Karan A. Cole
David E. Kern
One meaning of the word doctor is “teacher.” Through teaching, practitioners can help patients understand their conditions, be reassured, and adopt new treatment regimens. Most of the elements of communication during a visit, described in Chapter 3, contribute to effective teaching. Developing trust, identifying the patient's information needs and psychosocial context, and involving the patient in developing a plan are as important for successful outcomes as providing information.
Patient Education
Definition
Patient education occurs when the health practitioner uses a combination of educational assessment and intervention strategies that influence the patient's knowledge, attitudes, or health behaviors. Health behaviors encompass a wide range of activities that relate to health, including seeking health advice; keeping health care appointments; taking medications; undertaking preventive measures; modifying existing patterns of eating, exercising, or substance use; and solving problems. Patient education is sometimes completed during one practitioner–patient interaction, but more often it is an ongoing process that occurs over the course of several visits.
The Practitioner–Patient Relationship
Patient education takes place in the context of a practitioner–patient relationship, which influences the nature of the educational process. As discussed in Chapter 3, the relationship between practitioner and patient can be conceptualized as a spectrum that ranges from active–passive to mutual participation. In an active–passive relationship, the practitioner, as expert, is responsible for explaining and prescribing and the patient is responsible for following orders. This type of relationship presumes an authoritative approach to patient education and behavior change. In a mutual participation relationship, the patient and practitioner actively collaborate and patients take more responsibility for their care. This type of relationship assumes that most patients are capable of participating with the practitioner in the development of their own management plans. It incorporates an empowerment approach to patient education and behavior change, during which the practitioner facilitates patient involvement in goal identification, problem solving, and planning (1). Practitioners assume the role of mentor, consultant, and expert in medical knowledge.
Effective patient education does not involve the exclusive use of either an authoritative or an empowerment approach. Approaches often are combined, and the balance of authoritative and empowerment approaches within a given practitioner–patient interaction is determined by practitioner and patient attitudes and skills and by patient needs.
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Empowerment versus Compliance
Ambulatory patients are responsible for implementing most of the management strategies developed in practitioners’ offices. To implement a management plan, patients have to be ready for it, believe it is in their best interest, believe that they can accomplish it, and have to do it. Empowerment is the facilitation of active self-management by patients. The more complex and behaviorally demanding a management plan, the greater the challenge for the patient who must integrate it into the demands of day-to-day living.
Ideally, therefore, the goal of patient education is to provide patients with the knowledge, attitudes, and skills that will empower them to make informed decisions and adopt healthy behaviors, rather than simply comply with or adhere to practitioner-dictated treatment plans. The terms compliance, adherence, and noncompliance, used for many years to describe the extent to which patients follow through with medical advice or agreed-upon plans, are now believed to be problematic because they exaggerate the importance of the clinician, describe behavior inaccurately, and do not address motivation (2).
Importance
Regardless of terminology, it is well established that many patients fail to adopt healthy behaviors or follow through with agreed-upon treatment plans, often resulting in poor health outcomes. If practitioners are unaware of their patients’ health behaviors, they may falsely attribute poor outcomes to failure of a treatment approach, inadequate dosage, or incorrect diagnosis, and subsequently take inappropriate action. When patients do not adopt healthy behaviors, the use of health care services may increase. For example, such patients are more likely to be hospitalized, or, if elderly, to be placed in nursing homes. The cost and frequency of use of outpatient services, including emergency room care, may be increased (3). Consequently, an approach to patient education that helps patients to adopt healthy behaviors is a fundamental skill for the medical practitioner.
Educational and Behavioral Change Principles
An empowerment approach to patient education and behavioral change requires an understanding of certain principles that guide the assessment of educational needs and the planning of educational interventions.
Adult Learning
As people age, they become less dependent and more self-directed (4, 5, 6). They are more likely to make changes and to learn when they perceive a need to do so, rather than when they are told to do so. They prefer to be actively, rather than passively, involved with their learning, and tend to be problem-oriented rather than subject-oriented. As they age, people increasingly define themselves by their experience. Consequently, a practitioner who defines a goal and management strategy for a patient is less likely to be successful than the practitioner who involves the patient in clarifying needs and expectations and who collaborates with the patient to develop achievable goals. Effective management strategies incorporate the patient's past experiences, expectations, and strengths, and engage the patient in addressing barriers.
Single versus Multilevel Interventions
Clinical experience and research support the principle that knowledge is necessary, but insufficient when patients are expected to make lifestyle changes. Such changes range from fitting a medication regimen into a patient's daily routine to altering long-standing patient habits such as overeating or smoking. Educational interventions that are targeted at several levels, including knowledge, attitudes, behavior, and environment, are the most effective interventions. Studies of the impact of patient education on a number of conditions confirm this principle (7).
Readiness for Change
Matching the practitioner intervention to patient readiness for change predicts patient success (8). There are five stages of readiness for change: precontemplation, contemplation, preparation, action, and maintenance (Fig. 4.1). A patient may move back and forth on this cycle many times before successfully adopting a new habit. Relapse is the term applied when a patient regresses to an earlier stage. Successfully identifying the stage of readiness for change helps the practitioner target appropriate strategies to move the patient to the next phase. If a patient has not even considered a specific behavior change, such as stopping smoking (precontemplation), the practitioner might pursue
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strategies to help the patient move toward contemplation, such as exploring the patient's existing knowledge and attitudes toward smoking and providing an understanding of the hazards of smoking or reasons why the patient might want to stop. If the patient is contemplating a behavioral change, the practitioner might help the patient identify facilitators and barriers to change and make a commitment to change (preparation). In the action phase, the practitioner might work with the patient to set specific goals, anticipate and address problems, build skills, and develop strategies to support the behavioral change. In the maintenance phase, further problem solving, building of skills, and development of support strategies are appropriate to prevent relapse. Although not considered a separate stage, integration occurs when new behavior patterns are fully incorporated into the patient's life.
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FIGURE 4.1. The readiness for change cycle. |
Self-Efficacy
An important factor in predicting whether a patient will take action is the patient's self-efficacy, or confidence in performing a behavior (9). Past and current success with new behaviors, and observing others successfully perform a behavior, can increase a patient's confidence in his or her own capacities. Numerous studies have identified the relationship between self-efficacy and behavior, and demonstrated the effectiveness of interventions targeted toward increasing an individual's self-efficacy (10).
Health Locus of Control
Individual orientation to control (i.e., internal, external, or chance locus of control) influences beliefs about who is responsible for health status (11). A patient's orientation is relevant because it helps determine whether an authoritative or an empowerment approach will be most effective.
Patients who believe that their health is a consequence of their own efforts have an internal locus of control. They believe in mastery and control over their environment and prefer to take a high level of responsibility for their health care. For them, an empowerment approach to patient education and behavioral change is most appropriate.
Those who believe that their health is a consequence of the efforts of others, particularly practitioners, have an external locus of control. They prefer explicit directions from their practitioner. An authoritative approach to patient education is most appropriate. However, a patient's health locus of control can shift from external to internal if the patient has success as the result of his or her own efforts. Thus it is beneficial to gradually include empowerment approaches so as to help patients take more responsibility for their own health over time.
Finally, patients who have a chance locus of control believe that health-related outcomes are determined by fate and are therefore uncontrollable. When this belief is inappropriate to the situation (e.g., in a patient with uncontrolled hypertension), the practitioner may wish to explore and address the belief.
Health Beliefs and Explanatory Models
Patients come to a health practitioner with their own ideas about their health and health problems, which are grounded in their own experiences, social interactions, and culture. These ideas or beliefs inform patients’ explanatory models of illness and disease, and include ideas about etiology, pathophysiology, severity, prognosis, treatment, and prevention (12). They influence patients’ perceptions of potential threats to their health and the benefits of specific actions. The following perceptions, for example, influence a patient's health-related behavior (13):
It is important to remember that patients’ health beliefs and explanatory models are affected by both sociocultural and individual factors. The former include family, friends, social network, ethnicity, education, religion, and socioeconomic status. Practitioners who provide explanations and negotiate management plans that make sense in terms of patients’ own health belief systems and social contexts are more likely to satisfy patients and influence their behavior (14).
Behavioral Intention
Patients who intend to adopt or change behaviors are more likely to do so. Such intention is often a consequence of the aforementioned principles. Patients who are ready to make a behavior change, have high confidence in their ability to make the change, agree with the explanation provided by the practitioner, and believe that they will experience benefits if they make the behavior change and consequences if they do not, are likely to have a greater intention to adopt or change a behavior than are patients who do not have these characteristics. Also, patients who have been part of the decision-making process are more likely to have a greater intention to adopt or change a behavior than are patients who have simply been told to make a change.
