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MANAGING EDUCATIONAL, PSYCHOSOCIAL AND CULTURAL ISSUES

Rachael Ali-Permell, BS, RT,RRT-NPS, AE-C

Director Respiratory Therapy Department Long Island Jewish Medical Center

Faculty Quinones Healthcare Seminars, LLC

CONTENT

¢ Describe psychosocial, economic and family factors placing individuals with asthma at high risk for inadequate asthma control

¢  Implement ways to improve social support

¢ Recognize the importance of culturally sensitive approaches to individuals and families

¢  Implement education tools to help patients deal with

their concerns and fears and dispel myths

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WHEN TO REFER TO AN ASTHMA SPECIALIST?

¢ Patient had life-threatening exacerbations of asthma. ¢ Not meeting goals . ¢ Symptoms are atypical for asthma. ¢ Additional diagnostic testing needed (allergy,

bronchoscopy, etc.) ¢ Patient needs additional education and guidance ¢  Immunotherapy ¢ Received more than two courses of oral corticosteroids

in 1 year. ¢ Has physiological, psychosocial or family problems

that interferes with their asthma management plan. ¢ Severe Persistent asthma requiring step 4.

¢ To be successful the education must begin with an assessment of the patient and their family learning needs to determine the type of learning that must be executed to make the process effective.

¢ A healthcare providers goal in patients

education is the process of influencing the patients behavior and producing changes in knowledge, attitudes and skills necessary to maintain or improve health.

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WHY IS IT IMPORTANT TO UNDERSTAND?

Health Care Educator

Patient

*

A PATIENT’S ABILITY TO LEARN IS BASED ON:

�  Age and educational level �  Cultural and religious values �  Emotional barriers �  Motivation and desire to learn �  Language barriers

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LEARNING ¢ Formally or informally ¢ Take advantage of every teachable moment ¢ Beneficial to educate about:

�  Individual health status �  Use of medication and equipment �  Managing disease �  Nutrition �  Resources

LEARNING THRU MULTIPLE SENSES

¢ Always encourage the use of more than one sense. ¢ When you use an additional sense you double the

amount of material remembered.

“I hear and I forget, I see and I remember, I do and I understand”.

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LEARNING/ REMEMBERING

We Learn…… We Remember….. 1% through taste 10% what we read 1.5% through touch 20% what we hear 3.5% through smell 30% what we see 11% through hearing 50% what we see & hear 83% through sight 80% what we say 90% what we say & do Just Because you said it doesn’t mean they got it !!!

KEY POINTS TO DISCUSS

¢ Anyone with asthma can lead a normal life ¢ Asthma can be managed ¢ Patient and care giver must work as a team ¢ Asthma requires long- term care and monitoring ¢ Asthma ~ a chronic lung disease

~ Characterized by inflammation

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EXAMPLES OF UNHEALTHY BELIEFS AND ATTITUDES

¢ Beliefs that can hinder healthy behaviors �  Medications can be harmful �  I may become immune �  Manufactured drugs are “unnatural” �  I may become addicted

¢ Attitudes towards providers that interfere with

health �  Mistrust of health care providers �  “The quality of interactions between the

provider and patient can have a major influence on health outcomes” (Toelle, Peat and Dunn, 1980)

Goals of Managing Asthma ¢  Get an accurate asthma diagnosis. ¢  Work with your doctor to develop an asthma action plan. ¢  Monitor your peak flow rate daily and take appropriate measures

when it drops. ¢  Keep an asthma diary so you can track all your symptoms and

medication use. ¢  Avoid asthma triggers or causes of asthma, including outdoor

irritants such as smog. ¢  Seek medical advice and treatment for coexisting problems that

can worsen asthma symptoms, such as GERD, allergic rhinitis, and sinusitis.

¢  Exercise daily to maximize your aerobic fitness. ¢  Prevent exercise-induced asthma by medicating before exercise. ¢  Eat nutritious foods to maximize your immune defenses against

viral and bacterial infections. ¢  Maintain a normal weight. ¢  Get plenty of restful sleep. ¢  Call your doctor at the first sign of asthma symptoms. ¢  Check in with your doctor regularly for breathing tests to make

sure your asthma is managed and your medications are working optimally.

