561516

research-article2014

HPPXXX10.1177/1524839914561516Health Promotion PracticeLuquis, Paz / Health Promotion and Prevention

Primary Care

Attitudes About and Practices of Health Promotion and Prevention Among Primary Care Providers Raffy R. Luquis, PhD, MCHES1 Harold L. Paz, MD, MS2

The Patient Protection and Affordable Care Act’s emphasis on health promotion and prevention activities required an examination of the current practices of primary care providers in these areas. A total of 196 primary care providers completed a survey to assess current health promotion and prevention attitudes, practices, and barriers. Results of this study showed that family physicians in Pennsylvania recognize the importance of and their role in providing health promotion and prevention and offer advice in key behavioral and disease prevention areas. Results from the study suggest that their ability to provide these services is hindered by a lack of time and the heavy workload. Although most family physicians provided advice to patients in several health promotion and prevention areas, few participants reported that they referred patients to other health professionals. Finally, when it comes to preventive services, participants ranked blood pressure screening, tobacco use screening, and tobacco use cessation interventions as the most important services. Effective implementation of the Patient Protection and Affordable Care Act will require necessary resources and support of primary care providers to help patients achieve healthier lives.

Human Services [USDHHS], n.d.) has increased the emphasis on health promotion and disease prevention by making preventive care more accessible and affordable for many Americans. The ACA requires insurance companies to cover evidence-based preventive services without cost sharing (Pollack, 2011). Health care providers are urged to promote personalized wellness and prevention services, including smoking cessation, weight management, and nutrition among other activities (USDHHS, n.d.). These changes in the provision of health care require an examination of the current practices of primary care providers in the area of health promotion and prevention. For example, Marvasti and Stafford (2012) argued that there is a need to reengineer the health care system in order to place prevention in the forefront. They also acknowledged that our current culture regarding the health care system, the advancements in technology, and the economy represent obstacles in making prevention an important part of the health care system. The purpose of this study was to examine the current health promotion and prevention attitudes, practices, and barriers among family physicians in Pennsylvania. Specifically, the study addressed the following research questions:

Keywords: health promotion; medical care; health education; disease prevention; primary care

Research Question 1: What are the attitudes about and practices of health promotion and prevention among primary care providers? Research Question 2: What preventive practices do primary care providers provide their patients?

Introduction >> The enactment of the Patient Protection and Affordable Care Act (ACA; U.S. Department of Health &

Health Promotion Practice September 2015 Vol. 16, No. (5) 745­–755 DOI: 10.1177/1524839914561516 © 2014 Society for Public Health Education

1

Penn State Harrisburg, Middletown, PA, USA Aetna, Hartford, CT, USA

2

Authors’ Note: Address correspondence to Raffy R. Luquis, Program Coordinator and Associate Professor of Health Education, School of Behavioral Sciences and Education, Penn State Harrisburg, W314 Olmsted, 777 West Harrisburg Pike, Middletown, PA 17057-4898, USA; e-mail: [email protected].

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Research Question 3: What factors prevent primary care providers from focusing more on health promotion and preventive services? Research Question 4: What preventive services based on the ACA requirements do physicians rank as most important?

