EDUCATION PRINCIPLES FOR A PARTNERSHIP IN

ASTHMA CARE

Learning strategies that contribute to successful asthma management

Presented by :Christina Perry, PhD

1. Need for effective patient education2. Barriers to learning3. Current educational concepts

a. Styles of learningb. Age-appropriate teaching / learning strategiesc. Effective communication and interviewing skills

4. Selecting appropriate educational material5. Health literacy

This session will cover:

Working in small groups:1. Identify a recorder/reporter2. Brainstorm to identify possible barriers to

learning3. Be prepared to share your ideas4. List all ideas on flip chart paper

No fair looking at your notes!

Activity: Barriers to Learning

• Education level• Understanding level:

material is inappropriate or too complex

• Reading comprehension• Hearing/Visual

impairment• Language - English is a

second language• Too much information at

one time

Barriers to Learning and Adherence

• Conflicting information• Uncomfortable

environment • Uninformed instructor • Attitude of instructor• Previous negative

experiences with learning

• Some patients have grown accustomed to the limitations of uncontrolled asthma, help them redefine what normal is.

• Teach your patients how to communicate with health care professionals

• Adherence (Compliance) in the long-run depends on early and continued success.

Barriers to Learning for Adults

Current asthma management approaches require patients and families to:

Patient Education

EFFECTIVELY CARRY OUT COMPLEX PHARMACOLOGIC REGIMENS

INSTITUTE ENVIRONMENTAL CONTROL STRATEGIES

COMMUNICATE APPROPRIATELY WITH HEALTH CARE PROVIDERS

DETECT AND SELF-TREAT MOST ASTHMA EXACERBATIONS

• Mechanism through which patients learn to effectively manage their asthma

• Powerful tool for helping patients gain the motivation, skill, and confidence to control their asthma

Importance of Patient Education

Education should be integrated

into all aspects of asthma care.

Education should be integrated

into all aspects of asthma care.

Education should be integrated

into all aspects of asthma care.

Excellence in Patient

Education

Improves adherence

Begins at the time of

diagnosis

Systematic (according to

a plan)

Integrated with medical

careReinforces critical

information

Establishes a partnership

Tailored to an individual

Starts with “Needs

Assessment”

Opportunities for Education

Patient should be

educated at multiple points of

care

ED/Hospital-

Based Education

Clinic/Office Based

Pharmacists

School Settings

Community Based

Home

Computer-Based

Technology

KEY CONCEPTS IN ASTHMA EDUCATION

Key Concepts in Asthma EducationUnderstand the basic facts about asthma

Define well-controlled asthma and current level of control

Recognize the roles of medications

Assess skills

Identify when and how to handle signs and symptoms of worsening asthma

Recognize when and where to seek care

Identify environmental exposure control measures

Education should be

provided by all members of

the healthcare team

Teach asthma self-management, tailoring the approach to the needs of

each patient.

Jointly develop treatment goals.

Provide patients with a daily asthma diary.

Teach and Reinforce at Every Opportunity

• Basic facts about asthma

• Roles of medications

• Skills: inhalers, spacers, self-monitoring

• Environmental control measures

• When and how to take rescue actions

Key Concepts in Asthma Education

Educational Efforts Should Be Continuous

• It may take up to six months for the impact of education to be evident.

• It is necessary to periodically review information and skills covered previously because patient self-management behavior is likely to decline over time.

Key Concepts in Asthma Education

For someone to effectively manage their asthma they need to:

Turning Education into Action

• Use metered-dose inhalers, spacers, and nebulizers correctlyTake medications

as prescribedIdentify and control

factors that make asthma worse

Self-monitor to:

Follow the written action plan when symptoms

occur

Benefits of Self-Management Skills

• Reduction of urgent care visits and hospitalizations

• Reduction of asthma-related health care costs

• Improvement in health status

LEARNING STYLES

A learning style is the unique collection of individual skills and preferences that affect how a person perceives, gathers and processes information.

Learning Styles

Learning Styles

Learning styles affect how a person:

• Acts in a group• Learns• Participates in activities• Relates to others• Solves problems• Teaches• Works

Three Main Learning Styles:

Visual

Auditory

Kinesthetic (Active)

• Gather information best by looking, reading, and watching

• May tune out spoken directions and favor illustrated explanations or charts

• May take notes even when they have printed notes on the desk in front of them

Visual Learners

• Learn well by discussing ideas • May learn better by being read written

information out loud• Are easily distracted by noises• Like background music to muffle interrupting

sounds

Auditory Learners

• Learn effectively through touch, movement and space.

• Learn skills by imitation and practice.

Kinesthetic (Active) Learners

People Learn Best If They See, Hear, and Do

• Verbal Explanations with Demonstration

• Use Examples and Analogies

• Provide Written Materials in Basic Language

• Ask For Return Demonstrations (e.g., correct use of inhalers and peak flow meters)

Learning Styles

People Learn Best If They See, Hear, and Do

• Ask questions and LISTEN

• Encourage questions, and test their understanding

• End with “What else can I answer for you?” or “is there anything else that concerns you?”

