Clinical Preventive Medicine in Primary Care: Background and Practice:
2. Delivering Primary Preventive Services
DONALD D. HENSRUD, MD, MPH
Strategies to incorporate preventive services into primary
care settings have been underutilized. The first component
of delivering preventive services in the primary care set-
ting is the health risk assessment followed by establish-
ment of practice guidelines and protocols for preventive
services-who is eligible for what service (based on age,
sex, and other clinical characteristics) and when. A com-
puterized reminder system can be useful to track past and
currently due preventive services for each patient and can
also serve as a follow-up system for test results. Well-
trained paramedical personnel can perform appropriate
patient counseling and education. The goal of counseling
T he implementation of preventive services is high on
the nation's agenda. The US Department of Health and
Human Services has published Healthy People 2000: Na-
tional Health Promotion and Disease Prevention Objec-
tives. I The 3 main goals of this document are (I) to reduce
health disparities among Americans, (2) to achieve access
to preventive services for all Americans, and (3) to increase
the span of healthy life for Americans. Death is inevitable,
and some may feel this is a valid argument against preven-
tive services; ie, everyone dies of something. Preventing
premature death and improving the health and quality of
life through preventive efforts are far different than length-
ening life without maintaining quality of life.' An assess-
ment of the progress toward the goals of Healthy People
2000 has been published.' Shortfalls were noted in attain-
ing these goals, and corrections in the targets and strategies
to achieve them are being proposed.
In clinical practice, at least 4 components are neces-
sary for the successful delivery of preventive health care:
knowledge, skills, attitude, and organizational structure.'
Preferably, education about prevention should begin early
in medical school and continue through residency training
and on into practice. Yet, in 1989 more than 50% of gradu-
ating medical students in the United States reported inad-
From the Division of Preventive and Occupational Medicine and
Internal Medicine and Division of Endocrinology, Metabolism, Nutri-
tion and Internal Medicine, Mayo Clinic Rochester, Rochester, Minn.
Address reprint requests and correspondence to Donald D.
Hensrud, MD, MPH, Division of Preventive and Occupational Medi-
cine, Mayo Clinic Rochester, 200 First St SW, Rochester, MN
55905.
Mayo Clin Proc. 2000;75:255-264
For personal use, Mass reproduce only with permission from Mayo Clinic Proceedings,
and education is to change patient behavior. The first step
in this difficult process is once again to ascertain health
risks and then to determine the patient's stage of readi-
ness---defined as precontemplation, contemplation, prepa-
ration, action, and maintenance. The counselor assists in
identification of target behavior, advocates and commends
behavior change, reinforces health benefits of behavior
change, offers resources, strategies, and support, and cre-
ates a plan of action and monitoring mechanisms. Improved
implementation of preventive services in primary care
could have a major impact on the health of the population.
Mayo Clin Proc. 2000;75:255-264
equate instruction in preventive care, and almost 60% re-
ported inadequate instruction in nutrition.' Although proce-
dure-oriented prevention (eg, screening and immuniza-
tions) is taught fairly well, health promotion counseling, in
general, is poorly addressed at most medical schools.vRea-
sons for this have been described and relate, in part, to the
disease/treatment model of medical science and education
in which prevention is not emphasized.' Recommendations
and principles for incorporating preventive medicine into
the medical school curriculum have been published," and
they can be integrated into an existing curriculum," Recom-
mendations also exist for residency programs. 10 Neverthe-
less, data suggest adequate training in prevention is not
provided.':":" Approaches have been studied in an attempt
to improve on this.":"
Practicing physicians report a lack of confidence in their
ability to help patients bring about behavior change." Al-
though physicians recognize the need for education and
training to effect patient change.v-" a survey of continuing
medical education courses in the early 1980s revealed few
opportunities for physicians to acquire new knowledge and
skills in prevention. 18 Little has been published on continu-
ing medical education programs in prevention since then.
One published report described a clinically applied con-
tinuing medical education program that resulted in im-
proved cancer prevention activities among physicians in
the areas of smoking cessation and breast cancer screen-
ing.I''Clearly, increased efforts to teach and promote deliv-
ery of preventive health care are important first steps in
implementing preventive services, improving physician
skills, and ultimately changing patient behavior.
255 © 2000 Mayo Foundation/or Medical Education and Research
256 Clinical Preventive Medicine in Primary Care
Another important aspect of delivering preventive care
is the health care organization's structure. A system needs
to be in place that allows adequate time, attention, and
support for preventive activities." Programs that have ad-
dressed organizational or system issues have been fairly
successful,":" and novel approaches are being studied."
Specific factors important to the delivery of preventive
services in a large organization have been described."
These include use of a population-based epidemiologic
viewpoint applied at the level of the individual practice,
involvement of practitioners in the process, a systems ap-
proach, feedback of program outcomes, and automated
clinical information systems."
Although having a large organizational structure can be
helpful, preventive services can be incorporated into virtu-
ally any clinical practice in a variety of ways. Preventive
services can be delivered in a patient appointment specifi-
cally designated to discuss health promotion and disease
prevention activities. However, the US Preventive Services
Task Force recommends that preventive services should be
offered during any type of medical visit." During a physi-
cian office visit a simple reminder system such as a flow
sheet or checklist on the front of the patient chart can
trigger the ordering of screening tests or health assessment
and counseling." This ordering process can be automated
using computer reminders, which have been shown to im-
prove the delivery of preventive services.P""
Physicians are not the only health care providers who
can deliver preventive services. Although it is vitally im-
portant for physicians to be involved, paramedical person-
nel such as nurses, nurse practitioners, physician assistants,
dietitians, health educators, and others can ease some of the
time pressures on physicians and effectively deliver pre-
ventive services,":":" which should result in cost savings
both to patients and to the health care organization, Para-
medical personnel, including trained health educators in
larger centers, can deliver health education classes on nu-
trition, exercise, stress management, and other topics. The
need for preventive services can be determined and screen-
ing tests can be ordered by nurses, nurse practitioners, and
appointment secretaries using standard protocols. Appoint-
ments can be tied into computer reminder systems to no-
tify patients when it is time for a test," keeping in mind
that not all patients want to participate in such a system."
Written materials are widely available from the American
Cancer Society, American Heart Association, and other
organizations to supplement verbal education from health
care providers. It is important that handing out written
material not take the place of a face-to-face encounter in
which the patient can ask questions and voice concerns,
and where the health care provider can deliver a personal-
ized message.
For personal use, Mass reproduce only with permission from Mayo Clinic Proceedings,
Mayo Clin Proc, March 2000, Vol 75
PREVENTIVE SERVICES CLINIC
At Mayo Clinic Rochester we have initiated a Preventive
