Lizzie Wortley and Max Davie
What is health promotion and is it really in my job description?
Health promotion is often regarded as an ‘add on’ to the consultation, or as the remit of public health clinicians. This blog is to help support you to do health promotion as part of daily work and show you why that’s the best way to do it.
Let’s start with what it means. The WHO describes it as ‘the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions.’
Lots of clinicians are already doing health promotion in their work and may not even realise it. Whenever clinicians look beyond the signs and symptoms in front of them and place their patient and family in their wider social, cultural and economic context, they are practicing health promotion.
The usual medical school example of health promotion is around seeing a homeless person for a check-up and finding high blood pressure which you treat with a prescription. However, this is unlikely to result in improved BP readings because a) it’s not a priority to take it, b) one may not be able to access the medication regularly c) other factors are probably contributing to the raised blood pressure, and d) you should consider the safety of giving a medication with side effects such as dizziness, drowsiness and diarrhoea to someone without somewhere safe to live.
So with this (non-paediatric) example in mind, we would argue that by not considering the wider social and environmental impacts on our patients, we aren’t delivering safe, equitable and appropriate healthcare.
Surely this just means more work for me?
You could say that. A few extra questions and providing pointers to where someone can get support may technically increase your consultation time – but that’s balanced out by the better, more informative consultation you have had.
We would make the point that, if it is worth your time to get biochemistry and scans in the sometimes vain hope of helping the diagnostic process, then it is also worth your time to gather information about the social and psychological context that has an impact on the health of that child. Very often if you form a picture of the psychosocial context, the reasons for symptoms become clear, and further investigation can be curtailed, saving time and money as well as avoiding unpleasant procedures.
It’s also more fun to allow your curiosity to extend to a patient. They’re more likely to be able to engage with treatment or support, and then they may be less likely to require extra input from urgent services.
In our experience, you can be a highly efficient clinician and do this as part of your basic work without impeding on how quickly you see patients.
If this still doesn’t make sense, we struggle to think of an example where the life context of a child does not impact on their outcomes. Even cardiac surgery for the new-born, where the diagnosis is clear cut and the management is advanced surgery, the outcomes are impacted by the living conditions, parental education levels, engagement and other factors influencing what care that child receives both inside and outside the health setting. If we take these into consideration, we can make management plans and signpost families to services and support that can make good health outcomes more likely to happen.
So how do I get started then?
The key to effective health promotion is to make sure that you actively listen. Show curiosity about what is happening in the family and child or young person’s life. They probably already know what they want to, or ‘should’ be doing, how can you facilitate things so they can start to make small changes that could have a big impact over time?
That’s it – it’s just a conversation.
What do we need to bear in mind when doing health promotion?
- We need to be evidence based – please don’t promote the newest raw food diet (that is not peer reviewed or evidence based) because you think it has worked for you. Hearing it on Radio 4 does not qualify your advice as evidence-based.
- We need to be realistic about what advice and changes we think people can make
- We need to take account of where child, parent and family are and what choices they can actually make. (ie budget of family and food choices)
Stop preaching and start working with families:
With the above comments in mind, what can we confidently help support people to do? There are a number of things we can help with that are proven to help support and prevent mental and physical health problems. These are:
- Sleep – how often do we ask about this in consultations?
- Exercise – great as a preventer of obesity and mental health problems, treatment for MH issues has less robust evidence
- Social contact – this can be online but beware this is different in nature than social contact in person
- Avoiding obesity – current messages around healthy eating have become very complex and difficult to navigate for most people
This must be balanced against situation and constraints on people’s choices:
- Poverty (separate bedrooms and adjusting bedtimes might be tricky in a bedsit)
- Illness and disability in parents and other family members (bringing up children in the most positive way demands physical and mental energy)
- Built environment and Safety (is the local park safe?)
For example, 2 neighbouring London boroughs have starkly different obesity rates – Camberwell is 30%, Dulwich village is 10%. This is more than worse food choices of the Camberwell residents!
So how do you do health promotion without patronising people?
