Tag Archive for Communication

Starting Out Early

December 13, 2018 Child Health, Communication, Global Health, Health and Wellness Promotion, Infectious Diseases No comments

It is a hot, humid day in mid-June, 2011 in this remote village in Niger state, Nigeria. The state is in a low development region with poor health indicators. I am a newly qualified doctor and have just concluded a Lot Quality Assurance Sampling (LQAs) assignment for the state office of the World Health Organization (WHO). The LQAs is a method of assessing the vaccination coverage after the supplementary polio immunization campaigns. I am at the home of Mallam Adamu, a middle aged, poor peasant farmer. Adamu is married with 6 children, 3 of which are under the age of five and therefore eligible for the polio immunization.

He is visibly angry and in a loud voice yells “tefi” in Hausa, the local language to myself and my translator. “Tefi” means “go away”. My translator tells me that for the past 6 months, he has barred his 3 eligible children from receiving polio immunization. He has been reported to the Mai angwa (the local community chief) but he is adamant.

When he learnt I was a doctor, he visibly relaxed and we sat down on a mat in front of his mud house to chat. He has 6 kids and they have all received routine immunization. However, he wonders why the need for the yearly polio immunizations and wonders when they will cease. He has heard the rumours; these polio vaccines were created by the West to cause sterility among his people and he would never compromise the safety of his children. “Lekita, do you have kids?” he asked and I replied “no”. He shook his head slowly.

I proceeded to explain that the rumours are untrue. The vaccines are safe and nobody would deliberately administer a vaccine that can harm kids including myself. Perhaps I answered his questions satisfactorily or he believed me as a medical person but I learnt that on the next round of polio immunization he had allowed his kids to be vaccinated. The encounter however made me realise that I did not have enough answers myself!

As a healthcare provider, just how well did I know these vaccines that I confidently recommended for babies? How is their safety and effectiveness assessed? Yes, while undergoing paediatrics and family medicine training in medical school, I had received lectures on vaccination but there was a knowledge gap that could impact my ability to perform in this field. Three years after this encounter another incident would motivate me to gain more expertise in vaccinology.

This time, I was working at the paediatrics department of a large district hospital in another state in northern Nigeria. One morning a neonate who had been delivered at the hospital, given his first dose of birth vaccines which included the Bacillus Calmette Guerin (BCG) vaccine against tuberculosis and discharged home the previous day was rushed to the paediatric emergency room where I was stationed. His parents were visibly distraught- their son had a fever and a large swelling on his left upper arm, the BCG vaccine injection site. My team had admitted the baby for observation and he was discharged home 3 days later. Before being discharged, his father, a teacher in one of the state owned secondary schools confided in me that he may be unwilling to let the child receive further childhood vaccination and I had to spend considerable time reassuring him. Vaccines are administered to healthy people, usually kids, so there is a low tolerance for any risk and moreover, despite being generally very safe, an Adverse Event Following Immunization (AEFI) can occur, although not usually caused by the vaccine.

Vaccination has been a useful tool in the control of infectious diseases. It led to the eradication of small pox, the first disease to be eradicated through vaccination. Equally, progress is being made towards the elimination of another disease, polio. However, these feats recorded by vaccination paradoxically are beginning to lead to a tendency from the public to question the need for further vaccination and in some cases have led to outright refusal of parents to have their children vaccinated. Tragically this could lead to the resurgence of previously controlled diseases, for example, measles is resurfacing in some high income countries.

All of this must be a wake up call for Global Health. Across Africa, there are instances where rumours have derailed vaccination campaigns requiring intense advocacy to regain public trust and restart the campaigns.  Derailment is not only a political problem, derailment is a matter of life and death.

There is a need for a pool of well-trained local scientists in all spheres-research and development, academia, national regulatory agencies to engage with their communities and advocate for vaccination. Everyone has a right to know and to hear in their own language.  The public will need to be constantly reassured by their own sons and daughters. We cannot afford to wait until it is too late.