• Repeat key concepts in asthma education at each visit to reinforce asthma management skills

Learning Styles

COMMUNICATION SKILLS

COMMUNICATION IS CRITICAL

Encourage adherence: • promote open communication• individualize, review, and adjust plans as needed• emphasize goals and outcomes• encouraging family involvement

Document in the patient’s record:• key educational points• patient concerns • actions the patient agrees to take

Ask about patient concerns early.

Review the short-term goals agreed uponin the initial visit.

Review the action plan and the steps the

patient was to take.

Adjust the plan as needed.

Teach and reinforce key educational

messages.

Give patients simple, brief written materials that reinforce the actions recommended and

skills taught.

Promote Open Communication

• Show attentiveness (eye contact, attentive listening)• Give nonverbal encouragement (nodding agreement,

smiling)• Give verbal praise for effective management

strategies• Use open-ended questions:

Effective Interviewing Skills

Instead of “Have you tried to control the things that make your asthma worse?

If not, why not?

Try: “What have you done to control the things that make

your asthma worse?”

Assess Knowledge

• Identify what patient perceives as knowledge relevant to his care

• Determine education, literacy level

• Determine ability (and readiness) to learn and understand.

Use Effective Interviewing Skills To:

Assess patients’ and/or caregivers’ perception and beliefs about asthma and past experience:

• Belief in the severity and chronic nature of asthma and the efficacy of treatment

• Regarding use and long-term effects of medications

• Capacity to recognize severity of an exacerbation

Take Time to Listen

Knowledge

Motivation

Readiness to Learn

Health Literacy

Education / Understanding Barriers

Goals

Areas for Educational Assessment

Non-verbal communication

• Is recognizable in the initial three seconds after meeting someone for the first time.

• Can continue through the entire interaction. • Accounts for approximately 70% of a

communication episode.• Can impact the success of communication more

acutely than the spoken word.

Nonverbal Communication Skills

Voice

Facial Expression

Eye Contact

Posture

Gesture

TEACHING/LEARNING STRATEGIES

Attention Span

Information from: Pediatric Asthma Promoting Best Practice: Guide for Managing Asthma in Children. American Academy of Allergy, Asthma & Immunology

Deliver the information in a way that will be easily understood and accepted.

• Deliver the information in several different ways

• Repeat the information often

• Use written material for reinforcement

• Be aware of literacy issues

Teaching / Learning Strategies

For Preschool Children:• Keep teaching sessions short (no more than 15 minutes)

– Schedule sessions close together• Use small group sessions with peers help• Use short, simple, direct messages• Provide visual and physical stimuli, use bright bold colors

and pictures• Use active learning techniques

– Allow to play-act with dolls and puppets• Encourage child to participate in selecting between

teaching – learning options

Age-appropriate teaching strategies

For School-Aged Children:• Use analogies to increase understanding• Teach Skills• Use materials showing peers dealing with similar

problems• Provide opportunities for private instruction• Provide opportunities for group interaction and

games• Session can last for up to 30 minutes

– Spread sessions apart to allow for practice of new skills• Provide support

Age-appropriate teaching strategies

Treatment issues include:• Remembering to take medication• Handling exercise induced problems• Recognizing symptoms and requesting

treatment• Avoiding triggers

– Involve the child as much as possible, including development of the asthma plan.

Teaching Approaches for Children

For Teens: • Medication use and teen lifestyle• The need to conform vs. the need to avoid

triggers– Social situations– Physical activity

• Feeling of immortality• Lack of understanding from others

Adherence (Compliance) Issues

Adolescents should receive ALL informationTeens and young adults tend not to look after themselves and rarely ask for help. This is the result of four factors:1. Independence2. Rebellion3. Peer Influence4. Poor or non-compliance/adherence

Strategies for Teaching Teens

• Use one-on-one instruction when possible• Respond best to peers • Use group discussion with role-play and

interactive games• Use problem solving activities• Use various forms of visual educational tools

Strategies for Teaching Teens

• Clarify terminology• Provide sincere, honest personal contact• Treat them with respect, acknowledge their

feelings• Empower them to make their own decisions and

to take responsibility for their own care• Provide simple approaches to therapy

Strategies for Teaching Teens

Adults Learn Best When:• Learning is related to an immediate need, problem

or deficit• Learning is voluntary and self-regulated• Learning is person-centered and problem-centered• Learning is self-controlled and self-directed• The role of the teacher is one of facilitator• Information and assignments are pertinent• New material draws on past experiences and is

related to something the learner already knows

Strategies for Teaching Adults

Adults Learn Best When:• The threat to self is reduced to a minimum in the

educational situation• The learner is able to participate actively in the

learning process• The learner is able to learn in a group• The nature of the learning activity changes

frequently• Learning is reinforced by application and prompt

feedback.

Strategies for Teaching Adults

Source: Nurse as Educator: Principles of Teaching and Learning

• Build on and incorporate their experiences into their education plan.

• Present factual information that can help them make decisions and they prefer self-direction.

