www.jped.com.br
ORIGINAL
ARTICLE
Use
of
digital
media
for
the
education
of
health
professionals
in
the
treatment
of
childhood
asthma
夽
Helena
F.
Velasco
a,b,∗,
Catiane
Z.
Cabral
a,
Paula
P.
Pinheiro
b,
Rita
de
Cassia
S.
Azambuja
a,
Luciano
S.
Vitola
b,
Márcia
Rosa
da
Costa
a,
Sérgio
L.
Amantéa
a,baUniversidadeFederaldeCiênciasdaSaúdedePortoAlegre(UFCSPA),PortoAlegre,RS,Brazil
bPediatricEmergencyService,HospitaldaCrianc¸aSantoAntônio,IrmandadeSantaCasadeMisericórdiadePortoAlegre,Porto
Alegre,RS,Brazil
Received27March2014;accepted7July2014 Availableonline26November2014
KEYWORDS Asthma; Bronchodilators; Prevention&control
Abstract
Objectives: Inhalationtherapyisthemaintreatmentforasthmaanditsadequateusehasbeena factorresponsiblefordiseasecontrol;therefore,theaimofthestudywastodeterminewhether adigitalmediatool,whichfeaturesportabilityonmobilephones,modifiestheassimilationof theinhalationtechnique.
Methods: Atotalof66professionalsworkinginthehealthcareareawiththepediatric popula-tionwereselected.Theyweresubmittedtoapre-testontheirknowledgeofinhalationtherapy. Theprofessionalswererandomizedintotwogroups(AandB).GroupAreceivedamedia appli-cationontheirmobilephonesshowingthestepsofinhalationtherapy,whilegroupBreceived thesameinformationinwrittenformonly.Apost-testwasappliedafter15days.Theresults (pre-andpost-)wereanalyzedbytwopediatricpulmonologists.
Results: Ofthe66professionals,87.9%werefemales.Ofatotalpossiblescoreoften,themean scoreobtainedinthepre-testwas5.3±3,andinthesecondtest,7.5±2(p<0.000).There werenosignificantdifferenceswhencomparingthetwogroups(p=0.726).Thenurseshadthe lowestmeanscoresintheinitialtest(2.3±2);however,theywerethegroupthatlearnedthe mostwiththeintervention,showingsimilarmeanstothoseofothergroupsinthesecondtest (6.1±3).
Conclusion: Therewassignificantimprovementinknowledgeaboutinhalationtherapyinall professionalcategoriesusingbothmethods,demonstratingthateducation,whenavailableto professionals,positivelymodifiesmedicalpractice.
©2014SociedadeBrasileiradePediatria.PublishedbyElsevierEditoraLtda.Allrightsreserved.
夽
Pleasecitethisarticleas:VelascoHF,CabralCZ,PinheiroPP,AzambujaRC, VitolaLS,CostaMR,etal.Useofdigitalmediaforthe
educationofhealthprofessionalsinthetreatmentofchildhoodasthma.JPediatr(RioJ).2015;91:183---8.
∗Correspondingauthor.
E-mail:Helena.velasco@gmail.com(H.F.Velasco). http://dx.doi.org/10.1016/j.jped.2014.07.007
PALAVRAS-CHAVE Asma;
Broncodiltadores; Prevenc¸ão&Controle
Usodemídiadigitalnaeducac¸ãodeprofissionaisdesaúdeparatratamentodaasma
infantil
Resumo
Objetivos: AInaloterapiarepresentaaprincipalformadetratamentodaasmaeseuuso ade-quadotemsidofatorresponsávelpelocontroledadoenc¸a,dessemodooobjetivodoestudofoi determinarseumaferramentademídiadigital,dotadadeportabilidadenaformadetelefonia móvel,modificaaassimilac¸ãodatécnicainalatória.
Métodos: Foram selecionados 66 profissionais queatuam na área da saúdecom populac¸ão pediátrica.Estesforamsubmetidosaumpré-testesobreseusconhecimentosdeinaloterapia. Osprofissionaisforamrandomizadosemdoisgrupos(AeB).GrupoArecebeuemseutelefone móvelumaplicativodemídiacomospassosdainaloterapia,enquantogrupoBrecebeuas mes-masinformac¸õesapenasdeformaescrita.Após15dias,realizou-seumpós-teste.Osresultados (préepós)foramanalisadospordoispneumologistaspediátricos.
