Patient Requests in Family Practice: A Focal Point for Clinical Negotiations

A growing body of literature has stressed the importance ofeliciting the patient's views on the management of health andillness. In particular, it is recognized that patients frequentlyenter into clinical encounters with specific requests for services,that is ideas about how they hope to be helped. The presentinvestigation examined the following two questions: (1) whatkinds of requests do adult patients coming to a family practicecentre have prior to seeing the doctor; and (2) will factoranalysis of a 25-item patient request questionnaire provideevidence of the basic or most common dimensions of patient requestsin this population? Two newly-developed instruments were administeredto a sample of 144 adult patients before their visit to thedoctor. Factor analysis yielded five major request factors—‘medicalinformation’, ‘psycho-social assistance’,‘therapeutic listening’, ‘general health advice’,and ‘biomedical treatment’ —partially replicatingthe findings of an earlier pilot study. The clinical implicationsof eliciting patient requests in the light of current behaviouraland social science research into the doctor-patient relationshipare discussed. Future research directions are also outlined.     

Eclectic incentives for health protective behavior: an additional perspective on health oriented behavior change

A study carried out among a representative sample of JewishIsraeli adults (N = 1150) attempted to further the understandingof the factors involved in inducing healthy individuals to engagefin health protective behavior. A theoretically justified andempirically supported framework has been developed suggestinga typology of health protective behavior types. The typologysuggested a distinction among types of behavior according tothe type of effort needed to engage in each. Consequently, thelikelihood of engaging in each type of behavior differs accordingto both the type of stimulus and ‘enabling’ factors.The salience of a certain area of life may serve as a stimulus—salienceof health being only one of the possible stimuli and not necessarilyrelevant for all types of behavior. Control of ‘resources’and a consequent coping capacity constitute ‘enabling’factors—factors that may differ according to the typeof behavior. Conclusions regarding the implications for a healtheducation approach are derived from the data.     

Can One be a Good Doctor and have a Sexual Relationship with One's Patient?

This paper presents a qualitative exploration of social andsexual contact between general practitioners and their patients.Social contacts have been implicated in the development of sexualrelationships between members of the mental health professionsand their patients. However, there has been little examinationof the implications for general practitioners. Six focus groupswere conducted by teleconference with New Zealand general practitioners.Participant anonymity was maintained. Questions focused on issuesof social and sexual contact in general practice. Major themeswere extracted from the data. A range of definitions of ‘patient’,‘sexual contact’ and ‘social contact’were offered by the participants which demonstrated that ‘greyareas’ existed for them in relation to social and sexualrelationships with patients. Mandatory reporting of colleaguesfor alleged sexual misconduct was not supported, informal mechanismsbeing preferred. General practitioners need to be aware of potentialboundary violations in their practice. These issues are alsoimportant to address in the teaching of medical students, continuingmedical education, and in the development of appropriate guidelinesfor general practice.     

Muddling through the middle ground: theoretical concerns in intersectoral collaboration and health promotion

This paper considers the conceptual basis of intersectoral collaboration(ISC) in health promotion. It summarises concepts and perspectiveswithin literature loosely labelled as ‘interorganisationalrelations’. These are applied to health promotion, specificallythe development of healthy public policy at local level. Whilethe importance of collaboration and working together at practitionerlevel is acknowledged, the main emphasis is on strategic levelcollaboration and policy coordination. The aim is to consolidateunderstanding of the concept, its features and its ‘determinants’.Ways in which collaboration might be fostered are considered.     

Health education research: the problem of linkages

The idea that reality may be separated into a dichotomy is ancient,but equally ancient is the idea of the continuum. Current trendsin health education research are leading to the creation offalse dichotomies which are contrary to the best ‘spirit’of research concerned with understanding reality. The researchproblem is that of ‘linkage’. If health educationresearch continues to define reality bimodally, then it mustbe concerned with how the two ‘pieces’ relate toeach other. This paper limits its discussion to six dichotomieswhich are crucial to research in health education: (i) qualitative—quantitative,(ii) theory—method, (iii) concepts—research, (iv)knowledge/attitudes—behaviour, (v) campaign—evaluation,and (vi) individual—societal. The picture presented illustrateswhy dichotomies have been a source of difficulty in health-relatedresearch.     

