Smoking, poor nutrition, alcohol abuse and physical inactivity are related to chronic diseases like heart and vascular disease, diabetes type II, Chronic Obstructive Pulmonary Disease (COPD), certain cancers and hypertension [1
]. Changes in lifestyle, such as increased exercise, improved diet, lower alcohol consumption and non smoking can therefore improve overall health [3
] and subjective well-being [4
]. Governments and health service providers in many countries in the Western world recognize that advice on lifestyle risk factors is essential in the prevention of (chronic) diseases and the improvement of public health [5
]. Especially in recent years there is greater awareness of improving lifestyle behaviour [6
]. For example, in the Netherlands the government has developed a prevention bill, aimed at reducing the incidence of smoking, alcohol abuse, obesity, diabetes (type II) and depression [8
General practitioners (GPs) play an important role in discussing lifestyle factors with their patients. Yet, previous research indicates room for improvement in both the frequency and quality of lifestyle advice given [10
]. Common barriers for GPs to give advice about lifestyle are lack of confidence in its efficacy as well as a lack of time and financial incentives [12
GPs tend to provide lifestyle advice mainly to patients who are at high risk or already have symptoms of certain diseases. A population approach, discussing lifestyle behaviour as a routine procedure, seems less common according to Swedish and UK research [14
]. However, it is possible that these research findings do not apply to the situation in Dutch general practice, due to differences in health care systems and in policy on lifestyle behaviour. Furthermore, giving lifestyle advice to the patient is not within GP's task perception; GPs found it less relevant and appropriate than illness management [16
]. Recent developments, such as the expected introduction of a prevention consultation and the use of practice nurses in primary care may generate a more pivotal and responsible position for the GP (and practice nurses) regarding patients' lifestyle behaviour [17
]. The increasing prevalence of chronic diseases and the growing understanding that lifestyle behaviour plays an essential role in improving overall health [7
] suggest a need for increased attention to lifestyle choices in the consulting room.
Unhealthy lifestyle behaviour clusters in certain groups. It has a higher prevalence in lower socio-economic groups [11
], and there are indications that it is age and gender-dependent. A previous study showed that male patients from the age of 50 had a healthier lifestyle and their behaviour changes were of more significance than male patients aged between 30 and 49 [20
]. Another study found a higher prevalence of alcohol use, smoking and lower physical activity among male patients [21
]. It is not clear whether GPs adapt the discussion of lifestyle behaviour to specific patient groups.
To explore whether or not healthy and unhealthy lifestyle is being discussed more often in recent primary care consultations, we analysed consultations between GPs and patients in the Netherlands recorded on video between 1975 and 2008.
In addition, we are interested in the kind of approach (population, high risk or symptom approach) taken by GPs in relation to lifestyle behaviour, whether a GP's approach to lifestyle behaviour changes over time and whether GPs adapt the discussion of lifestyle behaviour to specific patient groups. Three approaches were defined, based on a combination of literature findings [14
] and our insights: 1. 'Population approach', GPs discuss lifestyle behaviour with all patients; 2. 'High risk approach', discussing lifestyle only with patients with (risk of) chronic diseases; and 3. 'Symptom approach', discussing lifestyle behaviour when it is relevant to the patient's presented symptom, without the patient being at high risk or having a chronic disease (for example asking about smoking habits if the patient is coughing).
To sum up, our research questions are:
1. How often is healthy and unhealthy behaviour of the patient (smoking, nutrition, alcohol consumption, and physical activity) discussed in GP consultations?
2. Has the frequency of discussing lifestyle during GP consultations changed over time?
3. Who takes the initiative (GP or patient) to discuss the patient's lifestyle behaviour? Has the initiative to discuss lifestyle behaviour changed over time?
4. What symptoms do patients show when lifestyle behaviour is discussed and to what extent do GPs use a 'population approach', 'high risk approach' or 'symptom approach' to discuss lifestyle behaviour? Has GPs' approach to discussing lifestyle behaviour changed over time?
5. Is lifestyle behaviour discussed more (or less) with certain patients during primary care consultations; depending on educational background, age group and/or gender?