FHI - Chapter 10

Behavior Change in the Clinic Setting
Preview Chapter 10 Introduction Patient education is the missing component of much STD care around the world. This chapter is intended to provide STD clinic managers and staff with information to help them design, implement and evaluate STD patient education at their clinic sites. The Role of the Clinic Manager For patient education to be effective, the clinic manager must play an active and supportive role. This includes allocating resources for educational materials, ensuring that providers have the time to educate patients and rewarding educational efforts. The Rationale for Providing Clinic-Based Education about STDs Among the reasons for educating within the clinic setting are the following: It is efficient. Often a patient is ready and receptive. There is a synergy of care and prevention. Community Efforts Are Reinforced. Goals and Objectives of Patient Education In STDs The main objectives: Resolve the patient's current infection. Prevent a recurrence of the infection. Prevent its spread to others in the community. Effective Patient Education General principles: Show respect and concern for the patient's safety. Make the education patient-centered. Address cognitive, affective and psychomotor learning domains. Use adult learning principles. Use multiple channels: visual, auditory and interpersonal. The Process of Patient Education Make an assessment. Establish priorities. Identify long- and short-term objectives. Identify barriers to learning. Assess the learning environment. Evaluate client progress. Approaches to Patient Education Determine the appropriate providers: most staff members have an educational role to play. Determine the points of opportunity: education can occur throughout the patient's visit to the clinic. Determine content and educational techniques: patient needs and knowledge levels determine content. Provider-patient interpersonal communication weighs heavily. Evaluating Patient Education at the Clinic Site Although tests are helpful, a high knowledge score is no guarantee that a patient will not return with, an STD. The most useful evaluational techniques are those that measure actual behavior change. Introduction Patient education is the missing component of much STD care around the world. In addition to understanding how to recognize STDs, patients must be motivated to prevent and properly treat them. Skillful approaches to patient education can nurture and sustain this motivation. This chapter is intended to provide STD clinic managers and staff with information to help them design, implement and evaluate STD patient education at their clinic sites. The chapter sets patient education in a framework, providing indicators for effective patient education, case examples, caveats and an approach that maximizes the effect of patient education by using multiple channels and complementing community-based efforts. The chapter offers practical approaches to a number of issues including the importance, aims and trademarks of effective patient education. In addition, the chapter discusses: How clinic-based patient education can contribute to behavior change in patients What providers need in order to do a good job of educating patients Important points to follow in designing behavior change messages The Role of the Clinic Manager Without the active support of the clinic manager it is difficult for clinic personnel to institute a successful program for patient education on STDs. The clinic manager is a facilitator of the process and the source of resources needed to provide quality patient education. Managers do this in the following ways: Allocate resources for patient education materials Allow providers time to educate patients Organize clinic facilities to allow for privacy and educational activities Reward efforts in patient education Include competence in patient education in the criteria for selected clinic positions Establish or support policies that protect patient confidentiality Although clinic managers might not use all of the principles and approaches described here, the content of this chapter can help in guiding decisions about clinic programs, designing program evaluations and hiring people to design education programs. The manager familiar with these principles and approaches has the means to oversee the implementation of an effective patient education program. The Rationale for Providing Clinic-Based Education about STDs There are many reasons supporting the use of a clinic visit as an opportunity for patient education: Efficiency Education within the clinic reaches patients where they are being treated and eliminates the need for additional patient or system transport, time and motivation. Patient Readiness A patient's decision to come to the clinic signals a level of concern that may provide the teachable moment. Evidence suggests that people are more willing to learn about a disease when they or someone close to them experiences its symptoms or consequences. Prior to coming to the clinic, many patients will have already sought the advice of friends or family.¹ Synergy with Community Education Community educational efforts are reinforced when patients receive the same messages during their visit to the clinic. ² Synergy of Care and Prevention Patients are more accepting of prevention advice when they know they are getting good clinical care as well. This was confirmed in Zaire during a 1988—1991 commercial sex worker (CSW) intervention when women became more receptive to safe-sex messages after they recognized the high quality of the care they were receiving.³ The difference between treating STDs and managing them effectively is the difference between providing drugs alone or providing drugs and instruction about why they are necessary, how and when to take them, possible side effects, and what to do if there is no improvement. A clinic may claim that it provides high quality treatment of STDs. But closer scrutiny of patient response to treatment can reveal that the appropriate drugs are prescribed but patients often take them improperly because of poor education, and frequently resort to other treatment methods after the first attempt by the clinic provider fails. In view of the relationship between HIV and STDs, the prevention and prompt and effective treatment of STDs have taken on increased importance. Clinic managers can contribute significantly to efforts to decrease the impact of HIV on communities by actively promoting, supporting and providing resources for effective patient education programs. Goals and Objectives of Patient Education in STDs The following are the main objectives of patient education in STDs: Resolve the current infection in the patient presenting to the clinic Prevent a recurrence of the infection in the patient Prevent the spread of that infection to others in the community The overall goal of patient education is to halt the spread of STDs in the community. A decrease in STDs can mean a decrease in the number of stillbirths, premature births, ectopic pregnancies, infertility, cases of HIV infection and AIDS, and a range of other problems stemming from STD-related morbidity.⁴ Patient education in STDs can be divided into the categories of preventing future infections and managing the current infection. Preventing future infections requires sustained behavior change or the consistent practice of low-risk sexual behavior. Managing the current infection both prevents further transmission of the STD to others and prevents complications in the patient.