Through the photo I want to make the observer curious about the connection between international anti-tobacco campaigns[1], a physiotherapists professional approach towards tobacco-related illnesses and a COPD diagnosed patient point of view on her/his illness and rehabilitation. The cigarette package and the book are not new and shiny, but well used. And tobacco-related illnesses and rehabilitation are in spite of the campaigns still a very relevant theme for us physiotherapy students today.
In this assignment I want to initiate a debate about how a societies view on smoking can lead to stigmatization of a group of patients and how this again might influence the understanding of a COPD patient’s self-worth. From my understanding both these aspects influence the rehabilitation process of COPD patients negativly. I also want to discuss if different underlying causes for developing COPD in South Africa and Norway might influence stigmatization, the rehabilitation processes in both lands and our role as physiotherapists.
COPD stigma in Norway and South Africa
COPD has besides of a global, national, economical dimension also a personal dimension and the rehabilitation of a COPD patient includes both biomedical, psychological and sociocultural elements. I will describe some form for stigmatization in this essay and how this affects the patient’s point of view on rehabilitation.
Many COPD patients feel social stigmatized and experience fear, anxiety and depression in addition to physical symptoms. If we look a little more into the stigmatizing process connected to COPD, the stigmas are often related to four main areas: (1) Physical manifestations of COPD symptoms like sever dyspnoea, productive cough and reduced range of movements are the first area. These manifestations might be experienced as embarrassing and might disrupt conversations and social interactions (Berger et al, 2011: 918). (2) Second COPD patient have often to use technical equipment (inhalators or oxygen supple) (Berger et al, 2011: 917), which makes the user visible and marks her/him as sick. (3) The third area is related to common sense: the anti-tobacco movement has stigmatized smokers in order to stigmatize smoking (Berger et al, 2011: 917). There is an overall expectation that reasonable persons would quit smoking as soon as they have learnt about this activity’s health consequence. (4) Finally the tobacco-related “campaigns might further stigmatize low-income and other vulnerable populations of smokers, who currently represent the majority of tobacco users” ([22] Riley, 2017: 3).
Many patients with tobacco-related illnesses feel ashamed, guilty, and stressed by the stigmatisation from others. One Norwegian patient said (translated by me 2019):“I know that most people think that this illness is self-inflicted and that in this way the person with COPD deserves that illness (www.helsenett.no, 2016). This form of “victim blaming” ([6] Riley, 2017: 3) enforces the social stigmatization.
In Norway 80-95% of all COPD cases are primarily and directly attributed to smoking(80–95 %) (Bahr, 2009: 375). Also the GOLD report 2019 points out the “Often, the prevalence of COPD is directly related to the prevalence of tobacco smoking, although in many countries outdoor, occupational and indoor air pollution (resulting from the burning of wood and other biomass fuels) are major COPD risk factors.” (Gold, 2019: 5). During Cipla Respiratory Congress in Cape Town in 2016 healthcare workers were also advised to look for other non-tobacco-related factors which might explain a very high level of COPD all over SA: “tuberculosis … dagga, biomass fuel indoor pollution, postTB obstructive lung disease, HIV and early childhood and intrauterine issues that impaired lung development“(Bateman, 2016: 654) and mining. In Norway other reasons than smoking are marginal.
That makes me wonder if South African COPD patients feel as stigmatized as Norwegian patients? And if the stigmatization is experienced worse in Norway than in South Africa? Even if there are negative connotations related to COPD in both countries, a South African patient might have a more valid, less “stupid” cause for hers/his disease than a Norwegian. I have not found any studies about this theme, but it is worth reflecting about them nevertheless. Perhaps we in Norway tend to classify tobacco-related illnesses more connected to low education, low self-control and self-inflictedness. In South Africa one also seems to attribute COPD to low education and low-income – but additionally it also is connected with other physical diseases (HIV, tuberculosis), living in rural areas, cultural aspects like biofuel cooking and the coloured people´s smoking habits in big cities like Cape Town (Bateman, 2016: 654). These aspects might explain why there are far more women than men and far more coloured people than white people who get COPD in SA compared to Norway.
How might these stigmas influence the rehabilitation of COPD patients?
One result of stigmatization is that COPD still is under-diagnosed both in Norway and in South Africa (Allwood & van Zyl-Smit, 2015) – people do not want to be associated with this illness (or lung cancer) and it might take longer time before they go to the doctors and are diagnosed. Another effect might be that the psychological stress due to stigmas might lead to low self-confidence, low mastering skills and reduced self-efficacy. Additionally to be visible ill (use of inhalators or oxygen supple) and the anxiety of others about getting infected (coughing) might influence the rehabilitation process negatively and the patient might isolate her/himself more, get less physical activ, don’t work out in a fitness center and get more mentally stressed – getting into a bad circle of development. The stigma might also lead to a lower trust into healthcare system, and the patient might feel helpless.
As a physiotherapist I hope that the COPD patients in future will meet less victim blaming – and that we can contribute with empathy, knowledge about physical activities and breathing techniques positive impact on COPDs development, which might make life easier for COPD patients. I hope that the patient’s point of view in this sense will grow stronger in the time to come.
References
- Allwood, B. & van Zyl-Smit, R. N., 2015. Chronic obstructive pulmonary disease in South Africa: Under-recognised and undertreated. In: S Afr Med J2015;105(9):785. DOI:10.7196/SAMJnew.8429
- Bahr, R. et al, 2009. Aktivitetshåndboka.
- Bateman, C. 2016. Alarming rate of COPD. In: SA, S Afr Med J2016;106(7):654. DOI:10.7196/SAMJ.2016.v106i7.11147
- Berger, B.E., Kapella, M.C. & Larson, J. L. 2011. The experience of stigma in chronical obstructive pulmonary disease.In: Western Journal of nursing research 33(7) 9 1 6-932
- GOLD, 2019. Global strategy for diagnosis, management, and prevention of, chronical obstructive pulmonary disease, 2019 report.