Background >> Previous studies have provided some evidence on health care providers’ attitudes about and practices of prevention and health promotion. Hung et  al. (2007) found that health risk assessment, behavioral counseling, and referral to community-based prevention programs were infrequent among primary care providers despite the strong evidence supporting these practices. Kotecki et  al. (2004) reported that family physicians believe that health-promoting behaviors (i.e., elimination of cigarette, healthy diets) were very important for their patients; however, they were concerned about not being able to successfully help patients change specific behaviors. Similarly, Wechsler, Levine, Idelson, Schor, and Coakley (1996) found that the majority of physicians believe that reduction or elimination of risky behaviors (i.e., smoking, drug and alcohol use) were very important and that they were responsible for educating their patients; however, they felt inadequate in educating patients on about risk factors. According to Orleans, George, Houpt, and Brodie (1985), although many family practice physicians regularly provide health education and advice to their patients, they do not offer systematic treatment or referral to their patients who smoke cigarettes, are obese, or engage in too little exercise. These authors concluded that physician attitudes about their patients’ abilities to change and their own confidence in providing lifestyle change advice were reported as major obstacles for the provision of prevention. Finally, Rosen, Logsdon, and Demak (1984) found that although physicians tend to be conscientious in educating their patients about their health risks, they spend little time in patient education given a lack of confidence in their patients and their own effectiveness in this area and lack of insurance reimbursement. Although these studies provided views of health care providers over the past few decades, there is a need to further examine these issues given the current expectations of the ACA. Results from studies outside the United States also provide some understanding to these issues. Johansson, Stenlund, Lundström, and Weinehall (2010) found that health service providers believe that they are responsible for health promotion and disease prevention; however, there was a difference in the interpretation of

prevention versus health promotion activities and their willingness to engage in these practices. In addition, health care providers encountered barriers such as heavy workload, lack of guidelines, and unclear objectives about prevention. Similarly, Johansson, Weinehall, and Emmelin (2010) found that health professionals have positive views and are willing to develop health promotion and preventive roles within their practices; still they felt limited by their existing values, structure, and resources. Brotons et al. (2005) found that although general practitioners believed they should conduct prevention and health promotion activities, they were less likely to do so due to heavy workload/lack of time and lack of reimbursement. In contrast, Kardakis, Weinehall, Jerdén, Nyström, and Johansson (2013) found that, overall, health professionals have positive attitudes toward and knowledge about lifestyle interventions (i.e., tobacco, alcohol, and eating habits) and that the majority of them would like to do more to influence patients’ lifestyles. Overall, health care providers appear to be committed to conduct health promotion and prevention activities for their patients in spite of the barriers presented.

Method >> Participants

Primary care providers were recruited from a list of active members of the family physicians practicing in the state of Pennsylvania. According to the American Academy of Family Physicians (AAFP) membership database, there were 3,078 active members residing in the state of Pennsylvania at the time the list was requested (Infocus Marketing, n.d.). The membership list from the AAFP included only the physical addresses of participants’ offices. Measures A survey based on the health promotion and prevention requirements stated in the ACA, as well as similar instruments used in other research studies, was developed for this study. The survey contained six questions to elicit demographic information (i.e., age, gender, and years working in the field). Participants’ attitudes about health promotion and prevention were measured using a 10-item scale similar to those used in other surveys (Johansson, Stenlund, et al., 2010; Kardakis et al., 2013). Participants were asked to indicate their degree of agreement with each statement using a 5-point Likert-type scale (strongly agree to strongly disagree). Participants were asked to respond to statements such as “Health promotion is the primary responsibility of the primary

