Adv. Cardiol., vol. 24, pp. 146-152 (Karger, Basel 1978)
Health Education in Cardiac Rehabilitation M. J.
HALHUBER
Rehabilitation Centre, Hohenried Heart Hospital, Bernried
In this brief report, I shall provide only a few key words as a general introduction to discussion, and characterize some crucial points of the farreaching topic of health education in cardiac rehabilitation. My paper is divided into three sections: (1) aims and tasks of health education in cardiac rehabilitation; (2) methods of health education in cardiac patients (reflecting and emphazising those which are important); and (3) critical comments on the traditional methods of health education from the cardiologist's point of view.
The importance physicians give to one aspect or another of patient information and motivation in order to exert an influence on their attitude and behaviour towards health, depends very much on on the physician's intention and aim, as each of them has a different 'background philosophy' and training. For a cardiologist, there are three theoretically different, but intervowen tasks: (1) Improvements of the patient's attitude and behaviour towards health, i. e. elimination of unhealthy habits and notably of coronary heart disease risk factors (as part of primary, secondary and tertiary prevention). (2) Improvement of the patient's attitude and behaviour towards his disease, i. e. regular medication (as part of the efforts. for the emancipation of the chronical diseased as an equal partner of his physician). Here the problem of the physician's compliance which has merely been realized - has to be taken into account.
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
Aims and Tasks of Health Education in Cardiac Rehabilitation
147
(3) Improvement of the general state of health of the coronary patients, i. e. psychic reduction of anxiety, depression, denial and overmotivation with better information and motivation (as part of group psychotherapy efforts which cannot be separated from health education). Why is a differentiation of these three tasks necessary? They are of great importance since they are three different, often mixed up points oftherapeutical and educational efforts. Preeminently, a change in the way oflife is necessary provided that impairing behaviour patterns are taken as risk factor. This factor is generally accepted but the results of the present traditional primary, secondary and tertiary prevention are disappointing. They are not only disappointing because the traditional methods (one-sided information and regulation of the way of life predominantly with prohibitions and rules) are out of date but also anxiety of the coronary patients and their depressive approach to life makes any kind of health education very difficult. Therefore, the third point deserves a closer inspection and asks for special group any psychotherapy methods. On an equal level, cardiologists should emphasize the importance of the patient's attitude towards his disease and his corresponding behaviour (compliance). This kind of health education means teaching the patient to react in the right way to his symptoms and complaints. Knowledge about the structure of the medical service system, the rights and duties (role expectancies) of the individual have to be supplied as well as abilities for self-diagnosis and a coordinated self-therapy, i. e. help in the field of medical service or the medical service system. The pedagogical and andragogical transmission of attitudes and behaviour securities in handling the phenomena of dying and death is called death education [5]. From studies about patient's compliance and cooperation, we know that only every other post-coronary patient takes regularly his drugs and only less than 25 % of hypertonics are motivated to a regular self-medication [7]. A fundamental reason for this aggravating situation may be found in the misunderstanding of the patient-doctor interaction and the patient's image which is no more up to date. Physicians need the patient as an equal partner, who is a 'specialist' for his own chronic disease. When reading this sentence, many doctors may feel uneasy. The acceptance of this provocative statement probably needs a profound change in attitude and a long learning process of the medical profession. I should like to quote v. TROSCHKE [5], a medical sociologist, regarding the efficience or rather inefficience of traditional health education: 'During the historical period of enlightenment, the aims and efforts of health educa-
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
HALHUBER
HAuruBER
148
tion were precise (the citizen being responsible for his own and his community's health). For the last 20 years, the variety of health educational activities and their aimlessness can be noticed. This can be explained by our lack of knowledge about the origin and development of environmental civilisational and behavioural diseases. Although epidemiological studies have detected many risk factors that are significantly correlated with certain diseases, relatively little is known about the causal linking of independent, intervening and dependent variables. Which behaviour patterns are health-impairing and may lead with probability to which diseases? In which behaviour context can this health-impairing behaviour patterns be found? Which are the essential behaviour-influencing social determinants? Which active health-improving behaviour patterns can prevent the development of behavioural diseases? These questions have to be solved before definite educational health measurements can be defined.
