Lecture Concept of Health /Health Literacy and Shared decision making 2025.ppt

10/28/25 Prof Muhammad Tauseef Jawaid 2

HEALTH AND DISEASE
HEALTH AND DISEASE
Prof. Dr Muhammad Tauseef
Prof. Dr Muhammad Tauseef
Jawaid
Jawaid

Health and disease
Health and disease –
– two essential categories
two essential categories
of medicine
of medicine
Definition of health
Definition of health
 Health
Health is
is defined as a
defined as a state of optimal physical,
state of optimal physical,
mental, and social well-being
mental, and social well-being and not merely
and not merely
the
the absence of disease
absence of disease and
and infirmity
infirmity
(according to W.H.O.)
(according to W.H.O.)
 Health can be defined as a
Health can be defined as a „
„state
state“
“ of the
of the person
person
who is able to meet the demands placed on
who is able to meet the demands placed on
his/her
his/her body
body and to
and to adapt to these demands or
adapt to these demands or
changes of
changes of the
the external
external environment
environment so
so as
as to
to
maintain reasonable constancy
maintain reasonable constancy of
of the
the internal
internal
environment
environment

 There
There is
is way of
way of measuring health in a negative
measuring health in a negative
sense.
sense. It is
It is measure
measured
d by
by the
the "5 d
"5 d
s" - death, disease,
s" - death, disease,
discomfort, disability, and dissatisfaction
discomfort, disability, and dissatisfaction.
. If there is
If there is
absence of 5 d
absence of 5 d‚
‚s we can say that person is healthy
s we can say that person is healthy
●
● In health there is freedom. Health is the first of
In health there is freedom. Health is the first of
all liberties
all liberties!
!
●
● Holistic
Holistic view
view to a health
to a health recogni
recogniz
zes the
es the inter
inter
relatedness of the
relatedness of the physical, psychological, emotional,
physical, psychological, emotional,
social, spiritual,
social, spiritual, and environmental factors
and environmental factors that
that
contribute to the overall quality of a person
contribute to the overall quality of a person
s life
s life

Two aspects of health can be distinguished:
1) Subjective – it is formed by sensations and feelings
of a person, e.g. high working capacity, ability to
overcome problems, optimistic thinking, happiness,
satisfaction...
2) Objective – its basis is formed by objective
parameters obtained by measurement of
strutures and functions of a person
Subjective and objective aspects of a health can differ
e.g. – Man with  systemic BP can feel healthy
Oposite – Man can feel ill despite no measurable changes of
structure and/or functions can be find

Positive cosequence of WHO definition of health:
– change of health care phylosophy
Classik phylosophy:
Diseased person  doctor  diagnosis  therapy
Modern phylosophy
healthy person
health promotion
health protection
prevention of disease
onset and development

Two dimensions of health according Nordenfeld (1986)
Scientistic = atomistic-biological dimension of health
- quantitative dimension of life
Non-scientistic = holistic-humanistic view on health
- rather qualitative dimension of life
- seeing health as the totality
seeing health as the totality of a person
of a person
s existence
s existence
Summary: ● health is defined by set of objective, measurable
parameters of structure and functions of the body
● health is defined also by set of subjective
parameters expressed by healthy person


 Positive wellness involves:
Positive wellness involves:
1. being free from symptoms of disease and pain
1. being free from symptoms of disease and pain
as much as possible;
as much as possible;
2. being able to be active - able to do what you
2. being able to be active - able to do what you
want
want
and what you
and what you have to do
have to do at the appropriate
at the appropriate
time;
time;
3. being in good spirits most of the time
3. being in good spirits most of the time

Concept of normalcy
Concept of normalcy
Norm
Norm (normal,
(normal, within the norm) = parameters or values
within the norm) = parameters or values
ranging
ranging from
from -
- to
to of bodily or
of bodily or mental
mental functions or
functions or
quantitative measur
quantitative measure
ements of biological
ments of biological indexes derived
indexes derived
statistically
statistically from
from "healthy
"healthy persons" of the specific
persons" of the specific g
group
roup
(
(hight
hight, body mass, heart
, body mass, heartrate
rate, respiration
, respiration rate
rate,
, blood
blood pressure
pressure,
,
body temperature, etc.)
body temperature, etc.)
Norm
Norm 
 H
Health
ealth; Health
; Health =
=Norm
Norm
Health –
Health – it is more qualitative term
it is more qualitative term
Norm –
Norm – it is more quantitative term
it is more quantitative term
Normal parameter – parameter presents most
Normal parameter – parameter presents most
frequently in healthy population
frequently in healthy population

Interindividual variability:
– each person has its own profile of structures and
functions, and almost each person is extreme in some
of
sign, and in different one
– in population is created by influence of many factors:
a) internal – mainly genetic
b) external – physical, chemical, biological, social...
– can be one explanation for different level of health in
different people, and different proneness to disease

