Seeking Information on the Internet

Whether individuals rely primarily on mainstream medicine,

alternatives or TM,
 Many seek information about their conditions on their own
 Rather than relying solely on information provided by HPs.
Some use the internet to seek health information
 Some diagnose themselves or others.
We know there is no control on quality of materials posted
 Making it difficult to police for fraudulent information
(such as claims that some herbs cure cancer or AIDS).
Information on the Internet…cont.
Popular search engines:
 takes users to websites run by individuals or corporations
that have vested economic interests in selling certain drugs
or treatments.
 Important for healthcare institutions to run own websites to
link users to reliable online sources of health information.
Despite limitations in:
 Most people’s ability to effectively search the internet or
evaluate the information they find;
Information on the Internet…cont.

 The internet has proven to be enormously beneficial to those

living with chronic health problems by:
- allowing individuals to find online forums designed to help
individuals who share similar health issues or concerns
- to find information far beyond what they otherwise could
access.
 This especially useful for those:
- confined to their homes by severe illness or disability,
- those with stigmatised illnesses who might shy away even
from doctor.
Information on the Internet…cont.

Internet can help patients:

 negotiate with healthcare providers regarding treatment,
 navigate the daily difficulties of living with a illness or
disability.
Internet gives individuals access to options that their own
doctors might reject as unethical.
 Placebos

Placebo is from Latin words ‘to please’.

Refers to a remedy without any direct active substance on
a disease:
 Given to help and keep the patient happy,
 To provoke perceived benefits despite the fact that
- there is no real medicine being ingested, patients feel
better.
- their pain or other symptoms go away.
- some patients improve simply because they think they are
getting real medicine.
Placebos…cont.
To persuade the prescriber that he/she is doing something
positive and useful.
Placebos have shown to bring about clinical improvement
in the different branches of medicine
(surgery, cancer treatment, dentistry, psychiatry, paediatrics
and others).
Its therefore important to understand:
 what placebos are,
 their benefits and
 how they work.
Placebos and Clinical Trials
Placebos produce the same phenomena observed in drugs with active
ingredients such as:
 Habitation (increase of dosage overtime)
 Withdrawal symptoms
 Dependency
Placebo clinical trials are often ‘double blind’ trials.
 Meaning, neither the patient nor the staff member administering the trial
is aware of which is;
- the experimental drug and
- which is the placebo.
This is to ensure that the patient’s expectation about the drug is not
influenced.
Types of Placebos

1. Pure or Inactive Placebo

- Contains no active ingredient (e.g. a sugar pill)
2. Impure or Active Placebo
- Contains an active ingredient but is not known to have
any effect on the condition being treated
(e.g., prescribing an antibiotic for a viral infection or
vitamin C to treat headache even when the patient
doesn’t need it).
 Factors Influencing Placebos

1. Physical appearance of the placebo

Example:
 Green pills reduce anxiety more than yellow or red,
 Blue pills are considered calming, while
 Red pills are considered activating;
 Bigger pills are thought to be better; and
 Capsules are preferred to tablets.
Factors Influencing Placebos…cont.

2. Reputation of the setting

Example: A university research unit is likely to enhance
treatment more than a small clinic.
3. Patient’s perception of the attitudes of staff members
Example: Where HP are judged as more:
- interested,
- friendly and
- considerate, the health results/outcomes are generally more
positive.
How Placebos Work

1. Social influence
(HP are perceived as people in authority, therefore, their
direction and expectations are likely to be followed).
2. Role expectation
(HP’s role is to treat whilst patient’s role is to get better. So
patient plays this role).
3. Classical conditioning
(for a patient, past experiences of taking drugs led to
improvement, so the administration of a new drug/medicine is
also likely to produce the same response).
How Placebos Work…cont.

4. Operant conditioning
(the HP rewards the patient who shows signs of
improvement, therefore increasing the probability that
the patient will continue to report improvement).
5. Cognitive influence
(if patient has firm beliefs that modern medicine is based
on scientific evidence, therefore it will be effective. If
patient believes modern medicine to be harmful, they
may experience adverse effects).
Ethical Concerns in the Clinical use of Placebos
Placebo effect is similar to faith-healing, where some medical
practitioners prefer to see medicine as a science.
The medical practitioner is:
 deceiving and
 betraying the patient.
 the decision whether or not to tell the patient the medicine is
fake.
The patient wants effective treatment; instead he/she receives a
placebo.
Ethical Concerns…Cont.
The potential for a patient's health not to improve
(since the placebo isn't a real medication).
The possibility that the HP is simply defaulting to thinking
the patient's problems are all in his/her head.
The potential for:
 a malpractice suit if someone is;
- harmed or dies because they were
- misdiagnosed or undiagnosed and prescribed a placebo.
Ethical Concerns…Cont.

