Transcript Présentation PowerPoint - The Association of Faculties of Medicine

PREVENTION AND
PROMOTION IN HEALTH
A LEARNING TOOL
Prevention and Promotion in Health: A Learning Tool
is licensed under a Creative Commons AttributionNonCommercial 4.0 International License.
Authors:
Geneviève Bustros-Lussier, MD
David-Martin Milot, MD
Andréanne Roy, MD
Residents in Public Health and Preventive Medicine
Université de Sherbrooke
Collaborators:
Dr Julie Dufort, MD, M.Sc., FRCPC
Dr Catherine Risi, MD, M.Sc
Mélanie Ann Smithman (translation)
Tool created in January 2014
Disclaimer
The authors are not responsible for errors or omissions or for
any consequences from application of the information in
this Learning Tool and make no warranty, expressed or implied,
with respect to the currency, completeness, or accuracy of the
contents of the publication. Application of the information in a
particular situation remains the professional responsibility of
the practitioner and reader.
Please note that you need to be in
"slideshow" mode in order for the
interactive parts of this tool to
work properly. Enjoy!
This training tool is also available
in French at your convenience.
CONTENT
This training tool is meant for clerkship students enrolled in Canadian
medical schools
It consists of the following:
Section
Time Required
Introduction
5 min.
Quiz
15 min.
Vignette no. 1
90 min.
Vignette no. 2
60 min.
Conclusion
10 min.
The vignettes may be completed with a supervisor or on your own.
INTRODUCTION
At the end of this training, you should be able to:
 Illustrate the concepts of disease prevention and health promotion;
 Explain the role of public health and preventive medicine physicians
with respect to disease prevention and health promotion;
 Identify strategies to apply disease prevention and health promotion to
your future clinical practice.
INTRODUCTION
First of all, a few definitions:
Prevention:
Disease prevention covers actions to prevent the occurrence of
disease, such as risk factor reduction, and also to arrest its progress
and reduce its consequences once established.
Health Promotion:
Activities that aims to enhance health by education, by
organizational, economic and political interventions to support
behavioural changes conducive to health.
“Glossary”. AFMC Primer on Population Health, The Association of Faculties of Medicine of Canada, http://phprimer.afmc.ca/Glossary
(retrieved January 2014) Permit : Creative Commons BY-NC-SA
INTRODUCTION
The concepts of disease prevention and health promotion
overlap.
In fact, the aim of health promotion includes, but also goes
beyond, preventing disease: it seeks, in addition, to strengthen
the skills and resiliency of individuals and of community groups.
The concepts of disease prevention and health promotion will
be illustrated throughout this training.
“Glossary”. AFMC Primer on Population Health, The Association of Faculties of Medicine of Canada, http://phprimer.afmc.ca/Glossary
(retrieved January 2014) Permit : Creative Commons BY-NC-SA
QUIZ
QUIZ
Before exploring the applications of promotion and prevention
in depth, here is a quiz that will help you answer a question that
is certainly on your mind :
Do you have what it takes to be a
public health and preventive medicine physician?
(Click on the image to take the quiz)
QUIZ
Click on the image with your score*:
0 to 19
20 to 39
40 to 60
*Please note that a higher score does not mean a better score.
QUIZ
You are a “bandage” type of doctor
As a doctor, treating disease is at the core of your work. While it is difficult to be
against the old adage “an ounce of prevention is worth a pound of cure”, when a
patient is in front of you, your main goal is to address problems.
Although treating disease is essential, it has also been shown that clinical
prevention is important both for patients and for reducing the costs and ensuring
the sustainability of the health care system.
You would benefit from this training tool by seeing how you could integrate the
preventive aspect into your clinical practice. After all, chronic diseases are largely
avoidable and effective prevention strategies exist. As a health professional, you
certainly have a role to play in this area.
What do you think ?
Click here to continue
QUIZ
You are a “protective helmet” type of doctor
It is clear to you that some health problems are avoidable. You seem committed
to disease prevention. You probably take advantage of each opportunity to offer
advice, screening, preventive medication and vaccines to your patients.
Moreover, you organize your workplace’s clinical environment to foster the
integration of preventive clinical practices. You firmly believe in the individual
approach to disease prevention. The integration of prevention in clinical practice
is important, but it has its limits. In fact, your patients are not entirely responsible
for their lifestyles: a number of factors including those linked to social and
physical environments influence them.
This training tool could help you understand why your patients do not always
make healthy lifestyle choices and do not follow all of your recommendations.
You will gain a better understanding of the determinants that impact your
patients’ health and how we can act.
Click here to continue
QUIZ
You are a “supportive environments” type of doctor
It is clear to you that most health problems are partially avoidable if we create
physical, social and political environments that are supportive of health. You
seem naturally interested in understanding why one population has more health
problems compared to another. This type of thinking makes up the foundation of
the population-based approach to disease prevention and brings us to address
the causes of problems by tackling the determinants of health.
This training tool will provide examples of broad prevention and promotion
strategies that can be implemented to improve the health of the population. You
might even find simple ways to integrate those concepts into your practice or
life.
Have you ever considered a career in public health?
Click here to continue
QUIZ
In summary, imagine the following situation :
A child riding a bicycle falls because of a pothole.
Dr. Bandage would treat the child.
Dr. Protective Helmet would tell the child to be more careful
and would suggest the child ride his bicycle on safer roads.
