Education about conditions and risks

As informed health professionals, we sometimes forget to tell patients the most basic information that they require to support their own self-management and motivation for behavioural change. We also need to make time to ask patients what they know, rather than rushing to tell them what we think  they need to know!

Is there a lack of patient education and awareness about hypertension and the risks of smoking?
Answer: Yes

HypertensionFindings from surveys of treated hypertensive patients, carried out in Victorian community pharmacies by Monash University and Flinders University researchers in 2009, suggest widespread lack of patient awareness about some of the basics relating to their own blood pressure.  Despite regular monitoring, 38% could not report their latest blood pressure reading and only 36% could state their target blood pressure.

A separate survey of Victorian pharmacy patients by the National Stroke Foundation identified that one in four adults with above-normal blood pressure readings did not link elevated blood pressure with stroke, heart attack, or heart failure; 55% were unaware of the link with kidney failure.

Smoking cessationThere is good general knowledge among most Australian smokers that tobacco use is harmful, but they often lack specific knowledge.

For example, Australian surveys of Aboriginal and non-Aboriginal pregnant women identified a common lack of awareness that smoking increased mothers' risk of diabetes, the likelihood of cot death, and impaired mental performance of the child when grown (Walsh et al, 1997; Gilligan et al, 2009).

A lack of detailed knowledge can also lead to certain misperceptions about quitting. For example, a belief that there is no point in quitting if still exposed passively to smoke (Gilligan et al, 2009), or patients deciding for themselves that cold turkey is safer than pharmacotherapy if taking other  medicines.

Despite several studies identifying widespread motivation to quit smoking, health professionals regularly overlook opportunities to intervene (Chapman et al, 2009; George et al, in press).

Does patient education improve blood pressure control and smoking cessation?
Answer: Yes

HypertensionA 2006 Cochrane systematic review concluded that there was a trend towards benefits from education (Fahey et al, 2006). One study which randomised 400 hypertensive patients to receive formal patient education or not (Morisky et al., 1983), found that the mortality rate five  years later was 57.3% less for the intervention group compared to the control group (12.9 deaths per 100 patients vs.30.2/100), and the hypertension-related mortality rate was reduced by 53.2% (8.9/100 vs. 19.0/100).

Researchers concluded it appears important to resolve patient confusion about their therapy and what they needed to do on a daily basis, hinting that development of patient self-management may also be very important.

Smoking cessationAustralian guidelines for smoking cessation identify a ‘dose-response' relationship between education and smoking cessation. The  likelihood of cessation increases with increasing amount of time spent counselling. Even 30-60 seconds spent providing basic education with individuals or simply creating an environment conducive to smoking cessation increases the likelihood of success.

What education should be provided?
Answer: Ensure basic awareness. Provide further support if the patient is likely to act on advice.

Patients should be told - or at least be given the opportunity to know - the basics about their condition or health risk, treatment targets and treatment options. A basic summary highlighting 3-4 key points can generally be provided in 30-60 seconds, and providing complementary written materials  improves patient knowledge. Awkward discussions about the risks from uncontrolled blood pressure or smoking might best be initiated by first asking the patient about their understanding of risks.

Written materials can save the health professional time and avoid confusing patients when they try later to recall what was said. Guidelines are useful tools for providing key pointers. The Pharmaceutical Society of Australia provides self-care cards for many common conditions including tobacco use  and hypertension. Alternative sources of patient information include the National Stroke Foundation , National Heart Foundation of Australia , QUIT Australia and the Better Health Channel .

If your motivational interviewing suggests the patient is keen to take action, you need to ask open questions and listen to the patient to understand their needs. It may be appropriate to provide more support such as detailed information on self-management, lifestyle modification, medicines adherence.

Written referral to GPs or specialist services, or requests for the patient to return for further counselling, may also be beneficial.

US guidelines (Chobanion et al.) recommend providing the following education:
"Patients should be told their blood pressure on each visit and be encouraged not only to ask for those numbers but to inquire as to why blood pressure is above the goal, if that is the case. They also should be given a written record to keep as their part of this commitment."

This statement also implies ensuring patients know their blood pressure targets. If they are being treated, a clear understanding of instructions on therapy should also be ensured.

Information on classification of blood pressure , targets for different patient groups, and consequences of uncontrolled blood pressure are all available in the national guidelines .

SmokingNational guidelines for smoking cessation recommend the following support for smokers (Department of Health, 2004):
"As a minimum all smokers should be offered minimal advice, information (e.g. a Quit Pack) and the option of referral to a support service (Quitline 131 848 )."

From a pharmacy perspective, this minimal advice may entail advice on (1) risks related to smoking, and benefits of cessation, (2) the effectiveness and appropriateness of pharmacological treatment options, and (3) the support available from pharmacists, GPs and others (e.g. QUIT). As with hypertension,  a clear understanding of instructions for any therapy should be ensured.

Where time pressures exist, it makes sense to invest more efforts in patients who become motivated to quit or to maintain cessation, and are willing to accept your assistance.
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