⁵ These efforts are most effective when accompanied by patient education that provides essential information and motivates the patient to follow treatment recommendations.⁶ Messages to prevent further infections should go hand in hand with correct management so that the patient is encouraged to adopt practices that will prevent a recurrence of STD. It is important to note that the patient may need emotional support. By providing this in a timely and effective manner, the provider can expedite the accomplishment of other patient education objectives. There is much a patient needs to know including prevention measures, facts about STD transmission, symptoms and treatment (see Box 2). It is well-known that even a mastery of the knowledge does not guarantee prevention of STDs. Motivation is important to the patient who needs it to consistently practice low-risk sexual behaviors.⁷ And providers must develop the skills that are useful in motivating patients. One aspect of patient education that is insufficiently recognized is the potential for a multiplying effect when patients take home materials and discuss what they have learned with family members and friends. If the community has an active outreach education program, this clinic-based education can reinforce those efforts. Effective Patient Education Background Counseling, advising and educating There is a difference between counseling, advising and educating. "Counseling" is generally accepted by mental health professionals to mean in-depth, long-term and repeated interactions between a trained counseling professional and a patient covering topics that can be very broad in scope and emotional in nature. For this reason, the phrase "behavior change advising" is preferred. This conveys the idea that in the STD clinic setting there are usually more limited human resources available and the interaction between patient and health care worker may be brief as well as restricted to only one encounter. The discussion here centers on behavior change advising in the clinic setting as a viable and under-utilized approach to stimulating behavioral risk reduction. "Education" will be used here as a cover term that includes behavior change advising among other approaches (e.g., health talks, posters, brochures, audio cassettes, etc.). Since it is generally accepted that education as information-giving alone is not a sufficient prevention strategy, education in this context includes motivational messages and approaches to changing behavior as well as factual information.⁸ Telling a patient how STDs are transmitted and the treatment for the STD they have is considered informational. As the provider answers questions and addresses behaviors related to prevention and treatment, he or she moves along the continuum toward counseling. This session might include an advisory component, such as "it might be best to take your pills in the morning when you are more likely to remember them," or "it is important that you discuss condoms with your partner." General Principles of Effective Patient Education This next section addresses the main principles that should be followed in designing an effective patient education program. The box below summarizes the major points discussed. The education shows respect and concern for the safety of the patient Patients who present to clinics with STDs are often embarrassed if not remorseful about their condition.⁹ There are all too familiar images of patients being admonished by the punitive physician or nurse who, with perhaps good intentions, wants to shame patients into behavior change. While this might be effective with a few, it is not likely to be successful with most patients. The basic premise on which patient education is based is that individuals deserve respect and need to feel comfortable in their learning environments if they are going to be able to listen, value what is heard and adopt new behaviors.⁹ Part of respect is not judging a patient. Providers who are sensitive to what it is like to reveal detailed sexual behavior information to a stranger are more likely to convey acceptance to the patient. This is often a challenge because of the provider's cultural norms or religious beliefs. In addition to understanding and valuing the importance of treating patients with respect, providers also need to ensure privacy and confidentiality during the patient history taking and exam. A lack of privacy and confidentiality are among the most common complaints that patients voice about STD services.¹⁰Without privacy patients are less likely to provide an accurate history and might have difficulty absorbing information and instructions. Thus, the time spent getting a history and providing advice or information about private matters in a public setting is likely to be time wasted. Other consequences of failing to provide privacy, confidentiality and a respectful attitude are that the patients are less likely to return when they need to, have trust and confidence in the treatment offered, or refer peers and family to the clinic for services. In a busy and under-staffed or under-funded clinic setting, it is a challenge to provide privacy. Taking whatever steps are realistic to improve the environment of confidentiality will go a long way. Although this will not likely reduce the social stigma attached to an STD infection, it will at least protect the patient from experiencing this stigma while they are seeking medical attention. There are three major ways in which clinic managers can facilitate the provision of privacy and confidentiality for patients. First of all, they can ensure that all clinics are arranged physically so that there is some opportunity for a private conversation between patient and provider during the clinic visit. When space is limited, this requires creativity, but it is usually possible. Secondly, there must be policies and procedures in place that guarantee confidentiality of the patient's clinic record. And last, staff must be guided by policies demanding confidentiality of information disclosed during the patient visit. These efforts to protect patients must be introduced and reinforced through training. Once the values of privacy and confidentiality have been institutionalized in the clinic, as shown through attitudes and supportive policies of providers, the benefits will be tangible in terms of patient satisfaction and the delivery of upgraded STD services. The education is patient-centered Patient-centered education takes into consideration the patient's values, culture, current knowledge, readiness to learn and style of learning. It gives priority to the needs of the patient rather than to the needs of the provider or institution. An important question for health providers to ask themselves when educating patients is, "Are we speaking the same language?" The different terminology used by patients and by health care workers as well as their differing perspectives on the importance or severity of an illness have an important effect on their ability to communicate with one another. For example, some women may consider vaginal discharge to be normal even though it would be characterized by a practitioner as symptomatic of an STD. Some male patients may consider an STD to be cured once the symptoms have disappeared, even though this does not correspond with an STD practitioner's definition of cure. And the term used by a physician to describe an STD infection may not always correspond with the words a patient uses to describe an illness with the same symptoms. It is sometimes difficult to understand the source of information that leads to the inaccurate ideas patients form about who is likely to transmit or become infected with an STD. It is important to know how these ideas, which may have emerged from both inaccurate and accurate medical information, are filtered by the patient and become popular concepts of illness and disease transmission. For example, a stated medical recommendation to use a condom with high-risk sexual contacts may be understood as applying only to commercial sex and not to casual sex or sex barter. Perhaps the term "high-risk sex" is interpreted to mean anal intercourse and not vaginal sex no matter who the partner is. Under other circumstances sexual behavior may be linked to the locus of control, or the person making the decision when and how to have sex or whether or not to use a condom.