Social Support
Social support can be defined as external resources that assist efforts of the patient to meet internal and external
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demands. A substantial body of literature explores the effectiveness of social support in preventing illness (15). Social support also improves adherence to medical recommendations (16), adjustment after myocardial infarction (17,18), and success in smoking cessation (19). In addition to the quantity, the quality of support is important. No matter how many potential supports are available, patients need to be asked about their own perception of them, because the available supports may actually be barriers to, rather than resources for, behavioral change. An unsatisfying marriage may be worse than no marriage for health outcomes (20). The overinvolvement of spouses, characterized as misguided helping, can have negative effects (20). When family members exhibit harmful behaviors that patients are trying to change, such as smoking or eating a high-fat diet, patients have a particularly difficult time changing their own behaviors. On the other hand, if family members can be enlisted to support patients in positive ways, patients are more likely to make healthy changes in their behaviors. Family involvement is influenced by culture, which, for example, may determine who makes decisions in a family, whether a family member should be present when negotiating a treatment plan, and how a family responds to a negotiated plan. In addition, patients may need to develop skills to communicate their need for support and to negotiate for appropriate support.
Assessment
Importance
Patient education can be conceptualized as successive cycles of assessment and intervention (Fig. 4.2). The effectiveness of an educational intervention depends on the accuracy of the educational assessment as well as the practitioner's skill in using specific instructional, behavioral, motivational/empowerment, mechanical, and organizational strategies (see Intervention). Patient education, therefore, should begin with an assessment of (a) background information that defines the patient's educational needs, the patient's capacities to adopt new behaviors, and environmental facilitators and barriers; and (b) the patient's current health-related behaviors, such as medication taking and nondrug treatments.
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FIGURE 4.2. The assessment–intervention spiral. |
Assessing Background Information
Many factors are associated with adherence to medical recommendations (Table 4.1) that should be considered before making an educational diagnosis and developing an educational intervention. Eliciting this background information from a patient makes it possible to individualize an explanation or a management plan in a way that is likely to be effective.
Patient Characteristics
Patients' decisions to seek health care and receptivity to practitioners and their recommendations are likely to be influenced by their own past and current experiences, the experience of others in their social circle, and cultural factors. They may face barriers to using mainstream health care because of accessibility, cost, language, or health literacy, and may already be using alternative health care resources. They may have experienced prior misunderstandings or conflict with a health care facility. In the case of refugees and immigrants, there is the potential for the restimulation of traumatic stress reactions and fear of deportation, resulting in the avoidance of formal services (21).
As noted previously, patients’ knowledge, attitudes, beliefs, and perceptions about a condition and its management influence their health-related behaviors. As distinguished from disease, which is an objective entity based on the presence of independently verifiable findings, a patient's explanation and experience of illness is a subjective state that is shaped by personal, interpersonal, and cultural factors. It is patients’ perceptions of an illness and its treatment that relate to adopting healthy behaviors, rather than the objective realities. An extreme example occurs in patients who deny illness. Patients who have had a myocardial infarction but answer “No” or “Maybe” rather than “Yes” when asked whether they believe that they have experienced a heart attack are less likely to follow the practitioner's instructions regarding activity level and smoking cessation (22).
Patients often have their own models of disease and treatment. If these models conflict with recommended regimens, patients may not follow the regimens. For example, the commonly held perception of hypertension as an intermittent, symptomatic, stress-related condition encourages an erratic approach to medication taking. Some patients with clearly diagnosable soft-tissue injuries may think that their evaluation was incomplete without a radiograph and therefore mistrust the practitioner's diagnosis. Ethnic concepts of disease and treatment can also
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conflict with the practitioner's approach to diagnosis and management. Such concepts are more prevalent among ethnic group members who experience a language barrier, are generationally close to immigration, live in segregated neighborhoods, are lower in education level and socioeconomic class, experience barriers to receiving personalized medical care, or lack experience with a Western health care system—that is, those who are least integrated into the mainstream culture. For example, some patients might change practitioners or refuse treatment if they are told they have both “high blood pressure” and a “low blood count” (anemia). According to some folk beliefs, these diagnoses are mutually exclusive, so the practitioner making them may be regarded as untrustworthy. Questions such as “Why do you think you are ill?” and “How would you like me to help?” can assist assessment of patient explanatory models. Health beliefs about management can be assessed by asking patients their perceptions of the benefits and risks of a suggested treatment strategy.
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TABLE 4.1 Assessment: Factors Associated with Adherence to Medical Recommendations |
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Patient values may be congruent with or conflict with those of the practitioner and affect adherence with practitioner recommendations. For example, elderly patients may value the quality of living and dying more highly than the simple preservation of life. Consequently, they may prefer to accept an increased risk of death rather than endure an inconvenient, impersonal hospitalization that separates them from home and family. Patients may also value certain ways of interacting with the world more highly than others (23). Patients who value anindividualistic orientation believe in self-sufficiency, individual responsibility, and personal autonomy. Those with a collective orientation believe in relational interdependence, group harmony, and in-group collaborative spirit. Power orientation determines whether patients will question authority. Privacy orientation influences patient disclosure of information. Patients who value access to information will want details about their condition and treatment. Recognition and accommodation of such values should help practitioners negotiate health management plans that are acceptable to patients.
Other important, often overlooked, patient characteristics are patients’ feelings and beliefs about themselves. As previously mentioned, an internal or external (as opposed to chance) locus of control, greater self-efficacy, a readiness for change, and strong behavioral intentions, are usually associated with adopting healthy behaviors.
Other feelings, such as dislike of taking medication, the desire not to depend on or be controlled by others, and the need to be seen by self or others as normal, can also interfere with patients’ adoption of appropriate treatment regimens. The practitioner can gain knowledge of many of these feelings and beliefs by simply listening to the patient and, when necessary, asking targeted, open-ended questions.
Self-care and self-management skills are important factors that vary among patients and affect a patient's ability to adopt healthy behaviors. These include general skills such as the ability to set and pursue goals, problem solve, make decisions, use coping skills, coordinate a variety of tasks, and use available support. Condition-specific skills, such as changing wound dressings, self-monitoring of blood pressure or blood sugar, and the mixing and injecting of insulin, are also important.
Previous or concurrent adoption of one aspect of a treatment plan usually relates to adoption of other aspects of the regimen.
Some studies found that psychological factors, such as immaturity, impulsivity, hostility, fear of dependence, denial, commitment to a bad decision, and type A personality, were related to nonadherence. Moreover, some patients who come to practitioners are experiencing considerable anxiety, which may interfere with cognitive functioning, of which comprehension is one element. Other patients may experience a period of grief in reaction to a diagnosis, such as diabetes or coronary artery disease, and such grief may interfere with their ability to master the demands of a new treatment regimen (24).
In many studies, sociodemographic variables, such as age, sex, race, education, occupation, income, and marital status, have shown little relationship to adherence behavior. On the other hand, elderly patients have been shown to have difficulty in opening childproof medication containers and are at increased risk for diseases that cause cognitive impairment, which, in turn, can affect comprehension, memory, and execution of a treatment plan. Lack of insurance and inability to pay for visits, medication, or transportation are important barriers for an increasing number of patients. Low health literacy, which is recognized as a common problem (25), and language barriers are additional sociodemographic factors that affect understanding and adoption of healthy behaviors. Some studies associated older age, retired status, married status, patient initiation (as opposed to provider initiation) of an appointment, and third-party payment, prepayment, or lack of copayment with improved appointment-keeping behavior, whereas lower education, lower socioeconomic status, and language barriers were negatively correlated with appointment-keeping behavior.
Disease Features
Patients who are experiencing symptoms such as pain, lethargy, and palpitations are more likely than asymptomatic patients to follow treatment recommendations, especially if the symptoms are relieved by the treatment. Conversely, patients may be so overwhelmed and debilitated by their symptoms that they are unable to follow through with aspects of the regimen.
Comorbidity may either create problems for patients or provide the patient with a set of self-management skills that are easily applied. For example, a patient with
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hypertension and diabetes who recently had a myocardial infarction may either have trouble following recommendations because of the multiple demands or may actually have an easier time as the result of having learned self-management skills with the hypertension and diabetes. Patients with depression or certain psychiatric illnesses, such as mania, schizophrenia, paranoia, or antisocial or paranoid personality disorder, are less likely to follow a treatment regimen. Factors that affect the patient's ability to comprehend or to organize and initiate deliberate behavior, such as dementia or mental retardation, should also be expected to impair the patient's ability to follow a treatment regimen. Alcoholism and drug addiction correlate highly with failure to follow prescribed regimens.
