8 PART I: PATIENT EDUCATION
others, however, there may be lingering confusion or
questions after this interview that will need to be add-
ressedatalatertime.Inaddition,certainaspectsofthe
treatmentplanthataremoredifcultforapatienttodeal
with(e.g.,makinglifestylechangessuchassmokingces-
sationorweightreduction)willneedtobereviewedand
further encouraged at a later appointment. It is always
prudenttoreviewapatient’streatmentplanateachsub-
sequent follow-up visit, offering praise for the accom-
plishmentsandnotingareasforadditionalattention.
It’s Okay to Say “I Don’t Know”
It is not uncommon for a healthcare professional to be
askedaquestionthatheorsheisunpreparedforandfor
which an answer is not immediately available. Rather
than trying to stumble through a lame explanation or
usingtechnicaljargoninanefforttocoverup,itisalways
recommendedthatthe interviewersimply respondwith
“Idon’tknow.”Realistically,onemaynothavetheanswer
to certain questions, and it is best to acknowledge this
fact.Theinterviewermightgoontosaysomethinglike,
“Ireallydon’tknowtheanswertothatquestion,butlet
melookintoitandI’llgetbacktoyouwithananswer.”
Other Factors Inuencing Patient
Education
Therearemanypartstotheconceptofhealth,including
howonethinksaboutdiseaseanditscures.Healthcare
intheUnitedStatesisbasedprimarilyontreatingacute,
well-advanced disease processes, using an infectious
disease paradigm. However, the causes of poor health
and serious disease processes are no longer associated
with a single infectious microbe but instead linked to
a multiplicity of factors, particularly behavioral and
cognitive habits along with specific social and physical
environments.Patientsoftenreacttoillnessanditsman-
agementinwayslearnedfromothers,accordingtotheir
cultural norms, and accordingto their own perception
oftheseverityoftheillness.
Age
Although an obvious consideration, age is not always
reectedinpatienteducationmaterialsandisoftenover-
lookedinthepatienteducationcounselingsession.One
mustrememberthattherangeofcarestartswithinfants
and ends with the elderly. Let us start with children.
Theyarenotsmalladults,andtheirwants,needs,think-
ing processes, and emotional and physical status differ
fromthoseofanadult.Forexample,smallchildrenoften
view hospitalization as a punishment, not as means of
getting well.
10
This belief is further reinforced when
parental gures make such statements as, “If you go
outsidewithoutshoeson,youmaygetsickandhaveto
goseethedoctor.”Thistypeofbeliefoftenleadstofalse
perceptionsaboutcliniciansandtoachild’sdifcultyin
acceptingmedicaladviceortreatment.Infants,although
notdirectlyinvolvedinpatientcounselingsessions,have
specialneedsandrespondtotouchandnonverbalcom-
munication.
10
Aschildrengrowolder,however,onemust
keepinmindthecurrentfads,language,andnorms.For
example,teenagersoftenbelievethemselvestobeexperts
in every area and, in some cases, do not heed advice.
Furthermore, certain instructions given to teenagers
regarding preventionofillnessmay not be “cool”orin
linewiththethinkingoftheirpeergroup.
Adults are more mature and have different concerns
fromadolescents.Forexample,youngadults(aged20to
40 years) areat a point in life where multiple activities
(e.g., college, relationships, children) keep them busy.
10
Thesepatientsneedpracticalapproachestoeducation—
approachesthat are not time consuming and unrealistic
inrelationtotheirlives.Asadultsgrowolder(aged40to
60years),theybecomemoreconsciousofthepossibility
ofhealthproblemsandinmostcasesarewillingtofollow
apatienteducationprescription.However,somemaylack
self-condence,whichcancauseavoidanceoftheriskof
failureinlearninganythingnew.
10
Adultsovertheageof
65yearsaresimilartomiddle-agedadultsintheirwilling-
nesstolearnnewideas,buttheprovidermustbeaware
oftheindividuals’past experiences, involve theminthe
learning process, and motivate them to learn.
10
Elderly
patientsmayfeelthatitishardlyworththeefforttolearn
newinformationandskills,becausetheythinktheirlife
isnearingtheend.
10
Ethnicity
Ethnicity pertains to a social group that claims or is
accorded special status on the basis of complex, often
variabletraitsincludingreligious,linguistic,ancestral,or
physicalcharacteristics.Ethnicityissimplydenedasthe
condition of belonging to a particular ethnic group.
Examples of ethnic groups in the United States include
AfricanAmerican,Asian,Caucasian,Hispanic,andNative
American.Thereareatleast106ethnicgroupsandmore
than170NativeAmericangroupsintheUnitedStates.
11
Ethnic groups should not be confused with minority
groups because the latter are seen as different from the
majority group. However, some ethnic groups are also
classiedasminorities,suchasAfricanAmericansinthe
UnitedStates.Onecanseethatthephenomenonofeth-
nicityiscomplex,ambivalent,paradoxical,andelusive.