Services Clinic. This type of clinic has been shown to
markedly increase prevention rates." Patients seen at Mayo
Clinic and their relatives may participate in this clinic, the
goal of which is to ensure screening tests and health promo-
tion education are appropriately recommended. Many pa-
tients will have these items addressed during their general
medical evaluation, but patients who are seen in a subspe-
cialty area for a specific medical problem need to have their
preventive services updated in addition to evaluation and
treatment of their subspecialty medical problem,
In this model, which could be modified and used in
virtually any medical practice, a patient first completes a
health risk appraisal instrument-a questionnaire that in-
quires about health behaviors and demographic data. Based
on responses to the questionnaire, an estimate of the risk of
developing certain diseases and overall mortality is deter-
mined. Next, based on sex, age, and risk factor profile, each
patient is scheduled for recommended screening tests in-
cluding blood pressure measurement, lipid screening, flex-
ible sigmoidoscopy, and a barium enema study. Women
receive a Papanicolaou test and mammography. Informa-
tion is provided to male patients regarding the pros and
cons of prostate cancer screening, including digital rectal
examination and prostate-specific antigen test, and testing
is performed at the discretion of the health care provider
and the patient, recognizing that proof supporting routine
screening is not available at this time. Immunization status
is updated. Patients also receive appropriate information
and counseling from a health educator regarding nutrition,
exercise, smoking cessation, and other health promotion
activities. If medical problems are discovered, referral to
the appropriate specialty area for further evaluation and
treatment is available.
This clinic is staffed by a nurse practitioner, who is
supervised by a physician and functions mainly by protocol
with relatively little physician input unless problems are
discovered. No symptomatic conditions are addressed; this
is purely a preventive visit. It is hoped reimbursement will
improve for this type of clinical activity as data accumulate
documenting its effectiveness relative to the cost.
COMPONENTS OF A PREVENTIVE SERVICES
OFFICE PRACTICE
To use this model effectively in a primary care practice,
certain features should be emphasized (Table 1). First, a
health risk appraisal instrument or questionnaire should be
selected, which gives desired information about the risk
factor status of the patient. Second, common guidelines for
preventive services should be established and protocols
outlined so specific screening tests, immunizations, and
Mayo Clin Proc, March 2000, Vol 75
Table 1. Desired Components of a
Primary Care Preventive Services Office Practice
1. Health risk appraisal
2. Guidelines and protocols for preventive services
3. Reminder system or flow chart outlining past and
currently due preventive services
4. Paramedical personnel to perform health promotion
counseling and provide educational information
5. Follow-up system for test results and future preventive
services
health promotion counseling can be initiated automatically
based on patient characteristics. Third, a reminder system
or flow chart outlining which preventive services have
already been provided and which ones are currently due
should be established, possibly using a computer and pref-
erably linked with the medical history. A record-keeping
system is vital when incorporating preventive services into
ongoing primary care.· Fourth, it is desirable to have para-
medical personnel available to coordinate testing, perform
health promotion counseling, and provide written informa-
tion and resources. Finally, a system for follow-up (perhaps
also using a computer) of test results, abnormal test find-
ings, and future preventive service recommendations
should be in place. A system that works effectively in one
office practice may not necessarily work in another. There-
fore, these components and how they are incorporated into
an office practice should be tailored to each practice. Al-
though it would require some effort initially to incorporate
such a system within an existing practice, once established
it should function relatively smoothly and help ensure rec-
ommended preventive care.
To enhance the delivery of preventive care in primary
practice, the US Public Health Service initiated the Put
Prevention Into Practice Campaign in 1994. Incorporation
of materials from this program into an established practice
can be challenging, however, and tailoring the approach to
meet the needs of the specific practice is important. 36,37 A
major part of the educational materials of this campaign is
The Clinician's Handbook of Preventive Services," This
handbook provides references on preventive health recom-
mendations for health counseling, immunizations, and
screening tests and is supplemented by resources for pa-
tients. Another reference that provides practical informa-
tion about performing clinical preventive services is Health
Promotion and Disease Prevention in Clinical Practice by
Woolf et al." For more information on the preventive
topics mentioned in this review, the reader is referred to
these excellent references.
Although there are some areas in which expert groups
do not agree, for the most part there is general agreement
among the different recommendations for preventive
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Clinical Preventive Medicine in Primary Care 257
care.t''Virtually all major authorities recommend some as-
pect of health promotion counseling at every patient visit.
A summary of the recommendations by major authorities
for preventive care is listed in Figure 1.38 Health mainte-
nance guidelines in the geriatric population have been re-
viewed elsewhere." Issues concerning specific preventive
recommendations will be discussed in more detail in subse-
quent sections.
PRIMARY PREVENTION
Immunizations
A large percentage of the population has not received
appropriate immunizations according to current guide-
Iinesv" (Table 2). In addition to recommended childhood
immunizations, all adults should receive a tetanus-diphthe-
ria booster every 10 years, pneumococcal vaccination at
age 65 years, and yearly influenza vaccination beginning at
age 65 years. Patients at increased risk should receive
earlier, more frequent, or additional immunizations as out-
lined in Table 2.
Immunizations can be delivered in a comprehensive yet
cost-effective way. In the ambulatory setting immunization
status can be part of a larger questionnaire on health risk
assessment. A protocol can be established whereby, after a
brief review of immunization status and potential contra-
indications, patients who are not up-to-date can automati-
cally be scheduled to receive indicated immunizations that
same day in the office. Once this is established, updating
immunizations should require minimal time on the part of
the physician. Paramedical personnel can assess the patient
and administer appropriate immunizations. This model of
providing immunizations by protocol can also be applied to
other health care settings. Offering immunizations during
an emergency depaitment visit" or at discharge following
hospitalizatiorr'v" has been shown to increase vaccination
rates. At Mayo-affiliated hospitals a program is in place to
immunize all hospitalized patients unless there are contra-
indications. Protocols such as these require minimum phy-
sician input and therefore save on expenses while achiev-
ing the goal of increased vaccination rates. Patients should
be encouraged to keep records of their immunization sta-
tus. At the Mayo Clinic each patient seen in the Immuniza-
tion Clinic is given a wallet-sized card containing a record
of all immunizations received in addition to other impor-
tant medical information.
Health Promotion
Health promotion counseling and patient education can
increase preventive behaviors." There are 6 main steps for
effective health promotion counseling (Table 3). The initial
step is an assessment of the demographic characteristics,
health habits, and health risks of the patient. This assess-
258 Clinical Preventive Medicine in Primary Care Mayo Clin Proc, March 2000, Vol 75

