GPs' and patients' discourses about HPP in PHC differed in priorities and contents. We therefore arranged the main findings of analysis in two sections. The first one was centred on GPs' perceptions and the second one on those of patients. In both cases HPP was the focus, but it was also important to know their mutual discourses about the role of patients and GPs in PHC. GPs linked their perceptions of HPP to their working conditions and experience in the health services. From their perspective, patients' attitudes and contexts added difficulty to a very often frustrating duty. For patients, habits were related to ways of life particularly influenced by close contexts. GPs' role was regarded as important but secondary. GPs had to be experts in helping them when necessary, but their own demands and responsibilities were not homogeneous.
1. Physicians' perspective: between duty and frustration
GPs' discourses were located in the context of health services and PHC centres. Their experiences about these services and the patients who, in many cases, they had treated for many years were particularly relevant. Contradictions between what should be done and what was actually done appeared frequently with a notable sense of frustration related to the current situation.
a) Health promotion and day-to-day working conditions
GPs were generally aware of the importance of HPP and the closeness and continuity of their handling of patients. However, the very nature of their care work made it difficult to incorporate HPP activities. GPs had first of all to respond to the demands considered as a priority by patients, which often meant that HPP was relegated to second place. In this sense, lack of time frequently appeared as a problem related to the characteristics of PHC and to the current HPP intervention and assessment models.
"-...To be honest I think that we see people a lot, on numerous occasions, and it is then when we can get involved and maybe identify the patient at risk... The motivation is often external. and that's when we can get involved...I believe that our advantage is that we are always there..." F2D2
"-...a patient isn't a single consultation, a patient can be seven consultations,... that back pain you have just there.... because if you take the back pain seriously, you then sort out the other one and the other one, so it´s not 10 minutes... So we have a mixture of things. In prevention, personally I have my four little elements." M2D1
"-...Well, the time... I have another problem... I find it difficult to perform preventative activities, not because I don't believe in them... it's just that I can't, I forget.... I remember that I have to do the PAPPS just as the patient is leaving...it's difficult... For me the consultation is something that I really get into, the reason for that day's consultation, I get caught up in the topic and when it's over the consultation has finished, it's difficult for me: "and am I going to ask the patient now?" ... My graphs aren't very good..." M1D2
GPs' accounts of their participation in the two previous studies made also frequent mention of the lack of time and additional workload they faced, with the subsequent doubts regarding their long-term feasibility. However, at the same time their impressions regarding their design, learning component and novelty with respect to the routine were favourable.
-"...The work was difficult for me personally at the time as it meant an increased workload... Everyone tells you when you participate in something like this that it's very easy. Well it's not." H2D2
-"... We learned everything we know there...But we must have ended up exhausted, because when the two years were up, because it lasted two years, there was an enormous shift wasn't there? The following year I think I was a bit scared to ask "would you like us to help you?"...Jesus, if they say yes, then tomorrow at 8:30, from 8:30 until 9:00 I'll be busy..." M2D1
-"...It seemed a good idea..., furthermore smoking was an important topic for me...for various reasons. I was already a bit fed up at that point with the protocols...and this represented something different...later I learned a lot..." M1D1
In other words, doubts regarding the conditions in which HPP was undertaken concerned both general resource-demand aspects and the management of these activities. The concept of HPP as an "ideological" imperative was questioned on the basis of the effectiveness of its actions, particularly when these actions were compared with the area of disease treatment.
"-...I think we shouldn't concentrate so much on success rates...at least in the short term... it's something we have to do because we believe in it, that's all... There must be some sort of ideology behind this...M1
-But we have to know whether things work or not! That's dangerous as well...I mean, maybe we're achieving something... and there should be some way of measuring it...." M1D1
"...What is the goal in health promotion?...That's what's worst, because we know what the goal is with pneumonia, we know what figure we need to reach with high blood pressure and so on...but for smoking... how many people are supposed to stop smoking with our help?...or how many are going to stop drinking? I don't touch alcohol any more, it terrifies me, I don't know about the rest of you..." F3D2
HPP activities assessment was a clear reason of discontent, and the design of the computer system used for this purpose in PHC was also questioned. In some cases this system was recognised useful as a reminder, but over all it was seen as unhelpful and even leading to the "devaluation" of HPP itself as data entry was considered as an end, rather than a means.
