Domain 3 Population health and the context of general practice

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Population health considers how to improve the wellbeing of a group, not just the individual. With 85% of the Australian population seeing a general practitioner (GP) at least once a year,1 GPs are well placed to have a wide impact on healthcare for both individuals and communities. Health promotion enables people to have control over the factors that influence their health, and involves activities that support healthy behaviours, environments and health literacy.2

Preventive health aims to prevent disease or mitigate its impact.3 Primary prevention aims to prevent disease before it happens through measures, including health promotion, vaccination programs and the use of preventive medications, such as chemoprevention of cancers.3–5

Secondary prevention aims to minimise the impact of existing disease. This includes screening to reduce morbidity and mortality through early detection.3,6 Patients might be able to undertake these programs directly, such as bowel cancer screening,6 but GPs still have an important role in encouraging uptake. Other programs operate primarily in the general practice setting, including cervical screening tests.6 Screening programs are not without harms; these include overdiagnosis, health anxiety and complications of testing procedures.1 It is important that GPs understand the specific patient groups for which the benefits of screening have been shown to outweigh the harms. Other examples of secondary prevention include medications after an illness to prevent recurrence, such as aspirin after acute coronary syndromes,7 or antibiotic prophylaxis for rheumatic fever.8 Later stages of preventive care include tertiary and quaternary prevention, which aim to reduce levels of impairment from disease and reduce the impacts of harms from treatment.3

Patients might not present for preventive health advice, so it is important that GPs are proactive in identifying opportunities for health promotion according to Australian general practice guidelines.3 Common areas for promotion include advice on smoking, nutrition, alcohol and physical activity (known collectively as ‘SNAP’).9 Current data show that one in seven Australian adults smoke daily.10 More than half of Australian adults do not meet physical activity guidelines, and most people do not eat the recommended amounts of fruits and vegetables.10 Preventive health is also important for children, with one in four children being overweight or obese, while two in three children do not meet physical activity guidelines.10 There is a strong evidence for brief interventions under three minutes for smoking cessation, which can be conducted even during a short patient encounter.11 Assessing readiness for change and motivational interviewing are other techniques that can be used in this space.12

Social determinants of health are factors outside of medicine that influence population and account for 30–55% of health outcomes.13 These include housing, education, environment, income and social inclusion. Some population groups also experience disparities in access to healthcare and health outcomes. This includes patients experiencing socioeconomic disadvantage, Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds and rural and remote populations. GPs should be aware of recommendations for preventive health for specific populations, such as the National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people.14 GPs have an important role in their community to advocate for access to healthcare and improvements in the social determinants of health.

Population health also includes the detection and management of public health risks, including communicable disease outbreaks, such as the COVID-19 pandemic. As frontline health workers, it is important that GPs can recognise transmissible and potentially reportable disease.15 There are nationally notifiable diseases, as well as specific lists in each state and territory.16 Advice about time out from school and workplaces is important to prevent spread of infectious diseases within the community.17 GPs might also be involved in contact tracing related to infectious disease, such as for sexually transmissible infections.18 This includes an awareness of professional, legal and ethical principles for managing sensitive information and mandatory reporting requirements.

Climate change is an emerging public health risk that poses a significant and urgent threat.19 This will present new direct and indirect challenges for many groups, including an increase in morbidity and mortality from higher temperatures, as well as groups who live in areas at risk of worsening natural disasters as a result of climate change.19 It is important for GPs to understand their role in identifying, reducing and managing adverse health effects of climate change on Australians.19 GPs also have an important role in addressing sustainability within their own practices, as well as being advocates within the community for broader mitigation strategies.20