Dr. Supportive Environments would instead wonder if
potholes cause a significant number of accidents. If so, he
would wonder how potholes come about and how to mitigate
them.
INTRODUCTION
According to their respective approaches, these doctors have
different positions on the following continuums:
To maintain health
Dr. Protective
Helmet
Dr. Supportive
Environments
Individualcentered
Populationbased
Dr. Bandage
To restore health or to alleviate disease
and its consequences
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003
INTRODUCTION
One of these continuums relates to the purpose of the
approach taken:
To maintain health
For healthy people
For sick people
To restore health or to alleviate disease
and its consequences
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003
INTRODUCTION
Health promotion and disease prevention mainly aim to
maintain health.
To maintain health
Health
Risk
Promote
Prevent
Disease
Cure
Chronicity
Treat
To restore health or to alleviate disease
and its consequences
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003
INTRODUCTION
The other continuum relates to the health approach’s subject
of interest:
The Individual
Individualcentered
-Their
immediate
environment
The Community
- The region
- The neighborhood
- Their families
- The age group
-Their friends
- The risk group
- Etc.
- Etc.
Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003
Populationbased
VIGNETTES
As shown in the diagram, health approaches may be individual or
population-based. The process used in either case remains similar.
Here are a few examples:
APPROACH
PROCESS
INVESTIGATION AND
DIAGNOSIS
Individual-centered
Population-Based
Medical history
and physical
examination
Notifiable disease
surveillance
Laboratory
examination
Imaging
Diagnostic tests
Opportunistic
screening
Environmental risk
assessment
Outbreak
investigation
Mass
screening
Monitoring health status and
determinants of health
VIGNETTES
APPROACH
PROCESS
TREATMENT
FOLLOW-UP
Individual-centered
Recommendations
and prescriptions
Population-Based
Programs, projects,
promotion, prevention
and protection activities
Legislation and
regulation support
Evidence-based
Evidence-based
Follow-up on
investigation and
treatment
Program, project and activity
evaluation
Yearly follow-up
Ongoing monitoring of the
population’s health status
Inspired by Kennedy et al. DSP Saguenay, Lac St-Jean, 2003
VIGNETTES
The difference between these two approaches lies mainly in the
unique vision and expertise of each of them.
APPROACH
SUBJECT OF
INTEREST
Individual-centered
The patient
Population-Based
The population
Note that, typically, a clinical physician will have an individualcentered approach while the public health and preventive medicine
physician will have a population-based approach.
Inspired by Kennedy et al. DSP Saguenay, Lac St-Jean, 2003
VIGNETTES
Health promotion and disease prevention can be integrated to
each approach.
However, disease prevention can be easier to apply and more
common in the individual setting. It is at the heart of prevention
in clinical practice.
The first vignette presents a case in which the individual
centered approach was put forth. Many concepts, specific to
this type of approach, such as prevention in clinical practice, will
be discussed.
VIGNETTES
Note that the following vignettes can be completed in two ways.
1) In interaction with a supervisor
• The questions will be asked by the supervisor (the
resident in charge of the public health and preventive
medicine internship). Therefore, it is now time to turn
off your computer and play a sport. You will look at the
vignettes with your supervisor at a time set aside for this
task.
2) In self-learning
• Answer the questions that will be asked by yourself and
compare your answers to those presented.
VIGNETTE NO. 1
INDIVIDUAL-CENTERED APPROACH
OBJECTIVES
Upon completion of this activity, the participant
will be able to :
• Explain the public health and preventive medicine physician’s role in
the individual-centered approach to disease prevention and health
promotion;
• Illustrate the concepts of disease prevention and health promotion;
• Identify strategies to apply disease prevention and health promotion at
the individual level.
Click here to
start
BACKGROUND INFORMATION
You are Dr. Protective Helmet, a physician in a clinic. Ms. Sweet
Tooth, 35 years old, comes to see you for her Pap test which is
“due”.
Since you do not know the patient, you ask her various questions
on her personal and family history. Her history is unremarkable.
She lives with her spouse and her 4-year-old son and works as a
cashier in a grocery store.
BACKGROUND INFORMATION
Lifestyle
She has been smoking a pack a day for the last 14 years. She does very
little exercise and her leisure activities are rather sedentary. She stands
a lot for work. She eats about 4 servings of fruit and vegetables a day.
Contraception et sexual health
She has had an IUD for 3 years. She has been with the same partner
for 7 years.
Screening
Her last PAP test was done 2 years ago and her STI screening is up-todate: it was done during her last pregnancy. She has not had other
partners since and neither has her spouse.
QUESTION
What is the purpose of asking Ms. Sweet Tooth all of
these questions?
ANSWER
The purpose of these questions is to find out more
about Ms. Sweet Tooth and to guide your preventive
clinical practice according to this patient’s
characteristics.
QUESTION
What is prevention in clinical practice?
ANSWER
Prevention in clinical practice
combines a set of various types of effective individual
interventions offered in a clinical setting, for example:
• counseling on lifestyle choices and habits,
• screening or identifying cases of certain diseases
or risk factors,
• immunization,
• chemoprophylaxis (prescription of medication for
preventive purposes).
MSSS (2008), Programme national de santé publique 2003-2012 - updated 2008, Québec, 103p.
QUESTION
How do we know if a preventive clinical practice
is recommended?
ANSWER
Many expert groups issue guidelines on prevention in clinical practice based
on the evidence available.
