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«HEALTH PSYCHOLOGY Series Editors: Sheila Payne and Sandra Horn Di an ne Be rr y ion at ce nic cti mu Pra om and h C ory alt The He Health ...»

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Health education is any intentional activity which is designed to achieve health- or illness-related learning, that is, some relatively permanent change in an individual’s capability or disposition. Effective health education can have many significant (positive) effects. Thus, it can produce changes in knowledge and understanding or ways of thinking; it can influence or clarify values; it can bring about some shifts in beliefs or attitudes; it can facilitate the learning of new skills; and, importantly, it can lead to desired changes in behaviour or lifestyle (Tones and Tilford, 2001).

Clearly, effective communication is key to effective health education.

There are numerous ways in which this communication can occur. Some of Health promotion and the wider public 91 the most common are via written Patient Information Leaflets, product labelling, the Internet, and media campaigns. Before looking at each of these in more detail, we will consider three general strategies or approaches to health promotion that can be taken.

Health promotion strategies Most countries have focused their efforts on primary prevention activities through the modification of lifestyle factors that account for the greatest share of the burden of disease (e.g. smoking, excess alcohol, poor diet and risky sexual behaviour). Key methods that have been used to address these include health education, fiscal and legislative measures (such as increased tax on cigarettes and alcohol, and compulsory wearing of car seatbelts) and environmental changes (such as the introduction of airbags into cars, and the removal of asbestos from old buildings). Interestingly, comparisons of the effectiveness of public health strategies that have used education/persuasion with those that have used financial or legal changes have shown the latter to be far more effective (e.g. Stroebe, 2000). Clearly, however, it is difficult to apply financial and legal sanctions to many aspects of unhealthy living.

Marks et al. (2000) outlined three main strategies or approaches to health promotion. These are the Behavioural Change approach, the Selfempowerment approach, and the Collective Action approach.

The Behavioural Change approach The key objective of this approach is to bring about changes in the behaviour of individuals through changing their cognitions (thoughts and beliefs). This typically requires increasing people’s knowledge about the causes of health and illness through the provision of information about health risks and hazards. The Behavioural Change approach is based on the assumption that people are rational decision makers and that their health behaviours are informed by their cognitions. Thus, applying social cognition models, such as the Health Belief Model (e.g. Rosenstock, 1974; see Chapter 3), to plan health interventions would be an example of this approach to health promotion. Limitations of this approach include its focus on the cognitions of individuals, its failure to take sufficient account of individual differences, and the fact that it has not had much success in targeting important socio-economic causes of ill health.

The Self-empowerment approach The main objective of this approach is to empower people to make healthy choices so that they can increase control over their physical, social and internal environments. This is mostly done through participatory learning 92 Health communication techniques (such as group work, counselling and social skills training). It is based on the assumption that power is a universal resource that can be used by everyone. However, a limitation is that it seems to ignore the fact that there are systematic inequalities that are known to exist with regard to access to material and psychological resources. Like the previous approach, the Self-empowerment approach has also been criticized for focusing on the individual as ‘the target for change’.

The Collective Action approach The main aim of this third approach to health promotion is to improve public health by addressing the important socio-economic and environmental determinants of health. Specifically, the key objective is to modify the relevant social, economic and physical structures that generate ill health.

In order to achieve this, however, individuals must act collectively to improve their social and physical environments. The Collective Action approach is therefore based on the assumption that individuals share sufficient interests to allow them to act in the necessary collective way. As should be apparent, this third approach is more ‘political’ than the other two approaches and, to be effective, can require significant resources.

Clearly, effective communication is central to all three approaches. However, the particular way in which it is applied will differ according to which approach is taken. Thus, the content of the message, and the way in which it is presented, will differ according to whether the main aim of the activity is to change individual behaviour, empower people or to address major socioeconomic and environmental determinants of health. An important point to note is that communication in all cases involves more that simply getting a message across. Rather, it involves building relationships and empowering people so that they can make appropriate health-related choices and decisions (Katz et al., 2000).

Patient Information Leaflets

Despite the considerable growth in the availability of computerized health information systems and access to health information via the Internet, written Patient Information Leaflets (PILs) are still one of the most common forms of disseminating information about illnesses and treatments. The Arthritis and Rheumatism Council in the UK, for example, produce over

1.5 million leaflets per year. This growth in the availability of PILs is due to several factors, including increased regulation (such as in relation to medicines), increased activities by self-help and other support groups, and enhanced public awareness and expectations (see also Mossman et al., 1999).

Patient Information Leaflets serve a number of purposes (Coulter et al., 1998). These include promoting better health and preventing disease, Health promotion and the wider public 93 encouraging self-care and reducing inappropriate service use, ensuring the appropriateness of treatment decisions and improving the effectiveness of clinical care.