References
  1. The Royal Australian College of General Practitioners. White book. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2021 [Accessed 29 September 2021].
  2. World Health Organization. Health promotion. Geneva: WHO 2021 [Accessed 29 September 2021].
  3. The Royal Australian College of General Practitioners. Green book. Putting prevention into practice: Guidelines for the implementation of prevention in the general practice setting. 3rd edn. East Melbourne, Vic: RACGP, 2018 [Accessed 29 September 2021].
  4. Australian Government Department of Health. National Immunisation Program Schedule. Canberra, ACT: Department of Health, 2021 [Accessed 29 September 2021].
  5. Emery J, Nguyen P, Minshall J, Cummings KL, Walker J. Chemoprevention: A new concept for cancer prevention in primary care. Aust J Gen Pract 2018;47(12):825–28. doi: 10.31128/AJGP-07-18-4644.
  6. Australian Government Department of Health. Screening for cancer. Canberra. ACT: Department of Health, 2021 [Accessed 29 September 2021].
  7. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand. Australian clinical guidelines for the management of acute coronary syndromes 2016. Melbourne, Vic: National Heart Foundation of Australia, 2016 [Accessed 29 September 2021].
  8. RHD Australia. The 2020 Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (3rd edn). Darwin, NT: RHD Australia, 2020 [Accessed 29 September 2021].
  9. The Royal Australian College of General Practitioners. Smoking, nutrition, alcohol, physical activity (SNAP): A population health guide to behavioural risk factors in general practice. 2nd edn. East Melbourne, VIC: RACGP, 2015 [Accessed 29 September 2021].
  10. Australian Government Department of Health. About preventive health in Australia. Canberra, ACT: Department of Health, 2021 [Accessed 29 September 2021].
  11. The Royal Australian College of General Practitioners. Supporting smoking cessation: A guide for health professionals. 2nd edn. East Melbourne, Vic: RACGP, 2014 [Accessed 29 September 2021].
  12. Hall K, Gibbie T, Lubman DI. Motivational interviewing techniques: Facilitating behaviour change in the general practice setting. Aust Fam Physician 2021;41(6):660–67.
  13. World Health Organization. Social determinants of health. Geneva: WHO, 2021 [Accessed 29 September 2021].
  14. National Aboriginal Community Controlled Health Organisation & the Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 3rd edn. East Melbourne, Vic: RACGP, 2018 [Accessed 29 September 2021].
  15. Ward JE. Communicable disease outbreaks: What is a case? Aust J Gen Pract 2020;49. doi: 10.31128/AJGP-COVID-24.
  16. Australian Government Department of Health. Australian national notifiable diseases and case definitions. Canberra, ACT: Department of Health 2021 [Accessed 29 September 2021].
  17. healthdirect. School exclusion for health reasons. Haymarket, NSW: healthdirect, 2020 [Accessed 29 September 2021].
  18. Ward JE. Communicable disease outbreaks: Contact tracing. Aust J Gen Pract 2020;49. doi: 10.31128/AJGP-COVID-26.
  19. The Royal Australian College of General Practitioners. The impact of climate change on human health. East Melbourne, Vic: RACGP, 2019 [Accessed 29 September 2021].
  20. Pendrey CGA, Beaton L, Kneebone JA. General practice in the era of planetary health: Responding to the climate health emergency. Aust J Gen Pract 2020;49(8):520–23. doi: 10.31128/AJGP-01-20-5207.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP. These are expressed as core competencies that are required of a GP across all clinical consultations, interactions and contexts. These core competencies are further detailed as measurable core competency outcomes.

Population health and the context of general practice 
Core competencies Core competency outcomes
  The GP is able to: 
  1. GPs practise in a sustainable and accountable manner to support the environment, their community and the Australian healthcare system
  1. incorporate epidemiology into screening and management practices
  2. utilise shared resources in a sustainable manner (acknowledging that resources will always be finite)
  3. manage current and emerging public health risks effectively
  4. engage in public health and health promotion activities (to promote health in the local community)
  1. GPs advocate for the needs of their community
  1. describe the barriers to health equity in Australia (in the context of general practice)
  2. undertake the necessary action(s) to bring about positive change for patients (and community)
  3. explain how social and environmental determinants impact health (in their community)
  4. advocate to remove the health inequities that exist between various groups within the community

Aboriginal and Torres Strait Islander health
  1. identify and promote ways to achieve health equity for Aboriginal and Torres Strait Islander people
  2. identify and promote social, environmental and cultural determinants of health in the local community
Rural health
  1. advocate for equitable access to appropriate services for rural and remote communities

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. People might not come to see you just for a health check or preventive health advice. Prevention can be opportunistically included in many types of consultations.
  2. Remember, preventive health is a lifelong process; you don’t need to cover everything in one consultation. Try not to overload the patient with too much health advice in a single consultation. It is also important to empower and assist patients in sharing responsibility for their preventive health needs.
  3. Vaccine hesitancy occurs on a spectrum. Address the individual’s concerns about vaccination; be non-judgemental and open to continuing the discussion if a patient is still unsure.
  4. Evidence is always evolving. It is more important to be able to rapidly find and evaluate the information you need, rather than to memorise everything.
  5. Social determinants of health have a significant impact on a patient’s health status. Always discuss the patient’s social situation. Know local social services in your area to refer patients to for assistance.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Domain 3 Population health and the context of general practice

Sam is a 35-year-old woman who presents for her annual influenza vaccination. She is feeling well. You note on her medical record that Sam smokes 10 cigarettes per day and has a family history of breast cancer. Her last cervical screen at your practice was six years ago. She doesn’t attend the practice regularly and you think about what preventive health measures you might be able to discuss opportunistically.