 

Dr Edem Bassey is an online scholar of the MSc in Global Health and Infectious Diseases at the University of Edinburgh. He works at the Medical Research Council, Unit the Gambia at the London School of Hygiene and Tropical Medicine (MRCG at LSHTM) as a research clinician where he is involved in the clinical trial of life saving vaccines for the developing world. 

 

If somebody had a crystal ball: The paradox of a self-defeating health policy.

June 12, 2017 Communication, E and M Health, Global Health, PhD, Uncategorized No comments

When I was a new graduate student of health policy, I was once asked by a professor whose class I took, why I had left clinical practice to study health policy. I replied naively, ‘I migrated from clinical practice because I don’t like the idea of working in a place where I can make one mistake and kill a person.’

‘I see,’ he said, ‘so you decided to come over to policy and kill thousands?’

His response, delivered in jest, was tacitly instructive about the importance of getting health policy right, because of the scale at which the impact can be felt. Indeed, one of the central tenets of governance in healthcare is the identification and rectification of problematic policies (WHO, 2017).

Even after learning at graduate school that policy work tends to be an arduous, convoluted and often contentious process, I still intuitively considered policy work to be safer, more elegant and less stressful than clinical work. It was experiences ‘from the trenches’ that revealed otherwise. Within a year of completing my masters, I was battling to pilot an intervention aimed at mitigating the undesirable effects of a well-intentioned health policy that has outlived its relevance in its context; a process which was the diametric opposite of ‘elegant and less stressful’!

 

When a health policy endangers health

Pharmacies in Zimbabwe, a low income country in Sub-Saharan Africa plagued by a protracted economic recession and a dilapidated health system (Meldrum, 2008), are prohibited by law from advertising their inventory to the general public unfettered like conventional businesses do (Health Professions Act, 2004; Medicines and Allied Substances Control Act, 2001; Pharmaceutical Professional Conduct Regulations, 1989). Given the information asymmetry characteristic of a typical healthcare market, and the potential severity of the consequences of such asymmetry, advertising restrictions are rightly intended to protect members of the public from product claims they are unequipped to evaluate objectively. However, to the extent that advertising restrictions interfere with information provision and transparency when accessing health care, they themselves are a health hazard and this is what the medicine advertising regulations in Zimbabwe have become. The fine line between availing information about care and protecting the public from exaggerated claims should be carefully navigated. Interventions which mitigate the deleterious effects of health information control policies can and should be developed.

In well-served health systems, restricting advertising in and of itself does not constitute a problem because a patient can reasonably expect to find the medicine(s) s/he requires after only one stop or at most few stops at pharmacies in his/her vicinity. However, in Zimbabwe today, systemic economic challenges are causing generalised medicine shortages. These challenges are, in the main, beyond the control of the pharmaceutical sector. As a result, the largest referral hospitals suspended elective surgeries (United Bulawayo Hospitals, 2016; Harare Hospital, 2016). Pharmacies that happen to have a particular medicine that is in short supply everywhere else, are precluded from overtly advertising this fact. Patients therefore have to rely on door-to-door enquiries at multiple pharmacies, serendipitous coincidences, intuition and the benevolence of some pharmacists who sometimes offer to help by contacting colleagues within their professional networks on behalf of patients. Electronic prescribing is not yet widely used in Zimbabwe so patients or their carers are the ones tasked with transmitting prescriptions between prescribers and the pharmacies that will ultimately dispense them. They therefore bear the transaction cost of this process and have to trudge from one pharmacy to the next until they eventually get to a pharmacy that can fill their prescriptions. When pharmacists turn away prescriptions but offer no additional information about where patients can get those prescriptions filled, they become the human face of a system that seems unresponsive to the plight of the ill. Once, I remarked to my colleagues, ‘If somebody had a crystal ball, they would be the oracle that informs patients where exactly to go to get their prescriptions filled and reduce the burden of medicine access.’