¹¹ For example, a woman who has non-consensual sex with her male partner may not easily identify with recommendations to use condoms. In addition, it is important to remember that more often than not, the patient's perception of risk is not calculated in the terms scientists use to describe the probability of infection (e.g., risk, odds ratio) but rather is couched in individual or personal term tied to one's sense of vulnerability when exposed to a possible infectious agent.¹² Cultural bias: The single most important first step is to acknowledge that everyone has cultural biases to a greater or lesser degree and that recognizing them is instrumental in reducing or eliminating their negative effect on patient communication. The health care worker is challenged to respect the point of view of each patient. By demonstrating this respect, the health care worker encourages and supports efforts of patients to communicate openly. Cultural sensitivity: This refers to a heightened awareness of the patient's point of view as it stems from culture, and an active consideration of this perspective in the tone of all educational encounters with patients and in the configuration of services. What has to be considered are the beliefs about causes and cures for illnesses related to sexual intercourse or, alternatively, illnesses that have STD symptoms but are believed to be transmitted by non-sexual means and cured by traditional means outside of the clinic system. The fundamental strategy is to be aware of these belief systems. Once aware, the health care worker can look for ways to encourage appropriate health-seeking behavior including symptom recognition and prompt use of clinic services while not undermining or directly conflicting with traditional belief systems. This holds true unless these traditional practices are dearly shown to be harmful or counterproductive.¹³ STD beliefs: Erroneous beliefs surrounding illnesses transmitted by sexual intercourse can be extensive. Some of the frequently held myths that are important to understand and address during health education encounters include those in Box 5. Customizing the approach: All too often providers satisfy their own need and tendency to communicate a list of facts and admonitions according to a formula or theory. It is critical that the provider begin by understanding the patient's current level of knowledge and how they usually learn. For example, do they read or do they like to talk and ask questions about what they want to know? By doing this, the provider avoids giving a lot of information that the patient either knows already, is not interested in, or does not understand. It is preferable that the provider initially spend time doing a brief assessment in preparation for any time spent on education. Conducting this assessment in a short time period requires skillful interview techniques that many providers need to learn through training. This subject is discussed further in the section in this chapter on "The Process of Patient Education." Sensitivity to the psycho-social dimension of behavior and behavior change is one of the most challenging aspects of health education in the clinic setting. The process of building a psycho-social sensitivity on the part of members of the health care team is ongoing and involves both introspection and empathy for the realities confronting patients on a daily basis.⁷Taking the concept of patient-centered education to the population level means that educational approaches directed to the entire clinic population reinforce the specific messages for target groups.² This information is usually presented in general terms and should always be complemented by specific action-oriented messages for distinct target groups. Most countries already have experience with general population education activities. These experiences show that education to encourage behavior change and reinforce these changes over time must also include tailored educational interventions for identified target groups. To develop programs of this nature, a collaborative effort with individuals with communications experience and/or expertise is advisable since communication methodology is beyond the scope of most STD clinic programs. The education addresses three domains of learning: cognitive, affective and psychomotor Attention to all three is required for education to be effective. The "mind" or cognitive domain includes ideas, facts and knowledge. The "emotions" or affective domain includes emotions and feelings. The "muscles" or psychomotor domain includes manual activities or skills-the "doing." ¹⁴ Different educational methods are used to address different learning domains. For example, health talks and informational brochures are most suited to the cognitive domain of learning, also known as the knowledge aspect of the education process. Videos, audiotapes, group discussions and role plays reach the affective or attitude domain. By hearing different opinions, and talking with or viewing others in similar situations, patients have the opportunity to grow in their attitudes and values, and deal with their emotions. For the psychomotor aspects of the education process, a simulation training method such as teaching patients to put a condom on a model is most effective. To illustrate this approach to skills building, consider the example of the mechanics of cooking: if you want to learn to make a great dessert, simply reading about how to make desserts is generally much less useful than actual hands-on practice (See Box 7). For patient education in STDs, the learning domains might be addressed in the manner described in Box 8. The education is delivered according to principles of adult learning Many providers may have experienced education only as it is delivered to children. Thus, it is important that provider training and the design of patient education take into account the principles of adult learning (see Chapter 6 for details). The design of teaching sessions and the overall clinic education program can be based on these principles: respect, immediacy, experience and learning style.¹⁵ The education uses multiple channels (visual, auditory, interpersonal) People learn by using different senses and combinations of senses. It is important to capitalize on this insight by using a variety of media or mutually reinforcing channels to transmit patient education messages (see Chapter 4). A patient education program with sound communication strategies might be illustrated this way: The patient at risk for an STD hears something about STDs on the radio, sees a poster on the way to the clinic, reaches a waiting room that has brochures about STDs and how to use a condom and, while in the interview or exam room, sees a poster with a similar message. Exposure to similar or complementary messages through different channels is thought to be a way to ensure that one of the messages will make sense to a patient and have an impact.