Methods of Health Education as Seen by the Cardiologist
Health Education with Individual Counselling (with the Integration of Various Media) Due to reasons like time, both the hospital physician and the family doctor are dependent on the help of books and brochures. It is already a great help if the physician can refer to brochures and books which the patient is able to understand and has already seen in the doctor's waiting-room or pharmacy. After reading it, he could come with special as well as individual questions to his doctor to use the theoretical knowledge for his personal case. The problems cannot be discussed in detail in this paper. However, I
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
Critique of the Traditional Methods Health education how it should not be done: (1) ideology instead of didactics; (2) fanatism instead of patient devotion; (3) overestimation of the physician's authority; (4) one-sided information; (5) underestimation of the social language barriers; (6) naive appeal to the anxiety of the patient; (7) overrestriction, and (8) lacking trustworthiness. In this context, I can only mention some catchwords. They are explained extensively in HALHUBER's [2] paper.
Health Education in Cardiac Rehabilitation
149
Theme-Centred Group Therapy [see e.g. v. TROSCHKE et al., 5] Health education will shift from individual therapy to group therapy not only due to time-saving reasons. Health-relevant attitudes and behaviour patterns are learned in social processes which are not only the result of specific experiences and are expressed under the concrete conditions of social situations. In this context, group dynamics can be explained as different methods and techniques which help the individual in a small group, even with non-therapeutical aims, to increase his self-knowledge [SPANDI, 4; cited by v. TRoscHKE et aI., 5]. This encounter group gives the patient a new orientation and supplies enough security to try and realize new behaviour patterns. Until now, health education has not enough used the methods of group dynamics, though their importance has been accepted and confirmed by health pedagogy [5]. In this field cardiologists working in prevention and rehabilitation have an incredible need for method knowledge and method training. I cannot give more details, but I should like to refer the reader to v. TROSCHKE et al. [5]. Already in the hospital during acute illness, theme-centred group dialogues as for example ward conversations are possible and profitable if there is a sufficiently engaged therapeutical team of physicians, nurses, social workers, dieteticians and physiotherapists. Especially, in the rehabilitation centre where the patient should become acquainted with the new way of life - if possible under everyday conditions - which can later be continued at home, the possibility for such group therapies is given. Since more than a year, infarction patients with early rehabilitation measures are invited to the rehabilitation centre at Hohenried for group dialogues under the supervision of a psychologist (Dr. GNADIGER) and various physicians. These group dialogues take place twice a week and last 45 min (together 8 times during the follow-up). It is much too early
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
think it is very important that books like all the other health educational programs should be critically examined in controlled empirical tests evaluating the effect of such articles on the readers. Such an efficiency control is planned and will be carried out by a psychological institute for a health advisory book by HALHUBER and HALHUBER [3]. As physicians, we cannot avoid - I think we should even assent to this situation - picking up informations which are given in papers, journals, in radio lectures, on television and health magazines and use them in individual counselling of the patient. Whether they are the right informations depends much on the readiness of physicians to cooperate with the mass media.
lIALHuBER
150
to report in detail on our experiences, but we are convinced that these group dialogues are an essential progress in the comprehensive care of coronary patients. In the ambulant coronary groups which are primarily orientated towards physiotherapy, the group dialogues play an important role at the end of the physical exercise lessons. Efficiency and effectiveness can certainly still be improved. Physicians need the help of psychosocial and pedagogic experts. They should admit that they have not enough experience in this field and draw the consequences. One-Sided Information The justified criticism of health education existing in only one-sided information and behaviour regulations with prohibitions and rules should not lead to the wrong conclusion. Myocardial infarction patients' general need for information can only be satisfied with a proposition for adequate health and disease behaviour. 75 % of the patients feel insufficiently informed about the cause and prognosis of their disease (as was confirmed by questionnaires answered by 477 out-patients and 566 in-patients [6]. Even with a presumed negative disease process, 62 % of the patients desire a complete explanation. As the questionnaires confirmed, only 20-30% of the general practitioners and 10% of the hospital physicians are willing to give explanations. But the patient is not only interested in etiology and prognosis but also in information which might motivate him to change his behaviour patterns. The diagnostic methods in cardiology are not sufficiently explained. This results in superfluous fear for the patient. Where are the introductory pamphlets and brochures in which the procedure for a coronary angiography is explained to the candidate in an understandable language which would reduce his anxiety? We are all very interested in such international information and its exchange. Here, the question arises also of whether the means with which the patients are informed of the results of diagnostic measurements, i.e. whether their coronary angiographies are satisfactory. In this connection, I should like to refer to a report by LEPPER [1].
