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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 training methods to the perception of the age group of patients, taking into account their psychomotor development and age-related features of psychology. A special group of studies consists of adolescents with 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), training with the participation of psychologists. One common form is the Asthma School;
• Patients, their parents and relatives should be educated at all stages of providing medical care to patients with bronchial asthma;
• educational programs should be directed not only to the family of the patient, but also to doctors, nurses, teachers, constantly engaged with a child suffering from bronchial asthma;
• psychological assistance, carried out in parallel with classes in 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 program for the treatment of bronchial asthma. The main purpose of educational programs is to increase the motivation of treatment - active and conscious following medical recommendations. The development of cooperation between the doctor and the patient (compliance, cooperativity) is a prerequisite for successful training.
Bronchial asthma requires from parents and the patient a long, sometimes continuous and careful adherence to drug programs, a special mode of life, a number of restrictions. The success of the patient management programs proposed by a specialist depends on compliance with these conditions.
To achieve optimal control of bronchial asthma and the formation of a high level of quality of life for patients, only a doctor’s contribution is not enough; collaboration with the patient is necessary. No most modern treatment methods will not have the desired effect if the patient does not strictly follow the medical recommendations. Lack of awareness of parents about the main etiological factors underlying the development and exacerbations of bronchial asthma, as well as about the existing modern methods of treatment leads to the fact that many of the patients ignore the doctor's prescriptions, discontinue treatment themselves or resort to the services of paramedics.
Adherence to treatment is characterized by the ratio of the amount of actually taken the drug to the theoretically appointed, expressed as a percentage. Possible violations due to insufficient compliance: overdose, dose reduction and indiscriminate medication. According to a number of studies, compliance with patients with bronchial asthma who have not completed educational programs does not exceed 40-50%. Patient education should begin from the time of diagnosis and continue throughout the observation period to achieve a high level of compliance (> 80% of the assignments). When choosing a method and form of training programs should take into account the age of patients. In the treatment of young children, the main object of training is the parents or persons caring for the child. Using adapted programs for young children, one 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 used are such forms of education as direct classes with patients (group or individual method), various types of publications for patients (books, newspapers, brochures, booklets, the journal Asthma and Allergy, etc.), audio and video tapes, special computer programs, educational Internet sites, telephone advisory lines "Asthma-help".
The individual training method is one of the most productive, but at the same time the most labor-intensive. Individual training is conducted by the attending physician, who knows in detail the features of the course of the disease in a given patient, monitors and improves the knowledge and skills of the patient at each visit. The key points of individual learning are partnership development, a long exchange of information, and discussion of the results obtained. 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 existing types of treatment, to demonstrate various types of inhalers so that the patient can take part in choosing the device that suits him the most. The patient should be given the opportunity to express his concerns about bronchial 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 proper peak flow metering techniques and diaries. At the end of the first consultation, it is recommended to provide the patient with written information on bronchial asthma and its treatment in order to consolidate the verbal information obtained. At subsequent consultations, it was recommended to develop a plan of self-study in collaboration with the patient (or parents). Ongoing consultations on individual patient education should include testing the techniques of inhalation therapy, checking the records of symptoms and peak flow metrics in the patient’s diary, as well as checking the adherence to the drug plan and the implementation of recommendations for secondary prevention. Considering that the duration of the first consultation with this variant of the educational program may exceed 1 hour, the possibility of its implementation in the conditions of outpatient admission is not always acceptable.
The most common method of study in Russia has become the group method, which makes it possible to simultaneously involve many patients in the process. Most often, this method is implemented in Asthma schools. Groups of Asthma schools can be formed from both parents and patients themselves over 7 years old. The basic principles of the formation of patient groups for Asthma schools imply a mandatory confirmation of the diagnosis, taking into account the age of patients (range of not more than 3 years), optimally - the same severity of the disease. It is important to bear in mind that parents with depressive tendencies and a high level of anxiety, initially focused on non-pharmacological treatment methods, are not well suited for group classes and should be trained 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 basics of psychology, including children and adolescents, is desirable. Thematic refresher courses that give doctors communication skills in working with patients, conducted with the participation of psychologists, are the best way to train specialists for Asthma schools (for details, visit http://lech.mma.ru/child). Methodologically, it is necessary to provide minimum equipment for classes - prints, posters, the possibility of video training, the availability of demonstration samples of various delivery systems, peak flow meters, etc. It is necessary that the approaches to treatment at the doctor who conducts classes at the Asthma School and the doctors who refer patients for training should be the same.