² Perhaps the message had the right tone or was presented through a medium suitable to the patient. Also, if the message appeared in different settings the impression would be created that there is a general norm regarding sexual behavior, making it more likely that the patient would adopt the new behavior. Principles of Behavior Change for Prevention and Patient Education Changing any health behavior is difficult, but changing sexual behavior is especially challenging. Cultural, political and strategic barriers may impede the implementation of effective sexual behavior change strategies. Proven principles of behavior change can provide a valuable reference.^16,17 Even if it is not possible to change the cultural, political, social or economic environment, it may be possible to use some of these principles to motivate change in some of the clients served by STD clinics. The importance of information Information is a good starting point in any behavior change effort. Although information-giving alone is rarely sufficient, it can be productive in starting people along the track to behavior change.¹⁸ To be effective, the information must: Help individuals understand the risks of engaging in behaviors that will transmit HIV and other STDs, and be accompanied by information about behavioral alternatives such as condom use Inform people about what they must do, emphasizing the importance of both new target behaviors as well as behaviors to be avoided as a way to protect their health Be easily understood and conceptually relevant for individuals Risk reduction education One aspect of risk reduction education is identifying the reasons why individuals are resistant to behavior change and then addressing these barriers. This can be done during the clinic visit through face-to-face behavior change advising reinforced by motivational messages in posters, fliers and other materials. The problem-posing approach For behavior change, this problem-posing approach is preferable to simply giving people facts and instructions about what they should do.¹⁴It means that the provider poses to the individual patient realistic and achievable behavior change options. Patient and provider then establish mutual goals for behavior change that the patient agrees are feasible. Providing options and establishing goals are effective approaches to stimulating behaviors that can be sustained by patients over time. The role of skill development In addition to risk behavior education, providers can assist patients in developing concrete skills to make and maintain behavioral changes.¹⁹Examples include practicing how to talk with a partner about delaying sex during treatment for STDs or using a condom at any time. To simply tell a patient that they must use a condom or insist that their partner use one is inadequate. This information can be read in a brochure. The value of the provider is that they can offer dialogue and feedback as patients rehearse their part in this interaction. Even more effective is providing an opportunity for patients to observe others like themselves demonstrating this skill, and then practicing it and getting immediate feedback. Relapse in behavior change Relapse is not unusual or a sign of failure. Individuals have a complex pattern for changing their behavior and then sustaining these changes over time. From time to time, people will experience a relapse and return to risky behaviors that they had been avoiding.To communicate preventive strategies so that patients anticipate and address the possibility of behavioral relapse is very important. Encouraging patients to plan ahead, asking them to imagine situations where it is difficult to maintain preventive behavior and then giving them suggestions and skills they can use in these situations are ways of helping them maintain the behavior over time. Patient ownership of behavior change decisions Make sure patients feel they are making the choice to change their behavior: Patient education for safer sex will be more effective if patients are offered even a limited number of choices.^7,20 Alternatively you can ask them to substitute behaviors instead of eliminating them. This is why patients may be more likely to use condoms than to give up sex or give up certain sex practices altogether. Campaigns that emphasize abstinence alone or sex with only one partner are less likely to succeed than campaigns that also include condom use as an alternative. In those situations where human resources are sufficient and depending on the cultural norms for sexual behavior, more in-depth behavior change advising to suggest alternative forms of sexual expression such as non-penetrative sex can be presented. The impact of the environment What we do is affected by where we are and by the people around us.²¹ People find it more difficult to refuse alcohol in a bar if they think everyone around them is continuing to drink. Others will find it more difficult to use condoms if they believe they are the only ones using them. Patient education might attempt to help people avoid environments associated with risky sexual behaviors. Alternatively, health care workers can contribute to the ideas that healthier behavior is acceptable in the society and that a significant number of people have already successfully changed their behavior. If community leaders change their behavior, others are likely to follow.²² We often follow the lead of people we respect. More successful behavior change programs use influential community leaders to talk about the behaviors openly and then encourage community members to adopt the behaviors as well. Adapting Education Messages for Behavior Change Use available information and formative research results Educational program design is a combination of scientific and creative efforts. The starting point in the process should include a review of available information on disease and behavioral patterns in the community.¹⁹ Formative research, sometimes called an assessment, is a powerful means to collect additional information, specifically for educational intervention design. Formative research activities vary in their scope depending on how much information is needed and the technical resources available (see section "The Process of Patient Education"). Segment the audience for education efforts Educational approaches to communicating behavior change messages are segmented for distinct target groups.