The independence of expert groups and the quality of the evidence may vary:
• Independent specialized sources
E.g.: Canadian Task Force on Preventive Health Care (CTFPHC),
Cochrane Collaboration, U.S. Preventive Services Task Force, etc.;
• Health professionals’ associations
E.g. : Society of Obstetricians and Gynaecologists of Canada;
• Associations dedicated to a certain disease or approach
E.g. : Canadian Diabetes Association;
• Expert groups and scholarly societies
E.g. : On topics such as hypertension, lipids;
• Pharmaceutical industry and other private interests.
ANSWER
Hence, there may be discrepancies between guidelines for the
same preventive practice, in particular due to:
• the date of the guideline;
• selected studies;
• methodology;
• the classification of levels of evidence;
• the social context to which it is being applied.
Source: Roy, A., Groulx, S., Dufort, J., Bélanger, H., Risi, C., Sissoko, H., Paquin, P., Lévesque, M. (2013), "Apprentissage au raisonnement clinique (ARC) en
Prévention clinique des maladies chroniques : Activité complémentaire au stage d’externat en santé communautaire," Faculté de médecine et des
sciences de la santé, Université de Sherbrooke, Direction de la santé publique de la Montérégie, Agence de la santé et des services sociaux de la
Montérégie.
ANSWER
At the Canadian level, the main independent expert group issuing guidelines on
prevention in clinical practice is the
Canadian Task Force on Preventive Health Care (CTFPHC)
Since 1979, this independent, government-funded, expert group studies the evidence
in the literature regarding the main preventive interventions and issues guidelines for
clinicians.
Their guidelines are available online. (Click here to view them).
The American equivalent of this group is the U.S. Preventive Services Task Force.
Their guidelines are also available online. (Click here to view them).
ANSWER
CTFPHC Recommendation Grades (for illustrative purposes)
No new recommendations were issued between 2006 and 2011.
Canadian recommendation classification until 2006
Recommendation Grades for Specific Clinical Preventive Actions
A
The CTF concludes that there is good evidence to recommend the clinical preventive action.
B
The CTF concludes that there is fair evidence to recommend the clinical preventive action.
C
The CTF concludes that the existing evidence is conflicting and does not allow making a recommendation
for or against use of the clinical preventive action, however other factors may influence decision-making.
D
The CTF concludes that there is fair evidence to recommend against the clinical preventive action.
E
The CTF concludes that there is good evidence to recommend against the clinical preventive action.
I
The CTF concludes that there is insufficient evidence (in quantity and/or quality) to make a
recommendation, however other factors may influence decision-making.
Canadian recommendation classification since 2011: G.R.A.D.E.
Recommendations are graded as either strong or weak according to quality of
evidence (high quality, moderate quality, low quality)
Click here to find out more
ANSWER
To find out more, here are a few references* …
… on prevention in adults (click on the image):
GROULX, S. « La prévention chez l'adulte : une occasion à saisir au vol! »,
Le Médecin du Québec, vol. 40, no 5, 2005, p. 65-73.
L'évaluation médicale périodique de l'adulte: Recommandations adaptées à
la pratique médicale au Québec, 2014
… on prevention in adolescents (click on the image):
LAMBERT, D. « La prévention chez l’adolescent: comment l’aborder? »,
Le Médecin du Québec, vol. 40, no 5, 2005, p. 55-62.
*Please note that these references are available in French only.
QUESTION
For this patient, what type of prevention in clinical
practice is recommended in terms of counseling?
ANSWER
Tobacco
Recommendation A (CTFPHC, 1994). More recently, the following
interventions have been shown to be effective (CAN-ADAPPT, 2011) :
1
Identify and update patients’ tobacco use status
2
If the smoker is ready to quit, encourage them through counseling and medical
treatment;
3
If the smoker is not ready to quit, use the motivational approach to increase the
smoker’s chances of quitting;
4
Facilitate access to more intensive counseling (individual, group or by phone) –
the more frequent and extended it is, the better the results;
5
Organize your clinic to offer a more systematic approach – such as a call back
system, referral procedures for resources in counseling and educational
materials.
CAN-ADAPTT. (2011), "Lignes directrices canadiennes de pratique clinique sur le renoncement au tabagisme : énoncés sommaires." Toronto, Canada.. Retrieved January 2014
from http://www.peelregion.ca/health/professionals/events/pdf/2013/canadaptt-summary-statements.pdf
ANSWER
Exercise/sedentary living
• Nutritional and exercise counseling for adults without hypertension, diabetes,
hyperlipidemia or heart disease
• Recommendation C (USPSTF, 2012)
Click here to find out more
Diet (intake of fruit and vegetables)
• Recommendations from Canada’s Food Guide (2011)
(Click on the image for more information)
• Behavioral counseling to promote a healthy diet and exercise to prevent
cardiovascular disease
• Recommendation C (USPSTF, 2012)
Click here to find out more
ANSWER
In conclusion, according to Ms. Sweet Tooth’s
characteristics, you can gather that there is stronger
evidence supporting the benefits of smoking cessation
counseling than of diet and exercise counseling. The
former would hence be a priority for her.
QUESTION
How would you go about providing good counseling to
Ms. Sweet Tooth?
ANSWER
• We can use the CTFPHC’s 5 “A” method
Assess
Advise
Agree
Assist
Arrange
and follow-up
Click here to find out more
ANSWER
At the "Assess" step, it is useful to assess the stage of change
according to Prochaska and DiClemente to evaluate the patient’s
receptiveness to our advice and readiness to adopt a behavioural
change.
