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Introducing Arabic language patient education materials in Jordan
Patient Education and Counseling 60 (2006) 142–145 www.elsevier.com/locate/pateducou
Introducing Arabic language patient education materials in Jordan Laeth S. Nasir*, Arwa K. Nasir Department of Family Medicine, University of Nebraska Medical Center, 983075 Nebraska Medical Center, Omaha, NE 68198-3075, USA Received 8 September 2004; received in revised form 1 December 2004; accepted 14 December 2004
Abstract Objectives: To describe the development and introduction of patient education materials in a primary care setting in Jordan. Methods: During the 2003–2004 academic year, the authors collaborated to produce more than 25 Arabic language written patient education materials designed to conform to cultural and social norms and expectations. Results: Patient education materials were frequently shared with friends and family members. Readability of materials was judged to be excellent when materials were presented at approximately a sixth grade reading level. Conclusions: Patient education materials are greatly needed in Jordan. A thorough understanding of the culture facilitates alignment of the health message with social norms and establishment of credibility with the target audience. The materials developed were well received by patients and physicians. Practice implications: The routine integration of patient education into all medical consultations in Jordan is an important goal. Practice based research will be vital in identifying and eliminating barriers to the introduction of patient education in the clinical setting. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Patient education; Jordan; Cross-cultural medicine
1. Introduction Jordan is a rapidly growing Middle Eastern country with a population of 5.3 million people. Over 50% of the population is under the age of 15. Ninety two percent of the population is Sunni Muslim, and most of the remainder are Christian. Arabic is the official language. The country has a relatively modern and functional medical system. The social structure of Jordan remains primarily clan based, with the foundational unit of society based on the family. Despite the relatively advanced scientific state of medicine in Jordan, the integration of patient education into everyday medical practice lags behind. Jordanian patients, particularly but not exclusively from the lower middle and lower socioeconomic classes have a limited knowledge of health related issues. There also tends to be a great deal of misinformation regarding health and disease.
* Corresponding author. Tel.: +1 402 559 5691; fax: +1 402 559 6501. E-mail address: [email protected] (L.S. Nasir).
Patient education has been defined as a process that influences ‘‘the changes in knowledge, attitudes and skills necessary to maintain or improve health’’ [1]. Issues such as lifestyle change can only be addressed through effective patient education, and changing behavior is important since most leading causes of illness and death are due to unhealthy lifestyles. Additionally, patient education can improve selfcare by patients suffering from chronic disease resulting in substantial improvements in disease outcome. Patient education also improves patients’ understanding of their illness or condition. This enhances their ability to participate in the process of medical decision making, and strengthens the bond of trust between patient and health care provider [2]. For all these reasons, patient education is considered an integral part of high quality medical care. Effective patient education calls for a variety of skills, including the assessment of patient educational needs and barriers to learning. Printed materials powerfully supplement patient education, making additional information available without a larger time commitment [3]. When designing educational materials, it is important to be
0738-3991/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2004.12.006
L.S. Nasir, A.K. Nasir / Patient Education and Counseling 60 (2006) 142–145
familiar with the cultural issues that must be taken into account in order to align the health message with social norms, identify barriers to learning, and establish credibility with the target audience [4]. It is also important to produce materials which are easily understood by the target population by building on pre-existing concepts or knowledge if possible. Readability and literacy issues in the target population are also important. Although the literacy rate in Jordan is 93%, versus 97% for the United States, and the average years of schooling for Jordanians is 6.9 years, versus 12 years for American students [5], a pilot study we carried out showed excellent comprehension when Jordanian patients were given materials written in colloquial Arabic at approximately a sixth grade reading level. This level is similar to the recommended reading level for patient educational materials in the United States. Factors related to language may also contribute to a lack of health awareness in the population. While Arabic is an extraordinarily rich language, it lacks a commonly understood vocabulary describing many modern concepts in health and medicine. Modern terms borrowed from other languages are often unfamiliar to the average person. Exacerbating the problem is the fact that patient educational materials are often written in the more formal, though less easily understood classical Arabic, rather than the more widely understood but less scientific colloquial form. Most of the limited amount of patient educational material currently available is inaccessible to the average reader for this reason. In the Middle East, society tends to be conservative, hierarchical and family centered. The individual tends to be seen as part of a family, rather than as a separate entity. This cultural dynamic often results in the patriarch of the family or other authority figure making important health decisions for family members. Therefore, while writing the materials, we emphasized the role of family involvement and care in management of the condition, and the patients’ recovery. Religious sensitivities and beliefs are also central in importance when designing educational material for this population. The Muslim religion is the major shared experience of the population of Jordan. Christians also, are very familiar with Islamic tradition. Religious traditions have both positive and negative effects on health behavior, and it is important to take these beliefs into account when designing educational materials. It is generally accepted, for example, that all occurrences in an individual’s life are the result of God’s will. Therefore, although divine intervention is to be hoped for, the final result is not to be questioned, ‘‘. . .but you may hate a thing although it is good for you, and love a thing although it is bad for you. (God) knows, but you do not’’ [6]. Many individuals also believe in supernatural forces such as spirits and spells, and some believe that illness, and particularly family violence, addictions, and mental illness may be attributed to these forces [7].
