Measures and methods in evaluating patient education programs for chronic illness

A systematic review of patient education in cardiac patients: do they increase knowledge and promote health behavior change?

OBJECTIVE

(1) To investigate the impact of education on patients' knowledge; (2) to determine if educational interventions are related to health behavior change in cardiac patients; and (3) to describe the nature of educational interventions.

METHODS

A literature search of several electronic databases was conducted for published articles from database inception to August 2012. Eligible articles included cardiac patients, and described delivery of educational interventions by a healthcare provider. Outcomes were knowledge, smoking, physical activity, dietary habits, response to symptoms, medication adherence, and psychosocial well-being. Articles were reviewed by 2 authors independently.

RESULTS

Overall, 42 articles were included, of which 23 (55%) were randomized controlled trials, and 16 (38%) were considered "good" quality. Eleven studies (26%) assessed knowledge, and 10 showed a significant increase with education. With regard to outcomes, educational interventions were significantly and positively related to physical activity, dietary habits, and smoking cessation. The nature of interventions was poorly described and most frequently delivered post-discharge, by a nurse, and in groups.

CONCLUSIONS

Findings support the benefits of educational interventions in CHD, though increase in patients' knowledge and behavior change.

PRACTICE IMPLICATIONS

Future reporting of education interventions should be more explicitly characterized, in order to be reproducible and assessed.

Changes in conceptions of meaning, effects and treatment of amblyopia. A phenomenographic analysis of interview data from parents of amblyopic children

The research reported is an experimental study on the effects of intensified education of parents of children with amblyopia on their understanding of the nature of the defect, its origins and treatment. Parents in the control group were exposed to the ordinary information provided at two departments of paediatric ophthalmology, whereas parents in the experimental group, attending the same clinics, were asked to read a booklet aiming at enhancing their understanding of amblyopia and its treatment. Experimental as well as control subjects were thereafter interviewed about their understanding of the meaning of amblyopia and amblyopia-related phenomena. Data were generated in single subject, semi-structured, in-depth interviews which were taped and transcribed in extenso. The interviews were analyzed according to the phenomenographic approach: i.e. the outcome is a description of the various conceptions that emerged in the interviews. In almost all cases the categories of meaning could be hierarchically ordered with regard to the level of understanding implied. Parallel to the interviews the subjects had also filled out a questionnaire assessing general and specific attitudes towards disease and treatment (the Health Belief Model, HBM). The results reveal a superior understanding among parents in the experimental group. The experimental group had also changed attitudes towards disease and treatment in a direction that would favour compliance, more than could be observed in the control group. The outcome is discussed in terms of the role of understanding for a compliant behaviour. It is also emphasised that health care personnel would profit from being aware of the nature of common misconceptions of diseases and their treatment, in the sense that they would be better prepared for entering instructional dialogues with patients or, as in this case, other persons responsible for the management of prescriptions provided.

Effects of an irritable bowel syndrome educational class on health-promoting behaviors and symptoms

OBJECTIVE

The degree to which patient education in the areas of diet, exercise, and stress management can improve symptoms of irritable bowel syndrome (IBS) through healthier lifestyle behaviors is unknown. The aim of this study was to determine the effects of outpatient education on the short and long term outcomes, and the association between health-promoting behaviors and symptoms.

METHODS

Pender's Health Promotion Model provided the theoretical framework. The study had a prospective longitudinal design. A consecutive sample of 52 adult outpatients with IBS attended a structured class that taught health-promoting modifications of lifestyle. Participants completed the Health-Promoting Lifestyle Profile (HPLP) and selected items from a Bowel Disease Questionnaire (BDQ) before the class and 1 month and 6 months later. Spearman rank correlations were used to assess the association between HPLP and symptom scores. Wilcoxon rank sum tests compared changes in scores versus their baseline values.

RESULTS

Response rates at 1 and 6 months were 75% and 83%, respectively. Results revealed significant 1- and 6 month-improvements in pain and Manning symptoms (p < 0.01) and in some HPLP scores (exercise at 1 month, p < 0.05; stress management at 6 months, p < 0.01). Significant associations were found between some, but not all, HPLP and symptom scores over time.

CONCLUSION

A structured IBS educational class for patients with IBS improved symptoms and some health-promoting behaviors. However, relationships among specific behaviors and specific symptoms did not consistently correspond with this improvement.