12
As clinicians, it is important to be aware of the ethnic
backgroundsofpatients.Thedifferencesinlanguageand
culture each group exhibits will certainly inuence the
waypatienteducationiscommunicated.
13,14
Forexample,
some people think that HIVprevention literatureis not
communicated effectively to African American popula-
tions. HIV programs are hampered because of the pres-
enceofculturallyspecicattitudesandbeliefs,including
thosepertainingtotherolesofmalesandfemales.
13
Family
Althoughconsiderationoftheindividualisimportantin
patienteducation,asmentionedearlier,thepatient’sfamily
isalsoofcentralimportanceifteachingistobeeffective.
15
Howafamilyfunctionsinuencesthehealthofitsmembers
as well as how an individual reactsto illness. Including
thefamilymembersandsignicantothersinpatientedu-
cationsessionswillfacilitateadherence,understandingof
Chapter 1: An Approach to Patient Education 9
the disease process, and condence needed to perform
specicskills. Hence,the healthcareprofessionalshould
capitalizeonwhatfamilymemberscandoforthepatient
andworkwiththeminencouragingthepatientin tasks
that may be difcult. For example, when educating a
patientwithdiabetesmellituswhorequiresinsulininjec-
tions,involvementofthefamilyinteachingsessionsdem-
onstrating insulin injections will most likely improve
compliance. Family members can also serve as trouble-
shooters when the patient has difculty performing
complex tasks. However, not all patientshave family or
signicantothersavailableforsupport.Thisisfrequently
seenincasesofHIVinfection.Patientsareoftenisolated
from others after their diagnosis is made known. These
patientsareoftenoncomplexmedicalregimensinvolving
the use of intravenous catheters. Unavailable support
sometimesleadstopoorcare,misseddoses,andincreased
morbidityandmortality.
The healthcare professionalcan do much to facilitate
the effectiveness ofpatient teaching by fostering discus-
sion among signicant others. A professional who has
continuedcontactwiththepatientandhisorhersigni-
cantothersmaycheckontheprogressofthepatientwhen
necessary (and when appropriate) and identify any new
problemsthatmayinterferewithoptimalcare.
Socioeconomic Status
Thesocioeconomicstatusofpatientsshouldbecarefully
consideredwheninitiatingeducationsessions.Individuals
inlowersocioeconomicgroupsarelesslikelytoseektreat-
ment;iftheyseektreatmenttheytendtoaccesshealthcare
laterinthecourseoftheirillness,andtheydiesoonerthan
individuals in higher socioeconomic classes. Hence, the
clinicianshouldbeawareofthepatient’spersonalincome,
livingarrangements,andemploymentstatusandalsohave
an increased awareness of the patient’s health. Lower
socioeconomicstatushasbeenlinkedtothedevelopment
of disease states, the most noted being coronary artery
disease.
16,17
Forexample,theproviderclearlycannoterase
povertyandimproveaccesstohealthcareforall;however,
heorshecanexertapositiveimpactonlowersocioeco-
nomicgroupsbyworkingwiththeirmemberstopromote
healthierlifestyles.
13
Someindividualsoftendonotknow
what resources are available. The provider should point
individualstolocalresourcesthatprovideservicesand,if
notpossible,attempttoarrangeforthoseservicesforthe
patient.
Chronicity of Disease
Finally, illnesses that are acute present differently from
thosethatarechronicandwillcauseavarietyofreactions
among patients. Healthcareproviders must be aware of
thoseillnessesthatrequireextraemotionalsupportand
possible psychiatric intervention when preparing for
patienteducationsessions.Furthermore,itisnotenough
tosimplyinformapatientofhisorhermedicalcondition
withouttimeforaninitialreaction.Patientsrequiretime
toreacttoanewdiagnosis.Theperceivedseriousnessand
natural course of a disease will help determine how a
patientwillrespond.Forexample,thepatientdiagnosed
withacutepharyngitismayfeelreallyterribleduringthe
illnessbutknowsthatitisacurablediseaseandisusually
self-limiting. Hence, this patient may have fewer emo-
tionalproblemsandrequirelesscounseling,whereasthe
patientdiagnosedwithend-stagecongestiveheartfailure,
inwhichthelong-termprognosisislikelyfatal,willhave
aresponsethatmayneedfurtherinterventioninvolving
apsychiatrist,socialworker,ornursingcare.
18
Conclusion
Itishopedthatthemodelandsuggestionsofferedinthis
chapteronhowtoapproachthepatienteducationinter-
viewwillserveasarefresherforthereader.Althoughthis
iscertainlynottheonlyapproachtouse,itisonethatis
comprehensive and addresses both process and content
aspectsoftheinterview.Itisexpectedthateachhealthcare
provider will develop his or her own style of interacting
withpatients,perhapsalteringthismodeltothisorher
specicneeds.
Asthereadergoesthroughthistext,heorsheshould
imaginehoweachparticularproblemmightbeadaptedto
theframeworkpresentedhere.
Acknowledgment
This chapter was revised and rewritten from the rst
editionmanuscriptbyCollierM.Cole.
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