Primary prevention in the general practitioner office – a mixed-method study

Introduction: In Germany legislation allows statutory health insurance companies to allocate a certain amount of their budget to primary prevention, especially for courses on nutrition, stress management, and physical activity. However, it is unclear if these courses are known to physicians who could recommend them. Similarly, little is known about the role primary prevention plays in German general practitioners' (GP) offices. In this paper we describe the prevalence of primary prevention in GPs offices in a large German city and analyse the barriers and facilitators to establish primary prevention in general practice.

Methods: We conducted a mixed-method study including a survey that was distributed between November 2010– February 2011 to all office-based GPs in Berlin (n=1168) and focus groups. A subsample of 15 GPs, a convenient sample, was selected to participate in one of four focus group discussions. The discussions were digitally recorded, transcribed and entered into the software program maxqda for qualitative content analysis. Two members of the research team coded and analyzed the materials.

Results: A total of 474 GPs responded to the survey (41%). Most considered primary prevention as part of their tasks (70%) but also thought that each individual (74%), schools, day care (57%), and insurance companies (42%) had a high responsibility for primary prevention. Especially physical activity, healthy eating, and smoking cessation were part of GPs health care recommendations if they thought it was indicated. The focus group discussions showed that GPs decided on a case-by-case basis if and how they addressed behaviour change. The discussants gave information and suggestions regarding lifestyle changes when it was related to the ailment that the patient presented. This seemed necessary because a discussion on behaviour change that was not initiated by the patient or not in relation to the patient's ailment was seen as a potential threat to the patient-physician-relationship. Overall, GPs perceived primary prevention a task in which many societal actors needed to take responsibility, especially educational institutions, communities, and individuals. GPs perceived themselves as those who could provide information in such a network on the negative consequences of unhealthy behaviours both in group settings as educational activity or public presentation and in consultations with their patients.

Discussion: The strength of the GP practice seemed to lie in the individualized approach that reacted to the patients' needs and demands. Such an approach established the long term strong relationships in which GP advice achieves a strong standing in a person's life when it may be important. In practice, this meant that most behaviour change suggestions in the GP practice needs to be seen as secondary and tertiary prevention. This sample of GPs saw prevention as an important task. However, the work in primary prevention may lie outside the GP practice in a network of primary prevention. The distinction of primary, secondary, and tertiary prevention does not seem feasible in the everyday practice of health care.