"-...The computer system... is going to end up like this, as form-filling. I don't see it as being particularly useful... Maybe if the computer system wasn't there you wouldn't even weigh [the patient]...but that's all...I don't believe the main point of medicine is to tick boxes... M2D1
"-...We've got a computer system containing all the preventative activities...that's a disaster....F3D2
-...And only what you enter is assessed.......and you can only enter what it lets you enter...the rest therefore doesn't exist...M1D2
-...We have to survive...M3D2
-...But if it doesn't matter why bother asking....as long as you tick the box...M1D2
-...So, what's important is to tick boxes?...F1D2
The duty imperative and frustration were located in this case in the requirement to fill in records that did not accurately reflect the role played by GPs in HPP activities.
b) Habits, patients, and their contexts
From GPs' perspective, patients may present various unhealthy habits whose management was not easy at all in light of the variability of their experiences, contexts and motivation to change. HPP activities were therefore perceived as "swimming against the tide", highlighting the importance of personalised treatment, empathy and opportunity concerning how and when to intervene.
...any change of habit requires facing up to a similar type of problem... overweight, obesity, a sedentary lifestyle, diabetes, pre-diabetes, a whole range of things... But all these possibilities suppose a lifestyle change.... so it feels a bit like always swimming against the current... F1D1
"-...And in the end, the culture and society in which we live, and the empathy you have with your patients in general, come into play....in other words, as we were saying earlier, if you connect with a patient you have more chances of changing that patient's habits...if you get on well with someone they take more notice of you...M1D1
"-...I think we know a lot about how to do things but not much about the background... I mean, I get stressed when a patient comes to me because he's losing weight and has a lymph node problem,...and then you go and ask him if he drinks...in other words,...I don't know... other things worry me more than the macro data..."M2D2
References to the social context in GPs' discourses located the problem beyond the scope of consultation. The importance of their effects on individual behaviour was reflected in the expectations and arguments with respect to what can be achieved at the PHC level. Frustration also emerged in GPs' accounts who, on the one hand, understood HPP as part of their day-to-day duties, and on the other, felt that a large part of the responsibility for the final success or failure lied outside their scope of action.
"-...We may want to undertake promotion and prevention, but we have to realise that it is extremely frustrating to find that, when the individual habit is indeed a habit, it's very difficult to change....In this case we still have to try, but health education must also be much more society oriented,... it must come from much higher than primary care... F2D4
"-... it's complicated, ok?. In other words, the epidemiological mechanisms...they tell you that the real power of preventative medicine isn't in the physicians' hands but in those of the Minister of Public Works and people like that....and that intervention at a population level is better than at an individual level. And as physicians we have to accept that, because if not, we get extremely frustrated....M3D1
Tensions between the "inside" and "outside" PHC poles made GPs ask themselves about how the effectiveness of HPP was assessed. References to resources external to health services and the convenience of coordinating efforts were also present in their discourses.
"-... I believe that we have indeed managed to convince patients that physical activity is important...as I now find... some patients... who you'd never see out walking previously and who now, with their sixty something or more years, go out for a walk...What percentage? I've no idea. Was it because of this? Probably not entirely... M3
- Can you now find elderly women in tracksuits because of this research? Surely it's for other reasons, isn't it? M2
-...Certainly. But to what degree? Who knows...M3D2"
"-...I think that, without trying to avoid the matter at hand, that there's something else that everyone's aware of, and that's community-based intervention.... I believe that town halls and the like should intervene as these are health habits...and, if they decide to do that, parallel activities aimed at the community which don't just involve ourselves...It would be the same as the positive effects we've seen with the anti-smoking laws...M2D1
However, their perceptions about the future were sceptical. Interventions at the community level were considered, in some cases, as utopian, whereas in others emphasis was placed on the need of support resources.
