Practicing health promotion in primary care -a reflective enquiry.

INTRODUCTION: Health promotion is an integral part of routine clinical practice. The physicians' role in improving the health status of the general population, through effective understanding and delivery of health promotion practice, is evident throughout the international literature. Data from India suggest that physicians have limited skills in delivering specific health promotion services. However, the data available on this is scarce. This study was planned to document the current health promotion knowledge, perception and practices of local primary care physicians in Odisha.
METHODS: An exploratory study was planned between the months of January - February 2013 in Odisha among primary care physicians working in government set up. This exploratory study was conducted, using a two-step self-administered questionnaire, thirty physicians practicing under government health system were asked to map their ideal and current health promotion practice, and potential health promotion elements to be worked upon to enhance the practice.
RESULTS: The study recorded a significant difference between the mean of current and ideal health promotion practices. The study reported that physicians want to increase their practice on health education.
CONCLUSION: We concluded that inclusion of health promotion practices in routine care is imperative for a strong healthcare system. It should be incorporated as a structured health promotion module in medical curriculum as well.

Introduction

With time there has been a growing interest in the role of primary care, and general practice in particular, in public health activities. General practice and general physicians are often regarded as the basic building blocks of public health, and primary care is seen as a logical location for local public health activities [1].The Alma-Ata declaration in 1978 identified the role of general physicians in public health as important, and 30 years later in a report on primary care the World Health Organization (WHO) confirmed this special relationship (WHO 1978, 2008). Health promotion has been identified one of the most important public health activities of physicians working on primary care settings [2-4].

Health promotion has a holistic approach of promoting health intervention to stimulate health and wellbeing i.e. proper nutrition and physical activities, preventing diseases, identification and maintaining health of persons suffering from the chronic illnesses [5, 6]. The physicians’ role in improving the health status of the general population, through effective understanding and delivery of health promotion practice, is evident throughout the international literature. The major role of the clinician in health promotion is at the individual level and involves screening for risk factors and disease, and providing early treatment, advice, counseling, and referral. Primary care physicians can further broaden their impact by assuming roles at organizational, community, and government levels (e.g., as an active member of an organization or a consultant to an outside organization, a community leader or an agent of change, an influential constituent or a lobbyist). These roles enable primary care physicians to have an impact both on individuals and on environments to reduce disease risk factors. For instance, randomized controlled trials addressing brief interventions in heavy alcohol consumers has clearly demonstrated the importance of behavioural-focused health promotion activities in addressing and lowering consumption trends [7]. Similarly in lifestyle modification behaviors, such as smoking cessation, increasing physical activity and tackling obesity [8-12]. However, much of this evidence occurs within Westernized countries with a more limited extent and importance attached to the health promotion role and function of physicians – particularly within South-East Asia [13]. Recent data from Global Adult Tobacco Survey (GATS), India show that less than half of smokers who visited health care providers were advised to stop smoking [14]. Data from India also suggests that physicians lack skills in delivering brief intervention and counseling in tobacco cessation [15, 16].

Potential reforms are needed in this geographical location to enhance the effectiveness of health promotion practice among general physicians. The intention of this study was to survey the current status of health promotion knowledge, perceptions and practices of local primary care physicians, with an intention to locate and improve such practice. It sought to identify both ‘ideal’ and ‘actual’ practice. To the best of our knowledge, no previous study of this kind has been conducted in Odisha state.

Methods

The present study was carried out in the month of January-February 2013 in the state of Odisha, India. This exploratory study was conducted, using a two-step self-administered questionnaire. Thirty physicians practicing under government health system were asked to map their ideal and current health promotion practice, and potential health promotion elements to be worked upon to enhance the practice. Physicians were purposively selected from the Community Health Centres (CHC). CHCs are the major primary health care providing institutions, under Indian healthcare system’. The physicians at CHCs are registered medical doctors (MBBS and MD) and are the first line of contact with the community. They are the focal person to engage in any kind of health promotion activity among the general population. At first step, different health promotion elements i.e. 1) Use of strategies, 2) Manifesting Features and 3) Expressing values were accessed. Sub-elements listed in each domains like health communication, health education, policy development, advocacy, determinants of health, empowerment and social justice and equity etc. were asked to be rated on a 10 point Likert scale, mapping both ideal as well as their current practice.