On these grounds, some have maintained that placebo

treatment will always:
 be unethical and
 a violation of the patient’s right to be truthfully informed
about treatment.
Managing Social Relationships and Social Standing

Chronic pain/illness/disability can:

 strengthen or
 strain relationships.
During this time:
 Relatives and friends pull together to face health problems,
 Old wounds are healed or put aside,
 Individuals realise how much they mean to each other
(this is especially true for females who are socialised to take
care of others).
Managing Social Relationships…Cont.

Friends and family often help each other willingly during:

 Acute illnesses or
 During the first few months of a chronic illness/traumatic
injury
 But tend to pull away overtime.
 The burden of gratitude can make those with chronic
pain/illness reluctant to ask for needed help.
 The need to rely on others for assistance can negatively
affect individuals image of themselves as competent adults.
Managing Social Relationships…Cont.
 This especially challenging for the elderly who may have:
- outlived close relatives and friends and
- must rely on more distant social connections for help and
support.
Relationships also suffer if individuals:
 are no longer able to participate in previous activities.
- Maintaining a relationship with a tennis partner,
- Maintaining a relationship with a friend when transportation
barriers keep you from going to movies/restaurants.
- Maintaining a relationship with a spouse/lover
Managing Social Relationships…Cont.
Decline in financial standing also strain relationships.
 An individual might have the physical ability but lack the
funding.
 This is especially true for the economically disadvantaged
groups of society, who are:
- either already unemployed or
- earn lower wages and/or
- have unpredictable work histories,
- Often they have to live on social grants
Managing Social Relationships…Cont.

Living with chronic pain/illness/disability also means living

with stigma.
To challenge stigma and discrimination individuals living with
chronic pain or at-risk of illness/disability sometimes turn to:
 collective actions such as Health Social Movements in efforts to
addressing their
- grievances and
- change something about the world that they believe is wrong.
(HSM – Basic Income Grant; Young Feminists Movement; Namibia Equal Rights
Movement, National Federation of People with Disabilities in Namibia, etc.)
Managing Social Relationships…Cont.
Living with chronic illness/disability can negatively affect the
self-concept.
 More so for men who are socialised to be:
- physically and financially independent – threatens their self-
esteem when they cant meet these expectations.
 It is however not solely negative outcome.
- It has little effect on overall life satisfaction or happiness of
an individual.
- Forces some to relook at themselves and their lives and
- redefine who they are with the chronic illness/disability.
Theme 8: Illness Behaviour and Patient-Healthcare Provider
Interaction
Understanding why people consult is important:
 Some HPs experience;
- frustration and anger
- due to what they perceive to be inappropriate or trivial
consultations.
 Some people;
- feel frustrated and angry with HP
- whom they perceive to show a disinterest in their
health challenges.
Illness Behaviour and…cont.

 Both experiences influence:

- subsequent consultations,
- adherence to treatment and
- health-seeking behaviour.
 Delays in healthcare consultations may:
- seriously affect a patient’s risk of disease progression and
- the development of health-related complications.
(Statistical evidence indicates higher mortality as a result of
delay in receiving medical care).
The Symptom Iceberg

The iceberg figure below demonstrates:

 how HPs do not see or treat illnesses that occurs in a
specific community.
 They see and treat symptoms of a disease
(referred to as the ‘tip of the iceberg’).
The Symptom Iceberg…cont.

 Meaning, a larger % of people may experience health

challenges that would:
- respond to medical treatment but may show no symptoms,
- they may take the symptoms lightly or
- they may choose to self-medicate or
- seek alternative treatments.
Differences in Symptom Perception
People perceive the seriousness of their symptoms
according to:
 The severity of the symptoms
 The familiarity of the symptoms and
 Duration and frequency of the symptoms.
Example:
 Rare headaches vs persistent headaches
(unless the symptoms are unusual, persists for longer than
usual or recurs more frequently than usual).
Differences in Symptom Explanation
 People make sense of their symptoms and
 explain them within the context of their lives.
 Using own lay knowledge and
 experience as well as
 the knowledge and experience of family and friends.
Example:
 a family history of cancer/heart disease vs those
without.
Differences in Symptom Evaluation
People weigh for themselves;
 What the relative costs and
 benefits will be to or not consult.
They may decide against consulting because;
 other things in their lives may take priority.
 may wait or take medication to see if symptoms cease over
time.
 may evaluate what the medical practitioner will think of
them,
Symptom Evaluation…cont.
 what they can do for them and their symptoms.
Example:
 breathing difficulties vs believes in difficulty communicating the
seriousness of the breathing concerns.
People with relatively minor symptoms may not consult due to anxiety
(fear the symptoms will turn out to be an indication of a serious health
condition).
Example:
 Mothers of younger children are conflicted with whether or not to
consult and
 risk being labelled as presenting trivial issues or bad parent.
Reasons People May or May Not Decide to Consult

The decision to consult is an interplay of physical,

psychological and social factors:
- Mismatch
(between what patients and healthcare practitioners perceive
as appropriate reason for consulting).
- Lack of knowledge.
- Use of substitute medication.
- Anxiousness that something serious may be indicated.
- Prioritising other aspects of one’s life.
Reasons People Decide or Not to Consult…cont.