Clinical Preventive Services for Normal-Risk Adults

Years or Age 18 25 30 35
I
40 45 50 55 60 65 70 75
i

1=~r~~~~~i~55$;,~IIIIII~;~::
Ocn ttiZt?:H
NcoholUse :;;mr;m' -e

Cholesterol
SCR EENING BloodPressure. He9n"nd We9n. L'l1
~~2 1c:»
<C
co

IMMUNIZATION Telanus-Diphlheria (Til)

varicella rtlV)
Me.""s.Mumps. Rubella (MMRTJ
Pr,eumocO<Xal
Inllucnza

COUNS ELING Women only:

CnlciiJm Intake
Fohc Acid"
Hormone RcpLlccme'" The<apy
MammographySctcering
_ _ __ . .D zuj

..-_!--..-.. --.-1II Ij
Men Only: 1IIIII

~
Prostate Cancer Sctcc ring
c:.
co
STOs8nd HIV. family
Tobacco
unintc.-.al
planning.
cessation. druq
inpries. seat
oomestic violence.
and alcohol use.}
bell use. nutrition.
,1-_~-. .--.-~~-'O:m:::m! a
flI1}'slcaI acIMIy. laWprevention and ~m,1CY (elderly)
_ Recommended by most US authorities
Recommended by some US authorities
P UT PREVENTION INTO PRACTICE
us O[PARlMINIOf Ilf h1. IU A pt{) >>lIMA~ S [ RVw:T S· rtJlU ~U(Al'H S lJN1C1 . '191

'There is no upper age limit lor Pap smears. but regular testing in women over age 65 years may be discontinued in those who have had regular
screening with consistently normal result s. Pap smears are not necessary in wom en who have undergone a hysterectomy in which the ce rvix was
removed for reasons other than cervical cance r or its precursors.
' Some authorities recommend initiating screening at age 19 years. Screening at less frequent intervals may be reason able in low risk individua ls.
including those with previous ly normal levels.
' MMR need only be given to women of childbearing age who lack documen ted evidence of immun ization and are capable of becoming pregn ant.
' Folic acid . 0.4 mg/d. is recomme nded for wome n of childbea ring age who are capable 01becom ing pregnant.

Figure 1.Screening, immunization, andcounseling recommendations for normal-risk adults (fromtheUS Department of Health and
Human Services").

ment can be done either formally using a health risk ap-
praisal instrument or informally during the medical history
taking. Issues surrounding the use of health risk appraisals
have been reviewed." Many different health risk appraisals
are in existence. Healthier People, developed by the Carter
Center and the Centers for Disease Control and Prevention,
is a widely used instrument. The benefits of using a written
appraisal instrument include efficiency, completeness, a
quantitative estimate of risk, and the ability to provide
individualized written feedback concerning health risks
and behavior change. Disadvantages of these instruments
include lack of a personal message and concerns about the
quality and overreliance on the data used to determine and
express risk. For example, benefits of behavior change are
sometimes reported as the additional time one can expect to
live, yet the improved quality of life is not addressed.
Stating on a report that exercising regularly will lead to an
increase in life span of only a few months will probably not
motivate many people. Health risk appraisals are popular in
the workplace, and there is limited evidence that a health
risk appraisal in combination with counseling can lead to
behavior change in this setting."
Health risk assessment can also be done informally by
asking patients questions concerning their health habits.
Suggested areas of discussion and possible questions to use
in assessing these areas are outlined in Table 4. This assess-
ment can be combined with a health questionnaire the
patient fills out ahead of time that can be reviewed when
the medical history is taken. Although inquiring about all
of these topics would appear to take a considerable amount
of time, in our experience use of a questionnaire and brief,
pointed questions requires only a few minutes to complete
the entire list. The questions in Table 4 attempt to gather
the maximum amount of information in a minimum
amount of time, which is necessary in a busy practice. For
example, nutritional habits could be assessed by many

