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Evidence-based Health Promotion in Clinical Settings

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1. Introduction

Efforts are underway worldwide to stem what has been called the "epidemic of chronic disease" by, in part, finding ways to improve the prevention and management of risk factors and chronic conditions. To this end, various approaches are being taken: policy and health systems changes; employing new collaborative approaches to care; partnering with patients and families; addressing underlying determinants of health; creating supportive environments; and shifting toward a stronger emphasis on health promotion and disease prevention.

This week's OHPE feature provides a basic overview, context and examples of evidence-based health promotion in clinical settings - an important and emerging, yet currently under-developed, area of research and practice in modern day hospitals and health services. It is believed that further development and integration of evidence-based health promotion and health-promoting practices into clinical settings will contribute to increased health gains for patients and families as well as overall improvement in the health of the population in general.

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2. Health Promotion in Hospitals and Health Services

In a health promoting hospital, health promotion is considered a core quality dimension of services in the same way as patient safety and clinical effectiveness. The provision of effective health promotion services that enable people to increase control over, and to improve, their health is an important factor for sustained health, quality of life and efficient use of scarce health care resources.

The Health Promoting Hospitals and Health Service (HPH) movement was initiated in the early nineties as a pilot project of the World Health Organization (WHO) European office. The HPH concept has a firm grounding in WHO's strategies for improving health services (e.g., the re-orientation of health services outlined in the Ottawa Charter for Health Promotion), as well as the WHO Healthy Systems Strategy that addresses the contribution of health services to the achievement of health system goals.

HPH has the following objectives (adapted from http://www.euro.who.int/healthpromohosp):

  • To change the culture of hospitals and health care services towards interdisciplinary practice and transparent decision-making, including active involvement of patients and families;
  • To evaluate health promotion activities in the health care setting and build a body of evidence as a base for future practices; and
  • To incorporate standards and indicators for health promotion in existing quality management systems at hospital/health services locally and nationally.

In recent decades, most health promotion and disease preventive activities in Ontario have tended to be delivered by pubic health units, community agencies or within community health centres. Health promoting activities have not been a high priority, nor have they been part of "core business" of other health care services, such as surgical and ambulatory clinics, general primary care practices and hospitals. More recently, however, the integration of health promotion and disease prevention in a more coordinated health care system is increasingly supported by governments in their rhetoric, strategies and new health care models. Two examples of this are the Family Health Teams and the Chronic Disease Prevention and Management Framework, which is Ontario's adaptation of the U.S. integrated Chronic Care Model (Wagner, 1998).

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3. What is Evidence-based Health Promotion in the Clinical Setting?

A relatively recent focus of research within the clinical setting, evidence-based health promotion is one important part of the overall HPH approach. While many health promotion activities are occurring in the clinical setting, robust, fully-evaluated and comprehensive evidence of the effectiveness of tools and training is still relatively scant.

Dr. Hanne Tønnesen, Director of the WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals recently gave a lecture in Toronto entitled "Evidence-based Health Promotion in Clinical Settings" (available at http://tinyurl.com/5lrb7q). Dr. Tønnesen supports an approach that uses the same principles as evidence-based medicine for the development of best practices in clinical health promotion. Her recommendation for applying the evidence-based approach in a clinical setting is to take into account the best available evidence, staff expertise and patient preferences.

These three elements of clinical evidence-based health promotion practice are illustrated below using smoking cessation or lifestyle intervention examples.

a. Best available evidence

Best available evidence for health promotion practice includes clinically relevant, patient-focused research. New evidence is used as a foundation for replacing earlier accepted procedures and protocols with newer, more effective interventions related to: diagnosis, prognosis, treatment, care, health promotion, disease prevention and rehabilitation.

For example, earlier research in clinical health promotion concluded that it could be more dangerous to stop smoking less than eight weeks before surgery than to continue smoking and have less risk of complications (Warner, 1984). More recent clinical research in health promotion using randomized control trial methodology suggests that in fact the opposite is true. In one study, patients who had a health promotion intervention and quit smoking 6 to 8 weeks before elective surgery cut post-surgery complications by more than half (Møller et al, 2002). Other studies have shown similar results (Sørensen et al, 2003; Lindstrom et al, 2008).

b. Staff expertise

Another essential element of the best health promotion practice involves the role and use of clinical staff expertise and experiences in relation to the intervention, as well as in meeting the patient's needs and wishes. A number of recent studies have shown that there is a positive relationship between the uptake of a brief health promotion intervention for smoking cessation and alcohol abuse given by specially trained nurses versus regular staff nurses (Nelborn et al, 2004; Backer et al, 2007; Tønnesen et al, 2008 submitted). Additionally, quit rates in those patients offered the brief intervention were very high; 30 to 50% stopped smoking and alcohol abuse for the shorter period and 5 to 10% stopped for at least a year.

c. Patient Preference

Each person has individual preferences, wishes and expectations from their contact with the health care system. In another example of health promotion interventions in a clinical setting, Danish researchers found that 80% of patients scheduled for surgery who were counseled for their high risk for complications wanted the hospital to support smoking cessation, alcohol cessation and weight loss. Of those 80%, a very high percentage participated in the randomized control trial for preoperative lifestyle interventions with high compliance (70-90%) (Møller et al, 2002 & 2004; Boel et al, 2004; Tønnesen et al, 1999; Nielsen et al, 2007 submitted).