-...I think we would be very good there, like some sort of linchpin between disease and health and such... to bring together health resources and the population, that's nice work....the only problem is that that's an utopia....M2D2
-...But it's complicated, you can't of course do it now...M1D2
-...Well, it all depends on interests from above, obviously, and the resources they give us, but in the state we are at the moment, nobody in their right mind would organise something like this...M3D2
-...It's difficult to try and fit this in to the schedule because it seems to me that as you get older you're less willing to volunteer your time... I mean, it's not the same you having to give a talk at 7 o'clock as your manager telling you "I'll give you 3 hours off and you can give the talk when you can"... You need time, money...because then you get the acute [cases], the colds, and you can't ignore them....M1D1
2) Patients' perspectives: feeling healthy and fear of disease in complex contexts
Patients' perspectives of HPP were more open and plural. Their role as individuals linked to specific socio-cultural contexts was clear in both groups. Their accounts often referred to habit changes on time scales different to those of interventions, and the reasons that led them to change differed in terms of priority and opportunity from those of GPs. The concepts of promotion and prevention were replaced by experiences with blurred boundaries between feeling healthy and the fear of disease.
a) The importance of micro-social factors
The strong influence of the social context corroborated GPs' perceptions, although for patients these factors seemed to be more complex and closer to micro-contexts. References to known cases about relations between habits and the likelihood of suffering a disease were especially visible.
"-...I was already being monitored, and on top of that the doctor encouraged me to do exercise..., but the cholesterol was something that I was already aware of... Two workmates of mine died from heart attacks and the last one terrified me, so I stopped smoking around two years ago. M4P1"
"-...it's not an excuse but... my father smoked all his life and lived to 85, and my father-in-law is still smoking at 91... so I haven't really seen anyone die young, therefore there's been no immediate reason to stop smoking right away." M2P2
This area included factors related to local customs, the socio-economic level, family, work, friends and gender roles which complicated the motivational map and the possible causal factors.
"-...We, at least our generation,... have this culture of eating, and when we get bored and don't know what to do we eat and drink, and when we're not bored because we're going out on the town, we eat and drink... M1P1
- I don't think so, each to his own...As a housewife my case is completely different, I have very little time to go out because I can't, I've got things to do, but my problem is anxiety... I'm either stressed because things aren't working out as expected or because of family problems... F2P1
- I work as a cleaner and when I get home it's more of the same. It's a routine which might just take you along with it... F3P1"
"-... I stopped smoking in solidarity with my husband and children..."F5P1
Clear attitude differences were seen as well in terms of a greater/lesser assumption of responsibility for their habits. In some cases decisions were accepted to be their own, whereas in others it was easier to project this responsibility externally.
"-...I smoke a lot, at least a packet, sometimes I overdo it...At times I tell myself "I'm going to stop smoking" and then I go and see the doctor... but then I say 'but if I don't really want to stop, what's the point of wasting the doctor's time if I'm really not motivated?" F2P2
"-... I think they should have provided help, or a treatment or support groups for those of us with a smoking problem to convince us to stop smoking rather than just coming up with a law,... F4P1"
The influence of external factors was occasionally located at a macro level, especially for smoking. Perceptions of feeling stigmatised were used, in some cases, as a reaffirmation, highlighting what they considered as "inconsistencies" with respect to other health problems. In others, their right to make decisions concerning their own habits was also argued in their "defence".
"-...I understand that it's difficult for someone to come up to me and call me an alcoholic because of the social rejection that goes with it. A smoker doesn't have that problem M3P1.
-...Somebody once complained that I was smoking in the street...in the street!." F4P1
"-...This goes in cycles, they bother you, it's a cycle... and suddenly you've got a cold because you smoke, you've got whatever because you smoke... everything is because you smoke. M1P2"
"-... when they keep insisting on how bad smoking is for you, you sometimes want to blow smoke in their face...... taking drugs is also bad for you, and roast suckling pig is terrible, and if you go to Segovia and don't eat it you're an outcast... Let's be a bit more logical here! Let's point the finger at everyone, not just at me...M2P2.
-...You're not going to tell me that now they're worried about us, they've never worried before... why bother worrying about smokers. For God's sake, worry about people who are dying of hunger, 4000 km from here they're dying of hunger, worry about them..." M4P2
The influence of diseases or disabilities related to unhealthy habits emerged as a clear discursive motivation for change, although the parameters related to "being healthy" were not as simple as "yes/no" or "good/bad" dichotomies.