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care provider,” “Primary care provider should make health promotion a priority as part of their practice,” and “Primary care provider should spend more time to providing preventive services to their patients.” All the attitudinal statements were positively stated; a lower score indicated positive attitudes. Participants were asked to report the percentage of time they spend talking to their patients about health promotion and prevention during a regular visit. A 5-point Likert-type scale (always to never) was used to assess how frequent participants provide advice about or refer patients in health promotion and preventive service areas such as healthy lifestyle, smoking cessation, weight and stress management, physical activity, and cardiovascular disease, diabetes, and cancer prevention (USDHHS, n.d.). A lower score indicated a high frequency of provided advice or referral. Physicians were asked to respond on a 5-point Likert-type scale (very likely to very unlikely) to 12 statements regarding factors or barriers, such as “lack of time,” “heavy workload,” and “lack of economic incentives,” that may prevent them from focusing on health promotion and preventive services. A lower score indicated a high likelihood of a barrier. Finally, physicians were asked to rank from 1 to 18 (most important to least important) preventive services to provide to their patients based on the ACA requirements for preventive services for adults and women (Centers for Medicare and Medicaid Services, n.d.; U.S. Preventive Services Task Force [USPSTF], 2014a, 2014b). To determine face and content validity of the instrument, the principal investigator (PI) sought feedback from two family physicians and two health promotion professionals. A pilot study with a sample of 20 participants was conducted to assess the reliability for each scale. Cronbach’s alpha was found to be .70 for the health promotion and prevention attitudes items, .92 to .93 for the items dealing with both provided and referred health promotion and prevention services, and .87 for the barriers to health promotion and prevention items. Cronbach’s alpha using the full data was found to be .85 to .87 for each of the scales, respectively. For the purpose of this study, the authors provided definitions to the participants for the following terms: health promotion, prevention, and preventive services. Health promotion was defined as the process of enabling people to increase control over, and to improve, their health; it moves beyond a focus on individual behavior toward a wide range of social and environmental interventions (World Health Organization, 2009). Prevention was defined as actions and interventions designed to identify risks and reduce susceptibility or exposure to health threats prior to disease onset, detect and treat disease in the early stages in order to

prevent progress or recurrence, and alleviate the effects of the disease and injury (Centers for Disease Control and Prevention, 2009). Preventive services were defined as routine health care services that include screenings, checkups, and patient counseling to prevent illnesses, disease, or other health problems (USDHHS, n.d.). Procedures and Statistics Analysis Each participant received a letter explaining the purpose of the investigation, informed consent, issues regarding anonymity, and contact information of the PI. The letter also provided the link to the website address (i.e., SurveyMonkey) to access the survey electronically. Participants had the option to contact the PI to receive the link to the survey via e-mail or to receive a hard copy of the survey to complete by mail. Participants were asked to complete the survey within 2 weeks. Since e-mail address and telephone number were not available from the membership list, a follow-up letter was sent via regular mail to all potential participants within 4 weeks to remind them about their participation. In addition, the PI posted a message on the Pennsylvania Academic of Family Physicians’ Facebook page requesting participation in the survey. The PI received approval of the Penn State Hershey Institutional Review Board and Human Subjects Protection Office prior to data collection. SPSS Version 20.0 was used to complete the data analysis. Descriptive statistics and Pearson’s chi-square were used to examine participants’ health promotion and prevention attitudes, health promotion and preventive services practices, barriers, and demographic variables. t test and analysis of variance were used to compare mean score ranking of preventive services by participants. The level of statistical significance was set at p < .05.

Results >> Two hundred and two participants completed the survey. Six participants completed only the demographic section; hence, they were excluded from the analysis, leaving 196 completed surveys. The sample size represents a response rate of 6%; the 95% confidence interval was calculated to be 6.7 (Creative Research Systems, 2012). Demographics of Participants Most of the participants were male (60%), practiced family medicine (97%), were affiliated with a medical practice at a medical center or hospital (66%), and

