Interventions

Session 2 - Health Education

Health Education, methodological approach

Étienne André

Public Health - Grenoble - France

Introduction

In the literature, poor treatment compliance is noted across many illnesses: half of the patients either do not take the treatments that are prescribed to them or they take the treatments irregularly. With regard to education, studies have long proven that simple information reduces cholesterol level by 3%, for example, while a more elaborate programme decreases it by 6.5% (1). Diabetics who have actively participated in education programmes have experienced a 50% decrease in the appearance or progression of retinopathy, renal insufficiency and the number of amputations (14). Studies indicate that medical costs are reduced by half among educated asthmatic patients, with a 75% prevention rate for asthmatic attacks and an 80% decrease in emergency consultations and hospitalizations.

Education for health

Health education takes its roots between 1978 (Alma-Ata), 1986 (Ottawa) and 1997 (Jakarta). Thus an inventory of the promotion of health is prepared, allowing its determining factors to be examined and its orientations to be defined as well as the strategies to be adopted in order to take up the challenges of the 21st century concerning it.

Education for health proposes actions that aim to maintain or to improve a state of health. It is a process whereby individuals and/or groups work together to improve their overall well-being, become autonomous in their lives and healthcare, and develop the ability to adapt in the face of risks or challenges to their health (2). This process emphasizes the opportunity for individuals to work with their doctors and others to facilitate behavior changes that are specifically directed toward achieving predetermined goals for improving their health (Nutbeam, W.H.O., 1986).

In practice, health education may be delivered in many ways, but it is always implemented for the following purposes:

To transmit information.

To allow for behavior modification, if the person concerned desires it.

Patient education and therapeutic education

The appropriation of a new life project

Patient Education and Therapeutic Education share the same values and respect the same principles as health education. They are focused on the patients, and they combine with the global management of the illness or pathology to form one body within the context of a multidisciplinary therapeutic approach.

Patient Education occurs at all levels of prevention and treatment. (see table 1).

Therapeutic Education concerns education in relation to the implementation of the treatment, for example, the proper usage of aerosols for an asthmatic patient. Patient Education takes into account the whole of his/her lifestyle, behavior and environment.

Patient Education falls within the appropriation of a new life project: “learn to live with...” say F. Divernois and R. Gagnaire.

The concept of “empowerment” in the Anglo-Saxon conception expresses the process whereby the patient becomes “autonomous” in his/her relationship with the disease, a process that allows the patient to achieve better control over his/her actions and of the decisions that influence his/her health (3).

A different approach according to the countries

The Netherlands has strongly integrated patient education into its health system and its care policy. This experience shows the limitations of basic information compared to education that includes help and psychosocial support.

Regular financing is in place in Italy, Germany and Great Britain (4).

In the Scandinavian countries, education is integrated into the basic care of chronic diseases.

In France, patient education remains marginal in the course of the general or specialized practitioner’s daily practice, or within pharmacies. It is becoming increasingly structured within a particularly active associative network, which may or may not be close to care centers: School of the back, School of atopy, School of respiration, etc.

Set the right objectives

The epidemiological transition has shifted the priorities towards the chronic disabling and social diseases. The search for quality and efficacy is the consequence of the general conditions created in the different countries guaranteeing the rights of patients and security. Patient Education also plays an economic role because it contributes, in principle, to reducing complications and, therefore, medical and hospitalization costs.

It is in this context that Patient Education has developed. It favors the patient’s ability to listen, his/her motivations and his/her projects: the therapy project is constructed within these parameters.

The objective of Patient Education is to encourage the patient to become a player in his/her health.

Numerous brakes exist: the requirement of an adaptation of the care to the person, the necessary cooperation between the different players concerned. For Brigitte Sandrin-Berthon, "the aim is to understand what he feels and the meaning which he gives to his disease, and to his treatment. Starting from there, one has more chances of being understood."

An accepted ideal would be to believe that the patient is only out for his own good and can only be in agreement with the care giver. The patient would be sensible and disciplined, “educable” and obedient. The reality is quite different because the person is not necessarily out for his own good (5-6).

The objective, therefore, is not to transform the patient to his/her detriment, against his/her will.

The modification of the care giver - care receiver relationship

Traditionally, the patients are managed, in the literal sense of the word, by the medical body and care giver. However, the patient is not always ready to be a stakeholder in his treatment and does not claim his autonomy. He has a need to rely on a doctor (7). Certain cultures favor this form of recourse to the medical authority or to the respect of those to whom the knowledge is conferred.

Jean-Pierre Marcantoni, Jordi Carbonell

The main principles

Two main stages condition the adoption of a new behavior:

Stage 1:

the acquisition of information that justifies the individual’s adoption of the behavior in question, and an explanation of the modalities of its adoption: the information is a central element in the confidence relationship between the therapist and the patient, and contributes to the patient’s active participation in his/her care (8);

Stage 2:

a time of reflection, called appropriation or integration, during which the patient compares the accepted information to his personal history, his motivations, his environment… At the end of this second stage, the patient may do one of the following:

Reformulate a new series of questions.

Decide to adopt or not to adopt the behavior in question.

This involves a succession of information-appropriation, information-appropriation, … stages until decision making.

Therapeutic education in 4 stages

L’ANAES (Agence Nationale d’Accréditation et d’Evaluation en Santé [National Agency of Accreditation and of Evaluation in Health]) (8) proposes a strategy in 4 stages (see table 2): a diagnosis for a therapeutic education that is adapted to each patient, the acquisition of competences by the patient, programmed educational activities and an evaluation.

The definition of the World Health Organisation

The position of the World Health Organisation (WHO) is that patients should be trained like professionals. WHO has underlined four important points on the therapeutic education of patients (9).

