor doubts about their own efficacy in these areas. Specialty differences exist in these parameters. Physicians evidence contradictory attitudes about prevention. They believe doctors should spend more time providing preventive services but also believe that the lack of insurance reimbursement is an obstacle to providing these services. The concept of structural or sociological ambivalence is advanced to explain this pattern.

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Despite the importance of health promotion, rates of health behavior advice remain low and little is known about how advice is integrated into routine primary care. This study examines how health behavior topics of diet, physical activity and smoking are initiated during outpatient visits.
Audio recording of 187 adults visit to five purposefully selected physicians. An iterative analysis involved listening to and discussing cases to identify emergent patterns of initiation of health behavior talk and advice that followed.
Physicians initiated 65% of discussions and used two overarching strategies (1) Structured: a routine to ask about health behavior and (2) Opportunistic: use of a trigger to make a transition to talk about health behavior. Opportunistic strategies identified a greater proportion of patients at risk (50% vs. 34%) and led to a greater rate of advice (100% vs. 75%). Patients initiated one-third of health behavior discussions and were more likely to receive advice if they explicitly indicated readiness to change.
Opportunistic strategies show promise for a higher yield of identifying patients at risk and leading to advice.
Encouraging patients to be explicit about their readiness to change is likely to increase physician advice and assistance.
Common Measures, Better Outcomes (COMBO). A Field Test of Brief Health Behavior Measures in Primary Care
2008, American Journal of Preventive Medicine
Citation Excerpt :
Coups et al.11 found that while most patients report having more than one risk behavior, approximately 28% were not screened for any. Regular screening for tobacco use, unhealthy diet, physical inactivity, and risky alcohol use in the primary care clinician's office is impeded by insufficient time,16 lack of reimbursement,17 low provider self-efficacy,18 lengthy assessments impractical for routine use, and relatively few effective interventions for physical activity and nutrition.19 Yet assessing these health risk behaviors may provide powerful individual-level metrics for both clinical decisions and for population-level decisions.12
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Of 227 adolescents and 5358 adults, most patients completed all of the survey questions. Two or more unhealthy behaviors were reported by 47.1% of adolescents and 69.2% of adults. Percentages of adults who completed all the survey items varied by health behavior: tobacco use, 98.5%; diet, 98.2%; physical activity, 96.2%; alcohol use, 85.1%. Missing data rates were higher for unassisted patient self-reporting.
A relatively brief set of health behavior measures was usable in a variety of primary care settings with adults and adolescents. The performance of these measures was uneven across behaviors and administration modes, but yielded estimates of unhealthy behaviors consistent overall with what would be expected based on published population estimates. Further work is needed on measures for alcohol use and physical activity to bring practical assessment tools for key health behaviors to routine primary care practice.
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Interventions that modify physician attitudes to enhance preventive service delivery are common, yet other factors may be relatively more important in determining whether these services are provided. We assessed associations between physicians' attitudes and delivery of preventive care, compared with factors related to the patient, visit, or practice.
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Importance of PSA screening and tobacco cessation counseling were weakly associated with patients' receipt of preventive care; no association between attitudes and other services was observed. Factors such as having a visit for well care and use of prevention flowcharts were associated with delivery of preventive services to a greater extent.
Physicians' attitudes toward prevention are necessary, but not sufficient in ensuring the delivery of preventive services. Future interventions should address visit- and practice-specific factors more closely associated with preventive care.
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2004, American Journal of Preventive Medicine
Screening rates in primary care for single behavioral health risk factors are widely documented. However, such risk factors cluster in individuals and populations. This article examines the number and types of behavioral risk factors that U.S. adults reported, and reported having been screened for in their last routine medical checkup.
The sample consisted of 16,818 adults from the 1998 National Health Interview Survey who reported having a routine checkup in the past year. Respondents completed questions regarding four behavioral risk factors (physical inactivity, overweight, cigarette smoking, risky drinking), and provider screening for behaviors related to these risk factors.
Half of the sample (52.0%) reported having two or more of the four risk factors, and more than half (59.4%) were screened for two or more risk behaviors during their last routine checkup, although 28.6% reported being screened for none of them. Respondents reporting at least one risk factor were screened for an average of 57.7% of their own risk factors. Women, adults with lower levels of income and education, and those aged 65 and older, reported being screened for fewer of their risk factors.
While guidelines for risk factor screening and intervention typically focus on single behavioral risk factors, most primary care patients present with, and are screened for, more than one. Behavioral risk factor screening tools and interventions must be expanded to cover multiple risks. Additionally, efforts are needed to reduce the substantial missed opportunities for screening, and to eliminate demographic disparities in screening practices and accuracy.

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General articlePrevention and health promotion in primary care: Baseline results on physicians from the INSURE project on lifecycle preventive health services☆

Abstract

Prev. Med.

Adult cancer prevention in primary care: Patterns of practice in Quebec

Amer. J. Public Health

Adult cancer prevention in primary care: Contrasts among primary care settings in Quebec

Amer. J. Public Health

The lifetime health monitoring program

New Engl. J. Med.

Task force report: The periodic health examination

Canad. Med. Assoc. J.

Preventive Health Care for Adults

Improving physician compliance with preventive medicine guidelines

Med. Care

Prevention in primary medical care: The insure Project

Md. State Med. J.

Preventive services for the well population

General article
Prevention and health promotion in primary care: Baseline results on physicians from the INSURE project on lifecycle preventive health services☆