PATIENT EDUCATION

Ian Couper

Professor of Rural Health

GEMP 2:Patient doctor themeChronic illness focus

Patient Doctor ThemeChronic Illness Focus

• Stigma and labeling

• Continuity of Care

• Early detection and prevention

• Principles of Chronic Illness Care

(Team management of diabetes)

• Patient Education

Why patient education?

• Community-doctor theme sessions on health promotion (TS 04.05.03 Health Promotion by Ms. M. Hlungwani) and prevention of illness (many)

• Fundamental to care of patients with chronic conditions (see previous lecture)

• Part of curriculum for each case/disease• Essential element of each consultation

(Stott's model)

The potential of every consultation

Address presenting complaint

Deal with ongoing problem

Do opportunistic health promotion

Modify help seeking behaviour

Modified from Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979; 29:201-205

Why

• So we know why!

• BUT …. How?

Aim

• To explain principles of adult learning, health communication strategies and change theory, and their application to the process of patient education.

• To review important questions that patients need answered about management options.

Outline (=objectives)

1. principles of adult learning with application to patient education

2. steps in communicating health information with application to the patient consultation

3. stages of change theory

4. motivational interviewing

5. important questions patients need to have answered about their health care, treatment and management options.

Principles of adult learning

Context = individual patient

But applicable to groups

DO NOT READDO NOT READ

Jane Vella

Learning to Listen, Learning to Teach

San Francisco: Jossey-Bass Publishers

1994

Adult learning principles

• Needs assessment: what does the learner (patient) need to hear?

• Respect for learners as subjects of their own learning: – control– choice

• Sound relationships: respect, listening, humility (Adult to adult)

• Immediacy: relevance to the situation

Adult learning principles

• Sequence and reinforcement– easy to difficult

– Repetition

• Clear roles: dialogue– What is the role of the doctor?

• Safety: non-judgmental environment, affirmation

Adult learning principles

• Recognising cognitive, affective and psychomotor aspects: learning is multidimensional– Cf. biopsychosocial model

• Praxis: learning by doing• Teamwork: learning enhanced by

peers– Learning groups = support groups

Health communication

“Always remember, communication is a two-way process. Ask people about their problems. Elicit their opinions and views. Listen carefully to the answers. These answers are most important for helping you decide what you want to communicate. Listening helps build trust. Listening helps you identify priorities.”

Voluntary Health Association of India, Health for the Millions, 1986.

Communicating Health

• See:

Glen Williams.

All for Health: A Resource Book for Facts for Life.

UNICEF

Steps in Communicating Health

• Define clearly what health behaviours you are promoting

• Decide who you are trying to influence• Determine whether the new health

behaviour requires new skills• Learn about the present health knowledge,

beliefs and behaviour of your “target”• Select the communication channel

– who, where, when, how

Steps in Communicating Health

• Design the appropriate health message– what– must be:

• Understandable• Culturally and socially appropriate• Practical• Brief• Relevant• Technically correct• Positive

Steps in Communicating Health

• Evaluate– understanding– action

• Adjust and repeat

Outcome

• Follow these steps and you WILL succeed!… maybe not

• Study: 1 in 20 patients educated about smoking gave up!

Russell MAH, Wilson C, Taylor C, Baker D. Effect of General Practitioners’ Advice Against Smoking. BMJ 1974; 3: 231-234

• Lots of good theory (See TS 05.03.004.

Behavioural change by Dr N Christofides), but …• Most patients don’t change!

Robbieby Chris Ellis*

I told Robbie to stopdrinking whisky today.He says he only drinks itbecause he likes the flavour.

His neighbour tells mehe went straight from my roomsto the bottle store,and bought an enormous4 ½ litre bottle of White Horse,and said “Bugger You.”

*Chris Ellis. Ruminations from Rural Practice. Johannesburg: Academy Publications, 1994.

Motivational interviewing

• One practical approach to behaviour change• Principles

– Telling the patient what to do can cause resistance– Information is not given in a neutral way: can increase

or decrease patient’s willingness to change– Readiness to change is a process, like change itself– Self-evaluation of benefits and losses is helpful– Patients’ own decisions more likely to lead to lasting

change

Stages of Change

• A model• See :

– Mhlongo SWP. Prevention and health promotion. In Mash B. (Ed) Handbook of Family Medicine. Cape Town: Oxford University Press, 2000

– Prochaska J, DiClemente C. Towards a Comprehensive Model of Change. In Miller W, Heather N (Eds) Treating Addictive Behaviors: Processes of change. New York: Plenum, 1986

Pre-contemplationContemplation

Preparation

Action

Maintenance

The Change SpiralThe Change Spiral

Stages of Change1. Pre-contemplation

– Low motivation– Denial

Response:• Understand the patient• Maintain the relationship• Give clear information• Be non-judgmental• Personalise the risk factors• Ask how the patient would know if a behaviour were a

health problem• BE PATIENT with the patient!

Stages of Change

2. Contemplation– Ambivalent– Discomfort about reality gap

Response:• Help patients examine the issue

– What are reasons for change– What are effects of not changing

• Self-evaluation– What are my reasons for not changing– What are the barriers which prevent me changing

Stages of Change

3. Preparation (Ready to change)– High motivation– Looking for ideas for action

Response:• Help with goal setting• Get practical• Encourage• Discuss obstacles and barriers• Identify a supporter

Stages of Change

4. Change (Action)– Sense of achievement– Success breeds success

Response:• Congratulate• Encourage

Stages of Change

5. Maintenance– Risk of relapse always a possibility– Risk depends on behaviour– Cycles

Response:• Encourage positive self-regard• Ensure support available

What patients need to ask

• Another aspect of patient education• Education about rights

– Fundamental is the right to information, in order to make informed health choices

• “Evidence based medicine” for patients• See:

Irwig J, Irwig L, Sweet M. Smart Health Choices: How to make informed health decisions. St Leonards, NSW: Allen & Unwin, 1999

Questions for patients to ask (and doctors to answer)

1. What will happen if I do nothing?2. What are the intervention options?

• What diagnostic tests?• What treatment options?

3. What are the benefits and harms of the intervention options?

• What?• When?• How long lasting?• How probable?

Questions for patients to ask (and doctors to answer)

4. How do the benefits and harms weigh up for me?

• How important are the benefits to me?• Am I prepared to risk the harms?

5. Do I have enough information to make a choice?

• If yes, I can make a decision• If no,

• Do I need to know more about the options?• Do I need to explore other options?

Review

• Patient education as a task of the consultation

• Adult learning – basis for educational approach

• Communicating health – practical structure• Motivational interviewing – one method• Stages of change – one model• Questions for patients – teaching them to

help themselves