Putting Participation into Practice

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  • SA Fam Pract 2004;46(5) 31

    INTRODUCTION ANDBACKGROUNDDifferent models of participation inthe doctor-patient relationship havebeen described in the past. Szaszand Hollenders models are wellknown and include the activity-passivity model, the guidance-cooperation model and the mutualparticipation model.1 Mutual partic-ipation as the basis of the doctor-patient relationship has been theideal for many years and is recom-mended by many role models infamily medicine and primary care.1,2

    Another way to look at mutual par-ticipation is to see the doctor-patientrelationship as a partnership.3 In

    terms of this partnership, the doctorand patient share decision makingand responsibilities.4 In contrast tothe mutual participatory model is theactivity-passivity model (or non-participation), according to whichthe clinician gives the instructionsand the patient only has to comply.1

    The literature now supports a linkbetween patient participation andimproved health outcomes.5,6,7,8,9

    Laine even argues that, as physi-cians, we are ethically bound to usethis model because of its positiveeffects on health outcomes.10 Otherconcepts that are linked to improvedhealth outcomes are self-care, self-sufficiency and the patients ability

    to take responsibility for their ownhealth care, to participate in healthactivities and to see themselves aspartners in the therapy.3,9,11,12 Thisexplains why primary care workersshould actively apply mutual partic-ipation when working with patients.

    I work in a remote health centrein the Greater Tzaneen Municipalityof the Limpopo Province of SouthAfrica. I want to share the results ofa research project in which I partic-ipated in this rural area. I asked fourof my regular patients with seriousincurable illnesses to participate.The aim of the study was to developa mutual participatory doctor-patientrelationship model, and to learn how

    Marincowitz GJO, MBChB (UFS), M Fam Med (Medunsa), MD (Medunsa)Department of Family Medicine and Primary Care, Limpopo Province Unit,

    Medical University of Southern Africa (Medunsa)

    Correspondence: Dr G Marincowitz, Department of Family Medicine and Primary Care, POBox 222, Medunsa, 0240, South Africa, e-mail: rhinorth@mweb.co.za

    Keywords: participatory action research, primary care, mutual participation


    Background: The aim of the article is to share the findings of participatory action research performed to developa mutual participatory doctor-patient relationship model, and to apply this model in a rural cross-cultural primarycare setting.

    Method: Participatory action research was performed with four patient groups. Four patients with incurable illnessesformed groups with their family members and significant others. Seven monthly meetings with each group wereaudio recorded. The question asked at each meeting was How can the group work together to achieve the bestpossible health outcome for the patient?. The recorded interviews were transcribed and translated from the localvernacular (Tsonga) into English. Themes were identified from the transcripts, field notes and a reflective diary.A list of combined themes was compiled and a model was constructed to depict the themes and their interrelatedness.The model was interpreted and conclusions were drawn.

    Results: To apply a mutual participatory model in a rural cross-cultural practice, the physician is required to operatefrom certain basic tenets. The patients have to participate actively to benefit optimally, and basic interviewingtechniques are helpful to facilitate mutual participation.

    Conclusions: It is not easy to implement a mutual participatory model in a disadvantaged, rural practice, but itis possible. We need a paradigm shift in health care, from helping patients (which may nurture dependence),towards facilitating the personal growth and development of patients (to nurture self-reliance).

    (SA Fam Pract 2004;46(5): 31-36)

    Original Research

    Putting Participationinto Practice

  • Original Research

    SA Fam Pract 2004;46(5)32

    to apply this model in a rural, cross-cultural primary health care setting.I believe the participation modeldeveloped and described for patientfamily groups is transferable andapplicable to the doctor-patient re-lationship. Some of the findings ofthis study were generated from myreflective diary and are thereforepersonal. When discussing my per-sonal reflections in reference to cur-rent academic literature, I will refer

    to myself in the first person. Writtenconsent was obtained from all theparticipants, as well as from theResearch, Ethics and PublicationsCommittee of Medunsa and the Lim-popo Provincial Department ofHealth and Welfare.

