Patient education: the use of the health belief model to promote positive behaviour change.
Patient education: the use of the health belief model to promote positive behaviour change. |
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Email: richard.bellamy@stees.nhs.uk
Key words: patient education, health belief model, adherence, compliance, behaviour change theory.
Summary
Patient education aims to improve health by enabling individuals to make informed decisions about their own health-related behaviour. The purpose of patient education is to promote healthy lifestyles and encourage adherence to agreed medical treatment plans. This is important in sexual health, both when educating patients about safer sexual practices and when encouraging patients to take medication correctly. The health belief model is widely used to explain individuals’ health-related behaviour. The four principal components of this model are (1) the individual’s perception of his/her own personal susceptibility to disease, (2) his/her perception of the severity of the disease, (3) his/her perception of the benefits from modifying behaviour and (4) his/her perception of the barriers to modifying behaviour. The health belief model can be used as a patient education strategy in HIV and sexual health clinics. ultrasound is an important tool in the diagnosis of chronic genital conditions seen by the genito-urinary medicine physicians. Analysis of the literature shows that genital ultrasound scan is an important tool in the investigation of the Genital and Pelvic conditions. The provision of scanning facilities on site depends on the interests of clinicians within the clinic as well as the availability of appropriate training. In view of the rising numbers of complex chronic conditions seen within a confidential setting, it seems to be a good idea.
Introduction
A substantial number of studies have shown that a large percentage of patients do not take the medications they are prescribed. Non-compliance with lifestyle advice (e.g. stopping smoking, taking more exercise and practising safer sex) is also a widespread problem. Previously many health care workers viewed compliance as entirely the patient’s own responsibility. When a patient did not comply with medical advice they were regarded as a “difficult patient” and were often blamed for any resultant adverse consequences. However compliance should not be seen as the patient’s duty but a joint responsibility of the health professional and the patient working in partnership. The term compliance is becoming increasingly unpopular because it implies that the health care worker makes the decisions and the patient must then follow them. Terms such as “therapeutic alliance” and “adherence” are now widely used in recognition that treatment plans should be agreed between the patient and health care provider.
Maximising adherence involves identifying barriers to patient understanding, identifying barriers to adherence and assisting the patient to develop his or her own treatment plan (1). Health professionals have a duty to educate patients to enable them to make informed decisions regarding their own health behaviour. Therefore being able to understand and apply the principles of patient education are essential competences for all health practitioners.
What are patient education and health education?
Patient education is an attempt to facilitate favourable behaviour change. Patient acquisition of knowledge is an essential component of patient education but it should not be limited to this. It is not sufficient to provide information, nor to provide an intervention such as counselling. Falvo (1994) tells us that “...before education can be said to have occurred, learning must take place...” and that “...learning implies some change in behaviour, skill or attitude...” (1). Therefore we cannot state that education has taken place unless some benefit can be demonstrated.
Health education initially developed as a public health tool and focused on topics such as sanitation and immunisation. During the 1950’s the concept of health education broadened and started to include chronic conditions such as tuberculosis. During the 1960’s health education (of the public) and patient
education (of individuals) were seen as distinct topics. However the difference between the terms “health education” and “patient education” is not always made clear. The term patient education is sometimes used when advice is given to an individual and is matched to his or her own individual health problems and health education is used when non-targeted advice is given to groups. However the distinction between health education and patient education is unclear and they are probably best regarded as two ends of a continuous spectrum. This review will use the terms health education and patient education interchangeably as the theoretical principles underlying them are essentially the same.
Health belief model
The health belief model developed from the work of several social psychologists during the 1950’s, who were trying to explain why individuals failed to participate in preventive health care (2). The model is derived from Lewin’s theories on behaviour (3). Lewin et al. (1944) hypothesised that an individual’s behaviour depends on the value that he or she places on an outcome and on the individual’s estimate that a particular action will result in that outcome (3). In adapting this to health behaviour, it was believed that an individual’s actions would depend on the following factors (4-5; see figure 1):
1. Perceived personal susceptibility to disease. Appropriate health behaviour is more likely to be practiced if the individual believes he/she is personally at risk of the consequences of the disease.
2. Perceived severity of disease. Appropriate health behaviour is more likely to be practiced if the individual believes that the consequences of the disease are serious.
3. Perceived benefits of preventive action. Appropriate health behaviour is more likely to be practiced if the individual believes that the behaviour will successfully avoid the adverse consequences of the disease.