Treatment Factors
The complexity of medical regimens relates inversely with adherence to them. Adherence decreases as the number of medications or the number of daily doses per medication increases. Unsynchronized schedules (e.g., one drug every 4 hours and another every 6 hours) should also be expected to affect medication-taking behavior adversely. The duration of therapy and the requirement for significant behavioral change (e.g., weight reduction, smoking cessation) are negatively correlated with adoption of healthy behaviors. Side effects of medications may result in failure to follow a medication regimen if they cause significant symptoms or interfere with an important function in the individual's life (e.g., impotence secondary to an antihypertensive drug in a young, sexually active man). Medication class is related to medication-taking behavior, with higher adherence rates for seemingly more important drugs (e.g., cardiac and diabetic agents—>70% adherence in cross-sectional studies) than for seemingly less important medicines (e.g., antacids, sedatives, and drugs prescribed for symptomatic relief—<50% adherence) (26,27). The reason for these differences is unknown; it could relate to sound patient judgment or to increased practitioner emphasis, supervision, and teaching. Expense to the patient is a barrier to medication taking for many patients because of the rising cost of drugs and limited or no insurance coverage. Software now exists (e.g., ePocrates) that permits practitioners to access and compare cost information on handheld computers in their office. Other aspects of the treatment regimen that can influence medication-taking behaviors include delayed or nonobvious benefits of the therapy and the degree of lifestyle interference.
Environmental Factors
Patients who have stable support systems and stable family situations are more likely to adopt healthy behaviors than those who do not. A spouse's concern about a patient's illness can encourage medication taking, appointment keeping, and behavior change (e.g., diet, smoking cessation). Advice and reinforcement from other family, friends, and lay practitioners can also encourage adoption. Nursing and office staff may promote healthy behaviors by demonstrating enthusiasm and positive attitudes about a treatment regimen. On the other hand, an overly protective family member can sabotage a plan for progressive return to normal function. Disinterested or poorly informed family members or friends may actually discourage patients from following a treatment plan. Family dysfunction or high levels of dependence on the patient (e.g., when the patient is a caretaker) can create a burden that makes adopting healthy behaviors difficult.
The cultural norms of social group, ethnicity, family, age, and gender also are important. Adherence to these norms is likely to supersede adherence to the norms of the medical profession when the two are in conflict. Patients may have competing priorities or environmental obstacles to adopting healthy behaviors, such as childcare problems, crime, poverty, and transportation difficulties.
It should be remembered that patients’ previous experiences of similar disease among relatives or friends can profoundly affect their beliefs about their own illnesses and influence their health-related behaviors.
Appointment keeping is positively correlated with appointment-scheduling systems that reduce waiting time, give individual rather than block appointments, minimize the time between scheduling and the actual appointment date, and make referrals to specific practitioners rather than to clinics. Convenience in terms of location or hours of operation of a practitioner's practice and support staff who are respectful, friendly, and helpful can also encourage appointment keeping and discourage dropping out.
Practitioner–Patient Relationship
Establishment of a good practitioner–patient relationship is well recognized to be an important determinant of patients’ adherence to treatment plans. Although effective communication is a prerequisite to the establishment of such a relationship and affects health care outcomes (28, 29, 30, 31), as well as the adoption of health-promoting behaviors (14,32,33), studies show that practitioners commonly communicate poorly with their patients (34). The necessary skills (see Chapter 3) can be learned and are being taught with increasing frequency in medical schools, residencies, and continuing-education courses (35).
Features of the communication process that relate to patient adherence to treatment regimens include the following (14,28,29,31, 32,33,36, 37, 38, 39):
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Effective transfer of information is important (40) because patients must understand their regimens before they can be expected to follow them (see Intervention Instructional Strategies). Because patients may already have some ideas and concerns about their problems, explanations that justify a treatment regimen, correct or accommodate misconceptions, and make sense to the patient are most likely to promote adoption of the regimen. Understanding of physician instructions may be hampered by the tendency of many patients to ask few questions of their practitioners even when they desire information (24). It should not be assumed in cross-cultural interactions that patients who do not ask questions are passive or apathetic. They may feel intimidated, or they may be observing cultural norms related to authority, status, and control.
Some practitioners prefer patients who do not ask too many questions and who simply follow instructions. Although this active–passive relationship may be appropriate for some patients, to be effective with other ambulatory patients, practitioners must enter into a relationship of mutual participation in which they listen to, educate, and negotiate with patients. A mutual participation approach positively relates to adherence outcomes (28,29,41) and need not be time-consuming. It is the quality of the interaction, not the amount of time spent, that relates to patient adoption of healthy behaviors and satisfaction (34).
Differences may exist between practitioner and patient styles of communication. These include implicit versus explicit, direct versus indirect, self-enhancement versus self-effacement, person-based versus status-based, and verbal-based versus silence-based styles. Practitioners’ adjustment of their styles of communication to meet the needs of different patients and different situations may enhance the effectiveness of interactions.
Language barriers are particularly pertinent to multicultural interactions between practitioners and patients. Even with the use of a translator, there may be mistranslation of concepts and errors of omission. Interactions can be optimized by using short and direct sentences; avoiding technical or professional jargon, idioms, and metaphors; avoiding complex questions; and allowing enough time (21).
In some cross-cultural interactions, it may be essential to accommodate to the norms of the patient's culture. For example, in traditional Navajo culture, it is important to present important medical information, such as information about a procedure that involves risk, in positive, not negative, ways (42). In some cultures it is important to communicate directly with a patient's family member, rather than with the patient. This applies to cultures where there are strict gender or generational roles that should be observed in the making of medical decisions.
Close supervision of the patient by the practitioner (or an assistant) is a feature of the practitioner–patient relationship that has proved to be a consistent and significant correlate of adherence to therapeutic regimens. In most studies, continuity in provider care has also contributed to adherence to therapeutic regimens.
Transference, or the subconscious redirection to one person (the practitioner) of feelings and attitudes for others (e.g., parents, siblings, authority figures), may further influence patients’ relationships to their practitioner. Depending on their nature, transference reactions, which are based on previous experiences, can promote adoption of healthy behaviors (e.g., the patient who finds it rewarding to please authority figures) or impede it (e.g., the patient who distrusts authority figures). Countertransference, the redirection toward the patient of previously developed practitioner attitudes and feelings, can also be detrimental or beneficial to the practitioner–patient relationship (seeChapter 20).
Many of the features just described contribute to the development of patient trust in the practitioner, and trust is one of the most important factors in any approach to helping people change. A key element of trust is self-disclosure. Because self-disclosure exposes the patient to possible rejection, ridicule, shame, or exploitation, it is important to elicit and respond to admissions of unhealthy behaviors in a nonjudgmental manner, in the context of a positive and supportive relationship. In cross-cultural interactions, additional aspects related to trust include respecting differences between the practitioner and patient in regard to comfort with personal distance, the amount and placement of touch, perceptions of privacy, and the use of informal or formal communication. With certain ethnicities, trust building may take additional time and effort on the part of the practitioner owing to the patient's feeling intimidated by the practitioner, difficult past experiences with health care providers, or feelings of powerlessness.
Methods for Assessing Background Information
Much of the information detailed previously may already be known to the practitioner who has an ongoing
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relationship with a patient. Review of the primary care and other front sheets (see Figs. 1.1, 1.2, and 14.3) in a well-maintained patient record is an efficient method of obtaining relevant information. A focused medical and social history can also elicit important background information. Whenever patients present with new problems or difficulty managing old ones, it is helpful to inquire about their understandings, beliefs, feelings, past experiences, and readiness for change related to the problem, as well as their expectations for the practitioner–patient encounter. The information-gathering skills described in Chapter 3 and demonstrated in the following examples pertain to this task.
Examples
Practitioner: Mrs. Smith, tell me your understanding of hypertension … what it is and how it should be treated. [understanding]
or
Practitioner: Mr. Jones, it seems like you have been troubled by this back pain for some time now. What would you most like me to do for you today? [expectations]
or
Practitioner: Ms. Jackson, tell me how you feel about stopping smoking? [readiness for change]
Some patients may not expect, or may feel awkward about, such open inquiry as to their opinions. Because the patient may be embarrassed to reveal their ideas or fear being ridiculed for them by the practitioner, a patient might initially avoid answering the questions. In these situations, it is helpful to be gently persistent while conveying genuine interest in and respect for the patient.
Example
Practitioner: Mr. Johnson, you seem worried about your sore throat. What do you think might be causing it?
Patient: I don't know. That's what I came here for … to find out. [possible avoidance]
Practitioner: Well, I have some ideas, but it's also helpful for me to hear about my patient's concerns so that I can make sure I address them. [gentle persistence]
Patient: Well, I really don't know. I just wanted to make sure it wasn't something serious, since it's been hanging on. You know I’m a smoker, and so was my dad. He died of throat cancer.
Practitioner: Well, that's a very understandable concern. [nonjudgmental, supportive, and respectful response]
Result: The practitioner proceeds to explain that there is no reason to suspect cancer on the basis of the history or physical examination and uses the opportunity to explore the patient's readiness to stop smoking.
