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EDUCATIONAL PROGRAMS FOR PATIENTS WITH BRONCHIAL ASTHMA AND THEIR PARENTS







KEY PROVISIONS:
• educational programs are an integral part of the comprehensive treatment of children with bronchial asthma; the purpose of the programs is to develop cooperation between the doctor and the patient;
• A feature of such programs in pediatrics is the mandatory adaptation of teaching methods to the perception of the age group of patients, taking into account their psychomotor development and age-related characteristics of psychology. A special group of training is made up of adolescents with bronchial asthma;
• there are various forms and methods of patient education: individual and group methods, video training, specialized Internet sites, adapted programs for young children (fairy tale therapy), trainings with the participation of psychologists. One common form is Asthma School;
• training of patients, their parents and relatives should be carried out at all stages of the provision of medical care to patients with bronchial asthma;
• educational programs should be directed not only to the patient’s family, but also to doctors, nurses, teachers who are constantly involved with a child suffering from bronchial asthma;
• psychological assistance, carried out in parallel with classes at the Asthma School, significantly increases the effectiveness of educational programs and improves compliance.
Education of patients and their parents is an integral part of a comprehensive asthma treatment program. The main purpose of educational programs is to increase the motivation of treatment - an active and conscious follow-up of medical recommendations. The development of cooperation between the doctor and the patient (compliance, cooperativeness) is a prerequisite for successful training.
Bronchial asthma requires long-term, sometimes continuous and careful adherence to medication programs from parents and the patient, a special mode of life, and a number of restrictions. The observance of these conditions determines the success of specialist management programs offered by a specialist.
To achieve optimal control of bronchial asthma and the formation of a high level of quality of life for patients, the contribution of only a doctor is not enough, cooperation with the patient is necessary. None of the most modern methods of treatment will have the desired effect if the patient does not strictly follow the medical recommendations. Lack of parental awareness of the main etiological factors underlying the development and exacerbations of bronchial asthma, as well as existing modern treatment methods, leads to the fact that many of the patients ignore the prescription of doctors, stop treatment on their own or resort to paramedics.
Adherence to treatment is characterized by the ratio of the amount of the drug actually taken to the theoretically prescribed, expressed as a percentage. Possible violations due to insufficient compliance: overdose, dose reduction and erratic medication. According to a number of studies, the compliance of patients with bronchial asthma who have not undergone educational programs is not more than 40-50%. Patient education should begin from the moment of diagnosis and continue throughout the observation period to achieve a high level of compliance (> 80% of the assignment). When choosing the method and form of training programs, the age of the patients should be taken into account. In the treatment of young children, the main object of education is the parents or persons caring for the child. Using adapted programs for young children, you can teach simple skills to control children from the age of three. Teenagers are a special group with a specific age psychology that needs to use special programs, the most effective of which are trainings with the participation of a psychologist.
There are various forms and methods of training. The most widely applicable forms of training are direct classes with patients (group or individual method), various types of printed publications for patients (books, newspapers, brochures, booklets, the journal Asthma and Allergy, etc.), audio and video cassettes, special computer programs, training Internet sites, Asthma-help advisory telephone lines.
An individual teaching method is one of the most productive, but at the same time the most labor-intensive. Individual training is carried out by the attending physician, who knows in detail the features of the course of the disease in this patient, monitors and improves the patient's knowledge and skills at each visit. The key points of individual training are partnership development, a long exchange of information, discussion of the results. The leading role in this program is given to the first consultation, during which it is recommended to give information about the diagnosis and simple information about the existing types of treatment, to demonstrate different types of inhalers, so that the patient can take part in choosing the device that suits him best. The patient should be given the opportunity to voice their concerns about asthma and its treatment and discuss them. Based on this, the doctor and the patient must agree on the goals of treatment. Already at the first visit, patients are trained in the correct technique of peak flowmetry and journaling. At the end of the first consultation, it is recommended to provide the patient with written information about bronchial asthma and its treatment in order to consolidate the verbal information received. In subsequent consultations, it is recommended that a self-management plan be developed with the patient (or parents). Ongoing consultations during individual patient education should include checking the technique of inhalation therapy, checking the records of symptoms and peak flow metrics in the patient’s diary, as well as checking that the drug plan is followed and that recommendations for secondary prevention are followed. Considering that the duration of the first consultation with this version of the educational program may exceed 1 hour, the possibility of its implementation in an outpatient setting is not always acceptable.
The most common teaching method in Russia has become the group method, which allows simultaneously involving many patients in the process. Most often, this method is implemented in asthma schools. Groups of asthma schools can be formed both from parents and from patients themselves older than 7 years. The basic principles of the formation of patient groups for Asthma schools require mandatory confirmation of the diagnosis, taking into account the age of the patients (spread no more than 3 years), optimally - the same severity of the disease. It is important to consider that parents with depressive tendencies and a high level of anxiety, initially focused on non-drug methods of treatment, are not suitable for group classes and should be studied individually.
In organizing the work of Asthma schools, the training of specialists for conducting classes is very important, previous pedagogical experience and knowledge of the fundamentals of psychology, including childhood and adolescence, are desirable. Thematic improvement courses that give doctors communicative skills for working with patients conducted with the participation of psychologists are the best option for training specialists for Asthma schools (for details, see http://lech.mma.ru/child). It is methodologically necessary to provide for the minimum equipment for classes - print media, posters, the possibility of video training, the availability of demonstration samples of various delivery vehicles, peak flow meters, etc. It is necessary that the approaches to treatment at the doctor conducting classes at the Asthma School and the doctors referring patients to training be uniform.

