Patient-centered education: applying learner-centered concepts to asthma education

Development of Healthcare Service Design Concepts for NICU Parental Education

The objective of this study was to develop healthcare service design concepts through an empirical study utilizing design thinking to improve the quality of caregiver education provided in the neonatal intensive care unit (NICU). This study adopted the Double Diamond Process of service design comprising the discover, define, and development stages. We identified 7 issues, organized into 10 healthcare service design concepts associated with NICU education: improving the design of educational material, improving materials for high-risk infant guidance, a practicum kit, a parent proficiency checklist, a systematic parent education manual, predictable guidelines for tests and treatment plans, waiting time that provides comfort, message cards that convey feelings, a reservation system for visits, and a post-discharge information sharing platform. The service concepts' effectiveness was verified through evaluations by healthcare experts. The results represent customers' perspectives and experiences regarding parental education. The application of the healthcare service design method could be further developed in future studies. The 10 service concepts derived from this study can be applied and evaluated as specific NICU educational programs.

An integrated operational definition and conceptual model of asthma self-management in teens

OBJECTIVES

A previous definition of adolescent asthma self-management was derived from interviews with clinicians/researchers and published literature; however, it did not incorporate perspectives of teens or parents. Therefore, we conducted in-depth interviews with teens and parents and synthesized present findings with the prior analysis to develop a more encompassing definition and model.

METHODS

Focal concepts were qualitatively extracted from 14-day self-management voice-diaries (n = 14) and 1-hour interviews (n = 42) with teens and parents (28 individuals) along with concepts found in the previous clinical/research oriented analysis. Conceptual structure and relationships were identified and key findings synthesized to develop a revised definition and model of adolescent asthma self-management.

RESULTS

There were two primary self-management constructs: processes of self-management and tasks of self-management. Self-management was defined as the iterative process of assessing, deciding, and responding to specific situations in order to achieve personally important outcomes. Clinically relevant asthma self-management tasks included monitoring asthma, managing active issues through pharmacologic and non-pharmacologic strategies, preventing future issues, and communicating with others as needed. Self-management processes were reciprocally influenced by intrapersonal factors (both cognitive and physical), interpersonal factors (family, social and physical environments), and personally relevant asthma and non-asthma outcomes.

CONCLUSION

This is the first definition of asthma self-management incorporating teen, parent, clinician, and researcher perspectives, which suggests that self-management processes and behaviors are influenced by individually variable personal and interpersonal factors, and are driven by personally important outcomes. Clinicians and researchers should investigate teens' symptom perceptions, medication beliefs, current approaches to symptom management, relevant outcomes, and personal priorities.

Training physiotherapy students to educate patients: A randomised controlled trial

OBJECTIVE

To determine the effect of a training intervention on physiotherapy students' self-efficacy and skills in the area of patient education.

METHODS

Final year physiotherapy students were randomised to an intervention group or a wait-list control group. The intervention group participated in a 3.5h training intervention about patient education that included video observation, simulated patient practice and structured feedback. The control group did not receive any training. Self-efficacy was assessed at baseline (T1) and after the intervention (or no intervention for the control group) (T2). Patient education performance was assessed by a blinded rater from a video-recorded standardised clinical examination.

RESULTS

83 students were randomised to the intervention group and 81 students to the control group. There were no differences in demographic variables or self-efficacy between groups at baseline. There was significant improvement in self-efficacy for the intervention group, but no change for the control group. The intervention group performed significantly better than the control group for nine of the eleven performance items, with significantly higher scores overall.

CONCLUSION

A training intervention enhances physiotherapy student self-efficacy and performance in patient education.

PRACTICE IMPLICATION

Use of patient education training is recommended to enhance student self-efficacy and performance.

Explaining the causal links between illness management and symptom reduction: Development of an evidence-based patient education strategy

OBJECTIVE

To determine whether explaining the causal links between illness management and symptom reduction would help younger and older adults learn and apply health information.

METHOD

Ninety younger and 51 older adults read about a fictitious disease with or without explanations about the cause-and-effects (causal information) of illness management. A knowledge test (applied vs. factual items) was administered immediately and 1-week following the presentation of health booklets. Reading comprehension, working memory and health literacy were assessed as covariate variables.

RESULTS

Younger adults outperformed older individuals on the applied and factual items at both time points. After controlling for covariates, causal information facilitated the comprehension and application of health information for younger but not older adults. Reading comprehension was the best predictor of test performance in the older sample.

CONCLUSIONS

Providing an explanation of why illness management is effective for reducing symptomatology can help improve knowledge and application of health information for younger individuals. For older adults, lowering the verbal demands of patient education materials may be a better way to help them learn new health information.

PRACTICE IMPLICATIONS

Use of causal information as a teaching strategy in patient education may enhance individuals' ability to learn about and implement self-care strategies.

A comparison of patient education practices and perceptions of novice and experienced physiotherapists in Australian physiotherapy settings

BACKGROUND

Patient education is an integral component of physiotherapy practice. Little is known about the differences in reported use and perception of patient education between experienced and novice physiotherapists. Understanding these differences has important implications for training approaches and physiotherapy practice.

