adesão ao tratamento

1. Therapeutic education of the patient
Therapeutic adhesion or compliance
In order to improve therapeutic adhesion of patients with coronary heart disease, it
is crucial to use tools developed for the treatment of chronic disease. Therapeutic
education and the spirit of motivational interviews are such tools. Moreover, the
tools used to give information have to perform well and be used at appropriate
moments so as to enhance their impact on the patient.
Therapeutic adhesion is conditioned by the quality of communication and
information regarding the disease and its treatment.
The objective of communication is to transmit a message from a teacher (in this
case a health care provider) to reach a therapeutic goal. In order for this to be
effective, the communication tools have to take into account two parameters: the
teaching ability of the health care provider and the learning ability of the patient.
These two parameters depend on a patient’s emotional, cognitive and relationship
factors, all of which have to be taken into account.
The finality is to have the patient convince himself to actively manage his disease
and to place himself at the centre of the treatment process. This ensures optimal
therapeutic adhesion and therefore diminishes the risk of recurrence of
cardiovascular events.
Therapeutic education: an effective approach to chronic disease
The chronic nature of the disease puts the temporal dimension at the centre of the
medical management of patients. Beyond primary and secondary prevention,
therapeutic education (TE) enriches the role of the health care provider as it
provides an opportunity to be a partner in the creation of a therapeutic project
which takes into account imperatives of the disease and the life project of the
patient.
“Therapeutic education must enable patients to acquire and maintain skills that
allow them to manage their treatment in an optimal manner in order to reach a

2. balance between their life and their disease. It is a continual process that is an
integral part of medical care. (…) TE is designed to help patients and their families
understand their disease and treatment, to cooperate with health care providers, to
live in a healthy manner and to increase their quality of life.” (OMS, 1988)
The usefulness of TE in the management of chronic disease has been shown for
diverse pathologies (diabetes, asthma heart failure, obesity, HIV), most notably by
improving adhesion to treatment, decreasing complications, and increasing quality
of life. In the area of coronary heart disease, a recent large meta analysis
confirmed the effectiveness of secondary prevention programmes in decreasing
mortality and recurrence of myocardial infarctions.
Other work has shown that paying attention to patients’ representations and
perceptions of their disease increases adhesion to cardiac rehabilitation
programmes.
The patient acquires the means to become an effective health care partner, which
in turn allows the heath care provider to be successful in his mandate. This
approach implies that constant attention be given to the psycho-affective
dimension. Acceptance, living with coronary heart disease, personal identity, and
self esteem are all essential elements that influence adhesion to treatment.
Moreover, long term management of disease requires behaviour and lifestyle
modification such as taking of medication, self surveillance, eating habits, regular
physical activity, all of which can be difficult to maintain. Motivational training is an
integral part of therapeutic education.
A new paradigm for the health care provider
In the keeping with the idea of accompanying a patient with chronic disease, TE
asks the health care provider to change paradigm.
Indeed, schematically, in acute disease the patient expects answers, solutions and
treatment, often in an urgent manner. The health care provider is active and the
patient is passive. In chronic disease, the patient is the principal actor in his
treatment.
The long term aspect of the disease requires the patient to be considered in his
entirety and that resources be developed that will accompany the patient
throughout the journey, these resources being his skills. In order to do this, the
health care provider will help the patient understand, learn and use these skills,
change his behaviour and find a meaning to all of this.
The health care provider creates a situation in which the patient’s beliefs can be
explored, in which curiosity is brought about, and in which the patient can find
answers and make educated decisions. The patient’s life experience is
considered as an opportunity to learn.
Multidisciplinary health care providers
ET unites a wide array of know-how and experience in order to grasp the full
complexity of each patient. This know-how or competency can be grouped into 4
main areas:
 biomedical
 psychosocial
 educational

3.  philosophical
In addition to biomedical know-how, which is essential, the input of psycho-
social competency is also important in medicine. Practical teaching tools as well
as appropriate attitudes are seldom taught to health care providers, and TE
therefore addresses this issue.
Another area of expertise is with respect to long term follow-up of chronic
disease. It may be described as existential or philosophical. It is the evaluation of
how an event such as learning of a disease can intrude and affect an individual’s
life. This is an area of course where there is no definitive truth or certainty. All the
required know-how can occasionally be found in one health care provider but
usually, and more realistically, this know-how is found amongst a team of health
care providers working in a multidisciplinary team.