Definition
Definitions
s of disease
of disease
 D
Disease
isease can be defined
can be defined as a
as a biosocial phenomenon
biosocial phenomenon
characterized
characterized by
by interactions of pathological
interactions of pathological
processes,
processes, defensive and adaptation processes
defensive and adaptation processes
resulting in
resulting in damage of the organism
damage of the organism as a whole
as a whole,
, in
in
limitation of the organism ability to adapt to
limitation of the organism ability to adapt to
living
living condition.
condition.
 Disease can be defined as a
Disease can be defined as a changes in individuals
changes in individuals
that cause their
that cause their health parameters to fall outside
health parameters to fall outside
the range of
the range of normal
normal
 The term disease means a
The term disease means a deviation from or an
deviation from or an
absence
absence of the normal state
of the normal state

The essential aspects of disease
The essential aspects of disease
1.
1. disease is a
disease is a new quality of life
new quality of life
Health is a friedom, disease is a prison
Health is a friedom, disease is a prison
2. disease is the
2. disease is the result of one or more causes
result of one or more causes
(noxas) and
(noxas) and suitable conditions
suitable conditions
3. disease is the
3. disease is the unity of damaging, adaptive,
unity of damaging, adaptive,
defensive and compensation mechanisms
defensive and compensation mechanisms

A picture of diseaase is created by:
– pathologic reactions
– pathologic processes
– pathologic states
Pathologic reaction
- It is the most simple, mainly short-lasting,
quantitativly and/or qualitativly non-adequate
response of organisms to some noxa
Examples: syncopa, short-lasting increase of BP,
tachycardia, bradycardia, vomiting,
diarhoe, hyperventilation ...

Pathologic process
It is the complex of pathologic and defensive-
- adaptive reactions induced by influence of noxa
on organism
Examples: inflammation, fever, hypoxia, growth
of tumor, edema, acidosis, alkalosis...
Pathologic state
Pathological change which is stabile or it changes
very slowly and in very small range during time period
Examples: congenital valvular heart disease, deafness,
blindness, colour blindness...

Dynamics of disease
Disease is a definite morbid process h
Disease is a definite morbid process ha
av
ve
ein
ing
g
a characteristic train of symptoms and signs
a characteristic train of symptoms and signs
Dynamics of disease is characterized by
stages of disease:
1st stage:
1st stage: latent – incubation
latent – incubation (in infections diseases
(in infections diseases)
)
Its duration is measured by time passed between
Its duration is measured by time passed between
beginning of noxa influence of body and beginning
beginning of noxa influence of body and beginning
of first non-specific symptoms and signs of disease
of first non-specific symptoms and signs of disease
There are no manifestations of disease during this stage
There are no manifestations of disease during this stage
2nd stage:
2nd stage: prodromal
prodromal
First non-specific symptoms and signs of disease arise
First non-specific symptoms and signs of disease arise

3rd stage: manifestation of disease
There are specific symptoms and signs characteristic for
specific disease
4th stage: disease outcomes
a) healing and convalescence
b) chronic disease
c) death
Forms of healing:
- restitutio or sanatio ad integrum
- sanatio per compensationem

Time course of disease
Time course of disease
a)
a) Peracute – onset during few seconds or minutes
Peracute – onset during few seconds or minutes
b)
b) Acute – onset during hours and days, duration up
Acute – onset during hours and days, duration up
to
to
3 weeks
3 weeks
a)
a) Subacute
Subacute –
– duration up to
duration up to 6 weeks
6 weeks
b)
b) Chronic – duration more than 6 weeks
Chronic – duration more than 6 weeks
Exacerbation of disease – usually sudden increse
intensity
of symptoms and signs of
chronic disease
Recidivation of disese – returning of previosly healed
disease
Remision of disease: decrese intensity of simptoms
and signs of disease

ILLNESS AND DISEASE
ILLNESS AND DISEASE

 It is more important to know
It is more important to know what sort of patient
what sort of patient
has a disease, than what sort of disease a patient has
has a disease, than what sort of disease a patient has

 A person may "feel ill" without a disease being evident or
A person may "feel ill" without a disease being evident or
diagnosed;
diagnosed; likewise, a person may have a disease without
likewise, a person may have a disease without
experiencing any illness or suffering
experiencing any illness or suffering

 Illness
Illness tends to be used to refer to
tends to be used to refer to what is wrong with
what is wrong with
the patient, disease to what is wrong with his body
the patient, disease to what is wrong with his body
●
● Illness
Illness is what the patient suffers from, what troubles
is what the patient suffers from, what troubles
him, what be complains of, and what prompts him to
him, what be complains of, and what prompts him to
seek medical attention
seek medical attention

