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PREVENTION AND PROMOTION IN HEALTH A LEARNING TOOL Prevention and Promotion in Health: A Learning Tool is licensed under a Creative Commons Attribution-

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1 PREVENTION AND PROMOTION IN HEALTH A LEARNING TOOL Prevention and Promotion in Health: A Learning Tool is licensed under a Creative Commons Attribution- NonCommercial 4.0 International License.Creative Commons Attribution- NonCommercial 4.0 International License

2 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

3 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.

4 Please note that you need to be in "slideshow" mode in order for the interactive parts of this tool to work properly. Enjoy!

5 This training tool is also available in French at your convenience.

6 CONTENT This training tool is meant for clerkship students enrolled in Canadian medical schools It consists of the following: The vignettes may be completed with a supervisor or on your own. SectionTime Required Introduction 5 min. Quiz 15 min. Vignette no. 1 90 min. Vignette no. 2 60 min. Conclusion 10 min.

7 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.

8 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

9 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

10 QUIZ

11 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)

12 QUIZ Click on the image with your score*: 0 to 1920 to 3940 to 60 *Please note that a higher score does not mean a better score.

13 QUIZ 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 ? You are a “bandage” type of doctor Click here to continue

14 QUIZ 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. You are a “protective helmet” type of doctor Click here to continue

15 QUIZ 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? You are a “supportive environments” type of doctor Click here to continue

16 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.

17 INTRODUCTION According to their respective approaches, these doctors have different positions on the following continuums: To maintain health To restore health or to alleviate disease and its consequences Individual- centered Population- based Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003 Dr. Protective Helmet Dr. Bandage Dr. Supportive Environments

18 INTRODUCTION One of these continuums relates to the purpose of the approach taken: To maintain health To restore health or to alleviate disease and its consequences Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003 For healthy people For sick people

19 INTRODUCTION Health promotion and disease prevention mainly aim to maintain health. To maintain health To restore health or to alleviate disease and its consequences Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003 HealthPromote RiskPrevent DiseaseCure ChronicityTreat

20 INTRODUCTION The other continuum relates to the health approach’s subject of interest: Individual- centered Population- based Inspired by Kennedy et al., DSP Saguenay, Lac St-Jean, 2003 The IndividualThe Community - Their immediate environment - Their families - Their friends - Etc. - The region - The neighborhood - The age group - The risk group - Etc.

21 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 Individual-centeredPopulation-Based INVESTIGATION AND DIAGNOSIS Medical history and physical examination Laboratory examination Imaging Diagnostic tests Opportunistic screening Monitoring health status and determinants of health Notifiable disease surveillance Outbreak investigation Environmental risk assessment Mass screening

22 VIGNETTES Inspired by Kennedy et al. DSP Saguenay, Lac St-Jean, 2003 APPROACH PROCESS Individual-centeredPopulation-Based TREATMENT FOLLOW-UP Recommendations and prescriptions Evidence-based Programs, projects, promotion, prevention and protection activities Legislation and regulation support Follow-up on investigation and treatment Yearly follow-up Program, project and activity evaluation Ongoing monitoring of the population’s health status

23 VIGNETTES The difference between these two approaches lies mainly in the unique vision and expertise of each of them. Note that, typically, a clinical physician will have an individual- centered approach while the public health and preventive medicine physician will have a population-based approach. APPROACHIndividual-centeredPopulation-Based SUBJECT OF INTEREST Inspired by Kennedy et al. DSP Saguenay, Lac St-Jean, 2003 The patient The population

24 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.

25 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.

26 INDIVIDUAL-CENTERED APPROACH VIGNETTE NO. 1

27 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

28 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.

29 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-to- date: it was done during her last pregnancy. She has not had other partners since and neither has her spouse.

30 QUESTION What is the purpose of asking Ms. Sweet Tooth all of these questions?

31 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.

32 QUESTION What is prevention in clinical practice?

33 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.

34 QUESTION How do we know if a preventive clinical practice is recommended?

35 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.

36 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.