- Difficulty accessing healthcare services

(physical distance, telephone to make an appointment,
unsuitable appointment slots, unfriendly healthcare
personnel, cost of payment).
- Recommendation/advice by a family member or friend to
consult.
- A change in a person’s social/work setting or personal life
(may trigger a consultation even when there’s no change in
their existing symptoms).
Consulting the Healthcare Professional

Consultation between patient and healthcare

professionals is the core of all helping professions.
Four (4) models of the patient-healthcare professional.
1. The paternalistic model
 Is disease-focused
 The HP conducts a systematic enquiry of health-related
questions and tests and patient answers
(usually closed-ended questions.
Four (4) Models…cont.

 The HP provides a range of possible diagnosis.

- HP than decides on the appropriate treatment
- Patient is expected to follow without treatment plan.
Four (4) Models…cont.
2. Mutual Model
 Recognises patients:
- autonomy;
- the importance of the patient’s own beliefs and knowledge
of their own health and illness,
- the social context in which the illness is experienced,
- uses a ‘person-centred approach’.
Four (4) Models…cont.
The Person-Centred Approach
 explores the patient’s main reason for the consultation,
 explores patient’s concerns and
 need for information;
 seeks an integrated understanding of the patient’s
world
(their emotional needs and social/life challenges);
 finds common ground on what the problem is and
mutually agrees on management.
Four (4) Models…cont.
 Enhances prevention and health promotion,
 Enhances the continuing relationship between the
patient and HP.
Patient-centred consultations generally take more time.
Longer patient consultations are associated with:
 Less prescribing of treatment;
 More advice on lifestyle changes and health-promoting
activities;
 Identification of patient’s psychosocial challenges;
Four (4) Models…cont.

- Better clinical care (especially of some chronic illnesses);

- Higher patient satisfaction.
The person-centred approach still includes:
 A systematic history taking of the patient’s presenting and
underlying problems,
 It however also incorporate the patient’s ideas,
knowledge, beliefs, concerns and expectations.
Lack of time unfortunately always constrains most HPs.
Four (4) Models…cont.

Patients are conscious of:

 not only consulting for trivial matters, but
 also weary of taking up too much of the HP ‘precious’ time.
Patients feel intimidated especially by HP and are at times:
 reluctant to ask questions,
 voice their ideas and
 anxieties for fear of being thought of as inappropriate,
stupid or time-wasting with trivial matters.
Four (4) Models…cont.

3. Consumerist Model
 Characterised by patients ‘shopping around’ for their preferred
type of healthcare.
 More common now with:
- Private health insurance/medical cover;
- Patient rights and charters;
- Patients choices on treatment options;
- Extension of initiatives for quicker access to HPs.
- Accompanied by thorough investigation of the type of healthcare,
treatment and sometimes lawsuits as a result of malpractice.
Four (4) Models…cont.

4. Default Model
 Characterised by low levels of engagement/interaction
(between patient and HP).
 Commonly observed in situations where the doctor
cannot find anything organically wrong
(to explain the patient’s symptoms, instead patient is
labelled as ‘somatising’).
Patient Adherence

Adherence means following the advice of HPs.

This includes:
 Taking preventative action
(e.g. reducing your alcohol intake);
 Keeping medical appointments
(e.g. screening or follow-ups);
 Following self-care advice
(e.g. caring for a wound after surgery);
Patient Adherence…cont.

 Taking medication as directed

(as per the dosage and time prescribed).
Most healthcare interventions greatly rely on patient
adherence to enhance medication effectiveness and
decrease harmful effect on health.
 Patient Adherence…cont.
Why patients have difficulty following advice?
 May forget
 May disagree with the recommended treatment regimen and may
decide:
- Not to take the medication;
- Take more or less than prescribed;
 Misunderstandings
(Between HP and patient regarding patient’s diagnosis).
Patient Adherence…cont.

Key Questions that influence patient adherence

 Do I really need this treatment?
 I’m I at risk of getting worse without applying what is
advised?
 How useful or beneficial is the recommended
treatment/action?
 What side effects will this treatment have?
 Will adherence conflict with other things I want to do?
Patient Adherence…cont.