²³ Meaningful segmentation of audiences for behavior change communication in the clinic setting includes analysis of the characteristics of the population served and then identification of key factors that have an impact on communications. These factors may involve gender, age and sexual risk behavior (types of sexual partners, types of sexual contact, number of partners, etc.), but can vary from one clinic setting to another. Adapt the message to decrease fear and shame Messages used in patient education should be designed to minimize rather than exacerbate the fear or shame that someone with STDs can feel. Health care workers might need sessions in which they confront and discuss their attitudes about patients with STDs as a way of sensitizing them to what they convey to patients verbally and nonverbally. Make the message clear The word "message" is not simply a rephrasing of medical advice or encouragement to adopt a set of new behaviors. Messages for health education must be developed mindful of several issues including medical advice, encouragement of new behaviors and some of the other factors summarized below. With a modest amount of planning and teamwork, involving several members of the clinic team and with input from individuals with communications expertise when available, a set of simple and clear messages directed to different types of patients can be developed. From the moment patients come into contact with a clinic facility and the members of the health care team, they encounter a series of elements that color their response to the health care setting and the information they receive from individuals in that setting. The patient response to these elements is affected by their emotional and psychological state when they encounter them as well as by the broader societal context. This is not to say that a patient's receptivity to educational messages is beyond the control of STD clinic managers and health care workers. In fact, it is their task to examine clinic services for ways to maximize patient receptivity to educational messages. In this regard, making the services more patient-oriented is important. Design the tone of the message Threats and instilling fear may help some individuals become more aware of the need to change behaviors. However, the use of fear has been found to be of limited value.²³ If fear becomes overwhelming for individuals, it can hinder rather than help efforts to change behavior by causing them to be anxious and deny their risk. One symptom of denial is that many patients rationalize their denial by pointing out that they know other people who practice risky behavior but do not have STDs. Some patients adopt a fatalistic attitude saying that some circumstance will end their life anyway, and so why should they worry. If health workers do use fear to convey an STD prevention message, great care must be taken to balance the level of fear so that patients are not pushed into denial.²⁴ Messages should give people realistic and effective alternatives and encourage them to take positive action in response to the threat conveyed in a fear message. An example that combines a threat or fear message with a message that conveys that the patient has control is as follows: If you have sex with many partners, you will get an STD and maybe even AIDS. If you have sex with fewer partners and use a condom each time, you are unlikely to get an STD, and you can reduce your risk of HIV infection. Design messages that stress positive results of healthy behavior In different cultural settings, there are many reasons why people are reluctant to use condoms. Some complain they are uncomfortable, reduce pleasure and even cause disease. Highlighting some of the pleasurable aspects of condoms while emphasizing the health risks of unprotected intercourse and other negative consequences can be useful. For example, among people who have a strong motivation to protect the health of their family, condom use with casual partners can seem like a reasonable alternative to facing the risk of infertility or STD infections in the newborn. Among sex workers, however, it may be more effective to suggest that these illnesses can have a negative effect on their income and that they can cause serious health problems for their children should they become pregnant. Make the target behavior easy and appealing Whenever possible, new behaviors should be explained step-by-step in order to give people the confidence that they can perform them on their own.²¹ Telling people that using a condom is easy can have negative consequences when the patient experience is otherwise. Also, telling STD patients to stop having casual partners may be unrealistic. It may be more effective to ask them to use condoms instead. Ideally, people should have the opportunity to plan and rehearse how they will behave in challenging situations. For this reason, teaching condom use skills is an essential part of STD patient education. Any opportunity to highlight the appealing aspects of the desired behavior and give people practical hints on how to negotiate condom use should be fully utilized. Practice sessions could include: How to put on and take off a condom How to use nonverbal techniques (e.g., handing a condom to a partner) for encouraging condom use or engaging in safer sex activities How to talk about safer sex and condom use For example, if a clinic education program objective is to teach sex workers that they should only accept sex with clients who are willing to use a condom, then they may want to rehearse some phrases. This will increase the probability that they will actually use these negotiation skills when talking with their clients. If this is done in a group, the sex workers themselves can recommend ways that they encourage condom use. Another way to make people feel capable of changing their behavior is to show them examples of people like themselves who have already changed. This is called modeling the desired behavior, and it can be very effective in getting people to feel comfortable and capable of trying new behaviors like condom use or reducing their number of partners. Posters and audiotaped or videotaped dramas depict couples talking about using condoms or sex workers negotiating condom use with clients may help people feel supported in adopting these behaviors as well.²⁵ Limit the number of messages A common problem with patient education is that health care workers often sense that they have one opportunity to give someone information. Therefore, they try to cover as many behavior change topics as they can in a limited amount of time. But communicating too many different messages can leave a patient overwhelmed and confused. Health care workers should use the concepts discussed in this chapter to assess which three or four behavior change messages are the key ones, and discuss with the patient during their brief meeting. The Process of Patient Education Make an assessment Assessment, sometimes called formative research, begins the process of designing an education program. The assessment phase of patient education in STDs should address both the community and individual levels. Managers need to know what else is being done about STDs in the community, other sources of information to which patients have access and in what ways their clinics can contribute the most to meeting patient needs. The assessment should answer the question of who needs what as defined by whom.¹⁴ This question might need to be asked repeatedly. To learn this from patients is quite useful. For example, if a group of young women were asked what they need to know about STDs, their answers might be quite different than what the clinic nurse might define as their learning needs. On a community level, conducting ethnographic research about STDs might be the most useful first step, whereas on an individual level letting patients ask questions or describe what they think causes and cures STDs is a good starting point.²⁶ (See Chapter 13.) On the individual level, assessment should address not only the content of the education program but also the method.