Resultados: Dos66profissionais,87,9%eramdosexofeminino.Numescoretotalpossívelde dez,amédiadasnotasobtidasnopré-testefoide5,3±3easdosegundoteste7,5±2(p<000). Nãohouvediferenc¸assignificativascomparandoosdoisgrupos(p=0,726).Osprofissionaisde enfermagemapresentaramamenormédianasprovasiniciais(2,3±2),porém,foiogrupoque aprendeumaiscomaintervenc¸ão,apresentandomédiasimilaraosoutrosgruposnasegunda prova(6,1±3).
Conclusão: Houve melhora significativa no conhecimento sobre inaloterapia em todas as categorias profissionais usando ambos os métodos, comprovando que a educac¸ão quando disponibilizadaaosprofissionais,modificapositivamenteapráticamédica.
©2014SociedadeBrasileiradePediatria.PublicadoporElsevierEditoraLtda.Todososdireitos reservados.
Introduction
Asthmahasanimportantroleinpediatricclinicalpractice duetoitsprevalence.Itcurrentlyaffectsroughly300million peopleworldwide.1
InBrazil,consideringtheoverallprevalenceof10%,itis estimatedthat thereare20 million asthmaticindividuals. Atotalof 160,000hospitalizationswererecordedin2011, makingasthmathefourthmostfrequentcauseof hospital-izationinthecountry.1
Severaldrugsanddifferentroutesofadministrationhave beenusedforadequatediseasecontrol.Theinhalationroute is currentlythe most frequentlyused andstudied for use bothduringcrisesandformaintenancedrugtherapy.2
Severalfactorsmaymodifythepharmacokineticsof med-ication:age,breathingpattern,useofspacers,andaspects relatedtothecorrectuseofthetechnique.3
The most commonly used inhalation devices in the pediatricpopulationarepressurizedmetered-doseinhalers (MDI).These, whenusedin children,require theuse ofa spacerthatminimizestheneedtocoordinatebreathingand reducesthedepositionofparticlesintheoralcavity, reduc-ingsideeffects.
Applying the adequate technique using the MDI with spacerisnotaconsensusamonghealthcareprofessionals. Fewknowhowtoperformorproperlyteachthetechnique to their patients. According to literature data, technical adequacy rates can range from 15% to 69% among these professionals, considering different professional areas.4 Studies comparing success rates and assimilation tech-niquehavebeen moresuccessfulregardingstrategiesthat
include a process of continuing education and periodic revision.5
Although one study4 has demonstrated improved tech-nique among health professionals who receive adequate information and those who review it frequently, there is nosuggestionintheliteratureforasimple,effective,and low-costwaytoprovidethistraining.
Furthermore,theimportanceof performingthe inhala-tion technique is still seldom discussed during medical training,lacking adequate emphasis intextbooks thatare notspecifictothearea,andfocusingsuchknowledgeonly onspecialists.
Considering the idea of improving asthma control and treatment through health professional and patient edu-cation, the authors developed a mobile application for continuing education directed at the adequate use of inhalers in the pediatric population, thereby creating a teachingtoolavailabletoallprofessionals.
Theaimofthisstudywastoevaluatetheknowledgeof differenthealthprofessionalsontheuseofinhalation ther-apyanddeterminewhetherthedigitalmediatool,available fortheAndroid(GoogleInc,CA,USA)and/oriOSplatform (AppleInc,CA,USA)foruseinmobilephones,modifiesthe assimilationofthe presentedcontent, thus more compre-hensivelydisseminatingknowledgeoninhalationtherapy.
Methods
Videos.mov
Videos.mp4
IInformation
Contact
Share Videos.droid
Adequate technique for children up to 7 years
Adequate technique for children olderthan 7 years
Step 1:
Remove inhaler cap
Step 2:
Insert inhaler into the spacer
Step 3:
Sit in the upright position
Step 6:
Hold the mask over the child’s facefor the duration of six respiratory movements
Step 7:
Wait a few seconds before administering the second dose
Step 8:
Rinse oral cavity with running water
Step 1:
Rinse oral cavity with running wate
Step 2:
Remove inhaler cap
Step 3:
Insert inhaler into the spacer
Step 4:
Sit in the upright position
Step 5:
Perform a deep expiration
Step 6:
Seal lips around spacer
Step 7:
Administer medication
Step 8:
Perform deep and slow inspiration movements
Step 9:
Hold the breath for 5 to 10 seconds
Step 10:
Step 10: Remove spacer from mouth and breathe normally
Step 12:
Rinse oral cavity with running water
Step 11:
Wait one minute before administering the second dose
Step 4:
Position mask over mouth and nose
Step 5:
Administer medication
Figure1 Imagesofthetechniquedemonstratedintheapplication.