Assessing Health-Related Behaviors
Knowledge of a patient's medication-taking and other health-related behaviors is a prerequisite to evaluating the effectiveness of current regimens and to determining whether there is a need for behavioral change or reinforcement. This section focuses on general assessment strategies. Subsequent chapters address the measurement of specific health-related behaviors (substance use, Chapters 27, 28, 29; exercise, Chapters 16 and 63; obesity, Chapter 83) and problem-solving styles (Chapters 19, 20, and 23).
Explicit assessment of health-related behaviors is important because studies show that practitioners are poor at subjectively predicting patients’ adherence to treatment regimens, sometimes performing no better than expected by chance (43, 44, 45). There are several approaches to assessing health behaviors in patients (Table 4.2). Because each method has some limitations, it is often necessary to use more than one method to arrive at a reasonably valid estimate of such behaviors in an individual patient.
Asking
The simplest and most practical method of assessing health-related behavior is to ask the patient. With straightforward questioning, however, only 40% to 80% of patients will acknowledge that they are not following treatment plans (poor sensitivity). On the other hand, self-reports by patients that they are not following desired regimens are generally valid (high specificity). There is even some evidence that patients who admit to not following
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recommendations may be more amenable to intervention than those who do not (46).
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TABLE 4.2 Assessment of Health-Related Behaviors |
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The manner of asking influences the accuracy of patient response and the degree of patient comfort. Some questioning techniques can provide reasonably valid estimates of patient health-related behaviors (47). It is generally agreed that patients should be questioned about their behavior in an open-ended, facilitative, nonthreatening, nonjudgmental, yet detailed and specific way. Questioning should continue until the patient has provided information about what medicines are being taken and how often, how often doses are missed, and what nonpharmacologic modes of treatment are being used. Patients should specifically be asked about health-related behaviors on the day of and the day preceding their visit. (For example, some diabetic patients routinely omit all drugs, including insulin, at the time of a morning visit;24-hour recalls are more accurate than general reports, which tend to be idealized.) Using such techniques, the practitioner will be able to identify 50% or more of those patients who are not following a negotiated regimen (and all of those who have not followed through because they did not understand the regimen). On occasion, more accurate information may be obtained by asking family or household members. In certain cross-cultural interactions, the practitioner may need to use an implicit or indirect approach to determining patient behavior.
Example: Ineffective Method
Practitioner: Now, Mrs. Smith, are you taking your medications as prescribed? [judgmental and leading question, permits a Yes/No answer and promotes a Yes answer, confines response to medications]
Patient: Yes, every day.
Result: The practitioner raises the dosage or adds a new medication because the patient's blood pressure is still inadequately controlled. The patient becomes frustrated.
Example: Effective Method
Practitioner: Now, Mrs. Smith, can you tell me what you are doing to control your blood pressure? [open-ended, nonjudgmental, focuses responsibility on the patient, does not confine response to medications]
Patient: Well, I’ve stopped adding salt to my food and have pretty much cut out all salted snacks. I do occasionally have a frozen dinner when I’m alone. And, of course, I’m taking the medication.
Practitioner: Uh, huh. [facilitative]
Patient: Yes, that blue pill.
Practitioner: And how are you taking it? [directive, not leading]
Patient: Twice a day.
Practitioner: Any other medications? [directive, not leading]
Patient: No. I stopped the fluid pill when we started the blue one.
Practitioner: And did you take the blue one this morning? [directive]
Patient: No, I never take my medicine the day I come to the office!
Practitioner: What about yesterday? [directive, not leading]
Patient: Yes … at least in the morning. Yesterday afternoon was so hectic! You know how busy my days are!
Practitioner: I guess it's hard to take that afternoon dose? [facilitative, empathetic, nonjudgmental]
Patient: Yes, because my schedule varies so much.
Practitioner: What did you decide about starting on an exercise program? [directive, nonjudgmental, focuses responsibility on the patient]
Patient: Thought about it, but haven't done anything yet. Do you really think it's important?
Result: The practitioner congratulates (positively reinforces) the patient on salt restriction, tailors a medication regimen to the patient's schedule, explains why the patient should take her medication on the day of an office visit, provides more information on the value of regular exercise, and provides written instructions and a contract to which both agree. The practitioner decides not to restart the diuretic because the patient has restricted her salt and because the current blood pressure reading does not reflect the effect of the patient's current medication regimen. If the dietary history had been less convincing or the patient had gained weight, the patient might have been asked for a 24-hour diet recall (which is more accurate than general questioning) on this and subsequent visits.
Medication Counts
Medication counts (pill counts) are a form of indirect behavioral monitoring that provides a more objective measure of how patients are following prescribed medication regimens than does simply asking. They have been used to demonstrate the lack of reliability of patient-reported medication-taking behavior. Results are usually expressed in terms of percentages. The ability to measure sequential behavior depends on the use of short intervals between counts, which is usually infeasible. Although more accurate than reported behavior, medication counts do have limitations. If patients are suspicious of being monitored, they can remove medicines from containers without
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ingesting them. Overestimates of medication usage can also occur if other people are using medicine from the same container. Medication usage may be underestimated if the patient is using two or more medication containers but makes only one available for counting. Many patients do not bring their medication containers with them to the practitioner's office despite reminders. Finally, some patients might take offense at having their medications counted, resulting in deterioration of the practitioner–patient relationship.
The medication count can be approximated by the more practical and less intrusive method of prescribing quantities of medication that should be consumed within a reasonable interval of time, and then observing the frequency with which prescription renewals are requested.
Ingenious medication dispensers have been devised that monitor not only the amount but also the regularity with which medicine is removed (48). They are emerging as a new gold standard for the assessment of medication-taking behavior, but currently they are used primarily in research trials, are expensive, and are not generally available for use in clinical practice.
Assays
An objective but indirect method of assessing medication-taking behavior involves testing drug levels in blood, urine, breath, or saliva. Drug levels correlate with compliance determined by other methods as well as by outcome. Marked variation in drug levels may reflect inconsistencies in medication taking. Monitoring drug levels and relaying results to the patient might improve medication-taking behavior.
However, there are limitations to this method. Assays can be expensive. For accurate assessment, multiple measurements are required over an extended period. There is the possibility that patients who know they are being monitored may take medicine immediately before the collection of specimens but not at other times. More important may be differences in drug absorption, distribution, metabolism, and excretion among individuals, which make it impossible to decide whether a low level represents ineffective medication-taking behavior or inadequate dosage in the individual patient. The absence of any drug in the specimen suggests failure to take any of the medication, assuming the specimen has been collected appropriately. The practitioner should have a working knowledge of the pharmacokinetics of the medicine being assayed so that the collection of specimens can be timed correctly. Short-acting drugs, which are rapidly cleared from the blood and excreted, are difficult to monitor by assay techniques because of the difficulty in collecting specimens at appropriate times. Finally, assays are not available for many medications.
Assays can also be used to assess abstention from alcohol, drugs, and smoking (see Chapters 27, 28, 29).
Outcomes
Another objective but more indirect method of assessing health-related behaviors is to monitor expected therapeutic or physiologic outcomes. For example, blood pressure can be monitored in a patient who is taking antihypertensive medication, weight in a patient on a weight-reduction diet, and pulse rate in a patient prescribed a β-blocker. Review of the longitudinal relationship between a specific therapeutic regimen and outcome measures can provide clues to health-related behaviors (e.g., the review may disclose widely varying blood pressures on a constant regimen). Such a review can be expedited by the presence and maintenance of a treatment versus outcome flow sheet (see Chapter 1). Feedback about outcomes to patients can also serve to motivate them to change their behavior or positively reinforce changes they have made.
Many of the limitations of drug assays also pertain to assessment of health-related behaviors by the monitoring of outcomes. Outcomes can be influenced by variations in drug bioavailability, absorption, distribution, and excretion; multiple measurements are required. Furthermore, additional factors can influence outcome. For example, a reduction in stress may lower blood pressure, or the presence of concomitant heart disease might be responsible for bradycardia.
Observation
An additional approach to assessing health-related behaviors is to observe patients directly, or indirectly through others, such as family members, household members, or visiting nurses. Patient self-monitoring reports can also serve as a form of indirect monitoring. They have the additional benefit of providing feedback to the patient, which can motivate the patient to change behaviors or positively reinforce changes that have been made.
An extension of this approach involves the comparison of drug levels or outcomes of therapy during observed versus unobserved periods of a targeted behavior such as medication consumption. Observations and measurements can be accomplished either in the office, at home, or during hospitalization, depending on the pharmacokinetics of a medication, insurance coverage, and the availability of home care resources. A specific example of this methodology is the 5-hour office blood pressure check in patients who have resistant hypertension, during which the patients take their medication under supervision, then have their blood pressure measured at regular intervals for several hours (49).