143
2. Methods In the 2003–2004 academic year, the authors collaborated to develop and introduce patient educational materials for the primary care setting while one of them (L.N.) was teaching Family Medicine in Jordan on a Fulbright scholarship. The subjects chosen were common conditions seen in primary care. Although English language medical texts were used as references, the materials were written de novo in Arabic. Since both authors are bilingual in Arabic and English, back translation was not felt to be necessary. The subjects ranged from materials about major depression to the correct use of Warfarin. Copies of some of the materials developed are available from the authors (see Table 1). This paper highlights some of the topics that needed particular care in planning in order to meet the cultural needs and expectations of the region. We give examples of written educational materials we developed for smoking cessation, domestic abuse, diabetes and major depression. 2.1. Smoking cessation It has been estimated that 29% of all Jordanian adults, and 48% of adult males are smokers putting Jordan 32nd among 130 countries for which data is available [8]. Cigarettes are the most common form of tobacco consumption, but a substantial minority of smokers use an argeela (hubblebubble or water pipe) to smoke tobacco. Many people who use an argeela do not consider it to be ‘‘smoking’’. Factors that predispose the population to smoking include poor knowledge about the adverse consequences of smoking, cultural norms that encourage conformity, and the fact that many decision makers and role models are smokers. Cultural factors that discourage smoking include the fact that Islam discourages the use of tobacco as well as social norms that emphasize self-control and the protection of family. In developing this particular topic, we avoided explicit discussion of a shortened life expectancy for smokers, as most Muslims believe that ‘‘No one dies unless (God) Table 1 List of Arabic language patient education materials available from the authors Anemia in children Adult onset diabetes mellitus Anxiety Asthma Chickenpox Conjunctivitis (infectious) Cholesterol Depression Healthy diet (two versions) Hypertension Head lice Warfarin
144
L.S. Nasir, A.K. Nasir / Patient Education and Counseling 60 (2006) 142–145
permits. The term of every life is fixed’’ [9]. Therefore, referring to a shortened lifespan might prove controversial to some. Instead, we focused on the positive benefits of abstinence, including easier breathing, financial savings, foods tasting better, and avoidance of smoking-related disease. We also discussed the harmful effects of secondhand smoke on other family members, particularly children. 2.2. Depression Depression is highly prevalent in the developing world, and Jordan is no exception. It is thought that the increase in depression is due to increased urbanization and the social and lifestyle changes that accompany it. In the Middle East, as is the case with much of the developing world, mental illness is highly stigmatized. Depression, in particular, is seen as a moral failing; the hopelessness characteristic of the disease is considered by many to arise from a lack of faith in God. We felt that the best approach would be to clearly state that the disease is a ‘‘chemical imbalance in the parts of the brain in charge of a persons’ mood’’, in the first sentence, clearly categorizing it as being a condition out of his or her control. We gave prominent place to the fact that lack of faith or character weakness was not a factor in the development of depression, or with the inability to cope with its symptoms. When discussing prevention and treatment of depression we stressed the importance of increased social contact with family and friends because this type of mutual assistance is common and minimally stigmatizing in the context of the local culture [10]. Formal counselling with a mental health professional was mentioned briefly; it is not widely available and is considered to be the most stigmatizing. Finally, when discussing pharmacologic treatment, it was important to emphasize that the medications used in the treatment of depression are not habit forming; in the public mind any type of psychoactive drug is believed to be addictive.