You will find Prochaska and DiClemente’s 6 Stages of Change on
the next slide.
ANSWER
1. Precontemplation
•The individual is not intending to change his behaviour.
2. Contemplation
•The individual is thinking about changing his behaviour and
intends to do something about it in the next 6 months.
3. Preparation
•The individual intends to change his behaviour in the next
30 days.
4. Action
•The individual has changed his behaviour in the past
6 months.
5. Maintenance
•The individual has practiced his new behaviour for
6 months.
6. Relapse
•The individual finds it hard to maintain the next behaviour
and relapses.
Click here to find out more
“Changing Behaviour”. AFMC Primer on Population Health, The Association of Faculties of Medicine of Canada, Retrieved January 2014
from: http://phprimer.afmc.ca/Part3-PracticeImprovingHealth/Chapter8IllnessPreventionAndHealthPromotion/Changingbehaviour
BACKGROUND INFORMATION
(CONTINUED)
You then decide to ask Ms. Sweet Tooth about her
motivation to quit smoking. She tells you that she has no
intention of quitting in the next year. She smokes outside
the house and never smokes in the car.
You consider the pros and cons of her tobacco use.
QUESTION
At what stage of change is she according to
Prochaska and DiClemente?
ANSWER
Ms. Sweet Tooth is at the:
Precontemplation
stage as she does not intend to stop smoking in the next year.
However, for exposure to second hand smoke, she is at the
action or maintenance stage.
QUESTION
What could you say to Ms. Sweet Tooth, at this point in
time, about her tobacco use according to the 5 “A”
model?
ANSWER
1
Assess her behavior, her intentions and her
motivation to stop smoking
• Already done
2
Advise
• Congratulate her on not smoking in the house or car,
which reduces her child’s exposure to second hand
smoke.
• Make a clear recommendation on the harmful effects of
tobacco and the importance of quitting as soon as
possible.
ANSWER
3
Agree
• Ask her if she would like to discuss it again at the next
appointment.
4
Assist
• Give her documentation.
5
Arrange & Follow-up
• Offer follow-up.
BACKGROUND INFORMATION
(CONTINUED)
You therefore take 2 minutes to bring the tobacco use
discussion to an end. You note it down in her medical
record.
You now move on to physical examination.
QUESTION
What preventive intervention would be relevant to do
during the physical examination?
ANSWER
Screening: overweight and obese
Calculation of BMI for all adults with an offer of referral for
intensive multidisciplinary follow-up if the BMI is 30 or more.
• Recommendation B (CTFPHC, 2006)
Click here to find out more
Screening: high blood pressure
• Strong recommendations (CTFPHC, 2012)
• Measure, at all appropriate visits, as per standardized measurement
techniques described in the Canadian Hypertension Education
Program (CHEP);
• Apply the CHEP criteria for assessment and diagnosis of individuals
found to be hypertensive during the screening.
Click here to find out more
ANSWER
Cervical cancer screening using the Pap test
• Strong recommendation; high quality evidence (for women aged
30 to 69) (CTFPHC, 2013)
Click here to find out more
BACKGROUND INFORMATION
(CONTINUED)
During her physical exam, her blood pressure is within the
normal range, her BMI is 31, her waist circumference is 100 cm.
You complete her physical exam with a Pap test.
Therefore, you offer her an intensive follow-up with a
multidisciplinary team. She seems interested, she had been
thinking about getting back into shape. As time is flying by, you
give her a referral for a follow-up and recommend that she go for
a first visit which does not commit her to anything. She accepts.
She then asks you what the purpose of a Pap test is. She does
not have any symptoms and has had the same partner for many
years.
QUESTION
How would you answer Ms. Sweet Tooth’s question?
ANSWER
Screening is an activity aimed at the early identification of
previously unrecognized disease or deficiencies using tests,
exams or other procedures that can be applied quickly.
Source: Shah, C.P. (1995), Médecine préventive et santé publique au Canada. Les Presses de l’Université Laval, Québec.
Screening aims at the early detection of a disease, before the
appearance of symptoms.
The objective of screening is therefore to reduce mortality
related to the disease.
Click here to find out more
QUESTION
Which prevention level are you acting at when you
screen a patient?
ANSWER
Screening is part of secondary prevention
Free translation from: D. Lafortune, M. Kiely; Santé mentale au Québec, 1989; XIV, 1.
ANSWER
Levels of prevention can be defined as follows
• Improving resistance and decreasing risk
factors
Primary
Secondary
• Early detection of disease at a stage when the
disease is easily curable
Tertiary
• Reducing complications, chronic disability and
premature mortality
Guay, M. (2013), Prévention en clinique: aspects théoriques, PowerPoint Presentation, Unpublished work.
BACKGROUND INFORMATION
(CONTINUED)
You now discuss prescriptions with Ms. Sweet Tooth.
She does not take any medication on a regular basis.
QUESTION
What relevant preventive medication could you
offer to Ms. Sweet Tooth?
ANSWER
Vitamin D supplements for osteoporosis prevention
• For all adults under the age of 50, prescribe vitamin D supplements,
400 to 1000 IU, daily from October to April
(Source: Papaioannou A et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada:
summary. CMAJ. 2010;182(17):1864-1873.)