Inspection of all pill bottles is a commonly used and important form of observation. Having patients routinely bring all medication containers to the office (including those for both prescribed and over-the-counter medications) may provide invaluable information. What a patient is actually taking is often different from what is recorded
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in the chart. Other health care providers may have added or subtracted a medication, for which the patient does not remember the name or dose. Sometimes the practitioner discovers that a patient is still taking a discontinued medication or is taking two different preparations of the same drug. Having patients bring medication bottles to each visit is particularly important for patients with cognitive impairment and for those on complicated medication regimens.
Intervention
General Principles
Once an educational assessment has been made, the practitioner is well positioned to help the patient acquire the information, attitudes, skills, and behaviors needed to deal with the medical problem. It is helpful to keep in mind some general principles (Table 4.3) when designing and implementing an educational intervention for a given patient.
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TABLE 4.3 Intervention: General Principles |
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Examples
Objective: Between this visit and the next, the patient will adhere to a medication regimen, agreed upon by him and me.
or
Objective: By the end of this visit, the patient will be reassured that her malaise and weight loss are unlikely to be caused by cancer (her fear) and will entertain the possibility of depression as a cause.
Examples
Practitioner: I know we covered a lot today. It would help if you could tell me in your own words what you are going to do between now and the next visit.
or
Practitioner: Last visit we discussed treatment options for your angina. I also gave you a handout on
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angina. I wonder what your thoughts are now about the options and my recommendations?
Applying these general principles to practitioner–patient educational interactions should enhance patients’ understanding, satisfaction, and adoption of desired health-related behaviors. Specific educational and behavioral change methods are discussed later in this chapter. They should be viewed as a menu of options that can be used in implementing the general principles that were discussed in this section and summarized in Table 4.3.
Efficacy of Educational and Behavioral Change Interventions
Educational and behavioral change interventions can be classified as instructional, behavioral, motivational/empowerment, mechanical aids, or organizational strategies. Successful interventions have increased adherence rates by amounts that range from <10% to almost 70%, averaging between 25% and 30% (percentage change equals percentage of adherent patients in the experimental group minus percentage of adherent patients in the control group). Adherence-improving interventions can also be cost-effective (3). A combination of instructional and behavioral/motivational interventions is more effective than instruction alone (50).
Instructional Strategies
Some sort of explanation or communication of information is a part of almost every practitioner–patient interaction. Sometimes the explanation is an end in itself (e.g., explaining to a patient the expected course of a condition for which there is no treatment, clarifying a patient's unfounded fears about a laboratory test). In other situations, it promotes adherence by providing patients with a rationale for treatment and clarifying a treatment regimen (40). The patient education content related to specific problems and diagnostic procedures is described in later chapters of this book (see especially Patient Experience examples related to procedures). Instructional strategies that enhance understanding, retention, and adherence are displayed in Table 4.4 and discussed next.
Information is most effective when it is targeted to the needs of the patient, provides an explanatory framework understandable and acceptable to the patient, and addresses misconceptions and potential barriers to adherence. The use of medical jargon should be avoided, and the use of language should be tailored to the educational and cultural background of the patient.
To improve retention, verbal instructions should be clear, concise, and explicit, with important features emphasized and repeated. When there is a large or complex body of information to be conveyed, it is helpful to break it down into understandable categories, as in “I am going to tell you what I think is causing your symptoms, what tests I am going to suggest, and the treatment that should help you. Now, what I think is causing these symptoms….” This technique has been shown to improve retention of information when compared with a less organized recitation of facts (40). An interactive approach to communicating information encourages patients to ask questions and have their questions answered. It permits ongoing targeting of the educational message and assessment of patient understanding. It should also increase retention.
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TABLE 4.4 Intervention: Instructional Strategies |
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Because patient factors such as anxiety and reluctance to ask questions can interfere with understanding, it is useful to check for patient understanding and retention of the essentials of the information that has been communicated. Furthermore, because patients tend to recall the diagnosis better than the treatment plan (40), it is important to ascertain retention of the essentials of the treatment plan. For example, for a streptococcal throat infection, determine whether the patient understands that penicillin will be taken for a full 10 days (not the exact dosage or schedule, which will be transcribed onto the pill bottle). So as not to offend the patient when checking for comprehension, it is helpful to use an approach such as, “We covered a lot today, and I’m not sure whether I have explained things clearly. It would help me if you would tell me what you understand to be the plan,” rather than directly ordering the patient, “Now tell me what the plan is.”
Written instructions further enhance adherence (40), and are an important adjunct to verbal instruction. They can be documented on self-duplicating forms (Fig. 4.3). The duplicate portion can be attached to a visit note or a specially constructed educational flow sheet for documentation and future reference. Providing patients with understandable charts that list medications and display
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the schedule for each medication enhances adherence to prescribed regimens (51). Legible written or printed instructions provide a remedy for forgetfulness and can be reviewed at leisure in the less stressful environment of the patient's home.
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FIGURE 4.3. Patient instruction form. (The form makes a copy for the patient's record.) |
Because it usually requires time to make sense out of information about one's condition (e.g., newly diagnosed hepatitis), because patients retain only about one-half of the essential information communicated at a visit (34,40), and because practitioner–patient communication is usually focused and time-limited, printed educational materials can be used to reinforce and expand on what the patient has been told. When printed materials are given to a patient, the practitioner can personalize them by underlining important points, writing down additional important information, and writing the day's date on it.
Complicating patient education and the promotion of healthy behaviors is the growing recognition that a surprisingly high percentage of patients have low literacy skills and a majority have difficulty understanding and implementing medical recommendations (25). Thus it behooves practitioners to assess the literacy level of their patients and to appropriately tailor educational interventions and written informational materials. Resources for patient educational materials and screening them for literacy level are discussed below under “Organizing a Practice for Patient Education.”
Behavioral Strategies
Communication of information is necessary but often insufficient to ensure the adoption and maintenance of health-related behaviors by a patient. This is particularly true in the setting of chronic disease, probably because most patients have already learned their prescribed regimen and have learned something about their disease. Behavioral strategies (Table 4.5) attempt to directly influence the adoption or maintenance of certain behaviors. Strategies that incorporate various combinations of patient involvement, alterations in the treatment regimen (simplification, tailoring, shaping), use of behavioral stimuli and reinforcements, and supervision have been shown to improve patient adherence to chronic and short-term therapeutic regimens.
Mechanisms of enhancing patient involvement include facilitating patient question asking, negotiating a treatment plan with the patient (rather than dictating a treatment plan to the patient), signing a contract with the patient, and encouraging patient self-monitoring, such as the measuring of glucose levels or taking of blood pressure readings at home. All of these measures increase patients’ responsibility for their own care, increase patient confidence, and enhance patient motivation to adopt healthy behaviors. Several studies have demonstrated that these measures improve health outcomes (28, 29, 30,41). Self-monitoring may also move patients from precontemplation to contemplation to action in the readiness for change
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cycle (Fig. 4.1), and may motivate problem solving in cases in which the patient is not following through with a treatment plan.
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TABLE 4.5 Intervention: Behavioral Strategies |
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Simplification of the treatment regimen refers to minimizing the number of medications, minimizing the duration of treatment (for short-term regimens), minimizing the frequency of dosing (e.g., once instead of three times daily), and synchronizing the dosing (e.g., three medicines twice daily instead of one medicine twice daily, the second medicine three times daily, and the third medicine four times daily). The less complex the regimen, the greater the adherence rate. This is a particularly important strategy both because of its effectiveness and its ease of implementation.
Tailoring is a process whereby the therapeutic regimen is fitted to the patient's characteristics and environment. Effective tailoring requires knowledge of patients as persons—their beliefs, lifestyles, social and family support systems, and, specifically, any barriers to adopting healthy behaviors. Forgetful patients may benefit from linking medication taking or prescribed activities to daily routines such as eating meals, brushing teeth, getting up in the morning, or going to bed at night. In addition, medication should be kept available where it is taken (e.g., at the breakfast table). If possible, patients should avoid taking medication at times of the day when their activities are variable or when they are likely to be distracted (e.g., at work). Other examples of tailoring include involving patients who like to be in control in planning and monitoring their own therapy; substituting liquid medication for patients who have difficulties swallowing tablets or capsules; increasing supervision and peer support for patients who are having difficulty on their own following a desired regimen (e.g., a weight-reduction diet); and recommending exercise programs that can be incorporated into the schedules of extremely busy, time-pressured patients and that eliminate travel, waiting time, and the need for special scheduling. When cost is a factor, less expensive regimens can be prescribed or financial assistance sought. When a patient's health belief or explanatory model of disease interferes, it can sometimes be accommodated. For example, Hispanic patients who subscribe to the hot–cold theory of health and disease avoid the use of hot substances during pregnancy and therefore may refuse to take hot medications such as iron and vitamins. Adherence in this situation may be obtained by encouraging the patient to neutralize the hot properties of these medications with cool substances such as fruit juices or herb teas.Language barriers can be addressed by involving translators or by using written, computerized, or automated voice messaging systems that match patients’ languages.