pressurized MDI+spacer. The video was divided into two segments,consideringdifferencesintheagestratum.The first segment explainedand demonstrated, withthe help ofa3-year-oldchild,theappropriatetechniqueforusinga mask.Inthesecond,a12-year-oldchilddemonstratedthe techniqueforpatientsolderthan7years.Theactorswere selectedfromtheclinicalofficeof oneoftheresearchers (SLA),werefamiliarwiththeprocedure,andwere consid-eredveryadequateastechniqueperformers.Tostandardize theprocedureandcreateameasurabletesttool,thisstudy usedthe step-by-step pattern recommendedby The Lung Association(CanadianLungAssociation,ON,Canada).6
Basedonthevideo,anapplicationprototypewas devel-oped, compatible with all mobile phone platforms with Internetaccess,andeasilyusedbyparticipants(Fig.1).
Totesttheapplication,professionalswereselectedwho workedinapediatricreferralhospital(HospitaldaCrianc¸a SantoAntônio[HCSA],PortoAlegre,RS,Brazil).
Based on a proportion of adequate knowledge among healthprofessionalsofapproximately40%(meanofresults inlearningstudies),considering asuggestedproportionof knowledgeof70%(tobeachievedpost-intervention),fora levelofsignificanceof5%andpowerof80%,theminimum samplesizeofsubjectstobeallocatedpergroupwas esti-matedat16,constitutingaglobalpopulationof64subjects (fourresearchgroups).
Department.Thegroupswereconstitutedasfollows: medi-calpediatricresidents(n=16),fromatotalof21;pediatric nurses (n=16), from a total of 47; pediatric emergency physicians (n=16), from a total of 25; and pediatric ICU physicians (n=16),from a total of 28. A second random-izationwasperformedwithinthegroupstodeterminewhich participantswouldhaveaccesstothevideoandwhichwould receiveonlywrittenmaterial.Theknowledgeofthe profes-sionalswascomparedwithingroupsandbetweengroups.
Allparticipantswereaskedtowrite,intheirownwords, asequential numericaldescription of theinhalation tech-nique. The only information available was three images (pressurizedinhaler, spacer,andpatient),representingall partsinvolvedintheinhalationtechniqueprocess.
Basedonarandomizationprocess(1:1),halfofeach pro-fessionalgrouphadtheapplicationavailableontheirmobile phones.Duringtheprocess,theywereinstructedonhowto useit.Theotherhalfreceivedonlythewrittenguidelines.
Professionals selectedfromthe randomizationlistthat did not have a mobile phone with Internet access were excluded from the study, and were replacedby the next listedmember.Twopediatricemergencyphysiciansandsix nurses were replaced because they did not have mobile phonescompatiblewiththeapplication.
Twoweeksafterthefirsttest,theresearchersvisitedthe participantsin their workplaceonce againand re-applied thetest.
After the twosteps were completed, both tests were corrected by two pediatric pulmonologists, who did not participateintheselectionandteachingprocess.Ina pre-liminarystep,theydevelopedastandardizedcorrectiontool thatscoredonascalefrom0to10.Fourdomainswere con-sideredthemostimportantforthecharacterizationofthe evaluation process:1) Order of steps associated withthe correctprocedure;2)Mostadequatechoiceofspacer avail-abilitytechniqueaccordingtoage(oral inhalationthrough amouthpieceversusinhalingthroughafacemask);3) Pro-cess of shaking the medication canister; 4) Performance ofadequateinspiratorytechnique.Eachdomainscored2.5 points,andwasconsideredonlyasachievedornotachieved, basedonthe written description of the techniqueby the participants.Notesfromthepre-andpost-testwerethen compared.
Means and standard deviations, distribution of fre-quencies, and percentages were used for quantitative data analysis. All analyses complied with the respective theoreticalcriteriafortheirperformance.7Bivariate anal-ysis was used for continuous variables with non-normal
compareresponsesbetweentests.Forcategoricalvariables (McNemartest)andforcontinuousones(Wilcoxontest)and forcomparisonbetweengroups(KruskalWallis).Statistically significantassociationsweresetatp<0.05.Dataprocessing andanalysiswasperformedusingStatasoftware,release11 (StataCorp,CollegeStation,TX,USA).
