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Green Book

Putting prevention into practice - Chapter 4.3

Receptivity (and engagement)

Guidelines for the implementation of prevention in the general practice setting
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  1. Figures and tables
  2. Green book video resources
  3. Provided under licence

Last revised: 01 May 2018

Key points

The PRACTICE framework:

  • Is useful when implementing preventive activities – it incorporates elements of several other theories and frameworks
  • Helps identify and overcome barriers to implementation (eg engagement, collaboration and systems)
  • Helps remind us that change is incremental and that we should plan for and recognise ‘small’ successes along the way.

The Green Book brings together two main themes: prevention and implementation.

Both of these sit within QI and are inherently associated with behaviour change.

Change is often more effective and efficient if a whole-of-practice approach is adopted. This means addressing receptivity to change and using strategies that promote engagement on all levels. This area is often overlooked.

Questions to ask include ‘Why consider changing?’ and ‘What’s in it for our patients and our practice?’ It is also important to consider:

  • how receptive and engaged your practice team will be to implementing new prevention activities
  • what preventive activities your practice population is likely to be receptive to.

Taking time to think about how you can address these within your practice can improve your chance of success.

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When considering preventive activities relating to overweight and obesity, there may be resistance because people feel they are being stigmatised. As a practice, we need to recognise this and address it. For example, consider using the word ‘weight’ rather than obesity.

– Prof Mark Harris, Green Book Editorial Committee
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General practice wellness and weight

The Stirling Central Health Clinic facilitates ‘Wellness and Weight’ groups for working adults aged 40–49 years with a BMI of >25 kg/m2. Six group sessions of approximately 10 participants are run over a number of weeks   and held after-hours. The group sessions focus on encouraging and enabling participants to identify and increase positive health activities rather than focusing solely on weight loss. Education is presented from a weight-inclusive perspective using positive language and includes presentations on mindful eating, positive body image, stress reduction, enjoyable activity versus ‘exercise’, and nutrition. Presenters include a clinical psychologist and dietician with a special interest in the management of obesity.

Participants develop and set SMART (Specific, Measurable, Assignable, Realistic, Time-related) program goals in conjunction with the PN, and outcomes are measured at three, six and 12 months. Measurements taken include BMI, blood pressure and bloods, as well as measurements of happiness and Depression, Anxiety and Stress Scale (DASS) score. Participants are also asked to identify healthy activities they would like to try and, where possible, one-off ‘try before you buy’ sessions are arranged in addition to the six sessions. Activities identified have included Pilates, a healthy cooking class and a screening of the documentary Embrace.

One of the most valuable outcomes has been the social support the participants find within the group setting, which helps them to continue their health-positive journey upon conclusion of the group sessions.

– Sally Jarrett, Practice Manager, Stirling Central Health Clinic
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Unless we understand the barriers that will arise, the process won’t be successful. We need to listen to the concerns of our team and offer explanations and solutions. For example, staff in a practice wanted to engage more in prevention, but felt they were lacking the staff to do so. Staff with the most appropriate expertise were identified and re-tasked.

– Assoc Prof John Litt, Green Book Editorial Committee

GPs, PNs and the practice team as a whole are more likely to be engaged in delivering preventive care if they believe it is beneficial and achievable.1–5 How you deliver preventive care also affects engagement (Table 3).6–10 Leadership is a key contributor to both engagement and capability for change. This can take a number of forms, including having ‘local champions’, facilitators and opinion leaders.11–17

Table 3. Improving general practice engagement in preventive care delivery

Table 3

Improving general practice engagement in preventive care delivery 

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An important motivator is seeing success. Lack of visible outcomes makes implementation of many prevention activities more problematic. We cannot know with certainty that our efforts have prevented the occurrence of an illness or disease in any individual. This is especially true for long-term outcomes. For example, advice about smoking is provided in the expectation that the patient will be less likely to get lung cancer or heart disease.

However, the patient may not feel any different (and may occasionally grieve for giving up something they enjoy), and the team may never see how their efforts affected the patient’s future.

A useful strategy is to select appropriate (observable or measurable) proxy measures of an outcome that may not be easy to measure (eg absolute cardiovascular risk as a marker of [reduced] risk for vascular disease). The prevention equivalent is to monitor the uptake of prevention activities (eg immunisation coverage) or, alternatively,the patient-reported behaviour (eg smoking status, alcohol consumption). This helps to ensure that all involved can see that something is being achieved. Providing meaningful feedback will require measurement of performance.

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Change is incremental.

To assist with engagement, it is often useful to have smaller targets along the way that you are working towards. One idea to make this visible and to keep everyone engaged is to make a wall chart in the staff area of your practice showing the progress you are making in your program.

– Dr Cory Lei, Green Book Editorial Committee
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We can take the SMART acronym18 used in project and business management when we look to make improvements:
S – Specific (target a specific area for improvement)
M – Measurable (have a quantity or an indicator of progress) A – Assignable (so that you can specify who will do it)
R – Realistic (goals should have achievable outcomes; they should also be ‘Relevant’ to your broader priorities)
T – Time-related (have clear time frames and deadlines)

– Dr Cory Lei, Green Book Editorial Committee
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