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings .
Mayo Clin Proc, March 2000, Vol 75 Clinical Preventive Medicine in Primary Care 259

Table 2. Summary of Adult Recommended Immunizations*

Vaccine Recommendation
Tetanus-diphtheria Every 10 years after the primary series of 3 doses
Pneumococcal Age 65 years or high risk,t then consider every 5-6 years for
high-risk persons
Influenza Yearly age 65 years or over, high risk,:j: nursing home resident, or
health care worker
Measles§ Adults born after 1956 with no previous immunization or history of
measles; 2 doses for health care workers, college students, or
travelers to foreign countries
Mumps§ Adults with no previous immunization, physician-diagnosed
mumps, or laboratory evidence of immunity
Rubella§ Adults, particularly women, with no previous immunization or
laboratory evidence of immunity
Hepatitis B High riskf
Hepatitis A Travelers to high-risk areas of the world, homosexuals, intravenous
drug users, chronic liver disease, or persons with clotting
disorders
Varicella Adults without a history of varicella, or those who are seronegative
*Data from the ACP Task Force on Adult Immunization and Infectious Diseases Society of
America" and the recommendations of the Advisory Committee on Immunization Prac-
tices."
tChronic cardiac, pulmonary, or liver disease, diabetes mellitus, alcoholism, chronic renal
failure, asplenia, human immunodeficiency virus infection, cerebrospinal fluid leak, hemato-
logic malignancy, organ transplantation, or other immunosuppressive condition (including
receiving corticosteroids).
:j:Persons with chronic cardiac, pulmonary, metabolic (including diabetes mellitus), or renal
disease; immunosuppressive conditions, other chronic disease requiring regular medical
care, or adults working or living with people who have these conditions.
§Measles, mumps, and rubella vaccines are often combined (MMR vaccine).
#Health care workers with blood exposure or staff of institutions for the developmentally
disabled, homosexual men or high-risk sexual comacts.ihemodialysis patients, intravenous
drug users, prison inmates, recipients of certain blood products, household and sexual
contacts of hepatitis B carriers, international travelers at increased risk, and immigrants from
countries where hepatitis B is endemic.

methods, including food frequency questionnaires, dietary
records, dietary recall, or detailed questions. Question 2 in
Table 4, if answered reasonably well, will give a fair
amount of qualitative and rough quantitative information
concerning typical food intakes, yet it does not require a
great deal of time. Some of these risk areas can be ad-
dressed quickly if health habits are good, while answers to
other questions that indicate a need for improvement may
lead to follow-up questions and more in-depth inquiries,
which can be pursued as necessary.
A particularly difficult area is communicating risk to the
patient. The goal in this is to help the patient understand
what their risk factor profile means in terms of the likeli-
hood of future morbidity, mortality, and quality of life.
There are many different ways to express risk-absolute
risk (10 per 100,000), relative risk (twice as likely to get a
disease compared with someone who doesn't have a par-
ticular risk factor), or risk age (40 years based on an
individual's risk factor profile compared with their chrono-
logic age of 37 years). Each of these measurements has
potential problems and can be intuitively difficult for pa-
tients to understand. Another approach is to combine rela-
tive risk with absolute risk and explain this to the patient.
This will give the patient an idea about how important it is
to change a specific risk factor along with a perspective on
the overall likelihood of disease. For example, one could
say, "Someone with a serum total cholesterol of 250 mg/dL
such as you is twice as likely to develop coronary heart
disease over his lifetime compared with someone with a
total cholesterol of 200. In addition, coronary heart disease
is the most common cause of death." This should be fol-
lowed by a discussion of the benefits of changing behaviors
(eg, diet) and providing resources to help facilitate change
(see below).
The second step that can be helpful in health promo-
tion counseling is determining the stage of readiness or
motivation of the patient. The stages of change include
(1) precontemplation: not thinking about changing behav-