When a regimen is particularly complex or difficult, behavior change may be facilitated by graduated regimen implementation, or shaping, whereby parts of the regimen are implemented and the patient is initially rewarded for adhering to only part of the regimen. Once the first part has been achieved, additional components of the regimen are added in stepwise fashion, with rewards being given when there is adherence to both previously accomplished and newly added components. Patient involvement in identifying the steps and the rewards further facilitates the process.
In addition to adjusting the therapeutic regimen to meet the patient's needs, patient and practitioner can work together to identify and manage behavioral stimuli (cues) and reinforcements that promote or diminish desired behaviors. Watching television, for example, may be an environmental cue for patients who have learned the habit of eating when they watch television, even when they are not hungry. To eliminate this behavior, the practitioner and the patient might reach an agreement whereby a patient eats only at the dining room table with the television off. Another behavioral cue might be the presence of cigarettes or a friend smoking. In preparation for a smoking cessation effort, a patient might want to remove all cigarettes from the house or to negotiate an agreement with the friend to refrain from smoking in the patient's presence. Patient involvement is critical, because almost all environmental stimuli exist in the patient's environment outside the practitioner's office and because something that might work from the practitioner's perspective might not work at all for the patient. Involvement of family and friends can be helpful in supporting the management of behavioral cues in the patient's environment. Alternatively, family and friends may be a barrier if they refuse to cooperate.
Reinforcement consists of feedback that can either promote or discourage specified behaviors. Reporting back to the patient the results of drug-level assays and therapeutic outcomes (e.g., decrease in blood pressure, cholesterol, or weight) is an example of a practitioner-controlled reinforcement. Together with the patient, the practitioner can identify existing reinforcements, support or initiate those that promote, and attempt to eliminate or diminish those that discourage desired behaviors. Because positive feedback is more effective than punishment in helping patients adopt new behaviors, measures and outcomes that indicate adoption of desired behaviors should be praised, otherwise rewarded, or viewed by the patient as rewards in themselves. When measures or outcomes suggest that the patient is not following the regimen, the problem should be discussed. Rewards should be appropriate to the goals (e.g., eating an ice cream cone would be an inappropriate reward for having followed a diet) and can be increased as the patient gets closer to achieving the goals.
Education and the use of family, friends, and employers may be required to optimize rewards for desired behaviors or to reduce the rewards for undesired behaviors at home and in the community. Two common indications for such an intervention are reversal of reinforced psychosocial
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disability in the physically capable patient after myocardial infarction and maintenance of abstention in the detoxified alcoholic patient.
Increased supervision is a specific form of stimulus management and reinforcement that has been shown to improve adherence. It includes the scheduling of more frequent provider–patient contacts, the use of reminders, the use of drug assays, the use of automated voice messaging, and the eliciting of family or community support to assist in administering and monitoring treatment. For example, the practitioner may request more frequent blood pressure values in a hypertensive patient. The blood pressure readings can be taken by either a nurse at the practitioner's office, a nurse at work, a family member, or the patient. The direct supervision of medication administration is an option that is especially helpful for ensuring adherence in situations where it is known to be low, such as with patients who are forgetful or unreliable, have impaired intellectual or psychological functioning (e.g., patients with alcoholism, dementia, or schizophrenia), or have challenging psychosocial situations. Examples include the use of a single, intramuscular, long-acting penicillin dose rather than 10 days of an oral preparation, intermittent supervised oral antituberculosis therapy, and use of long-acting parenteral drugs in the ambulatory management of schizophrenia.
Motivation and Empowerment Strategies
Adoption of healthy behaviors tends to decay toward baseline after the cessation of many successful interventions. One explanation for the failure of most adherence-improving interventions to have enduring impact is their reliance on actions and supports that are external to the patient. Based on reviews of the relevant adherence, psychological, sociologic, and behavioral literature, DiMatteo et al. suggestedapproaches that promote internalization of the patient's motivation and ability to adhere (see DiMatteo and DiNicola, Achieving Patient's Compliance, http://www.hopkinsbayview.org/PAMreferences). These approaches include helping patients to adopt new beliefs, attitudes, or values; setting agreed-upon goals; enhancing patients’ perceptions of their self-efficacy; and facilitating new skill development in patients (Table 4.6).
Patients may have to adopt new beliefs, attitudes, or values and abandon others. Because practitioners are a major source of health information for most Americans (34), they can assist in this process. They are more likely to succeed if they have earned the patient's trust and if they incorporate empowerment strategies that involve the patient in setting goals, solving problems, and planning for the intervention (see Practitioner–Patient Relationship). As previously mentioned, the first step in promoting change in health attitudes is to explore the patient's present knowledge, beliefs, attitudes, and values, as well as the patient's social and cultural norms. Education about the patient's diseases and regimens then can be tailored to correct misconceptions, fill in gaps in the patient's knowledge base, provide explanations that are understandable and acceptable to the patient, and motivate the patient in the context of the patient's value, social, and cultural systems. Simply taking time for discussion will raise the salience in the patient's mind of the issue being discussed. Threat or fear messages can motivate behavioral change, but they should not be too strong (i.e., so strong as to cause patient denial or paralysis) or too weak. Furthermore, they should be combined with a positive message about a feasible (for the patient) and effective therapeutic regimen. Because patients are often more present-oriented than future-oriented, short-term as well as long-term benefits of any regimen should be stressed. Because behavior can influence attitudes, and vice versa, the practitioner should point out the patient's own behaviors that support the attitude being promoted. One can help integrate the new attitude into the patient's total system of beliefs by noting how it correlates with other beliefs the patient has. One can also note how the new attitude adheres to cultural and social norms. Of course, new attitudes and beliefs need positive reinforcement, as previously discussed.
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TABLE 4.6 Intervention: Motivation and Empowerment Strategies |
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Mutually negotiating agreed-upon goals can be motivational and can provide direction for the patient. Patient involvement in, and preferably initiation of, goal setting is
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a crucial component of this step. For goals to be most effective, they must be “owned” by the patient. Goals should be set at two levels. The first level is long-term goals such as, “I want to quit smoking in 6 months.” The second level is short-term, or proximal, goals. These goals refer to the specific actions that will be required to meet the long-term goal, such as, “I will begin using Nicorette gum at a 4-mg dosage next Monday, and I will reduce this to 2 mg in 6 weeks.” These goals are actually more helpful to the patient because they are easier to achieve and can be measured more directly. To be effective, they should be specific, measurable, realistic, and achievable. Having the patient sign a contract can further increase the likelihood of success.
Patients with unhealthy self-perceptions or perceived low self-efficacy may need to be convinced that they can indeed effect a change in their lives (a process sometimes called cognitive restructuring). The practitioner can help by emphasizing the patient's past and present behaviors that demonstrated self-control, by enhancing the patient's feelings of responsibility for accomplished changes, by pointing out inaccuracies in the patient's negative self-perceptions, and by having and projecting a positive attitude to the patient about his or her ability to change.
Examples
Practitioner: On one hand, you say you have no self-control. On the other, you tell me you stopped smoking for the entire period of your second pregnancy. That demonstrates to me that you can exhibit tremendous self-control.
Practitioner: Two months ago you told me that you would never be able to manage insulin. Now you are monitoring your own blood sugars and calling me to propose changes in your insulin schedule. What does that tell you about yourself?
Patients and their practitioners often view partial successes as failures (e.g., the patient who has started drinking or smoking after a period of abstinence, the patient who has cut caffeine intake in half). In the office, practitioners can promote patients’ self-esteem and sense of self-efficacy by reframing these “failures” as successes, as important steps along the way to accomplishing important health goals.
Example
Practitioner: It's great you were able to stop smoking for a month! That really increases your chances of being able to quit for good. Did you know that most people who stop smoking require more than one attempt?
In addition, patients can learn how to shift their own self-perceptions during vulnerable moments at home, when negative thoughts may interfere with following through with a plan. In anticipation, patients can be asked about potential “sticking points.” In response to having experienced these sticking points, they can be encouraged to reflect on and contrast their thoughts during the times they have been successful versus the times they have not. Using these “awarenesses,” they can reframe a failure into a partial success in the moment, or they can use previously effective positive self-statements (e.g., “I can do this”). Patients can take this one step further by posting positive statements or images as reminders where they can often see them, or at places where they are likely to be tempted to not follow through with a treatment plan. Family members can be enlisted as verbal sources of positive statements or to help patients reframe their negative thoughts. It is essential, however, that patients consider this as helpful and not as overinvolvement or an attempt by the family to control their behaviors.