At second step, physicians were asked to choose and identify the health promotion elements which they think have big gap in their current and the ideal practice and to state the desired changes in terms of ‘start’ or ‘stop’ and ‘increase’ or ‘decrease’ terminologies. The quantitative data hence obtained were entered in the MS Excel Software and imported into SPSS Version 17.0. Mean score of each element is calculated and were compared between current and ideal practice using t-test statistics. Value of p < 0.005 were considered significant and p < 0.001 were considered highly significant. Results were represented in tabular formats. Health promotion elements listed as the area to be start or stop and increase or decrease are listed in the box according to their frequency as quoted by the participants.

Objective of the study was explained to the study participants before the execution of the questionnaire and informed consent has been taken before administration of the tool. Unique ID has been assigned to each participant and anonymity is maintained through the process.

Results

Table I illustrates mean score comparison of health promotion elements between the ideal and the current practices of the physicians. It is evident that for each of the 16 elements listed, the difference between the mean of current and ideal is highly significant. Amongst the three main domains i.e. Using Strategies, Manifesting Features and Expressing Values, maximum differences has been observed in health communication, participatory approaches and empowerment respectively under each category.

Tab. I

Comparative table of ideal and current practice of Health Promotion Elements.

S. No.	Health Promotion Elements	Ideal Practice(+/-SD)	Current Practice(+/-SD)	Difference(Ideal – Current)
1	Health Communication	8.90 (0.93)	4.69 (1.36)	4.21*
2	Health Education	8.72 (1.16)	5.14 (1.86)	3.58*
3	Self Help Mutual Aid	8.10 (1.23)	4.41 (2.18)	3.69*
4	Organizational Change	8.03 (0.98)	4.21 (1.71)	3.82*
5	Community Development and Mobilization	8.55 (1.05)	4.45 (1.90)	4.10*
6	Policy Development	8.45 (1.42)	4.52 (1.95)	3.93*
7	Advocacy	7.97 (1.14)	4.28 (1.85)	3.69*
8	Holistic View of Health	8.59 (1.40)	4.66 (2.34)	3.93*
9	Participatory Approaches	8.52 (1.05)	4.45 (2.30)	4.07*
10	Determinants of Health	8.69 (0.96)	4.86 (2.03)	3.83*
11	Focus on strengths and assets	8.41 (1.05)	4.90 (1.98)	3.51*
12	Using multiple complementary strategies	8.52 (1.05)	4.72 (1.94)	3.80*
13	Empowerment	8.97 (0.98)	4.31 (1.98)	4.66*
14	Social Justice and equity	8.97 (0.86)	4.34 (2.05)	4.63*
15	Inclusion	8.41 (1.24)	4.69 (2.03)	3.72*
16	Respect	8.72 (1.36)	5.03 (2.51)	3.69*

* < 0.001 Significance

Table II represents the frequency of participants under each health promotion elements identified as the desired area of change, mostly, ‘increasing’ the already existing practice or to ‘start’ a new initiative under that element. In the current study, majority of the participants reported a desired change in use of strategy to practice health promotion. Under the domain using strategy, physician wants to increase their practice on health education, followed by holistic view of health, under manifesting features and social justice and equity under expressing values.

Tab. II

Health promotion elements listing.

S. No.	Health promotion elements	Frequency of participants reported a ‘start’ or ‘increase’
Using strategies
1	Health Communication	8
2	Health Education	14
3	Self Help Mutual Aid	2
4	Organizational Change	5
5	Community Development and Mobilization	5
6	Policy Development	8
7	Advocacy	3
Sub-Total		45
Manifesting features
8	Holistic View of Health	13
9	Participatory Approaches	7
10	Determinants of Health	7
11	Focus on strengths and assets	3
12	Using multiple complementary strategies	4
Sub-Total		34
Expressing values
13	Empowerment	9
14	Social Justice and equity	22
15	Inclusion	6
16	Respect	1
Sub-Total		38

Table III represents the physicians’ understanding of the American Journal of Health Promotion and the Ottawa Charter definition of health promotion.

Tab. III

Physicians’ understanding of the American Journal of Health Promotion and the Ottawa Charter definition of health promotion.