Using sponsorship to create healthy environments for sport, racing and arts venues in Western Australia

The development of healthy public policy and the creation ofenvironments that support health are two of the Ottawa Charter'sgoals for health promotion action. The Western Australian HealthPromotion Foundation (referred to as ‘Healthway’)is an independent statutory body funded by a levy raised onthe wholesale sales of tobacco products. Healthway's legislativecharter defines a number of objectives for the Foundation. Theseinclude: funding activities related to the promotion of goodhealth; offering an alternative source of funds for sport, racingand arts activities previously supported by tobacco sponsorship;and supporting sport, racing and arts activities that encouragehealthy lifestyles and advance health promotion programs. Healthwayhas interpreted this charter from a health promotion perspectiveand ties the offer of sponsorship to sport, racing and artsorganisations with policies that create healthy environments.While the major focus of Healthway's healthy public policy interventionshas been the creation of smoke-free environments, importantgains have also been made in the provision of healthy food choices,safe alcohol practices, sun protection policies and access fordisadvantaged groups. This paper describes the results of asurvey of organisations funded by Healthway and explores theprevalence and reach of structural reforms in sport and culturalsettings. The development of structural reform policies amongdifferent types of organisations receiving different levelsof sponsorship is described. While not all of the structuralreforms observed in this survey can be attributed to Healthway,it is clear from the research that Healthway has contributedto the rate of policy development amongst ‘structuralreform laggards’. The implications for ‘active encouragement’of intersectoral co-operation through government sponsored grantsis discussed.     

Public Health Renaissance and the Role of Schools of Public Health

In these turbulent times of political, social and economic changesin Europe public health is again coming into focus. Schoolsof public health, for long the basis for education of publichealth leaders will also in the future play a key role in promotingthe ‘new’ public health agenda. Based on ecologicalawareness and public involvement in health their teaching, researchand policy development should make them be seen as Centres ofRelevance and not only as Centres of Excellence, thus gearingtheir activities to the needs of new generations of practitionerswho can be both activists and advocates for health. If trainingand research are made relevant for practice and community service,then schools will be in the centre of public health insteadof in the periphery of medicine. Elements of a strategy to achievethese objectives are discussed.     

Addressing the costs of quitting' smoking: a health promotion issue for adolescent girls in Canada

While intense efforts have been implemented to address the problemof cigarette smoking, the prevalence of tobacco use among adolescents,in particular young women, remains high. Older adolescent girlsare joining their younger counterparts in taking up the smokinghabit. The literature has examined the reasons for young peoplestarting to smoke; however, little is known about the smokingcessation process in adolescents. This paper reports findingsfrom an in-depth qualitative study of 25 girls ages 18 and 19which uncovered the struggles young women experience as theyattempt to quit smoking. These struggles and losses are referredto as the ‘costs’ of quitting smoking. The ‘costs’reflect not only their ‘real’ experiences when attemptingto quit smoking, but also reflect ‘anticipated’struggles and losses. The study addressed the ‘costs’in relation to the social, emotional and physiological domainsof the adolescent girl's life. Findings from this research projectprovide theoretical direction for the development of comprehensivehealth promotion interventions. If health care professionalsare to assist in reducing cigarette smoking among young women,the ‘costs’ which girls see to quitting smokingmust be considered.     