 

The intervention: Controlled democratisation of pharmaceutical inventory information

Accessing medicines should not depend on unsystematic methods of search and we most certainly shouldn’t have to look to clairvoyance to make health systems more efficient and transparent – especially when advances in health informatics and Web 2.0 coupled with the ubiquity of portable information and communication devices have increased the interconnectedness of actors and rendered faster sharing of information across large networks possible. After a content analysis of the statutory instruments governing the practice of pharmacy in Zimbabwe, with the view to finding a legal workaround for the advertising rules, I discovered a loophole. While advertising inventory to the general public is prohibited in Zimbabwe, advertising to another health professional is not. Therefore, if a vertical search engine that is populated by real-time crowdsourced inventory data from retail pharmacies all over the country was set up, and if the back-end of that search engine was managed by a pharmacist, then it could be used by that pharmacist to advise patients, on a case by case basis, even remotely via the internet, about the exact locations of pharmacies stocking specified medicines. A prototype meant to achieve this was designed and the three statutory bodies that regulate healthcare practice in Zimbabwe were approached for approval before launch.

The unfavourable response received from them, was unexpected. An email communication was circulated to all the registered practitioners, cautioning them against what the chief regulatory institution considered an ‘illegal project’ that was tantamount to advertising. I was explicitly informed that I was risking censure by setting the ball rolling with it and was sufficiently intimidated. Of all the illegal things a health professional in Zimbabwe can do, outside of malpractice, experimenting with advertising is considered the most negligent because it is so easy to avoid. It is seared onto our minds right from pre-qualification training that advertising by health professionals is simply not acceptable, so it is almost a reflex response for healthcare providers to stonewall anything that bears advertising connotations.

Regulators were re-engaged because their endorsement is crucial. Without this it is not possible to persuade pharmacies to volunteer the essential crowdsourced data needed to populate the vertical search engine that drives the intervention. Although they acknowledged unreservedly the existence of the problem that the advertising policy has given rise to, regulators remained steadfast in their position that the proposed vertical search platform solution was illegal and ‘was not in the best interests of the public’. The judiciary arm of the state was therefore invoked in the hope that it could rule on the legality of the proposed intervention.

The intermediate goal became to obtain a court judgement that would compel the regulatory bodies to allow this intervention to be tried. A High Court application (Herald, 2016a) citing the health minister and all three relevant regulatory entities as respondents, was filed. We currently await a judgement pronouncement but continue to keep the discussion about the matter alive, for example through the press (Herald, 2016b). Meanwhile, one of the regulatory bodies has responded to our court application with a counter-suit for costs because according to it, we ‘brought a case before the Court prematurely.’

 

The Future

Towards the end of 2016 a press announcement notified the public of the healthcare regulators’ intention to relax draconian advertising policies (Herald, 2016c), having recognised the need for the public to access information about healthcare providers and services. I count this a small victory and look forward to the green light to implement the ‘Crystal ball’ project with much optimism. Lessons from its implementation could bode well for health systems facing similar governance problems.

Determined to build my credibility with policymakers and take forward my academic studies, I enrolled for a PhD with the Global eHealth research group at the University of Edinburgh and am now 10 months into a three-year programme. Taking this parallel pathway, whilst continuing to fight the case for better information sharing about community pharmacy stocks in Zimbabwe, has forced me to critically examine my assumptions and proposition and to mentally separate my personas as an objective researcher of eHealth innovation and as an innovator/entrepreneur. It has provided an opportunity take an in-depth look at the technical and legal feasibility of alternative approaches, and their ethical, legal and governance implications, as well as to study a wider range of innovative digital approaches for supporting pharmacy practice and strengthening health systems. This transition has been guided and encouraged by my PhD supervisors Dr Claudia Pagliari and Dr Raluca Bunduchi, who have kept my feet on the ground and combine expertise in health technology assessment, health policy and innovation studies. Our new opinion piece in BMJ Global Health (June, 2017), aims to draw wider attention to the challenges facing Zimbabwe and seeks ideas and opinions from researchers, policymakers and practitioners facing similar problems elsewhere in the world.

 

By Dudzai Mureyi, Global eHealth PhD student

Dudzai Mureyi is a first year PhD student on the Global eHealth programme at the University of Edinburgh, supervised by Dr Claudia Pagliari (eHealth Research Group) and Dr Raluca Bunduchi (Entrepreneurship and Innovation Group).