²⁷ Individual styles and the need to address the different domains of learning are discussed elsewhere in this chapter. The purpose of the assessment phase is to gather the information needed to determine the learning style and critical content of the education program. The assessment can be done using key informant interviews, focus groups, individual interviews, and knowledge, attitude, behavior and practice (KABP) studies. The answers to the assessment questions form the basis for the design of educational materials, audiotapes and content for health talks or advising sessions, and help the provider know what a patient from the local community is likely to believe about STDs. This helps the provider to use local terminology, correct misconceptions and redirect health-seeking behaviors. Questions that need to be addressed by the assessment used to design an educational program include the following:²⁸ What are the target behaviors of the patients related to STDs that need to be changed? What are the patient abilities and constraints in making the changes? What adverse effects (e.g., a partner's embarrassment) would develop for others if the behavior changes occurred? What environmental factors facilitate or prevent change? What consequences does the behavior have for the patient and for others he or she interacts with in the community? What satisfactions continue for the patient if the problem behavior continues? What satisfactions would occur if the behavior were changed? Is the patient capable of undertaking the recommendations for behavior change? Assessment also needs to address questions such as these: What do patients see as the types of STDs and what terms do they use to describe them? What do patients think causes each STD syndrome and how do they think it is transmitted? What do patients think prevents STDs? What do patients currently do about STDs and at what point during an STD episode? What do patients think cures an STD? On an individual level the provider should also assess whether the patient is ready to learn at a given point in time. The patient who presents to the clinic with acute pain due to pelvic inflammatory disease (PID), for example, is not a candidate at that point in time for a discussion about her sexual behavior or the intricacies of persuading her partner to use a condom. This should be addressed at a time when she is not in pain and can participate fully. Also, a young woman might not be ready to learn about STD complications if she just experienced her first intercourse and is very upset about mild vaginitis. Establish priorities When time with a patient is very limited, as is usually the case, it is important that the provider make a sound decision about what should be the priority issues to address. Too often providers feel compelled to deliver a long list of facts covering everything they would like patients to master about STDs. This window of opportunity should instead be used to find out the information need of a particular patient. Then the provider should choose the three or four most relevant topics to discuss with him or her. The antenatal clinic client with syphilis needs to know more about her treatment, the risks to her infant and the importance of returning for follow-up than she does about vaginal discharge and its causes. On the other hand, a man coming to the clinic with urethritis needs to know less about ophthalmia neonatorum as a consequence of urethritis and more about what lubricants it is recommended to use with a condom and how to complete his course of medication and partner treatment. Identify long- and short-term objectives The identification of long- and short-term objectives of patient education is part of the planning process. The young woman who just had her first intercourse certainly has a need to know more about STDs and HIV. But the short-term objective of her patient education is that she understand that the vaginitis she developed is not gonorrhea or chlamydial infection and can be easily treated. The long-term objective is that she understand her risk of contracting other STDs, their relationship to HIV/AIDS and the means of preventing them. Identify barriers to learning Prior to initiating efforts at patient education, the provider must identify barriers to learning, be they on the individual or group level. Common barriers in the area of STDs include a cultural taboo on the discussion of sexual issues or functions, a taboo against speaking of sexual matters with someone of the opposite sex, beliefs that define causes as magical or supernatural and other traditional beliefs that do not match or may contradict biomedically based explanations. Assess the learning environment It is critical to ensure that the environment is conducive to the educational method being employed. For example, the waiting room is appropriate for a presentation in which patients need not reveal very much personal information, whereas the interview room is not well suited to an interactive presentation or group session. Evaluate client progress In all matters of health care, there is usually an advantage to continuity of care. When possible, it can be of tremendous importance that the patient return to see the same provider or participate in a session led by this individual. This allows the provider to set short-and long-term objectives and move the patient along the continuum at a pace suitable to the learner. When this is not feasible, as is often the case, the provider delivering an educational message or program must assess the client's progress in learning about STDs and in adopting risk reduction behaviors. Approaches to Patient Education There are many different methods that can be used to deliver education to patients in the clinic setting. It is useful to determine which methods will be used by asking basic who, when, where and what questions, as outlined below. Determining the appropriate providers All staff members can contribute to a patient education program. Some health care workers contribute simply by being empathetic, respectful, and reassuring, which preserves patient dignity and reduces the fear and shame that a patient may feel. Others might focus on giving more complex technical information in an understandable and non-threatening fashion, and in a limited time period. A clinic manager should examine the entire staff, both professionals and non-professionals, to determine their roles in providing patient education. The preparation of the personnel in a clinic should determine which provider can best address which aspect of patient education. The basic facts about STDs can be taught by several levels of health care workers. But, the finer points of counseling a woman about how to encourage a hostile husband to use a condom requires that a provider be a trained counselor or at least have learned techniques suitable to this sort of intervention. The person most suited to advise regarding the meaning of certain symptoms or complications would be the most medically trained person available.An effective means of reinforcing health education messages is having the front desk registration staff, security guard or cleaning person talk about condoms in a positive light, as long as they are willing and comfortable interacting with patients. In general, it is advisable to develop an approach that utilizes many persons on the team. As a result, the different points of opportunity for education during the patient's clinic visit are taken advantage of and messages are conveyed repeatedly. Determining the points of opportunity Managers should be sure that the design of patient education is based on the concept that it is useful for messages to be transmitted at numerous times during the patient's visit to the clinic. By analyzing the steps patients go through when they come for services, such as registering, waiting and being examined, one can address the various points of opportunity for education. The method should be suited to the point of opportunity. To ensure this, it is helpful to analyze a given clinic encounter and how it is composed of many different action intervals at various locations within the clinic. For example, a patient enters most clinics through a waiting area. Then there