with effective treatment, an individual with diabetes can live a normal life. 2.4. Domestic violence Little objective information about domestic violence exists in Jordan. ‘‘Honor killings’’ of women by male relatives for actual or perceived sexual indiscretion, while uncommon, only are the most visible manifestation of domestic violence. The subject of domestic violence remains a taboo subject in Jordan. Factors which make it difficult to address include traditions of strict family privacy, the cultural perception that women are subservient to men, and the perception that Islam allows men to physically discipline their wives in certain circumstances. Unfortunately, the current political climate has made the topic even more difficult to discuss dispassionately, due to the hardening of attitudes in some quarters towards ideas that are perceived to affect traditional social patterns. We decided that the best way to approach this sensitive topic was to write the educational material using gender inclusive language in order to take advantage of the strong cultural consensus that physical violence in general is improper. Emphasis was placed on the fact that violence is not the victim’s fault, but that this kind of violence typically is a learned behavior and may have its genesis in the abusers family of origin. Practical steps for the victim to take were discussed, including family mediation, which is the solution recommended by the Koran for recalcitrant marital difficulties. We also discussed other actions, such as informing supportive people of the abuse as soon as possible, and to make plans for leaving if the abuse escalates. We also elected not to include mention of sexual abuse in the materials, as in Arab culture sexual abuse is considered to be in an entirely separate and much more severe category of offence.
2.3. Diabetes mellitus
3. Introducing the materials
Diabetes mellitus is a major health problem in Jordan. It is estimated to affect 13.4% of the adult population [11], more than double the United States rate. Misconceptions about the causes, treatment and outcome of diabetes abound. Obesity is generally seen as a benign characteristic and is even encouraged in some quarters as a sign of good health. Lack of knowledge about the causes of diabetes and the efficacy of modern treatments put many at risk for the use of ineffective treatments such as traditional herbs or folk remedies such as diets supplemented with large portions of dried dates and honey, foods which some believe to have miraculous healing powers. We began by providing simple explanations of the causes of diabetes and the main types of medical treatments available. We also briefly reviewed diabetes self-care, diet, exercise, the importance of adherence to the prescribed regimen and reassurance that
Several unexpected barriers were found to exist in some settings when patient educational materials were introduced. These barriers were identified as physiciandependent and physician-independent. Physician dependent factors included a perception among many in the medical profession in Jordan that patients would not be interested in reading printed materials. Some physicians in Jordan have been trained in countries where patient education is not emphasized. These physicians may feel poorly prepared to educate patients. Additionally, practice styles among some physicians may emphasize the authoritarian medical model in their clinical interactions; among this group there may be an unconscious perception that educational materials detract from the physicians’ authority by allowing the patient greater control over his or her illness.
L.S. Nasir, A.K. Nasir / Patient Education and Counseling 60 (2006) 142–145
Patient reaction to the materials was positive overall. Older, illiterate patients were usually accompanied by an educated family member to whom the information could be given. The educational materials often sparked great interest and additional questions on follow up visits. The patient education materials were initially introduced at the Family Medicine outpatient clinics of the University of Jordan. Subsequently, selected materials were introduced in the Endocrinology clinics, and the Pulmonary Medicine clinics. A number of private physicians also used the patient materials. Feedback from physicians and interviews with patients suggested that the materials were found to be very useful, and contributed positively to patient care. We discovered that patients frequently share educational materials with family members and friends. Therefore, patient educational materials can be used by the health care provider to develop an alliance with the family, in part by encouraging family support and contributions to healthy behaviors. Feedback from patients and physicians also resulted in some modifications of the educational materials and in the choice of topics. For example, some physicians suggested topics requiring additional emphasis, or conditions that they saw frequently in their own practices (such as chickenpox or head lice). Little exists in the medical literature describing the development of patient educational materials in other parts of the Middle East, particularly material focused on primary care. It may be that more visible issues of access and quality have until recently obscured the need for written patient educational materials, or that issues in local medical culture as described above have made the development or introduction of such material difficult. Another important
145
issue is that although the Arab world shares a language and religion, culture and local dialect often differ sufficiently from one region to another that materials appropriate for one country or area may not be suitable in another. Although the provision and introduction of patient educational materials initially appeared to be successful, much work remains to be done in expanding and refining the materials, through more in-depth evaluations of the materials, such as focus groups, eliciting ongoing physician and patient feedback, and over time, integrating patient education into every medical consultation.