37 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).here 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).here

38 ANSWER CTFPHC Recommendation Grades (for illustrative purposes) No new recommendations were issued between 2006 and 2011. Canadian recommendation classification until 2006 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) 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. Click here to find out more

39 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.

40 QUESTION For this patient, what type of prevention in clinical practice is recommended in terms of counseling?

41 ANSWER Tobacco Recommendation A (CTFPHC, 1994). More recently, the following interventions have been shown to be effective (CAN-ADAPPT, 2011) : Identify and update patients’ tobacco use status If the smoker is ready to quit, encourage them through counseling and medical treatment; If the smoker is not ready to quit, use the motivational approach to increase the smoker’s chances of quitting ; Facilitate access to more intensive counseling (individual, group or by phone) – the more frequent and extended it is, the better the results; Organize your clinic to offer a more systematic approach – such as a call back system, referral procedures for resources in counseling and educational materials. 1 2 3 4 5 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

42 ANSWER Exercise/sedentary living Nutritional and exercise counseling for adults without hypertension, diabetes, hyperlipidemia or heart disease Recommendation C (USPSTF, 2012) 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

43 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.

44 QUESTION How would you go about providing good counseling to Ms. Sweet Tooth?

45 ANSWER We can use the CTFPHC’s 5 “A” method Click here to find out more AssessAdviseAgreeAssist Arrange and follow-up

46 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.

47 ANSWER Click here to find out more The individual is not intending to change his behaviour. 1. Precontemplation The individual is thinking about changing his behaviour and intends to do something about it in the next 6 months. 2. Contemplation The individual intends to change his behaviour in the next 30 days. 3. Preparation The individual has changed his behaviour in the past 6 months. 4. Action The individual has practiced his new behaviour for 6 months. 5. Maintenance The individual finds it hard to maintain the next behaviour and relapses. 6. Relapse “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

48 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.

49 QUESTION At what stage of change is she according to Prochaska and DiClemente?

50 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.

51 QUESTION What could you say to Ms. Sweet Tooth, at this point in time, about her tobacco use according to the 5 “A” model?

52 ANSWER Assess her behavior, her intentions and her motivation to stop smoking Already done 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. 1 2

53 ANSWER Agree Ask her if she would like to discuss it again at the next appointment. Assist Give her documentation. Arrange & Follow-up Offer follow-up. 3 4 5

54 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.

55 QUESTION What preventive intervention would be relevant to do during the physical examination?

56 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) 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

57 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

58 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.

59 QUESTION How would you answer Ms. Sweet Tooth’s question?

60 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

61 QUESTION Which prevention level are you acting at when you screen a patient?

62 ANSWER Screening is part of secondary prevention Free translation from: D. Lafortune, M. Kiely; Santé mentale au Québec, 1989; XIV, 1.

63 ANSWER Primary Improving resistance and decreasing risk factors 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. Levels of prevention can be defined as follows

64 BACKGROUND INFORMATION (CONTINUED) You now discuss prescriptions with Ms. Sweet Tooth. She does not take any medication on a regular basis.

65 QUESTION What relevant preventive medication could you offer to Ms. Sweet Tooth?

66 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.) 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

67 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.

68 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…

69 QUESTION What influences the application of preventive clinical practices?

70 ANSWER Many factors can influence the application of preventive clinical practices! Factors related to the patient Fear, expectations, beliefs, ability to ask, comments from loved ones Factors related to the physician Beliefs, personal lifestyle, expertise, training, support from colleagues Factors related to the preventive clinical practice Effectiveness, safety, discomfort 1 2 3

71 QUESTION What strategies could you use to facilitate the application of prevention in your clinical practice?

72 ANSWER Strategies facilitating the application of prevention in clinical practice can be divided according to their level of effectiveness : Most effective strategies 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. 1 A

73 ANSWER Most effective strategies (continued) 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. 1 B

74 ANSWER Most effective strategies (continued) Patient-centered interventions E.g.: Posters on smoking cessation resources in the waiting room. E.g.: Educational material on contraceptive methods for patients. 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). 1 C D

75 As previously mentioned, if these strategies of varying effectiveness are combined with other strategies, their overall effectiveness is improved. ANSWER Strategies of varying effectiveness 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) Electronic medical record E.g..: Setting up a reminder notification system in children’s electronic medical records for vaccination at the recommended times. 2 A B

76 ANSWER Low effectiveness strategies 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) 3 Again, if these strategies are combined with others, their global effectiveness will be much greater. A 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)

77 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.