Applying logics of change to the evaluation of community development in health promotion

Evaluation of community-oriented health promotion programs requirethat professional evaluators clearly distinguish between exogenouslyand endogenously defined goals and definitions of ‘success’.Acknowledging the different dynamics which underpin community-ledchange and externally initiated health programs and interventionsis essential to this task. It will be argued that the intersectionof, and boundaries around, exogenous and endogenous change canbest be understood and clarified through the application of‘logics of rationality’, adapted from social theory.Community activity is characterised by what we have called ‘lifeworldrationality’ community-based health promotion interventionsare characterised by ‘formal ratonality’. In addition,we suggest that the value dimensions (‘substantive rationality’)underpinning programs and interventions may be overlooked bypolicy makers, program planners and professional evaluatorsunder pressure to demonstrate cost-effectiveness and efficiency.Key requirements for successful and appropriate evaluation ofcommunity-based programs which are sensitive to the needs andsuccess criteria of communities include a shared understandingby the researchers, program sponsors and community actors ofthe nature of the changes sought. The co-production of healthpromotion standards and of indicators to judge the performanceof the program or intervention by all stakeholders should bepreferred over the trend for establishing community-controlledprocess evaluations to coexist alongside expert-controlled impactevaluations. It is argued that current approaches to standardsetting and indicator development to judge the processes andimpacts of interventions are inadequate and several principlesfor improving their content are given. A locally controlledethnographic approach to evaluate endogenous community-led changeis described in the hope that program planners and evaluatorsmay become more sensitive and receptive to local knowledge.We suggest that engagement with what we have termed the ‘communitystory’ should be a fundamental requirement for the planningand evaluation of community health programs.     

Health promotion in the market place: constraints and opportunities

An emerging trend internationally is for health promo tion servicesto be privatised and organised through a division of ‘purchaser’and ‘provider’ functions. This paper examines theconstraints and opportunities for health promotion in the marketplace through a discus sion often ‘vital signs’drawing on British experience where appropriate. If the marketis not closely managed there are considerable concerns thathealth inequalities could increase, that ethical issues couldbe ignored, and that health promotion practice could be seriouslycom promised. Nevertheless, there are also potential benefitsfrom a market economy, but these will only be realised if thereis a shared understanding of the purchaser/provider roles, adequateskills and resources for the purchaser function, earmarked fundingfor health promotion investment, effective monitoring and refereeingby government as ‘regulator’, and training for thenew tasks and responsibilities. To improve pe, formance a distinctionshould be made between health promotion Design, Development,and Delivery-the three ‘Ds’ of health promotionpractice. Tasks for the three stages are described, togetherwith the potential roles of govern ment, public sector agencies,professional bodies, voluntary organisations and private sectorcompanies. Long-and medium-term time scales are essential foreffective implementation.     

Creating supportive environments for health: a case study from Australia in developing national goals and targets for healthy environments

Creating healthy living and working conditions are central goalsin public health which have re-emerged in prominence in thepast decade. The roots of thLs revival of interest can be tracedto include improved under standing of the relationship betweenliving conditions and health, prompting by the World HealthOrganiza non (WHO) through its ‘Health for All’strategy which has drawn attention to underlying causes of inequitiesin health in society, and a more general international concernwith ecologically sustainable development. Australia has respondeduniquely to the challenge of developing a strategy to createsustainable, supportive environments for health through itsNational Health Goals and Targets. These targets, publishedin 1993, include a range of targets for Healthy Environmentswhich were developed from a ‘health’ perspective,but in co-operation with the different sectors of governmentresponsible for action to achieve them. These include housing,transportation, education and employment. Early responses tothe publication of the targets are encouraging, but will requiresustained governmental support to reach fruition. Critical tosuccess in develop ing and implementing the targets will berecognition by government, and particularly the health sector,of the legitimacy of inter-sectoral action for health. Negotiations to resolve potential conflicts in the priorities of differentsectors should ensure that attention is focused on the commonground for practical inter-sectoral action to improve health.The Australian Targets Report identifies a series of concreteactions required to create supportive environments for health.A willingness to account for pro gress in achieving the targetsfor Healthy Environments will be an important measure of thecom mitment of the Australian federal and state governmentsto the health and well-being of their citizens.     