- Riley, K.E., Ulrich, M.R., Hamann, H.A. PhD, and Ostroff, J.S. 2017. Decreasing Smoking but Increasing Stigma? Anti-tobacco Campaigns, Public Health, and Cancer Care. In: AMA J Ethics. ; 19(5): 475–485. doi:10.1001/journalofethics.2017.19.5.msoc1-1705.
Digital references
- https://www.helsenett.no/239-sykdommer/astma-og-kols/konsultasjoner/19714-deprimert-av-kols.html, downloaded 30.05.2019
- https://ec.europa.eu/health/sites/health/files/tobacco/docs/help_legacy.pdf, downloaded 30.05.2019
[1]The anti-tobacco campaigns, which obviously have changed smoking habits throughout the past 20-30 years, changed their “languages” from pure information about the negative consequences of smoking over advertisement restrictions, increasing the age of sale for tobacco and national prohibition or restriction of smoking in public places (forbidden by laws from 2003 in New York, 2004 in Norway and (https://snl.no/røykeloven) and as early as 1993 South Africa (downloaded 2019 04 22: The Tobacco Products Control Act of 1993 remains the principal tobacco control law in South Africa. 1993) to fear-arousing visual messages like on this cigarette package. You can read more about the campaigns development on https://ec.europa.eu/health/sites/health/files/tobacco/docs/help_legacy.pdfand at Riley, 2017.
3 thoughts on “Kaufmann, Martina: COPD stigma in Norway and South Africa from a patient’s point of view”
I really like the topic that you choose on the point of view of a patient, because at some point I also argued that people should somehow be held responsible for their actions specially when it comes to smoking. Despite the lack of education on the dangers of smoking, smokers are not completely oblivious of the fact that it influences health negatively. However, your assignment was an eye-opener since it made me aware of the patients’ reactions to these situations.
I would suggest that you clearly distinguish between the reflection and the academic pieces. I noted that some parts (e.g. the first few sentences of the last paragraph under the heading “COPD stigma in Norway and South Africa”) in the academic piece can be actually be discussed in the reflection and then just be supported by evidence in the academic part. The content is good and the text reflect the topic of the assignment instructions, the picture correlates with the text and the piece definitely changed my approach of what I patient might feel in clinical practice.
You made knowledgeable claims and provided good evidence. Just remember to make your views clear in the reflection and then provide evidence for those claims in the academic piece, as it than makes it easy for the reader to grasp your views followed by the evidence provided to support them. This than would make your piece logically consistent. Furthermore, I agree with a few points that you made, such as the negative effects stigma has on the mental health of patients and that there are definitely more underlying reasons for COPD cases in South Africa.
The references that you made use of are relatively strong, since it comes from journals and reports and they I feel quite confident about how they support your claims. Also, I have noticed that you made use of two different types of referencing styles, it is thus advised to stick to the APA reference style.
It reminds me that there are some grammar and spelling (e.g. the difference between patients and patient’s and activities instead of activity’s) mistakes that you should attend to in order to improve the overall piece. Word of advice: ask someone else to read over your piece after you made all corrections and feel ready to submit (another pair of eyes are often able to point out small mistake we tend to overlook).
Thank you for this assiagnment and how COPD in norway and south Africa is perceived differently.
Immediately when I saw your heading of the assignment, I was hoping you used a cigarette packaging for you picture. As a child I never understood why there were warnings on the packaging. I always thought people knew what they were doing to their bodies and just didnt care.
I like how the entire essay is on stigma. As what other people think also have an impact on the healing process of your patient. The most interesting part was how COPD is seen in you country and then seen in mine. If I received a COPD patient, different causes would fill my mind and not just smoking.
When writing an essay I usually take it as if the person reading it has no idea what Im talking about. Have you considered going more into depth about what COPD is, or even what it stands for? Also bring your thoughts and feelings about the subject into the essay. When elaborating on what a patient has told you about the topic, again give insight to the way the patient said it and how you think the patient was feeling when speaking to you about it.
I am glad you mentioned victim blaming because us as physiotherapists do it too. And we do it usually when just reading the file of the patient and not meeting them yet. It reminds me of a patient I received. All the information in the file was negative reports about how the person lives their life and then when meeting the patient I soon realised that it was a long time ago that the patient lived like that.
How does knowing COPD is not generalised in other countries? How does that make you feel as a physiotherapist?
Thank you so much for sharing this with me. I leant alot and it gave me more in sight in how patients feel about the disease they have and how what other peoples thoughts influence the patient as well.
Hi Martina , thank you for the assignment on COPD stigma in Norway and South Africa from a patient’s point of view. I have never really sat down and thought about what patients go through to get the treatment they need. I have never thought about how it could affect them socially and emotionally either. I like the picture that was chosen, it gives the reader an idea of what you’ll be talking about and the “connection” between the two topics. I like this cigarette packaging and I wish they had this visual packaging all over the world. I feel as if though people are not educated enough about the use of cigarettes here in South Africa. An image would make it clear to those who are literate and illiterate of what could happen to their lungs. I feel that people in South Africa are not as stigmatized as they are in Norway.
In the beginning of your essay, I feel that you could maybe give an explanation to what COPD’s are, as people who are not in the medical field would not understand it or maybe the explanation could help refresh the memories of those who are in the medical field. I like that you are fixed on one topic and you do not get lost on another topic. There are minor grammar issues that can be fixed. Maybe you could elaborate more on the points you have made, but your claims are well supported.
I like that the end of your essay ends on a positive, hopeful note for the future. Thank you for opening my eyes with this piece of work, I enjoyed reading it.