●
● When we say "a person is ill " we mean he feels
When we say "a person is ill " we mean he feels
uncomfortable, he is suffering from certain symptoms
uncomfortable, he is suffering from certain symptoms
such as nausea, headache, abdominal cramps, or just
such as nausea, headache, abdominal cramps, or just
fatigue that can
fatigue that can'
't be explained on the
t be explained on the basis of exertion
basis of exertion
●
● Disease refers to various structural disorders of the
Disease refers to various structural disorders of the
individual
individual
s tissues and organs that give rise to the signs
s tissues and organs that give rise to the signs
of ill - health
of ill - health


 The principal factors accounting for nearly all
The principal factors accounting for nearly all
diseases are:
diseases are:
1. heredity - inherited (genetic
1. heredity - inherited (genetic)
) diseases,
diseases,
2. infectious organisms - infectious diseases,
2. infectious organisms - infectious diseases,
nosocomial disease
nosocomial disease
3. lifestyle and personal habits - lifestyle
3. lifestyle and personal habits - lifestyle
diseases
diseases
4. accidents
4. accidents
5.
5. physical, chemical noxas (
physical, chemical noxas (poisons and
poisons and
toxi
toxins)
ns)


 Most standard medical textbooks attribute anywhere
Most standard medical textbooks attribute anywhere
from 50 to 80% of all disease to
from 50 to 80% of all disease to psychosomatic or
psychosomatic or
stress-related origins
stress-related origins
Examples of psychosomatic diseases:
Examples of psychosomatic diseases:
- peptic ulcer, essential hypertension, bronchial asthma,
- peptic ulcer, essential hypertension, bronchial asthma,
hyperreactive thyroid, rheumatoid arthritis, ulcerative
hyperreactive thyroid, rheumatoid arthritis, ulcerative
colitis
colitis.....
.....
P
Partially or wholly psychosomatic disorders:
artially or wholly psychosomatic disorders:
hay fever, acne, diarrhea, impotency, warts, eczema,
hay fever, acne, diarrhea, impotency, warts, eczema,
tinnitus, bruxism (grinding of teeth), nail biting,
tinnitus, bruxism (grinding of teeth), nail biting,
tension headaches, back pain, insomnia
tension headaches, back pain, insomnia.....
.....


 Psychosomatic illness are caused by
Psychosomatic illness are caused by negative mental
negative mental
states
states and attitudes
and attitudes that harmfully change
that harmfully change the
the
physiology
physiology
 Psychosomatic illness are real
Psychosomatic illness are real - as real as appendicitis
- as real as appendicitis
or pneumonia
or pneumonia
 Placebo effect
Placebo effect = the healing that results from a
= the healing that results from a
person
person
s
s
belief in substances or treatments that have no
belief in substances or treatments that have no medical
medical
value in themselves
value in themselves

 The power of healing does not reside so much
The power of healing does not reside so much
in the healer as in the belief of the patient
in the healer as in the belief of the patient.
.
The cures that results from placebo effects sometimes
The cures that results from placebo effects sometimes
seem miraculous but actually are caused by physiological
seem miraculous but actually are caused by physiological
changes brought about by peoples
changes brought about by peoples
 beliefs and mental
beliefs and mental
states.
states. The mind is healer
The mind is healer!!!
!!!


 In nature there are neither rewards nor
In nature there are neither rewards nor
punishments - only consequences
punishments - only consequences

 All manifestations of human disease are the
All manifestations of human disease are the
consequence of the interplay between body,
consequence of the interplay between body,
mind, and environment
mind, and environment
Relation: disease - punishment

Topics today
• Definitions of literacy and health literacy
• Why it matters
• Current trends
• Resources

What is Literacy?
National Assessment of Adult Literacy (NAAL
2003)
“Using printed and written information to
function in society, to achieve one's goals, and
to develop one's knowledge and potential.”

Definition of literacy in Pakistan
• 1998 Census.
• The definition of literacy in Pakistan has
evolved to mean the ability to read and
understand a simple text, write a simple
letter, and perform basic math
calculations (counting and
addition/subtraction) in any language.

Current definition (since 2017
census)
• Ability to read and understand simple
text: This can be from a newspaper or magazine.
• Ability to write a simple letter: Individuals must
be able to write a simple letter in any language.
• Basic numeracy skills: The ability to perform
basic mathematical calculations, such as counting
and addition/subtraction, is now a requirement.

What is Literacy?
• Literacy is a combination of skills:
– Verbal Listening
– Reading Writing
– Numeracy
– Critical analysis

More than just reading grade level
• Prose Literacy
– Written text like instructions or newspaper article
• Document literacy
– Short forms or graphically displayed information
found in everyday life
• Quantitative Literacy
– Arithmetic using numbers imbedded in print

What is Health Literacy?