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SOCIAL FACTORS

¢  Lack of social support �  Poor family dynamics

¢  Low income �  Poor access to care

¢  Money/insurance ¢  Transportation ¢  Medications

¢  Low literacy �  Associated with inadequate comprehension of asthma symptoms

and severity

STRATEGIES FOR INCREASING SOCIAL SUPPORT

¢  Identify the key people supporting the patient and influencing care

¢  Involve the family/support persons in planning of care

¢ Develop community and school resources

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Possible Interventions

Resources for the Uninsured Pharmaceutical Company Programs

ASTHMA IN THE ELDERLY

¢ Usually goes undiagnosed ¢ Poor perceivers ¢ Nighttime cough ¢ More medication side effects ¢ Requires special training for asthma medication and

devices ¢ Transportation and medication expenses possible

concern ¢ Diagnosing between asthma and COPD may require

trial period of bronchodilator and steroid therapy.

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ALTERNATIVE THERAPIES

¢ Provides peace of mind and relief of pain ¢ Emphasize the importance of informing the health

care provider of use. ¢ Advise from health care provider should only be

given when appropriate or requested.

Can Natural Therapies Help to Manage Asthma?

¢  Some natural relaxation remedies like deep abdominal breathing, progressive muscle relaxation, guided imagery, and biofeedback can help relieve stress.

¢  Other findings suggest that diet plays a role in alleviating asthma symptoms. Example: Omega-3 fatty acids found naturally in high-fat fish such as salmon, mackerel, or cod enable the body to make more products that tend to decrease inflammation.

Benefits to those with asthma is still unproven.

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TWO EXAMPLES OF TRADITIONAL HEALING PRACTICES

A traditional Asian form of healing is “coin rubbing,” which is based on the belief that illness needs to be “drawn

out” to restore balance in the body. Rubbing produces welts, making it appear that the illness has been brought to the surface. Nurses can ask patients about such welts and what they mean to them. For patients practicing coin rubbing, it may be useful to say that an inhaled bronchodilator can “draw out” the tightness in the chest and wheezing.

Some Hispanics/Latinos believe that health conditions are

either hot or cold and that cold conditions should be treated with hot remedies and vice versa. Asthma is considered to be a cold condition. Thus, recommending that the asthma medications be taken with hot herbal teas may promote effective asthma management.

COMMON ALTERNATIVE THERAPIES

Acupuncture ~ Energy flow stabilizes and health restored

Herbalism ~ Herbs may interact or contain an ingredient that may interact with conventional medications.

Homeopathic ~ These remedies may delay diagnosis and treatment of the disease. Naturopathy ~ Eliminate the cause of illness through diet, nutrition and lifestyle changes. Chiropractic ~ Manipulation of the spine to reduce and correct interference with nerve impulse transmission. Holistic ~ Physical, nutritional, environmental, emotional, social, spiritual and lifestyle values Yoga ~ Study shows improvement in asthma by reducing stress levels, breathing becomes easier.

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WHY IS IT IMPORTANT TO UNDERSTAND CULTURAL DIVERSITY?

¢  In order to develop interventions that help others to adopt healthy behaviors it is important to understand what influences and molds health beliefs and behaviors

¢ Even when we don’t agree to recognize health beliefs that are harmful we need to remain respectful and establish a trusting relationship in order to change beliefs through education

Cultural Diversity

¢ Things to know before meeting with a patient that’s an immigrant �  Country of origin �  How recently they relocated �  Their religion

Helps to develop an educational plan that is focused on that individual.

