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Health Promotion and Disease Prevention Attitudes of Canadian Emergency Physicians: Findings from a National Study

I Introduction
II Methods
III Physician Attitudes about Health Promotion and Disease Prevention
IV Correlational Results
V Conclusion
VI References

-- by Kent V. Rondeau, PhD, and Louis H. Francescutti, MD, PhD, MPH, Department of Public Health Sciences, University of Alberta

This article is part of a series inspired by CPHA's 2003 conference. For more information, read our introduction to the series in the OHPE News and Summary section of OHPE 344.0 (http://www.ohpe.ca/ebulletin/ ViewAnnouncements.cfm?ISSUE_ID=344).

If you have a resource or point of view to add to this article, let us know by writing to [email protected]. More information on our Letters to the Editor column can be found in our submission guidelines (http://www.ohpe.ca/ebulletin/submit.html).

I Introduction

In the past two decades, the prevention of disease and the promotion of healthy lifestyles have received increasing attention. While hospital emergency departments provide a potential setting for health-promotion interventions, they are grounded in episodic treatment of acute conditions and are generally not considered traditional places to practice health promotion and disease prevention (Goel and MacIsaac, 2002). Yet, physicians and nurses in emergency departments are in a unique position to be advocates for, and practitioners of, health-promoting interventions:
* Emergency medicine and health promotion share similar goals for the improvement of individual and community health.
* Hospital emergency departments are repositories of significant health-care resources, professional skills, and medical technology.
* These departments are established entry-points into the health-care system and credible conduits for health information, advice, and expertise to the community.
* Emergency departments have infrastructure for health promotion through their established professional affiliations and community networks (Bensberg and Kennedy, 2002).
* Emergency physicians and nurses often provide the only source of medical care to a significant number of disadvantaged persons (Williams, Chinnis, and Gutman, 2000) and are in a unique position to intervene with and influence the behaviours of "at-risk" populations.

However, if physicians and nurses in emergency departments are to embrace a meaningful role in health promotion, a significant shift must occur in their traditional role--they would need to possess the appropriate attitudes, knowledge, and skills.

This paper reports on health promotion and disease prevention attitudes and practices of a large sample of Canadian emergency room physicians. The objective of our study was to assess existing attitudes, beliefs, knowledge, and practices with respect to health-promotion and - prevention activities in the emergency-room setting. Readers may contact the study investigators to learn more.

II Methods

A. Survey Participants and Procedure

In 2001, a survey questionnaire was sent to 1,500 Canadian emergency physicians. The study database was provided by the Canadian Association of Emergency Physicians (CAEP) and comprised emergency physicians in all Canadian provinces and territories. All participants were informed about the nature of the study and that participation was voluntary, confidential, and anonymous. Six weeks after the initial mailing, we sent another questionnaire to all physicians in the database. In total, 428 usable questionnaires were returned. After subtracting questionnaires that were refused or identified as undeliverable (66), an overall response rate of 29.8% was attained.

B. Profile of Emergency Physicians in our Study

Physicians in our study sample demonstrate a number of medical specializations. Most have training and certification in emergency medicine (75.0%), while family medicine (14.5%), general practice (8.6%), internal medicine (0.2%), and other specialties (1.7%) are also represented. Most physicians in our sample (63.8%) spend 76 to 100% percent of their total practice time in emergency medicine. Most physicians in our sample (43.5%) indicated they receive compensation for their emergency room work on the basis of fee-for-service, while 22.9% receive straight salary and 18.7% receive a combined fee-for-service/salary compensation.

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III Physician Attitudes about Health Promotion and Disease Prevention

Emergency physicians were asked about their general attitudes about health promotion and disease prevention. Survey respondents have very favourable attitudes towards health promotion as "the best way of maintaining good health" and are "strong believers in the benefits of health promotion." However, about one in five respondents questioned the cost effectiveness and general rationale of health-promotion interventions.