ThestudywassubmittedtoandapprovedbytheResearch Ethics Committee of UniversidadeFederal de Ciênciasda Saúde de Porto Alegre (CAAE:17165313.0.0000.5345). All participantssignedaninformedconsent.
Results
A total of 66 professionals who worked in the HCSA par-ticipated in the study.Ofthese, 58(87.9%) were females andeight(12.1%)weremales.Allrandomizedparticipants completedthefirststepoftheresearch.Whenapplyingthe second intervention,sixprofessionals wereexcludedfrom thestudy(apediatricICU physician,twopediatricnurses, twopediatricemergencyphysicians,andonepediatric res-ident).
Theprofessionalswhocompletedthetestsdemonstrated a significant development in the knowledge of inhalation technique.Themeanscoreinthefirsttestwas5.3±3and themeaninthesecondtest was7.5±2(p<0.000).There wasnosignificantdifferencebetweentheimprovementin thescoresbetweenthegroupreceivingthevideocompared to the group receiving written information, as shown in Table1(p=0.726).
Testcorrection was concentrated in fourareas consid-eredimportantforinhalationtechnique.Errorsinthefirst assessmentoccurredmostlyregardingtheadequatechoice ofthetechnique,34(51%),andtheappropriateinspiratory technique,36(54%).Thesewerealsotheitemsthatshowed greaterprogressinlearning,withadecreaseto19(29%)in errorsassociated withchoiceof technique(p=0.001) and to 16 (24%) in errors related tothe adequate inspiratory technique(p=0.001;Table2).
Therewasnostatisticaldifferencebetweenthetypesof errorsmadebyparticipantsinthetwogroups.
Whenanalyzingtheresultsconsideringthedifferent pro-fessionalgroups,itwasverifiedthatthegroupofnurseshad thelowestmeanattheinitialassessment(2.3±2),butwas alsothegroupwiththehighestevolutionafterthe interven-tion,withameansimilartothatoftheothergroupsinthe post-test(Table3).
Table1 Comparisonbetweenmethodsoflearninginthefirstandsecondtest.
Method Firsttest Secondtest pa pb pc
Digitalmedia 4.8±3 7.5±2 0.000
Writtenadvice 5.9±3 7.5±3 0.005 0.155 0.726
Total 5.3±3 7.5±2 0.000
Samplesize=66participants.Datapresentedasmean±standarddeviation.
aWilcoxonTest,firsttestvs.secondtest.
b Mann-WhitneyTest,videovs.pamphletinthefirsttest.
Table2 Assessmentoferrorsbetweentests.
Errors Firsttest Secondtest pa
Inadequateprocessorder 6(9) 1(1) 0.125
Inadequatechoiceofspacer 34(51) 19(29) 0.001
Notshakingthedevice 14(21) 13(20) 1.000
Inappropriateinhalationtechnique 36(54) 16(24) 0.001
Samplesize=66participants.Datapresentedasn(%).
a McNemartest.
Table3 Comparisonofmeansbetweentestsbyprofessionals.
Professionals Firsttest pa Secondtest pa
Emergency 5.7±3 0.001 8.6±2 0.026
ICU 6.2±3 7.0±3
Nursingstaff 2.3±2 6.1±3
Residents 6.8±3 8.3±2
Samplesize=66participants.Datapresentedasmean±standarddeviation.
a KruskalWallisTest.
Discussion
Successfulasthmatreatmentcanbeattributed10%to med-icationand90%toeducation.Regardlessofthemedication composition, if it does not achieve an adequate dose in thelowerairways,itwillnotprovideeffectivetreatment. Basedonthisrationale,theeducationofpatientsandhealth professionals on the proper use of inhalersis one of the mainstays for the treatment of asthma in the pediatric population.8---11
Inspiteoftherelevancethatthissubjectmaydeserve, littleinformationisprovidedontheimportanceofthe cor-rectinhalationtherapyintechnicalbooks.10Currently,such informationhasbeen regarded asvaluable appreciatedin international consensuses, specialty societies, and formal guidelinesestablishedbydiseasecontrolinitiatives.
However,itisnotclearhowtoproceedinorderto ade-quatelyteachpatients,consideringthevariability(31-85%) of health professionals who can adequately perform the inhalationtechnique.12,13Thiswasthemainchallengethat motivatedthedevelopmentofthepresentstudy.This pro-posaltocreateapracticalteachingtoolwitheasyaccessto healthprofessionals isunprecedented,andisalignedwith currenttrendsofbehavior.