78 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.

79 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.

80 POPULATION-BASED APPROACH VIGNETTE NO. 2

81 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

82 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.

83 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?

84 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.http://publications.msss.gouv.qc.ca/acrobat/f/documentation/2011/11-202-06.pdf

85 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?

86 ANSWER The determinants of health can be classified in different ways. Here is one way to classify them: 1.Individual characteristics 2.Individual behavior 3.Physical environment 4.Socio-economic environment 5.Healthcare services Free translation from: Éric Litvak et al., Guide de planification populationnelle, 2005

87 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?

88 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.here

89 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.

90 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.

91 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?

92 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-sante- communautaire/fileadmin/sites/dep-sciences-sante- communautaire/documents/MedecinSpecialisteSanteComm.pdf".

93 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-sante- communautaire/fileadmin/sites/dep-sciences-sante- communautaire/documents/MedecinSpecialisteSanteComm.pdf".

94 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-sante- communautaire/fileadmin/sites/dep-sciences-sante- communautaire/documents/MedecinSpecialisteSanteComm.pdf".

95 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-sante- communautaire/fileadmin/sites/dep-sciences-sante- communautaire/documents/MedecinSpecialisteSanteComm.pdf".

96 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.

97 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…

98 QUESTION You ask Dr. Supportive Environments to help you answer this question: What strategies does he use to promote health at the population level?

99 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/Part1- TheoryThinkingAboutHealth/Chapter4BasicConceptsInPreventionSurveillanceAndHealthPromotion/Implementingpreventionhealthprote ctionandhealthpromotion (retrieved January 2014) Permit : Creative Commons BY-NC-SA

100 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)

101 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.

102 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.

103 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.

104 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.

105 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.

106 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"

107 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

108 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.)

109 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.

110 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)here Take a look at the Public Health Primer (click here)here

111 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…

112 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.

113 BACKGROUND INFORMATION (CONTINUED) With a bag full of ideas on these health determinants, disease prevention and health promotion strategies, you head home…

114 QUESTION At the wheel of the car, you buckle your seatbelt. Mmmh… is the seatbelt a health promotion strategy?

115 ANSWER As a matter of fact, seatbelt legislation is part of building health public policy aiming to decrease unintentional injuries.

116 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!

117 QUESTION Are roundabouts related in any way to public health?

118 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)?

119 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…

120 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.

121 END OF THE VIGNETTES

122 CONCLUSION

123 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.

124 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.

125 CONCLUSION 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: Illustrating the concepts of disease prevention and health promotion 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

126 CONCLUSION 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.Individual characteristics 2.Individual behavior 3.Physical environment 4.Socio-economic environment 5.Health care services Illustrating the concepts of disease prevention and health promotion Free translation from: Éric Litvak et al., Guide de planification populationnelle, 2005

127 CONCLUSION With regards to health promotion, the Ottawa Charter is a well recognized tool. The charter presents 5 major strategies in health promotion: 1.Developing personal skills 2.Creating supportive environments 3.Building healthy public policy 4.Strengthening community action 5.Re-orienting health services Illustrating the concepts of disease prevention and health promotion

128 CONCLUSION 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. Explaining the public health and preventive medicine physician’s role in disease prevention and health promotion

129 CONCLUSION 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. Identifying strategies to apply disease prevention and health promotion to your future clinical practice.

130 CONCLUSION 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. Identifying strategies to apply disease prevention and health promotion to your future clinical practice.

131 THANK YOU For any comment or question, please write to: preventionpromotion@gmail.com


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