In total, we interviewed sixteen GPs and nine PNs of seventeen different practices. In four different regions we interviewed three GPs of different practices and one PN. In one region we interviewed four GPs and five PNs. The characteristics are illustrated in Table .
Characteristics of included GPs and PNs
The majority of the GPs and minority of the PNs worked fulltime and two thirds of the participants are women. Seventy-five GPs did not want to participate in this study due to a lack of time (N=68), lack of interest (N= 6) or pregnancy (N=1).
Health promotion activities in general practice
Table shows that all GPs said that they actively ask patients with lifestyle related symptoms about their lifestyles. Most GPs said they give patients lifestyle advice as well. The advise includes information about the consequences of their unhealthy lifestyle and stimulates awareness of the problem, motivation aspects and what healthy behaviour consists of. Moreover, the GP or PN try to find out why a patient has an unhealthy lifestyle.
Most often mentioned activities to promote a healthy lifestyle and of related patient groups
As one PN stated: “I discus what is healthy or accepted, and If a patient drinks too much I try to find out the underlying reason”.
If patients are motivated to change their behaviour, GPs and/or PNs give advice about the options how to change their unhealthy behaviour and try to help them. Most of the PNs said they use motivational interviewing. The information they provide is based on the national general practitioner guidelines.
Besides this, GPs or PNs said they refer patients to other disciplines, for instance, to the dietician, physiotherapist, psychologist or addiction care. As one GP expressed:
"‘I have to say, I give a referral quite easily to Iriszorg (addiction care). In the past I tried to counsel alcoholics myself, but it was very disappointing’."
Some of the GPs mentioned giving patients referrals to nationally disseminated health promotion programs. Others said they had referred patients to these programs in the past, but due to lack of proven effectiveness and reimbursements they stopped referring. Moreover, GPs expressed they prefer to offer health promotion programs in their own practice, especially exercise programs in collaboration with physiotherapists, instead of national programs outside their practice. They stated it is easier accessible and more familiar for patients.
The activities of the PNs are listed in Table as well. PNs reported they give lifestyle counselling to chronically ill patients in general practice, mainly to patients with diabetes, COPD and cardiovascular diseases. PNs actively ask these patients about their lifestyles and give them lifestyle advice. Furthermore, PNs said they give lifestyle counselling for patients who want to quit smoking.
Barriers and facilitators experienced by GPs and PNs
During the interviews, GPs and PNs mentioned 41 different barriers with respect to delivering health promotion activities in general practice (see Table ).
Barriers and facilitators for delivering health promotion activities
Firstly, GPs and PNs mentioned barriers regarding their patients: patients were not motivated to change their unhealthy lifestyles and deny and lie about their behaviour. Furthermore, some patients were said to not appreciate discussing their lifestyles and GPs and PNs stated that an unhealthy lifestyle is socially accepted, especially drinking alcohol.
Secondly, GPs and PNs experienced barriers related to their own practice: they stated they have a lack of time in their consultations to discuss lifestyle issues with their patients. Moreover, they mentioned there is a lack of corporation with other disciplines.
Thirdly, GPs and PNs stated they experience problems regarding the content of health promotion programs. According to them, there is a lack of proven (long-term) effectiveness, and next to this, there is no overview of existing programs in the neighbourhood.
Fourthly, respondents stated that reimbursement of the programs is a barrier: a lot of health promotion programs are not financed or only financed for a short period. Due to that, there is lack of continuity, there are no long- term programs and therefore there is uncertainty and lack of trust to implement new initiatives.
As one GP said:
"‘This is the second year that we offer this program to our patients. Now, the program is granted…as long as it lasts’."
Moreover, programs are not always accessible for patients with a low socio-economic status (SES) and if a general practice receives a reimbursement, they have to meet strict and time-consuming requirements from insurance companies or research institutes. Examples are the registration of performed activities, the inclusion of patients and the required education and skills of practice nurses to take certified courses and training.
At last, contradictory policy of the government is an experienced barrier as well: for instance GPs mentioned the inconsistent smoking policy (in 2008 smoking was banned in all restaurants, clubs and hotels but this was overturned in 2012).
As one GP expressed:
"‘We are glad, because we get support and reimbursements to motivate people to stop smoking. However, when I heard on the radio “It is allowed to smoke in small cafes again”, I thought; “What do they want?!”’"
Most cited facilitators are the availability of PNs in general practices, reimbursement of lifestyle programs, having programs in their own practice, the development of programs by umbrella GP organizations and collaboration with several disciplines in general practice, like dieticians, physiotherapist and psychologist (see Table ).
Remarkably, there are some contradictions in the mentioned barriers and facilitators. With respect to the contribution patients have to pay for certain health promotion programs, some GPs and PNs stated this is a barrier because programs are not accessible for everyone, especially not for patients with a low SES. However, others think it is a facilitator, because if patients have to pay for a program they will be more motivated to change their behaviour. Another contradiction is whether GPs and PNs own healthy behaviour will influence health promotion activities positively or not. It could be a barrier, especially with regard to drinking alcohol, as one GP expressed:
"‘We do very little about reducing alcohol intake by patients, but it might have something to do with the fact that the doctor drinks alcohol as well’"
But it could also be a facilitator:
"‘I was a smoker. I have stopped. If I can do it, you can do it too’."
Attitude of GPs and PNs
Although the majority of the GPs stated they are capable to fulfil the health promotion tasks, there are differences in their attitudes about their perceived roles and responsibilities. To describe and visualize these differences, six different types of GPs were identified: the ‘ignorer’, ‘adviser’, ‘confirmer’, ‘evangelist’, ‘interferer’ and ‘nurturer’ (see Table ).
Attitude of GPs toward discussing lifestyle with patients: a typology of GPs
The ‘ignorers’ stated that their role as a GP in health promotion activities, is limited and that the government should take more responsibilities. The ‘advisers’ mentioned that health promotion is part of their job and think it is worthwhile to spend time on giving lifestyle advices. The ‘confirmers’ emphasized the importance of the PNs and as a GP they confirm and support the plans made between the PN and patients. The ‘evangelists’ stated that even though they are sceptical about the effects, they are sure that they can help at least some patients. The ‘interferers’ discussed lifestyle with their patients by confronting them, even if there are no lifestyle related symptoms. The ‘nurturer’ stated that the GPs’ role is like the role of a teacher, to raise and educate their patients. In most cases a GP fits into one role. However, sometimes a GP fits into several roles, depending on the lifestyle factor she/he has to deal with. For example, a nurturer can become ignorer when there is a patient with alcohol problems. It may depend on the lifestyle topic, the problem, the patient and/ or the situation in which role a GP fits.
The PNs were also asked about their attitudes. They were unanimous. PNs stated that patients are always responsible for their own lifestyle and they quit giving support if a patient does not want to change or does not appreciate it when his or her lifestyle is discussed. The patient can come back when he or she is ready for it. Despite the fact they cannot help all patients and the results are minimal, PNs think discussing lifestyle is worthwhile. As one PN expressed:
"‘Lifestyle is more important than all the other things I do’."