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TIPS FOR DEALING WITH CULTURAL DIFFERENCES

¢ Start by being more formal with patients who were born in another culture

¢ Don’t be put off if the patient does not look you in the eye or ask questions

¢ Don’t make any assumptions regarding the patient’s concept about maintaining health, causes of illness, ways to prevent illness

¢ Allow patient to be open and honest by not discounting or laughing at beliefs that are not western biomedical traditions

TIPS FOR COMMUNICATING WITH PATIENTS SPEAKING LIMITED ENGLISH

¢ Speak slowly not loudly

¢ Face the patient and use gestures, pictures and facial expressions

¢ Avoid difficult words and idiomatic expressions

¢ Keep it simple

¢ Use open ended questions (questions that cannot be answered “yes” or “no”)

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Teaching patients of different cultures

¢ Use adjunct teaching aids �  Pictures �  Models �  Videos

Enhance the patients understanding of the subject matter.

Interpreter helpful.

CULTURAL COMPETENCE IN HEALTHCARE, HOW CAN IT BE ACHIEVED?

¢ The Art Of Culturally Sensitive Interviewing, questions:

-  What do you think caused the problem? -  Why do you think it started when it did? -  What type of treatment do you think you should

receive? -  What do you fear most from the illness? -  What are the chief problems the sickness has caused? -  What are the most important results you hope to

achieve from the treatment?

*An understanding of and respect for patient’s differing cultures, beliefs and practices is critical to effectively working in cross-cultural situations

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Outcomes Assessment

¢ The final course of education is to determine if the goals were accomplished

�  Monitoring outcomes �  Identify problems and adjustments made to

care plan

�  Measuring: ¢ Symptoms ¢ Lung Function

Measuring Outcomes

¢ Patient must be asked about frequency, extent and intensity of:

�  Wheezing �  Dyspnea �  Coughing �  Chest tightness �  Nightime awakening

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Measuring Outcomes

¢ Lung Function

�  Spirometry values ¢ Peak Expiratory Flow (daily)

¢ Compare value to personal best ¢ Detects airflow obstruction before patient

is aware

¢ FEV1 and FVC (every 1-2 years if stable) (more frequently if asthma is unstable)

To determine if asthma is adequately controlled ask:

¢ Has PF reduced by at least 20% from personal best?

¢ Does PF vary more than 20% between morning & evening readings

If “yes” to any of these questions then uncontrolled

asthma. Further PFT should be done.

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Helpful indications of limitation due to asthma

¢ Number of lost school days or work days

¢  Is patient able to maintain their normal activity levels, physically and socially.

¢ Quality of life questionnaires explore patient’s anxieties and fears.

¢ Determining presence of social or psychological stresses for patient and family.

Self Management skills

Skills that are the core of patient education.

Patient that follow their action plan and is able to respond quickly to deteriorating symptoms have better outcomes.

Patients should understand their medications and know which to use and when.

Understand what triggers their asthma and to avoid.

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Health Resource Utilization

¢ Number of hospital admissions ¢ Number of days in the hospital ¢ Number of prescriptions have been filled ¢ Number of ED or urgent care visits due to

asthma

Source for this data: ¢ Patient interviews ¢  Insurance claims information and hospital

admission records

Asthma Control Test (ACT)

¢ The Asthma Control Test and Childhood Asthma Control Test align with criteria set by the NIH to help your patients meet their goals of therapy.

¢ Simple tools that are completed by the patient

and parents/caregivers ¢ Clinically validated by specialist assessment and

spirometry ¢ Recognized by the National Institutes of Health

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FOR PATIENTS: ¢ Asthma Control Test (ACT) for people 12 yrs and

older. �  Step 1 Write the number of each answer in the score box provided. �  Step 2 Add the score boxes for your total. �  Step 3 Take the test to the doctor to talk about your score.

¢ Childhood Asthma Control Test for children 4 to

11 years.

*Refer to ACT questionnaire in back of chapter

If your score is 19 or less, your asthma may not be controlled as well as it could be. Talk to your doctor

Childhood Asthma Control Test children (4 to 11 years) ¢  Step 1 Let the child respond to the first four questions (1

to 4). If the child needs help reading or understanding the question, parent may help, but let the child select the response. Parents must complete the remaining three questions (5 to 7) on their own and without letting their child’s response influence their answers. There are no right or wrong answers.