Healthy Cities and Local Agenda 21: the UK experience--challenges for the new millennium

Healthy Cities and Local Agenda 21 both offer strategic frameworksfor the development and implementation of theory and practicein the related fields of health promotion/public health andsustainable development. Whilst the close links between healthand sustainable development are widely acknowledged, the twoframeworks continue to operate largely in parallel. This paperreviews concepts of health and sustainable development, andrelates the evolution of thinking that has taken place to thehistorical development of the Health for All (HFA) and Agenda21 movements. It is argued that towns, cities and communitiescommitted to promoting health and sustainability face two keychallenges as they approach the new millennium: how to movefrom the margins to the mainstream; and how to integrate theframeworks. Discussions from a recent national ‘roundtable’ meeting are used to illustrate a range of key issuesand highlight implications for people working at local, nationaland international levels.     

The Psychosocial Impact of Mass Screening for Cardiovascular Risk Factors

In Leek, a small town in the north of the Netherlands, 428 menaged between 30–33 years were invited to take part ina screening test for cardiovascular risk factors. Questionnaireswere sent to the 267 men who had participated in the screeningtest as well as to the 161 non-participants, in order to gainan insight into the participatory behaviour and the experienceof those involved. The non-participants gave a diversity ofmotives for not taking part but did not admit to anxiety aboutfinding abnormal results. More than half of the participantswho replied (51%, n = 107) were found to have an ‘abnormality’—;thatis they scored on one or more of cigarette smoking, overweight,hypertension, hyperlipoproteinaemia, albuminuna or glucosuria.The supplementary information provided on nutrition and smokingcaused a large proportion of them to claim they had changedto a more healthy life-style after the screening test. Thosewho were under the impression that they had led healthy livesbut were still found to have an ‘abnormality’ wereoften very astonished and sometimes worried about the result.The men without ‘abnormalities’ did not lead significantlyhealthier lives than the rest in terms of exercise, smoking,diet and so on; for them the result might have a ‘certificateof health’ effect justifying their not always healthybehaviour.     

Factor analysis as a tool in community diagnosis

For the family physician, community diagnosis can be likenedto individual diagnosis by the application of methods of informationacquisition and analysis. This paper describes the techniqueof factor analysis, applied to data from an urban inner-cityarea, for reducing a multitude of factors to a manageable numberwithout an appreciable loss of information. The variables wereselected from four broad categories which have been shown toinfluence both health states and health care needs: demography,socioeconomics, social disorganization and morbidity/mortality.A correlation matrix based on 40 of the most accessible indicesserved as input for a principal axes factor analysis. Six factors acounted for 74% of the total variance and wereinterpreted as: ‘Poverty and social disorgan ization’,‘Distribution and problems of the elderly’, ‘Ethniccomposition’, ‘Fertility’, ‘Infant mortality’and ‘Foetal mortality’. Representative indices fromeach factor were then mapped to identify and display censustract differences. Finally, the application of the factors toa specific community illustrated important differences withinthe community and identified areas of high risk and need.     

Paternalism in Public Health Care

Measures in public health care (PHC) seem vulnerable to chargesof paternalism: their aim is to protect, restore, or promotepeople's health, but the public character of these measuresseems to leave insufficient room for respect for individualautonomy. This paper wants to explore three challenges to thesecharges: (i) Measures in PHC are aimed to protect, restore orpromote ‘deep autonomy’, (ii) Measures in PHC aredirected at the public and, as such, they do show respect forautonomy, and (iii) Some measures in PHC can be justified ongrounds of justice and need not be defended as cases of ‘justifiedpaternalism’. Although charges of unjustified paternalismin PHC might still be relevant, we should at least face thesedifferent challenges.     

