Screening and prevention

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chapter 13 Screening and prevention

INTRODUCTION AND OVERVIEW

Although the healthcare system still tends to undervalue and under-fund preventive medicine and health promotion, there has nevertheless been a growing recognition of the need to undertake preventive activities and screening within primary healthcare. General practitioners are well placed to be at the forefront of these activities because of their long-term and regular contact with patients and families, providing avenues for both opportunistic and structured approaches.

Preventive and screening activities require informed, disciplined and motivated patients as well as doctors. It also requires the support of reliable systems for recording data and sending reminders. Respective colleges in Australia through the RACGP,¹ and in the United Kingdom, United States and many other countries, along with the World Health Organization,² have actively reviewed evidence and made recommendations for best practice in screening and preventive activities. This chapter attempts to distill some of the key points raised by these recommendations.

PREVENTION

There are three main levels of prevention.

• Primary—the aim is to prevent an illness before it has got under way, such as through the promotion of healthy lifestyle and nutrition to prevent bowel cancer. Here the cost/benefit ratio tends to be most favourable but it can be difficult to motivate patients who are still ‘well’ to make the changes required to prevent an illness many years hence. Here the side effects of lifestyle change are beneficial.

• Secondary—the aim is to identify an illness early in its development before it has caused significant symptoms and while it is still reversible, such as the early detection of bowel cancer with faecal occult blood measurement or colonoscopy. This is where most funding for prevention and screening is directed within the healthcare system.

• Tertiary—here the condition is well under way and causing symptoms. Now the aim is to prevent further recurrence and complications through more radical treatments, such as for advanced bowel cancer. Here the cost/benefit ratio is least favourable and the side effects of treatment can be considerable.

PATIENT EDUCATION

Helping patients to make healthy change in their lives is one aspect of clinical medicine that requires as much art as science. Factors that enhance this process include:³

• health literacy and making sure the message is appropriate to the patient’s education level, language skills and cultural background

• the doctor–patient relationship, which is based on trust and mutual agreement

• provision of enabling strategies such as stress management, goal setting, the cycle of change and behavioural strategies (see Ch 7, Behaviour change, for more details)

• communication skills and methods such as a face-to-face delivery, providing the opportunity to ask questions, reinforcing key messages, using motivational interviewing skills and clarifying concerns and misconceptions

• consideration of the costs and benefits for changing or not changing the given behaviour

• individualising advice to better manage the behavioural enhancers and barriers

• managing relapse and reframing it as a learning opportunity rather than a failure

• the use of decision aids and reading materials such as patient education sheets.

SCREENING

Screening, whether through physical examination (e.g. blood pressure, random blood glucose) or special tests (e.g. mammography, colonoscopy), is the mainstay of preventive activities within general practice. Which tests to order, how often to perform them and for whom—and whether to order them at all—are far from clear-cut. Guidelines often shift with each new study that comes out, making decisions difficult for clinicians and patients.

Research must determine whether there are significant gains to be made that outweigh the costs to the patient and community in terms of time, emotional and physical discomfort, side effects and monetary expense, before a test can be widely recommended and funded. These issues may also need to be addressed with an individual patient in order for them to have a positive attitude to screening activities. In other words, the case for screening needs to be made—it should not be assumed that a patient will wish to follow guidelines just because they are there.

The WHO recommends that for a screening activity to be widely taken up, it should be identifying important health conditions (i.e. common, disabling and/or life-threatening) where there is a window of opportunity between latency and clinical manifestation. The test should be simple, as uninvasive as possible, safe, accurate and supported by evidence. Treatment for the health condition should be available and have been demonstrated to have a beneficial outcome. The outcomes should be of benefit in terms of morbidity or mortality, the benefits should outweigh the side effects and it should be cost-effective.

There are many shades of grey in answering these questions and in deciding who, where and when people are screened. Ultimately, it is the patient who will make their own informed choice as to whether to accept the guidelines or their doctor’s advice, and so although guidelines are useful, they will need to be individualised for each patient. A very anxious patient, for example, may be a candidate for screening at an earlier age than someone less anxious. Furthermore, guidelines may vary between various groups in the community (e.g. taking into account the relevance of ethnic background or socioeconomic status) as to who may be at greater or lesser risk.

Specific recommendations on screening for various conditions in children and adults are given in the charts in Guidelines for Preventive Activities Over the Lifecycle, which can be downloaded and/or printed for use in the patient records (see the Resources list at the end of this chapter). The charts provide an excellent summary that can be used to help to keep track of which examinations and tests have been done and what the key findings were. Further details regarding each of these activities can also be explored on the RACGP Red Book (page numbers are given on the charts), which can also be downloaded and/or printed.