References [1] American Academy of Family Physicians. Patient Education. Am Fam Phys 2000;62:60–72. [2] Brody D. Promoting the development of doctoring competencies in clinical settings. Fam Med 2004;36:S105–9. [3] Monsivais D. Developing and evaluating patient education materials. J Cont Educ Nurs 2003;34:172–6. [4] Nationmaster.com: http://www.nationmaster.com/country/jo/Education. Accessed 10 August 2004. [5] Talbert R. Developing bilingual patient educational materials, problems and solutions. J Biocommun 1981;8:23–8. [6] The Koran. Fourth revised edition translated by NJ Dawood. New York: Penguin; 1987. Chapter 2, Verse: 216. [7] Al-Krenawi A. Explanations of mental health symptoms by the Bedouin-Arabs of the Negev. Int Social Psych 1999;45:56–64. [8] Nationmaster.com: http://www.nationmaster.com/country/jo/Health. Accessed 10 August 2004. [9] The Koran. Fourth Revised Edition. Translated by NJ Dawood. New York: Penguin; 1987. Chapter 3, Verse: 145. [10] Al-Krenawi A. Mental Health Service utilization Among the Arabs in Israel. Social Work Health Care 2002;35:577–89. [11] Ajlouni K. Diabetes and impaired glucose tolerance in Jordan: prevalence and associated risk factors. J Int Med 1998;244:317–23.
Introducing Arabic language patient education materials in Jordan Laeth S. Nasir*, Arwa K. Nasir Department of Family Medicine, University of Nebraska Medical Center, 983075 Nebraska Medical Center, Omaha, NE 68198-3075, USA Received 8 September 2004; received in revised form 1 December 2004; accepted 14 December 2004
Abstract Objectives: To describe the development and introduction of patient education materials in a primary care setting in Jordan. Methods: During the 2003–2004 academic year, the authors collaborated to produce more than 25 Arabic language written patient education materials designed to conform to cultural and social norms and expectations. Results: Patient education materials were frequently shared with friends and family members. Readability of materials was judged to be excellent when materials were presented at approximately a sixth grade reading level. Conclusions: Patient education materials are greatly needed in Jordan. A thorough understanding of the culture facilitates alignment of the health message with social norms and establishment of credibility with the target audience. The materials developed were well received by patients and physicians. Practice implications: The routine integration of patient education into all medical consultations in Jordan is an important goal. Practice based research will be vital in identifying and eliminating barriers to the introduction of patient education in the clinical setting. # 2004 Elsevier Ireland Ltd. All rights reserved. Keywords: Patient education; Jordan; Cross-cultural medicine
1. Introduction Jordan is a rapidly growing Middle Eastern country with a population of 5.3 million people. Over 50% of the population is under the age of 15. Ninety two percent of the population is Sunni Muslim, and most of the remainder are Christian. Arabic is the official language. The country has a relatively modern and functional medical system. The social structure of Jordan remains primarily clan based, with the foundational unit of society based on the family. Despite the relatively advanced scientific state of medicine in Jordan, the integration of patient education into everyday medical practice lags behind. Jordanian patients, particularly but not exclusively from the lower middle and lower socioeconomic classes have a limited knowledge of health related issues. There also tends to be a great deal of misinformation regarding health and disease.
* Corresponding author. Tel.: +1 402 559 5691; fax: +1 402 559 6501. E-mail address: [email protected] (L.S. Nasir).