We were also interested in learning about the usefulness of health-promotion interventions in the emergency room. Not surprisingly, emergency physicians were less certain about the role of health promotion in emergency medicine. Physician respondents in our sample questioned the economic viability and practicality of practicing health promotion in the emergency room. A number of significant barriers were identified that undermine the potential of health-promotion interventions to be effectively delivered in the emergency setting:
* About eight out of ten physicians agreed with the propositions that there are insufficient resources provided in the emergency department for health promotion interventions and health promotion follow-up.
* About seven out of ten physicians agreed that they were insufficiently rewarded for making health-promotion interventions.
* When health-promotion and disease-prevention interventions were provided, they were done so only after treating acute illness (82.5%) and only if the physician has enough time to do so (82.1%). About 70% of emergency physicians indicate that they usually do not have sufficient time to practice health-promotion interventions, even though about 42% of respondents report they routinely provide such interventions in the emergency setting.
* Physicians were generally split on the role of triage nursing to appropriately identify patients for health promotion interventions.
* Although only a minority (28.2%) of respondents agreed with the statement "it is not my responsibility to engage in health-promotion and disease-prevention activities in the emergency department," 54.7% did not feel they were sufficiently aware of the health promotion interventions that are routinely provided by their establishments.
* Most physicians report that their patients do not expect them to make health-promotion interventions on their behalf, even though most respondents (77.8%) report that many of their patients are in need of health-promotion interventions.
* Respondents report that the decision to practice health promotion interventions in the emergency setting is generally not seen to be influenced by the capability of the institution to provide appropriate follow-up care, nor is the decision to provide such interventions influenced by whether a patient has a primary care physician.

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IV Correlational Results

Simple bivariate correlations were performed to investigate broad associations between study variables. A five-item scale was constructed assessing physicians' general attitude about health promotion (non-emergency context) and a five-item scale assessing physicians' attitude about health promotion in the emergency context. In addition, scales were constructed assessing physicians' knowledge of health-promotion practices (nine items), b) physicians' assessment of their responsibility for health promotion (15 items), c) physician job satisfaction (6 items), d) physician-patient commitment (eight items), and e) physician extra-role behaviour (four items). In addition, scales were constructed measuring health-promotion screening activity (12 items), health promotion counseling activity (10 items) and disease prevention interventions (five items). Cronbach alphas were calculated for each scale to assess internal reliability. Interested readers can contact the study researchers for details and results at [email protected].

A. Physician General Attitudes about Health Promotion (in the Non-Emergency Setting)

Emergency physicians with more favourable attitudes towards health promotion (in general) are slightly more likely to be female (p<.05), to be younger in age (p<.001), have fewer years of practice in emergency medicine (p<.001), and to have certification in family medicine (p<.01). Respondent physicians with more favourable general attitudes towards health promotion are also found to be slightly more likely to demonstrate greater patient commitment (p<.05), have more knowledge about health-promotion interventions (p<.01), and believe they have a greater responsibility for health-promotion interventions in the emergency room setting (p<.001). These physicians were also found to spend more time with each patient (p<.01), a necessary requirement if health-promotion interventions are to be advanced. However, no associations were found with respect to the cumulative frequency of screening, counseling, or immunization behaviour. That is to say, having a more favourable attitude towards health-promotion intervention is not found to be associated with greater cumulative frequency in screening, counseling, or immunization health promotion practices.

B. Physician Attitudes about Health Promotion in the Emergency Setting

Emergency physicians with more favourable attitudes towards health promotion (as practiced in the emergency room setting) are much more likely to demonstrate greater patient commitment (p<.001), demonstrate greater extra-role behaviour (p<.01), report having more knowledge about health promotion interventions (p<.001), and believe they have a greater responsibility for health- promotion interventions in the emergency-room setting (p<.001). Physicians with more favourable attitudes also report more health-promotion screening (p<.001), as well as counseling (p<.001) behaviours. However, no statistically significant associations were found with respect to the physician gender or age or in having certification in family or emergency medicine.

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V Conclusion

If hospital emergency departments are to play an important role in health promotion and disease prevention, health professionals who work in this venue must demonstrate the appropriate attitudes, knowledge, and practices.

This work forms the basis for further knowledge development and research around the determinants of health-promotion behaviours in specific emergency settings. Emergency departments in Canada, and elsewhere, are the first (and last) line of defense and form a critical "safety net" function. It is logical that health-promotion and disease-prevention interventions be added to the traditional armamentarium of treatment services provided by the hospital emergency department. Shaping the attitudes, education, and practice of emergency physicians about health promotion will increasingly become a priority as hospitals increasingly embrace this new role.

VI References

Bensberg, M., and Kennedy, M. (2002). "A framework for health promoting emergency departments." Health Promotion International 17(2), 179-188.

Goel, V., and McIsaac, W. (2000). "Health promotion in clinical practice." Poland, B., Green, L., and Rootman, I. (Eds.). Settings for health promotion: linking theory and practice. (Newbury Park, CA: Sage Publications.

Williams, J.M., Chinnis, A.C., and Gutman, D. (2000). "Health promotion practices of emergency physicians." American Journal of Emergency Medicine 18(1), 17-21.