Kids Health Day: one community hospital's approach to health education for families

This paper describes a health fair for children and their families that is designed to decrease children's fear and apprehension about being hospitalized either as inpatients or outpatients; introduce hospital departments, personnel, equipment and tests to children in a non-threatening atmosphere; teach children about good health and safety, and encourage them to use sound health processes. The sponsor, Kennebec Valley Medical Center, is a 165 bed community hospital in Central Maine which serves a primarily rural population base of approximately 70,000 people. The planning process is discussed, activities and events are highlighted, and financial and promotional caveats and examples are provided. Screening data are presented, along with their outcomes, and evaluation instruments and findings also are discussed. Kids Health Day received a 1994 Blue Ribbon Award from the New England Healthcare Assembly.

The role of patient education in cancer pain control

Patient education should be a central component of pain control regimens for cancer patients. Few systematically developed and carefully evaluated pain control patient education programs have been reported. Patient education for cancer pain control should include five phases: assessment, goal setting, selection of educational strategies, implementation and reassessment. Each of these phases should be included to maximize the goals of pain prevention and pain relief.

[Level of knowledge of patients with type II diabetes mellitus in primary care]

A personal interview to 148 patients was carried out with the aim of getting to know the level of information of type II diabetic patients at an Urban Health Center in Santander. A validated questionnaire made up of 14 questions on general aspects of diabetis, dietetic habits and capability to handle complications was used. The Cronbach's alpha coefficient of questionnaire was 0.69. The correct answer average was 6.3 (IC = 5.9-6.5). Patients were best informed about general aspects and had much less information with regard to the handling of complications and to their diet. The differences among these three sections of questions were significative (p less than 0.001). The patients under diet treatment obtained worse results than those treated with oral hipoglucemiants and insulin. Our results are worse than those reported by other similar populations at a national level. Also, and due to the differences in knowledge within this group, we believe that the establishment of groups and subgroups when educating diabetic patients is possible and also highly recommended.

The relationship between a couple's marital adjustment and beliefs about diabetes mellitus

Twenty married couples with one partner diagnosed as having diabetes at age 40 or older within the past 5 years participated in this study. Participants completed the diabetes or family version of Beliefs About Diabetes (BAD) and the Dyadic Adjustment Scale (DAS). Results showed that perceived barriers to diet and to medication by the person with diabetes were associated with higher marital satisfaction and quality of marriage. In contrast, for the nondiabetic spouse, the perceived benefits of diet were negatively associated with the ability to work with the diabetic spouse. Additional research is needed to better understand the effect of diabetes on the marital relationship.

Importance of attitude evaluation in diabetes patient education

Attitudes were evaluated according to the 'Personal Responsibility Attitude Assessment System' (PRAS), which allows grading of patients' attitudes into five levels of perception of responsibility toward their disease. In 59 diabetics evaluated in this study, no sex difference was observed in attitude level, but more of those aged less than 40 years showed lower attitude levels (levels 1-4) than those aged 40 years or over (P less than 0.01). Of those aged 40 or over, more patients with a high attitude level (level 5) had had diabetes for 10 years or longer than those with low attitude levels (levels 1-4) (P less than 0.05). Among those not treated with insulin, patients with a low attitude level showed higher hemoglobin A1 (HbA1) levels (P less than 0.01) and more frequently had retinopathy (P less than 0.05) than patients with high attitude levels. As for women, low attitude level patients consumed less fruit, meat or fish, and vegetables (P less than 0.05) but more fat and sweetening agents (P less than 0.05) than high attitude level patients. These results suggest an association between the attitude level of diabetic patients evaluated by PRAS and the degree of their self-care. Evaluation of patients' attitudes is important in predicting the response to educational intervention in diabetes.

Response of diabetic patients to a community-based education program

A community-based diabetes education program was developed in rural Minnesota in conjunction with the Minnesota Department of Health and the Centers for Disease Control, Division of Diabetes Control. A patient education program was a part of this effort and was structured to provide information according to the needs of the diabetic individual. Patient progress was measured at four intervals (base line, 3 months, 6 months, 12 months) throughout a one-year period using standardized behav ioral and physiologic measures. Preliminary results demonstrated improvements in dietary com pliance among all program participants, and improvements in home glucose monitoring com pliance among Type II diabetic participants only. Among Type II participants, total glycosylated hemoglobin values demonstrated a statistically significant decrease from the baseline measure. These results suggest that educational efforts have been successful and that the program appears to be a viable model for rural communities.

