health promotion and lifestyle advice in a general practice: what do patients think?

ISSUES AND INNOVATIONS IN NURSING PRACTICE

Health promotion and lifestyle advice in a general practice:

what do patients think?

Maria Jose Duaso BSc MA RGN

Lecturer, School of Nursing, University of Navarra, Pamplona, Spain

and Philip Cheung BA MA Ed PhD

Director of the Centre for Comparative Public Health, School for Health, University of Durham, Durham, UK

Submitted for publication 4 October 2001

Accepted for publication 31 May 2002

Introduction

The term health promotion encompasses a range of compo-

nent activities contributing to health. Health promotion has

been conceived as: �a multifactorial process operating on

communities, through education, prevention and protecting

measures� (Tannahill 1985, p. 167); �the process of enabling

people to increase control over, and to improve, their health�

(World Health Organisation [WHO] 1986: http://

www.who.int); and as �an umbrella term that includes all

472 � 2002 Blackwell Science Ltd

Correspondence:

Maria J. Duaso,

Escuela Universitaria de Enfermerı́a,

Universidad de Navarra,

c/Irunlarrea,

s/n,

31008 Pamplona (Navarra),

Spain.

E-mail: [email protected]

DUASO M J & CHEUNG P (2002)DUASO M.J. & CHEUNG P. (2002) Journal of Advanced Nursing 39(5), 472–479

Health promotion and lifestyle advice in a general practice: what do patients think?

Background/rationale. Since 1990 health promotion and lifestyle advice has been

integrated in general practice and has been mainly undertaken by practice nurses.

However little is known about patients’ views of the service provided.

Aims of the study. To examine patients’ recall and perceptions of lifestyle counselling

received from practice nurses in a general practice in the North-east of England. To

investigate the extent to which patients’ needs are met. To assess the main sources of

health information sought by patients.

Design/methods. Cross-sectional descriptive survey. A total of 512 patients were sent

a postal questionnaire about current lifestyle, recall of lifestyle advice received and

perceptions of the advice provided.

Findings. A response rate of 64% was achieved. Questionnaire analysis revealed

unhealthy lifestyles among the population studied that could be addressed through

health promotion, e.g. 25% were smokers; 44% exercised occasionally; 40% had a

body mass index>25 kg/m2. Advice received on diet was reported by 6% of patients;

on exercise by 4%; on smoking by 4% and on alcohol consumption by 2%. Patients

were willing to receive more health promotion in areas such as stress, exercise and

weight reduction. Magazines (67%) and TV (47%) were selected as the main sources

for health promotion information.

Conclusions. Health needs to be promoted. The low rate of lifestyle advice reported

by the patients implies that more preventive advice should be provided in primary care

settings. More effective health promotion should be planned according to the needs of

the practice population.

Keywords: health promotion, lifestyle advice, risk factors, practice nurses, primary

care, postal questionnaire, patient’s needs, mass media

those activities intended to prevent disease, improve health

and enhance well-being� (Naidoo & Wills 1998, p. 3).

The statement of principles known as the Ottawa

Charter for Health Promotion, developed by the WHO, is

internationally accepted as the guiding framework for health

promotion activity. This charter identified five priority areas

of action: building healthy public policy; creating supportive

environments; strengthening community action; developing

personal skills and reorienting health services (WHO 1986).

Yet, it has been criticised for producing a �catch-all frame-

work for health promotion in which priorities are unclear�

(Jones 1997, p. 7). The definition of health promotion

indicated in the Ottawa Charter is extremely broad, encom-

passing health education, public policy change, environmen-

talism and community action.

Health promotion is underpinned by a strong emphasis

on healthy public policy. In other words, it is based on the

potential to achieve social change via economic, environ-

mental and legal measures. Health promotion is also

concerned with helping to raise awareness in the individual

on how to prevent illness. However, as Delaney suggests, it

would appear unfair to expect any group or individual to

operate at all levels in health promotion (Delaney 1994).

Therefore, it seems necessary to identify the limits and extent

of nurses’ contribution to health promotion at a primary care

level. In practice, clinical health promotion has been defined

as �health education and patient counselling aimed at

behaviour change in patients at risk for lifestyle related

illnesses, or who have diseases for which lifestyle modifica-

tion can improve function or outcome� (Herbert 1995,

p. 278). According to Herbert’s definition, health promotion

is related to the provision of help support for people to

change lifestyles which are either causing them problems or

are potentially harmful.