New skills can also be taught to patients, an empowerment approach that enhances their ability, as well as motivation, to initiate and maintain adherence to a difficult regimen. Patients can learn problem-solving skills by analyzing, with the practitioner, the health problem, treatment alternatives, and the advantages and disadvantages of potential actions. They can participate in the development of overall treatment goals. They can be tutored in developing specific, feasible, and measurable behavioral objectives for themselves and in breaking down large tasks into several small, manageable steps. When patients have adopted new attitudes, beliefs, or behaviors, they can be taught to anticipate and prepare themselves for likely challenges.
Examples
Practitioner to the recovering alcoholic: What challenges do you expect to your new sobriety? How are you going to handle it when people try to get you to drink at your niece's wedding this weekend?
Practitioner to the hypertensive patient who is sensitive to being viewed as ill by others: How are you going to respond when one of your colleagues at work sees you taking your medication and says, “Oh, you have to take medicine now! What's wrong with you?”
Patients can also be taught to analyze and learn from past failures to enhance the likelihood of future success.
Examples
Practitioner: Why has it been difficult for you to take the second dose?
Practitioner: Exactly how did it occur, when you started smoking again? What does that tell you?
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Practitioner: If you could overcome that problem, your chances for success would be really high! Any ideas?
Efforts to help patients adopt appropriate health-promoting beliefs, attitudes, values, skills, and behaviors can be integrated into ongoing care and usually should span several office visits. Once patients have experienced success in implementing changes in one health-related behavior, their sense of efficacy increases, and they are more likely to be successful in changing other behaviors.
Mechanical Aids
Medication-taking behavior can also be improved by the use of a number of mechanical aids. These include well-labeled medication containers (52), medication charts (51), pill calendars (devices on which patients keep track of their medication taking), special pharmaceutical packaging designed to aid memory (e.g., the packaging of birth control pills), and pill dispensers (devices that can be purchased for laying out medications in advance by day and, when necessary, by time of day). Well-designed forms can promote the use and effectiveness of written instructions (Fig. 4.3) (52) and patient adherence to self-monitoring (e.g., by providing patients with flow sheets for recording blood pressure or blood sugar values and asking the patients to bring the sheets with them to their next visit).
Appointment Keeping
A number of factors have been shown to improve appointment keeping by patients (53). Table 4.7 lists the strategies that can be used to improve appointment-keeping behavior.
Telephone and mail reminders, in which patients receive messages several days before their scheduled visits informing them of the dates and times of their appointments or messages inviting patients to reschedule after missed appointments, have consistently improved adherence, usually by 10% to 20%. The impact of the reminders may attenuate over time, however (54), and it may be possible to discontinue reminders without a subsequent increase in missed appointments (55). Wording of the message may be influential. In one study of high-risk patients (56), postcards with a persuasive educational message resulted in a significantly higher adherence rate for influenza vaccination than postcards with a neutral message that simply announced the availability of the vaccine.
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TABLE 4.7 Intervention: Improving Appointment Keeping Behavior |
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The introduction of individual instead of block appointment systems and the substitution of a single provider for multiple providers have resulted in decreased waiting time and improved appointment keeping. Individual appointment systems give each patient a precise time for an appointment; block systems schedule several or all patients for the same time, usually at the beginning of office hours.
Techniques that the practitioner can use to improve appointment keeping for individual patients include logically bridging to the next visit by discussing its purpose with the patient (e.g., monitoring for recurrence, review of test results, decision about therapy); negotiating a visit interval that is mutually acceptable; tailoring the appointment time to the patient's needs; obtaining a verbal agreement from the patient to follow through; and scheduling the appointment instead of asking the patient to call for an appointment. Bridging and scheduling were tested successfully in a clinical trial (57).
Because missed appointments could presage dropouts from treatment, the charts or names of patients who miss their appointments should be reviewed daily by the patient's practitioner or by a nurse familiar with the patient. When indicated, the patient can be contacted by telephone, letter, or postcard. This review method helps prevent dropping out by patients given a followup appointment at the time of the previous visit, but it fails to identify dropouts who were instructed to call for their next appointment.
If referral is required, educating the patient about the purpose of referral, minimizing the elapsed time between the referral and the referral appointment, providing secretarial assistance to facilitate scheduling and transportation, and referring the patient to a specific practitioner and not simply to a specialty group or clinic have also been shown to improve appointment keeping for diagnostic studies and specialty consultations.
Organizing a Practice for Patient Education
Patient education and adoption of healthy behaviors can be further enhanced through the implementation of effective practice operations.Practice support staff often have considerable interest in patient education, and involving them in this effort can save practitioner time and enhance the effectiveness of care. Many office practices involve
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nursing staff in educating patients about preventive measures such as immunizations, breast cancer screening, and family planning, and in working with patients who have newly diagnosed chronic illnesses such as diabetes mellitus, asthma, or hypertension. In these instances, it is important to agree in advance which aspects of patient education will be covered by the practice's support staff and which will be covered by the practitioner.
Mailing test results or providing this information to patients through the use of automated voice messaging are services that can be incorporated into routine office operations. Depending on the situation, additional information (e.g., norms and goals for test results, changes in regimen based on test results) can be included.
A collection of preselected printed patient educational materials can be maintained in an office file or on an office computer and distributed at the discretion of the practitioner or nursing staff. The materials should be available in languages and reading levels that are appropriate for the patient populations that the practice serves. Patient handouts for specific conditions are available via the Internet from government and health organizations and are cited in subsequent chapters of this book (also see below, Web-based resources under Using Resources Beyond the Practice). Patient handouts on a variety of subjects are also available via Internet services used primarily by institutions (e.g., Krames on Demand) and in the periodically updated book and CD-ROM Griffith's Instructions for Patients (seehttp://www.hopkinsbayview.org/PAMreferences). It is important to provide handouts at a reading level that matches the patient's literacy level. The reading level for printed material can be calculated by using a readability index such as the Fog Index, the Flesch Reading Ease Scale, or the Flesch-Kincaid Grade Level; formulas can be found using Internet search engines.
A certain amount of general patient education can be promoted in the waiting room by setting up a pamphlet rack containing 10 to 15 of the most commonly applicable printed materials. These might include pamphlets on age- and gender-appropriate preventive measures, smoking cessation, weight reduction, low-salt diets, exercise, and other topics of interest to patients and their families. Some practices have found it helpful to have a bulletin board with newspaper clippings about current health topics.
Other possibilities include the delivery of health messages to patients on telephone hold and the use of office newsletters, audiovisual materials, and computerized interactive programs (58). Automated voice messaging can be used to send messages to patients, as well as to receive patient questions and respond to them (59).
Finally, medical records and related forms can be structured in ways that promote the education and monitoring of patients. As mentioned earlier, self-duplicating forms for written instructions (Fig. 4.3) facilitate both the provision of written instructions to the patient and followup by the practitioner at the next visit. Preprinted forms can be used to facilitate or to assist the practitioner in the mailing of diagnostic test results to patients. A flow sheet that chronologically aligns chronic medications and nondrug therapies with clinical and laboratory data (Fig. 1.2) facilitates review of the relationship between a specific therapeutic regimen and associated clinical or laboratory parameters. A method for keeping track of prescription renewals can be incorporated into the patient record, such as the attachment of duplicate copies of all written prescriptions to a flow-carrier sheet. Such a method allows the practitioner to ascertain quickly when the patient is due for a refill. This is especially helpful when prescriptions are filled by more than one practitioner in the practice.
Using Resources beyond the Practice
Resources beyond the practitioner's practice can provide information, support, and skills training for patients. The use of such resources is particularly helpful when the practitioner's practice has limited resources or when the educational task is time-consuming or complex. In such situations, the practitioner's efforts should be supplemented by referral to
Volunteer patients who are followed regularly in one's practice, or provided by outside organizations, and who have successfully managed their chronic illness can serve as important resources to patients newly diagnosed with the same condition. Telephone hotlines can provide immediate access to patients who are in distress or in need of immediate information (60) (e.g., patients who are victims of domestic violence). Patients can also be referred to specific Internet sites or provided with audiovisual or CD-ROM interactive tutorials. These have the advantages of
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availability, a private learning environment, and immediate reinforcement of learning (58).
Combining Strategies (Case Example)
Strategies that combine two or more methods are generally much more effective than single interventions (7). Such combination strategies have been shown to improve adherence in patients with asthma (61), congestive heart failure (62), diabetes (63), and hypertension (64), and after myocardial infarction (65). In the last study, patient involvement was accomplished by having patients set their own goals and monitor their own behavior. Frequent contact with the practitioner allowed reinforcement, modification of goals on a negotiated basis, and discussion of problems with the regimen. Involvement of the spouse led to increased supervision and support. In the asthma study, adherence and functional status were better after 1 year in a group of patients with asthma who received an instructional workbook and one-on-one counseling, participated in self-monitoring and an asthma support group, and were asked to identify an asthma control partner, than in a group given standard informational pamphlets on asthma.
The following example illustrates how instructional, behavioral, and motivational/empowerment strategies can be integrated into an office visit (this is a continuation of an earlier example).