Despite the variety of options for conducting Asthma schools by the duration and intensity of training, the program for patients and parents must necessarily include the following topics:
• basic information about the anatomy, physiology of respiration, the nature of the disease;
• understanding of bronchial asthma as a chronic disease, and therefore the need for constant monitoring and treatment;
• information about the main allergens and irritants, the principles of elimination therapy and allergen-specific immunotherapy;
• self-monitoring of the condition: symptoms and assessment of peak flowmetry, skill in measuring heart rate, heart rate, filling out a self-observation diary;
• basic knowledge about the main groups of drugs for the treatment of bronchial asthma, the concept of basic and symptomatic therapy;
• familiarity with the main types of means of inhalation drug delivery and the development of inhalation techniques;
• analysis of action algorithms for an attack and exacerbation of bronchial asthma, plans for self-monitoring in the "system of color zones";
• characteristics of the main non-drug treatment methods (various methods of breathing exercises, massage, hardening, physiotherapy) as alternative and auxiliary treatment options;
• training parents in the necessary skills of emergency first aid (elimination of adverse factors, water regimen, classical massage and massage of biologically active points, breathing exercises, psychotherapeutic methods; drug treatment, medical treatment);
• discussion of issues of social and psychological adaptation of children with bronchial asthma and career guidance.

When presenting the material, it is very important to adapt the terminology, making it understandable for parents and children of different age groups. There is no need for excessive detailing of the material. During classes, the doctor should not go from considering general issues to particular problems of a particular child.
All this volume of necessary knowledge and skills can be implemented in the process of conducting
personal number of classes: from 2-3 to 8-10 or more. The number and intensity of classes depends on the organizational capabilities of the health facilities where the Asthma School is held. In Russia, there is experience in conducting such schools at the bases of specialized sanatoriums, hospitals, and clinics. It should be understood that Asthma-school is only the basic stage of training. Improvement and control of knowledge and skills should last throughout the observation of the patient.
Combined teaching methods are most acceptable and appropriate when basic knowledge is given to the patient in the form of group exercises, and then the attending physician improves and replenishes this knowledge during the observation process.
A feature of educational programs in pediatrics is the mandatory adaptation of teaching methods to the perception of the age group of patients, taking into account their psychomotor development and age-related characteristics of psychology (Table 9.1).
Table 9.1. The level of patient cooperativeness depending on age *
Age Description of patient cooperativeness
Children under 5 years old Able to passively fulfill the requests of adults (taking pills, inhalation through a spacer with the help of a parent, etc.)
5-7 years old They are able to master most of the necessary skills (peak flowmetry, the use of various types of inhalers, etc.), but under control and when reminded of adult family members
8-10 years Able to understand the appropriateness of prescribing drugs, they are guided in their names, the purpose of their use, side effects, contraindications
11-12 years old They correctly assess their condition before and after taking medications and are actively involved in the selection of drug therapy under the supervision of an adult, independently and regularly use a peak flow meter and keep a self-observation diary
13-14 years old They are able not only to demonstrate good knowledge of drugs, but also to plan their treatment without the participation of adult family members, without reminder, independently monitor the availability of the necessary drug for a week in advance, independently maintain and store self-monitoring diaries without the participation of adult family members