ISSUES IN PREVENTION AND SCREENING

This section comments on some specific issues in relation to particular conditions or patient groups. Other chapters also have content on this topic—see, for example, the chapters on sexual health (Ch 61), cardiovascular disease (Ch 25), diabetes (Ch 26), cancer (Ch 24) and psychiatry and psychology (Ch 40).

PREGNANCY

Apart from the usual medical care and attention to gynaecological history, a number of factors need attention prior to and during pregnancy. These include:

• history of previous pregnancies, past medical history, blood pressure, blood glucose level, BMI, periodontal disease, thyroid function, family history of genetic illnesses

• vaccinations (e.g. varicella, hepatitis B, diphtheria/tetanus/pertussis, rubella, measles, mumps); other immunisation screening

• folic acid—an adequate intake from diet and supplementation (0.5 mg daily) at least a month before planned pregnancy

• healthy weight—achieve and maintain a healthy weight range prior to conception

• healthy diet—a nutritionally rich diet based on whole foods and including sources of omega-3 fatty acids, iron and essential vitamins and minerals; a discussion about a pre-conception multivitamin and mineral supplement is advisable

• regular, moderate, aerobic physical exercise, and specific exercises aimed at flexibility and relaxation

• adequate vitamin D—regular, moderate sunlight, and vitamin D supplements if vitamin D deficient

• good mental health—poor mental health and chronic stress can both affect fetal development as well as maternal wellbeing

• social and emotional support, and an exploration of parenting philosophies

• avoiding cigarettes and alcohol altogether during pregnancy

• avoiding environmental exposure to infections such as toxoplasmosis (sources include garden soil, uncooked meat, unpasteurised milk), cytomegalovirus (CMV sources include dirty hands, soiled nappies; risk for healthcare workers) and listeriosis (sources include pâté, soft cheeses, delicatessen meats, chilled seafood)

• (consider) taking a regular supplement of omega-3 fatty acids, especially so for women choosing to avoid seafood during pregnancy

• avoiding unnecessary medications and over-the-counter preparations; if any are taken, ensure they are safe during pregnancy.

CHILDREN

The health and development of children is exquisitely affected by the family as well as the educational, cultural and environmental milieu within which the child is raised. The prevention or management of illnesses in children should therefore never be in isolation from these factors, particularly parenting and schooling. If parents, particularly mothers, are at risk, then children are at risk. Preventive issues therefore involve:

• parental education and support, including:

• screening mothers for postnatal depression, and both parents for substance abuse

• screening for neglect or mistreatment—the presence or absence of local laws on the mandatory reporting of such problems need to be considered

• provision of advice, particularly for first-time mothers, on accident and injury prevention, especially for young children (e.g. stair guards, fire alarms, electric socket protectors, fire guards, safe storage of poisons and medications, water safety and monitoring, car safety and appropriate car restraints, bike helmets and safety in the kitchen)

• keeping up to date with immunisations

• according to the skin type, time of year and environment, following guidelines on safe sun exposure, taking care to avoid inadequate sun exposure as well as sunburn or excessive sun exposure

• weight and nutritional management:

• educating the parents as well as the children, especially when parents are overweight

• promoting breastfeeding

• promoting daily physical activity and recommending limiting ‘screen time’ (television and computer) during leisure time to 2 hours per day

• promoting a nutritious whole-food diet (everyday foods) and limiting empty calories, fast food and processed food (sometimes foods)

• preferring water to sweet soft-drinks

• following growth charts, BMI and pattern of fat distribution

• promoting spending meal times with the family as a very important part of enhancing connectedness

• encouraging good dental care

• regular vision and hearing assessments, especially in early childhood and school years

• being on the lookout for emerging behavioural problems—attention deficit disorder is also often used as a coverall for behavioural and family problems

• as a child gets older, providing education about avoidance of substance abuse or considering harm minimisation where necessary

• encouraging healthy ‘food for the mind’ as much as healthy food for the body

• developing coping and stress management skills from an early age

• developing regular and healthy sleep patterns.

GENETIC COUNSELLING AND TESTING

Current recommendations largely focus on targeted screening of at-risk individuals based on a detailed family history, association with the early onset of chronic illnesses, or illnesses within a family when they are at a far higher rate than would be expected (e.g. breast or colon cancer) in the general community. Other indications include birth-related health problems, intellectual disability, multiple stillbirths or congenital abnormalities. Genetic conditions common enough to be seen on a semi-regular basis in the primary care setting include cystic fibrosis, Down syndrome, haemachromotosis, thalassaemia and fragile-X syndrome. Where these conditions are suspected, reliable sources of information and specialist opinion should be consulted in order to confirm the diagnosis and direct treatment.