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worked in a suburban area (55%). Participants were between 26 and 68 years, in the age-groups 26 to 39 (29%), 40 to 49 years (28%), 50 to 59 years (30%), and 60 to 68 years (13%; M = 47.2, SD = 10.2). When asked about the years working in primary care, 40% of the participants reported 22 years or more, followed by 8 to 14 (25%), 0 to 7 (20%), and 15 to 21 (16%) years. Attitudes About and Practices of Health Promotion and Prevention Responses on the attitudinal scale were categorized as strongly agree/agree versus neutral/disagree/strongly disagree. Results showed that the majority of participants strongly agree/agree that it is important to provide health promotion (99%) and prevention (99%), that it is important to make health promotion (92%) and prevention (96%) a priority, and that health promotion (89%) and prevention (82%) are the responsibility of the entire health care team. Most participants also strongly agree/agree that prevention is the responsibility of the primary care provider (74%), they should spend more time providing preventive services (71%) and health promotion services (69%), and health promotion is the responsibility of the primary care provider (67%). A chi-square analysis showed no significance difference across participants (see Table 1). Health Promotion and Preventive Services Responses to the nine health promotion and prevention areas were grouped into always/often versus sometimes/rarely/never. As seen in Table 2, the majority of participants always/very often provided advice to patients in smoking cessation (91%), healthy lifestyle (86%), weight management (82%), physical activity (82%), healthy eating (77%), and cardiovascular disease (73%). Almost two third always/often provided advice in diabetes prevention (67%) and cancer prevention (62%). Chi-square analyses showed significant difference by practice setting and age. Participants who practiced in urban areas were less likely to provide advice on healthy lifestyle than those in suburban or rural areas (χ2 = 6.077, p = .048). Participants who practiced in suburban areas were more likely to provide advice about cardiovascular disease prevention than their counterparts (χ2 = 6.748, p = .034). Older participants (>60 years) were less likely to provide advice on healthy eating habits and nutrition (χ2 = 8.984, p = .029). Few participants reported that they always/often referred patients to other health care professionals to get advice or services in health promotion and prevention areas (see Table 2). Less than a third of participants

referred patients to other providers for advice in cancer prevention (30%), stress management (23%), and healthy eating (22%). Even fewer of the participants referred patients for other services. Chi-square analyses showed significant difference by gender and years in practice. Women were more likely to refer patients to other professionals for weight management (χ2 = 4.451, p = .035) and for diabetes prevention services (χ2 = 4.922, p = .027). Participants with 15 or more years in practice were more likely to refer patients for weight management services (χ2 = 5.206, p = .023). On a separate question, participants were asked to report the percentage of their time they spend talking to patients about these topics during a regular visit. Sixty percent of the participants reported spending up to 25%, with 31% reporting up to 50%, and 6% up to 75% (not shown in table). Chi-square analyses showed no significant difference across participants. Barriers for Health Promotion and Preventive Services Responses to the 12 barriers were also dichotomized into very likely/likely versus neither/unlikely/ very unlikely. Most participants reported that lack of time (80%-86%), heavy workload (81%), and multiple roles within practice (65%) were factors that very likely/likely prevent them from providing health promotion and preventive services. Approximately half of the participants (48% to 53%) reported that lack of economic incentives prevents them from providing health promotion and preventive services (see Table 3). Chi-square analyses showed significant difference in responses by gender, age, and years in practice. Men were more likely to report that lack of time (χ2 = 5.331, p = .021) prevent them from providing preventive services, and lack of economic incentives prevent them from providing health promotion (χ2 = 4.226, p = .040) and preventive services (χ2 = 5.743, p = .016). Participants between the ages of 50 and 59 years were more likely to report that lack of time prevent them for providing health promotion services (χ2 = 7.823, p = .050). Participants with more than 15 years of practice were more likely to report that lack of time (χ2 = 5.704, p = .017), need to fulfill multiple roles (χ2 = 4.725, p = .030), and lack of economic incentives (χ2 = 4.385, p = .036) prevent them from providing preventive services. Ranking of Preventive Services On average, participants ranked blood pressure screening and tobacco use screening and cessation interventions as the two most important services to

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Table 1 Attitudes Toward Health Promotion and Prevention (Percentage of Those Who Reported Strongly Agree/Agree) Gender Statement It is important to provide health promotion services to our patients. It is important to provide preventive services to our patients. Health promotion is the primary responsibility of the primary care provider. Prevention is the primary responsibility of the primary care provider. Health promotion is the primary responsibility of the entire health care provider team. Prevention is the primary responsibility of the entire health care provider team. Primary care providers should make health promotion a priority and part of their practice. Primary care providers should make preventive services a priority as part of their practice. Primary care providers should spend more time to providing health promotion services to their patients. Primary care providers should spend more time to providing preventive services to their patients.