Empowerment
Shared decision making
Participation in care

Calgary Charter, 2008
“Health literacy allows the public and
personnel working in all health-related
contexts to find, understand, evaluate,
communicate, and use information. “
centreforliteracy.qc.ca/health_literacy/calgary_charter

Health Literacy Includes:
• Finding health information
• Understanding it
• Evaluating it
• Communicating it
• Using it…acting on it…to live longer and better!

Latest HL Concept? A Quiz:

Two Sides to the Equation

People (Info-seekers) need to learn
to:
• Find health information
• Understand it
• Evaluate it
• Communicate their needs and questions
• Use what they learn…act on it…to live healthier!

The Info-givers need to learn to:
•

In Their Own Words
• Insert video clip here

So What?
• Who’s at risk?
• What happens?

2003 National Assessment
of Adult Literacy
• NAAL health literacy assessment
• 28 questions specifically related to health
– 3 clinical
– 14 prevention
– 11 system navigation

2003 National Assessment
of Adult Literacy
• 4 categories of literacy
– Below basic
– Basic
– Intermediate
– Proficient

NAAL Health Literacy Assessment
• Below Basic literacy – one piece of information
• Can:
– Sign name on a document
– Identify a country in a short article
– Total a bank deposit slip

• Below Basic literacy – one piece of
information
• Cannot:
– Enter information on a social security card application
– Locate an intersection on street map
– Calculate the total cost on an order form

• Basic literacy – two related pieces of
information
• Can:
– Identify YTD gross pay on a paycheck
– Determine price difference between tickets for 2 shows

• Basic literacy – two related pieces of information
• Cannot:
– Use a bus schedule
– Balance a check book
– Write a short letter explaining error on a credit card bill

Health literacy of U.S. Adults
12% 14%
22%
52%
Below Basic
Basic
Intermediate
Proficient
(NAAL, 2003)
88% of U.S. Adults below Proficient level
That is nearly 9 out of every 10 adults!
~ Andrew Pleasant, Canyon Ranch Institute
PLUS: 3% could
NOT be tested

• Basic and Below Basic by
Self-reported health status
– Excellent 25%
– Very Good 28%
– Good 43%
– Fair 63%
– Poor 69%

The Impact of Low Literacy on Health
 Poorer health knowledge
 Poorer health status
 Higher mortality

The Impact of Low Literacy on Health
 Increased hospital use
 Increased Emergency Department use
 Mixed results for:
 Use of preventive services
 Chronic health care
 Tobacco use

Where do we go from here?
Vision:
Every patient or their caregiver
understands what the health issue is,
what to do about it and why it’s
important.

How do we get there?
• Education
• Effective Communication
• Universal Design
– If it works for people with limited literacy or
limited English skills, it will work for everyone.

Re-Designing What We Do
• Someone takes ownership of Health Literacy
– Grass roots
– Leadership buy in = resources : people and $
• Infuse health literacy concepts in new programs
and redesign of current materials and processes

Trends: What People are Doing
• Research and Interventions
• Prescription labeling
• Integrating health literacy into
medical education

Trends: What People are Doing
• Policy initiatives
• Regional health literacy efforts
• National health literacy association
• Effective communication

Research and Interventions
• Literacy research in medicine only goes back
about 25 years
• Research idea to published article:
Foundation funding: 2-3 years or more
Federal funding: 5-9 years
• Interventions are just starting to be tested

Why are Literacy Programs a good
venue to address health literacy?

Partnerships Between Literacy &
Health Organizations
Health curricula in literacy/English classes
Guest speakers from local health centers
Mini exams from nursing students
Health fairs


Newer Partnerships
Student navigation assessments for hospitals
Students testing written materials
Teachers advising health care providers
Teachers and students consulting to health programs


Newer Partnerships
• Statewide and multi-state coalitions
• Cross referrals
• Dual Projects



Adult Education Jargon
• ABE = Adult Basic Education
• ASE = Adult Secondary Education
• ESL = English as a Second Language
• ESOL = English for Speakers of Other
Languages
• ELL =English Language Learners

What can YOU do?
• Learn more
• Find partners
• Start re-designing
–Processes
–Forms and other documents
–Curricula and training

Rights AND RESPONSIBILITIES OF
PATIENTS AND DOCTORS

Prof Umar’s model of clinically oriented
integrated Lecture
First Year MBBS
Core subject 90%
≈ 11-12 slides
Horizontal integration
( Same year subjects)
Anatomy, Biochemistry,
Physiology
0%
Vertical Integration
(Basic sciences subjects of
different years(Forensic
Medicine, Pharmacology,
Community medicine
0%
Vertical Integration
Clinical Subjects (Medicine,
Surgery, Gynae/Obs etc)
0%
Longitudinal/ ongoing
integration ( Bioethics,
Research, Artificial
Intelligence, Family
Medicine
10%
≈ 2 slides