- Think about what my attitudes are:
Our personal opinions come across far more easily than we think. The language we use and our attitudes are vital to how well we achieve our aims in patient and parent communication. That’s why having a basic understanding of the principles of social medicine can be revelatory and hugely impactful to the way we deliver healthcare to our patients because it can fundamentally change attitudes. It involves respecting people for the life choices they have made in the circumstances they made them in, whether you think you’d have done the same or not.
We can’t put it better than Greg Boyle, a priest from LA: “What we need in this world is a compassion that stands in awe of the burdens that the poor have to carry rather than stands in judgement at the way they carry them.”
- Actively Listen:
Again, listen. What is being said? Not just by words, but by inflection, body language, emphasis and what they are showing and telling you is their concern. It may not fit with your own agenda, but their real worries are going to have a much bigger impact on health behaviour than anything you say and it therefore needs addressing.
- Keep it simple:
Simple messages and supporting things that are easy to change are going to be more effective. The ratio of questions to advice giving should be heavily weighted to gaining information from your patient and helping them come up with their own solutions.
- Work at the level the family is at, not at your own
Similar to looking at your attitudes, but more focused on the individual needs of the family in front of you, what they are coping with and what their current needs and priorities are. If the letter for housing is more important than attending for the blood test to them, don’t delay the letter to housing. Maybe do telephone follow-ups, check in with how it is going, let them know you are there and help them find appropriate support if you don’t think that’s you.
- Know your community
Rather than give non-specific and generic ‘helpful’ advice, think about what the family can really do locally. What services are available – do you know about them? Who else can help – health visitors, GPs, education staff, early years support. What do you have?
Invite people in to discuss things, go visit them, see a community centre, go to the group meeting. Make connections, make friends.
- Don’t forget third parties
We know people feel nervous recommending charities or services they don’t know, so get to know them. Remember that people can make their own minds up about whether or not they want to get involved, there is no rule that they have to follow your advice, but be aware that people can take what you say seriously, and often literally. It’s a balance, but knowing what else is available locally – exercise groups, community centres, mental health charities, support groups, specific condition charities all do wonderful and supportive work for CYP and families that extend far beyond healthcare needs and provisions.
- Finally, don’t work in a silo
It can be really easy to think that the hospital, clinic or doctor is the centre of the important part of the world – it is not. It is a small, small part in a very complex world. Be humble and remember your part may have significant consequences (good and bad) and you can do wonderful things, but we are not superheroes and lots of others also do remarkable work and can have a bigger impact.
Tools that can help:
- HEEADSSSSS – Home, Education/Employment, Eating, Activities, Drugs and alcohol, Sex, Safety, Social media, Suicide and Sleep
- Motivational interviewing – (Royal college of nursing)
- Conversation inviting change (John Launer) or similar concept
- Understanding more about self harm – #noharmdone videos on youtube
- Bioechogram (Tamhne & Blair 2002) – see figure 1 for use with families in clinic
- Anna Freud website for apps, internet resources, self-mental-health-help and local services.
Doing health promotion:
- The Role of paediatricians in Public Health – L Weil, C Lemer, R Cheung – education and practice 2016 101:181-186
- Promoting children’s health – Mitch Blair, Paediatrics and Child Health, 2010 20;4:174-178 ))
Public health data for local areas (explore this with your team – its fascinating to know what the real local issues are)
- England: https://fingertips.phe.org.uk/
- Scotland: https://scotland.shinyapps.io/ScotPHO_profiles_tool/
- Wales: http://www.publichealthwalesobservatory.wales.nhs.uk/home
- Northern Ireland: https://www.publichealth.hscni.net/directorates
Inspirational work in less than 20 minutes!
Atul Gawande – curiosity piece in New Yorker June 2018
Rishi Manchanda – Upstreamism TED talk
Michael Marmot – key note address at the Kings Fund 2017
One final thought
If all of the above hasn’t convinced you, we leave you with this. We are all in need of services at some point in our lives. The children and young people we are seeing and treating today are the taxpayer, voters and professionals of the future. They will decide our future when we’re old and require care ourselves. By extending our reach into ‘health promotion’ we are helping not only them, but our future selves too. If our young people can’t stay healthy, build relationships, gain qualifications and support themselves to work, we all miss out.
This article is based on a RCPCH webinar of the same name. You can find it here.