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
260 Clinical Preventive Medicine in Primary Care
Table 3. Steps in Administering
Health Promotion Counseling
l. Define health risks
2. Determine stage of readiness of the patient
3. Advocate and commend behavior change
4. Assist in identification of a target behavior;
identify barriers vs benefits
5. Reinforce health benefits of behavior change
6. Offer resources, strategies, and support; create
plan of action and monitoring mechanisms
ior; (2) contemplation: considering changing behavior in
the foreseeable future; (3) preparation: making plans for
changing behavior in the near future; (4) action: in the
process of changing behavior; and (5) maintenance: con-
tinuing behavior changes for an extended period." A rea-
sonable goal is to try to help the patient progress from one
stage to the next. It is important to realize that a person may
relapse through these stages several times prior to making a
permanent change. Therefore, past attempts at behavior
change should be determined along with the reason they
did not work over the long term. The stages of change have
been used to describe behavioral change in at least a dozen
different areas, including diet, safer sexual activity, exer-
cise, and smoking cessation."
The third step from Table 3 in administering health
promotion counseling is to advocate and commend behav-
ior change. An important factor in motivating patients to
change behavior is the relationship between the patient and
the health care provider. The health care provider's role is
to provide information, resources, and a supportive envi-
ronment to facilitate behavior change. During the initial
portion of the patient-health care provider encounter the
health care provider is gathering information while build-
ing and establishing a relationship. Critical aspects during
this time are the clinician's ability to listen, empathize,
legitimize, and support the patient. This is truly the art of
medicine and underlies the success of many outstanding
clinicians.
Reading the patient correctly sets the stage for indi-
vidual recommendations. Some people respond to a "soft
sell" approach. A direct and frank approach works better
for others. In either case it is important to make recommen-
dations in a manner that the patient can understand. When
counseling patients, it is important to be optimistic and
empathic, yet at the same time give clear, unequivocal mes-
sages that impress on the patient the importance of making
the behavioral change. For example, when seeing patients
who smoke, the clinician must acknowledge, with appro-
priate empathy and without judgment, the difficulties of
quitting. However, a firm recommendation to stop smoking
should always be given to the patient.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, March 2000, Vol 75
Health care providers develop their own style of coun-
seling. Sometimes this is based on a personal experience
that can help to illustrate a point and motivate a patient if
used effectively. Outlined in Table 5 are examples of brief
counseling messages that can be used in a few areas of
health promotion. These brief examples of "sound bites"
can be used in counseling at the same time an informal
health risk assessment is being performed. In some cases,
such as discussing postmenopausal hormone replacement
therapy, a longer discussion is necessary. These discus-
sions can be supplemented with written material and refer-
rals to paramedical personnel for more detailed education
and counseling.
Patients should be involved in choosing which behavior
to work on (Table 3, step 4). A health care provider may
have an idea about what they would like the patient to
change and can express this to the patient in terms of health
risks, but the patient may have different views. Moreover,
if patients disagree with a dogmatic recommendation, they
will do what they want after leaving anyway. All the areas
of health promotion listed in Table 4 should be assessed,
and perhaps a brief health behavior message delivered
during health promotion counseling. However, it may be
desirable to focus on only 1 major behavioral change at a
time so as not to overwhelm the patient with too many
changes at once. Part of assisting in identification of the
target behavior is assessing the barriers vs the benefits of
changing a behavior and personalizing this for the patient.
Encouraging the patient to consider these issues should
help the patient arrive at a plan that is realistic and well
thought out.
Once a target behavior is identified, the physician
should reinforce the health benefits specific to that behav-
ior change (Table 3, step 5). For example, confirming and
discussing the many benefits of regular exercise can pro-
vide further information to a patient and can be a strong
motivating factor as well.
Offering resources, strategies, and support as well as
appropriate referrals are all part of formulating a plan of
action (Table 3, step 6). The patient's stage of change
should be considered and be a primary determinant of the
type of intervention recommended. For someone in the
precontemplation stage, just providing literature and infor-
mation may be all that is appropriate. Giving advice on
taking action may be ineffective for this patient. On the
other hand, for someone in the action stage, providing
specific help in making the change can be important.
Just as involving the patient in choosing which health
behavior to work on is important, it is also important to
involve the patient in designing the plan of action. It should
be clear to patients that they are the ones who are respon-
sible for their health behaviors. If available, appropriate
Mayo Clin Proc, March 2000, Vol7S Clinical Preventive Medicine in Primary Care 261

Table 4. Areas to Explore and Potential Questions During Informal Risk Assessment
I. Tobacco use
Question: Do you use tobacco? (Does anyone in the house smoke?)
Follow-up question: What type and how often? Remember the 4 A's:
Ask your patients about smoking.
Advise your patients to stop. Set a quit date.
Assist your patients to stop by providing resources.
Arrange follow-up.
2. Nutrition
Question: What do you eat in a typical day for breakfast, lunch, dinner, and snacks?
Follow-up question: How much fruit and vegetables do you eat?
3. Exercise
Question: Do you get regular physical activity or exercise?
Follow-up question: What type of physical activity or exercise and how often?
4. Seat belt use
Question: What percentage of the time do you wear your seat belt?
Follow-up question: Does your car have airbags?
5. Alcohol
Question: How much alcohol do you drink in an average day (or week)?
Follow-up question: What type? CAGE questions" could also be asked here:
Have you ever felt you should Cut down on your drinking?
Have you been Annoyed when someone has criticized your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had or thought about having a drink in the morning (Eye-opener)?
6. Stress
Question: How much stress are you experiencing at home or work?
Follow-up question: What do you do to relieve stress?
7. Skin protection
Question: What percentage of the time do you use sunscreen or wear protective clothing when you are out in the sun?
Follow-up question: What sun protection factor do you use?
8. Smoke detector
Question: Do you have smoke detectors and carbon monoxide detectors on every floor of your house?
Follow-up question: Do you have a fire extinguisher handy?
9. Sexual practices (This area should obviously be explored with some sensitivity.)
Question: Are you currently or were you recently in a sexual relationship?
Follow-up question: What precautions do you take to decrease your risk of contacting a sexually transmitted disease
or AIDS?
Second follow-up question: What method of contraception do you use?
10. Immunizations
Question: Have you had a tetanus shot in the last 10 years?
Follow-up question: The follow-up question should relate to the patient's specific risk factors. For example, if the
patient has diabetes, it would be appropriate to ask about a yearly influenza vaccine and pneumococcus vaccine.
II. Firearms
Question: Do you keep firearms in the house?
Follow-up question: Are they in a safe place, unloaded, and away from ammunition?
12. Safety helmets
Question: Do you (and your children) wear helmets when riding a bicycle (or motorcycle)?
13. Domestic violence
Question: Have you ever been emotionally or physically abused?
Follow-up question: Do you feel safe in your home?
14. Depression
Question: Have you felt down or blue lately?
Follow-up question: Have you had any problems with change of appetite (or trouble sleeping, difficulty
concentrating, tiredness, or thoughts of hurting yourself)?
15. Dental health
Question: Do you see your dentist yearly?
Follow-up question: When did you last see your dentist and when is your next appointment?
16. Hormone replacement therapy
Question: What are your thoughts about taking hormone replacement after menopause?
Follow-up question: Would you like to discuss some of the issues concerning this?

