title: Primary prevention in general practice - views of German general practitioners: a mixed-methods study.
abstract: BACKGROUND
  Policy efforts focus on a reorientation of health care systems towards primary prevention. To guide such efforts, we analyzed the role of primary prevention in general practice and general practitioners' (GPs) attitudes toward primary prevention.
  
  
  METHODS
  Mixed-method study including a cross-sectional survey of all community-based GPs and focus groups in a sample of GPs who collaborated with the Institute of General Practice in Berlin, Germany in 2011. Of 1168 GPs 474 returned the mail survey. Fifteen GPs participated in focus group discussions. Survey and interview guidelines were developed and tested to assess and discuss beliefs, attitudes, and practices regarding primary prevention.
  
  
  RESULTS
  Most respondents considered primary prevention within their realm of responsibility (70%). Primary prevention, especially physical activity, healthy eating, and smoking cessation, was part of the GPs' health care recommendations if they thought it was indicated. Still a quarter of survey respondents discussed reduction of alcohol consumption with their patients infrequently even when they thought it was indicated. Similarly 18% claimed that they discuss smoking cessation only sometimes. The focus groups revealed that GPs were concerned about the detrimental effects an uninvited health behavior suggestion could have on patients and were hesitant to take on the role of "health policing". GPs saw primary prevention as the responsibility of multiple actors in a network of societal and municipal institutions.
  
  
  CONCLUSIONS
  The mixed-method study showed that primary prevention approaches such as lifestyle counseling is not well established in primary care. GPs used a selective approach to offer preventive advice based upon indication. GPs had a strong sense that a universal prevention approach carried the potential to destroy a good patient-physician relationship. Other approaches to public health may be warranted such as a multisectoral approach to population health. This type of restructuring of the health care sector may benefit patients who are unable to afford specific prevention programmes and who have competing demands that hinder their ability to focus on behavior change.
authors.affiliation: Berlin School of Public Health, Charité Universitätsmedizin Berlin, Seestr, 73, 13347 Berlin, Germany. christine.holmberg@charite.de.
authors.forename: Christine
authors.initials: C
authors.lastname: Holmberg
authors.forename: Giselle
authors.initials: G
authors.lastname: Sarganas
authors.forename: Nadine
authors.initials: N
authors.lastname: Mittring
authors.forename: Vittoria
authors.initials: V
authors.lastname: Braun
authors.forename: Lorena
authors.initials: L
authors.lastname: Dini
authors.forename: Christoph
authors.initials: C
authors.lastname: Heintze
authors.forename: Nina
authors.initials: N
authors.lastname: Rieckmann
authors.forename: Rebecca
authors.initials: R
authors.lastname: Muckelbauer
authors.forename: Jacqueline
authors.initials: J
authors.lastname: Müller-Nordhorn
mesh_terms: D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D003625:Data Collection / Q000379:methods; D005260:Female; D058006:General Practice / Q000458:organization & administration*; D058005:General Practitioners / Q000523:psychology*; D005858:Germany; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D008297:Male; D008875:Middle Aged; D011322:Primary Prevention