UEMO Consensus Document on Preventive Activities
Adopted by the UEMO General Assembly in Florence on 5 october 2002

Preamble

Healthy living includes good nutrition, a tobacco-free lifestyle, regular physical exercise and a supportive environment. The UEMO, representing General Practitioners in the European Countries has an important role in advocating policies that could lead to better health status of the population. This UEMO Consensus Document is a call for further action in Prevention and Health Promotion.

The EU has launched a Public Health Plan which is to last for six years (2001-2006, see doc 01/024)). The overall aim of the public health program is to make a contribution towards the attainment of a high level of health protection, by directing action towards improving public health, preventing human illness and disease, and obviating sources of danger to health. Action should be guided by the need to prevent premature death, increase life expectancy, without disability or sickness, promote quality of life and physical and mental well being, and minimise the economic and social consequences of ill health, thus reducing inequalities. In order to bridge the gap between science and "policy in action" partnerships are needed among all levels of government; health and education and social science professionals and associations; media organizations; voluntary agencies; the research community and industry. Each partner has a role to play.

1 - Definition of Prevention

1.1 Clinical preventive medicine is defined as the maintenance and promotion of health and the identification and reduction of risk factors that result in injury and disease.

1.2 - Types of Prevention

1.2.1 Primary Prevention refers to services directed at the prevention of disease before its onset.

1.2.2 Secondary Prevention involves manoeuvres designed to detect diseases at an earlier pre-symptomatic stage so as to decrease morbidity and mortality.

1.2.3 Tertiary Prevention is the care directly associated with preventing complications or undue morbidity in persons with established symptomatic chronic disease.

2 - Introduction

2.1 The leading causes of death in industrialized countries have changed markedly since the beginning of the last century. There has been a shift from acute infections to chronic diseases. A decline in the incidence of acute infectious diseases secondary to increased delivery of immunizations has been well documented. Most of the current leading causes of death from chronic diseases are related to social and environmental factors, and to lifestyle. The increased prevalence of mental ill health is often related to a hostile social environment. Although immunizations and screening tests remain important preventive services, the most promising role for prevention in current medical practice may lie in changing the personal health behaviours of patients long before clinical disease develops.

2.2 Implicit in this is that patients must be helped to assume greater responsibility for their own health and therefore the Health Care and Social Sector need to be prepared to provide proper counselling and appropriate resources.

2.3 The increasing recognition of the potential of preventive activities however raises questions about the evidence and effectiveness of preventive services in decreasing morbidity and mortality and improving the quality of life. Through systematic reviews medical scientists in the field of preventive medicine have found that many traditional tests and procedures cannot be justified or are performed too often. This underlines the continuing need to reassess the evidence and the impact of various preventive or screening programs.

3 - Barriers to preventive work

The most common barriers to preventive work are financial, structural and personal barriers. These relate to the physician, patient and the health care system.

3.1 - Physician barriers:

• Knowledge (lack of)

• Uncertainty about conflicting recommendations

• Uncertainty about the value of tests or interventions

• Disorganised medical records

• Delayed and indirect rewards from screening

• Lack of time

• Attitudes and personal characteristics

• Fear of litigation leading to an increase in false positives

3.2 - Patient barriers:

• Ignorance of benefits

• Awareness about the uncertainty of benefit

• Cost of procedures

• Discomfort and embarrassment

• Social and cultural norms

3.3 Health system barriers:

• Inadequate amount and system of reimbursement

• Lack of health insurance

• Population mobility

• Patients with multiple physicians

• Screening programs lacking scientific support

• Inadequate information systems

• Lack of specific preventive service systems.

• Other political factors that decide overall funding of preventive services

4 - Responsibility

4.1 As family doctors, GPs serve their clients from crib to grave and often know their social and genetic environment better than any other health professionals. This puts them in a unique position to provide information about relevant risks to health and to play a leading role in the work of prevention.

4.2 In order to do this properly GPs must retain a broad competence in preventive activities as changes in society with new health hazards will in the future lead to new tasks with new approaches.

4.3 Whatever system is involved it should be the health policy in every country to organize and finance the primary health care system so that it can take the responsibility for effective preventive services and health promotion.

4.4 GPs should use their professional influence to advocate for the implementation of policies and programs that can improve health of people regardless of age, gender, health status or socio-economic background.

The greatest opportunities for reducing health disparities are in empowering individuals to make informed decisions. For this to happen we have to create living and working environments and social support that sustain healthy life-styles. By promoting community wide safety, employment opportunities and equal access to education and health care we are more likely to reach our goal.