Learning Outcomes
At the end of the session the participants should be
able to
• Understand the rights and responsibilities of
doctors
• Understand the rights and responsibilities of
patients
• Analyze critical situations/ challenges in
clinical practice to solve clinical problems

• The basis of the unique relationship between doctor and
patient is the capacity of the doctor to appreciate the
complexity of human behavior.
• A doctor must be sensitive to the effects of history, culture,
and environment on his patients. At the center of this
therapeutic relationship is the trust that a patient has in the
doctor,
• This trust is built on the unconditional positive regard that
the doctor holds for the patient, irrespective of their gender,
social class, caste, color or creed.
Core Concept
Doctor-Patient Relationship

Core Concept
Rights of a Patient

Responsibilities of the Patients
• Know their own medical history including
medications taken
• Keep appointments or advise / inform those
concerned if they are unable to do so.
• Comply with the treatment advised / supplied.
• Inform the doctor if they are receiving treatment
from another health professional
• Know how their charges of treatment are best
covered.
• Conduct themselves in a manner which will not
interfere with the welt-being or rights of other
patients or staff.

Rights of the Doctor

Responsibilities of Doctor

The impact of artificial intelligence on the person-centred, doctor-patient
relationship: some problems and solutions
Aurelia Sauerbrei et al.
Published: 20 April 2023
Volume 23, article number 73
• This study explores the impact of artificial
intelligence (AI) on empathy, compassion, and
trust in doctor-patient relationships.
• It highlights the need for AI to be used in an
assistive role and for medical education to adapt
accordingly.
• The authors emphasize intentional efforts to
ensure AI supports, rather than undermines,
person-centered care.
https://link.springer.com/article/10.1186/s12911-
023-02162-y
Longitudinal Integration

• The principle of confidentiality is the ethical obligation of
physician to preserve the information gathered in association
with patient care.
The patient needs to be able to trust the physicians, will protect
the information shared in confidence.
It is worth emphasizing that, confidentiality can be breached in
few cases, to other healthcare personnels for patient care,
patient can harm oneself or others or required by law.
Confidentiality
Longitudinal Integration

MCQ
1. A 45-year-old patient with hypertension refuses to take
his prescribed medication, stating that he prefers herbal
remedies. The doctor believes this will negatively impact
his health. What is the doctor’s ethical responsibility in this
situation?
A) Force the patient to take the medication for their own
benefit
B) Respect the patient’s autonomy but provide information
on the risks of not taking the medication
C) Stop treating the patient as they are non-compliant
D) Prescribe an herbal remedy instead to satisfy the patient
Answer: B

MCQ
A 30-year-old woman requests a medical procedure
that the doctor believes is unnecessary and may pose
risks to her health. What is the doctor’s ethical
responsibility?
A) Perform the procedure because the patient has the
right to request it
B) Refuse the procedure without explanation
C) Explain the risks and benefits and decline if it is not
medically justified
D) Proceed with the procedure to maintain a good
doctor-patient relationship
Answer: C

MCQ
3. A patient undergoing surgery insists that only a male doctor
perform the procedure due to cultural beliefs. The hospital has only
female surgeons available. What should be the doctor's response?
A) Insist that the patient undergoes surgery with the available
doctor, as it is medically necessary
B) Respect the patient’s cultural beliefs and try to arrange for a
male surgeon if possible
C) Refuse to treat the patient since they are being unreasonable
D) Inform the patient that they must sign a consent form
acknowledging they are declining treatment due to personal
preference
Answer: B

Shared Decision-Making
In this section of the lesson, we will define
shared decision-making and discuss ways to
assess patient’s willingness and ability to be
involved in the treatment planning process.

Learning Objectives
After completing this lesson, you will be able to:
•Encourage active participation by the patient in decision-making and explain choices or rights
to the patient in a patient-centered manner
•Assess patient desire and capacity to be involved and responsible in the decision-making
process
•Determine patient preferences and priorities for treatment
•Identify strategies to assist patients in discussing preferences and priorities with clinician
•Support the patient in the decision-making process in alignment with desired level of
engagement
•Describe a treatment plan
•Assess barriers to patient adherence to the plan
•Develop a plan with the patient for addressing adherence challenges
•Identify self-management and health promotion resources

What is Shared Decision-Making?
“A process in which patients are involved as active partners
with the clinician in clarifying acceptable medical options and
in choosing a preferred course of clinical care.”
Improved
Sources: Sheridan et al. 2004; Fraenkel et al. 2007

Elements of Shared Decision-Making

Encouraging Patient Participation in
Shared Decision-Making
Source: Epstein et al. 2007

Discussing Treatment Preferences
and Priorities
• Do you have any religious beliefs? If so, how do those impact your
care? What about spiritual beliefs?
• How do you like to learn new information? (Give examples of visual,
auditory and kinetic learning styles)
• How much information would you like to have about your particular
disease or treatment?
• What is the best way to communicate with you?
• Is there anyone else you would like to be involved in your care, like a
friend, family member or religious/spiritual advisor?
• What do you do to take care of yourself? How can our team support
you in taking care of yourself?