Differences in patient knowledge about diabetes as a function of type of primary care physician

This study examined whether or not patients (n =57) of specialists in diabetes differed from patients (n=211) ofnonspecialists in terms of their knowledge about diabetes before and after a standardized patient education program in diabetes. A specialist was defined as a physician whose practice consisted of 50 % or more diabetic patients. Patient knowledge about diabetes was measured with a 50-item ques tionnaire consisting of seven subscores and a total score. Prior to the program, the two groups did not differ on five of the subscores nor on the total score. There were statistically significant differences on two of the subscores on the pretest: Methods of Control and Pattern Control, with the specialist group scoring better than the nonspecialist group. No differences on any of the scores were found at the end of the program, nor were there differ ences in the amount of knowledge gained during the program. Several interpretations of these findings are suggested and the implications for patient and physician education and the need for further research are discussed.

The differential impact of diabetes type on female sexuality

Although diabetes is associated with a high prevalence of erectile impairment in men, its effect on the sexuality of women remains unclear. Since diabetes consists of different disorders, diabetes type may have confounded previous studies by differentially impacting on sexual functioning and marital satisfaction. To evaluate this possibility, 35 Type I diabetic married women were compared with 42 healthy married controls and 23 Type II diabetic women with 23 controls. Assessments were made on all aspects of sexual response, activity, dysfunction and satisfaction; on cognitive and psychological dimensions of sexuality; and on marital adjustment. Results indicated that diabetes type is highly associated with sexual responsiveness and marital satisfaction. Type I diabetes was found to have little or no effect on women, while Type II diabetes had a pervasively negative impact on sexual desire, orgasmic capacity, lubrication, sexual satisfaction, sexual activity, and on the relationship with the sexual partner.

Anxiety and the timing of diabetes teaching in the hospital: a literature review

The literature on anxiety and learn ing, especially as it relates to the newly diagnosed hospitalized adult diabetic patient, was reviewed. The concept that the diabetes diagnosis does consti tute an anxiety-producing event was well substantiated, as well as the con cept that such anxiety can and does interfere with learning. The literature suggests that the deterrent effect of this anxiety may be modified by proper timing of the teaching as well as knowledge of other environmental stressors. Useful strategies for the health educator to employ in such situations are suggested.

Adaptation in chronic illness: an eclectic model for nurses

The growing prevalence of chronic illness is due, in large part, to the control and/or eradication of infectious diseases as well as, in North America, the increasingly aged population and overall lengthening life span. Although the trajectory of chronic illness is in a generally downward direction, the rate of progression may vary as plateaux an remissions occur. As these changes occur, the individual and his family move through a process of continual adjustment. This paper presents a conceptual model of the process of adaptation in chronic illness. The primary concept in the model is appraisal (Lazarus, 1966) and the thought that continuous appraisal/reappraisal of the individual's progress toward the goal of adaptation is required by the individual, his family, and the nurse. The focus of the model is the chronically ill individual and his family. The goal is movement toward adaptation to the illness and its ramifications. The process is caring, which facilitates movement towards the goal. The model and its interpretation are outlined in the paper. Finally, some strategies for nurses, and others, are suggested as ways in which the concepts may be applied and implemented in practice.

The effectiveness of progressive relaxation in chronic hemodialysis patients

An experimental group of 38 patients on chronic hemodialysis were presented a 30-min, self-instructional, color videotape on progressive relaxation (PR) exercises; and a control group of 23 patients viewed a neutral videotape. Both groups were given the State-Trait Anxiety Inventory while on the dialysis machine, before and after the actual viewing. The experimental group significantly reduced its state anxiety level while the control group remained the same. Patients who reported higher levels of state anxiety and experienced tension more frequently tended to achieve the greater benefit from the program. It is postulated that PR can be a useful resource to overcome the sometimes severe anxiety related to the stresses of chronic hemodialysis.

Education and counselling for cancer patients--lifting the shroud of silence

A demonstration education and counselling project for cancer patients was developed in a community hospital. A team comprising a psychologist and a nurse patient educator were added to existing hospital staff. Based on this experience, we have defined the primary educational and emotional needs of the cancer patient and delineated the related functions and activities of project staff. The organization, nature, and volume of the education and counselling services are presented to provide a framework for others interested in embarking on similar efforts.