Key Determinants of Patient Adherence

 Adherence is more likely when:
- patients understand what they are being asked to do and
- why;
- when they can remember it and
- when they are satisfied with the HP approach and
- the consultation.
Patient Adherence…cont.
How HP can increase adherence and patient satisfaction
 By considering and discussing the:
- patient’s perspective and
- understanding on their illness and treatment methods.
(By jointly agreeing on treatment methods patient is more
likely to be committed and follow through with the advice).
 Promote patient satisfaction by:
- being friendly and approachable.
Patient Adherence…cont.

 Increase patient understanding by:

- simplifying information and
- discussing patient’s health beliefs.
 Assist patients to remember/recall by:
- labelling information,
- repeating instructions and
- giving clear and specific advice.
Communication Skills

Consultation between patient-HP is central to:

 effective health practices and
 can affect quality of care.
Patient-HP is characterised by two (2) primary
communicative tasks:
 Relational Development and
 Information Exchange
Communication Skills…cont.

Failure of a HP at accomplishing these communicative

tasks may lead to:
 Failure to identify the patient’s main problem;
 Inaccurate diagnosis and inappropriate investigations;
 Poor adherence with treatment;
 Patient dissatisfaction and complaints;
 Patient choosing litigation if a medical error is made.
Communication Skills…cont.
Factors Affecting HP-Patient Communication
1. Physical Setting
 Refers to the environment within which the HP
interviews/consults with a patient.
2. Non-verbal Behaviour (NVC)
 Behaviour other than what is said.
3. Verbal Communication
 Appropriate language and
 clear exchange of information with patients.
Communication Skills…cont.

4. Psychosocial Context
 Refers to the characteristics of the HP or patients and
 how they relate to one another.
Communication Skills…cont.
Physical Setting includes:
 Seating:
- a patient is likely to feel uncomfortable if a HP sits directly
facing them,
- sits behind a desk or
- stands whilst patient is sitting or lying down.
 Privacy:
- patients are likely to talk freely if they believe they won’t
be overheard.
Communication Skills…cont.

 Noise and interruptions:

- intrusions that disturb patient/HP’s concentration may
result in an ineffective consultation.
Communication Skills…cont.
Non-verbal behaviour: Important aspects to consider of
non-verbal communication:
 Proximity:
- sitting a comfortable distance from the patient
(not too distant - aloof or too close - appear threatening).
 Posture:
- sitting upright but relaxed, arms and legs uncrossed,
- leaning towards the patient (convey attentiveness),
- leaning back/slouching (suggest lack of interest).
Communication Skills…cont.
 Eye contact:
- The most powerful NVC for initiating, maintaining and
ending communication.
- Gaze in direction of patient without staring.
 Facial expressions:
- are important in showing or reflecting emotions so that
the patient feels understood and
- not prejudiced based on preconceived opinions.
Communication Skills…cont.
 Head nods:
- convey understanding and encouragement for the patient to share
more.
- However, vigorous nodding may be interpreted as being impatient.
 Touch:
- Can be facilitative
(i.e. shaking hands to establish a relationship or meeting),
- Functional
(i.e. carry out physical examinations) and
- Therapeutic
(to console a distressed patient).
Communication Skills…cont.

Silence:
- may occur when a patient is taking time to decide how to answer,
- trying to recall a detail or
- is experiencing a difficult emotion.
(Do not fill the silence with another question immediately, reflect for
clarification of thoughts and feelings).
Paralinguistic features:
- variations in vocal attributes such as:
a. tone,
b. pitch and
c. volume when expressing a statement of fact, surprise or a question.
Communication Skills…cont.
Verbal communication: Different aspects of verbal
clinical communication include:
 Questioning: Different types of questions
a. Closed questions:
- limit the patient’s responses
(i.e. when did the discomfort start? Are you still
experiencing it?).
b. Open questions:
- allow patient more discretion in their responses and
(what seem to have been troubling you?)
Communication Skills…cont.

- are good for eliciting beliefs, opinions or feelings.

- Useful early on at the start of the consultation to allow the
patient to describe their health issue fully
 Reflecting:
- encourages patient to talk and
- it demonstrates active listening skills.
 Summarizing:
- the HP summarise significant content of what the patient has
said,
- their symptoms and
Communication Skills…cont.
- key points of treatment.
- Allows for any misinterpretations to be clarified for both
patient and HP.
 Explaining:
- the ability for HP to deliver clear and coherent explanations on
the patients:
a. understanding of their illness,
b. diagnosis,
c. treatment and/or
d. further tests.
Communication Skills…cont.
When explaining:
 Provide logical points.
 Avoid jargon/unnecessary explanations.
 Repeat and emphasise key points.
 Use examples/diagrams/images/pictures.
 Give specifics and not vague advice.
 Ask for feedback on patient’s understanding.
Communication Skills…cont.
Psychosocial context: refers to attributes such as:
 Personal values,
 Attitudes and
 Beliefs
(which may reflect the influences of family, socioeconomic
status, religion or ethnic background).