To train the patient so that he can acquire adequate know-how in order for him to reach a balance between his life and the optimal control of the disease.

The therapeutic education of the patient is a continuous process that is an integral part of the medical care.

The therapeutic education of the patient comprises awareness, information, apprenticeship, and psychosocial support, all linked to the disease and to the treatment

The training must allow the patient and his family to collaborate better with the care givers.

Content of the competences to be acquired

The professionals must acquire the following competences: capacity of organization, methodological knowledge, relational and educational capacity and, of course, knowledge of the pathology and of its treatment. The associations are also concerned because they all suffer from a lack of training in all the fields quoted above.

The patients must acquire capacities of analysis and self-surveillance, decision-making autonomy and capacities of adaptation. Finally, patients must have good knowledge of the health care system and its resources.

The brakes on Patient Education

There are numerous reasons why health care professionals do not incorporate patient education into their care:

A lack of motivation, a fear of change, a lack of time, and insufficient training among the professionals.

A feeling of loss of their power, of their authority and, therefore, a fear of failure: doctors do not have the failure culture.

Incapacity to work in a network and an absence of recognition in a job shared with others.

The reticence of the patient, often more a pretext than reality.

The low involvement of the families and, in particular, their difficulty in communicating in certain diseases. Example: HIV.

A lack of means; in particular, financial.

The social and environmental situation of the patient. For example, after ten years of action in the fight against growing obesity in a disadvantaged environment, without convincing results, Dr JL Grenier, diabetologist and nutritionist at Roubaix - F, reorients the objectives of nutritional education toward the problem of precariousness (10).

When the participants are studied in the framework of Patient Education programmes, the modest level of involvement of certain professions in the competences that are indispensable for the patients’ autonomy is noted: dieticians, physiotherapists, occupational therapists, among others.

The fields concerned by Patient Education

Acceptance of the disease

In the case of a chronic disease, acceptance is difficult. When patients are asked to choose between the two formulations: "I have fibromyalgia" or "I am fibromyalgic", they prefer the first, where the relation to the disease is not ontological.

Compliance with the treatment

In France, for an average level of compliance of 50 to 60% in the “unsorted” patients, it is clearly less than asthma, since currently "more than 80% of patients who are suffering from it do not follow their therapies sufficiently in order to obtain optimal benefits".

Knowledge of the disease

Good usage of the treatment

Aerosols in asthmatics, anticoagulants, antihypertensive drugs, insulin, for example.

Acceptance of hospitalization

The implementation of specific behaviors in certain diseases

Let us loosely cite a few behaviors capable of being the subject of a Patient Education action:

Nutritional modification in the obese or in patients suffering from sleep apnea syndrome,

Smoking cessation in… Everybody!

Re-adaptation to physical effort post-infarct,

Biological self-surveillance in the diabetic,

Maintenance of physical activity in a fibromyalgia patient, etc.

Compliance and hygiene in case of allergies,

Maintenance of an activity in handicapped patients,

Abstinence in alcoholic patients in a restricting social environment, …

Diabetes is, by far, the disease that has given rise to the most Patient Education centers.

Chris Henriksson, Piercarlo Sarzi Puttini, Jaime Branco, Dan Buskila, Olivier Vitton

The players of Patient Education
Practical solutions

"The schools"

School of the back, School of atopy, School of respiration, Schools of asthma (see charter in annex 2), Multidisciplinary Centre in Patient Education, Centre of prevention of atherosclerosis and Anglo-Saxon "Heart Failure Clinics," as much as structures that bring practical responses to the patients and a framework of work to the professionals.

The institutional frameworks of interventions are very dissimilar:

volunteer associations and structures are numerous, often leaders in the southern European countries: more than 500 in France

private clinic

hospital or public care centre

Fabien Pillard, Daniel Rivière, Florence Gaudoux, François Brackman, Viviana Tavares

The isolated health professional

Patient education is problematic for the individual doctor, or pharmacist, for example, because patient education can only be conceived within the framework of a concerted effort that is programmed in a more or less formalized network, which gives coherence to multidisciplinary management.

The role of the media and of Internet sites

As with everything, the best and the worst information is found here. With regard to content, the patients discover, exchange and break their isolation. With regard to format, the information does not present any scientific or educational guarantee.

These supports, however, represent powerful, useful tools because they contribute to the following:

Increased awareness of the population in a given subject: One of the best, French-speaking examples was the National campaign on the moderation of alcohol consumption: "One glass, fine, three glasses… sparks will fly."

Information on behaviors with risks or on preventative behaviors: European campaign on 5 fruits or vegetables per day.

Establishing a dialogue between patients: Forum on HIV positive patients.

Proposing concrete responses: Education of diabetics…

In rheumatology

Patient education programmes exist in rheumatology: close to 50% in the local hospitals, 30% in referring hospitals and rarely in long-term care establishments.

In a French study on the training of rheumatology teams in patient education, the results show that the whole team is trained in 1.3% of the programmes described in this inquiry, part of the team is trained in 29.3% of the cases, a single person is trained in 14.7% of the cases, and no team members are specifically trained in 48% of the programmes that take place.

The case of fibromyalgia

Maintenance of physical activity or of exercise, cognitive-behavioral therapy (CBT), self-management and medicines have been proposed. It appears that it is very much the combination of several approaches, including physical activity, information and CBT, that is the most promising good management of Fibromyalgia patients (11-12-13). Again, it is necessary that these patients find a trained team ready to greet them.

Conclusion

Therapeutic education is a profound change because the patient is no longer the object but becomes the subject of the care that is delivered to him.