Example
Practitioner: Well, Mrs. Smith, your blood pressure is 150/100 today, which, as you can see on this flow sheet, is better than when we started, but not as low as we’d like it. Do you remember the goal we agreed on? [The word “we” implies shared responsibility. The practitioner focuses the patient's attention on a specific, measurable objective. The practitioner points out that some progress has been made, using a clinical flow sheet.]
Patient: I believe it was less than 140 on the top and less than 90 on the bottom.
Practitioner: Right. What do you think you could do to bring it down further? [The practitioner further involves the patient and transfers responsibility to her.]
Patient: Well, as you said, part of the problem with today's blood pressure could be my not taking the medicine this morning. So I’ll be sure to take it from now on, including the days I come to see you. Also I’ve been thinking about enrolling at the athletic club. I like dancing. The club has convenient hours and is on my way to work. I’d prefer not to take any more medicines.
Practitioner: The athletic club is an excellent idea. Regular exercise not only has an effect that directly lowers blood pressure, but it might also indirectly lower your pressure by helping you to lose weight. [The practitioner provides positive reinforcement and notes an added benefit that relates to another goal the patient has for herself.]
Patient: That would be nice.
Practitioner: Does the club have a trainer? A trainer could help ensure that your workout is aerobic and individualized to your needs. [The practitioner enlists the help of a resource external to the practice.]
Patient: I think so. That's a good idea.
Practitioner: I am still concerned about the difficulty you have getting the second dose of medication into your schedule. Blood pressure pills work best when you can take them almost 100% of the time. [The practitioner provides a rationale for his concern.] Would dinner time be a good time for you? [The practitioner initiates the negotiation process.]
Patient: My meal times are irregular, and I don't always eat at home.
Practitioner: How about bedtime?
Patient: Sometimes I’m so exhausted, I just fall asleep while I’m reading, before I’ve brushed my teeth or anything. Don't you have a pill that can be taken just once a day?
Practitioner: As a matter of fact, that is a possibility. When would you take it?
Patient: With my morning coffee. I never miss that!
Practitioner: Fine, I’ll give you a prescription for a pill that you can take once a day with your morning coffee, 100% of the time, even the mornings you come to my office. Is that a deal? [Repetition and emphasis to increase retention.]
Patient: Yes! [Solution and verbal contract achieved through tailoring and negotiation.]
Practitioner: The side effects for this medicine are the same as for the other. Because you experienced no side effects with the other medicine, you should tolerate this one well.
Patient: Good.
Practitioner: Together with the salt restriction and exercise program, this medicine alone may be enough to control your blood pressure. [The practitioner provides further motivation for salt restriction and exercise.] Of course, we’ll start with a low dosage, so we may have to increase it. Can you come back in 2 weeks?
Patient: How about 2 months?
Practitioner: Well, I’d really like to see you more often until your blood pressure is controlled. Of course, if you monitored your own blood pressure at home, you could call the results in to me and there would be less need for frequent office visits. [The practitioner prefers not
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to yield on the followup interval and uses the opportunity to motivate the patient to become further involved in her own management and to create a new environmental reinforcement.]
Patient: How can I do that? [The practitioner proceeds to explain the process of getting a blood pressure cuff, coming to the office to have it checked, and learning how to use it; to test the patient for her understanding of her responsibilities; to get her verbal commitment; and to write down for her the new management plan.]
Followup
Education can involve the adoption of new beliefs, attitudes, or values; the development of a patient's sense of self-efficacy and self-management skills; the setting of agreed-upon goals; the adoption of new or cessation of old behaviors; and the maintenance of successfully changed behaviors (e.g., the taking of a chronic medication, the cessation of smoking). In the process, patients move forward in the readiness-for-change cycle (Fig. 4.1). Sometimes, as in the case of diabetes, the required cognitive and behavioral changes are both numerous and complex (see Chapter 79, Patient Education) and are best implemented in incremental steps (see earlier discussion) over the span of several visits. Commonly, patients successfully implement only part of a prescribed or agreed-upon regimen. Periods of successful implementation often are followed by periods of relapse (Fig. 4.1). Consequently, follow-up is a crucial component of patient education.Repetitive cycles of assessment and intervention (Fig. 4.2) are associated with increased success in helping patients adopt and maintain healthy behaviors and should therefore be integrated into ongoing care. The following example illustrates this principle.
Example
A patient with hypertension, diabetes, and hypercholesterolemia was also a heavy smoker. Over the course of 2 years, he gradually succeeded in accepting and understanding his medical conditions; reliably taking his antihypertensive, oral hypoglycemic, and lipid-lowering medications; altering his diet to one low in cholesterol, saturated fats, salt, and concentrated sweets; inspecting his feet regularly; and having yearly eye examinations. Initially, however, he was very resistant to the suggestion that he stop smoking [precontemplation stage]. However, his practitioner listed smoking as a problem on his medical problem list and let him know that smoking cessation was probably the single most effective thing he could do to improve his health [instruction].
On successive visits, the practitioner explored with the patient his feelings about smoking, the pros and cons of his stopping, the barriers to his stopping [assessment, raising the problem to the level of contemplation], and the role of nicotine use in smoking cessation [instruction]. She expressed confidence in his ability to stop when he was ready and indicated her interest in helping him [promotion of the patient's sense of self-efficacy and support]. She checked on his smoking behavior and readiness to stop periodically [maintenance of contemplation].
The patient made one attempt to stop after 2 years [action] and succeeded for 2 months, but then resumed smoking during a period of stress at work [relapse]. His practitioner congratulated him on his success and told him that it proved he was capable of quitting. She noted that most patients who successfully quit require more than one attempt [reframing a “failure” as a success].
Two months later, after discussing with his practitioner his brother's death from a myocardial infarction [additional stimulus, moving the patient from contemplation to action], the patient set a quit date, removed all cigarettes from his home and work environment, elicited support for his quitting from family and friends, and planned for his responses to stressful situations. With the additional help of a nicotine patch and periodic encouragement from his practitioner, he succeeded in stopping for good.
Ethical Considerations
It has been suggested that the following three conditions be met before attempting to improve adherence: (a) the diagnosis should be correct; (b) the therapy should be proven to be efficacious, and the benefits should outweigh the adverse effects; and (c) the patient should be an informed and willing partner in the intervention (66).
Although the first two conditions are probably applicable to interventions directed toward populations, they may be too rigid for application to individual patients. In some circumstances, it may be reasonable to prescribe an efficacious treatment as a therapeutic trial when the diagnosis is in question. Furthermore, many treatments have not been unequivocally proven to be efficacious, although some evidence supports their usefulness. The practitioner is justified in encouraging the use of such therapies in an attempt to determine whether they relieve symptoms or improve functional status. How else will the practitioner know whether a given antidepressant or analgesic, for example, is effective for a given patient?
In individual practice, therefore, the first two conditions might be replaced with the following requirements: (a) that the therapy be rational and based on sound medical knowledge, and (b) that the potential risks of therapy be less than the likely benefits.
The third condition is that of an informed and willing partner in the intervention. In medical practice one may encounter patients who understand their regimen, but who
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fail to adhere against their own best interest. Is the practitioner justified in increasing supervision or attempting to elicit familial support to improve adherence, without obtaining explicit consent from the patient? On one hand, the patient has come to the practitioner's office, voluntarily entered into the patient–practitioner relationship, and accepted a prescribed regimen, suggesting implicit consent. On the other hand, the patient is willfully not adhering to the regimen, suggesting a rejection of the regimen at some level. The dilemma may be somewhat artificial, because most adherence-improving strategies require participation of the patient and therefore require implicit consent. Going beyond the patient–practitioner relationship to enroll family help, however, requires consideration of the patient's feelings with respect to this intervention. Some patients are mentally or psychologically impaired in their ability to understand or make sound decisions regarding their situation. An example might be the symptomatic schizophrenic patient who fails to follow through with taking oral antipsychotic medication; the introduction of long-acting parenteral therapy could reduce symptoms and decrease the rate of relapse and number of rehospitalizations. There are no definitive guidelines in these situations, but the following suggestions may be helpful:
Finally, there is the question of where the patient's responsibilities begin and the practitioner's end. Is the practitioner ethically bound to check for behaviors that compromise the patient's health and to facilitate behaviors that promote the patient's health? Once a patient–practitioner relationship has been established, it is certainly the practitioner's responsibility to work with the patient to improve his or her health status to the best of the practitioner's ability, taking into consideration the severity of the problem, economic constraints, time constraints, and competing obligations to other patients. We believe that the practitioner's responsibility often extends beyond the traditional methods of diagnosing diseases and recommending treatments to facilitating the adoption of healthy behaviors.
Specific References*
For annotated General References and resources related to this chapter, visit http://www.hopkinsbayview.org/PAMreferences.
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