Assessing Desire for Decision-
Making
Sources: Beagley. 2011; Coulter et al. 2008

Checkpoint
Which of the following impacts a patient’s
capacity for shared decision-making?
a)Health literacy
b)Language
c)Physical condition and environment
d)Learning style
e)All of the above

Assessing Capacity for Decision-
Making
Sources: U.S. Department of Health and Human
Services. n.d.; Nielsen-Bohlman et al. 2004; Beagley.
2011; Kutner et al. 2006

Assessing Health Literacy
Clues that Your Patient May Have Low Health Literacy
“I forgot my glasses today,
could you read that for
me?”
Source: Cornett. 2009

Limited English Proficiency (LEP)
• Struggles with communicating in English
• Interpreter services are required by law and policy guidance:
- Title VI of the Civil Rights Act of 1964
- HHS Policy Guidance on the Prohibition Against National Origin Discrimination
as it Affects Persons With Limited English Proficiency
- DOJ Guidance to Federal Financial Assistance Recipients Regarding Title VI
Prohibition Against National Origin Discrimination Affecting Limited English
Proficient Persons
- Culturally and Linguistically Appropriate Services Standards for Health Care
- Executive Order 13166
- Strategic Plan to Improve Access to HHS Programs and Activities by Limited
English Proficiency Persons
Sources: U.S. Department of Health and Human Services. n.d.; National
Council on Interpreting in Health Care. n.d

What is your patient’s learning style?
• Visual (pictures, charts, videos)
• Auditory (verbal information)
• Read or write (written words)
• Kinesthetic (hands-on learning)
Sources: Beagley. 2011; Inott et al. 2011; Fleming et al. 1992

Supporting Patients in the Decision-
Making Process

Treatment Plans and Self-Management
This next section of the lesson explores
treatment plan adherence, or whether patients
follow the plan. We will identify ways that
patient navigators can help patients to follow
their treatment plans as well as support their
patient in self-management of their condition.

Discussing Treatment Preferences
and Priorities
• Understand what patients need to make
informed decisions
• Coordinate with clinicians
• Use decision aids and tailored information
• Communicate effectively
• Return to the 5As (Ask, Assess, Advise, Assist,
Arrange)

Treatment Plan
Source: Balogh et al. 2011
- Care
coordination
- Addressing
barriers

• Fail to fill prescriptions due to
- Feeling that the medication wasn’t necessary
- Unable to afford the medication
- Not wanting to take the medication
- Not believing the medication would be effective
• Not wanting to change their behavior
• Wanting to avoid the side effects of treatment
• Disbelief about the severity of their condition
• Feeling too busy or too stressed to follow the treatment plan
• Feeling incapable of changing their behavior
• Uninvolved in treatment plan creation
Barriers to Treatment Plan Adherence

Addressing Challenges to Adhering to
the Treatment Plan

Self-Management
Increased/
Improved
Decreased

Self-Management
Taking the actions necessary to live well and manage chronic
conditions
Sources: Adams et al. 2004; Pearson et al. 2007

Self-Management and Health
Promotion Resources

Conclusion
In this lesson you learned to:
• Encourage active participation by the patient in decision-making and
explain choices or rights to the patient in a patient-centered manner
• Assess patient desire and capacity to be involved and responsible in the
decision-making process
• Determine patient preferences and priorities for treatment
• Identify strategies to assist patients in discussing preferences and priorities
with clinician
• Support the patient in the decision-making process in alignment with
desired level of engagement
• Describe a treatment plan
• Assess barriers to patient adherence to the plan
• Develop a plan with the patient for addressing adherence challenges
• Identify self-management and health promotion resources

References
• Adams, K. G., Greiner, A. C., & Corrigan, J. M. (Eds.). (2004). Committee on the crossing the quality chasm: Next steps
toward a new health care system. The 1st annual crossing the quality chasm summit: A focus on communities.
Washington(DC): National Academies Press. ISBN: 0 309 09303 1.
‐ ‐ ‐
• Balogh, E. P., Ganz, P. A., Murphy, S. B., Nass, S. J., Ferrell, B. R., & Stovall, E. (2011). Patient centered cancer treatment
‐
planning: Improving the quality of oncology care. Summary of an Institute of Medicine workshop. Oncologist, 16(12):1800‐
5. doi: 10.1634/theoncologist.2011 0252.
‐
• Beagley, L. (2011). Educating patients: Understanding barriers, learning styles, and teaching techniques. Journal of
PeriAnesthesia Nursing, 26(5):331 337. doi: 10.1016/j.jopan.2011.06.002.
‐
• Butterworth, S. W. (2008). Influencing patient adherence to treatment guidelines. Journal of Managed Care Specialty
Pharmacy, 14(6 Suppl B):21 24. doi:
‐ 10.18553/jmcp.2008.14.S6-B.21
• Cornett, S. (2009). Assessing and addressing health literacy. The Online Journal of Issues in Nursing, 14(3):Manuscript 2.
doi: 10.3912/OJIN.Vol14No03Man02.
• Coulter, A., Parsons, S., & Askham, J. (2008). Where are the patients in decision making about their own care
‐ .
http://www.who.int/management/general/decisionmaking/WhereArePatientsinDecisionMakin g.pdf.
• Epstein, R. M., & Street, R. L. Jr. (2007). Patient centered communication in cancer care: Promoting healing and reducing
‐
suffering. National Cancer Institute, NIH Publication No. 07 6225. Bethesda, MD.
‐
• Fleming, N. D., & Mills, C. (1992). Not another inventory, rather a catalyst for reflection. To Improve the Academy, 11:137‐
155.