For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
262 Clinical Preventive Medicine in Primary Care
Table 5. Examples of Brief Counseling Messages
Smoking cessation: "The most important thing you can do for
your long-term health is to quit smoking , no matter how difficult
it is. If you quit now, it is likely you will live longer and
healthier. There are medications and programs available to help
you quit."
Nutrition (general): "Two important dietary changes people
can make are to eat less fat and to cat more fruits and vegetables .
One way to begin doing this is to eat one less serving of meat
and one more serving of fruit and vegetables each day compared
to what you are currently eating ." (It is important to tell people
not only what not to eat, but also what to eat.)
Exercise: "Current recommendations are to try to obtain at least
30 minutes of moderately vigorous physical activity daily such
as vigorous walking or climbing stairs. Any activity is good
activity , but if you begin to participate in formal exercise, I
would recommend that you choose an exercise that you enjoy ,
that you can perform regularly and consistently, and that you
strive to continue indefinitely."
Seat belt use: "Even if you're a good driver, accidents can
happen very quickly, even around your own neighborhood.
Wearing your seat belt could save your life someday . Besides,
after a little while, it becomes a habit and you'll feel bare
without it."
referrals could be considered to a dietitian, physician-
nutrition specialist, exercise physiologist, physical thera-
pist, sports medicine physician, nicotine dependence coun-
selor, or patient education specialist. Identifying appropri-
ate goals should be included in this plan of action. Patients
should be encouraged to formulate goals that are specific,
measurable, and realistic. Finally, monitoring is necessary
to follow through on the behavior change. A specific plan
for follow-up should be in place as well as a plan in case of
relapse.
Chemoprevention
In recent years, increasing interest has focused on
chemoprevention as a means of preventing disease,
particularly in the area of cancer.r':" Chemoprevention
includes a wide variety of compounds such as vitamins
and other nutrients (retinoids, carotenoids, antioxidants),
hormonally related agents (tamoxifen, dehydroepian-
drosterone, finasteride), phytochemicals (genistein from
soybeans, allyl sulfides from onions and garlic, isothio-
cyanates from cruciferous vegetables), and nonsteroidal
anti-inflammatory drugs (aspirin, sulindac). Chemopre-
vention could be primary, secondary, or tertiary preven-
tion . Taking folic acid to prevent neural tube defects is an
example of primary prevention. Tamoxifen treatment
could be either secondary prevention (taken by someone
with proliferative breast disease who is at high risk for
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings,
Mayo Clin Proc, March 2000, Vol 75
breast cancer) or tertiary prevention (taken by someone
with established breast cancer to prevent recurrence). It is
beyond the scope of this article to review the details of the
different types of chernoprevention, but a few comments
are in order.
When taking a substance for chemoprevention, the pa-
tient must be aware of the potential risks as weIl as the
benefits. It is particularly unfortunate when a healthy per-
son is taking an agent for prevention of a condition and an
adverse event occurs. For example, beta carotene supple-
mentation was believed to be protective against cancer and
cardiovascular disease after observational studies reported
that increased dietary intake and blood levels of beta caro-
tene were associated with a reduced risk of these condi-
tions. Moreover, the risk of adverse effects of taking a
dietary supplement such as beta carotene was believed to
be small. However, large-scale randomized trials reported
no benefit, and 2 large studies showed an increase in lung
cancer mortality and overall mortality in smokers who took
beta carotene supplernents.P-" Another related point is that
there is no quality control for dietary supplements, and
therefore the potential for contamination, inaccurate dose,
and other adverse consequences is always present.
Aspirin deserves specific mention because it is widely
used for chemoprevention against coronary heart disease
and cerebrovascular disease and is promising for prevent-
ing colon polyps and cancer,58.61 The evidence for aspirin in
the tertiary prevention of coronary heart disease and cere-
brovascular disease is strong. 58.60 In general, aspirin (75-
325 mg/d) should be considered for patients with a history
of coronary heart disease, stroke, or transient ischemic
attack, provided there are no contraindications. In primary
prevention the data are less c1ear.58-60 Benefits have been
demonstrated, particularly in men, but there is also an
increased risk of gastrointestinal bleeding and possibly
hemorrhagic stroke.58.59.62 Therefore, in primary prevention,
aspirin should probably be reserved for those at high risk,
including individuals older than 50 years with more than 1
risk factor for cardiovascular disease.59,60
The area of chemoprevention will almost certainly con-
tinue to grow in the future . It will be important that physi-
cians and the public are aware of not only the potential
benefits, but also the potential risks and other related issues
surrounding the use of chemopreventive agents.
CONCLUSION