Thedataindicatefavorableresponsesinallprofessional categories, regardless of the educational tool used. This studywasunabletoidentifydifferencesinlearningbetween the two educational techniques. However, it is notewor-thythatthetimeintervalbetweentheapplicationsofthe two assessment methods (15 days) may have contributed toalackofdifferenceinresults.Memorybiasesareoften foundinlongerperiodsofinterventionbetweenthetests, which could result in a greater difference between the tools.
The frequency of access to the two training modali-ties could influence the learning curves and the attained results.However,thisvariablewasnotmeasured,makingit impossibletodeterminewhethertheresultcouldhavebeen influencedbyahigherfrequencyofaccess.
Intheauthors’view,moreimportantthanthefrequency ofaccessistheresultobtainedfromtheprovided informa-tion.Thefrequencyofaccessmaybeintrinsicallyassociated withthemethod.
Atatimeofundevelopeddigitalmedia(1982),patients disclosedthattheydidnotconsiderwritteninformationto beveryusefulintermsofrecommendationsandthatthey oftendisposed of it out without reading it.14 Moreover,a studyregardingtheconsiderationsofhealthcare profession-alsandpatientsontheuseofmobiletechnologyforasthma controlshowedthat43%oftheprofessionalsand52%ofthe patients credited tothis technology the capacity to con-tributetoabettercontrolofthedisease;15however,itwas notpossibletoconfirmsuchbehavior.
The literature demonstrates the preference of profes-sionalsandpatientsfortheuseofdigitalmedia.16---18Astudy focused on the comparison of teaching through video or writtentextsshowedabetterunderstandingofthe proce-duresinteachingtechniqueswithvideo.Furthermore,the studyshowedthatimagesimprovelong-termmemoryofthe obtainedknowledge.19
Inhalation therapy is a matter of relevance within the pediatric practice; however, a consensus onthe best techniquetoconsolidatethisknowledgehasnotbeen estab-lished. The useof a video reduces thetime spentby the professionalteaching thispractice, making it more feasi-bleineverydaylife.Theuseofdigitalmediaalsobecomes important in light of the need for a more interactive educationthatmeetstheneedsofanewgenerationof pro-fessionalswhousetechnologyasawork tool.17 Studies on educationhave found that students do not want to read longtexts,andarestimulatedbyrapidlearningandmedia toolswhereinformationismadeavailableinamoredynamic manner.16
thenextrandomizedparticipant.Thisindicates thatmost oftheselectedhealthprofessionals(87.5%)canaccessthe applicationwithoutdifficulty.
Studieshaveshown thatregularrepetitionisan impor-tantfactorfor maintainingknowledgeassociatedwiththe useofinhaling devices.4,17 Ateightmonthsafterthe edu-cationalintervention,only59%ofphysiciansstillperformed theinhalation techniqueadequately, reinforcingthe need for constant re-training.12 Considering this finding, the intrinsic characteristics of digital media (availability and portability)maycontributetothisongoingprocessof learn-ing.
Thegroupofnurseshadthelowestinitialmean,whichis noteworthyastheyrepresenttheprofessionalclassthatis assignedtoperformtheinhalationtechniquetogetherwith thepatient.However,itwasalsothegroupthatshowedthe greatestimprovementbetweenthetwotests,equalingthe performanceof other groupsin the finalassessment. This demonstratesthatmorefrequentapplicationofeducational processescouldinfluencememorizationandlearningofthe technique.
Asthma, as all other chronic diseases, represents an importanteconomicburdenforpatients,aswellasforthe health system.9 Expenses related to the incorrect use of medicationsfor asthmavarybetweensevenand15billion dollars/yearintheUSA.Theestimatedcostforthe educa-tionofpatientswithchronicdiseasesisUS$30perpatient. Ifitisconsideredthatthereare30millioninhalerusers, there will be a cost of 900 million dollars in education alone.10 The training of health professionals through the application,considering thatit is easy touse and freeof charge,couldreducethesecostsandallowtheuseofpublic resourcesinotherareas,suchasmedicationsupply.
The lack of difference between the two interventions shouldnotbeseen asadiscouragementtothe implemen-tation of any one of the tools, considering the overall improvement attained. This finding further supports the importanceof creating strategies in continuing education forinhalingtechniquetraining,especiallyamong profession-alswhopracticeitdaily.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
Acknowledgments
Theauthorswouldliketothanktheprofessionalswho par-ticipatedinthestudy,aswellastheexpertiseofmarketing professionalBernardoFleckManganelli,forthesupportand developmentofthedigitalmedia.
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