might be an intake area or a place where vital signs are checked. Usually, the patient then returns again to the waiting area. In some clinics, patients subsequently are sent to the lab. Next, they are seen in an examining room and, after that, sent to a clinic pharmacy or one in the community. The analysis of a patient visit would lead one to conclude, for example, that counseling should not occur in the intake area, since counseling cannot be conducted as effectively in hearing distance of other patients as it can be in privacy. In other words, interventions can be timed to reach patients during many different but appropriate moments during their clinic encounter. Different intervals may be associated with different levels of patient receptivity to education. For example, although diagnosed with an STD for the second or third time by the same practitioner, a male patient may be so relieved after being told of his negative HIV test results that he does not show an interest in behavior change advice. Alternatively, a woman may be so concerned with supervising the three children she has brought with her and feel anxious about the implications of an STD infection that she is unable to focus on the posters or printed information she encounters in the waiting area. At each point during the patient's visit there are opportunities for patient education that might take the form of playing an audio cassette dramatizing some aspect of condom use, having a poster in a place where it can be looked at for a period of time, reading materials or setting up an interaction between provider and patient. The examples in Box 11 illustrate making full use of clinic opportunities for patient education. Patient education content and focus differ according to type of clinic site. The content of what is offered in patient education must be tailored to the type of clinic service for which the educational materials or provider messages are designed. In addition to clinic sites designed for STD and HIV/AIDS patients, primary care, family planning, antenatal, maternal and child health, and obstetrics and gynecology clinics can all better serve patients by including STD patient education. The STD patient education program must be designed taking into consideration the priorities, values and level of understanding of the clientele of each clinic. For example, in a typical family planning clinic, the priority of the patients and health care workers is on encouraging patients to select and consistently use a contraceptive method that is right for them. However, it is important to note that the woman seeking a family planning method might have a husband who is HIV-infected or who has an STD. She could also benefit from information and discussion about the signs and symptoms, risks and ways to prevent STDs. The same holds true for clients in the other clinics, especially antenatal clinics, if one considers the risks of congenital syphilis and the effects of chlamydial infection and gonorrhea on infants (see Chapter 9). Since the mind-set of the patients might not be on learning about STDs, the health care worker must take this into account and introduce the topic sensitively. For a patient with an STD, it is expected that STD education will take priority over other topics. Although patients may be uncomfortable talking about sexual behavior, they are likely to understand why this is a topic of discussion. Instructions and messages for these patients will be more detailed and be given greater priority than in the clinic situations mentioned above. The response of health personnel to patients with an STD diagnosis might differ according to the type of clinical service in which they work. For example, in a primary clinic, a nurse might not be accustomed to dealing with young men with penile discharge. Her reaction to this may be awkward or she may express some discomfort or a hypercritical attitude. This can raise the young man's anxiety level and compromise his confidence in the nurse, her message and the treatment she offers. There are logistical and resource challenges clinic managers must face. The clinic manager is challenged to help health care workers modify the clinic configuration to facilitate the implementation of the principles discussed in this chapter: providing privacy and confidentiality; establishing the ideal moments during the visit for different aspects of patient education; understanding the value of using multiple channels; and knowing how to take advantage of every opportunity. The physical circumstances in clinic settings may dictate the type and amount of patient education. A patient flow of 15 or 20 people per hour makes it unrealistic to expect more than basic patient education, including time-efficient behavior change advising, to occur during the exam portion of the visit.If a certain degree of privacy and confidentiality can be assured, face-to-face communication between patient and health care worker can address the specific obstacles and motivation for behavior change. With large groups of people in waiting areas, it may be difficult to transmit personal or sensitive information. But a waiting area may be the ideal setting for posters, audio and/or video, flip charts to reinforce behavior change, either before or after a confidential face-to-face interaction with a provider. Determining content and educational techniques The range of content is determined by the patient population-principally the reasons for their visits as well as their individual and collective levels of knowledge. Boxes 1 and 8 of this chapter outline major components of information that most patients need. The final step in planning is to determine the best educational approach and specific content to use at the different points of opportunity that arise during the clinic visit. Summarized below and discussed in detail in Chapter 4 are some of the most commonly used techniques for delivering effective education in the clinic setting. Interpersonal communication: The quality and tone of communication between provider and patient determines its effectiveness. When patients feel comfortable in a clinic environment, they will be more interested in behavior change information, less ashamed of having an STD infection and perhaps more inclined to ask questions. This makes it much easier to deliver health education information that meets their individual needs. Health care workers can examine the ways they communicate with patients both verbally and nonverbally in order to enhance educational impact. As tools for self-learning, posters are another approach to patient education in the waiting area of a clinic. Content can include basic STD prevention messages or information on how STDs are and are not transmitted, if this is appropriate in the local culture. Also, posters that reassure patients that confidentiality is respected and protected can be as important as STD prevention posters in supporting health education in the clinic setting. Videotapes or audiotapes also can be used in the waiting area, as can pamphlets or short story books that use cartoons to describe situations patients can identify with. The content of these materials will vary according to the information needs of the population and the acceptability of printed material discussing or illustrating aspects of sexuality. This invites the patient to refer to the materials later, reinforcing the messages conveyed during the clinic encounter. For example, small pocket-sized formats and simple unprovocative covers can be used for brochures for adolescents. Developing patient education materials is an