Age, Years

Years of Practice

Primary Care Setting

Male Female ≤39 40-49 50-59 ≥60 0-14 15+ Urban Suburban Rural All (n = 117) (n = 78) (n = 53) (n = 51) (n = 54) (n = 24) (n = 87) (n = 107) (n = 38) (n = 107) (n = 49) 99

100

96

98

98

98

100

99

98

100

98

98

99

100

99

98

100

100

100

99

100

100

99

100

67

67

67

60

71

67

75

65

68

66

65

74

74

72

76

70

76

72

75

74

73

79

71

78

89

89

89

89

91

87

92

88

89

82

91

90

82

83

81

75

86

81

83

81

83

71

86

82

92

94

90

92

90

96

92

93

92

95

93

88

96

96

96

92

96

96

100

95

96

97

96

94

69

70

67

70

65

62

71

69

69

66

68

72

71

76

65

67

65

68

69

66

76

68

72

71

NOTE: N = 196.

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Table 2 Provide and Refer Health Promotion or Prevention Advice to Patients (Percentage of Those Who Reported Always/Very Often) Gender Statement

All

Age, Years

Male Female ≤39 40-49 (n = 117) (n = 78) (n = 53) (n = 51)

Smoking cessation  Provide 91 90  Refer 14 15 Healthy lifestyle  Provide 86 84  Refer 7 7 Physical activity and fitness 83 80  Provide 8 6  Refer Weight management 82 81  Provide 19 14  Refer Healthy eating habits and nutrition 77 73  Provide 22 20  Refer Cardiovascular disease prevention 73 73  Provide 8 6  Refer Diabetes prevention 67 64  Provide  Refer 15 10 Cancer prevention 62 61  Provide 30 27  Refer Stress management 43 40  Provide 23 20  Refer

Years of Practice

Primary Care Setting

50-59 ≥60 0-14 15+ Urban (n = 54) (n = 24) (n = 87) (n = 107) (n = 38)

Suburban (n = 107)

Rural (n = 49)

94 11

92 8

88 18

89 11

96 21

88 13

94 15

87 13

95 16

86 10

88 8

89 9

84 10

85 6

87 4

85 9

87 6

74* 5

89 7

90 8

87 10

88 6

80 11

81 8

75 8

84 7

81 9

74 14

84 6

86 8

82 26*

87 13

84 20

80 17

71 25

85 11

79 24*

74 21

82 17

86 20

84 24

83 19

82 29

75 18

54* 21

83 22

73 22

79 32

76 19

80 20

73 10

74 4

74 11

70 7

79 12

72 8

74 7

63 10

80* 7

65 6

70 22*

66 9

69 16

65 19

71 21

65 14

69 16

60 21

73 13

58 14

64 35

58 26

65 31

60 37

71 32

60 28

64 32

53 29

64 32

66 26

47 28

47 31

48 22

44 20

33 21

50 26

37 21

39 29

46 27

39 10*

NOTE: N = 195. *p < .05.

provide to patients. Participants ranked cholesterol screening, colorectal cancer screening, and diabetes screening for adults with high blood pressure as the next three important preventive services to provide (see Table 4). A series of t test and analyses of variance showed significant difference of the average ranking by characteristics of participants. Females ranked routine health and wellness checkup higher than males (t = 2.0868, p = .040). Participants older than 60 ranked cholesterol screening more important (F = 3.352, p = .020). Those younger than 39 and those with less than 15 years in practice in health care field ranked abdominal aortic aneurysm screening less important (F = 3.379, p = .020; t = 2.649, p = .009) than their counterparts.

Finally, those practicing in the urban setting ranked cholesterol screening and routine health and wellness checkup less important (F = 6.958, p = .001; F = 3.935, p = .021, respectively) and HIV screening more important (F = 3.333, p = .038) than participants in suburban and rural settings.