Townsend in 1982 and Whitehead in 1987, pointed out

the link between poverty and health and that the gap in

health between the rich and the poor had widened

(Townsend & Davidson 1982, Whitehead 1987). Politicians

are changing their policies, acknowledging that health and

wealth are inextricably linked. It is the responsibility of

health professionals to equip individuals with the appropri-

ate knowledge and support and to work with them to

provide them with the facilities they need in order to lead a

healthier lifestyle.

Since 1990, several measures have been taken in the United

Kingdom (UK) to encourage health promotion in primary

care settings. The government national health strategy,

Saving Lives: Our Healthier Nation, targets heart disease

and stroke, accidents, cancer and mental health and identifies

professional advice on healthier living as a key component of

its national contract for health (Department of Health [DoH]

1999). Nurses and doctors working in primary care have

been identified as key figures to promote health. Because of

their close relationships with patients registered with GP

practice, primary health care teams are more likely to identify

health issues and needs of the population and provide health

promotion and education accordingly.

However, a decade after the introduction of the 1990 GP

contract, how successful has the DoH’s intervention been?

What contribution have practice nurses been able to make in

health promotion terms? Two major randomized controlled

trials took place in England to assess the effectiveness of

health checks by nurses in reducing risk factors for cardio-

vascular diseases (Family Heart Study 1994, Imperial Cancer

Research Fund OXCHECK Study Group 1995). Although

the reports of these studies called into question the efficacy of

general population interventions in general practice, they do

demonstrate positive effects on health promotion activity in

terms of promoting dietary change and reducing cholesterol

levels (O’Neill 1994). Qualitative research conducted about

nurses’ health promotion role, suggest that nurses have a

positive attitude to health promotion although their under-

standing of the concept is more centred on ill-health than

well-being (Davis 1995, Le Touze 1996, Sourtzi et al. 1996,

Steptoe et al. 1999). Most of the studies have focused on

surveying the nurses but there are few that have considered

the patients’ perceptions of the role of nurses in health

promotion (Poulton 1990, Silagy et al. 1992, Eggleston et al.

1995).

The successful implementation of health promotion and

health education activities will depend on numerous factors

such as resources, expertise, and more importantly the extent

to which the practice population is involved in the process of

planning. Merely providing the necessary health information

does not necessarily result in the modification of the patient’s

health related behaviour (Whitehead 2001). Health promo-

tion should be tailored to patients’ needs. In this study, the

current and future health needs of a practice population were

identified by means of a postal questionnaire.

The study

The objectives of this study are:

• to examine patients’ recall and perceptions of lifestyle ad-

vice received from practice nurses in a particular GP

practice in the Northeast of England;

• to investigate whether the advice provided in this GP

practice meets the needs of the practice population;

• to assess the main sources of health information sought by

the patients.

Issues and innovations in nursing practice Health promotion and lifestyle advice in a general practice

� 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 472–479 473

Methods

Setting

The practice is a five-doctor partnership located in a resi-

dential area in a town in the Northeast of England. The an-

cillary staff comprised the practice manager, receptionists,

two practice nurses, two health visitors, secretary and com-

puting staff. They also had two midwives, three district

nurses and a counsellor who attended the surgery. The sur-

gery provides a range of medical services, including maternity

care, cervical smears, family planning, minor surgery, child-

hood and adult immunizations, healthy heart, asthma and

diabetes clinics.

The practice provides primary health care to 9200 patients.

The boundary embraces the town area and nine villages

around. The ranks of the Indices of Deprivation of the

electoral wards served by the practice ranged from 519 to

7713 (with rank 1 being the most deprived ward in England

out of a total of 8414 English wards (National Statistics

Great Britain 2000).

Sample size calculation (for a¼ 0Æ05)

For the sample size calculation the following requirement was

made: the probability that the estimated proportion is within

0Æ05 of the actual value is at least 0Æ95 (1–a). In other words,

a 95% confidence interval for the proportion will have a

maximum width of 0Æ10. This requirement is met if the

sample size is 384. However literature reviews from previous

studies that have used postal questionnaires to patients from

a GP practice showed response rates ranging from 60% to

80% (Silagy et al. 1992, Ruta et al. 1997). Assuming a

response rate of around 75%, the required sample size was

512 to achieve 384 responses.