Click here to find out more
Folic acid for neural tube defect prevention
• A daily supplement of folic acid is recommended for all women of
childbearing age
• Recommendation A (USPTF, 2009)
Click here to find out more
BACKGROUND INFORMATION
(CONTINUED)
As time is flying by, you note in her medical record to discuss
preventive medication and to review her vaccination at her next
visit. Prescribing folic acid does not seem like a priority to you at
this time. After all, she has an IUD and her risk of pregnancy is
small.
With her consent, you plan a follow-up appointment in 3 months
regarding her intensive follow-up with the multidisciplinary
team.
BACKGROUND INFORMATION
(CONTINUED)
Ms. Sweet Tooth leaves your office satisfied. You are aware that
you have done a lot of prevention during this last visit.
Since Ms. Sweet Tooth was your last patient of the day, you
decide to take a look at the latest Canadian guidelines on
diabetes.
You realize that some recommendations are easier for you to
apply than others…
QUESTION
What influences the application of
preventive clinical practices?
ANSWER
Many factors can influence the application of preventive
clinical practices!
1
Factors related to the patient
Fear, expectations, beliefs, ability to ask, comments from
loved ones
2
Factors related to the physician
Beliefs, personal lifestyle, expertise, training, support from
colleagues
3
Factors related to the preventive clinical practice
Effectiveness, safety, discomfort
QUESTION
What strategies could you use to facilitate the
application of prevention in your clinical practice?
ANSWER
Strategies facilitating the application of prevention in clinical
practice can be divided according to their level of effectiveness :
1
Most effective strategies
A
Reminder notification systems aimed at clinicians
E.g.: Putting stickers or a note in all smoker patients’ files as a reminder to
do some counseling.
E.g.: In a radiology clinic, setting up an electronic reminder notification
system, taking into account the age of the patients, so that the
administrative officer asks the women in the relevant age group if they are
taking part in a breast cancer screening program.
ANSWER
1
Most effective strategies (continued)
B
Tailored office system and facilitation
• Optimize patient care paths, create care and group prescription protocols
E.g..: A patient presenting with high blood pressure for the first time will be seen
by a nurse that will have a care and group prescription protocol for the follow-up
and for ordering blood tests. Hence, when the patient goes back to the physician
with many high blood pressure measures, all tests will have been done and the
only thing left to do will be to prescribe medication.
• Use the community resources
E.g..: Refer a patient presenting with addiction problems to a community
organisation specialized in the matter.
• Inter-professional collaboration
E.g.: Get the nursing personnel, the social workers, etc. involved in your practice
for a more holistic preventive approach to the patient.
ANSWER
1
Most effective strategies (continued)
C
Patient-centered interventions
E.g.: Posters on smoking cessation resources in the waiting room.
E.g.: Educational material on contraceptive methods for patients.
D
Multifaceted interventions
• The effectiveness of a preventive clinical practice is much greater if
many interventions are put in place, including some aimed at the
organization of the clinic (physical environment).
ANSWER
2
Strategies of varying effectiveness
A
Audit and feedback
E.g.: A doctor reviews about thirty medical records of patients he has seen
in his clinic to see if tobacco use has decreased in his patients that are
smokers; if this is not the case, he consults his clinic’s staff to see which
interventions can be put in place to improve this aspect (reflective
practice)
B
Electronic medical record
E.g..: Setting up a reminder notification system in children’s electronic
medical records for vaccination at the recommended times.
As previously mentioned, if these strategies of varying effectiveness are
combined with other strategies, their overall effectiveness is improved.
ANSWER
3
Low effectiveness strategies
A
Continuing medical education
• E.g..: Getting training on motivational interviewing to better support patients that
want to change a habit that is bad for their health (a bad habit in their diet, for
example)
Again, if these strategies are combined with others, their global
effectiveness will be much greater.
Provost, M.-H., et al. Description, impact et conditions d’efficacité des stratégies visant l’intégration de la prévention
dans les pratiques cliniques: revue de la littérature, Québec, ministère de la Santé et des Services sociaux, 2007,
168p. (Collection L’intégration de pratiques cliniques préventives)
ANSWER
There are many strategies that exist and that can be put
forth to facilitate the application of prevention in clinical
practice in your clinic. Regardless of the strategies used, the
following are a few points to keep in mind:
It is better to put in place many strategies to improve their overall
effectiveness.
The organisation of the clinic is an essential aspect to consider in the
implementation of effective preventive clinical practices.
BACKGROUND INFORMATION
(CONTINUED)
You decide to give Dr. Supportive Environments, a public
health and preventive medicine physician, a call.
After talking to him, he puts you in touch with the nurse in
charge of supporting preventive clinical practices. She will
be able to assess with you your clinic’s needs, will provide
you with tools and guide you in possible improvements.
VIGNETTE CONCLUSION
The vignette of the individual-centered approach has now been
completed. However, be sure to keep in mind these key
elements:
•
It is important to implement prevention in clinical practice
according to the patient’s characteristics to ensure that they are
effective.
•
It is essential to prioritise the preventive interventions that
we want to apply. We cannot do everything in a single visit.
• Support from public health is available to facilitate the
application of preventive clinical practices.
VIGNETTE NO. 2
POPULATION-BASED APPROACH
OBJECTIVES
Upon completion of this activity, the participant
will be able to :
• Explain the public health and preventive medicine physician’s role in
disease prevention and health promotion;
• Illustrate the concepts of disease prevention and health promotion;
• Identify strategies to apply disease prevention and health promotion at
the population level.