    METHODParticipatory action research (PAR)was undertaken with four patientgroups. Patients with serious incur-

    able illnesses formed groups withtheir family members, the home-based care worker caring for themand some close friends. Seven meet-ings with each group were audiorecorded over the research periodof six months. On the patients re-quest, the meetings were held intheir respective homes and the lan-guage spoken was the local vernac-ular, Tsonga. The question at eachmeeting was How the can the group








    Health workers (including the family physician/researcher)

    Basic tenets for the family physician:A family physician needs to: Take a holistic view of illness. Focus on the personal growth and development of the patient. Understand the personal gains connected to helping patients. Understand the effect of status and education on the relationship

    between a family physician and his/her patients.

    Maintain relationships. Confirm and respect the participants (especially the patients) values,

    opinions, actions and abilities. Provide encouragement and support. Focus on the patients responsibility. Focus on what is possible and what is positive It gives hope. Encourage truthfulness, honesty and openness. Raise awareness about unresolved conflicts and concerns. Focus on religion, prayer and trust in God.

    I, as the researcher, used a number of interviewing techniquesto encourage contributions in the meetings: Asked for clarification Gave reflective summaries Encouraged the asking of questions Provided summaries of the previous meetings.

    Techniques that were specifically important include the following: I motivated and encouraged all participants to participate in the

    meetings by repeatedly asking about their opinions, ideas,suggestions, plans and solutions.

    I acknowledged the pain and gave the patients the opportunity toventilate their concerns about and experience of the pain.

    I gave choices to the patients. When plans were formulated, I focused on actions, solutions and

    concrete plans with short-term objectives. The participation in the group, cooperation and the implementation

    of plans were negotiated. Feedback was given about the implementation of action plans.

    Ignore cues. Incongruence. Nurturing dependence. Being different. Being neutral. Negative feelings. Blaming the patient.

    Patient (including family)

    The patients expressed their ideas, wishesand plans, asked for explanation andclarification about their own role and askedfor opinions, ideas and solut ions.

    One patient expressed a strong desire to dothings for herself.

    The ability to take responsibility and make acommitment

    The ability to address conflict in the family(reconciliation).

    Disenabled. Focus on helplessness. Unwill ingness to take responsibil ity. Unresolved conflict in the family. Focus on outside solutions (sometimes

    unrealistic expectations). Fixation on the problem. Blaming another person. Defensiveness. Feelings of rejection. Passive resistance.

    Table I: Combined list of themes

  • SA Fam Pract 2004;46(5) 33

    Original Research

    work together to achieve the bestpossible health outcome for the pa-tient?. Each group was encouragedto give ideas on patient manage-ment. Action plans were formulatedand tried out. Decisions were madeafter consensus had been reachedby the whole group. The transcribedaudio recording of each meetingwas summarised and themes wereidentified through the cut-and-pastemethod on computer. Summariesand identified themes were verifiedwith the individual groups at thefollowing meeting. Minutes were keptby a group member and were readat the beginning of each meeting.Feedback on the effects of the im-plemented action plans was givenduring subsequent meetings, andthe effect of actions taken was alsodiscussed. The patients clinical con-dition was evaluated at each meet-ing, while the group also discussedthe effect of implemented (or non-implemented) action plans on thepatient as a whole. I made field notes(generally after the meetings) andkept a reflective diary during theresearch period. The group was fa-cilitated to continue generating moreideas and plans for action. This proc-ess continued for five meetings. Afterfour meetings it was noticed thatvery few new themes were generat-ed. What happened, however, wasthat the same themes were dis-cussed repeatedly, but on a signifi-cantly deeper level.

    The sixth meeting of each groupwas a free-attitude focus group in-terview. The purpose of this interviewwas to understand the groups per-ceptions regarding the effect of theparticipation process on the patientshealth. The results of these inter-views, as well as the results from allprevious meetings, were validatedwithin the different groups duringthe seventh meeting.

    A reflective diary was keptthroughout the research period torecord my thoughts on the researchmeetings. I documented communi-

    cations with others about the patientsand their illnesses, as well as mythoughts about the concepts andprocesses relevant to the researchtopic.

    One of the co-researchers (GSF)did three free-attitude interviews withmyself as the research facilitator.The purpose of these interviews wasto increase awareness about myperceptions regarding participationat different times during the researchperiod.