Patient education has been defined as a process that influences ‘‘the changes in knowledge, attitudes and skills necessary to maintain or improve health’’ [1]. Issues such as lifestyle change can only be addressed through effective patient education, and changing behavior is important since most leading causes of illness and death are due to unhealthy lifestyles. Additionally, patient education can improve selfcare by patients suffering from chronic disease resulting in substantial improvements in disease outcome. Patient education also improves patients’ understanding of their illness or condition. This enhances their ability to participate in the process of medical decision making, and strengthens the bond of trust between patient and health care provider [2]. For all these reasons, patient education is considered an integral part of high quality medical care. Effective patient education calls for a variety of skills, including the assessment of patient educational needs and barriers to learning. Printed materials powerfully supplement patient education, making additional information available without a larger time commitment [3]. When designing educational materials, it is important to be
0738-3991/$ – see front matter # 2004 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2004.12.006
L.S. Nasir, A.K. Nasir / Patient Education and Counseling 60 (2006) 142–145
familiar with the cultural issues that must be taken into account in order to align the health message with social norms, identify barriers to learning, and establish credibility with the target audience [4]. It is also important to produce materials which are easily understood by the target population by building on pre-existing concepts or knowledge if possible. Readability and literacy issues in the target population are also important. Although the literacy rate in Jordan is 93%, versus 97% for the United States, and the average years of schooling for Jordanians is 6.9 years, versus 12 years for American students [5], a pilot study we carried out showed excellent comprehension when Jordanian patients were given materials written in colloquial Arabic at approximately a sixth grade reading level. This level is similar to the recommended reading level for patient educational materials in the United States. Factors related to language may also contribute to a lack of health awareness in the population. While Arabic is an extraordinarily rich language, it lacks a commonly understood vocabulary describing many modern concepts in health and medicine. Modern terms borrowed from other languages are often unfamiliar to the average person. Exacerbating the problem is the fact that patient educational materials are often written in the more formal, though less easily understood classical Arabic, rather than the more widely understood but less scientific colloquial form. Most of the limited amount of patient educational material currently available is inaccessible to the average reader for this reason. In the Middle East, society tends to be conservative, hierarchical and family centered. The individual tends to be seen as part of a family, rather than as a separate entity. This cultural dynamic often results in the patriarch of the family or other authority figure making important health decisions for family members. Therefore, while writing the materials, we emphasized the role of family involvement and care in management of the condition, and the patients’ recovery. Religious sensitivities and beliefs are also central in importance when designing educational material for this population. The Muslim religion is the major shared experience of the population of Jordan. Christians also, are very familiar with Islamic tradition. Religious traditions have both positive and negative effects on health behavior, and it is important to take these beliefs into account when designing educational materials. It is generally accepted, for example, that all occurrences in an individual’s life are the result of God’s will. Therefore, although divine intervention is to be hoped for, the final result is not to be questioned, ‘‘. . .but you may hate a thing although it is good for you, and love a thing although it is bad for you. (God) knows, but you do not’’ [6]. Many individuals also believe in supernatural forces such as spirits and spells, and some believe that illness, and particularly family violence, addictions, and mental illness may be attributed to these forces [7].