Improved implementation of preventive services in pri-
mary care could have a major impact on the health of the
population. This includes primary preventive services such
as immunizations and health promotion counseling. The
next article in this review will discuss secondary preven-
tion (screening).
Mayo Clin Proc, March 2000, Vol 75
REFERENCES
1. Healthy People 2000: National Health Promotion and Disease
Prevention Objectives. Washington, DC: US Government Printing
Office; 1991. Publication PHS 91-50212.
2. Leaf A. Preventive medicine for our ailing health care system.
]AMA. 1993;269:616-618.
3. McGinnis JM, Lee PRoHealthy People 2000 at mid decade. ]AMA.
1995;273: 1123-1129.
4. Preventive Health Care Committee, Society for Research and Edu-
cation in Primary Care Internal Medicine. Preventive medicine in
general internal medicine residency training. Ann Intern Med.
1985;102:859-861.
5. Wheat JR, Killian CD, Melnick DE. Reevaluation of medical edu-
cation: a behavioral model to assess health promotion/disease pre-
vention instruction. Eval Health Prof. 1991; 14:304-318.
6. Blumenthal DS. Prevention in the medical curriculum: reform and
opportunity. Am] Prey Med. 1993;9:122-123.
7. Jonas S. Health promotion in medical education. Am J Health
Promot. 1988;3:37-42,51.
8. Altekruse J, Goldenberg K, Rabin DL, Riegelman RK, Wiese WHo
Implementing the Association of Teachers of Preventive Med-
icine's recommendations into the undergraduate medical school
curriculum. Acad Med. 1991;66:312-316.
9. Ockene JK, Ockene IS, Kabat-Zinn J, Greene HL, Frid D. Teaching
risk-factor counseling skills to medical students, house staff, and
fellows. Am] Prev Med. 1990;6{suppl):35-42.
10. Collins TR, Goldenberg K, Ring A, Nelson K, Konen J. The
Association of Teachers of Preventive Medicine's recommenda-
tions for postgraduate education in prevention. Acad Med. 1991;
66:317-320.
I I. Goldenberg K. Periodic health examination: comparison of resi-
dency programs and national recommendations. J Gen Intern Med.
1986; I :282-286.
12. Attarian L, Fleming OM, Barron P, Strecher V. A comparison of
health promotion practices of general practitioners and residen-
cy trained family physicians. J Community Health. 1987;12:31-
39.
13. Geiger WJ, Neuberger MJ, Bell Gc. Implementing the US preven-
tive services guidelines in a family practice residency. Fam Med.
1993;25:447-45 I.
14. Pololi LH, Potter S. Behavioral change in preventive medicine: an
efficacy assessment of a physician education module. J Gen Intern
Med. 1996;11:545-547.
15. Orleans CT, George LK, Houpt JL, Brodie KH. Health promotion
in primary care: a survey of U.S. family practitioners. Prev Med.
1985;14:636-647.
16. Ockene JK, Aney J, Goldberg RJ, Klar JM, Williams JW. A survey
of Massachusetts physicians' smoking intervention practices. Am J
Prey Med. 1988;4: 14-20.
17. Costanza ME, Hoople NE, Gaw VP, Stoddard AM. Cancer preven-
tion practices and continuing education needs of primary care
physicians. Am] Prev Med. 1993;9: 107-112.
18. Weinberg A, Andrus PL. Continuing medical education: does it
address prevention?] Community Health. 1982;7:211-214.
19. Carney PA, Dietrich AJ, Freeman DH Jr, Mott LA. A standardized-
patient assessment of a continuing medical education program to
improve physicians' cancer-control clinical skills. Acad Med.
1995;70:52-58.
20. Solberg LI, Kottke TE, Brekke ML, Calomeni CA, Conn SA,
Davidson G. Using continuous quality improvement to increase
preventive services in clinical practice-going beyond guidelines.
Prey Med. 1996;25:259-267.
21. Carney PA, Dietrich AI, Keller A, Landgraf J, O'Connor GT.
Tools, teamwork, and tenacity: an office system for cancer preven-
tion.v Fam Pract. 1992;35:388-394.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Clinical Preventive Medicine in Primary Care 263
22. Dietrich AJ, WoodruffCB, Carney PA. Changing office routines to
enhance preventive care: the preventive GAPS approach. Arch Fam
Med. 1994;3:176-183.
23. Dietrich AJ, O'ConnorGT, Keller A, Carney PA, Levy D, Whaley
FS. Cancer: improving early detection and prevention: a commu-
nity practice randomised trial. 8M]. 1992;304:687-691.
24. McPhee SJ, Detmer WM. Office-based interventions to improve
delivery of cancer prevention services by primary care physicians.
Cancer. 1993;72{suppl):IlOO-1l12.
25. Thompson RS, Taplin SH, McAfee TA, Mendelson MT, Smith AE.
Primary and secondary prevention services in clinical practice:
twenty years' experience in development, implementation, and
evaluation. ]AMA. 1995;273:1130-1135.
26. US Preventive Services Task Force. Guide to Clinical Preventive
Services. 2nd ed. Alexandria, Va: International Medical Publish-
ing; 1996.
27. Frame PS. A critical review of adult health maintenance, part 4:
prevention of metabolic, behavioral, and miscellaneous conditions
[published correction appears in] Fam Pract, 1986;23 :537]. J Fam
Pract. 1986;23:29-39.
28. McPhee SJ, Bird JA, Fordham D, Rodnick IE, Osborn EH. Promot-
ing cancer prevention activities by primary care physicians: results
of a randomized, controlled trial. ]AMA. 1991;266:538-544.
29. Frame PS, Zimmer JG, Werth PL, Hall WJ, Eberly SW. Computer-
based vs manual health maintenance tracking: a controlled trial.
Arch Fam Med. 1994;3:581-588.
30. Shea S, DuMouchel W, Bahamonde L. A meta-analysis of 16
randomized controlled trials to evaluate computer-based clinical
reminder systems for preventive care in the ambulatory setting. J
Am Med Inform Assoc. 1996;3:399-409.
