«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 ...»
Ethical issues in disseminating health information to the wider public It should be no surprise that working to improve the health of the public, irrespective of the age of the target audience, is likely to involve ethical value judgements. In the previous chapter we considered four basic principles that are used to guide health professionals’ decisions. These principles (respect for autonomy, non-maleﬁcence or doing no harm, beneﬁcence or doing good, and justice) are also key to ethical health promotion. A higher-order principle that is often applied in relation to health promotion is that professionals should act in ways such that the beneﬁts of any action will outweigh any disadvantages. However, the application of this principle can create conﬂict with the other principles. Thus, the introduction of smoking bans in public places is argued to oﬀer the greatest beneﬁt for the largest number of people, but can also directly conﬂict with the principle of autonomy when it comes to looking at the rights of individual smokers. The issues are even more complex when it comes to areas of health such as vaccination and screening programmes. Again, these can be well justiﬁed in terms of doing the greatest amount of good for the largest number of people, but may not be in the best interests of every individual child or parent. Freed et al.
These ethical issues are addressed in the UK government’s recent White Paper on public health (Department of Health, 2004). In the introduction to the paper, UK Health Minister, John Reid, stated that while we respect an individual’s right to make their own choices, we need to respond to public concern that some people’s choices can have a dangerous eﬀect on other people’s health. We therefore need to strike the right balance between allowing people to decide their own actions, while not allowing these actions to unduly inconvenience or damage the health of others.
The ethical principle of justice, or fairness for all, is particularly relevant in the area of health promotion, as decisions usually need to be made about allocating limited resources between diﬀerent individuals and sectors of the population. Thus, in the previous chapter, we considered whether, in the case of screening, a less eﬀective procedure for a relatively common condition should take priority (when resources are limited) over a very eﬀective procedure for a much rarer condition. In order to weigh the Health promotion and the wider public 111 potential beneﬁts of any health programme against the risks, a distinction can be made between cost–beneﬁt analysis and cost-eﬀectiveness analysis (BMA, 1990). In the former case, a decision is typically whether to spend money to save lives, that is, to attempt to weigh lives against sums of money.
In contrast, cost-eﬀectiveness analysis makes the assumption that resources are available, even if limited, and is used to determine how best to limit any risks. As the BMA (1990) noted, given that risks to health may either relate to length of life or to quality of life, there is interest in making rationing fairer by combining these elements to produce an overall measure of beneﬁt.
This chapter has looked at communication issues in relation to health promotion and disseminating information to the wider public. It started by considering what is involved in health promotion and then looked at health promotion in schools and the workplace. We next looked at three general strategies or approaches to health promotion and then considered in more detail three diﬀerent channels (Patient Information Leaﬂets, the media and the Internet) that are commonly used to disseminate information to the wider public. Finally, we considered some ethical issues that arise in relation to health promotion and communicating health information to the general population.
Communication skills training In several of the earlier chapters in this book we have noted the importance of healthcare professionals having good communication skills. There is now a large body of empirical evidence to show that healthcare providers who communicate well with patients make more accurate and complete diagnoses, are more likely to detect distress in patients and have patients who are more satisﬁed and less anxious. Their patients are also more likely to follow recommended advice and treatments, and have improved health indices and recovery rates (e.g. Di Blasi et al., 2001; Dulmen and Bensing, 2001; Fallowﬁeld et al., 2002; Williams et al., 1998). Conversely, there is also evidence to show that poor communication between health professionals and patients can result in a number of negative health outcomes (e.g.
MacDonald, 2004). Unfortunately, the manner of communication between doctors and patients is still a major cause of patient dissatisfaction (e.g.
Roberts et al., 2001). Interestingly, most complaints about doctors concern poor communication and failure to listen, rather than competence or more technical aspects of consultations.
We also noted in Chapter 1 that poor communication between healthcare providers and patients is often the result of inadequate training in communication skills. Somewhat surprisingly, an individual doctor may carry out between 150 000 and 200 000 patient interviews during the course of his or her career, but very few have received any formal training in communication, and much of the training that has been provided has been inadequate. The UK Health Services Commissioner’s Annual Report (1993) noted that one reason for the inadequate training was that communication tends to be relegated to the hidden curriculum, rather than being formally and explicitly addressed. As Sleight (1995) pointed out, however, teaching communication skills is arguably one of the most important parts of the medical curriculum, and should not be considered to be an optional extra. Fortunately, there is now a growing body of empirical evidence to Communication skills training 113 suggest that the provision of formal communication skills can signiﬁcantly improve the quality of communications between healthcare providers and patients.
Chapter 5 included a number of useful guidelines for healthcare professionals when dealing with particular sub-groups of the population (such as older adults, children and parents, diﬀerent ethnic groups and withdrawn or aggressive patients). Similarly, Chapter 6 included guidelines to help healthcare professionals to communicate complex risk information or bad news to patients or others. Many of these guidelines are likely to be incorporated into current communication skills training programmes. In addition, such programmes might also cover tips for how to increase the likelihood of particular aspects of the environment facilitating communication (as outlined in Chapter 2). The present chapter supplements the information that has already been covered in these earlier chapters. It starts by considering the diﬀerent communication skills that are typically targeted in training programmes, including a number of the more basic skills, as well as the more complex skills needed for managing and resolving conﬂict in healthcare settings. It then looks at a number of diﬀerent approaches to the provision of training. Finally, it reviews much of the empirical evidence from studies that have evaluated the success of existing programmes.
