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Physical activity promotion in primary health care in Slovenia

Janet Djomba1, Sanja Vrbovšek1, Breda Čuš1
1 Department of Public Health, Faculty of Medicine Ljubljana/National Institute of Public Health of the Republic of Slovenia

Abstract

In Slovenia, the role of general practitioners in counselling physical activity for prevention of cardiovascular disease (CVD) is well recognized. The role of general practitioners in advising healthy lifestyle for individuals who are at risk of developing CVD is formally defined in the National Program for Primary Prevention of Cardiovascular Disease, which has been running since 2001. Part of the program is counselling on healthy lifestyle including physical activity, performed in all health centres across the country. First a screening and medical examination is performed. In case of higher risk for CVD (>20%) the physician should give advice on the particular risk factor and direct patients to health-education centres, where they can participate in healthy lifestyle workshops lead by health professionals. Physicians and other health professionals who are involved in the implementation of prevention activities within the program need knowledge and skills that are crucial for successful counselling on healthy lifestyle. The educational program “basic education in health promotion and prevention of chronic non-communicable diseases in primary health care/family medicine” consists of two parts. The first part of the training is open to all health professionals working within the
program. The second part is intended for health professionals working in health-education workshops. In the last few years a new family practice model has been introduced and disseminated. Some duties of the family physician, including health promotion and counselling, are being transferred to graduate nurses who become part of the family practice team. This new division of work undoubtedly brings many advantages, both in terms of the work organization, and of high-quality patient care. Nevertheless preventive action cannot be fully passed on to graduate nurses. Careful planning and education are needed to ensure a comprehensive approach in healthy life style counselling.

Zusammenfassung

Die Rolle der Hausärztinnen und Hausärzte bei der Bewegungsberatung zur Vorbeugung von Herzkreislaufkrankheiten ist in Slowenien gut etabliert. Das nationale Programm zur Primärprävention von kardiovaskulären Krankheiten aus dem Jahr 2001 definiert ihre Aufgaben bei der Lebensstilberatung von Personen mit erhöhtem Risiko. Dazu gehört die Beratung für einen gesunden Lebensstil inklusive Bewegungsverhalten, die in allen Gesundheitszentren des Landes angeboten wird. Dabei wird zuerst eine Screeninguntersuchung durchgeführt. Wird bei dieser das Risiko für eine Herzkreislaufkrankheit höher als 20% eingeschätzt, bieten Ärztinnen oder Ärzte eine Beratung bezüglich der spezifischen Risikofaktoren an und überweisen die Patienten an ein Gesundheitsförderungszentrum zu einem von qualifizierten Pflegefachpersonen angebotenen Lebensstil-Workshop. Ärztinnen, Ärzte sowie Vertreterinnen und Vertreter anderer Gesundheitsberufe, die an den Präventionsaktivitäten des Programms beteiligt sind, brauchen spezifische Kenntnisse und Fertigkeiten. Das Ausbildungsprogramm «Grundausbildung in Gesundheitsförderung und Prävention nichtübertragbarer Krankheiten in der medizinischen Grundversorgung» besteht aus zwei Teilen. Der erste Teil steht allen im Programm tätigen Gesundheitsberufen offen, der zweite den in den Lebensstil-Workshops involvierten Spezialisten. In den letzten Jahren wurde ein neues Grundversorgungsmodell eingeführt und verbreitet. Dabei werden einige Aufgaben von Hausärztin und Hausarzt, darunter Gesundheitsförderung und Beratung, an Diplom-Krankenschwestern als neue Mitglieder des Grundversorgungsteams übertragen. Diese neue Arbeitsteilung bringt verschiedene Vorteile mit sich, sowohl in organisatorischer als auch in qualitativer Hinsicht. Trotzdem kann die Präventionstätigkeit nicht gänzlich an die Pflegefachpersonen delegiert werden. Sorgfältige Planung und Ausbildung sind notwendig, um einen integrierten Ansatz in der Lebensstilberatung zu realisieren.

