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1. Year 2 Semester 2 Discipline of Primary Health Care
1 05 April 2024
ADHERENCE & HEALTH EDUCATION
Training developed by: Maaike Flinkenflogel
Lecturer: Dr. Mahoro Khelia

2. Year 2 Semester 2 Discipline of Primary Health Care
2 05 April 2024
Please, participate actively and don't disturb the class. Therefore:
1. DON’T BE LATE (if you are- don’t enter, or enter VERY quiet)
2. Trust your bladder during class. Use the toilet BEFORE class.
Don't walk in and out
3. Be quiet - unless we ask you to discuss, or you have a
question/point to share with everyone (if you must ask a fellow
student something related to class - whisper and be short)
4. Put away computers, telephones and books for other classes
If you think it will be difficult to live up to the above - maybe you
should stay home
LEARNING IS NOT AUTOMATIC
BE RESPONSIBLE
AS INDIVIDUALS AND AS A CLASS

3. Year 2 Semester 2 Discipline of Primary Health Care
3 05 April 2024
• Discuss adherence (compared to compliance and
concordance)
• Describe the role of the health care provider and the
patient in decision-making and implementation of a
management plan
• Discuss factors that can influence decision-making and
implementation of a management plan in a negative
and positive way
• Describe strategies to improve decision-making and
implementation of a management plan
Objectives

4. Year 2 Semester 2 Discipline of Primary Health Care
4 05 April 2024
• Describe the principles of health education
• Discuss the importance of health education tailored to
the patient and the community
• Discuss the role of health education in every medical
consultation
• Discuss different methods to provide health education
to the patient and community
Objectives

5. Year 2 Semester 2 Discipline of Primary Health Care
5 05 April 2024
• Health care doesn’t end with finding the correct
diagnosis and writing the right medications on the
prescription note
• This is only where it starts:
– Did the patient understand and agree with the treatment
– Is the patient able to get the medication
– Will the patient take the medications correctly
– Will the patient continue to take the meds until the end
Management plan

6. Year 2 Semester 2 Discipline of Primary Health Care
6 05 April 2024
• Patient centredness is essential to develop a
management plan:
 care provider together with the patient discuss:
– What is happening |signs, symptoms
– ICE | ideas, concerns, expectations
– Influencing factors |social determinants of health
– Diagnostic tools and the outcomes
– Possible treatment options |not only medication, but
also behaviour change, continuity of care, referral
Patient-centredness

7. Year 2 Semester 2 Discipline of Primary Health Care
7 05 April 2024
• Adherence is extremely important to make the
management plan work
• Who is responsible for adherence?
– Patient?
– Care provider?
– Family?
• When there is non-adherence, who is to blame?
DO NOT EVER BLAME, this is only counterproductive
Try to find the cause and overcome this TOGETHER
Adherence
• Community?
• Health system?
• ….?

8. Year 2 Semester 2 Discipline of Primary Health Care
8 05 April 2024
• Adhere: take the right medication, in the right
dosage at the right time
• Very high numbers of people do not adhere to
treatment
• Deaths around the world due to non-adherence are
much higher
What did we read?

9. Year 2 Semester 2 Discipline of Primary Health Care
9 05 April 2024
“the extent to which a person’s
behaviour– taking medication,
following a diet, and/or executing
lifestyle changes, corresponds with
agreed recommendations from a
health care provider”
“the extent to which the patient
follows medical instructions”
What is adherence?
World Health Organisation report on Adherence 2003

10. Year 2 Semester 2 Discipline of Primary Health Care
10 05 April 2024
• Compliance and concordance are two other terms
being used similar but not the same:
• Compliance: patient follows doctors instructions
• Concordance: describes how the consultation process
advocates for a sharing of power in the care provider-
patient interaction
• Valuing of patient’s perspective and even expertise of
his/ her body’s experience of illness and treatment
What is adherence?