5 - Methodology

To achieve this a systematic approach to health improvement is paramount. It is composed of four key elements:

5.1 Goals

5.2 Objectives

5.3 Determinants of health

5.4 Health status

The ultimate measure of success in any health improvement efforts is the health status of the target population.

5.1 - Goals

• To increase quality and years of healthy life

• To eliminate health disparities

5.2 - Objectives

They should reflect the depth of scientific knowledge as well of the breadth of diversity of the European Nations΄ Communities. The leading Health Indicators are:

• Physical activity

• Overweight and obesity

• Tobacco use

• Substance abuse

• Responsible sexual behaviour

• Mental health

• Injury and violence

• Environmental quality

• Immunizations

• Access to health care

5.2 - Determinants of health

These are:

• Individual biology

• Individual behaviour

• Social environment

• Physical environment

• Policies and interventions

• Access to quality health care

Individual behaviours and environmental factors are responsible for the majority of premature deaths in the industrialized world. Developing and implementing policies and preventive interventions that effectively address these determinants can reduce the burden of illness, enhance quality of life, and increase longevity.

A prerequisite for achieving the prime goals of increased quality and years of life and of elimination of health disparities is the understanding of the main determinants of health. An evaluation of these determinants is an important part of developing any strategy to improve health.

5.3 - Health status

To understand the health status of nations or a population, it is essential to monitor and evaluate the consequences of the determinants of health. Health status can be measured by different data as:

• Birth and death rates

• Life expectancy

• Quality of life

• Morbidity from specific diseases

• Risk factors

• Use of ambulatory or inpatient care

• Accessibility of health personnel and facilities

• Financing or insurance coverage of health care

Understanding and monitoring behaviours, environmental factors, and community health systems may prove more useful to monitor the true health of the nations, and in driving health improvement activities, than the death rates that reflect the cumulative impact of these factors.

6 - Important facts about Preventive Activities

6.1 A variety of preventive interventions are effective, many of which are under utilized in routine practices.

6.2 Some widely used preventive practices, many of which are costly and some of which are even dangerous, show little or no evidence that they improve health.

6.3 The recommendations for prevention practices should rest on sound scientific evidence.

6.4 Counselling patients about personal health practices (smoking, diet, physical activity, drinking, injury prevention and sexual practices) remains one of the most underused, but important parts of the health visit. However, the uncertainty of extrapolating population data to a given individual must be acknowledged. The dignity of autonomous adults must be respected; patients should be given information and offered appropriate choices, but never coerced.

6.5 Preventive services offered by the clinician should be tailored to the specific behaviours and risk factors of individual patients.

6.6 Patients should share in decisions about preventive services. Their personal preferences are important in determining an approach to prevention that is optimal for them as individuals.

6.7 Health care in the broadest sense includes not only services received through health care providers but also health information and services received through other venues in the community.

7 - Strategies

It is evident that changes are necessary in a number of areas to help break down barriers and improve the practice of preventive medicine. Changes in the health care systems will be necessary to increase preventive services on a population-wide basis.

The UEMO calls for action in:

7.1 - Awareness:

• Educating the public and health care providers and providing the skills and information people need to adopt health promoting life patterns.

• Expanding and enhancing resources in the European Communities for disease prevention programs and their assessment and treatment. This should be directed at prevention programmes offering substantial benefits.

• Developing and implementing strategies to reduce the stigma associated with diseases like mental illness, substance abuse, and suicidal behaviour and with seeking help for such problems.

7.2 - Intervention:

• Improve the ability of primary care providers to recognize and offer treatment for the various risk factors. Institute training for all health care providers in preventive activities.

• Eliminate barriers in public and private insurance programs for provision of quality treatment and create incentives to treat patients at risk.

• Enhance community care resources by increasing the use of schools and workplaces as access and referral points for mental and physical health services and substance abuse treatment programs.

• Promote a public/private collaboration with the media to assure that entertainment and news coverage represent balanced and informed portrayals of risk behaviour and diseases and their risk factors and as well as approaches to prevention and treatment of these.

7.3 - Developing methods and improving the quality of preventive activities by:

• Enhancing research to understand risk and protective factors related to diseases and risk behaviour. Additionally increasing research on effective prevention programs, clinical treatments for individuals at risk, and culture specific interventions. Reassessing the continuing efficacy of existing programmes.

