Prevention

The following is mostly a summary of the "Red Book" Guidelines for preventative activities in general practice.

          Screening

Involves conducting tests (questionnaires or lab tests) on patients to work out who is more likely to be helped than harmed by further tests of treatment to reduce the risk of a disease.

          Informed consent

Must be obtained before carrying out any screening test.

For example I saw a patient the other day for a review of results and I had not specifically taken the time to explain what the implications of doing a fasting blood glucose level might be. The result was 14 suggesting that combined with her history and weight that she had undiagnosed diabetes. She was angry and shocked when I told her and has since left the practice. The background of which I was unaware is that her husband has severe type 2 diabetes and she has always said that she would never get it and if she did she would rather die than be on any medication. I could have prevented this by specifically providing pre-test counselling and education about what a diagnosis of diabetes might mean for her.

There are various guidelines which help determine what screening programs are effective. These guidelines deal with

• The condition
• The test
• The treatment
• The outcome

The condition should be important, it should be recognisable early on (e.g. cervical dysplasia precedes CIS).
The test should be simple, safe and validated.
There disease must be treatable by a means that is agreed upon and effective.
Screening should result in an outcome of reduced morbidity and mortality.

Patient education is important in helping patients reduce their risk of developing an illness.
Effective patient education depends on:

• The GP enquiring about what the patient understands of a condition
• The patient feeling they can trust their GP
• Face to face communication
• The patient being able to be involved in decision making
• The GP highlighting the benefits and costs of change vs no change
• Strategies to help the patient remember what you've told them
• The GP tailoring the information to the patient's interest in change (see stages of change model)

          Stages of Change Model

Remember the dam PC has broken again! (PCDAM)

Pre-contemplation (Mrs Wrinkles smokes 2 packs a day and hasn't even thought of quitting)
Contemplation (Mr Wobbles is beginning to wonder if all the Big Macs might be giving him indigestion. He's looking for information in the Woman's Weekly but isn't ready to take action yet)
Determination (Mr Stoned has lost his job and decided he's sick of his drug habit ruling his life. He's ready to change!)
Action (Mrs Papilloma has made an appointment to have her pap smear and is in the waiting room after not having had one for 10 years)
Maintenance (Sporty Spice is working to keep up her exercise and diet but she needs a bit of encouragement to avoid falling back into her old ways)

Motivational interviewing is about understanding where the patient is at by asking questions and listening and then it is about helping them move from one stage to the next by asking more questions and providing appropriate information. There's no point discussing nicotine replacement or varenicicline with Mrs Wrinkles in the above scenario. You need to ask her about any negative experiences she or anyone else had had by smoking..ask her to imagine what possible negatives there are. Give her some relevant details about the health benefits of quitting etc.

Prevantative activities before pregnancy
Target: Women aged 15 to 49
SNAP PIC

Smoking
Nutrition and folate
Alcohol (and other drugs prescribed and illicit)
Physical Activity, Obesity

Psycho-social support
Immunisations
Co-morbid conditions (including genetic/ family hx and chronic conditions)

Note that women receiving live viral vaccines such as MMR and varicella should be advised against falling pregnant within 28 days of vaccination.

Influenza vaccine is recommended during pregnancy (especialy if they will be in 2nd or 3rd trimester during flu season)

DTP should be considered before conception.

Folate 0.5mg should be started 1 month before pregnancy and continued until 3 months after pregnancy.
High risk for NTD = previous pregnancy affected by NTD, those on anti-epileptics, those who have diabetes: These women should be on 5mg daily folic acid.