11. Year 2 Semester 2 Discipline of Primary Health Care
11 05 April 2024
• Remember when we talked about care provider-patient
relationship, this is important in adherence and in health
education
Relationship
Doctor control
Low
Doctor control
High
Patient control
Low
Paternalism
Doctor-centred
Patient control
High
Consumerism
(often in private
care)
Mutuality
Patient-centred

12. Year 2 Semester 2 Discipline of Primary Health Care
12 05 April 2024
“A recent review of adherence concluded
that the full benefits of medication cannot
be realized at currently achievable levels of
adherence due to the paternalistic approach
for ensuring the best use of medicines
Will concordance ensure a more effective
use of medicines — less drug wastage and
fewer hospital admissions due to the
iatrogenic effects of drugs?”

13. Year 2 Semester 2 Discipline of Primary Health Care
13 05 April 2024
Discuss with your neighbour:
1. What are risks of not adhering to treatment
2. What do you think are reasons people do or do not
adhere to treatment in the following 5 categories:
– Patient related factors
– Therapy related factors
– Health system and health care team related factors
– Condition (disease) related factors
– Social-economic related factors
Think moment

14. Year 2 Semester 2 Discipline of Primary Health Care
14 05 April 2024

15. Year 2 Semester 2 Discipline of Primary Health Care
15 05 April 2024
• When we want to increase adherence or decrease
non adherence
• Behavior change is important (both patients, care
providers and other people involved like family,
community, health system managers, pharmaceutical
industry managers, …)
• Health education is one of the ways we can improve
Adherence  Behavior change

16. Year 2 Semester 2 Discipline of Primary Health Care
16 05 April 2024
• Is behaviour change easy?
• What is needed?
– Increased knowledge and clear understanding
– Changed attitude
– Support from family, friends and health care providers
– Supportive circumstances
Behaviour change

17. Year 2 Semester 2 Discipline of Primary Health Care
17 05 April 2024
• We want to improve people’s health
• We want to increase their knowledge
What is our goal when we
provide health education?
 How?
: is that enough?
We want behaviour change!
 How?
We need to work WITH the
patient on change of attitude

18. Year 2 Semester 2 Discipline of Primary Health Care
18 05 April 2024
What is health education?
“Health education is any
combination of learning
experiences designed to help
individuals and communities
improve their health, by increasing
their knowledge or influencing
their attitudes”

19. Year 2 Semester 2 Discipline of Primary Health Care
19 05 April 2024
Where does health
education fit?
• Functions of Primary Health Care
– Promotion of health
– Prevention of illness (primary, secondary and
tertiary)
– Treatment of illness (cure and care)

20. Year 2 Semester 2 Discipline of Primary Health Care
20 05 April 2024
Who gives health education?
• Health education is the job of everyone!
• Not only doctors and nurses
• Also other health care workers: CHW’s, dentists, social
workers, even cleaners in the hospital, ...
• And other authorities: teachers, priests, parents, radio
and tv-presentors, musicians, ...
• Traditional healers, ...

21. Year 2 Semester 2 Discipline of Primary Health Care
21 05 April 2024
Is all health education correct?
• Unfortunately not
• This creates confusion and misunderstanding
• Be aware of this when you give health education!
• Examples:
– Parents and traditional beliefs: solid food when diarrhoea
– Church: condoms are bad
– Traditional healer: sex with virgin cures HIV
– ...

22. Year 2 Semester 2 Discipline of Primary Health Care
22 05 April 2024
• Always check what the patient already knows (knowledge)
or thinks (attitude)
• Provide tailored health education, integrated in the care
you are providing
• It is not just an activity you do besides or only after the
consultation,
 it should be woven into your consultations, management
plans, overall to patients and to communities
Therefore

23. Year 2 Semester 2 Discipline of Primary Health Care
23 05 April 2024
• There are many ways to provide health education
– Explaining patient during consultation
– Answering questions and concerns of patient
– Lecture to a group of people
– Facilitating interactive discussions
– Posters, leaflets
– Songs, plays, theatre
– Sharing experiences
– Etc.
How?

24. Year 2 Semester 2 Discipline of Primary Health Care
24 05 April 2024

25. Year 2 Semester 2 Discipline of Primary Health Care
25 05 April 2024
Health education to a
group of people
• Know who you want to teach:
– Who is your audience?
– How can you approach them best?
• Know what you want to teach:
– What is the existing knowledge, attitude, practice?
– Where does this KAP need improvement?
• How do you want to teach?
– What tools, what information
– What is accepted?
– What is your budget?
– ...