OBJECTIVES

To compare how experienced and novice physiotherapists report frequency of patient education practices and their perceptions of the importance of these practices.

DESIGN AND METHODS

A web-based purpose-designed survey was developed, piloted and administered to practicing physiotherapists through direct email. Of 305 complete responses, two subgroups were explored for comparative analysis: 'novice' (≤5years' experience, n = 52); and 'experienced' (≥11 years' experience, n = 204).

RESULTS

The experienced group rated 14 of 15 educational items higher than the novice group in relation to frequency of use and perceived importance. Experienced physiotherapists reported a significantly higher frequency of using one-to-one discussion, personalised handouts and explicitly seeking patient understanding (p < 0.05). Novice physiotherapists perceived more barriers to patient education, particularly those related to characteristics of the patient (p < 0.05).

CONCLUSION

Experienced physiotherapists report higher use of self-management education and education content that is patient-centred. Experienced therapists report a higher frequency of seeking explicit patient understanding to evaluate their teaching than novice physiotherapists and perceive fewer patient-related barriers to their practice. These findings are important when considering teaching and learning of patient education skills. Students or novice physiotherapists may benefit from strategies to facilitate patient-centred education, self-management education, evaluation approaches and strategies to manage barriers.

Asthma in intellectual disability: are we managing our patients appropriately?

People with intellectual disability are a vulnerable group of people with asthma that has, to date, largely been ignored in the medical literature. Although guidelines for medication management for people with intellectual disability suggest asthma is treated as for other populations, there are special considerations that should be taken into account when managing asthma in this group. Due to their cognitive impairment as well as comorbidities, they are likely to require support with asthma self-management, including inhaler use. Their varying degrees of autonomy mean that there is often a need to provide education and information to both the person and their caregivers.

EDUCATIONAL AIMS

To understand general principles of health of people with intellectual disability and how this affects the healthcare professional's approach to asthma management.To understand how intellectual disability affects cognition, autonomy and communication, and therefore the ability of a person to self-manage asthma.To recognise ways of mitigating respiratory disease risk in people with intellectual disability.To describe ways for healthcare professionals to support people with intellectual disability and their caregivers in asthma management.

Knowledge that people with intellectual disabilities have of their inhaled asthma medications: messages for pharmacists

BACKGROUND

Fifteen percent of Australians with intellectual disability (ID) are reported to have asthma. People with ID are at risk of poor health knowledge due to deficits in intellectual and adaptive functioning, but their medication knowledge has largely been ignored in research to date.

OBJECTIVE

To explore the level of understanding of asthma medication use of people with ID who self-administer their inhaled medications, in order to inform future educational support. Setting The research was conducted in NSW, Australia, at the participants' homes, the point of health care access, or the offices of relevant support organisations.

METHOD

In this qualitative study face-to-face interviews were conducted with people with ID using a semi-structured interview guide. The interviews were recorded, transcribed and thematically analysed. Main outcome Identification of barriers to asthma medication self-management by people with ID.

RESULTS

Seventeen people with ID who self-administer their asthma medications were interviewed. Factors influencing their asthma medication knowledge and use included understanding of their illness and the need for medication; aspects of self-management and autonomy versus dependence. This sample of people with ID had a good understanding of the importance of using their inhaled asthma medications, as well as asthma triggers, and the difference between use of preventer and reliever medications. Both enablers and barriers to asthma medication self-management were identified in the domains of managing attacks, adherence, knowledge of side effects and sources of information on correct use of inhalers. The level of autonomy for medication use varied, with motivation to self-manage asthma influenced by the level of support that was practically available to individual participants.

CONCLUSION

This research investigated aspects of asthma medication self-management of people with ID. Based on the barriers identified, pharmacists should promote use of spacers and written asthma action plans as well as counsel people with ID about how to recognise and minimise side effects of asthma medications. Specific strategies for pharmacists when educating people with ID and their caregivers include active listening to determine understanding of concepts, exercising care with language, and working with the person's known routines to maximise adherence with preventer medications.

Asthma self management in adults: a review of current literature

Self management programs for chronic conditions, such as asthma, have an important place in healthcare delivery. When properly implemented, they can curb the impact of disease and reduce both the high personal costs for individuals and significant financial costs for health care systems. The purpose of this review was to establish an understanding of current published literature on asthma self management programs in adults and to identify any reported attributes or components which serve to either assist or obstruct the uptake of self management strategies. Electronic data sources including Scopus, Proquest 5000, CINAHL, PubMed and Web of Science were accessed and literature searches were conducted using the key terms: asthma, chronic disease, self management, morbidity, quality of life, health outcomes, patient education and best practice. Inclusion criteria for the search included journal articles relating to adults with asthma published in English in peer reviewed journals from 1995 to 2011. Exclusion criteria included research targeting children, parents of children or families; and articles examining Asthma and COPD (or any other co-morbidity). Sixty four articles were included in this review due to their relevance to the major components of asthma self management, as defined by the Australian Asthma Management Handbook. A major conclusion from this review was that the uptake of asthma self management strategies is poor despite global recommendations for over twenty years; and that a likely reason for this is that generic asthma self management advice does not engage the individual with asthma.