Questions for you to consider Clinical exam assessment area Domains

What communication techniques could you use to talk to Sam about smoking cessation?

How might your communication be different in a telehealth consultation compared with face to face? How might it be different in a consultation using an interpreter?

How would you explain the concept of risk to Sam?

  1. Communication and consultation skills
1,2,5
 

What other history do you need to assess Sam’s risk of breast cancer? 

What resources would help you recommend evidence-based screening tests for Sam?

What questions would you ask to take a history of lifestyle risk factors?

  1. Clinical information gathering and interpretation
2   

What does Sam’s family history of breast cancer mean for screening and prevention? How would this be different if she were 45 years old?

Should a cardiovascular risk assessment be performed for Sam? What if she were Aboriginal or Torres Strait Islander?

  1. Making a diagnosis, decision making and reasoning
2   

What preventive health measures could you offer Sam today? How would you prioritise them?

What preventive health measures would you discuss if Sam were pregnant?

What are the differences in how you would investigate a patient with breast cancer symptoms compared with screening?

If Sam’s cervical screening revealed high-grade cellular change, how would you involve other health professionals in her care? What if she lived in a rural community and needed to travel for treatment?

  1. Clinical management and therapeutic reasoning
2   

How would you work with Sam to develop shared health goals?

Sam says that many people in her family and local community also smoke. What strategies could you use to address this at a community level?

  1. Preventive and population health
1,2,3      

 

As part of her health check, Sam tests positive for a notifiable disease. How would you explain to her the processes of notification and contact tracing? What considerations would there be for managing confidentiality in a rural community?

  1. Professionalism
4   

How might you use practice software to set recalls for future health screening? If you were going on leave, how would you ensure Sam’s test results are checked and followed up appropriately?

How might you audit your practice population to identify other patients who are overdue for cervical screening?

If Sam reported having a cervical screening test interstate recently, how could you obtain the result?

  1. General practice systems and regulatory requirement
5   

How do you prepare, administer and record vaccines in your practice? How would you manage and report any adverse events following vaccination?

How do you perform a cervical screening test? What measures would you have in place to ensure patient comfort and privacy?

  1. Procedural skills
2   

How would you manage the consultation if Sam told you she isn’t sure that she wants to participate in health screening?

  1. Managing uncertainty
2   

What serious illnesses might be detected from routine health checks?

How would you manage positive screening for a serious illness? What if you were in a remote location?

  1. Identifying and managing the significantly ill patient

     

2   

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Find and review the National Immunisation Program Schedule for your state or territory. Learn about vaccine-preventable diseases and think about how you would explain to a patient what each vaccine is for.

  • Are there any additional vaccines recommended in your state or territory? Where would you find this information?
  • What about schedules for catch-ups or additional vaccinations for special groups, for example, new arrivals to Australia, immunocompromised patients or Aboriginal and Torres Strait Islander people?
  • What additional vaccines could be available privately? When are they indicated?

Do a case analysis of a patient you have seen recently for a prescription renewal.

  • Did you discuss any preventive health in the consultation? Were there any issues you could have discussed opportunistically?
  • Check if the patient is up to date with their health screening and vaccinations. Consider what you might want to discuss if the patient returns for another consultation.
With a supervisor
Role-play a consultation with a vaccine-hesitant patient.
  • Try out different strategies for discussing the risks and benefits of vaccination. Provide education about the diseases each vaccination is for.
  • How would you find reliable patient information and handouts?
  • What advice does your supervisor have? 

Discuss your clinic processes for identifying patients recommended for health screening.

  • How can recall systems help? How are patients contacted with reminders?
  • What audits could you do to assess if the practice population is up to date with health screening?
  • How are results managed if the requesting doctor is away?

Ask your supervisor about how they include preventive health in their consultations. If you have the opportunity, talk to others in your practice about their approach to preventive health and compare their different approaches and communication styles.

  • Discuss how your supervisor adapts their communication style to engage different patient groups. How do they tailor their communication style to the individual?
In a small group

Role-play talking to a patient about improvements they could make to their lifestyle and behaviour. Swap roles. Have different members of the group try out different models and techniques, for example, brief intervention or motivational interviewing.