143
2. Methods In the 2003–2004 academic year, the authors collaborated to develop and introduce patient educational materials for the primary care setting while one of them (L.N.) was teaching Family Medicine in Jordan on a Fulbright scholarship. The subjects chosen were common conditions seen in primary care. Although English language medical texts were used as references, the materials were written de novo in Arabic. Since both authors are bilingual in Arabic and English, back translation was not felt to be necessary. The subjects ranged from materials about major depression to the correct use of Warfarin. Copies of some of the materials developed are available from the authors (see Table 1). This paper highlights some of the topics that needed particular care in planning in order to meet the cultural needs and expectations of the region. We give examples of written educational materials we developed for smoking cessation, domestic abuse, diabetes and major depression. 2.1. Smoking cessation It has been estimated that 29% of all Jordanian adults, and 48% of adult males are smokers putting Jordan 32nd among 130 countries for which data is available [8]. Cigarettes are the most common form of tobacco consumption, but a substantial minority of smokers use an argeela (hubblebubble or water pipe) to smoke tobacco. Many people who use an argeela do not consider it to be ‘‘smoking’’. Factors that predispose the population to smoking include poor knowledge about the adverse consequences of smoking, cultural norms that encourage conformity, and the fact that many decision makers and role models are smokers. Cultural factors that discourage smoking include the fact that Islam discourages the use of tobacco as well as social norms that emphasize self-control and the protection of family. In developing this particular topic, we avoided explicit discussion of a shortened life expectancy for smokers, as most Muslims believe that ‘‘No one dies unless (God) Table 1 List of Arabic language patient education materials available from the authors Anemia in children Adult onset diabetes mellitus Anxiety Asthma Chickenpox Conjunctivitis (infectious) Cholesterol Depression Healthy diet (two versions) Hypertension Head lice Warfarin
144
L.S. Nasir, A.K. Nasir / Patient Education and Counseling 60 (2006) 142–145
permits. The term of every life is fixed’’ [9]. Therefore, referring to a shortened lifespan might prove controversial to some. Instead, we focused on the positive benefits of abstinence, including easier breathing, financial savings, foods tasting better, and avoidance of smoking-related disease. We also discussed the harmful effects of secondhand smoke on other family members, particularly children. 2.2. Depression Depression is highly prevalent in the developing world, and Jordan is no exception. It is thought that the increase in depression is due to increased urbanization and the social and lifestyle changes that accompany it. In the Middle East, as is the case with much of the developing world, mental illness is highly stigmatized. Depression, in particular, is seen as a moral failing; the hopelessness characteristic of the disease is considered by many to arise from a lack of faith in God. We felt that the best approach would be to clearly state that the disease is a ‘‘chemical imbalance in the parts of the brain in charge of a persons’ mood’’, in the first sentence, clearly categorizing it as being a condition out of his or her control. We gave prominent place to the fact that lack of faith or character weakness was not a factor in the development of depression, or with the inability to cope with its symptoms. When discussing prevention and treatment of depression we stressed the importance of increased social contact with family and friends because this type of mutual assistance is common and minimally stigmatizing in the context of the local culture [10]. Formal counselling with a mental health professional was mentioned briefly; it is not widely available and is considered to be the most stigmatizing. Finally, when discussing pharmacologic treatment, it was important to emphasize that the medications used in the treatment of depression are not habit forming; in the public mind any type of psychoactive drug is believed to be addictive.
with effective treatment, an individual with diabetes can live a normal life. 2.4. Domestic violence Little objective information about domestic violence exists in Jordan. ‘‘Honor killings’’ of women by male relatives for actual or perceived sexual indiscretion, while uncommon, only are the most visible manifestation of domestic violence. The subject of domestic violence remains a taboo subject in Jordan. Factors which make it difficult to address include traditions of strict family privacy, the cultural perception that women are subservient to men, and the perception that Islam allows men to physically discipline their wives in certain circumstances. Unfortunately, the current political climate has made the topic even more difficult to discuss dispassionately, due to the hardening of attitudes in some quarters towards ideas that are perceived to affect traditional social patterns. We decided that the best way to approach this sensitive topic was to write the educational material using gender inclusive language in order to take advantage of the strong cultural consensus that physical violence in general is improper. Emphasis was placed on the fact that violence is not the victim’s fault, but that this kind of violence typically is a learned behavior and may have its genesis in the abusers family of origin. Practical steps for the victim to take were discussed, including family mediation, which is the solution recommended by the Koran for recalcitrant marital difficulties. We also discussed other actions, such as informing supportive people of the abuse as soon as possible, and to make plans for leaving if the abuse escalates. We also elected not to include mention of sexual abuse in the materials, as in Arab culture sexual abuse is considered to be in an entirely separate and much more severe category of offence.