Electronic reminders to patients within an interactive patient health record

Keeping patients with complex medical illnesses up to date with their preventive care and chronic disease management services, such as lipid testing and retinal exam in patients with diabetes, is challenging. Within a commercially available electronic health record (EHR) with a secure personal health record (PHR), we developed a system that sends up to three weekly reminders to patients who will soon be due for preventive care services. The reminder messages reside within the secure PHR, which is linked to the EHR, and are displayed on a screen where patients can also send to the physician's office an electronic message to request appointments for the needed services. The reminder messages stop when the patient logs on to review the reminders. The system, designed with patient input, groups together all services that will be due in the next 3 months to avoid repeatedly messaging the patient. After 2 months, the cycle of reminders begins again. This system, which is feasible and economical to build, has the potential to improve care and compliance with quality measures.

The effects of combining Web-based eHealth with telephone nurse case management for pediatric asthma control: a randomized controlled trial

Background

Asthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games.

Objectives

To test the effects of (1) CHESS+CM, a system for parents and children ages 4–12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children.

Methods

We identified eligible parent–child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data.

Results

Of 305 parent–child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child’s Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = –0.31, 95% confidence limits [CL] –0.56, –0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL –0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL –8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM’s effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64).

Conclusions

Integrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control.

Trial Registration

Clinicaltrials.gov NCT00214383; http://clinicaltrials.gov/ct2/show/NCT00214383 (Archived by WebCite at http://www.webcitation.org/68OVwqMPz)

Patient-centered care and its effect on outcomes in the treatment of asthma

Patient-centered care may be pivotal in improving health outcomes for patients with asthma. In addition to increased attention in both research and clinical forums, recent legislation also highlights the importance of patient-centered outcomes research in the Patient Protection and Affordable Care Act. However, whether patient-centered care has been shown to improve outcomes for this population is unclear. To answer this question, we performed a systematic review of the literature that aimed to define current patient-focused management issues, characterize important patient-defined outcomes in asthma control, and identify current and emerging treatments related to patient outcomes and perspectives. We used a parallel search strategy via Medline(®), Cochrane Central Register of Controlled Trials, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO(®), complemented with a reference review of key articles that resulted in a total of 133 articles; 58 were interventions that evaluated the effect on patient-centered outcomes, and 75 were descriptive studies. The majority of intervention studies demonstrated improved patient outcomes (44; "positive" results); none showed true harm (0; "negative"); and the remainder were equivocal (14; "neutral"). Key themes emerged relating to patients' desires for asthma knowledge, preferences for tailored management plans, and simplification of treatment regimens. We also found discordance between physicians and patients regarding patients' needs, beliefs, and expectations about asthma. Although some studies show promise regarding the benefits of patient-focused care, these methods require additional study on feasibility and strategies for implementation in real world settings. Further, it is imperative that future studies must be, themselves, patient-centered (eg, pragmatic comparative effectiveness studies) and applicable to a variety of patient populations and settings. Despite the need for further research, enough evidence exists that supports incorporating a patient-centered approach to asthma management, in order to achieve improved outcomes and patient health.

Feasibility of promoting smoking cessation among methadone users using multimedia computer-assisted education

Background

The prevalence of smoking is very high among methadone users. As a method of delivering health education, computers can be utilized effectively. However computer-assisted education in methadone users has not been evaluated systematically.

Objective

This study was aimed at assessing feasibility and patient acceptance of an interactive educational module of a multi-component smoking cessation counseling computer program for former illicit drug users treated in an outpatient methadone clinic.

Methods

The computer-mediated education for hazards of smoking utilized in this study was driven by major constructs of adult learning theories. The program interface was tailored to individuals with minimal computer experience and was implemented on a touch screen tablet PC. The number of consecutive methadone-treated current smokers enrolled in the study was 35. After providing socio-demographic and smoking profiles, the patients were asked to use the educational program for 40 minutes. The impact of the computer-mediated education was assessed by administering a pre- and post-intervention Hazards of Smoking Knowledge Survey (HSKS). An attitudinal survey and semi-structured qualitative interview were used after the educational session to assess the opinions of participants about their educational experience.

Results

The computer-mediated education resulted in significant increase of HSKS scores from 60.5 ± 16.3 to 70.4 ± 11.7 with t value 3.69 and P < .001. The majority of the patients (78.8%) felt the tablet PC was easy to use, and most of the patients (91.4%) rated the educational experience as good or excellent. After controlling for patient baseline characteristics, the effect of computer-mediated education remained statistically significant.

Conclusions

Computer-assisted education using tablet PCs was feasible, well-accepted, and an effective means of providing hazards of smoking education among methadone users.