  • Discuss what techniques were more effective.
  • How might communication need to be modified for different patient groups?

Run a journal club in your group and have each person select a research article to discuss.

  • Identify the research question and whether the methodology was appropriate. Can you explain the epidemiological and research terms used in the article?
  • Consider if the article is relevant to your population and whether it changes your practice.

Research the health concerns in your local population or the health priorities for your practice. Have each member of the group run a teaching session on a different health issue. Run a presentation at your practice about the health issue.

  • Consider what your practice is currently doing for health promotion on your chosen issue, and how you might advocate for health promotion in your community.
  • What did you learn from your peers’ presentations?
With a friend or family member

Ask your friend or family member what they think might be an important health issue in their local community.

  • How does this compare with evidence about local health priorities?
  • How can you as a GP address their concerns?
  • How can you advocate within the community for health issues of concern to them? How can you involve community members in health advocacy?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Provide age-appropriate education and promote healthy behaviours specific to the individual on topics, including:
    • smoking
    • nutrition
    • alcohol and other drugs
    • physical activity.
  • Provide advice on health-promotion measures for individual circumstances across the lifespan. Consider the specific needs of population groups, including:
    • pregnant people
    • Aboriginal and Torres Strait Islander peoples
    • refugees and asylum seekers
    • culturally and linguistically diverse groups
    • LGBTIQ+ people  
    • people experiencing socioeconomic deprivation, including homelessness and unemployment
    • people with disabilities.
  • Assess and manage specific health risks in the individual, such as:
    • risk of developing chronic disease, including a mental health disorder
    • risk of infectious diseases
    • cancer risk
    • occupations with specific workplace exposures
    • risks arising from existing health conditions.
  • Use a range of communication strategies to encourage behaviour change, such as:
    • brief interventions
    • motivational interviewing.
  • Advise patients on evidence-based screening measures recommended for their individual circumstances, and appropriately explain the risks and benefits of screening tools.
  • Provide screening measures that occur in the general practice setting and refer patients to outside services when required.
  • Recommend, prescribe and administer appropriate vaccinations:
    • in accordance with the National Immunisation Program Schedule
    • for a patient newly arrived in Australia
    • for travel
    • for occupational health, for example, healthcare workers
    • for a patient eligible for additional vaccines available privately.
  • Manage potentially transmissible diseases by:
    • following practice policies and procedures, for example, using personal protective equipment, cleaning and patient flow
    • providing guidance to patients on reducing transmission to others, for example, hygiene and appropriate exclusion from school and work.
  • Use mandatory reporting mechanisms, for example, for notifiable diseases, adverse drug reactions and childhood immunisations.
  • Find information on local health concerns that might be relevant to your practice population.
  • Conduct practice audits to assess the health of the patient population and identify areas for improvement.
  • Advocate for measures in the local community to address social determinants of health, reduce inequality and improve access to healthcare.
  • Manage confidentiality of health information when conducting individual patient consultations and population health activities.
  • Use practice recall systems for health screening.
  • Understand and interpret commonly used research and epidemiological terms in journal articles relevant to general practice.
  • Demonstrate awareness of emerging population health concerns, including environmental health and climate change.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
Using motivational interviewing as a communication technique. Prevention strategies to manage the increased risk of cardiovascular disease in patients with severe mental illness.

Textbooks
Evaluating health evidence and interventions. 
  • Straus S, Glasziou P, Richardson WS, Haynes RB. Evidence-based medicine: How to practice and teach EBM. 5th edn. Edinburgh: Elsevier, 2018. (Available from the RACGP library.)
Online resources
Use this website to review the national notifiable diseases and those applicable to your own state or territory. Information about vaccine preventable diseases and recommended immunisations in Australia. Preventive activities for different patient groups. Recommended testing and screening for genetic diseases. The evidence-based components of a preventive health check for Aboriginal and Torres Strait Islander peoples.
Learning activities
  • The Royal Australian College of General Practitioners. gplearning:
    • Adult preventive care: Applying the RACGP Red book every day
    • Practical use of guidelines for preventive health in the general practice setting
    • check, unit 561, June 2019: Preventive health for Australia's First Peoples
    • How to provide culturally safe health checks and preventive health advice for Aboriginal and Torres Strait Islander people
    • check, unit 572, June 2020: Preventive health
    • Common scenarios in preventive health that arise in general practice
    • check, unit 576, October 2020: Environmental healthThe impacts of the environment on human health, including heat and climate change.
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/domain-3 27/09/2022