2.3. Diabetes mellitus
3. Introducing the materials
Diabetes mellitus is a major health problem in Jordan. It is estimated to affect 13.4% of the adult population [11], more than double the United States rate. Misconceptions about the causes, treatment and outcome of diabetes abound. Obesity is generally seen as a benign characteristic and is even encouraged in some quarters as a sign of good health. Lack of knowledge about the causes of diabetes and the efficacy of modern treatments put many at risk for the use of ineffective treatments such as traditional herbs or folk remedies such as diets supplemented with large portions of dried dates and honey, foods which some believe to have miraculous healing powers. We began by providing simple explanations of the causes of diabetes and the main types of medical treatments available. We also briefly reviewed diabetes self-care, diet, exercise, the importance of adherence to the prescribed regimen and reassurance that
Several unexpected barriers were found to exist in some settings when patient educational materials were introduced. These barriers were identified as physiciandependent and physician-independent. Physician dependent factors included a perception among many in the medical profession in Jordan that patients would not be interested in reading printed materials. Some physicians in Jordan have been trained in countries where patient education is not emphasized. These physicians may feel poorly prepared to educate patients. Additionally, practice styles among some physicians may emphasize the authoritarian medical model in their clinical interactions; among this group there may be an unconscious perception that educational materials detract from the physicians’ authority by allowing the patient greater control over his or her illness.
L.S. Nasir, A.K. Nasir / Patient Education and Counseling 60 (2006) 142–145
Patient reaction to the materials was positive overall. Older, illiterate patients were usually accompanied by an educated family member to whom the information could be given. The educational materials often sparked great interest and additional questions on follow up visits. The patient education materials were initially introduced at the Family Medicine outpatient clinics of the University of Jordan. Subsequently, selected materials were introduced in the Endocrinology clinics, and the Pulmonary Medicine clinics. A number of private physicians also used the patient materials. Feedback from physicians and interviews with patients suggested that the materials were found to be very useful, and contributed positively to patient care. We discovered that patients frequently share educational materials with family members and friends. Therefore, patient educational materials can be used by the health care provider to develop an alliance with the family, in part by encouraging family support and contributions to healthy behaviors. Feedback from patients and physicians also resulted in some modifications of the educational materials and in the choice of topics. For example, some physicians suggested topics requiring additional emphasis, or conditions that they saw frequently in their own practices (such as chickenpox or head lice). Little exists in the medical literature describing the development of patient educational materials in other parts of the Middle East, particularly material focused on primary care. It may be that more visible issues of access and quality have until recently obscured the need for written patient educational materials, or that issues in local medical culture as described above have made the development or introduction of such material difficult. Another important
145
issue is that although the Arab world shares a language and religion, culture and local dialect often differ sufficiently from one region to another that materials appropriate for one country or area may not be suitable in another. Although the provision and introduction of patient educational materials initially appeared to be successful, much work remains to be done in expanding and refining the materials, through more in-depth evaluations of the materials, such as focus groups, eliciting ongoing physician and patient feedback, and over time, integrating patient education into every medical consultation.
References [1] American Academy of Family Physicians. Patient Education. Am Fam Phys 2000;62:60–72. [2] Brody D. Promoting the development of doctoring competencies in clinical settings. Fam Med 2004;36:S105–9. [3] Monsivais D. Developing and evaluating patient education materials. J Cont Educ Nurs 2003;34:172–6. [4] Nationmaster.com: http://www.nationmaster.com/country/jo/Education. Accessed 10 August 2004. [5] Talbert R. Developing bilingual patient educational materials, problems and solutions. J Biocommun 1981;8:23–8. [6] The Koran. Fourth revised edition translated by NJ Dawood. New York: Penguin; 1987. Chapter 2, Verse: 216. [7] Al-Krenawi A. Explanations of mental health symptoms by the Bedouin-Arabs of the Negev. Int Social Psych 1999;45:56–64. [8] Nationmaster.com: http://www.nationmaster.com/country/jo/Health. Accessed 10 August 2004. [9] The Koran. Fourth Revised Edition. Translated by NJ Dawood. New York: Penguin; 1987. Chapter 3, Verse: 145. [10] Al-Krenawi A. Mental Health Service utilization Among the Arabs in Israel. Social Work Health Care 2002;35:577–89. [11] Ajlouni K. Diabetes and impaired glucose tolerance in Jordan: prevalence and associated risk factors. J Int Med 1998;244:317–23.