    The data was analysed as fol-lows: The recorded meetings wereall transcribed and translated intoEnglish from Tsonga. The analysedtranscripts of the meetings wereused to identify themes from theEnglish manuscript; these were thenverified with the Tsonga text. Thethemes in all the meetings were iden-tified with the cut-and-paste compu-ter method. The text was specificallysearched to identify themes thatdescribed action plans and themesdescribing participation. The partic-ipants could only be involved to thelevel of verifying and elaborating onthe summaries and themes from theinterviews in their own groups, asfurther analysis by them was hin-dered because of literacy and lan-guage barriers. Themes from thereflective diary and the three free-attitude interviews were also identi-fied through the cut-and-paste com-puter method.

    The transcribed records of themeetings were then re-analysed todescribe the process of each inter-action that took place during thedifferent meetings. The descriptionsof the interaction processes andthemes from the different patient-group meetings were combined withthe list of themes from the reflectivediary and free-attitude interviews.A combined list of themes was thuscreated.

    The combined list of themes wasused to construct a visual schematicmodel that demonstrates the interre-latedness of the different themes.

    The model was interpreted and con-clusions were drawn.

    RESULTSThe results are summarised in thecombined list of themes presentedin Table I. A model of the combinedlist of themes is depicted in Figure1, followed by a discussion of themodel. The discussion highlightssome differences between the find-ings of this research project and theliterature. The positive effect of supportiverelationships and the negative effectof conflict and distrust in relation-ships on health were suggested bymost of the participants. In eachgroup, the patients and family mem-bers repeatedly stated that the sup-port visits of the home-based careworker and the support they re-ceived during the meetings had apositive effect on their well-being.They repeatedly said these visitsmust continue. One family experi-enced heightened levels of internalconflict and a participant stated: Itis not going well with our sisterbecause there is no peace in thishouse.

    Certain basic tenets emergedthat would help the family physicianto implement a mutual participationmodel. The majority of these tenetswere identified during the analysisof the reflective diary. One of thesetenets is that, when patients abilitiesand contributions are respected andvalued, a positive effect on theirparticipation and their experienceof well-being can be identified. Otherimportant tenets include a prepared-ness to learn from patients, and be-ing aware that, as health workers,we also benefit from helping patients.It is necessary to have a holistic viewof medicine, to be aware of the lim-itations of Western medicine and toaspire for the personal growth anddevelopment of patients. Beingaware of the influence of status onthe therapeutic relationship helpedme to apply the mutual participation

  • SA Fam Pract 2004;46(5)34

    model. The health workers statusoften comes from his/her knowledgeand posit ion within society.

    The transcribed manuscripts ofthe group meeting were reviewed toidentify facilitation processes thatencouraged participation. Basic in-terviewing techniques, such as re-flection, summaries and giving op-portunities to ask questions, wereidentified as having impacted posi-tively on group participation. Fromthe manuscripts it became clear thatparticipation usually started after theparticipants had repeatedly beenasked for their ideas, opinions, sug-gestions and plans.

    Some of the actions of the care-taker team had a negative effect onthe participation and well-being ofthe patients. Examples of these in-clude ignoring cues from the patient,incongruent actions, nurturing de-pendence, being different from thepatient, a pretence of being neutral,negative feelings towards the patientand blaming the patient. One patiententered into a relationship with awoman against the advice of thegroup. None of the group were em-

    pathetic towards him, and all of themhad different views on the matter.Group members blamed him for thedecision and the subsequent dete-rioration of his health. In two of thegroups, group members who werenot family members took responsi-bility for providing food for thepatients. Those patients becamedependent on these contributions,which resulted in the patientsthemselves and their family mem-bers participating less during thediscussions.

    Active participation by the patientand his/her family, for example givingopinions, taking responsibility andtaking action to contribute to theirhealth, contributed to their overallsense of well-being. Open and hon-est discussion of concerns and un-resolved conflict, including attemptsto reconcile the issues, also had apositive effect on patients. One pa-tients daughter described the patientas stubborn because she wouldnot allow them to help her. Shewanted to do things...