 

  1. Harare Central Hospital (2016). Internal memo: Suspension of Elective Lists-Drug Shortages. Harare. [WWW] Available from https://zimnews.net/zimbabwe-suspends-surgeries-harare-hospital/ Accessed 06 February 2017.
  2. Meldrum A, (2008). Zimbabwe’s health-care system struggles on. Lancet 371(9615); 1059-1060.
  3. Parliament of Zimbabwe (2001) Medicines and Allied Substances Control Act [15:03]. Harare. Parliament of Zimbabwe.
  4. Parliament of Zimbabwe (2004) Health Professions Act [27:19]. Harare. Parliament of Zimbabwe.
  5. Parliament of Zimbabwe (1989) Statutory instrument 232 Pharmaceutical Professional Conduct Regulations. Harare. Parliament of Zimbabwe.
  6. The Herald (2016a). Pharmacist Seeks Court Order for private pharmacy stocks database. [WWW] Available from  http://www.herald.co.zw/pharmacist-seeks-court-order-for-private-pharmacy-stocks-database/  Accessed 06 February 2017.
  7. The Herald (2016b). When regulation is outpaced by technology. [WWW] Available from  www.herald.co.zw/when-regulation-is-outpaced-by-technology/ Accessed on 06 February 2017.
  8. The Herald (2016c). Zimbabwe: Govt relaxes Medical advertising rules. [WWW] Available from http://allafrica.com/stories/201611280215.html Accessed 06 February 2017
  9. United Bulawayo Hospitals (2016). Internal memo: Cancellation of Elective Surgical Operations. [WWW] Available from http://www.africanews.com/2016/10/15/drug-shortage-hits-zimbabwe-hospitals-suspends-some-surgical-operations// Accessed 06 February 2017.
  10. WHO (2017) Governance. [WWW] Available from http://www.who.int/healthsystems/topics/stewardship/en/ Accessed 06 February 2017.
  11. Mureyi D, Pagliari C, Bunduchi R (2017) Drug advertising riles and the patient safety paradoc in Zimbabwe. BMJ Global Health (Opinions), June 8th 2017 http://blogs.bmj.com/bmj/2017/06/08/dudzai-mureyi-et-al-drug-advertising-rules-and-the-patient-safety-paradox-in-zimbabwe/ Accessed on 10 June 2017

The Importance of Good Communication Skills

October 27, 2015 Communication, Health and Wellness Promotion, Life Stages and Care Pathways, Oncology No comments

Good communication should never be underestimated at any time, however this is never more important than when communicating with someone in relation to their health. It is impossible to overstate the importance of creating good communication between health professionals and patients in optimising health care.

As a medical oncologist for over 30 years I have seen many examples of both good and bad communication, with a recent example coming to mind. I met an old friend who informed me that he had just been diagnosed with prostate cancer – highly intelligent, well-read but non-medical he told me that the moment he heard the work “cancer” his mind blotted out completely. He remembers nothing of the rest of the consultation and left knowing next to nothing of the proposed management or his future. This is a frequently reported occurrence and for doctors the process of explaining a cancer diagnosis, outlining investigations necessary for staging and possible options for treatment this is ever more challenging.

Over the years I have seen and participated in amazing progresses in the science of cancer and the ever increasing knowledge and understanding regarding individual cancers, not to mention the possibilities for investigation and more and more available treatments. Good medical practice carries with it a responsibility to explain as much as possible to patients, but how and when to do this requires training and expertise. Time is a major pressure with often too much to explain in a single consultation. Patients can only absorb so much information at a time, if any as my friend found.

Sharing explanations between doctors and nurses can help patients digest what matters most to them, and having a relative or close friend with them doubles the hearing/comprehension experience.   Hand-outs are no substitute for face-to-face conversation and doctors really have to work hard to develop the skill of “listening”! Thank goodness the art of medicine has not been totally replaced by science, but communication skills need to be practiced and continuously developed by all of us in helping patients to understand the complexity of a diagnosis of cancer.

 

Professor John F Smyth, Emeritus Professor Medical Oncology, University of Edinburgh

Communicating with Cancer Patients