The effects of providing written information Several researchers have argued that providing information in written form is more effective than via spoken communications (e.g. Ley, 1988; Ley and Llewellyn, 1995; Raynor, 1998). What are now considered to be classic studies of Ley (1973), for example, showed that after five minutes, patients forgot about half of the spoken information given to them in the consultation. Similarly, Wilson et al. (1992) found that, after 24 hours, patients could remember only a third of the spoken information given to them by pharmacists. However, there is also evidence that the combination of the two forms of information can be more effective than providing written information alone. Johnson and Sandford (2004), for instance, found that providing a combination of written and spoken health information for patients being discharged from acute hospital settings was more effective in improving patient knowledge and satisfaction, than was providing spoken information alone. Raynor (1998) suggested that the combination of the two forms of information can maximize effectiveness through mechanisms such as repetition, reinforcement and signalling importance. In addition, Morris (1989) argued that the strongest beneficial effects are often when written information is combined with other educational interventions, such as videos, talks and one-to-one spoken communications. This argument was supported by Semple and McGowan (2002) when they suggested that, in many situations, written information should be used to supplement and reinforce information obtained from direct contact with health professionals.

Whether used in isolation, or in combination with other methods, it is generally acknowledged that a major benefit of written leaflets is that they can be referred to by patients (or by their relatives) when they are away from the stressful environment of the consultation room. This allows patients to ‘refresh and review their knowledge at all stages of their condition’ (Kenny et al., 1998, p. 473). Raynor (1998, p. 86) suggested that written information has the potential to influence health behaviours in at least three different

ways, in that it can influence:

♦ patients who want to follow the recommended treatment but need more information to do so ♦ patients who have fears and misconceptions that need countering ♦ patients who are dissatisfied with their care.

Thus, written information materials can be aimed at providing specific instructions, influencing beliefs, and/or generally increasing satisfaction. A number of studies have shown that many leaflets do have positive effects on 94 Health communication patients’ knowledge and health outcomes. Bishop et al. (1996), for instance, found that people with rheumatoid arthritis who received a written information leaflet showed an increase in knowledge about their condition, and reported less pain and decreased depression. A follow-on study showed that the short-term increase in knowledge was maintained over a six-month period (Barlow and Wright, 1998). Benefits were also reported by MacFarlane et al. (1997), who found that issuing a written leaflet to patients with respiratory infections reduced their reconsultation rates. Similarly, a more recent study by Coudeyre et al. (2002) found that the provision of leaflets for low back pain patients undergoing steroid injections under fluoroscopy reduced state anxiety and increased patients’ knowledge and satisfaction with the information provided.

Not all studies have reported such beneficial effects, however. Turner and Williams (2002), for example, reported that older adults who were given a written leaflet, following the provision of spoken information during a consultation, had forgotten most of it after six weeks. Similarly, Brown et al. (2003) found that recall of surgical complications from otologic surgery was equally poor both with written and spoken information, and that the poor performance was independent of age and education.

Assessment of existing Patient Information Leaflets Despite the positive results reported earlier, it must be recognized that the provision of written information is not likely to have a positive effect on health behaviours and outcomes if it is of poor quality or not easily accessible. Detrimental effects can occur if people are given unclear, conflicting, overly complex or too much information. In 1993 a survey by the Audit Commission in the UK found several inadequacies in the quality and availability of written information for patients. The Commission made a number of recommendations for improving the situation, specifically suggesting that

clinical staff and general managers should work together to:

♦ review the written information currently distributed, as well as the distribution mechanisms ♦ find out what kind of information patients and relatives want to be given ♦ provide written information about conditions, procedures and postoperative care ♦ make written information from national organizations available to patients and caregivers ♦ allocate resources to help fund the production and purchase of written information ♦ make clear arrangements for distributing written information at the right time.

To be effective, a leaflet must be noticed, read, understood, believed and remembered (Kenny et al., 1998). Unfortunately a national survey of Health promotion and the wider public 95 written information given to patients in the UK (Payne et al., 2000) showed that 64 per cent of leaflets could be understood by only 40 per cent of the population. In addition, many of the leaflets did not meet basic guidelines for legibility and readability. Coulter et al. (1998, p. 16) listed a number of criteria that have been recommended for evaluating the quality of PILs,


♦ accessibility ♦ acceptability ♦ readability and comprehensibility ♦ style and attractiveness of presentation ♦ accuracy and reliability of content ♦ coverage and comprehensiveness ♦ currency and arrangements for editorial review ♦ references to sources and strength of evidence ♦ where to find further information ♦ credibility of authors, publishers, sponsors ♦ relevance and utility.

Coulter et al (1998) reported a large-scale study which assessed the extent and nature of information materials available for patients for 10 common health problems (for example, back pain, depression, infertility), as well as assessing the quality of the materials. Initial focus group discussions identied a number of different purposes for which patients reported needing good-quality PILs. These included: the need to understand what is wrong with them, to gain a realistic picture of their likely prognosis and to understand the processes and likely outcomes of potential tests and treatments. In addition, the information should aid people in self-care, inform them about available services and sources of support, and help them to identify the best healthcare providers. Finally, they wanted PILs to provide reassurance and to help other people to understand their condition and its treatment.

Overall, the study’s findings gave cause for concern in relation to both the availability and quality of existing PILs. In particular, it was found that most patients did not receive the information about treatment options that they needed to participate in decision making. In addition, the quality of most of the reviewed patient information materials was unsatisfactory.

Specifically, many contained inaccurate and outdated information and few provided appropriate information about treatment risks and side effects.

Topics of relevance were often not included and coverage of treatment options was incomplete. Furthermore, technical terms were not explained, uncertainties were either glossed over or ignored, and information about the effectiveness of different treatments was often unreliable or missing.

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