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Karl Krajic  |  Jürgen M Pelikan  |  Petra Plunger  |  Ursula Reichenpfader
Project summary

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In Summer 1998, the European Commission, General Directorate for health and consumer protection (formally DG V), Action Program for Health Promotion, Dr.Matti Rajala, commissioned the project under the official title "Development of quality assured and quality assuring patient-oriented health promotion in primary health care - general practitioners and pharmacies." The project was supported by the Austrian Federal Ministry for Health and co-financed by the "Fonds Gesundes Österreich".
In the further course of the project, it was agreed to use a shortened title "Health Promotion in General Practice and Community Pharmacy - A European Project".
The project was completed in April 2001.

1. Goals and main strategies of the project

The main defined goal of the project was to make a meaningful contribution to the development of quality assured and quality assuring patient-oriented health promotion in general practice and community pharmacy in all Member States of the European Union. The primary strategies of the project were to:
1) Put health promotion higher on the agenda - make the issue more relevant
2) Further European exchange and mutual learning
3) Develop common European perspectives on the issue
4) Support Health Promotion by
 providing systematically organised knowledge about models of good and best practice
identifying strategic options for national implementation
developing European (guidelines) conclusions and proposals

After intensive consultations with the partners, the initially defined strategy "developing European guidelines" was abandoned because it was considered neither feasible nor appropriate. Instead, extended conclusions and proposals were the preferred option.

2. Project Partners

Project Co-ordination

The Ludwig Boltzmann-Institute for the Sociology of Health and Medicine was invited to manage the project because of a track record of building up the International Network of Health Promoting Hospitals collaboration with WHO Euro since 1990. The Institute, part of a larger private, non-profit research organisation in Austria, is a WHO Collaborating Centre for Hospitals and Health Promotion.
It had previously conducted some smaller projects in the field for the European Commission, DG Health and Consumer Protection.

European Expert Group

International Experts from general practice, community pharmacy, patients' organisations, health policy and health promotion collaborated in a "European Expert Group", consulting on content and strategy with the project sponsors and co-ordinators.

Organisations from the two professions

Co-operation with organisations from general practice and community pharmacy was established on the European and national level.

Professional associations on the European level:

In a first step, the presidents of European/ International professional organisations were invited in autumn 1998 to participate in the Expert group.: for general practice Wonca Europe - ESGP/FM, UEMO and the Europrev-Network; for community pharmacy PGEU and the EuroPharm Forum. All with the exception of UEMO (the medico-political organisation of general practitioners) accepted the invitation personally or sent an expert representative. In a second step, these organisations plus FIP/ Community Pharmacy Section were invited to co-organise the European Conference as "European Supporting Partners" of the project and accepted this invitation.

Professional associations on the National level

In May 1999, professional associations from general practice and community pharmacy (those representing the profession legally/ politically) in the 15 Member States of the Union were invited to become "Trans-national partners of the project. Other national professional organisations (voluntary associations) were informed about the project and invited to co-operate in a looser fashion.

The project was successful in establishing good working relationships with partners in 12 of the 15 Member States for community pharmacy and 8 Member States for general practice.
Although this result can be considered to be quite satisfactory, the process of finding national partners proved much more difficult and time and energy - consuming than expected. The project co-ordinators interpret these difficulties as having three central problems:

- It has proven difficult to address the two professions in one project - several organisations on the general practice side openly showed reservations about collaborating so closely with the other profession.

- The involvement of (European) health policy into everyday practice of the professions - by suggesting that European guidelines could be developed - was not considered appropriate by several potential partners.

- The European dimension has proven less attractive than expected - not all national partners could be convinced that there was an added value of the complex European dimension.

Other organisations

In addition to the professional organisations, the project has managed to co-operate with
- IUHPE - International Union for Health Promotion and Education
- IAPO - International Alliance of Patients' Organizations
- WHO Regional Office for Europe
These organisations have also acted as European Supporting Partners and co-organisers of the conference.

3. Main products of the project

On the basis of the project agreement, advice by the European Expert Group, discussions with the project partners in two meetings, the following final products were defined in April 2000 :
- Concept papers in the form of working definitions of health promotion in general practice and community pharmacy and background papers based on a literature search
- Country Reports from participating member states, provided by national professional associations co-operating in the project and a cross analysis of these reports-
- A European Database on health promotion projects
- A European Conference on Health Promotion in General Practice and Community Pharmacy
- Project Conclusions and Proposals, summarising important results of the project
- A Final Publication distributing the project results to project partners and other interested organisations and individuals.