Evidence-based health promotion suggests that programs and interventions should be built using already existing relevant evidence and practices. It is also important to adapt methods and models to the environment and needs of a given population in order to determine the best approach for further development of interventions in that particular context.

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4. Challenges and Opportunities for Health Promotion in Clinical Settings

There are a great number of challenges at the system, organization and patient/provider level to integrate even the current limited evidence-base for health promotion in clinical settings. But there are also many exciting opportunities to do further research and implement new, innovative practices in this field that will contribute to the development of this important area of knowledge.

One of the biggest challenges for some health care providers is the development of new skills and change of attitude to become more patient-, versus provider-centred. This culture shift would see clinicians having a greater role as health promoters and partners who can significantly influence the behaviours and attitudes of their individual patients. Evidence suggests that well-designed training courses can improve the communication skills of doctors, nurses and pharmacists (Fellowes et al, cited in WHO 2008 Policy Brief).

This cultural change would also mean acknowledging the patient's central role in their own care, and applying recent evidence-based self-management programs, tools and approaches to collaborate to define problems, establish goals and create treatment plans to support those goals. This change requires an explicit shift of control to the patient and family. It means that the care team is accountable for activating and providing relevant and appropriate information to the patient and family, versus telling them what to do in a more traditional didactic and ultimately less effective way.

According to an unpublished joint paper from the U.K. Picker Institute and U.S. MacColl Institute, there is also a need for more research and better studies in the area of patient-provider "agreements" (formally negotiated and agreed upon plans for self-managed care, including prevention, management and health promotion). What existing research has shown so far is that greater patient empowerment and better patient-provider communication increases adherence, facilitates behaviour change and improves health outcomes. Furthermore, when a patient is engaged as an active player in their health, evidence exists that this not only improves their experience and satisfaction, but can be clinically and economically effective (Coulter, 2007).

Other promising areas of clinical research related to health promotion include

  • Continuing investigation of effective lifestyle behaviour change and risk factors prevention;
  • Promotion of an active role for patients by building health literacy, promoting patient involvement in treatment decisions and educating patients to play an active role in self-management of chronic conditions (WHO 2008 Policy Brief); and
  • The connection of mental health promotion, spiritual care and chronic disease prevention and management. This is another significant and less-explored area of research that is generating new, important evidence for health promoting practices in clinical settings. For example, mindfulness meditation, acceptance and commitment therapy, self-help and peer support groups, spiritual-religious practices related to addictions and coping with chronic conditions.  

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5. Conclusion

There is a tremendous, untapped opportunity to influence people in a more positive way within our overall health care system, and within the treatment/rehabilitation sector in particular. In Ontario alone, approximately 300,000 people interact with our hospitals and health services everyday (adapted from Manuel, 2006).

A few recommendations to help shift the health care delivery system to become more "health promoting" are

  • Include evidence-based health promotion and proven patient-centred care delivery models in the training and education of all physicians, clinicians and public health professionals.
  • Translate more of the already existing evidence-based research into new tools and practices for implementation in clinical settings.
  • Have funders, policy-makers and health administrators shift resources and provide incentives to integrate disease prevention, clinical health promotion and new models of patient education into clinical settings.

Research is demonstrating more and more that integrated disease prevention and health promotion in hospitals and health services can have a lasting impact on patients and families - individuals who are often more responsive to health advice when they, or someone close to them, is experiencing ill-health (from Ogden, 1996).

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6. Selected References

Askham J, Coulter A, Parsons S. WHO Policy Brief: Where are the patients in decision-making about their own care? June 2008. Accessed at http://www.euro.who.int/document/hsm/3_hsc08_epb_6.pdf.

Coulter A. Informed and empowered individuals, families and communities: a whole systems approach. Picker Institute Europe (2007). Accessed at http://www.pickereurope.org/page.php?id=69.

Manuel DG, et al., Primary Care in Ontario, Primary Care in the Health Care System, ICES Atlas, Chapter 2, Institute of Clinical Evaluative Sciences, November 2006.

Ogden J. Health Psychology: A Textbook Oxford, Open University Press, 1996.

Wagner EH. Chronic disease management: what will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2-4.

Others cited in Evidenced Based Health Promotion in Clinical Settings, June 2008 lecture by Dr. Hanne Tønnesen, Director of the WHO Collaborating Centre for Evidence-Based Health Promotion in Hospitals, as part of the LiveWell! Lecture Series, Bridgepoint Health. http://tinyurl.com/5lrb7q