Key Points
* The quality of the health care organisation can be a key factor in determining professional attitudes.
* Coordination between collective (public health) and health care services (primary care) can increase the effectiveness and efficiency of preventive interventions.
* Health promotion is much more than just the prevention of diseases.
* The involvement of the whole of society is fundamental to the success of health promotion and protection programmes.
The results of the investigation by Nebot et al are plausible, both in its currently widespread meaning of "acceptable" and in its more authentically Spanish/Castilian meaning of "laudable," by highlighting the attitudes among professionals themselves to the barriers for developing health promotion in primary care. Indeed, it is unusual to admit ones' own responsibilities when analysing health problems.
Of course, they also identify lack of time as a crucial obstacle. An explanatory recourse that has already become a topic when analysing the possible deficiencies of this health setting. The fact is that the preventive clinical activities recommended by the health authorities take up a lot of time, from 2 and a half hours1 to almost 8 hours2 daily for a reference population of 2000 people. But, despite what is required, more time is not sufficient to guarantee adequate intervention. As the authors point out, they also lack certain skills and, in particular, an appropriate attitude.
However, perhaps it would be worthwhile considering at first whether primary care is the ideal care setting to effectively manage health promotion in the reference population. Maybe the lack of a suitable attitude could, at least partly, be due to reasons associated with the inappropriateness of the care structure to carry out these types of activities.
It is known that information on its own is not enough to change personal behaviour. The persistence of smoking among health professionals is a good example. Although British doctors reacted to the publications of Doll and Hill by quitting smoking, it was much more difficult for other health professionals. And ourselves, an appreciable reduction in smoking had not been obtained among health professionals until the European Community adopted measures, mainly legislative, which have become a social, not exclusively health, objective.
A recent study on the dietary habits of a university student population did not show any differences between nutrition and dietetic students and those of pharmacy, nursing and chiropody.3 Despite both their own perception, as well as the proportion of correct answers, a questionnaire on diet and nutrition showed that the former had more knowledge on diet and nutrition than the rest. Thus, other factors besides information determine the behaviour of a person. Factors that are associated with culture, in its wider sense, working hours, changes in the composition and function, and even the purchasing power of the family.4
Therefore it is more logical if health promotion and protection (preventive) clinical activities are set in a community context and that they are complemented with collective interventions jointly with public health services and, in particular with civic institutions and bodies. Without this coordination, the care efforts will not be very efficient. This is demonstrated by the fact that medical prescriptions for hypotensive and cholesterol reducing drugs make up more than 15% of the total public pharmaceutical spending, which is 5% of current spending on health in the public sector, while the prevalence of hypertension, overweight and obesity keep on increasing. And this is without taking into account the cost and, in particular, the care effort in terms of visits and complementary tests. A healthcare load that surely has a lot to do with the frustration of the professionals. This is not about deferring prevention among healthcare activities as some consider,5,6 the pendulum swinging to the other side, but more about carrying them out more appropriately. And this could be achieved, on the one hand, if the health care services, mainly primary care, and the collective public health services would act as components of the same health system and collaborate closely to satisfy the health needs of the population that they theoretically serve. And on the other hand, they will in reality rely on the population.
In this sense, intervention priorities do not have to be limited to behavioural changes in the users and, to a lesser extent on the reference population.
Apart from the social and community factors that have to be approached, the health system itself has become a not inconsiderable source of disease. Iatrogenesis these days is no longer anecdotal and has structural reasons and scope, particularly due to inappropriate use of health resources and lack of rigour in establishing the indications, which also include preventive clinical interventions.
Hence the advice is that preventive emphasis also includes tertiary and quaternary interventions; to reduce complications and after effects using rigorous medical practices and, in particular, to comply with the Hippocratic maxim primum non nocere. It is a responsibility directly applicable to health systems.
Finally, it is worth clarifying that the convergence of prevention and health promotion activities is a result of the bias introduced into the perspective of preventive medicine. Although it is true that when preventive activities are successful, they improve health, but the increase in health does not only, nor mainly, involve prevention of diseases. If we assume that health is not just the absence of disease, but more a way to having an independent, supportive and full life, or put another way, maximum physical, psychic and social well-being, health promotion is not just about current health protection, reducing the incidence of new disease cases, or improving the prognosis of diseases in their preclinical states.
So, health promotion cannot be an exclusive aim of the health system, but of society as a whole, which perhaps might contribute to health, particularly if it does not involve reducing patient and population independence, by excessive medication.