Instrument: questionnaire

A structured questionnaire was developed by the researchers.

It contained three sets of questions. The first section was

designed to obtain data on socio-demographic characteristics

including age, gender, marital status and occupation. The

second part, measured lifestyle and health status of the

sample, using both positive and negative indicators of health,

e.g. exercise and fitness vs. presence of illness. Smokers were

classified as light smokers (fewer than 15 cigarettes per day),

moderate smokers (15–19 cigarettes per day) and heavy

smokers (20 or more cigarettes per day) (United States

Department of Health and Human Services [USDHHS]

1986). Alcohol consumption was graded according to

reported weekly intake of standard units of alcohol. Exces-

sive drinking was defined as 21 or more units for men and 14

or more units for women (DoH 1995). In order to identify the

prevalence of obesity and overweight, the WHO’s classifica-

tion on Body Mass Index (kg/m2) was used (WHO 1996).

Patients were defined as underweight (if they were under

20 kg/m2), desirable weight (20–25 kg/m2), overweight

(25–30 kg/m2) and obese (over 30 kg/m2).

The third part of the questionnaire was concerned with

health promotion issues. Patients were asked whether they

had received preventive advice about specific aspects of

health behaviour from a practice nurse during the preceding

12 months, how useful they had found it and whether they

would like to receive any additional lifestyle advice. They

were also asked about their main sources of health promotion

information.

The questionnaire was piloted with 20 patients who did

not take part in the final sample. On the basis of the

comments made the questionnaire was revised. No major

changes were made. The final sample consisted of 516

subjects selected from the 3612 patients aged from 17 to 45

registered in this practice. A computer generated list

ordered by age was obtained and every seventh patient

was selected. This would ensure a representative proportion

of every age-group. Two mailings were undertaken between

February and March 1999. The questionnaire was sent

together with a covering letter signed by one of the doctors

of the practice explaining the aims of the survey and asking

for collaboration. A stamped self-addressed envelope was

also provided.

Data analysis

SPSS was used for quantitative analysis. Open questions were

codified into groups by content analysis technique and

introduced into the data base as categorical variables. Means

were compared using Student’s t-test. Chi-square test or

Fisher’s exact test were used in analyses that entailed com-

parisons of proportions. The missing data were excluded

from the analysis. All tests were performed at a two-tailed

significance level (P) set at 0Æ05.

Ethical considerations

The covering letter sent with the questionnaire emphasized

that the responses would be confidential. During the data

analysis confidentiality was maintained by data coding to

eliminate identifying data with personal information.

Results

Survey response

Of the 516 questionnaires initially sent, 21 were returned

by the Post Office because of �addressee has gone away�

M.J. Duaso and P. Cheung

474 � 2002 Blackwell Science Ltd, Journal of Advanced Nursing, 39(5), 472–479

or �addressee unknown�. Out of 495 patients, 228 (46%)

replied within a month. Then a reminder was sent

to nonrespondents. The final response rate was 316

(64%).

In order to assess the representativeness of the results, the

response rate by gender, age and post code was studied.

According to the Office of Population Censuses and Surveys

(OPCS), post code areas can be used as a proxy for social

classes (OPCS 1994). Respondents were more likely to be

female (P < 0Æ001) and were 3 years older on average than

nonrespondents (P < 0Æ001). The difference in response rate

by post code areas was not statistically significant.

Socio-demographic characteristics

Participants in the study were 34-year-old on average, most

of them were married with an average family size of 1Æ2

children and working full time. Tables 1a and b show socio-

demographic characteristics by gender.

Health status and lifestyles

Questionnaire analysis revealed unhealthy lifestyles that

could be addressed through health promotion. For exam-

ple, 25% (95% CI ¼ 21–31) were smokers, from which

63% (95% CI ¼ 51–74) wanted to receive help to quit the

habit; 44% (95% CI ¼ 39–50) exercised occasionally;

39% (95% CI ¼ 34–45) had a BMI > 25 kg/m2 (see

Table 2). There were significant differences in some

lifestyles between male and female. Men drink more

than women, and the percentage of overweight was

higher among men. However, obesity was more prevalent

among women and they seem to become anxious more

often.