'Well-being': health promotion's red herring

‘Well-being’ is frequently said to be the ultimategoal of health promotion. However, health promotion author itiesdo no: offer a clear definition of ‘well-being’.Instead health promoters either assume a causal relationshipbetween their activities and the increase of ‘well-being’or claim privileged knowledge of ‘well-being’ andits means of production, or both. These health promotion strategiesare questioned, and it is suggested that the use of ‘well-being’in health promotion acts to obscure the analysis of health promotionphilosophy and practice. It is concluded that either the term‘well-being’ should be given clear and substantialcontent, or it should be discarded by health promoters. Thelatter option is favoured.     

Social Marketing: Principles and Practice

This book provides a comprehensive review of the key principlesof social marketing, and critically appraises their applicationto health education and health promotion. The authors seek tomove beyond the (original) definition of social marketing as‘...an application of marketing principles and tools tothe achievement of socially desirable ends’ and, consequently,they adopt a broader approach which has particular relevanceto health promotion. For example, in addition to emphasizingthe distinction between social and commercial marketing, thebook also elaborates on the nature of the particular sociallydesirable goals that should be espoused by health promotion—assertingthat these should be firmly rooted in the ideology of the UnitedNations Charter on Human Rights. In short, the authors not onlyreject a narrow victim-blaming approach     

Promoting school health education: examining the role of a statewide conference for school and community leaders

Improving the delivery of school health education may well belinked to the inclusion of and commitment from high-rankingdecision makers from schools and youth organizations. This studyexamined the role of a statewide school health summit in promotinghealth education among representatives from state and communityorganizations. We conducted the study in two phases: (1) developmentand testing of a measuring instrument, and (2) role examinationvia conference assessment. Overall, the measurement instrumenthelped us investigate two areas: the inclination of an individualleader of a health organization to promote organizational changesto assist school health education and the background of a participantin school health education, which affects his/her likelihoodto take action. Three factors (‘Participant Awarenessand Compatibility’, ‘Draft Plan Development’and ‘Summit Experiences and Satisfaction’) werefound to be important predictors of leaders’ ‘FutureAction’ and ‘Advocate Impact’ (P < 0.01).Future interventions targeted to influence health, educationand social service professionals’ support and adoptionof school health education should be structured to reinforcethese three variables.     

Preliminary results of an evaluation of three Healthy Cities initiatives in the Montreal area

In September 1991, we began to evaluate three Healthy Citiesinitiatives in the Montreal area using a holistic approach,based on the theory of negotiated mode of action. We are experimentingwith an interactive evaluation method which aims to involveparticipants in the process and to help them gain a better understandingof their project. Two techniques are being used to concretizethe process: a steering committee who interpret the data collectedthroughout the process and a newsletter that outlines the resultsto participants at all sites. This paper describes how three elements of the Healthy Citiesconcept—sharing of common objectives, intersectoral actionand citizen participation—are being implemented at thethree sites being analyzed. We will show that the three initiativesunderline the negotiation process that must be respected tomaintain the balance between the objectives of intersectoralaction and citizen participation. Preliminary results also showthe importance of the healthy public policies strategy thatshould be analyzed as one part of a three-headed concept withthe two precedent objectives. We will discuss also the requirementsof an interactive evaluation approach, both for the evaluatorsand ‘evaluatees’. Evaluators must be able to communicate,motivate and negotiate and participants must take an interestin the evaluation process and agree to listen to opinions onthe development of their project that may be different fromtheir own views.     

Health education and the ideology of health promotion: a review of alternative approaches

This paper discusses various approaches to the definition of‘health promotion’ and examines the role of theWorld Health Organization in its popularization. Health promotionis conceptualized as any deliberate intervention which seeksto promote health and prevent disease and disability. It incorporates‘health education’ and gives prominence to the influenceof legal, fiscal, economic and environmental measures on communityhealth. Various ‘models’ of health education areexplored and their contribution to health promotion is discussed.It is argued that ‘selfempowerment’ should be themain focus for health education programmes.