Finally, I should like to summarize in 10 theses the reasons of the discrepancy between the great efforts and the low efficience of health education
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
Critical Comments on the Traditional Methods of Health Education from the Cardiologist's Viewpoint
Health Education in Cardiac Rehabilitation
151
in relation to cardiological rehabilitation referring to v. TROSCHKE et al. (1) Isolated cognitive, i. e. just explanatory health and disease education neglects the interrelation of attitudes, behaviour patterns and interests. Nutrition, leisure time, consumption, sleeping and work patterns cannot be separated. (Here lays the chance for group actions as they are possible in rehabilitation centres and ambulant coronary groups.) (2) The media information often comes to a dead-end. Intensive, multiple interaction and communication processes between tutor and taught person are rarely found in health education. (Cardiologists need a basic training in psychosociology and medical concepts of comprehensive rehabilitation. The effects of books and brochures, films on certain groups have to be proved with modem scientific methods.) (3) There is very little intercommunication between the various groups (as for example group discussions with infarction patients about a film, a book or slides). (4) Often, there is a lack of confidence and trustworthiness towards health education training. Only 34 % of the whole population believe that their physician obeys all the regulations he recommends to his patients. (How many cardiologists are smokers, are overweight, do no physical exercise and are helpless against their psychosocial stress?) (5) Alternative behaviour patterns are usually only theoretical and cognitively transmitted to the groups. Any personal experience in alternative behaviour is neither controlled nor corrected. (Here as well is a special chance for institutionalized rehabilitation and also ambulant coronary groups.) (6) Health educational actions are usually of very short duration. Even in group therapies of myocardial infarction patients, repetition of apparently simple information is necessary. Quite often, physicians tend to get very impatient about this. (7) A disease behaviour pattern is only experienced but not systematically learned 'as unconducted socialitsation' in hospital or the physician's waiting-room. (The patient's compliance has to be consciously encouraged already in the intensive care ward and constantly trained in the ambulant coronary groups.) (8) Health, disease and death education is started much too late. (It should already begin in early childhood as it used to be possible in a large family with the identification of the ill grandfather. At what time do the health education and comprehensive rehabilitation start for example in children with inherited hypercholesterinaemia and how could it be achieved?)
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
[5].
HALHUBER
152
(9) The teachers of the various types of schools are not trained in health, disease and death education. What can cardiologists do to remedy this state of things? (10) The fact that health-impairing goods are produced (tobacco, alcohol, cars) is not realized consciously enough and taken into account. This can only be solved both on the political (i. e. investments in leisure time activities) and on the individual level (becoming conscious of the apparent selfrealization of personal needs for social consumption). We must realize that in the future, the cardiologist will not only have to be a technician, an educator and a social worker but he will also have to deal with politics.
References
2 3 4 5
6 7
LEPPER, M.: Psychosocial stress caused by cardiological diagnostic. Workshop dialogue, Hohenried 1976; in Psychosocial stress and coronary heart disease (Springer 1977). HALHUBER, C.: Problems and experience in health education in the hospital. Therapie Gegenw. 116: 340-362 (1977). HALHUBER, C. und HALHUBER, M. J.: Sprechstunde Herzinfarkt (Graefe & Unzer, Miinchen 1977). SPANDI, J.: Cited by v. TROSCHKE et al. [5]. TROSCHKE, J. V.; ERLBRUCH, U.; HERZOG, M., and FULLER, A.: Elements for death, disease and death education of grown-ups: how important is our health (in press, 1977). HABECK, D.; ENGEL, H. J., und MUNSTERMANN, W.: Patientenmeinungen zur arztlichen Informierung. Miinch. med. Wschr. 25: 851 (1977). GUNDERT-REMY, U.: Compliance stationarer und ambulanter Patienten. Ergebnisse eigener Studien. Verhandlungsbericht yom Werkstattgesprach iiber PatientenCompliance, Frankfurt 1977.
Prof. M. J. HALHUBER, Medical Director, Rehabilitation Centre, Hohenried Heart Hospital, D-8J3J Bernried (FRG)
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
2
Health Education in Cardiac Rehabilitation M. J.
