Information Information Information Information therapy therapy therapy therapy India is deemed an economic powerhouse, comparatively insulated against recession but open to investment. While population is the strength in terms of domestic consumption it is also a deterrent in reach of literacy and health care services. Epidemiological transition has bestowed India with the entire gamut of healthcare problems ranging from infections to lifestyle diseases. So we are blessed with an increasing life expectancy with chronic ailments. The healthcare scenario is such that fertility rate needs to be tackled to keep population at bay and on the other hand infertility treatment is a galloping segment. Healthcare institutions, governmental bodies and NGOs are fighting to improvise the reach and quality of healthcare, although the effort is limited due to lack of funds, inadequate reach and lack of insurance coverage to majority of the population. This unique scenario is juxtaposed with the rising awareness, internet and expectation of better service standards by the literate population. Information if it is available to the right person at the right time can play a significant role in improving the prognosis and meeting the service expectation. This can have a direct impact on adherence to treatment and therefore outcomes which ultimately reduce the economic impact to the individual, the family and the society at large. To the health care practitioner it can provide more satisfying practice, more time available for the new patients which in turn improves patient flow. As we are all are patients at some point of time an understanding of the patient related factors will help us to assess the situation and suggest methods to improve the outcomes. Patient-related factors represent the resources, knowledge, attitudes, beliefs, perceptions and expectations. Some of the patient-related factors reported to affect adherence are: forgetfulness; psychosocial stress; possible adverse effects; low motivation; inadequate knowledge; lack of self-perceived need for treatment; lack of perceived effect of treatment; negative beliefs regarding the efficacy of the treatment; misunderstanding and non-acceptance of the disease; disbelief in the diagnosis; lack of perception of the health risk related to the disease; misunderstanding of treatment instructions; lack of acceptance of monitoring; low treatment expectations; low attendance at follow-up, or at counselling, motivational, behavioural, or psychotherapy classes; hopelessness and negative feelings; frustration with health care providers; fear of dependence; anxiety over the complexity of the drug regimen and feeling stigmatized by the disease

1.

Perceptions of personal need for medication are influenced by symptoms, expectations and experiences and by recognition of the illness

2. Concerns about medication typically arise

from beliefs about side-effects, disruption of lifestyle and from worries about the long-term effects and dependence. They are related to negative views about medicines as a whole and suspicions that doctors over-prescribe medicines

3,4 as well as to a broader “world view”

characterized by suspicions of chemicals in food and environment5and of science, medicine

and technology6.

Patients may also become frustrated if their preferences in treatment-related decisions are not sought and taken into account. For example, patients who felt less empowered in relation to treatment decisions had more negative attitudes towards prescribed antiretroviral therapy and reported lower rates of adherence

7.

According to WHO, increasing the effectiveness of adherence might have a far greater impact on the health of the population than any improvement in specific medical treatments

8.

The IMB model9, 10

– Information motivation and behaviour puts information at the priority to change patient behaviour, however by itself information is insufficient and motivation is a key factor in the transition to bring change in behaviour. Therefore therapy which provides information and motivation will be the successful therapy.

The successful use of information therapy will therefore depend on 1. The ability of clinics and associated health care personnel to share information on patients’ behaviour 2. The type of systems adopted will determine the level of communication with patients and their relatives. 3. Ongoing communication efforts that keep the patient engaged in health care may be the simplest and most cost-effective strategy for improving adherence

11.

• Considering the information is vital, every clinic visit will be preceded or followed by

information therapy prescriptions. Making the right information accessible before the

clinic visit and providing information after will ensure that the patient is not prey to

inadequate and dangerous half knowledge.

• Every medical test and surgery will be preceded and followed by information therapy

prescriptions which will increase trust.

• Efforts to engage patient and family support through information therapy

prescriptions.

Prominent interventions to address patient related factors which can lead to information therapy are:- 1. More instruction for patients, e.g. verbal, written, or visual material programmed learning and formal education sessions This method has the rate limiting factor of literacy. Some of the methods adopted are organising free anaemia detection camps conducted through support staff at nursing homes have attempted to use visual material to demonstrate the adverse effects of anaemia on health and pregnancy. Regional languages have been increasingly used to reach to a larger audience. Private hospitals have been organizing weekly meetings on nutrition in pregnancy, diabetes related complications etc. Camps have also been organized for diabetes detection among susceptible population, for neuropathy in diabetes OPDs through trained personnel. However the lack of continuity and lack of long term commitment severely impedes the estimation of success of these methods.

2) Counselling about the patients’ target disease, the importance of therapy and compliance with therapy, the possible side-effects, patient empowerment, and couple-focused therapy to increase social support. This method has been tried in India in improving outcomes in asthma by counselling camps organized through a club with community service as one of its missions. This method provides the route which is trusted by the recipients since they are directly involved in the decision making. Uses of simple concepts like cartoons have helped patients to understand complicated procedures in IVF treatment and help making a decision.