Evidence-Based Clinical
Decision-Making
• Integrating Evidence, Expertise, and Patient
Values
• Presented by: Dr. Muhammad Tauseef
Javed
• Department of Community

Learning Objectives
• By the end of this session, students will be able to:
• 1. Define evidence-based clinical decision-making
(EBCDM).
• 2. Describe the three key components of EBCDM.
• 3. Explain the steps in applying EBCDM.
• 4. Recognize the importance and benefits of
EBCDM in patient care.

What is EBCDM?
• Definition:
• “The conscientious, explicit, and judicious
use of current best evidence in making
decisions about the care of individual
patients.” (Sackett et al., BMJ, 1996)
• In essence: Combine best evidence + clinical
expertise + patient preferences.

The Three Pillars of EBCDM
• 1. 🧠 Best Research Evidence – from
clinical studies, guidelines, and systematic
reviews.
• 2. Clinical Expertise – skills and past
‍
⚕️
‍
️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️
‍
⚕️ ‍
⚕️
experience of the clinician.
• 3. Patient Values & Preferences –
❤️
patient’s needs, beliefs, and expectations.

Steps in EBCDM (The 5 A’s)
• 1. Ask – Formulate a clinical question (PICO).
• 2. Acquire – Search for relevant evidence.
• 3. Appraise – Critically evaluate evidence
quality.
• 4. Apply – Integrate with expertise and patient
values.
• 5. Assess – Evaluate outcome and learning.

Example – Applying EBCDM
• Clinical Scenario:
• A 50-year-old hypertensive male visits your clinic.
• Decision Process:
• • Evidence: Studies show ACE inhibitors reduce
morbidity and mortality.
• • Expertise: Doctor confirms normal kidney function.
• • Patient Preference: Prefers once-daily oral medication.
• Final Decision: Start ACE inhibitor + lifestyle counseling.

Content

What is Evidence-Based Practice?
• Scientific
Research &
Theory
• Client’s
Contribution
• RD Practice
Experience and
Wisdom
Evidence
Effectively
integrating
evidence into
dietetic practice.
Practic
e
Ensuring
public safety
and client-
centred
services
Public
Section
I

“Evidence-based decision-making
refers to making decisions that affect
[client] patient care based on the best
available evidence”

“Evidence-based practice is using
the best evidence to balance
anticipated benefits and risks to
support decisions for optimizing
client-centred services.“

Scienc
e
+ RD
Practice
+ Client
Input

Section II
Evidence-Based Practice in Changing
Environments.
• Scientific
Research &
Theory
• Client’s
Contribution
• RD Practice
Experience and
Wisdom
Evidence
RD professional &
regulatory
obligations for EPB
including keeping
current, self-
assessment and
professional
development.
Practic
e
EBP ensures
public safety
and client-
centred
services
Public

Evolvin
g
Changin
g
Advancin
g

Self-
Assessment
Continuing Education
Professional
Development
Regulated Health
Professions Act Quality
Assurance Regulation

Importance of EBCDM
A. Improves quality and consistency of care.
B. Promotes rational and cost-effective
practice.
C. Reduces medical errors.
D. Encourages shared decision-making with
patients.
E. Strengthens lifelong learning.

Challenges in Practicing
EBCDM
• • Limited time for literature search.
• • Difficulty appraising research quality.
• • Access issues to databases or journals.
• • Resistance to change or reliance on
traditional practice.

Strategies to Promote EBCDM
• • Teach EBP skills early in medical
education.
• • Encourage journal clubs and case
discussions.
• • Use evidence-based clinical guidelines.
• • Foster a culture of inquiry and reflection.