31. Margolis KL, Lurie N, McGovern PG, Tyrrell M, Slater JS. In-
creasing breast and cervical cancer screening in low-income
womenJ Gen Intern Med. 1998;13:515-521.
32. Cargill VA, Conti M, Neuhauser D, McClish D. Improving the
effectiveness of screening for colorectal cancer by involving nurse
clinicians. Med Care. 1991;29:1-5.
33. Wagner TH. The effectiveness of mailed patient reminders on
mammography screening: a meta-analysis. Am] Prey Med. 1998;
14:64-70.
34. Kottke TE, Trapp MA, Fores MM, et al. Cancer screening behav-
iors and attitudes of women in southeastern Minnesota. ]AMA.
1995;273: 1099-1105.
35. Belcher DW. Implementing preventive services: success and fail-
ure in an outpatient trial. Arch Intern Med. 1990;150:2533-2541.
36. McVea K, Crabtree BF, Medder JD, et al. An ounce of prevention?
evaluation of the "Put Prevention into Practice" program. J Fam
Pract. 1996;43:361-369.
37. Kikano GE, Stange KC, Flocke SA, Zyzanski SJ. Put Prevention
into Practice: outcomes in a family practice center. Am] Prey Med.
1997;13:352-354.
38. US Department of Health and Human Services. The Clinician's
Handbook of Preventive Services. 2nd ed. Washington, DC: US
Government Printing Office; 1998.
39. Woolf SH, Jonas S, Lawrence RS, eds. Health Promotion and
Disease Prevention in Clinical Practice. Baltimore, Md: Williams
& Wilkins; 1996.
40. Hayward RS, Steinberg EP, Ford DE, Roizen MF, Roach KW,
American College of Physicians, Canadian Task Force on the
Periodic Health Examination, United States Preventive Services
Task Force. Preventive care guidelines: 1991. Ann Intern Med.
1991;114:758-783.
41. Scheitel SM, Fleming KC, Chutka DS, Evans JM. Geriatric health
maintenance. Mayo Clin Proc. 1996;71 :289-302.
42. Williams WW, Hickson MA, Kane MA, Kendal AP, Spika JS,
Hinman AR. Immunization policies and vaccine coverage among
264 Clinical Preventive Medicine in Primary Care
adults: the risk for missed opportunities [published correction ap-
pears in Ann Intern Med. 1988;109:348]. Ann Intern Med. 1988;
108:616-625.
43. ACP Task Force on Adult Immunization and Infectious Diseases
Society of America. Guide for Adult Immunization. 3rd ed. Phila-
delphia, Pa: American College of Physicians; 1994.
44. Centers for Disease Control and Prevention. Update on adult im-
munization: recommendations ofthe Immunization Practices Advi-
sory Committee (ACIP). MMWR Morb Mortal Wkly Rep. 1991;
40(RR-12): 1-94.
45. Polis MA, Smith lP, Sainer 0, Brenneman MN, Kaslow RA.
Prospects for an emergency department-based adult immunization
program. Arch Intern Med. 1987;147:1999-2001.
46. Fedson OS, Kessler HA. A hospital-based influenza immunization
program, 1977-78. Am 1 Public Health. 1983;73:442-445.
47. Klein RS, Adachi N. An effective hospital-based pneumococcal
immunization program. Arch Intern Med. 1986;146:327-329.
48. Mullen PO, Simons-Morton DG, Ramirez G, Frankowski RF,
Green LW, Mains DA. A meta-analysis of trials evaluating patient
education and counseling for three groups of preventive health
behaviors. Patient Educ Couns. 1997;32:157-173.
49. DeFriese GH, Fielding JE. Health risk appraisal in the 1990s:
opportunities, challenges, and expectations. Annu Rev Public
Health. 1990;11:401-418.
50. Kellerman ST, Felts WM, Chenier TC. The impact on factory
workers of health risk appraisal and counseling in health promo-
tion. Am 1 Prev Med. 1992;8:37-42.
51. Ewing lA. Detecting alcoholism: the CAGE questionnaire: a criti-
cal review. lAMA. 1984;252:1905-1907.
52. Prochaska 10, DiClemente CC. Stages of change in the modi-
fication of problem behaviors. Prog Behav Modif. 1992;28:183-
218.
For personal use. Mass reproduce only with permission from Mayo Clinic Proceedings.
Mayo Clin Proc, March 2000, Vol 75
53. Prochaska 10, Velicer WF, Rossi lS, et al. Stages of change and
decisional balance for 12 problem behaviors. Health Psychol.
1994;13:39-46.
54. Singh OK, Lippman SM. Cancer chemoprevention, part I:
retinoids and carotenoids and other classic antioxidants. Oncology
(Huntingt). 1998;12:1643-1653, 1657-1658.
55. Singh OK, Lippman SM. Cancer chemoprevention, part 2: hor-
mones, nonclassic antioxidant natural agents, NSAIDs, and other
agents. Oncology (Huntingt}, 1998;12:1787-1800.
56. Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group.
The effect of vitamin E and beta carotene on the incidence of lung
cancer and other cancers in male smokers. N Engl 1 Med. 1994;
330:1029-1035.
57. Omenn GS, Goodman GE, Thornquist MD, et al. Effects of a
combination of beta carotene and vitamin A on lung cancer and
cardiovascular disease. N Engl 1 Med. 1996;334:1150-1155.
58. Antiplatelet Trialists' Collaboration. Collaborative overview of
randomised trials of antiplatelet therapy, I: prevention of death,
myocardial infarction, and stroke by prolonged antiplatelet therapy
in various categories of patients [published correction appears in
BMl. 1994;308:1540]. BMl. 1994;308:81-106.
59. Cairns lA, Lewis HD lr, Meade TW, Sutton GC, Theroux P.
Antithrombotic agents in coronary artery disease. Chest. 1995;
108(suppl):380S-400S.
60. Tisdale lE. Antiplatelet therapy in coronary artery disease: review
and update of efficacy studies. Am 1 Health Syst Pharm. 1998;
55(suppl I):S8-S16.
61. Thun Ml. Aspirin and gastrointestinal cancer. Adv Exp Med Bioi.
I997;400A:395-402.
62. Steering Committee of the Physicians ' Health Study Research
Group. Final report on the aspirin component of the ongoing Physi-
cians' Health Study. N Engl 1 Med. 1989;321:129-135.