3) Automated telephone, Manual telephone computer-assisted patient monitoring and counselling and information websites In India this method has been adopted successfully by Institutions and companies that provide treatment of vascular ailments. Organizations which provide support in logistics, content and feedback have sprung up in response to these ailments in India. Patients are contacted through reminder text messages on their mobile phones after they have registered; Sops to stay connected include information, free medication on continuation of the treatment, invitations to counselling and free checks. In hypertension management involving patients more through self-monitoring of their blood pressure, reinforcement or rewards for both improved adherence and treatment response has been in practice. Improved compliance is recognized and rewarded through reduced frequency of visits and partial payment for blood pressure monitoring equipment. Interactive websites dedicated to treatment in different disease groups enables patients with access to internet, to access information. In developed countries regulatory bodies and associations of practitioners provide comprehensive data at a single source. Patients have a dedicated link to resources on websites of NIH and American Diabetes Association etc. In our country, this is beginning to happen and some associations, NGOs and companies have patient education resources on their sites.

4) Group meetings Obesity management has utilized this method to foster motivation and improved self image which translates into better outcomes. There are also support groups for Thalessemia, AIDS, prostate cancer and other conditions. Group meetings are also the norm in de-addiction methods. 5) Family intervention Can be particularly useful where behavioural changes are required by the patient to combat illness or where the patient is a child. Bedwetting is an unusual problem not considered to be an illness but parental information therapy does a long way in alleviating the lack of self esteem in the child.

Family intervention in diabetes is also important so as to create an atmosphere where the patient’s craving for sweets is reduced by the entire family abstaining from consumption of sweets at the dinner table. Family intervention is a particularly important method in smoking and alcohol cessation especially by the pregnant woman and her spouse. The family intervention can provide the right estimate of the change in the smoker from unwillingness to willingness and consideration of options in view of the harmful effects on the unborn child. 6) Simplified dosing In the treatment of inflammatory bowel disease, the dosing used to be cumbersome. Three times daily dosing has been tackled with once daily dosing granules which can deliver the complete dose. Information therapy can help reduce the morbidity through better remission rates achieved through better dosing form and compliance. As it can be expected in a highly competitive environment, Insulin companies responded to the patient requirement and have benefitted from both the simplified painless injection as well as the dosing schedule.

The dissemination of the information in the right media and the reach is critical as simplified dosing without information does not lead to improved usage or outcomes. Reminders, programmed devices and tailoring the regimen to daily dosing could also help provided it is programmed as information therapy. 7) Augmented pharmacy services. Internationally the pharmacist has already adapted to a new role in providing augmented services especially in counselling. In India mostly this is a self motivated approach where the pharmacist if he/she is a registered health practitioner,

takes an active interest in dosage form, compliance and other issues to be explained to the patient. Again as the situation could demand, use of special needleless devices, orthotics and prosthetics has made the Pharmacist an important part of the health care chain. Formal and informal training provided to these personnel has increased awareness and provided valuable information therapy by better usage. 8) Different medication formulations, such as tablet versus syrup, granules versus tablets, and spray versus tablets have been introduced to favourably impact the patient’s attitude towards medicine.

9) Crisis intervention conducted when necessary, e.g. for attempted suicide, aggressive and destructive behaviour with information therapy can reduce the chances of a relapse of the behaviour. 10) Direct observation of treatments (DOTS) by health workers or family members. In T.B the DOTS program has been implemented with the help of WHO. Information and posters are available in 11 regional languages on the government of India website

http://www.tbcindia.org/

11) Various ways to increase the convenience of care, e.g. provision at the worksite or at home. Vaccination against swine flu is now part of the organizations which has employees who travel abroad frequently. Some organizations have provided check ups and information on cholesterol, mammograms to executives. Polio drops have reached homes and residential areas with information and vaccine. A successful implementation of programs in information therapy stems from conviction and willingness to long term commitment. Results can be obvious and parallels can be drawn from the west where successful programs have been put into place. Pharmaco-economics will be trending in India soon, recognition of this important gap and successfully implementing a program can bring in tangible benefits. The challenge is to overcome the formidable barriers of language, geographical and demographical differences in different states. Since Doctors are at the centre of the health care system and part of the local ethos, a practitioner centric information therapy could yield meaningful results quickly.

References 1. Adherence to long term therapies, evidence for action, WHO 2003 ISBN 9241545992 2 Grella CE et al.Drug and Alcohol Dependence, 1999, 57:151-166 3. Hoffman JA et al. Journal of Substance Abuse Treatment, 1996, 13:3-11 4. Whitlock EP et al. American Journal of Preventive Medicine 1997, 13:159-166 5. Managing chronic illness: A bio psychosocial perspective. Washington DC, American Psychological Association, 1995 6. Nessman DG et al, Archives of Internal Medicine, 1980, 140:1427-1430 7. Bloom BS. British Medical Journal, 2001, 323: 647 8. Scharloo M et al.Journal of Psychosomatic Research, 1998, 44:573-585 9. Fisher JD, Fisher WA.Psychological Bulletin, 1992, 111:455-474 10. Fisher JD et al.Health Psychology, 1996, 15:114-123 11. Carey M P et al, Journal of Consulting and Clinical Psychology,1997, 65:531-541