HALHUBER
Rehabilitation Centre, Hohenried Heart Hospital, Bernried
In this brief report, I shall provide only a few key words as a general introduction to discussion, and characterize some crucial points of the farreaching topic of health education in cardiac rehabilitation. My paper is divided into three sections: (1) aims and tasks of health education in cardiac rehabilitation; (2) methods of health education in cardiac patients (reflecting and emphazising those which are important); and (3) critical comments on the traditional methods of health education from the cardiologist's point of view.
The importance physicians give to one aspect or another of patient information and motivation in order to exert an influence on their attitude and behaviour towards health, depends very much on on the physician's intention and aim, as each of them has a different 'background philosophy' and training. For a cardiologist, there are three theoretically different, but intervowen tasks: (1) Improvements of the patient's attitude and behaviour towards health, i. e. elimination of unhealthy habits and notably of coronary heart disease risk factors (as part of primary, secondary and tertiary prevention). (2) Improvement of the patient's attitude and behaviour towards his disease, i. e. regular medication (as part of the efforts. for the emancipation of the chronical diseased as an equal partner of his physician). Here the problem of the physician's compliance which has merely been realized - has to be taken into account.
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
Aims and Tasks of Health Education in Cardiac Rehabilitation
147
(3) Improvement of the general state of health of the coronary patients, i. e. psychic reduction of anxiety, depression, denial and overmotivation with better information and motivation (as part of group psychotherapy efforts which cannot be separated from health education). Why is a differentiation of these three tasks necessary? They are of great importance since they are three different, often mixed up points oftherapeutical and educational efforts. Preeminently, a change in the way oflife is necessary provided that impairing behaviour patterns are taken as risk factor. This factor is generally accepted but the results of the present traditional primary, secondary and tertiary prevention are disappointing. They are not only disappointing because the traditional methods (one-sided information and regulation of the way of life predominantly with prohibitions and rules) are out of date but also anxiety of the coronary patients and their depressive approach to life makes any kind of health education very difficult. Therefore, the third point deserves a closer inspection and asks for special group any psychotherapy methods. On an equal level, cardiologists should emphasize the importance of the patient's attitude towards his disease and his corresponding behaviour (compliance). This kind of health education means teaching the patient to react in the right way to his symptoms and complaints. Knowledge about the structure of the medical service system, the rights and duties (role expectancies) of the individual have to be supplied as well as abilities for self-diagnosis and a coordinated self-therapy, i. e. help in the field of medical service or the medical service system. The pedagogical and andragogical transmission of attitudes and behaviour securities in handling the phenomena of dying and death is called death education [5]. From studies about patient's compliance and cooperation, we know that only every other post-coronary patient takes regularly his drugs and only less than 25 % of hypertonics are motivated to a regular self-medication [7]. A fundamental reason for this aggravating situation may be found in the misunderstanding of the patient-doctor interaction and the patient's image which is no more up to date. Physicians need the patient as an equal partner, who is a 'specialist' for his own chronic disease. When reading this sentence, many doctors may feel uneasy. The acceptance of this provocative statement probably needs a profound change in attitude and a long learning process of the medical profession. I should like to quote v. TROSCHKE [5], a medical sociologist, regarding the efficience or rather inefficience of traditional health education: 'During the historical period of enlightenment, the aims and efforts of health educa-
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
HALHUBER
HAuruBER
148
tion were precise (the citizen being responsible for his own and his community's health). For the last 20 years, the variety of health educational activities and their aimlessness can be noticed. This can be explained by our lack of knowledge about the origin and development of environmental civilisational and behavioural diseases. Although epidemiological studies have detected many risk factors that are significantly correlated with certain diseases, relatively little is known about the causal linking of independent, intervening and dependent variables. Which behaviour patterns are health-impairing and may lead with probability to which diseases? In which behaviour context can this health-impairing behaviour patterns be found? Which are the essential behaviour-influencing social determinants? Which active health-improving behaviour patterns can prevent the development of behavioural diseases? These questions have to be solved before definite educational health measurements can be defined.