"-...I smoked for maybe 15 years or more until one day I said, this can't go on, this looks like it's leading to cancer so I have to stop smoking... I went to buy my packet of cigarettes with bronchitis, on the point of developing cancer...and I simply put the packet in my handbag... One day I went to the doctor's and he said to me 'So, have you stopped smoking yet?' 'Yes, I've given up, I haven't smoked for almost a year"F3P1.
"-...I also play sports and so obviously... when my doctor told me about stopping smoking I had no intention of stopping, just like now... Everyone needs a vice, it's not as if I eat or drink too much... I often go into the high mountains and I don't feel unwell... I get on ok... but I walk a lot better than many people who don't smoke,..." M4P2
"-...I don't smoke a lot, six or seven a day at the most and I've never been pressured into stopping... although I'd never defend smoking. I had a spirometry test just over a year ago and I was at 100%, I had just over 98% lung capacity, although that's not to say I'm defending anything, just that I haven't noticed anything..." M2P2
b) The GPs' role
Even when the influence of social environment was overwhelming, especially at the micro-social level, the health care was recognised as an important reference concerning habit maintenance or change. Patients viewed their GP's work in the HPP field favourably; indeed, GP's influence when deciding to participate in the two previous studies was clear. However, awareness of its limited effects also appeared in their discourses.
"-...Basically because my GP asked me to participate, not for any other reason. I went to see my GP and he asked me 'How would you like to participate in some projects?', 'Well, ok then'. As I had time, I went. F1P1"
"-...That's the GP's role, to help you, to be the one who's always insisting, and who says to you every time you visit '...What's my GP going to do, to force me? No... then to be so insistent that in the end I ask what he wants. That's his role....M1P1
- No, I don't think the GP has much of an influence, it's us who have to....it doesn't matter how much he insists.... he can help a bit but that's all. F1P1
- I think he does help because it's him who tells you what to do, although whether you then take any notice of what he's telling you, or whether you're able to do it...F4P1
- The only thing the GP can do is advise you, and advise you well, but everything else has to come from you...or give you a bit of a fright...M2P1"
GP's advice was therefore somewhat expected, and to some extent welcome, but it was treated as an advice that can be followed or not and, furthermore, which loses its effect if given indiscriminately without considering each patient's circumstances and characteristics.
"- I once knew a GP who said to an 85-year-old who smoked four cigarettes a day - it was his only vice and he was practically at death's door anyway: 'Do you smoke?' 'Yes, four [a day]' 'Well you should stop'. With all due respect, you feel like saying to the GP 'stop working'... it doesn't seem very logical to me. M1P1"
"-... I think that for a person to give advice about something, that person should have some degree of moral authority to do it. I mean, if you go to a doctor it's because he is able to help you on health matters. So, if he says to you clearly 'you shouldn't smoke'...But it shouldn't be that every time you visit it's like...'my back hurts', 'ok, but you shouldn't smoke' (laughs) M2P2"
The fear of disease was also present in their communications with health professionals, and not only with their GPs. This focus on disease was also present in the reasons why some patients decided to participate in the previous studies, regarding the possibility of complementary tests (analyses, etc.) as a better prevention.
"-...my GP, who I've known all my life, has been continually trying to get me to stop smoking... smoking didn't affect my physical activity... until one day I had a sore throat,.... I went to see my GP, who sent me to see a specialist who scared the life out of me. The specialist told me he was going to make a small hole, and since that day, July 16th at half past nine in the morning, I haven't smoked a single cigarette." M1P1
"-...I've had a snoring problem for a long time... Obviously, my GP said I should stop smoking... In the end, I went to the ENT specialist and finally needed an operation on my vocal cords... But I carried on smoking... Then, one day, he told me about the small hole, you're going to end up with a small hole. I don't know whether it was because it scared me so much or because he got me at a good moment, I don't think I'll ever know to be honest, but I decided to stop smoking on a certain date. That was a year ago" F2P1
"-...My GP encouraged me to participate in this programme. I was having my cholesterol monitored, it's a bit too high. He also encouraged me to take more exercise and he told me that every time I attended this programme they would do another control... When he told me that I thought, great, because as well as coming here to see how I'm getting on with my cholesterol, then this programme will monitor other things... One year is a long time..."M4P1