¢  Step 2 Write the number of each answer in the score box provided.

¢  Step 3 Add up each score box for the total. ¢  Step 4 Take the test to the doctor to talk about the child’s

total score. *Refer to ACT form in back of chapter

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Asthma Therapy Assessment Questionnaire (ATAQ) to help monitor asthma control

What is measured by the ATAQ instrument? The ATAQ instrument highlights potential asthma management issues, such as:

¢  self-reported asthma symptom control ¢  missed daily activities ¢  missed work and/or school ¢  nocturnal awakenings ¢  high use of quick-reliever medication. For children ¢  wheeze during the day when exercising and when not exercising.

*Refer to ATAQ form in back of chapter

Asthma Therapy Assessment Questionnaire (ATAQ) ¢  0=asthma is well controlled. ¢  1–2=asthma is not well controlled. ¢  3–4=asthma is poorly controlled.

The guidelines also note that patients and parents are more likely to appreciate tools like ATAQ if they receive feedback from the clinician who helps them recognize the value of self-monitoring.

More satisfied a patient is with their healthcare, the more likely they adhere to treatment plan.

*Refer to ATAQ form in back of chapter

Copyright © 2009 Merck & Co., Inc. Whitehouse Station, NJ 08889, USA. All rights reserved.

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SO WHAT DOES THIS MEAN FOR ASTHMA EDUCATORS?

¢  It is important to recognize that knowledge and skill are not sufficient to influence behavior change

¢ Understand that a persons attitudes and beliefs influence their tendency to adopt a behavior change

¢ Recognize the impact of depression and life stresses in ability to control asthma

¢ Evaluate coping skills and encourage positive skills for dealing with having asthma

SUMMARY

¢ Effective asthma education cannot be accomplished without understanding the patient and family’s preconceived health beliefs and the social and cultural influences

¢ Interventions must go beyond the giving written educational materials

¢ Interventions must involve dialogue and the establishment of a trusting relationship

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TEST YOUR KNOWLEDGE

1. In order to have a successful teaching and Learning outcome, the Asthma Educator must begin by assessing:

A. How many school days were missed this year B. The patient and their family learning needs

C. How many hospitalizations the patient had this year

D. The patients health status

2. A person of immigrant status recently arrived from the middle East seeks advise from an Asthma Educator about her asthma. During the session, the woman sits down very close to the Asthma Educator. How should the Asthma Educator handle this situation?

A. Have an assistant present in the room during the interview

B. Don’t get offended C. Remain standing while speaking to the patient D. Ask the patient for more space and maintain a

professional attitude

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3. A 15 year old girl is having difficulty managing her asthma after knowing that her parents are getting a divorce The asthma specialist should refer the girl to a/an:

A. Pediatrician

B. Allergist

C. Social Worker D. Pulmonologist

4. A patient with asthma can benefit from yoga by:

A. Helping to reduce stress which allows the patient to breathe easier. B. Manipulation of the spine.

C. It promotes the body’s ability to self heal. D. It restores balance to the body.

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5. A 14 year old asthmatic and her parent is given the Asthma Control Test (ACT) and the Asthma Therapy Assessment Questionnaire (ATAQ) to complete. The Asthma educator should know that the results of these instruments will provide information about the patient’s

A. Ability to administer their medications

B. Perceived dyspnea level C. Quality of Life

D. PFT results

REFERENCE

Donna Falvo. (2005) Medical and Psychosocial Aspect of Chronic Illness and Disability 3rd Edition Ilene Morof Lubkin. (1995) Chronic Illness Impact and Interventions 3rd Edition Health and Administration Group, Asthma Management: Clinical Pathways, Guidelines and Patient Education, Aspen Publication NIH, Asthma Guidelines AMA, Health Literacy: A Manual for Clinicians, 2003, ISBN # 1-57947-502-7 Copyright © 2009 Merck & Co., Inc. Whitehouse Station, NJ 08889, USA. All rights reserved.