Methods of Health Education as Seen by the Cardiologist
Health Education with Individual Counselling (with the Integration of Various Media) Due to reasons like time, both the hospital physician and the family doctor are dependent on the help of books and brochures. It is already a great help if the physician can refer to brochures and books which the patient is able to understand and has already seen in the doctor's waiting-room or pharmacy. After reading it, he could come with special as well as individual questions to his doctor to use the theoretical knowledge for his personal case. The problems cannot be discussed in detail in this paper. However, I
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
Critique of the Traditional Methods Health education how it should not be done: (1) ideology instead of didactics; (2) fanatism instead of patient devotion; (3) overestimation of the physician's authority; (4) one-sided information; (5) underestimation of the social language barriers; (6) naive appeal to the anxiety of the patient; (7) overrestriction, and (8) lacking trustworthiness. In this context, I can only mention some catchwords. They are explained extensively in HALHUBER's [2] paper.
Health Education in Cardiac Rehabilitation
149
Theme-Centred Group Therapy [see e.g. v. TROSCHKE et al., 5] Health education will shift from individual therapy to group therapy not only due to time-saving reasons. Health-relevant attitudes and behaviour patterns are learned in social processes which are not only the result of specific experiences and are expressed under the concrete conditions of social situations. In this context, group dynamics can be explained as different methods and techniques which help the individual in a small group, even with non-therapeutical aims, to increase his self-knowledge [SPANDI, 4; cited by v. TRoscHKE et aI., 5]. This encounter group gives the patient a new orientation and supplies enough security to try and realize new behaviour patterns. Until now, health education has not enough used the methods of group dynamics, though their importance has been accepted and confirmed by health pedagogy [5]. In this field cardiologists working in prevention and rehabilitation have an incredible need for method knowledge and method training. I cannot give more details, but I should like to refer the reader to v. TROSCHKE et al. [5]. Already in the hospital during acute illness, theme-centred group dialogues as for example ward conversations are possible and profitable if there is a sufficiently engaged therapeutical team of physicians, nurses, social workers, dieteticians and physiotherapists. Especially, in the rehabilitation centre where the patient should become acquainted with the new way of life - if possible under everyday conditions - which can later be continued at home, the possibility for such group therapies is given. Since more than a year, infarction patients with early rehabilitation measures are invited to the rehabilitation centre at Hohenried for group dialogues under the supervision of a psychologist (Dr. GNADIGER) and various physicians. These group dialogues take place twice a week and last 45 min (together 8 times during the follow-up). It is much too early
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
think it is very important that books like all the other health educational programs should be critically examined in controlled empirical tests evaluating the effect of such articles on the readers. Such an efficiency control is planned and will be carried out by a psychological institute for a health advisory book by HALHUBER and HALHUBER [3]. As physicians, we cannot avoid - I think we should even assent to this situation - picking up informations which are given in papers, journals, in radio lectures, on television and health magazines and use them in individual counselling of the patient. Whether they are the right informations depends much on the readiness of physicians to cooperate with the mass media.
lIALHuBER
150
to report in detail on our experiences, but we are convinced that these group dialogues are an essential progress in the comprehensive care of coronary patients. In the ambulant coronary groups which are primarily orientated towards physiotherapy, the group dialogues play an important role at the end of the physical exercise lessons. Efficiency and effectiveness can certainly still be improved. Physicians need the help of psychosocial and pedagogic experts. They should admit that they have not enough experience in this field and draw the consequences. One-Sided Information The justified criticism of health education existing in only one-sided information and behaviour regulations with prohibitions and rules should not lead to the wrong conclusion. Myocardial infarction patients' general need for information can only be satisfied with a proposition for adequate health and disease behaviour. 75 % of the patients feel insufficiently informed about the cause and prognosis of their disease (as was confirmed by questionnaires answered by 477 out-patients and 566 in-patients [6]. Even with a presumed negative disease process, 62 % of the patients desire a complete explanation. As the questionnaires confirmed, only 20-30% of the general practitioners and 10% of the hospital physicians are willing to give explanations. But the patient is not only interested in etiology and prognosis but also in information which might motivate him to change his behaviour patterns. The diagnostic methods in cardiology are not sufficiently explained. This results in superfluous fear for the patient. Where are the introductory pamphlets and brochures in which the procedure for a coronary angiography is explained to the candidate in an understandable language which would reduce his anxiety? We are all very interested in such international information and its exchange. Here, the question arises also of whether the means with which the patients are informed of the results of diagnostic measurements, i.e. whether their coronary angiographies are satisfactory. In this connection, I should like to refer to a report by LEPPER [1].