Click here to
start
BACKGROUND INFORMATION
Almost 3 months after your conversation with Ms. Sweet Tooth, she
comes back to your clinic for a follow-up appointment. She claims that
she has made many changes in her lifestyle and that she has lost
nearly 10 pounds!
The scale concurs: she has lost 11 pounds since her last visit!
She thanks you for helping her initiate this change.
QUESTION
After her visit, you are happy for her, but you start to wonder:
Why is it that some patients like Ms. Sweet Tooth can change their
lifestyles, while others are unable to?
Do you have any ideas?
ANSWER
One way to look at this problem is to see it in terms of the
determinants of health.
The determinants of health are in fact individual, social, economic and
environmental factors that can be associated to a particular health
problem or even to a general state of health.
Therefore, determinants influence the population’s health in a positive
or negative way.
MSSS (2012). La santé et ses déterminants, mieux comprendre pour mieux agir (page 5). Retrieved January 2014
from http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2011/11-202-06.pdf.
QUESTION
For Ms. Sweet Tooth, it would therefore be a matter of seeing which
determinants of health have influenced her health in a positive way so
that she was able to make changes to her lifestyle.
Can you name the determinants of health?
Can you give examples for each determinant of health related to the
example of Ms. Sweet Tooth?
ANSWER
The determinants of health can be classified in different
ways. Here is one way to classify them:
1.
2.
3.
4.
5.
Individual characteristics
Individual behavior
Physical environment
Socio-economic environment
Healthcare services
Free translation from: Éric Litvak et al., Guide de planification populationnelle, 2005
ANSWER
Examples related to Ms. Sweet Tooth:
1.
Individual characteristics:
What is Ms. Sweet Tooth’s attitude towards exercise?
Does she have genetic factors related to obesity?
2.
Individual behavior:
Does she smoke?
Does she exercise?
3.
Physical environment:
Does she live near a bicycle path?
Is the outdoor air quality good near her home?
ANSWER
Examples related to Ms. Sweet Tooth (continued):
4.
Socio-economic environment:
Is she living in poverty?
What is her level of education?
5.
Health care services:
Does she have access to a nutritionist
or a kinesiologist ?
To find out more about the determinants of health, click here.
BACKGROUND INFORMATION
(CONTINUED)
With these few examples, you understand that the determinants
of health greatly influence your patients’ health and the success
of your interventions.
In fact, if you recommend, for instance, that your patients
exercise, but that they do not have the means to get a gym
membership, your intervention may be less effective.
BACKGROUND INFORMATION
(CONTINUED)
You were just thinking that free sports programs in your
community are rare and that you would like to change things.
You get an idea: you could organize a walk and invite people
from your community to participate…
All this thinking has made you hungry: it is already noon! Time to
go eat!
It just so happens that you have a lunch conference on chronic
disease prevention with Dr. Supportive Environments, a public
health and preventive medicine physician.
QUESTION
A medical student doing his internship at the clinic asks you what
the exact role of a public health and preventive medicine
physician is in health promotion and disease prevention?
You see Dr. Supportive Environments often, but you cannot quite
answer your student’s questions…
You call Dr. Supportive Environments to the rescue…What does
he do exactly?
ANSWER
What is a public health and preventive
medicine physician?
A physician specialized in disease
prevention, health protection and
health promotion at the individual and
community levels.
Jacques, L. (s.d.). Le médecin spécialiste en santé communautaire: sa mission, sa spécificité, ses compétences, ses
rôles, sa formation et ses valeurs. Retrieved January 2014 from "http://www.usherbrooke.ca/dep-sciences-santecommunautaire/fileadmin/sites/dep-sciences-santecommunautaire/documents/MedecinSpecialisteSanteComm.pdf".
ANSWER
What is the public health physician’s mission?
Contributing to reducing the frequency and severity of health
problems and to protect and promote the community’s health
by addressing individual and community determinants of
health.
Jacques, L. (s.d.). Le médecin spécialiste en santé communautaire: sa mission, sa spécificité, ses compétences, ses
rôles, sa formation et ses valeurs. Retrieved January 2014 from "http://www.usherbrooke.ca/dep-sciences-santecommunautaire/fileadmin/sites/dep-sciences-santecommunautaire/documents/MedecinSpecialisteSanteComm.pdf".
ANSWER
Public
health
physicians
can
implement individual-centered and
population-based interventions in
health promotion and disease
prevention.
Jacques, L. (s.d.). Le médecin spécialiste en santé communautaire: sa mission, sa spécificité, ses compétences, ses
rôles, sa formation et ses valeurs. Retrieved January 2014 from "http://www.usherbrooke.ca/dep-sciences-santecommunautaire/fileadmin/sites/dep-sciences-santecommunautaire/documents/MedecinSpecialisteSanteComm.pdf".
ANSWER
Through population-based interventions, they can:
• Do interdisciplinary work with various organizations, policymakers or
actors (healthcare system institutions, municipalities, school
environments, work places, community organizations, etc.
• Analyse and investigate health problems with evidence, present an
analysis and summary of the data, develop solutions by including key
stakeholders, participate to varying degrees in the implementation of
the solutions, monitor and evaluate the development of the project to
ensure that the objectives are met, etc.