Despite the variety of options for Asthma schools for the duration and intensity of training, the program for patients and parents must include the following topics:
• basic information about the anatomy, physiology of respiration, the nature of the disease;
• understanding of asthma as a chronic disease, and therefore the need for continuous monitoring and treatment;
• information on the main allergens and irritants, principles of elimination therapy and allergen-specific immunotherapy;
• self-monitoring of the condition: symptoms and assessment of peak flow measurement, measurement of heart rate, RR, filling in the self-observation diary;
• basic knowledge of 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 inhalation techniques;
• analysis of action algorithms for attacks and exacerbations of asthma, plans for self-control in the “system of color zones”;
• characterization of the main non-pharmacological treatment methods (various methods of breathing exercises, massage, hardening, physiotherapy) as alternative and auxiliary treatment options;
• training of parents in the necessary skills of emergency first aid (elimination of adverse factors, water regime, classical massage and massage of biologically active points, breathing exercises, psychotherapeutic methods; drug treatment, treatment to a doctor);
• discussion of issues of social and psychological adaptation of children with asthma and vocational guidance.

In the presentation of the material is very important to adapt the terminology, making it understandable for parents and children of different age groups. No need for unnecessary detail of the material. During classes, the doctor should not move from the consideration of general issues to the particular problems of a particular child.
All this amount of necessary knowledge and skills can be implemented in the process of
personal number of classes: from 2-3 to 8-10 and more. The number and intensity of classes depends on the organizational capacity of the health care facility where the Asthma School is conducted. In Russia, there is experience in conducting such schools on the bases of specialized sanatoriums, hospitals, and polyclinics. At the same time, it is necessary to understand that the Asthma School is only a basic stage of study. The improvement and control of knowledge and skills should last throughout the entire observation of the patient.
Combined teaching methods are most acceptable and expedient when basic knowledge is given to a patient in the form of group sessions, and then the attending physician improves and supplements this knowledge in the course of observation.
A feature of educational programs in pediatrics is the mandatory adaptation of training methods to the perception of the age group of patients, taking into account their psychomotor development and age-related features of psychology (Table 9.1).
Table 9.1. The level of patient cooperativeness depending on age *
Age Patient Cooperative Description
Children under 5 years Able to passively fulfill the requests of adults (taking pills, inhalation through the spacer with the help of a parent, etc.)
5-7 years They are able to master most of the necessary skills (peak flowmetry, the use of various types of inhalers, etc.), but under control and with the reminder of adult family members
8-10 years Capable of understanding the expediency of prescribing drugs, are guided in their names, the purpose of their use, side effects, contraindications
11-12 years old Properly assess their condition before and after taking medication and are actively involved in the selection of drug therapy under the supervision of an adult, use a peak flow meter independently and regularly, and keep a diary of self-observation
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 reminders, independently control the availability of the necessary drug for the week ahead, independently keep and keep diaries of self-control without the participation of adult family members

* According to Howell JH et al. (1992).
Easily reproducible and effective techniques for young children, such as “Honor together a fairy tale” with figurative presentation of material on bronchial asthma, which can be implemented as a group fairy tale therapy and as individual training with the active participation of parents.
Special tact and endurance must be followed when teaching 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 smoking tobacco, thereby expanding the range of risk factors. In this group, the usual forms and methods of teaching are unacceptable. A Russian study showed that adolescents consider Internet projects, trainings, and booklets designed in a certain style to be the most attractive form of education. To conduct trainings for teenagers, 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 asthma, all programs for adolescents should necessarily include a discussion of this aspect.
It is necessary to emphasize the higher efficacy of treatment, provided that both the whole family and the doctors, nurses, teachers constantly engaged with a child suffering from bronchial asthma are educated. Family rehabilitation should be the main method of rehabilitation of children with asthma.
Education of patients, their parents and relatives should be carried out at all stages of medical care.
Opportunities for patient education are presented at the stage of rehabilitation in specialized sanatoriums, rehabilitation departments.
Practice shows that the implementation of educational programs is reduced:
• number of attacks of bronchial asthma;
• the frequency of seeking medical help;
• the number of school passes;
• the number of sheets of incapacity for work of parents in connection with the care of sick children;
• bronchial lability;
• number of hospitalizations.
Educational programs should not be limited to the attitude of the doctor-parents (doctor-patient). In pediatrics, the interpersonal contact system significantly expands its boundaries and can be designated as:
• parents-child;
• child peers;
• child educator, teacher;
• child medical staff;
• adult child.
Education of all those around the sick child, their cooperation at all stages allows to 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 the psychological problems of many children with asthma, it makes sense to involve a psychologist in their work with them who are familiar with the methods of individual and group psychotherapy and psychocorrection. Such psychological assistance, carried out in parallel with classes in the Asthma School, significantly increases the effectiveness of the latter and improves patient compliance. An individual approach to the rehabilitation of a sick child should include the possibility of consulting social workers who help to solve difficult 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 asthma (with the participation of the school doctor, teachers and parents).
It seems expedient to organize educational work at all levels of regional children's specialized allergological and respiratory centers, which allows methodically and organizationally to ensure the implementation of comprehensive coordinated therapeutic and preventive measures in a particular region, to ensure continuous monitoring of patients (from infancy to adolescence), to reduce financial costs overlapping medical services and units.
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EDUCATIONAL PROGRAMS FOR PATIENTS WITH BRONCHIAL ASTHMA AND THEIR PARENTS

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  2. The program of management of patients with bronchial asthma: 6 parts
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