Educators use Third World training approach in U.S.
Staff, patients enact problems in new video
When two Atlanta professionals from two different disciplines set out to make a video aimed at improving patient compliance, only one of them knew ahead of time what the answers were "supposed" to be and she made sure not to tell her colleague.
Instead, the TB expert Naomi Bock, MD, MS, assistant professor of medicine at Emory University School of Medicine and her collaborator, anthropologist Claudia Fishman, PhD, assistant professor in the Department of International Health at Emory’s Rollins School of Public Health, tried a different approach. Instead of going in with ready-made concepts and a survey to match, they asked the people who were the intended targets of the intervention what they thought about the situation.
Those who’ve previewed the video that resulted from the research say "it cuts straight to the core issues," says Bock. "It really seems to resonate."
Bock and Fishman’s project is intended as an educational tool for a specific group: those who provide healthcare to TB patients who are urban, indigent African-Americans at risk for drug and alcohol abuse. The video comprises six short scenes, each of which describes an interaction between a hapless TB patient and a member of the health care team which is supposed to, at least, be meeting his needs.
Health care team blows it, again and again
Instead, as the video shows, health care team members unintentionally throw up one obstacle after another. There’s the stony-hearted clerk in admissions; the well-meaning doctor who overwhelms the patient with too much information; the TB nurse who mistakenly gives a confusing message; the doctor who publicly upbraids his staff for mistakes . . . and, sad to say, much more.
Research for the video drew on techniques derived from Rapid Rural Appraisal (RRA), a participatory approach to analysis and problem-solving used in economic development projects in the Third World, Bock says. A key component of RRA is "people who are the target of the intervention are brought on board from the very beginning as part of the research team," Bock says.
That focus supplants traditional academic studies where, as Bock describes it, "you go in and say, I have a PhD in health education, and I know more than you do. So we’re going to ask you some important questions, and after you provide the answers, we’ll do a statistical analysis.’"
Using the RRA approach, Bock says she and Fishman made two discoveries.
The first is that "compliance" is not a single response to a single situation, Bock says. Rather, the course of treatment includes many points (from getting off the street into initial diagnosis, to starting therapy, to staying in therapy, to naming contacts) where a patient can get lost. In other words, "there’s not one simple thing the patient has to comply’ with," Boch says.
Second, the two discovered it’s critical for members of a health care team to stay in close communication. Otherwise, they send conflicting messages to the patient and undermine each other.
Control anger toward noncompliant patients
Worse, the messages they send are frequently angry ones, Bock says. "Everyone from the doctor on down has so much anger at the patient," she says. They might say things such as, "You brought this on yourself. Why can’t you take care of yourself? You promised me you wouldn’t drink!’" The point isn’t to deny the anger, she says, "but to deal with it elsewhere so you can do what you have to do."
The research began with Fishman training Bock’s staff to do focus groups with other TB teams. By using quantitative methods such as phrase counting, the newly trained focus-group leaders gradually developed a list of key issues.
Then, borrowing another page from RRA techniques (look beyond the obvious), Bock and Fishman hit the streets and detention facilities and talked to noncompliant TB patients. Interviewing compliant patients sitting in a TB clinic would have been easier, but then "we’d have been talking to the wrong people," Bock adds.
In the last stage, Bock’s staff role-played what they’d decided were the issues. Professional scriptwriters and actors provided a final, more polished version, resulting in a production that lacks only a title which satisfies its creators, Bock says. (So far, the leading contender is "101 Ways To Lose a TB Patient.")
Characters and scenes, though vivid and true to life, are subtly drawn, Bock says, and intentionally steer clear of presenting mere caricatures of bad behavior. Instead, each vignette is intended to stimulate debate and discussion among viewers and lead to changes in their behavior.
Bock warns the video "is going to bring up a lot of issues." Staff members, forced to confront their feelings about each other and about their patients, will need help sorting through their reactions. With that in mind, Bock and Fishman have designed a participant manual and are putting finishing touches on a training program (also with a manual) designed for facilitators who’ll lead post-viewing discussions. Facilitators "don’t need to know much about TB; they will need to be skilled in interpersonal relationships," Bock says.
Videos and manuals will be ready for distribution by June and will be distributed through the Georgia Lung Association, perhaps at a small charge. A train-the-trainer workshop for facilitators will be held the day before the TB Controllers’ conference coming up this fall. To order a copy or to enroll in the train-the-trainer workshop, call Bock’s secretary, Jimmy Clanton, at (404) 657-2634.
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