Lifestyle advice rates

The overall reported rate of advice was 6% (95% CI ¼ 3–10)

for diet, 4% (95% CI ¼ 2–7) for exercise, 4% (95% CI ¼2–7) for smoking, and 4% (95% CI ¼ 2–7) for weight

reduction (Figure 1). As expected, those with unhealthy

behaviour profiles seem to have received more advice. For

instance, 11% of smokers had received advice on smoking

or 8% of those with BMI higher than 25 kg/m2 had received

advice on weight reduction.

There appears to be a discrepancy between patients’

expectations of lifestyle advice from the practice nurses and

the receipt of such advice. Patients were willing to receive

more advice on healthier living in areas such as stress,

exercise and weight reduction. Figure 1 indicates whether

there was a difference between the lifestyle advice received

and expected.

As shown in Figure 2, those who had received lifestyle

advice from practice nurses (n ¼ 102) found it, on average,

very/fairly helpful. However, there were significant differ-

ences between male and female perceptions of the advice

Table 2 Prevalence of risk factors among participants by gender

Risk factors

Men

(n ¼ 129)

% (95% CI)

Women

(n ¼ 187)

% (95% CI)

P-value

v2

Smoking 25 (18–33) 26 (20–33) N.S.

Drinking in excess* 21 (14–29) 11 (7–16) P < 0Æ01

BMI

<20 (kg/m2) 2 (0–6) 17 (12–23)

20–25(kg/m2) 46 (37–55) 53 (46–61) P < 0Æ001

25–30 (kg/m2) 44 (36–54) 15 (10–21)

>30 (kg/m2) 8 (4–14) 15 (10–21)

Exercise

Very often 16 (10–24) 11 (7–16)

Often 31 (23–40) 39 (32–46) N.S

Occasionally 43 (34–52) 46 (38–53)

Not at all 9 (5–16) 5 (2–10)

Become anxious

Very often 8 (4–14) 16 (11–22)

Often 20 (13–28) 34 (27–41)

Occasionally 58 (49–67) 46 (39–53) P < 0Æ001

Not at all 14 (9–22) 4 (2–8)

*Defined as 21 or more units/week for men; 14 units or more/week

for women.

Table 1 Socio-demographic characteristics of participants by gender

Men

(n ¼ 129)

mean (SD)

Women

(n ¼ 187)

mean (SD)

(a) Continuous characteristics

Age (years) 34Æ1 (7Æ2) 33Æ6 (8Æ3)

Number of persons in household 2Æ1 (1Æ3) 2Æ3 (1Æ2)

Number of children 1Æ0 (1Æ0) 1Æ3 (1Æ2)

% (n) % (n)

(b) Categorical characteristics

Married 54 (70) 58 (109)

Ethnic group

White 92 (119) 97 (181)

Employment

Working full time 76 (98) 39 (72)

Working part time 4 (5) 25 (46)



received from the practice nurses. Most of the female patients

found the health promotion provided by nurses in the

practice very/fairly helpful while male patients were more

dubious about it.

Sources of health information

When asked about the main sources of health promotion

information, magazines (67%; 95% CI ¼ 62–73) and televi-

sion (47%; 95% CI ¼ 41–53) rated the highest. Health

professionals had lower rates: 22% (95% CI ¼ 18–28) cited

the doctor, 14% (95% CI ¼ 10–19) the chemist and only 5%

(95% CI ¼ 3–8) of them referred to the practice nurse. As

can be seen in Figure 3, while significantly more women than

men chose magazines as the main source (P < 0Æ05),

significantly more men than women chose TV as the main

source (P < 0Æ05).

Discussion

This study explored patients’ recall and perceptions of

lifestyle counselling received from practice nurses in a general

practice in the North-east of England. The results reflect

the situation in a particular practice, therefore wider

generalizations cannot be established. In spite of these

Figure 1 Lifestyle advice received vs.

expected (n ¼ 316). j Percentage of

patients who recalled receiving lifestyle

advice; percentage of patients who would

like to receive more health promotion.

Figure 2 Patients’ evaluation of the lifestyle advice received

(n ¼ 102). v2 ¼ 9.84; d.f. 3; P < 0.05. Men; j Women.

Figure 3 Main sources of health information (n ¼ 316) (participants

could indicate more than one source of information). Men;

j Women.



limitations, this study provides some evidence that can enable

practice nurses to plan future services according to the client’s

needs.

Although the accuracy of our estimate is limited by the

restricted response rate, results of this study suggest that there

is still considerable room for improvement in preventive

activity. The questionnaire sent to 516 patients of the

practice, reveals unhealthy lifestyles among the population

that can and should be addressed through health promotion.