S. No.	Core Themes	Domains	Major Contrasting difference between American Journal of Health Promotion & Ottawa Charter
1.	Emergence of definitions	Formulated byDimensionsProcess of promotion	‘AJHP Definition has been formulated by a single person and Ottawa charter was formulated during a conference of many experts’. [3+]‘Spiritual and intellectual dimensions were included in AJHP definition which is not there in Ottawa definition’. [3+]‘AJPH definition helps people to reach the optimal level of health whereas Ottawa enables people to attain optimal health’. [3+]
2.	Areas of development	Pre-Requisites	‘AJHP definition has large number of pre-requisite like but Ottawa has very few’. [2+]
3.	Approach	StakeholdersPolicy PerspectiveEquity	‘AJPH has more of an individualistic Approach while Ottawa has programme, community and local need based approach’. [3+]‘AJPH do not highlight the policy intervention in health promotion programme but importance of same has been highlighted in Ottawa charter’. [2+]‘AJPH doesn’t Emphasized on Equity in Health, while Ottawa highlighted the importance of the same’. [1+]
4.	Strategies of definition	Political CommitmentMulti-Sectoral CollaborationAccountability	AJPH didn’t highlight the importance of political commitment whereas Ottawa definition clearly quoted the importance of the same. [3+]AJPH didn’t discuss about multi-Sectoral collaboration whereas Ottawa definition clearly demonstrated the importance of the same. [2+]Optimal Health through health promotion is much accounted at individual level by AJHP whereas Ottawa made community, government and society as a whole responsible for it. [3+]

Discussion

The aim of this study was to comprehend the present level of understanding on health promotion among in-service health professionals. The study would also enable an assessment of what is required to further enhance health promotion component in the context of primary care delivery. It is important that health professionals are able to understand and delineate exactly what constitutes health promotion practice. Effective health promotion practice is dependent on sound theory and clear conceptualization of the matter by the health professionals [17]. Even though health promotion is strongly built into the concept of all the national health programs with implementation envisaged through the primary health care system based on the principles on equitable distribution, community participation, inter-sectoral coordination and appropriate technology, it has received lower priority compared to clinical care [18]. The present Indian medicine (MBBS) curriculum lacks health promotion component during formative training [19]. Evidence from earlier Indian studies on the student’s beliefs and practices of health promotion reported that most students assessed preventive practices in their patients but did not feel well prepared and competent enough to counsel patients about health issues [20]. Furthermore, physicians have not been trained in-service. Though there are limited evidence published documenting the health promotion practices among physicians, some studies from other regions of the country demonstrated limited capacity of the physicians to practice health promotion related activities. Study from Chhattisgarh, an eastern state of India, reported that Fifty-four percent of practitioners were of the opinion that counselling is ineffective and 62% considered counselling as time-consuming process. Majority of physician expressed their willingness to undergo additional training in nutrition. Similarly, a study from Karnataka, southern state of India reported poor knowledge of primary care physicians about pharmacological as well as non-pharmacological methods of treatment of nicotine dependence. This could hampers the tobacco cessation practice among the physicians. In an another study conducted in Karnataka, physicians expressed requirement of continuing education about nutrition education, lactation management, and a greater awareness about the influence of inappropriate promotional practices by companies.

Health promotion and education plays a vital role in providing care for the Non-Communicable Diseases (NCDs). In response to current trends, the global health care community has begun to emphasize on health promotion as an essential tool to curtail the rise of individuals experiencing chronic diseases. Addressing the main determinants of these diseases such as tobacco use, improper diet, sedentary lifestyle and obesity, from a preventive approach could serve to be a cost-effective and sustainable strategy in heavily populous developing country like India. Tobacco, for instance, is a major risk factor for a number of morbidities and mortalities. Recent data from the Global Adult Tobacco Survey (GATS) in India showed that less than half of smokers who visited health care providers were advised to stop smoking [14]. Published data from India also suggest that physicians lack skills in delivering health promotion counseling services on tobacco cessation [24, 25]. One of the reasons identified for such lack of preparedness by health professionals is the fact that there is no well-established health promotion component during formative training in the country.

However, as a recently development, health promotion education has been launched by many elite government and private institutions of the country. Two year post graduate diploma on health education being run by Central Health Education Bureau (CHEB), which is an apex institute created in 1956 under the Directorate General of Health Services (DGHS), Ministry of Health and family welfare, India. Similarly, private and autonomous institutions like Public health foundation of India, The Gandhigram Institute of Rural Health and Family Welfare Trust, Ambathurai, All india Institute of hygiene and public health, Kolkata offers certificate and Post Graduate Diploma in Health Promotion (PGD-HP) [20]. The program aims to build public health capacity of the participants to enhance the understanding of health promotion and enhance their skills and proficiency in designing and implementation of health promotion programs. It can be inferred that health promotion is an intriguing field of public health gaining popularity steadily and significant efforts being made for capacity building of young public health workforce as well as in-service candidates (medical doctors and other staff). Though, an integrated health promotion in main stream curricula is still missing.