4. Project Milestones

09/1998 Official Project Start
12/1998 1st meeting of the Expert Group
03/1999 2nd meeting of the Expert Group
09/1999 Kick-Off Meeting with partner organisations
05/2000 2nd Project Meeting with partner organisations and experts
11/2000 European Conference in Brussels, locally hosted by the professional associations from Community Pharmacy and General Practice
11/2000 Launch of a European health promotion in community pharmacy project database on the Internet - project website (http:\\
untill 2/2001 Further development of country reports, development of a cross analysis, of project conclusions and proposals, editing of conference proceedings
untill 4/2001 Editing of a final publication

5. Opportunities for health promotion in general practice and community pharmacy

For collaborating with the partners on these products, it proved important to find some common ground, to negotiate a shared understanding of health promotion.
On the basis of the Ottawa Charter for Health Promotion, conceptual drafts discussed at project meetings and an analysis of published literature, working definitions of Health Promotion in Primary Health Care (General Practice, Community Pharmacy) were developed in co-operation with partners in the framework of a project task force.

Patient/ user oriented health promotion in general practice and community pharmacy can be viewed
 as a process by which the general practitioner/ the community pharmacist and her/ his team in a patient-centred or patient-focused approach, primarily in direct face-to-face interaction
aims at enabling or empowering the patient/ user of general practice or community pharmacy services to better control and improve her/ his health - health, understood as absence of disease and disability and positive health, including the complex bio-psycho-social dimensions of health in everyday life

At the conference, there were several contributions which further elaborated conceptual issues, especially the keynote lectures by Ilona Kickbusch, presenting principles of health promotion and highlighting "health literacy" as an important area for investment, Claire Anderson, providing an overview of many health promotion options for community pharmacy , Chris van Weel, discussing the relationship of health promotion, primary health care concepts and a patient-centred approach, Sylvie Stachenko sketching the larger health policy framework and Sue Ziebland presenting a social science perspective what systematically taking into account the patient perspective (as distinct from the professional perspective) could mean.

6. Conclusions (See Conclusions and Proposals)

Why are general practice and community pharmacy interesting settings for health promotion?

General practice and community pharmacy both offer good opportunities for health promotion: in most Member States, they are the low threshold entry points of the health care system, utilised with high frequency. General practitioners and community pharmacists see large parts of the population regularly, and their patients/clients represent a broad section of the population: from healthy people to chronically ill persons, and people from all social strata and ethnic backgrounds.

Most general practitioners and also many community pharmacists have long standing relationships with many of their patients/ clients. General practice offers good opportunities for a strong person- and context-orientation, and community pharmacy interventions also regularly include interactive, communicative and counselling aspects - that can be utilised as opportunities for health promotion.

Has health promotion been recognised as an integral element of the professional roles - and to what extent has health promotion been realised in professional practice?

Health promotion - understood as a broad umbrella concept including medical preventive measures and health education, primarily carried out in individually-oriented interventions within the consultation - has been integrated into the role understanding put forward by many general practice associations in Europe.

Health promotion also received increased attention as professional task for community pharmacy: The core of the professional role of community pharmacists remains centred on provision of medication (including advice), but the role-perception has broadened in recent years, now attempting to position the community pharmacist as an important actor in public health and the community pharmacy as a "centre for health".

In discussions with both professions, health promotion seems to be the more attractive the closer its practical implementation is related to current core tasks of the two professions. In community pharmacy, this interest can also be related to a general shift towards a patient centred approach as a specific asset of this institution.

However, there seems quite a lot of potential for further development of health promotion in daily practice: The project has succeeded in making visible a range of models and initiatives in various fields of health promotion (see e.g. the cross analysis on health promotion in general practice and community pharmacy, but it also made visible the general lack of any systematic data on this issue in most Member States. Nevertheless, it seems obvious that the extent to which individual general practitioners and community pharmacies utilise health promotion aims and principles to orient their daily professional practice varies considerably between countries and individual practitioners.

To what extent has health promotion become an element in professional education and training?

