1. INNOVATION IN RURAL HEALTH CARE DR. MEL BORINS Associate Professor Faculty of Medicine University of Toronto active staff St. Joseph’s Health Center www.melborins.com
18. ACCESSIBILITY IS A CHALLENGE 80% of the world's inhabitants still rely chiefly on traditional medicines for their primary health care needs . Akerele Olayiwola, Nature's medicinal bounty: don't throw it away. World Health Forum 1993;14:390-395
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Editor's Notes
By understanding change as a process we can be better prepared to help patients to take the steps they need to change. Many if not most of you have probably heard about the Stages of Change Model. This model, developed by Jim Prochaska and Carlo DiClemente at the University of Rhode Island, is based on studies of patients over time. What they learned by studying the change process is that change is a journey with several stops and starts along the way. Research has demonstrated that most individuals are not ready to commit to taking action to change their behavior. In fact, the vast majority are at what have been called early stages of change - like precontemplation (or not even thinking about it) and contemplation (or thinking about it but not ready to commit to some action. Also, when we offer action-based strategies (like a prescription) to patients in early stages, it has little, and sometimes even a detrimental effect. The good news is that patients who take one step along the stages of change are more likely to take action in the future. We will show you how to use the stages of change to help revise your goals for intervention. More about this later.
In 2004, Mokdad and colleagues at the Centers for Disease Control and Prevention (CDC) conducted an extensive epidemiologic analysis of the actual causes of death in the US. These numbers are based on the known effects of each of these factors on mortality Almost 50% of all deaths could be linked to specific causes. (The other 50% are unknown factors). As you can see from this list the vast majority of these known causes are behaviors that are preventable. Tobacco, Diet/activity and Alcohol along account for almost 40 percent of all deaths. [The CDC also noted that deaths cause by poor diet and physical inactivity had increased sharply since 1990 (from 300,000 to 400,000). This parallels an alarming increase in the prevalence of obesity over the last couple of decades. Deaths from unhealthy diet and inactivity is projected to overtake tobacco use as the leading cause of death within a few years.] These are behaviors that clinicians can influence. There is good evidence that clinicians can influence tobacco use, alcohol use, diet, and physical activity. They may also have an impact on several of the other behaviors listed here. Clinician advice and counseling also has an important effect on patient adherence to preventive screening guidelines, esp. those for mammography and cervical cancer screening.
There questions will enable the clinician to get a better idea of each patient’s important health behaviors and permit effective and efficient tailoring of patient education and counseling efforts The first deals with risk. (read) Patients may not a respond truthfully to this questions the first time it is asked, but over time, as they begin to recognize the clinician’s sincere interest, discussion of these behaviors may begin to emerge. The wording you might choose may be different, these are simply suggestions. You will notice that the first two question begin with a statement that gives the patient “permission” to tell you about their problematic behavior.
The second question has to do with following through. (read) or “…with the plan we decided on last visit”. Again, the question begins with a legitimizing or normalizing statement. We know this is true from the literature. I know it is true for me as well! If we think of our own medicine cabinets and the bottles still there of half taken prescriptions, we can get the picture. Or, as a friend of mine pointed out, so how many of us floss every day? There is evidence that adherence can be increased by simply asking about it. Once we find out about non-adherence, we can then find out the barriers and problems, and help our patients to solve or overcome them. This workshop will help you with that task.
I really like this third question! It’s very positive in tone and gives the patient an opportunity to share something they are proud or happy about accomplishing. The medical world is only recently beginning to move away from the focus on disease to health optimization. This is not simply the prevention of disease, it is the recognition that optimal health enhances the quality of life and that the clinician can provide guidance in how to bring this about. We believe asking these three questions will provide clues as to where the clinician should focus.