Against this backdrop, strengthening of health promotion and protection through development of an integrated education and health promotion programme, which has relevance to the local context, is important. There is a strong need of developing and incorporating a structured health promotion module in undergraduate and post-graduate medical curriculum to address the gap. Considering that health is essential for learning and development, health promotion should also be gradually built into all aspects of life in school as well as community. In-service physicians should be provided with compulsory hands-on training through specialized health promotion as part of their Continuing medical education.

A study conducted in Saudi Arabia to understand the health promotion practices of nurses reveals that while nurses had necessary skills, it was preferred that they focus on delivering acute care within the hospital setting and that the patients did not always appreciate nurses asking about health-related behavior switch were not directly linked to their present health problems [26]. Therefore, raising awareness among patients and educating them on the risks factors of NCDs through necessary health promotion initiatives is also a critical factor for prevention and control of NCDs.

It has also been observed that health promotion has never been incorporated in the duties or job responsibility of physician during primary care delivery services in India. This could have resulted in ‘lay away’ of health promotion practice compared to regular curative practices. Primary health care providers constitute the first point of contact between population and health system, and are suitably placed to assist individuals. Emphasizing health promotion at the primary care level is therefore important and can be addressed by introducing patient counseling or information dissemination on preventive aspects of prevalent diseases, as job responsibilities of primary care physicians.

The lack of awareness of the importance of health promotion has often prevented the proper recognition by managers and health workers. Physicians may have knowledge and skills but often their perception is that their role is as a sole point of care with curative services having immediate outcome with immediate diagnosis and treatment [27, 28]. In the earlier studies, physicians have suggested that the main negative outcome associated with this role behavior was the de-prioritization of primary preventive care in favor of the immediate benefits of secondary care [29, 30]. . Second reason which could possibly lead to de-prioritization of health promotion practice could be the overburden of program implementation and increased patient load on physicians. Heavy inflow of patients for curative services might result in no choice but prioritization of curative services [29]. Training the allied health professionals like AYUSH practitioners, dieticians, physiotherapists etc. for counseling, nutrition education, hygiene, physical activities etc. could be a cost effective and efficient solution for the same.

The recent National Health Policy (NHP) 2017 recognizes and build upon the preventive and promotive care. The policy targets on school health- by incorporating health education as part of the curriculum, promoting hygiene and safe health practices by acting as a site of primary health care. Policy also promotes healthy living and prevention strategies from AYUSH (Indigenous system of medicine in India) and Yoga at the work-place, in the schools and in the community. However, there is very little documented evidence on health promotion practice in the country, which is limited to individual practices and motivation [31]. Due to recent policy push, we could expect an increase in health promotion practices among population and healthcare providers. An assessment in near future is desirable to ensure that the health promotion practice is incorporated and practiced effectively by primary healthcare providers.

Moreover, since it is difficult to measure the outcome of preventive services, the physician often tends to lacks motivation, given there is no official recognition, patient recognition, peer recognition, community recognition for the same. In addition to the above, there is also no incentive or financial benefits attached to it. Efforts should be made on designing framework for measurement of outcomes of preventive services and also generate sufficient awareness on the issue for patient and community recognition. The possibility of replicating successful global health promotion initiatives at the country level, customized according to country-level needs could also be explored.

The current study though provides a useful insight of physicians’ health promotion practices but findings cannot be generalized to all physicians due to nonprobability sampling which includes purposive selection of physicians. However, findings from the study can be used as pilot exercise and more epidemiologically systematic studies can be undertaken to generate generalizable results.

Conclusions

Inclusion of health promotion practices in routine clinical care is imperative for building a strong healthcare system that ensures positive health outcomes, effectiveness and efficiency and health equity. This is all the more important in primary care settings as it is the first contact in a healthcare system for individuals and is characterized by longitudinally, comprehensiveness, and coordination. Health promotion should also be incorporated as a structured health promotion module in undergraduate and post-graduate medical curriculum. This will help the professional perceive health promotion as an integral part of health service delivery.