important process that should be executed systematically. The technical expertise for pre-testing educational materials is frequently available on the local level in most countries of the world. Ensuring that the development of educational materials goes through the necessary steps can improve the quality and effectiveness of educational materials for the clinic setting.Other approaches to patient education such as presentations or talks using an interactive approach instead of a didactic one, group discussions and role plays can also be effective. These require leadership by an informed and skilled provider. Group discussions are useful because individuals can gain insight from the input of others who have similar problems. These groups can also transmit knowledge and provide emotional support. Role plays are excellent skill-building tools, especially in the area of interpersonal communications. During role plays, patients have the opportunity to practice what the provider has suggested that they do. They can get immediate feedback and build confidence in a non-threatening situation, enhancing their potential for performing well in real-life situations. Role plays are useful in helping patients explain to their partner that they have an STD, in requesting that their partner use a condom or that they use one; also, in requesting that their partner agree to delaying intercourse for as long as the patient has an STD or until the partner can get treated as well. Evaluating Patient Education at the Clinic Site There are a variety of techniques for evaluating the success of patient education. The most powerful techniques are ones that measure actual behavior change, since that is the goal. A pre- and post-test could easily assess knowledge gain. But it is possible that the patient with a perfect knowledge score might return with an STD because they were never convinced about or never comfortable with condom use.Other techniques such as mystery patients (where a health care provider poses as a patient in order to observe a clinician's performance) and in-clinic observations have been used in some cases. There has been much work but no final definitive recommendations about the perfect technique for evaluating the success of patient education interventions. Clinic managers have the responsibility of choosing the most cost-effective, valid and reliable method of evaluating their patient education efforts (see Chapter 14). Being clear about educational objectives and providing the means to achieve competency in delivering patient education are the first steps. References Amaro H, Gornemann I. Health care utilization for sexually transmitted diseases: influence of patient and provider characteristics. In: Wasserheit J, Aral S, Holmes K, eds. Research issues in human behavior and sexually transmitted diseases in the AIDS era. Washington, DC: American Society for Microbiology, 1991:140—160. Making health communications programs work: a planner's guide. US Department of Health and Human Services, Public Health Service, National Institutes of Health, Office of Cancer Communications, National Cancer Institute, 1992: NIH publication no 92—1493. Laga M, Alary M, Nzila N, et al. Condom promotion, sexually transmitted disease treatment, and declining incidence of HIV-1 infection in female Zairian sex workers. Lancet 1994; 344:246—248. Wasserheit J, Holmes K. Reproductive tract infections: challenges for international health policy, programs, and research. In: Germain A, Holmes K, Piot P, Wasserheit J, eds. Reproductive tract infections: global impact and priorities for women's reproductive health. New York: Plenum Press, 1992:733. Last JM. A dictionary of epidemiology. New York: Oxford University Press, 1988. Buv‚ A, Laga M, Piot P. Where are we now? Sexually transmitted diseases. Health Policy Plan, 1993; 8(3):277—281. Parra W, Drotman P, Siegel K, Esteves K, Baker T. Patient counseling and behavior modification. In: Holmes K, Mardh P. Sparling PF, et al., eds. Sexually transmitted diseases. 2nd ed. New York: McGraw-Hill Inc, 1990:1057—1068. The STD case management series. Educating the patient. World Health Organization/Global Programme on AIDS, Workbook 5, 1995. Smith LS, Lauver D, Gray A. Sexually transmitted diseases. In: Fogel C, Lauver D. Sexual health promotion. Philadelphia: W B Saunders, 1990:459—461. Niang CI. Premiére version du rapport final du projet du recherce d'intervention cibl‚e sur les maladies sexuellement transmissibles au Senegal, Dakar. Unpublished report. Arlington, Virginia: Family Health International, 1995. Reid Elizabeth. Gender, knowledge and responsibility. In: Mann J, Tarantola D, Netter TW, eds. AIDS in the world. Cambridge, Massachusetts: Harvard University Press, 1992:657—666. Rosenstock I, Strecher V, Becker M. Social learning theory and the health belief model. Health Ed Q 1988;15:175—183. Maggwa ABN, Ngugi EN. Reproductive tract infections in Kenya: insights for action from research. In: Germain A, Holmes K, Piot P, Wasserheit J, eds. Reproductive tract infections: global impact and priorities for women's reproductive health. New York: Plenum Press, 1992:278—295. Vella J. Learning to listen, learning to teach: the power of dialogue in educating adults. San Francisco: Jossey-Bass Publishers, 1994. Vella J. Learning to teach: training of trainers for community development. Westport, Connecticut: Save the Children Federation/OEF International, 1989:22—25. Hornik, R. Alternative models of behavior change. In: Wasserheit J, Aral S, Holmes K: 1991:201—218. Fishbein M, Middlestadt SE, Hitchcock PJ. Using information to change sexually transmitted disease-related behaviors: an analysis based on the theory of reasoned action. In: Wasserheit J, Aral S, Holmes K, eds. Research issues in human behavior and sexually transmitted diseases in the AIDS era. Washington, DC: American Society for Microbiology, 1991:243—257. Aboagye-Kwarteng T, Moodie R, eds. Community action on HIV: a resource manual for HIV prevention and care. Australian Agency for International Development, 1995. Coates T, Greenblat R. Behavioral change using interventions at the community level. In: Holmes K, Mardh P, Sparling PF, et al., eds. Sexually transmitted diseases, 2nd ed. New York: McGraw-Hill Inc, 1990:1077—1080. Carter WB, Gayle TC, Baker S. Behavioral intervention and the individual. In: Holmes K, Mardh P, Sparling, et al.:1990:1069—1074. Coates T. Strategies for modifying sexual behavior for the primary and secondary prevention of HIV disease. Journal of Consulting and Clinical Psychology 1990;58(1):57—69. Brownlee AT. Community, culture and care: a cross-cultural guide for health workers. St. Louis: CV Mosby, 1978:97. Edgar T, Hammond SL, Freimuth VS. The role of mass media in interpersonal communication in promoting AIDS-related behavioral change. AIDS and Public Policy Journal, 1989;4(1):3—8. Aboagye-Kwarteng T. Moodie R. eds. Community action on HIV: A resource manual for HIV prevention and care. 1995:97.26. Green LW, Kreuter MW, et al. Health education planning: A diagnostic approach. Palo Alto, California: Mayfield Publications, 1980. Kelly JA, Murphy DA. Psychological interventions to prevent HIV infection are urgently needed: new priorities for behavioral research in the second decade of AIDS. American Psychologist 1993;1023—1034. Cohen-Cole SA. The medical interview: the three function approach. Baltimore, Maryland: Mosby Year Book, 1991. Green LW, Kreuter MW, et al. Health education planning: a diagnostic approach. 1980. Pender N. Health promotion in nursing practice. Norwalk, Connecticut: Appleton-Century-Crofts, 1982:54—61.