Strategies for Teaching Adults

• Alterations in physiological functioning can lead secondarily to changes in learning ability– Slower processing time– Persistence of stimulus (afterimage)

• Confuse a previous symbol or work with a new one

– Decreased short-term memory– Increased test anxiety – anxious

about making mistakes– Altered time perception

• I’ll worry about that tomorrow

Older Adults

Older adults constitute approximately 12% of the US population. By 2030, this number is expected to increase to 21%.

• Compensate for visual changes– Environment that is well-lit– Visual Aids in large print, well spaced– Avoid blue, blue-green and violet hues

• Compensate for hearing loss– Eliminate extra noise– Speak face to face

• Short sessions with frequent breaks• Check psychomotor skills• Allow increased time to process and react to

information

Teaching Strategies for Older Adults

• Teach Problem Solving Skills• Define problem in behavioral terms• Divide stressful events into smaller, manageable

tasks• View “failure” as learning via feedback• Generate & evaluate solutions• Make contingency plans

Teaching Strategies for all ages

HEALTH LITERACY

Key Messages:• Assess understanding at every opportunity.• Enlist family members or volunteers to help.

If low-literacy is suspected, tell the patient, “Many people have trouble reading and remembering these materials.” Ask, “is that a problem for you?”

Low Literacy

Health literacy refers to the ability to read, understand, and act on health information:

• A 1999 report from the American Medical Association (AMA), points out that, “Poor literacy is a national crisis… almost half our adult population has basic deficiencies in reading, computational skills, or English.”

• The AMA reports that low health literacy is a major cause of rehospitalization and other complications among the elderly, the group that uses medical services most often; the decline in health literacy occurs regardless of education level.

Health Literacy

One-third of English-speaking patients at two public hospitals could not read and understand basic health-related materials:

• Overall, 42% of patients were unable to comprehend directions for taking medication on an empty stomach

• 26% could not understand information on an appointment slip

• 60% could not understand a standard consent form

Functional Health Literacy

Williams MV, Parker RM, Baker DW, et al, Inadequate functional health literacy among patients at 2 public hospitals. JAMA. 1995; 274: 1677-1682.

• People with low literacy, language barriers, lack of education, or the elderly or poor often face the most challenges in practicing healthy behaviors and navigating the healthcare system.

• However, even highly educated people when faced with a disturbing diagnosis, a chronic disease, or the anxiety associated with an unexplained pain can be affected by health illiteracy.

Health Literacy

The Rhode Island health Literacy Project http://www.rihlp.org/index.cfm

DESIGNING PATIENT EDUCATION MATERIALS

People at all literacy levels prefer simple materials

• Supplement text with pictures or diagrams• Reading level should be no higher than 5th grade.• Put most important information first and separate from the text. • Use clear captions and ample white space• Use short, simple words and common terms whenever possible (for example “cut” instead of

laceration). • Define medical or insurance terms in simple language.

Designing Patient Education Materials

• Emphasize the desired behavior (call to action), rather than the medical facts. Use examples.

• Limit to one or two educational objectives.• Use personal pronouns such as “you” and “your.” • Be culturally inclusive with text and graphics.

Address the cultural and ethnic diversity of the target audience.

Designing Patient Education Materials

• SMOG uses 30 sentences and the number of words with three or more syllables.

• FOG uses the number of word per sentence and the number of words with three syllables or more.

• Flesch Formula uses average sentence length in selected samples of 100 words.

All of these indicate reading ease and not comprehension.

Readability Formulas

• Written materials and formal education programs can supplement, but not replace patient education provided in the office.

• Patients may benefit from a formal asthma education program that has been evaluated and reported in the literature to be effective.

http://www.cdc.gov/asthma/interventions/children.htm#schoolsOpen Airways for Schools: 1-800-LUNG-USAAsthma Care Training (ACT) for Kids: 1-800-7-ASTHMA Creating a Medical Home for Asthma:http://www.nyc.gov/html/doh/html/cmha/index.html.

Educational Resources

All materials should be evaluated before you use them for teaching.

• From a reliable source• Accurate• Culturally relevant• Current• Written at the appropriate educational level

Selecting Patient Education Materials

Materials must be:

American Academy of Allergy, Asthma and Immunology. Pediatric Asthma Promoting Best Practice – Guide for Managing Asthma in Children. 1999.

Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. NHLBI/WHO Workshop Report.

American Association for Respiratory Care. Clinical Practice Guideline:Providing Patient and Caregiver Training. Respiratory Care 1996; 41(7):658-663

National Asthma Education and Prevention Program Task Force on the Cost Effectiveness, Quality of Care, and Financing of Asthma Care. National Institutes of Health, 1996

Better Communication, Better Care: Provider Tools to Care for Diverse Populations. Health Industry Collaboration Effort (ICE).

References

• Lori KondasAmerican Lung Association in Ohio

• Michelle Mercure, CHESAmerican Lung Association in Wisconsin

Acknowledgements

We will breathe easier when the air in everyAmerican community is clean and healthy.

 We will breathe easier when people are free from the addictivegrip of cigarettes and the debilitating effects of lung disease. 

We will breathe easier when the air in our public spaces andworkplaces is clear of secondhand smoke.

We will breathe easier when children no longerbattle airborne poisons or fear an asthma attack. 

Until then, we are fighting for air.