Finally, I should like to summarize in 10 theses the reasons of the discrepancy between the great efforts and the low efficience of health education
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
Critical Comments on the Traditional Methods of Health Education from the Cardiologist's Viewpoint
Health Education in Cardiac Rehabilitation
151
in relation to cardiological rehabilitation referring to v. TROSCHKE et al. (1) Isolated cognitive, i. e. just explanatory health and disease education neglects the interrelation of attitudes, behaviour patterns and interests. Nutrition, leisure time, consumption, sleeping and work patterns cannot be separated. (Here lays the chance for group actions as they are possible in rehabilitation centres and ambulant coronary groups.) (2) The media information often comes to a dead-end. Intensive, multiple interaction and communication processes between tutor and taught person are rarely found in health education. (Cardiologists need a basic training in psychosociology and medical concepts of comprehensive rehabilitation. The effects of books and brochures, films on certain groups have to be proved with modem scientific methods.) (3) There is very little intercommunication between the various groups (as for example group discussions with infarction patients about a film, a book or slides). (4) Often, there is a lack of confidence and trustworthiness towards health education training. Only 34 % of the whole population believe that their physician obeys all the regulations he recommends to his patients. (How many cardiologists are smokers, are overweight, do no physical exercise and are helpless against their psychosocial stress?) (5) Alternative behaviour patterns are usually only theoretical and cognitively transmitted to the groups. Any personal experience in alternative behaviour is neither controlled nor corrected. (Here as well is a special chance for institutionalized rehabilitation and also ambulant coronary groups.) (6) Health educational actions are usually of very short duration. Even in group therapies of myocardial infarction patients, repetition of apparently simple information is necessary. Quite often, physicians tend to get very impatient about this. (7) A disease behaviour pattern is only experienced but not systematically learned 'as unconducted socialitsation' in hospital or the physician's waiting-room. (The patient's compliance has to be consciously encouraged already in the intensive care ward and constantly trained in the ambulant coronary groups.) (8) Health, disease and death education is started much too late. (It should already begin in early childhood as it used to be possible in a large family with the identification of the ill grandfather. At what time do the health education and comprehensive rehabilitation start for example in children with inherited hypercholesterinaemia and how could it be achieved?)
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
[5].
HALHUBER
152
(9) The teachers of the various types of schools are not trained in health, disease and death education. What can cardiologists do to remedy this state of things? (10) The fact that health-impairing goods are produced (tobacco, alcohol, cars) is not realized consciously enough and taken into account. This can only be solved both on the political (i. e. investments in leisure time activities) and on the individual level (becoming conscious of the apparent selfrealization of personal needs for social consumption). We must realize that in the future, the cardiologist will not only have to be a technician, an educator and a social worker but he will also have to deal with politics.
References
2 3 4 5
6 7
LEPPER, M.: Psychosocial stress caused by cardiological diagnostic. Workshop dialogue, Hohenried 1976; in Psychosocial stress and coronary heart disease (Springer 1977). HALHUBER, C.: Problems and experience in health education in the hospital. Therapie Gegenw. 116: 340-362 (1977). HALHUBER, C. und HALHUBER, M. J.: Sprechstunde Herzinfarkt (Graefe & Unzer, Miinchen 1977). SPANDI, J.: Cited by v. TROSCHKE et al. [5]. TROSCHKE, J. V.; ERLBRUCH, U.; HERZOG, M., and FULLER, A.: Elements for death, disease and death education of grown-ups: how important is our health (in press, 1977). HABECK, D.; ENGEL, H. J., und MUNSTERMANN, W.: Patientenmeinungen zur arztlichen Informierung. Miinch. med. Wschr. 25: 851 (1977). GUNDERT-REMY, U.: Compliance stationarer und ambulanter Patienten. Ergebnisse eigener Studien. Verhandlungsbericht yom Werkstattgesprach iiber PatientenCompliance, Frankfurt 1977.
Prof. M. J. HALHUBER, Medical Director, Rehabilitation Centre, Hohenried Heart Hospital, D-8J3J Bernried (FRG)
Downloaded by: University of Cambridge 131.111.164.128 - 3/20/2019 11:14:58 AM
2
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