* According to Howell JH et al. (1992).
Easily reproducible and effective methods for young children, such as “Let's read a fairy tale together” with a figurative presentation of material on bronchial asthma, which can be implemented as a group fairy tale therapy and as individual instruction with the active participation of parents.
A special tact and endurance must be adhered to during the training of adolescents, and the course of bronchial asthma largely depends on the adequacy of their behavior and systematic treatment. Youthful maximalism and negativism contribute to the abandonment of observation and treatment, the formation of bad habits such as tobacco smoking, thereby expanding the range of risk factors. In this group, the usual forms and methods of teaching are unacceptable. Russian research has shown that adolescents consider Internet projects, trainings, booklets designed in a certain style to be the most attractive form of education. To conduct trainings for adolescents, it is necessary to involve a psychologist or a doctor trained by a psychologist. Given the high prevalence of tobacco smoking in adolescence and the proven negative effect of this dependence on the course of bronchial asthma, all programs for adolescents should necessarily include a discussion of this aspect.
It is necessary to emphasize the higher effectiveness of treatment provided that both the whole family and doctors, nursing staff, teachers who are constantly involved with a child suffering from bronchial asthma are educated. Family rehabilitation should be the main rehabilitation method for children with bronchial asthma.
Education of patients, their parents and relatives should be carried out at all stages of medical care.
Ample opportunities for patient education are presented at the rehabilitation stage in specialized sanatoriums, rehabilitation treatment departments.
Practice shows that in the implementation of educational programs is reduced:
• the number of asthma attacks;
• frequency of requests for medical care;
• number of absenteeism from school;
• the number of parental disability sheets in connection with caring for sick children;
• bronchial lability;
• number of hospitalizations.
Educational programs should not be limited only by the attitude of the doctor-parents (doctor-patient). In pediatrics, the system of interpersonal contacts significantly extends its boundaries and can be designated as:
• parent-child;
• peer children;
• child-educator, teacher;
• child medical personnel;
• adult children.
Education of everyone who surrounds a sick child, their cooperation at all stages can improve the course and prognosis of the disease, reduce the percentage of disability and improve the quality of life of children suffering from bronchial asthma.
Taking into account psychological problems in many children with asthma, it makes sense to involve a specialist psychologist who knows the methods of individual and group psychotherapy and psychocorrection. Such psychological assistance, carried out in parallel with classes at the Asthma School, significantly increases the effectiveness of the latter and improves patients' compliance. An individual approach to the rehabilitation of a sick child should include the possibility of consulting social workers who help solve complex problems of social adaptation of patients and their families regarding changes in living conditions, etc. One of the important aspects of social adaptation is also the timely professional orientation of children with bronchial asthma (with the participation of a school doctor, teachers and parents).
It seems advisable to organize educational work in all parts of the regional children’s specialized allergological and respiratory centers, which allows methodically and organizationally to provide comprehensive coordinated treatment and prophylactic measures in a specific region, to provide long-term follow-up of patients (from infancy to adolescence), and reduce financial costs duplicating medical services and units.
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EDUCATIONAL PROGRAMS FOR PATIENTS WITH BRONCHIAL ASTHMA AND THEIR PARENTS

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