MIDDLE AGE AND OLD AGE

The preventive and screening issues for these age groups are well covered in the RACGP lifecycle chart for adults (see Resources list). The aim should be to add not just years to life, but also quality to those years. In order for people to take the time to engage in preventive activities during young adulthood and middle age—which is often the busiest time in a person’s life because of work and family commitments—it is important for regular encouragement and reminders to be given, particularly for men, who are far more likely to avoid self-care and health maintenance. Particular issues for men and women are covered in the chapters on men’s health (chs 48–50 ch 49 ch 50), and women’s health (chs 51–53 ch 52 ch 53).

For the elderly, isolation and lack of mobility can be significant impediments to taking up preventive opportunities. Polypharmacy is also a major source of iatrogenic illness, and so review and rationalisation of medications should be a regular practice. Attitudes to ageing can also affect quality of life and the progression of chronic illnesses, and so positive attitudes to ageing should be cultivated from an early age.

INFECTIOUS DISEASES

Patterns of infectious and communicable disease vary from country to country, and laws on the notification of these diseases will also vary. Immunisation is obviously the most important preventive strategy available, although concerns arise for an increasing number of people as to which immunisations to have and how often they are really necessary. People with an interest in complementary medicine (CM) are more likely to have an anti-immunisation stance, although the great majority of people with an interest in CM do not have a negative attitude towards immunisation. This issue needs to be negotiated with each patient or parent. The most common reasons for failure of completion of immunisation schedules are system failure and patient/parent apathy or fear of adverse effects.

Doctors should be well-prepared with detailed information to address patients’ concerns, as many of them will have investigated the issue extensively for themselves. Local immunisation schedules should be consulted and a reliable system of patient reminders and recall put in place. In parallel with immunisation is the behavioural and lifestyle prevention of infectious diseases. For example, good mental health is also associated with a reduced risk of infections, as are regular physical exercise, healthy nutrition and being an optimal weight.

Vector avoidance is essential along with appropriate immunisation, in prevention of travel-associated infectious diseases.

CHRONIC DISEASE PREVENTION AND SELF-MANAGEMENT

The SNAP (smoking, nutrition, alcohol and physical activity) guidelines ⁴ are a good starting point for the prevention and management of chronic illnesses. In this book, the ESSENCE Model (education, stress management, spirituality, exercise, nutrition, connectedness, environment) has been used and is more comprehensive because it includes environment, and psychological and social factors.⁵

The ‘5A’s approach’⁶ has been used in order to help streamline and systematise the assessment of various risk and protective factors.

• Ask—all patients about smoking, nutrition, alcohol or physical activity.

• Assess—the patient’s readiness to change, and dependence (smoking and alcohol).

• Advise—provide brief, non-judgmental advice with patient education materials (e.g. life scripts) and motivational interviewing.

• Assist—by providing motivational counselling and a prescription (life script or pharmacotherapy if indicated for nicotine or alcohol dependence).

• Arrange—referral to telephone support services, group lifestyle programs or an individual provider (e.g. dietician or exercise physiologist) and a regular follow-up visit.

In considering the prevention or management of any particular chronic condition, the relevant chapters of this book should be consulted.

American Academy of Family Physicians, guidelines on prevention. http://www.aafp.org/online/en/home/clinical/exam.html.

Royal Australia College of General Practitioners (RACGP, Melbourne), guidelines for preventive activities in general practice. http://www.racgp.org.au/guidelines/redbook.

UK National Health Services, UK National Screening Committee. http://www.nsc.nhs.uk/index.htm.

World Health Organization. Screening for various cancers. http://www.who.int/cancer/detection/variouscancer/en/.

1 Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. Melbourne: RACGP; 2009. Online. Available: http://www.racgp.org.au/guidelines/redbook.

2 World Health Organization. Screening for various cancers. Geneva: WHO; 2005. Online. Available: http://www.who.int/cancer/detection/variouscancer/en/.

3 Mullen P, Simons-Morton DG, Ramirez G, et al. A meta-analysis of trials evaluating patient education and counselling for three groups of preventive health behaviours. Patient Educ Couns. 1997;32(3):159-173.

4 Royal Australian College of General Practitioners. Smoking, nutrition, alcohol and physical activity: a population health guide to behavioural risk factors for general practices. Melbourne: RACGP, 2004.

5 Hassed C. The Essence of health: the seven pillars of wellbeing. Sydney: Random House, 2008.

6 Cited in the RACGP ‘Red book’ (see reference 1): Dolan M, Mullen P, Simons-Morton DG et al. A meta-analysis of trials evaluating patient education and counselling for three groups of preventive health behaviours. Cochrane Database Syst Rev 1997.

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