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Ludwig Boltzmann-Institut for Sociology of Health and Medicine
1. Proposal for a "Working Definition of Health Promotion in General Practice"

This “Working Definition” has been developed as basis for common understanding in the Project “Health Promotion in Primary Health Care: General Practice and Community Pharmacy”. The frame of reference for this proposal of a working definition of health promotion have been concepts of health promotion and their realisation to date within the profession, as laid out in professional policy documents and in the scientific literature(1) and the definition of health promotion as set out in the Ottawa Charter (WHO 1986) along with the Health Promotion Glossary.(Nutbeam 1998)
Drafts of this paper and several previous forms have been discussed with the project expert group, other partners in the framework of a task force and at a project meeting in May 2000.

Proposed working definition

"Patient/ user-oriented health promotion in general practice should be understood
1) as a patient-centered (2) communication and interaction process (3) by which the general practitioner (4)
2) aims at enabling (5) or empowering (6) the patient (7)
3) to better control and improve her/ his health (8)."

A guiding principle in health promotion interventions is the process of empowerment and the encouragement of patients'/ clients' participation in the clinical encounter. It is concerned with good practice in communication and partnership arrangements following a model of mutual interdependence (Caraher 1998).

Health promotion activities in general practice(9) should include several aspects(10):

identification and enhancement of positive health and general health resources

including patients'/ clients' resources (Noack, in Abelin, Brzezinski et al. 1987, pp 13-19;), (e.g. coping ability, family function, work satisfaction, health knowledge, competence, and general health literacy) both in management of disease and well-care (McWhinney 1997)

prevention of disease/impairment/disabilities (McWhinney 1997):

primary prevention
(with services such as immunization, child and prenatal care)
secondary prevention
early detection of disease (screening, risk assessment and risk reduction, including encouraging uptake of preventive programs for early diagnosis (e.g. mammography (Boerma, Fleming 1998)), potentially including the routine surveillance of the population)
case finding with investigation including the management of the problem
tertiary prevention
(prevention of complications, enhancement of recovery/ rehabilitation) with support of patients with chronic disease and their families.

This can be accomplished by a range of strategies:

specific interventions supporting healthy choices in individualised ways to meet each patients’/ clients’ needs including:
exploration of relevant psycho-social and biological pre-determinants for ill-health and disease to "predispose, enable and reinforce patients to take greater control of the non-medical determinants of their own health" (Herbert, Visser 1995)
discussion of lifestyle questions and providing information and advice catered to patients'/ clients' individual needs (UEMO Policy Statement in Kennedy 1999) by the provision of health education and counselling (e.g. Moser, McCance et al. 1991); e.g. nutrition, exercise and leisure activities, sexuality, tobacco, alcohol and substance abuse, drug use, sleeping behaviour, safety, interpersonal violence, environmental health.

These interventions should always be done:

according to high ethical standards (UEMO Policy Statement); e.g. assessment of potential harmful effect of intervention imposed on the client,
as an integrated part of patient care and disease management, rather than as a separate activity" (Crebolder, Van der Horst 1996) in a routine (face-to-face) consultation,
and can be complemented "beyond the clinical encounter", by referring and "linking patients with community resources and groups that can help to deal with the non-medical determinants of health" (Herbert, Visser 1995)

Interventions should be (Lauritzen,T.: Presentation at Kick-off Meeting, Vienna 1999)

"science and knowledge-based,
acceptable to the target audience,
and their implementation be organized and re-evaluated."

Health promotion efforts in general practice should be provided in awareness that

there are important other health promotion/ health professionals catering to the same individuals, groups and population
as are there lay persons actively involved in the promotion of health and care.
It heavily draws on the expertise and skills of these professionals and therefore strives for optimal collaboration and integration.

Health promoting opportunities also comprise activities not explicitly in the scope of this project, notably

involvement in community health promotion
advocacy and political lobbying (e.g. environmental health, social policy, housing)
(McWhinney, I.R. (1997) A Textbook of Family Medicine )
and settings-oriented health promotion.

WHO (Hg.)(1986): Health Promotion. Ottawa Charter. Genf: WHO.

Abelin, T., Brzezinski, Z.J., Carstairs, V.D.L. (Hg.)(1987): Measurement in health promotion and protection. Copenhagen: WHO Regional Office for Europe. WHO Regional Publications, European Series No. 22.

Kennedy, T.E. (Hg.)(1999): European Union of General Practitioners Reference Book 1999/ 2000. Kensington Publications/ UEMO.

Boerma, W.G.W., Fleming, D.M. (1998): The Role of general practice in primary health care. Publ. on behalf of the WHO-Europe. London: Stationary Office.

Caraher, M. (1998): Patient education and health promotion: clinical health promotion - the conceptual link. In: Patient Education and Counseling, 33, S. 49-58.

Crebolder, H.F.J.M., Van der Horst, F.G. (1996): Anticipatory care and the role of Dutch general practice in health promotion - a critical reflection. In: Patient Education and Counseling, 28, S. 51-55.

Herbert, C., Visser, A. (1995): Clinical Health Promotion and Family Physicians (Editorial). In: Patient Education and Counseling, 25, S. 223-226.

Howie, J.G.R., Heaney, D.J., Maxwell, M. (1997): Measuring quality in general practice. Pilot study of a needs process and outcome measure. Royal College of General Practitioners.

Howie, J.G.R., Heaney, D.J., Maxwell, M., Walker, J.J. (1998): A comparison of a Patient Enablement Instrument (PEI) against two established satisfaction scales as an outcome measure of primary care consultations. In: Family Practice, 15, 2, S. 165-171.

McWhinney, I.R. (1997): A Textbook of Family Medicine.

Moser, R., McCance, K.L., Smith, K.R. (1991): Results of a National Survey of Physicians' Knowledge and Application of Prevention Capabilities. In: American Journal of Preventive Medicine, 7, 6, S. 384-390.

Nutbeam, D. (1998): Health promotion glossary. In: Health Promotion International, 13, 4, S. 349 -364.