The Health Educator Community

Here we feature Notes in the Field where health educators can post their experiences for others to learn from. If you'd like to submit an essay for consideration please write 300 to 800 words, include your name and city, state and send to chec@healthletter.com We may edit for content and length.

Notes in the Field by you in the Health Educator Community:
Kathryn A.—Austin, Texas

I’ve been involved in a project that has given me the opportunity to visit many clinics across the country. My colleagues and I have been looking at the variety of ways these clinics address risk assessment for communicable diseases, particularly those transmitted sexually and through IV drug use. We’ve observed across a wide range of clinics, both community health centers and local health departments, and in acute and primary care settings, and in STD and family planning settings. You can imagine there was a wide range of practice and protocol in these clinics!

One common issue, however, stood out. Sexual risk assessment is difficult to do. People on both sides of a sexual risk assessment, the patient and the provider, either feared making the other uncomfortable or felt uncomfortable themselves. In truth, it’s difficult to imagine any other context in which it is socially acceptable to ask the questions asked in risk assessments. Some examples:  “how many partners have you had in the last six months,” or “does your partner have other partners?”

Our role as health educators was to develop training for clinic staff that would encourage and enable them to do more risk assessment, to help raise awareness among their patients and to provide education about hepatitis, a common and communicable disease. As the project progressed, I began to think of my job as a health educator a little differently than as a teacher of skills, though that too was part of the training we developed. I began to think of it as working to help change the clinic context

Here’s an example. The clinic is a perfectly understood and acceptable context for a physical exam, or a rectal or a pelvic exam. Patients may feel uncomfortable with these procedures—in fact, may not go to the doctor to avoid this discomfort—but probably they do not question that these are normal procedures and routines for the doctor’s office. Medical schools, acknowledging discomfort, teach ways to alleviate it, including explaining what is going to happen, and guiding the patient verbally through a physical procedure.

I’m not so sure, after many clinic visits, that risk assessments are an understood and acceptable part of a clinic routine, either for provider or patient. In order to be acceptable, the clinic—in particular, the exam room—needs to be a context in which the patient understands why the risk assessment questions are being asked and knows that these questions are appropriate and normal.

Imagine two different patients, with two different potential sources of discomfort. Patient A is secretly worried that she has been exposed to an STD like Hepatitis B.  But she is visiting the doctor for a physical exam required by work and she has no idea how to ask, and is embarrassed to reveal why she’s worried. 

Patient B, at the doctor’s office for flu-like symptoms, feels defensive.  He feels like the doctor suspects that he is the kind of person who has not been taking care of himself and is likely to give him a lecture. If the doctor asks risk assessment questions “out of the blue,” this patient suspects the doctor saw or heard something indicating a problem—maybe even “bad behavior.”

We worked to change the clinic context so that each of these patients feels more comfortable.  Here are two of our “context changers” or training tips. 

1. Have materials—posters and brochures—with information about communicable diseases in the clinic, visible and available to clients.

2.  Memorize a few opening lines that introduce and “normalize” your risk assessment questions.

How will these help ease the discomfort of asking risk assessment questions with Patient A?  In her case, the educational materials in the clinic may have already cued her into the idea that these topics are okay to talk about.  She may feel comfortable enough to bring them up on her own.  But if she isn’t, by asking, the provider also signaled that this topic is okay, this is an appropriate context to talk about her worries, and has done something for her that she may be afraid to do on her own. 

What about Patient B?  Again, in his case, having information about communicable diseases available in waiting rooms or exam may help him to understand that these are community health issues—“we are talking to everyone here.”  This message can be reinforced if the provider explains why he’s asking risk assessment questions. If the provider says, “We ask all our patients these questions because they help us to understand your general health better,” the patient understands that this is part of a clinic routine, and is less likely to feel singled out or judged by the provider.  The provider can acknowledge the difficulty and discomfort of the topic, and help guide the conversation, in much the same way as a pelvic exam is guided by verbal explanations to the patient.

In other words, having some opening lines, in which the provider “normalizes” the asking of questions about risks for communicable diseases, and having public and shared information about communicable diseases, helps to make them acceptable, routine topics of conversation in the clinic context.