4. Perceived barriers to preventive action. Appropriate health behaviour is more likely to be practiced if the individual believes that the barriers can be easily overcome.
5. Modifying factors such as demographic variables and social influences. Health behaviour is influenced by age, sex, education and the influences of friends and family.
6. Cues to action such as advice from others and media reporting. Appropriate health behaviour may be encouraged by increased attention in the media (e.g. safer sex campaigns).
The first four of these factors are amenable to change during the patient consultation. Health professionals should therefore think about each of these factors in turn when encouraging adherence to medication or promoting behaviour change.
The health belief model has been modified to incorporate components of several other models of health behaviour. This combined model is called the “health decision model” (6). The components of the health decision model are:
1. General health beliefs: This relates to how concerned a person is about his or her health in general, willingness to accept medical direction and his satisfaction with his interaction with health care advisors. The patient is more likely to follow the treatment plan if he/she places a high value on health, accepts medical advice and is satisfied with his/her health care advisor.
2. Specific health beliefs: This relates to perceived susceptibility and perceived severity of the specific illness. The patient is more likely to follow the treatment plan if he/she believes that he/she is susceptible to the disease and that the disease is serious.
3. Patient preferences: The individual has to weigh up the perceived barriers and benefits of behaviour change. It is the patient’s perceptions which count rather than the real risks and benefits. For example a patient is more likely to practise safer sex if he/she believes that the barriers to condom use can be easily overcome.
4. Experience: The person may have experienced disease, treatment or other health behaviours previously. His/her perceptions of that experience and of his/her health care providers can alter future decisions. For example if a patient has seen a friend die of AIDS this may raise his/her awareness of the consequences of the disease and this may make safer sex practices more likely to be followed.
5. Knowledge: Specific knowledge of a disease and the diagnostic and therapeutic interventions to be considered can be important influences. Knowledge of a disease and its consequences is the first step towards recognition that one should practise behaviour which avoids that disease.
6. Social interaction: Supervision by others, social support and social networks can influence our experience and knowledge. For example adherence to anti-retroviral therapy can be assisted by support from family or friends.
7. Sociodemographic factors: Age, sex, income, educational level and possession of health insurance may influence knowledge, experience and social interaction.
8. Previous health decisions, health behaviour and the resultant health outcomes: The results of previous health decisions can affect knowledge and
experience. For example if a patient has taken anti-retroviral drugs previously and suffered serious adverse effects, the patient may be reluctant to re-commence anti-retroviral therapy.
Patient education in clinical practice
A basic understanding of the preceding educational models can assist health care workers in their day-to-day communication with patients. Communication is important because it improves patient compliance and produces health benefits (7). Patients who are given more information about their illness have fewer problems (8-10). Patients who are warned of likely side effects from medicines are less likely to stop taking them when they occur (11). Non-compliance is often linked to the physician’s failure to communicate the purpose of the treatment (12-13). Higher rates of patient compliance occur when the health care practitioner has better communication skills (14) and when the patient perceives himself or herself as an active participant in treatment planning (15).
Studies suggest that patients remember only 50% of what they are told in a clinic visit (16). Patients must therefore be given sufficient time in order to understand the information they are given. Information may often need to be repeated and the patient should be encouraged to ask questions. There is a tendency for health care practitioners to spend less time on health education of patients with lower educational achievements (17-18). However research shows that patients with less formal education have a greater need for health education and therefore additional effort should be made to meet these needs (19).
Szasz and Hollender (1956) describe three models of health care practitioner-patient interaction (20). In the activity-passivity model the health care practitioner gives instructions for the patient to follow. In the guidance-cooperation model the patient’s cooperation is sought but the health care practitioner remains in charge. In the mutual participation model joint decisions are made. This latter model is what health care practitioners should be aiming to achieve (20). Mutual participation forms the basis of health care practitioner-patient contracts where both health worker and patient must be willing to negotiate and both should gain from the
encounter (21). The aim should be to make the patient less dependent on the health professional by increasing his or her knowledge, skills and self-reliance (22). The patient then feels ownership of the decisions reached so that he or she is more committed to them.
Conclusions
Patient education is an essential component of effective health care delivery. Educational models based on behavioural theory can help us to understand patients’ actions and to plan effective educational interventions. If health care practitioners are to deliver high quality patient education in the future it is important that this subject is incorporated into medical curricula.
References
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