The tradition of health promotion in primary care

In Slovenia, health promotion in primary health care has a long tradition and the importance of family physicians in counselling physical activity for prevention of cardiovascular disease (CVD) is well recognized (Fraz 2002a, Fraz 2002b). The role of family physicians in advising healthy lifestyle for individuals who are at risk of developing CVD is formally defined in the National Program for Primary Prevention of Cardiovascular Disease (NPPPCVD), which has been running since 2001 (Fraz et al, 2009). The target population for the NPPPCVD are women aged 45–70 years and men aged 35–65 years. Individuals within those age groups are invited from their family medicine practice every five years to attend a preventive examination. The NPPPCVD consists of two major parts: screening for CVD risk and lifestyle intervention. First a screening and medical examination (physical examination, anthropometric measurements, laboratory tests) is performed to identify individuals at risk for CVD. In case of higher risk for CVD (>20%) the physician should give advice on the particular risk factor and direct patients to health-education centres, where they can participate in healthy lifestyle workshops (short introductory workshops and long workshops on healthy nutrition, physical activity, healthy weight loss and smoking cessation) led by health professionals. Workshops on physical activity are led by physiotherapists preferably. They consists of twelve meetings and includes demonstration and performing different kinds of exercise, continuous performance of selected exercise, motivation, individual assessment and management of potential barriers and evaluation of progress by the 2 km walk test performed and the beginning and the end of the workshop.
Family physicians working in the public primary health care system are obliged to carry out the screening process on their registered patients every five years. Screening for CVDs is a part of the work in family medicine practices therefore family physicians do not get additional payment for it. Workshops are performed in health education centres located in all community health centres in the country. Costs of the NPPPCVD, including screening, lifestyle interventions, national and regional coordination and maintenance of the register of people at risk for CVD, are covered by the National Health Insurance Institute. Screening, counselling and participation in healthy lifestyle workshops are free of charge for the patients.
The National Institute of Public Health (NIPH) coordinates the NPPPCVD on the national level, both the work of family physicians and the health education centres. The NIPH also carries out educational trainings for health professionals working in the program and reports to the insurance institute. Regional coordinators are responsible for coordination and communication on the local level and reporting to the national coordinator.

Current developments

Currently a new information system is being developed to assist and improve the patient’s treatment within the NPPPCVD. The new IT system will improve the quality of counselling, the communication between the physician and the health education centre and follow up of patients.
Physicians and other health professionals who are involved in the implementation of prevention activities within the NPPPCVD need knowledge and skills that are crucial for successful counselling on healthy lifestyle. Educational trainings are performed continuously to assure adequate knowledge of health professionals entering the NPPPCVD. The educational program “basic education in health promotion and prevention of chronic non-communicable diseases in primary health care/family medicine” consists of two parts. The first part of the training is open to all health professionals working within the program. Participants learn about risk factors for CVDs, health promotion, behaviour change theory etc. After the training participants are able to provide counselling on healthy lifestyle and risk factor management and to perform the introductory workshops. The second part is intended for health professionals working in health-education centres.
Participants learn how to lead, perform and organize the individual workshops (Cindi Slovenia 2014). Experience shows that after the first few years physicians don’t attend the trainings anymore.
In the last few years a new family practice model has been introduced and disseminated (Ministrstvo za zdravje Republike Slovenije 2014). There are two important changes regarding preventive activities. First, the screening is extended to other non-communicable chronic diseases as well and the age limit is lowered to 30 years for both sexes. Second, some duties of the family physician, including screening, counselling and health promotion, are transferred to graduate nurses. They become part of the family practice team to improve the treatment of chronic patients and perform preventive measures. All graduate nurses working in those model practices have to undergo an educational training which includes modules on treatment of patients with individual NCDs and preventive measures. The module on preventive measures is carried out by the NIPH. It includes basic information about lifestyle risk factors for NCDs, screening procedures for individual NCDs, behaviour change theory and training on counselling at individual risk factors. This new division of work undoubtedly brings many advantages, both in terms of the organization of work, as well as high-quality patient care. Nevertheless preventive action cannot be fully passed on to graduate nurses,
especially because most patients wish and expect advice on healthy lifestyle from their physician (Klemenc-Ketis et al., 2011).

Family physicians and physical activity counselling

Slovenian studies (Petek et al., 2013, Bulc 2006, Kersnik et al., 2009, Petek-Ster et al., 2007, Petek-Ster et al., 2005) have shown that the opinion of family physicians towards counselling on healthy lifestyle is positive. Counselling is more often provided focused on present risk factors, rather than healthy lifestyle advice to healthy individuals (Petek et al., 2013). The results of the latter study also showed that family physicians give advice on physical activity mostly as part of healthy lifestyle counselling in general.
Careful planning and education of all health professionals involved are needed to ensure a comprehensive approach in healthy life style counselling.

Corresponding author

Dr. med. Janet Klara Djomba
Katedra za javno zdravje
Medicinska fakulteta
Univerza v Ljubljani Zaloška cesta 4
SI-1000 Ljubljana, Slovenia
E-Mail: janet-klara.djomba@mf.uni-lj.si
Phone +386 1 543-75-46

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