Jacques, L. (s.d.). Le médecin spécialiste en santé communautaire: sa mission, sa spécificité, ses compétences, ses
rôles, sa formation et ses valeurs. Retrieved January 2014 from "http://www.usherbrooke.ca/dep-sciences-santecommunautaire/fileadmin/sites/dep-sciences-santecommunautaire/documents/MedecinSpecialisteSanteComm.pdf".
BACKGROUND INFORMATION
(CONTINUED)
Thus, public health physicians address the determinants of
health!
Maybe they could help you organize your walk in the
community? You talk about with Dr. Supportive Environments
and he is keen on your idea!
You will work with public health professionals to set up your
project.
BACKGROUND INFORMATION
(CONTINUED)
As a clinician, you are used to applying guidelines in health
promotion and disease prevention at the individual level.
You applied them, for instance, with Ms. Sweet Tooth by
suggesting she exercise and make some changes in her diet.
However, at the population level, you are not quite sure how to
go about it…
QUESTION
You ask Dr. Supportive Environments to
help you answer this question:
What strategies does he use to promote
health at the population level?
ANSWER
Health Promotion strategies (according to the Ottawa Charter):
Dr. Supportive Environments, like many public health physicians,
draws on the health promotion strategies of the Ottawa Charter:
 Developing personal skills
 Creating supportive environments
 Building healthy public policy
 Strengthening community action
 Re-orienting health services
AFMC Primer on Population Health, The Association of Faculties of Medicine of Canada, http://phprimer.afmc.ca/Part1TheoryThinkingAboutHealth/Chapter4BasicConceptsInPreventionSurveillanceAndHealthPromotion/Implementingpreventionhealthprote
ctionandhealthpromotion (retrieved January 2014) Permit : Creative Commons BY-NC-SA
QUESTION
Drawing on the previous slide, could you give some examples of how
the Ottawa Charter’s strategies could be applied?
(An example of "developing personal skills" could be promoting
exercise)
ANSWER
1. Developing personal skills
Examples:
• Health education programs (sexuality, parenting skills, etc.)
• Communication campaigns and tools (flyers, posters, kiosks,
etc.)
• Prevention in clinical practice (promotion exercise)
• Etc.
Risi et al. (2013), Interventions efficaces et stratégies gagnantes en santé publique, PowerPoint presentation,
Unpublished work.
ANSWER
2. Creating supportive environments
Examples:
• Development of bicycle paths
• Condom distribution
• Disposal system for used needles and syringes
• Availability of healthy foods (vending machines, public
markets)
• Hospital sanitation
• Etc.
Risi et al. (2013), Interventions efficaces et stratégies gagnantes en santé publique, PowerPoint presentation,
Unpublished work.
ANSWER
3. Building healthy public policy
Examples:
• Counseling remuneration for STIs
• Public health Act/Notifiable diseases
• Anti-tobacco laws
• Municipal policies
• Etc.
Risi et al. (2013), Interventions efficaces et stratégies gagnantes en santé publique, PowerPoint presentation,
Unpublished work.
ANSWER
4. Strengthening community action
Examples:
• Volunteering, mentoring
• Community development/community action (youth centres,
community groups for vulnerable populations, etc.)
• Inter-sectorial action (E.g.: Inter-sectorial tables on childhood
and youth
• Outreach work
• Etc.
Risi et al. (2013), Interventions efficaces et stratégies gagnantes en santé publique, PowerPoint presentation,
Unpublished work.
ANSWER
5. Re-orienting health services
Examples:
• Vaccination clinics
• Youth clinics
• Preventive clinical practices
(see Vignette on the individual-centered
approach)
• Etc.
Risi et al. (2013), Interventions efficaces et stratégies gagnantes en santé publique, PowerPoint presentation,
Unpublished work.
BACKGROUND INFORMATION
(CONTINUED)
Dr. Supportive Environments mentions that there are strategies
in disease prevention complementary to health promotion
strategies.
They mostly refer to controlling risk factors, immunization and
screening.
Risi, C. et St-Cyr, L. (2009). Stratégies gagnantes en promotion/prévention. Retrieved January 2014 from
"http://www.agencesss04.qc.ca/images/images/santepublique/direction/jarsp2009/conference%20catherine%20ris
i.pdf"
QUESTION
Take a few seconds to find an example of prevention at the
population level for each of these strategies:
• Controlling risk factors
• Immunization
• Screening
ANSWER
Prevention strategies (examples):
Controlling risk factors:
E.g.: Noting that workers from a certain type of industry are at
risk for developing a certain disease and working to decrease
these risk factors.
(For example, if a link exists between exposure to rubber in its
transformation process and bladder cancer, working to decrease
workers’ risk.)
ANSWER
Prevention strategies (examples):
Immunization:
E.g.: Developing different strategies aimed at increasing
influenza immunization rates in health professionals to limit the
spread of influenza in hospitalized patients.
ANSWER
Prevention strategies (examples):
Screening:
E.g.: Identifying and working to apply guidelines related to
screening, for instance
To find out more about screening:
• Review the vignette on the individual-centered approach (click here)
• Take a look at the Public Health Primer (click here)
ANSWER
You notice that many connections can be made
between disease prevention at the individual level and
disease prevention at the population level.
Family doctors often work with public health and
preventive medicine physicians without even knowing…
BACKGROUND INFORMATION
(CONTINUED)
After talking with Dr. Supportive Environments, you decide
to get the municipality involved in your community walk
project.