Although there are promising initiatives in some countries in both professions, health promotion and relevant skills and competencies do not yet figure very prominently in professional education and training. This is very clearly the case in basic professional education at university level in most of the Member States. Also with regard to vocational training in both professions, systematic learning processes of relevant issues, e.g. knowledge about prevention and health development, development of practical communication skills seem to offer good opportunities for further development - there appears to be a tendency in community pharmacy to increase attention for related issues.
In (voluntary) Continuing Medical Education for General Practitioners, a larger number of structured programmes for lifelong learning have been developed - a necessity recognised also by professional associations in Community Pharmacy.

To what extent has health promotion become an element in practice research?

As is the case with many other Primary Health Care services, health promotion interventions in general practice and community pharmacy have not been well documented and evaluated to date. Although there are several models and initiatives, the number of systematically designed, documented and evaluated intervention studies in this area seems very small. The limited interest of industry in non-product related innovations and related research is one important factor to explain this deficit.

Nevertheless, in general practice, some research activities, increasingly with involvement in national and multi-national research initiatives, are developing and small local research activities are being piloted. In many countries, research infrastructure and measures supporting general practitioners in getting involved in research in general are still in an early developmental stage. A coherent framework for research and evaluation seems to be lacking so far.

In community pharmacy, research relevant for health promotion in community pharmacy has only been partially realised as compared to research activities in traditional areas. However, there are some promising approaches towards research related to health promotion, be it in university departments for health promotion or Social Pharmacy, or via (international) co-operation of researchers and practitioners/representatives of professional bodies.

What is the impact of practice infrastructure on health promotion practice?

Not surprisingly, financial incentives as represented in reimbursement schemes have been made responsible for under-used opportunities in general practice by professional associations in several Member States participating in the project. Services understood under the umbrella of "health promotion" seem to be not well supported in these schemes. Comparatively rather well represented are (especially in social insurance systems) prevention activities such as cancer screening, health checks and also well child clinics, as well as specific counselling in disease-oriented clinics. But there seem to be hardly any models to explicitly financially reward communication or relationship aspects in the consultation. On the other hand, health systems that are characterised by a primary care orientation (more frequently in national health systems) seem to better enable general practitioners to work with a collaborative and co-operative, team- and community-oriented approach. In health systems with general practitioners predominantly in solo practice, it was felt that this form of general practice was not supportive of practitioners' health promotion and prevention work. Nevertheless, individual projects and initiatives to overcome this barrier have been launched and have been reported to be well accepted locally. With regard to systematic quality improvement strategies, only a few guidance instruments (both guidelines and protocols) seem to have been implemented - evaluation seems to be generally lacking so far.

For community pharmacy, a still rather critical picture of the incentives is dominated by the reimbursement system predominantly based on margins and/or a fixed amount of money per medication dispensed. Although cognitive services like counselling in community pharmacy clearly show a product link (medications or other health related products), new innovative systems accounting for the increasing emphasis on cognitive services will have to be explored.
Organisation of workflow and the development of the physical setting can also be further developed with an emphasis on patient/user-centred practice and qualified staff can be assigned more time for counselling and advising patients.

Is there a potential for Health Promotion at the interface of general practice, community pharmacy and patients/ users?

In the project, there has been significant interest in an integrated collaborative approach to health promotion in primary health care, with a special focus on patients, their needs and demands (patient centred approach), optimising the interface between general practice and community pharmacy:

7. Proposals to the European Commission

The project has developed proposals for possible action of the European Commission concerning all areas sketched above in the conclusions (see Conclusions and Proposals). Just to highlight one issue, the project has found a significant lack of research and knowledge development especially on health promotion interventions that are focussed on communication.
A narrow research base and lack of systematic reviews, making it difficult to distinguish innovation from simple local variation, seems especially problematic problematic in professional fields like medical and pharmaceutical practice dominated by a fast pace of (technological) innovation. This technological innovation is usually well supported by industry-financed research and by meta-analysis of this research, systematically disseminated in Evidence Based Medicine structures, providing practitioners with fast and reliable information on good and best practice. This innovation process is also extremely well supported by an elaborate structure of advertisements, publications, conferences, workshops and personal pharmaceutical company representatives for every doctor.

If health care and health promotion interventions are to have a more balanced development in the coming years, giving communication-centred interventions like most forms of health promotion a fair chance in this fierce competition for attention and priorities of practitioners, the Commission should invest
- in research, especially practice-oriented model projects, networking and exchange of experiences between these projects
- in supporting Evidence Based Medicine strategies of review and dissemination for primarily communicative health promotion interventions
- in conferences and workshops
- and in introducing this type of knowledge and skills into all forms of professional education.