I have been following the discussion on compliance. I've found this
discussion very interesting particular the discussion between Tasha and
Esther re the role of health practitioners aiding their patient's
compliance adherence.
The issues experienced by indigenous communities are a difficult one.
Particularly considering how to best measure treatment compliance. I work
at a National Centre that specialises in HIV social research. We have a
cohort study of HIV positive people. Within this study there are some items
which measure compliance - though these measures are self reported measures
which document both the frequency of missing doses and the reasons for
missing doses (deliberate or forgetting). Not sure if these items would
help you Judith but I'll happily forward them to you if you think they
would help.
Some of our qualitative work involves analysis of the interactions between
doctors and HIV-positive patients. These analyses have focused upon the
ways in which compliance is understood and negotiated between doctors and
their patients.
A key issue emerging from this research is the way medical discourse
dominates the clinical encounter between doctor and patient. The patient is
expected to adapt themselves (their culture, lifestyle, values and beliefs)
to the dictates of the treatment regime. Through this medical imperative
the patient's world is often viewed as a obstacle to successful compliance
that must be overcome.
Very little time is given, within the medical encounter, for exploring the
ways in which the patient's world could help enable or facilitate adherence
to treatments. To do this would require a shift in the ways in which
doctors understand the power relationships between themselves and their
patients. By sharing the responsibility of the decision-making and by
working with the patient the potential of adherence to complex treatment
regime (particularly for the chronically ill) might be improved. This would
involve doctors encouraging a process of personal reflection and critical
engagement with the patient exploring the ways the treatments might fit in
with the patient's world.
It might be argued that the discourse of 'informed choice' works to hand
responsibility to the patient for adhering to treatment regimes. Rather
than doctors and patients working together to develop individually tailored
solutions. Solutions that draw upon the aspects of the patient's world that
could better facilitate adherence such as domestic routines and social
schedules.
Of course an important element excluded from the above is the important
role of other health care workers. Certainly encouraging doctors to work
collaboratively with other health professionals might also aid the
opportunities for patients to critically consider the way in which
treatments can be woven into their lives.
Joseph
At 08:35 06/09/2001 +0100, you wrote:
> --- Tasha Beauchamp <[log in to unmask]> wrote:
>>
>
>
>I am impressed about that "HABIT" news letter you talk
>about Tasha. Just looking at the summary it just goes
>to confirm why possibly some interventions fail in
>communities. Most of the time we as health
>professionals mascarade in total "uprightness" and
>"impose" on communities that we may not so completely
>understand .Communties that existed for years with
>culture , values , beliefs about the way life is or
>should be. Indeed health promotion or the new public
>health now focusses on community aspects as well as
>other issues ( 5 requirements ) and it is amazing how
>long it has taken us to finally appreciate the
>importance of this in what we do.It is not surprising
>that we shall continue to echo the appalling health
>indicators in indeginous populations further showing
>us how "not very succesful " current interventions are
>or have been . It would be nice if Judith`s compliance
>work might indeed focus on the health care providers,
>may be it already does , as well ( for example
>instructions to patients if any on how , when , why
>they are on medication, adequate time with the doctor/
> nurse, patient numbers per day , staff morale and
>motivation for those handling the local population
>e.t.c ) It is not uncommon for patients to be given
>drugs with instructions written in a language unknown
>to them and numbers stating 2 times 2 .Talk about
>literacy!
>
>
>
>
>
>
>
>
> Dear Judith,
>>
>> Actually, I just read in the "HABIT"(Health Behavior
>> Information Transfer)
>> e-mail newsletter, the following mini-article which
>> actually relates
>> specifically to your stomping grounds! Hope this
>> helps.
>>
>> Tasha
>>
>>
>> 1. Physician: Comply Thyself: Looking at Adherence
>> in New Ways
>>
>> One of the most intractable problems in health care
>> is helping people
>> comply, or -- in the more common parlance today --
>> adhere to recommended
>> treatments and behavior changes to manage existing
>> health problems and
>> prevent new ones. Progress in improving adherence
>> has been painstakingly
>> slow, but hope is not lost; researchers and
>> clinicians are starting to look
>> at these issues in new ways.
>>
>> A book recently published in Australia flips the
>> issue of compliance on its
>> head by examining the culture of health
>> professionals' work, rather than
>> recipients of care, as a central influence on
>> non-compliance.
>>
>> ěForgetting Compliance ń Aboriginal Health and
>> Medical Cultureî by Kim
>> Humphery and Tarun Weeramanthri, with Joseph Fritz,
>> critically reviews the
>> health sciences literature on patient compliance.
>> The authors also analyze
>> the failure of more than 20 years of targeted
>> research on compliance issues
>> to achieve significant improvements in treatment
>> uptake.
>>
>> The central focus of the book, however, is the
>> analysis of interviews with
>> 76 health care providers working in Aboriginal
>> health in the Northern
>> Territory of Australia. Although the cultural
>> context and geographical
>> settings in which these individuals provide care are
>> unique, the
>> conclusions the authors draw are likely to have more
>> general impact:
>> ěProvision and uptake of services are two sides of
>> the same coin. If we are
>> to rethink compliance, we need to remake health
>> services practices and
>> institutional arrangements. More radically, we need
>> to forget compliance as
>> a ëproblem,í and see it as a natural marker of the
>> differences (in values,
>> in power and in resources) between professional
>> systems and clients.î
>>
>> For information about how to order ěForgetting
>> Compliance,î e-mail
>> [log in to unmask]
>>
>> Send your ideas, comments and resources to
>> [log in to unmask]
>> Subscribe to HABIT by visiting
>> http://www.cfah.org/habitsubscribers.htm
>>
>>
>> >The Tiwi Health Board (an Aboriginal Community
>> Controlled Health Provider)
>> >are interested in examining the impact of health
>> promotion strategies on
>> >medication compliance, specifically medications for
>> the chronic diseases
>> >diabetes, hypertension, and renal impairment.
>> >
>> >I am interested to know if anyone has any
>> experience with measuring
>> >compliance to treatment regimens (specifically
>> relating to medications for
>> >chronic diseases) in indigenous populations, and if
>> so, what measurement
>> >tools were used.
>> >
>> >Judith Oliver
>> >Consultant Pharmacist
>> >Tiwi Health Board
>> >Darwin, NT
>> >Australia.
>>
>>
>> + + + + + + + + + + + + + + + + + + + + + + + + + +
>> + + + + + + + + + + + +
>>
>> Natasha Beauchamp
>> Project Coordinator
>> ORegon Center for Applied Science, Inc. (ORCAS)
>> 1839 Garden Ave.
>> Eugene, OR 97405
>>
>> Tel: (541) 342-7227
>> Toll Free: (888) 349-5472
>> Fax: (541) 342-4270
>> mailto:[log in to unmask]
>> Website: http://www.orcasinc.com
>
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