26. Year 2 Semester 2 Discipline of Primary Health Care
26 05 April 2024
• Multiple people and different ways to send the message is
useful
• Always check of your patient understands it and all
questions are answered:
– Ask if your patient can summarize what you explained
– Specifically ask if there are questions (in an open way)
Repetition and summarizing

27. Year 2 Semester 2 Discipline of Primary Health Care
27 05 April 2024
• Josephine had been coughing a lot recently, especially when
she was running with the children in her class during the
sports class.
• When she went to her doctor in the health centre he
diagnosed exercise asthma and prescribed her with two
types of medication (both inhalers)
– Salbutamol: to use at the moment of the wheezing
– Beclomethasone: 3 puffs, 2 times per day
• Josephine had a few problems with her new medication
– She felt the medication gave her some itch in her throat
– She often mixed up the two puffers
– She sometimes forgot the one she had to take every day
Josephine and her asthma

28. Year 2 Semester 2 Discipline of Primary Health Care
28 05 April 2024
• When she went back to her doctor he discussed with her
the importance of adherence and taking the right
medication in the right dose at the right time.
• She asked herself why it was necessary to take the
medication even on the days that she felt fine.
Josephine and adherence

29. Year 2 Semester 2 Discipline of Primary Health Care
29 05 April 2024
• She then thought of many times that she or people around
here were not adhering:
– She sometimes would not finish the antimalaria Coartem
when she felt her children were completely well
– She had a boy with HIV in her class who was very ashamed
and therefore did not want to take his meds
– Her neighbor with many children but no job often did not
have money to pay for the prescribed meds
– Her husband stopped the anti hypertensive meds as it gave
him side effects when he started them
Josephine and adherence

30. Year 2 Semester 2 Discipline of Primary Health Care
30 05 April 2024
• Discuss with your neighbour
• What do you think of Josephine’s case: what would
you have done in her situation
• Do you always take your medication, are you
adhering? Why or why not?
• How is the health education in the health system
presently: Good, sufficient, bad? Why?
What do you think?

31. Year 2 Semester 2 Discipline of Primary Health Care
31 05 April 2024
The desired Rwandan Health Care
Provider | What can we do?
• Think and discuss with your
neighbors:
1. What could you as a health care
provider do to increase adherence
in all these situations?
2. How can health education
influence adherence?
3. How do all the competencies of
the Desired Rwandan HCP relate
to adherence and health
education?

32. Year 2 Semester 2 Discipline of Primary Health Care
32 05 April 2024
• Respect, trust, communication and collaboration are
essential in making an optimal management plan
• Adherence is an essential part in providing quality
health care, we as health care providers always need
to take this into consideration
• Health education is another essential aspect of
management plan and leading to good health and
holistic health care
Take home message

33. Year 2 Semester 2 Discipline of Primary Health Care
33 05 April 2024
• World Health Organisation. Adherence to long term therapies.
Evidence for action. 2003
• www.pharmaceutical-journal.com/learning/learning-
article/what-is-concordance/10988929.article
• www.who.int/topics/health_education/en/
• https://www.youtube.com/watch?v=_pTKhytFdWs
• https://www.youtube.com/watch?v=mSr61ip3L7M
• https://www.youtube.com/watch?v=YOD2fflXIfM
• https://www.youtube.com/watch?v=pqx7fAqfFy8
• https://www.youtube.com/watch?v=ucKjwSDsQuc
• https://www.youtube.com/watch?v=wF8pqxvfRXQ
• https://www.youtube.com/watch?v=4lgFLKoyKKc
References

34. Year 2 Semester 2 Discipline of Primary Health Care
34 05 April 2024
• Read page 31-35 of the WHO report on adherence to long
term treatment
• Discuss with your group the case of Josephine again related
to the different factors influencing her non-adherence
• Discuss the solutions towards the different problems
Josephine has been facing based on the pages from the
report that you have read.
Home group work