Reflective Questions

Section III
Integrating Evidence into clinical Practice
• Scientific
Research &
Theory
• Client’s
Contribution
• RD Practice
Experience and
Wisdom
Evidence
The 5-Step EBP
Model for RDs helps
integrate evidence
into clinical
practice.
Practic
e
EBP ensures
public safety
and client-
centred
services.
Publi
c

Clien
t
Step
1
ASK
Step 2
ACCES
S
Step 3
APPRAI
SE
Step
4
ACT
Step 5
ASSESS
(Gilgun 2005; Spring 2007; Smith 2008; Fischer & Orme 2009; Mazurek Melnyk 2010)

PICO Model

PICO Model
Problem or population of client- Who or What?
Describe a group of clients similar to your
own.
Intervention/exposure/ maneuver - How?
What intervention are you considering?
Comparison- What is the main alternative? (If
appropriate)?
Outcome - What are you
trying to accomplish, measure, improve,
effect?

PICO Case Scenario
Elderly suffering from bedsores
Population: Elderly or aged Intervention: Nutrition
supplement Comparison: None
Outcome: Reduction in incidence and severity of
bed sores
Question:
•"What nutrition interventions reduce the incidence
and severity of bed sores in elderly residents of LTC
facilities?"

Reflective Question

PICO Case Scenario: Vegan Diet

Is there a significant reduction in
cardiovascular disease when adults
suffering from the disease are
treated with a vegan diet in
comparison to other vegetarian or
healthy heart diets?
PICO Case Scenario: Vegan Diet
Aswerable Question

Clien
t
Step
1
ASK
5-Step Evidence-Based Practice
Model
Step 1: Ask Focused Questions

Model
Step 2: Access Best Available Evidence
Step 1 ASK
Step 2
ACCESS
Client
(

Hierarchy
of
Scientific
Evidence
(Gray & Gray 2002)

Use Reliable Websites for Research

Science + Client
Input
+ Practice
Science alone is not sufficient.

Client-
centred

Reflective
Question
Did you ever have an experience
where you needed to access
information at the point of service?
What did you do?

Model
Step 3: Critical Appraisal
Step 1 ASK
Step 2
ACCESS
Client
Step 3
APPRAI
SE

Summary
• • EBCDM = Best evidence + Clinical
expertise + Patient preferences.
• • Involves a systematic 5-step process (Ask,
Acquire, Appraise, Apply, Assess).
• • Enhances patient outcomes and
professional accountability.

Learn to tell good from bad
research

vali
d
applicabl
e
releva
nt
reliabl
e
importa
nt
Rapid Critical
Appraisal

Critical Appraisal
Gilgun’s Four Cornerstones of EBP
Research
&
Theory
Practic
e
Wisdo
m
Personal
Assumptio
ns
Client’s
Contributi
on
(Gilgun, 2005)

Research
&
Theory
PRACTIC
E
WISDOM
Personal
Assumptio
ns
Client’s
Contributi
on
Critical Appraisal

Research
&
Theory
Practic
e
Wisdo
m
PERSONAL
ASSUMPTION
S
Client’s
Contributi
on
Critical Appraisal

Case Scenario: The Vegan Diet

Science + Client
Input
+ Practice
Critical Thinking and Reflection

Critical Thinking and Reflection
Kolb'S Learning Style Theory Revisited
Educational and Psychological Measurement June 1, 1994, 54:317-
327

Critical Appraisal

Select the best options for safe client-centred
services.

Interprofessional
Collaboration
Collaborativ
e
Negotiating
Discussion

Make sure your
evidence is current and
client-centred.

Evidence-based
practice helps clients
exercise their right
and responsibility to
make informed
decisions and consent
to treatment.

Reflective
Question
How do client needs and values
affect the decision-making
process in your practice?

Model
Step 5 Assessing Performance
Clien
t
Step
1
ASK
Step 2
ACCES
S
Step 3
APPRAI
SE
Step
4
ACT
Step 5
ASSESS

 Monitor & evaluate
 Support positive
changes
 Consider new
benefits
 Pay attention to risks
Step 5: Assessing
Performance
Audit and
Feedback

Reflective Question
What changes have you made to
your practice to help clients
make informed decisions?
How did you evaluate the
changes?

Scienc
e
+ RD
Practice
+ Client
Input
Evidence-Based Practice
Regulatory and Professional Obligations
for RDs
Section IV –
Summary

Public Safety & Interest
Maintaining Competence
Evidence-Based
Practice
Regulatory and Professional Obligations
for RDs

Clien
t
Step
1
ASK
Step 2
ACCES
S
Step 3
APPRAI
SE
Step
4
ACT
Step 5
ASSESS
5-Step Evidence-Based Practice Model

References
• 1. Sackett DL et al. Evidence-Based Medicine:
What It Is and What It Isn’t. BMJ. 1996.
• 2. Straus SE, Glasziou P, Richardson WS,
Haynes RB. Evidence-Based Medicine: How to
Practice and Teach It. 5th ed. Elsevier, 2018.
• 3. WHO. EBM in Primary Care. Geneva, 2020.

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