Basic communication skills
Communicating eﬀectively with others requires the skilled use of various diﬀerent techniques. In healthcare situations, the most commonly employed communication skills are questioning (including carrying out the ‘medical’ interview), explaining and providing information, listening, reinforcement and reﬂection, as well as being able to open and close interactions satisfactorily. Many of these skills include both verbal and non-verbal aspects, and communication skills training now routinely covers both the verbal and nonverbal components. These basic communication techniques will now be discussed in more detail.
Questioning Questions are verbal statements, or non-verbal acts, that invite a answer (Stewart and Cash, 2000). We noted in Chapter 2 that to ask a question is one of the most powerful tools in communication (Hawkins and Power, 1999), as questions are at the heart of most interpersonal interactions.
Clearly, the ability to ask questions eﬀectively is a core skill for most health professionals, as they need to be able to ascertain certain basic information from patients and others before they can begin to make a diagnosis or give advice. Questions serve a number of diﬀerent purposes, including opening discussions, obtaining information, assessing a patient’s condition, 114 Health communication diagnosing what is likely to be wrong and determining the most appropriate treatment or follow-up course of action. They can also be used to elicit the patient’s attitudes and feelings, demonstrate interest and maintain control of the interaction.
As we noted in Chapter 2, there are two basic types of question. Open questions (such as ‘what is the problem?’) encourage longer unstructured answers. Clearly, these allow patients to say what is wrong with them in their own words, and discuss how they feel about it, but can result in irrelevant information being introduced into discussions. In contrast, closed questions (such as, ‘have you been taking your medication?’) typically encourage short yes/no responses. Closed questions are most useful for obtaining a limited amount of factual information in a limited time, or when it is necessary to obtain speciﬁc information which the patient has not provided. However, it must be recognized that the information elicited will depend on the speciﬁc questions asked, and may lead to the patient feeling frustrated as they have had little opportunity to express their own concerns and feelings. A number of studies have shown that healthcare providers tend to overuse closed questions (presumably to reduce the length of consultations), and often need training to use more open questions. In practice, most healthcare interactions will beneﬁt from the use of a combination of open and closed questions. Whatever combination is decided on, overly complex questions (that often contain two or more sub-questions) and leading questions (that bias people towards responding in a particular way) should be avoided. Thus, a leading question, such as ‘how beneﬁcial did you ﬁnd the medicine?’ should be rephrased, or preceded by the more neutral question, ‘has the medicine had any eﬀect?’ The ‘medical interview’ Much of the question asking that takes place in healthcare interactions will occur in the context of what is known as ‘the medical interview’.
Such interviews take place in many diﬀerent settings, such as on hospital wards, in clinics, in GP surgeries and in community pharmacies. Whatever the particular setting, it is preferable to use quiet, private and comfortable conditions, with an appropriate seating arrangement (with the health professional facing the patient). Lloyd and Bor (1996) outlined a number of guidelines for conducting interviews. In terms of starting the interview, they suggested that patients should be greeted by name and asked to sit down.
The healthcare professional should introduce themselves and explain the purpose of the interview, the need to take notes, and the attendance of others if relevant. During the main part of the interview, the professional should try to maintain a positive atmosphere, warm manner and good eye contact, should use open questions at the beginning, switching to speciﬁc closed questions when needed, and should listen carefully. While doing this they should be alert and responsive to both verbal and non-verbal cues that Communication skills training 115 are emitted by the patient, and should facilitate the patient’s input by using appropriate verbal and non-verbal responses themselves. At the end of the interview the professional should summarize what the patient has said and check that their understanding is accurate, ask them if there is anything that has been missed, and thank the patient. If relevant, they should explain what will happen next.
Explaining and providing information Information provision serves a number of diﬀerent purposes. Thus, information may be provided to help the patient understand what is wrong with them and how it might be treated, to reduce their uncertainty and anxiety, to correct mistaken beliefs, to give advice and to gain their co-operation in their healthcare management. Clearly, the way in which information is provided or explained can have a major eﬀect on several aspects of patient care. As we have seen earlier in this book, a number of studies have shown that people who are provided with more, relevant, information often have higher levels of satisfaction, feel less anxious, experience less pain, are more adherent and have other improved health outcomes (e.g. Culos-Reed et al., 2000; Roter, 2000; Roter et al., 2001). Unfortunately, studies have also shown that healthcare providers are often not very good at providing the information that patients most want (e.g. Donovan and Blake, 1992; Noble, 1998; Williams, 1993). Indeed, failure to give adequate information or provide an adequate level of explanation has been noted to be one of the most common causes of dissatisfaction among patients (Berry, 2004; Luker et al., 1997).