Do you floss your teeth?

It is one thing to know what you should do, yet quite another thing to actually do it.

I know I should floss my teeth regularly ……but do I do it?

I know I should exercise regularly, eat healthily and have 5 portions of fruit and veg per day – but do I do it ALL the time…..or just SOME of the time…..or NEVER !!

For the last 18 months I have been attempting to create the strategy, then design and implement a new Mercy Ships Healthcare Education Program in the Republic of Congo, and I have learnt a lot. One thing I keep coming back to is the idea that education and training is fundamentally about behaviour change. An education program can increase knowledge and skills, but if we don’t apply those skills through a sustainable change in our behaviour then there will be little long term change. We all know we should eat healthily, take regular exercise, floss our teeth etc, but how many of us actually do it all the time? It is hard to change / modify our behaviour. It isn’t enough to simply know what is best.

The World Health Organisation (WHO) 2nd Global Patients Safety Challenge is called Safe Surgery Saves Lives. They have designed a Safe Surgery Checklist to make surgery safer. The checklist is based around 6 key steps to check:
1. you have the right patient for the right procedure
2. the anesthetist has done a risk assessment for placement of the breathing tube
3. the anesthetist is using a monitor to keep an eye on the oxygen levels in your body
4. the team have evaluated the risk of major blood loss
5. antibiotics are given on time
6. that swabs and instruments are counted at the end of the surgery to make sure nothing is left inside the patient.

These are pretty basic things that most people think they do all the time. But when this was studied in 8 countries (England, US, Canada, NZ, India, Philippines, Jordan, and Tanzania) they realised these key steps only happened 1/3 of the time….and that wasn’t just in the low-income countries! A simple checklist helped improve behaviour so that these 6 steps were done 2/3 of the time. Still not ALL the time. But even doing it 2/3 of the time led to a reduction in mortality and infection rates of almost 50%. Wow! Unbelievable. Not new drugs or equipment, but simple behaviour change can improve health! And that is good news for where I work in West and Central Africa because it doesn’t cost much, and it is something everyone can do! BUT behaviour change is difficult.

Using a locally adapted version of the WHO safe surgery checklist has been mandatory in UK hospitals for several years, but still doctors and nurses are resistant to it. Studies of hand washing in hospitals are the same. Everyone knows they must wash their hands, but time and time again, studies show health care professionals do not do what they are supposed to do.
Why is that?
Perhaps it is the same reason you and I do not ALWAYS, ALL THE TIME take regular exercise, eat healthily and floss our teeth. Behaviour change is hard. I think we need a significant event or relationship to motivate us. Rather like if I suffered a heart attack and nearly died I would be more likely be motivated to modify my diet and exercise regime. Or if my spouse was a dental hygienist, out of love and respect, then perhaps I would probably be more likely to floss my teeth regularly? Relationship and personal relevance are, I think, some of the biggest motivators for behaviour change. So, these are some of the foundation stones of the Mercy Ships Healthcare Education strategy. Relationship and Relevance. Our training program aims to train the whole surgical ecosystem – surgeons, anesthesia, OR nurses, ward nurses, sterile processing technicians etc.

I am immensely proud of what we have done and still continue to do in the Republic of Congo. Recently we took a team to Dolisie Hospital (check out the pictures above). This was a partnership with Lifebox www.lifebox.org and SPECT www.spedc.org We aimed to provide individual education for the anesthetists, OR nurses and Sterile Processing technicians and help them create their own version of the WHO safe surgery checklist. We built relationships, showed the relevance to them of how something simple can save lives, and tried to impart knowledge, skills and professional attitude. We all worked hard and by the end of 4 days we were proud to help them present their own checklist to the Hospital Director. We will return in 6 weeks to encourage them and see how things are going. Behaviour change is hard. We all need encouragement.

Since we returned from Dolisie, I have eaten healthily but I haven’t been running, nor have I flossed my teeth. (oh dear – my uncle is my dentist so there’s a confession!) I have only done 1 out of 3 things I know are important. My prayer for those at Dolisie is that they might do better than me. I hope they will have been able to do more than one of the 6 checklist steps that are important. I do not expect them to achieve everything. Behaviour change is hard. But we will go back to encourage them and continue to build relationships and share our hearts desire – that we all become better doctors and nurses so that we can serve our patients better and make health care safer.

Footnote: This last month we also ran an anesthesia course called SAFE Obstetric Anesthesia in association with AAGBI. Some good photos can be found on a friends blog www.stephcongo.blogspot.com She is a French lady who lives in Ottawa and came all the way to help translate for us and serve the people of Pointe Noire, by helping to train anesthetists.