• Creating additional scientific strategies for evaluating disease prevention interventions and ensuring that evaluation components are included in all prevention programs.

• Establishing mechanisms for public health collaboration toward improving monitoring systems for risk behaviours and developing and promoting standard terminology in these systems.

8 - Important strategies at the Primary Care level

• Appropriate reimbursement and adequate funding of preventive services could have a major effect on reducing morbidity and mortality from many diseases.

• Good quality education is necessary for patients, physicians and other health care providers.

• Development of guidelines for the appropriate use of resources to diagnose, treat and prevent diseases. This may have a strong influence on the way clinical medicine is practised but, as with all other interventions, their effectiveness must be established through research..

• Building a comprehensive database (medical-, family-, social-, occupational/environmental- and sexual history, data of laboratory tests). The importance of confidentiality of personal information and using data only with properly informed consent must be emphasised.

• Health risk appraisal and flexibility by recognising the value of modifying screening recommendations to individual patients based on their risk status, i.e., case finding.

• Follow-up system for test results and future preventive services. The prevention profile should be appropriate for each patient with the doctor having the option to suppress reminders when they are no longer warranted or the patient chooses not to participate.

• Perform outcomes research to document the effectiveness of preventive services. The doctor should be able to derive summary statistics so as to gauge overall performance.

• Self-completed history forms and questionnaires may spare time.

• Literature and pamphlets emphasising the importance of preventive care are often effective in increasing patient awareness and interest. Translation and interpretation is important so that people from different cultures have equal access to information and guidance.

• Paramedical personnel where available can ease some of the time pressure on GPs and effectively deliver preventive services which could result in cost savings both to patients and to the health care organisation.

9 - Summary and Conclusion

This Statement is a call for scientists, health, education and social science professionals, policy-makers, media organizations and health program planners to recognize the importance of sharing the task in reaching the following objectives.

9.1 - Main objectives:

• To achieve access to preventive services for all the population•

• To increase the span of healthy life for the population

• To reduce health disparities among the population in Europe

9.2 - For Preventive Activities to be successful the following components are necessary:

• Knowledge

• Skills

• Attitude

• Organizational structure

Preventive activities have a tremendous potential not only to decrease morbidity and mortality but also to influence the quality of life. For these reasons primary and secondary services should be part of every day services in General Practice. In the coming years health system reform may lead to changes in the way health care is delivered. In whatever form health care services are ultimately packaged, preventive services should justifiably occupy a more central position. This calls for more resources and new strategies.

The UEMO believes that:

• Preventive Activities are an important component of Primary Care with GPs having a leading role

• Preventive Activities should be an integral part of every GP΄s work

• Preventive Activities should be effective and built on scientific evidence. The content should constantly be reassessed in reflect of experience and knowledge

• Preventive Activities in Primary Care should be efficiently funded (manpower, other resources needed)

• Standards of education, pre- and post gradual training and CME/CPD in the field of prevention/health promotion should be high and sufficiently financed

• Preventive Activities should be well documented and evaluated in order to be a source for research and base for further health care planning

• Preventive activities within health care should be supported and supplemented by societal interventions, which promote health through reducing material poverty and improving employment and educational opportunity.

• Preventive Activities should accommodate and respect patient autonomy and freedom of choice.

References

1. EU Public health policy, UEMO doc 01/024

2. Textbook of Primary Care Medicine Second Edition. St. Louis: Mosby, 1996

3. Hensrud DD.Clinical Preventive medicine in primary care: Background and Practice: 1. Rationale and current preventive Practices. Mayo Clin Proc.2000;75:165-172

4. Hensrud DD.Clinical Preventive medicine in primary care: Background and Practice: 2. Delivering Primary Preventive Services. Mayo Clin Proc.2000; 75:255-264

5. Hensrud DD.Clinical Preventive medicine in primary care: Background and Practice: 3. Delivering Preventive Services. Mayo Clin Proc.2000; 75:381-385

6. Guide to Clinical Preventive Services. Report of the U.S. Preventive Services Taskforce Second Edition Baltimore: Williams & Wilkins, 1996

7. Press Conference, Release of the Guide to Clinical Preventive Services, Second Edition, Report of the U.S. Preventive Services Task Force Donald M. Berwick, M.D, President and CEO, Institute for Healthcare Improvement, Washington, D.C.

8. Healthy People 2010: Understanding and Improving Health. http://www.health.gov/healthypeople/