With regards to the developing healthy and safe
environments strategy, you organize your walks on a
predetermined itinerary that the town will ensure is well
plowed in the winter.
BACKGROUND INFORMATION
(CONTINUED)
With a bag full of ideas on these health determinants,
disease prevention and health promotion strategies, you
head home…
QUESTION
At the wheel of the car, you
buckle your seatbelt.
Mmmh… is the seatbelt a health
promotion strategy?
ANSWER
As a matter of fact, seatbelt legislation is part of building
health public policy aiming to decrease unintentional
injuries.
BACKGROUND INFORMATION
(CONTINUED)
After a few kilometers, you are
stuck in a traffic jam caused by road
work.
Yes, the municipality had decided
to transform the intersection into a
roundabout.
You have a date tonight, this is not
a good time to be stuck in traffic!
QUESTION
Are roundabouts related in any way to public health?
ANSWER
Yes, roundabouts are part of creating supportive
environments aiming to decrease unintentional injuries.
Have you noticed that traffic jams influence air quality, a
determinant of health (physical environment)?
BACKGROUND INFORMATION
(CONTINUED)
You have only just left work when you realize that
public health, the determinants of health and
promotion strategies are part of our everyday lives.
Just imagine the extent to which they are omnipresent
and the impact you could have if you expanded your
knowledge on this topic…
VIGNETTE CONCLUSION
The vignette on the population-based approach has now been
completed. However, be sure to keep in mind these key
elements:
•
The determinants of health are omnipresent and influence health
in positive or negative ways.
•
Public health and preventive medicine physicians address these
determinants of health to improve the health of individuals and
communities.
•
There are many strategies in health promotion and disease
prevention at the population level and public health physicians
work with various actors of the healthcare system to implement
them.
END OF THE VIGNETTES
CONCLUSION
CONCLUSION
You have completed this training. We hope that is has helped
you to better understand certain concepts of public health
related to health promotion and disease prevention.
To help you keep in mind the key elements of this training tool,
here is a summary of the elements that you have explored while
going through it.
CONCLUSION
The concepts of health promotion and disease prevention overlap a
lot, although they are distinct.
They can both be applied to the individual-centered approach and the
population-based approach to health, although disease prevention is
more common than health promotion in the individual clinical setting.
Although the individual-centered approach and the population-based
approach involve a similar thought process for health professionals,
they are distinguishable from one another by the vision and expertise
that they require.
Clinicians typically use the individual-centered approach for which the
subject of interest in the patients. On the other hand, public health
and preventive medicine physicians usually use the population-based
approach in their practice. They are interested in populations.
CONCLUSION
Illustrating the concepts of disease prevention and health promotion
Prevention in clinical practice must be adapted to patients’ needs. There are
many of these practices (counseling, screening, immunization,
chemoprophylaxis, etc.) and they are effective. Expert groups such as the
Canadian Task Force on Preventive Health Care (CTFPHC) publish guidelines
and grade their effectiveness provide recommendations for clinicians.
There are different levels of disease prevention, defined as follows:
Primary
prevention
Improving resistance and decreasing risk factors
Secondary
prevention
Early detection of disease at a stage when the disease is
easily curable.
Tertiary
prevetion
Reducing complications, chronic disability and premature
mortality
CONCLUSION
Illustrating the concepts of disease prevention and health promotion
It is important to always keep in mind that many factors influence the
population’s health positively or negatively. These factors are the
determinants of health. The can be divided as such:
1.
2.
3.
4.
5.
Individual characteristics
Individual behavior
Physical environment
Socio-economic environment
Health care services
Free translation from: Éric Litvak et al., Guide de planification populationnelle, 2005
CONCLUSION
Illustrating the concepts of disease prevention and health promotion
With regards to health promotion, the Ottawa Charter is a well recognized
tool. The charter presents 5 major strategies in health promotion:
1.
2.
3.
4.
5.
Developing personal skills
Creating supportive environments
Building healthy public policy
Strengthening community action
Re-orienting health services
CONCLUSION
Explaining the public health and preventive medicine physician’s role in disease
prevention and health promotion
The public health and preventive medicine physicians are interested in disease
prevention as well as health protection and promotion at the individual and
population levels.
As previously mentioned, their practice focuses mostly on populations. They
mainly address the determinants of health. They often work in an
interdisciplinary setting.
The analysis of needs, the investigation of health problems, the development and
implementation of solutions to address them are amongst their tasks. These
physicians can offer support to clinicians interested in integrating preventive
measures to their professional practice.
CONCLUSION
Identifying strategies to apply disease prevention and health promotion to your
future clinical practice.
Many factors related to patients, physicians and to preventive clinical
practices influence the application of the concept of prevention in clinicians’
professional practice. However, various strategies, of documented
effectiveness, enable us to optimize the application of such concepts. These
strategies’ effectiveness is optimal when they are combined and when they
include the organization of the clinic.
In a population setting, the control of risk factors, immunization and
screening are amongst the effective prevention strategies.
CONCLUSION
Identifying strategies to apply disease prevention and health promotion to your
future clinical practice.
At the population level, the Ottawa Charter’s five strategies for health
promotion can be adapted to the health professionals’ practice setting.
Communication campaigns, development of bicycle paths, anti-tobacco laws,
inter-sectorial action and support for prevention in clinical practice are
amongst the many examples of such strategies.
THANK YOU
For any comment or question, please write to: [email protected]