Discussion >> According to Koh and Sebelius (2010), Americans receive only about half of the recommended preventative health services; consequently, they are not reaching their ideal health. Family physicians can play a key role in promoting health by providing preventive

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Table 3 Barrier for Focusing on Health Promotion and Preventive Services (Percentage of Those Who Reported Very Likely/Likely) Gender Statement Lack of time to provide health promotion services Lack of time to provide preventive services Heavy workload as part of my practice Need to fulfill multiple roles as part of my practice Lack of economic incentives to provide health promotion services Lack of economic incentives to provide preventive services Lack of support from management and/or administration Lack of knowledge regarding community resources for health promotion and prevention Lack of guidelines regarding health promotion services Lack of knowledge, competence, and skills in health promotion strategies Lack of guidelines regarding preventive services Lack of knowledge, competence, and skills in preventive services

Age, Years

Years of Practice

Primary Care Setting

Male Female ≤39 40-49 50-59 ≥60 0-14 15+ Urban Suburban Rural All (n = 117) (n = 78) (n = 53) (n = 51) (n = 54) (n = 24) (n = 87) (n = 107) (n = 38) (n = 107) (n = 49) 86

86

84

83

78

96*

79

80

90

87

85

86

80

85

72*

75

71

89

88

72

86*

84

77

82

81

83

79

79

76

89

79

78

84

89

79

82

65

69

59

66

61

76

63

57

72*

74

65

57

53

59

44*

42

55

52

54

45

59

53

51

55

48

55

37*

39

45

50

53

39

55*

45

48

49

37

37

37

33

45

35

30

36

39

40

36

39

30

27

35

33

35

26

13

35

26

21

31

35

14

14

14

12

18

13

8

13

15

16

11

18

7

9

5

10

9

6

0

8

7

8

5

12

5

6

4

4

6

4

8

6

5

5

5

6

3

3

3

4

4

2

0

5

2

3

5

0

NOTE: N = 195.

*p < .05.

services to and encouraging their patients to engage in healthier behaviors (Simon, 2012; USDHHS, 2013). The present study shows that family physicians in Pennsylvania recognize the importance and their role in providing health promotion and prevention and provide advice in key behavioral and disease preven-

tion areas; these findings are similar to previous studies (Brotons et  al., 2005; Johansson, Stenlund, et  al., 2010; Johansson, Weinehall, et al., 2010; Kardakis et al., 2013; Kotecki et  al., 2004). Nonetheless, results from this survey showed that most of the participants spend 25% or less of their time per visit discussing health Luquis, Paz / HEALTH PROMOTION AND PREVENTION  751

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Table 4 Mean Score of Ranking of Preventive Services by Characteristics Gender

Age, Years

Years of Practice

Service

All

Male (n = 114)

Female (n = 76)

≤39 (n = 49)

40-49 (n = 50)

50-59 (n = 54)

≥60 0-14 (n = 24) (n = 82)

Blood pressure screening for all adults Tobacco use screening for all adults and cessation interventions for tobacco users Cholesterol screening for adults of certain ages or at higher risk Colorectal cancer screening for adults >50 years Diabetes (type 2) screening for adults with high blood pressure Immunization vaccines for all adults based on age and risk factors Obesity screening and counseling for all adults Breast cancer mammography screenings every 1 year to 2 years for women >40 years Cervical cancer screening for sexually active women

2.9

2.8

3.1

3.3

2.9

2.5

2.8

3.9

3.8

4.2

3.6

4.7

3.4

6.7

6.2

7.3

7.5

6.5

6.8

6.7

6.9

6.8

7.1

6.8

7.3

7.4

7.5

7.8

Alcohol misuse screening and counseling Diet counseling for adults at higher risk for chronic disease Aspirin use to prevent cardiovascular disease for men and women of certain ages Depression screening for adults Routine health and wellness checkup for all adults

Attitudes About and Practices of Health Promotion and Prevention Among Primary Care Providers.

The Patient Protection and Affordable Care Act's emphasis on health promotion and prevention activities required an examination of the current practic...
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