Obesity, or being overweight, together with smoking, stress-

ful environment, excessive alcohol consumption and lack of

physical activity were prevalent among the population

studied and form a group of lifestyle risk factors associated

with increased morbidity and mortality from noncommuni-

cable diseases (WHO 1996).

Smoking, for instance, is the single greatest cause of

avoidable illness and preventable ill health in UK (DoH

1998a). In the present study, one in four respondents was a

smoker; 63% of smokers wanted to receive help to quit the

habit. However, only 11% of the smokers who visited the

surgery during the previous year had received health promo-

tion advice from the nurses, encouraging them to give up

smoking. The findings suggest that more emphasis should be

placed on regular smoking screening and smoking cessation

clinics which would be welcomed by the patients.

According to recent accounts, obesity leads to much

suffering in the UK by contributing to chronic disease and

premature mortality (Great Britain Parliament House of

Commons Committee of Public Accounts 2002). The increase

in obesity reflects changes in lifestyle, people being more

sedentary and a diet richer in energy dense foods (DoH

1998b). In the present survey, 44% of the men and 15% of

the women were overweight and 8% of men and 15% of

women were obese. However, general practices are uniquely

placed in the management of obesity, as they are often the

first port of call to those seeking help. Practice nurses can play

a valuable role identifying patients with weight problems and

in providing advice and support on weight control.

Mental health was also shown to be an important issue

among this practice population. Anxiety, also appeared to be

a common problem: one in two women and one in three men

reported becoming anxious about things often/very often.

Stress management was the most selected topic (33%) when

asked about the kind of health promotion information they

were willing to receive. However, only 1% patients recalled

having received advice in this area. This is consistent with

recent reports that claim that in England, on average, family

doctors identify only about half of the people who come to

them with depression and anxiety (DoH 1999).

Because of their close relationships with patients registered

with the surgery, practice nurses would appear to be in an

ideal position to identify the health issues and needs of the

population and provide health promotion accordingly. How-

ever our results suggest that the frequency with which

patients recall having received lifestyle advice was low. This

rate is consistent with previously reported studies (Silagy

et al. 1992, Deehan et al. 1998, Little et al. 1999). Therefore,

more emphasis should be placed on health promotion,

particularly through the use of screening instruments and

brief interventions.

Part of the explanation for the low advice rates observed

in this study may be because of the reporting bias. Under-

reporting by patients might be either because they forgot that

advice was offered or because they failed to recognize that

advice was given. Lack of training in lifestyle counselling has

also been perceived as a problem. Steptoe et al. (1999) found

that the majority of the nurses felt that lifestyle counselling

was difficult and thought that the influence on their patients

was limited. Additional training for health professionals

especially those who are closely involved in health promotion

should be provided. A further explanation of the low advice

rates maybe the lack of time. Previous studies have shown

that nurses have a positive attitude to health promotion

although they identified problems with administration and

data collection (Le Touze 1996, Broadbent 1998) Appropri-

ate resources are required for lifestyle surveillance in each

practice so that future actions can be planned and imple-

mented based on research evidence.

Mass media resources have an enormous potential to

influence health-related behaviour (Flyn et al. 1994, Finnegan

et al. 1999). Patients in this practice have reported TV and

magazines to be the main sources of health information. It

has been claimed that the incorporation of health-related

mass media initiatives into nursing’s health promotional role

can increase the overall effectiveness in a very interesting and

empowering way (Whitehead 2000). Nurses in primary care

could incorporate effective mass media resources into their

practices, improving current levels of health promotion

advice.

Although our results suggest that the frequency with which

patients recall having received lifestyle advice is not very

high, patients in this practice were interested in receiving

more health education and on average, patients found the

advice received from the practice nurses very/fairly helpful.

This should encourage nurses working in primary care to

continuing developing and improve their practice providing

patients with the ability and opportunity and power to

change.



Conclusion

This study raises a number of preventive and public health

issues. First, there is a need for regular and planned

health surveillance in each GP practice, so that preventive

health strategies are updated and that those who carry a

number of health risks can be targeted. The lack of human

and financial resources places severe constraints on primary

health services. Nurses working in primary care should

review their practices and be innovative in their approach to

health promotion. It would appear that media, particularly

magazines and TV have a major role to play in providing

counselling and advice.

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