Feature

A little information may be a little pointless

Labour’s health policy is placing increasing emphasis on promoting ‘self care’. But providing information on common ailments isn’t enough, say Timothy Milewa and Michael Calnan

The government and health authorities have put considerable effort into deterring ‘inappropriate’ use of general practitioner services by patients. The NHS Direct strategy, for example, will encompass telephone helplines, High Street information points and written advice.¹ This is in addition to a booklet on common ailments, distributed routinely to new mothers, and the large volume of patient education literature circulated locally by health authorities and general practices.^{2 3} But what do patients make of these booklets and leaflets? We spoke to 85 randomly selected residents in an area of outer London where a health authority was promoting one such free booklet – What Should I Do?⁴

Three factors in particular appeared to influence the how patients see and respond to such literature.⁵ First, understandings of bad health – as a trigger for a visit to the doctor – varied markedly. Most conceptions of bad health fell into just three categories: about 41% of people identified bad health only with the presence of illness, just over 30% linked bad health only to an inability to perform normal tasks while 3.5% referred only to the absence of a feeling of well-being.⁶

[Bad health’s] not feeling fit and well…just sort of constantly going down with things, bugs and just generally feeling unwell a lot of the time.

The definition of bad health is someone who can’t carry out a full-time occupation, someone that has to be careful about their diet, someone who has to be careful to not be too enthusiastic about too many things (in other words using up to much energy).

When you can’t be bothered to do much, you’re not interested in much. You don’t want to go nowhere, you don’t want to do nothing - you just want to sit there and feel miserable until you gradually pull yourself round. And it’s down to you to pull yourself round as well.

Second, self-referral was often justified in terms beyond purely medical need. Reassurance, perhaps following earlier illness or the ailments of friends and relatives was typically regarded as a justifiable rationale. Similarly, mention was also made of the role consultations played in alleviating loneliness among some older people.

I think they would just need to know their ailments are not serious. If you have no idea what’s happening to you I think it can be very upsetting for some people and they get very anxious. Even if you deep-down know you will get better and it’s a very short-term illness I think people do like to know that – have that confirmed.

Some people like attention – if they’re sick people attend to them and feel sorry for them. And if they go to a doctor and talk to other people they feel happier; it helps them feel happier if someone is looking at them and giving them attention.

Third, a substantial minority of people placed little value on ‘educational’ booklets. Of the 33% of interviewees who possessed no written advice nearly all were able to offer reasons for not keeping booklets like What Should I Do?. In this group, the publications were linked to hypochondriasis, the risk of misdiagnosis or statements of the obvious.

I’m sure I’d be a hypochondriac if I had one of those [booklets]…People I know who’ve got them look at them even when their child’s not ill or even when they’re not ill and then start possibly misjudging symptoms.

I’ve never found them particularly useful really. I’ve looked at them but I think it’s more common sense really.

Such perceptions of written advice have an immediate implication for the informational approach at the heart of NHS Direct and more local campaigns such as that associated with What Should I Do?. Written advice, however clear and evidence-based, does not necessarily ‘sell’ itself to the intended readership. Official perceptions of inappropriate consultation fail to take account of the breadth of reasons people have for visiting their doctor. These include different definitions of bad health, the need for reassurance and ‘preventative maintenance’.

So information campaigns should, where practical, reflect deficiencies identified by local communities or patient groups in addition to the ‘educational’ objectives defined by professionals. Standard approaches to local needs assessment – by health authorities, primary care groups or social services departments – might be expanded to include a focus upon information needs as well as health and social care requirements. This bottom-up approach could be used to supplement and focus the medically driven advice on self-referral and self-care central to information campaigns.