Asthma is one of the most widely spread chronic illnesses and, along with chronic obstructive pulmonary disease or COPD, one of the two most prevalent pulmonary disorders in the United States. It affects different population groups and has a considerable prevalence in children younger than 18. According to Root and Small (2019), the asthma prevalence rate for patients under 18 is 8.4 percent nationwide and, depending on the state, may rise higher than 9 percent. Additionally, the prevalence of asthma may rise further depending on the age group and a particular geographic location since environmental factors have a prominent effect on morbidity. For instance, statistics for California demonstrate that the children from 5 to 17 specifically have asthma prevalence of up to 14 percent at the highest (Root & Small, 2019). Moreover, there are counties in the state that have an average asthma prevalence of more than 25 percent (Root & Small, 2019). Considering these numbers, one may safely state that asthma in patients under 18 is a significant health issue. Therefore, improving disease control among children is a health outcome of high priority.
There are effective treatments for controlling asthma and managing and mitigating its symptoms while meeting therapeutic goals. Many readmissions of patients with asthma are considered preventable if the patients possess sufficient skill in control and self-management of their condition (Press et al., 2017). The use of the inhaler is one of the essential means of successful asthma control in all patients, including children under 18. However, there is evidence that incorrect inhaler use is a significant issue in asthma control and self-management. According to Root and Small (2019), as much as 80 percent of those with asthma and approximately two-thirds of healthcare providers have not mastered the correct techniques of using the inhaler. The socioeconomic status of some patients limits their access to healthcare services, and language barriers to communication undermine health literacy and exacerbate the issue even further (Myers & Murray, 2019). Additionally, children with asthma require interventions that would be developmentally appropriate for them. Hence, healthcare providers have to put an increased emphasis on educating children with asthma about the correct inhaler using suitable approaches such as the Teach-to-Goal method.
Background of the Problem
After its invention in 1957, pMDI-VHC had soon become a widely spread treatment for pulmonary disorders and, in particular, asthma. However, the correct use of the inhaler requires performing a specific sequence consisting of several actions in a precise order. These include putting the canister on the holder chamber, shaking it, exhaling, putting the inhaler in a correct position between teeth and lips, tilting the head back, pressing down on the canister, and holding breath. Studies indicate that not everyone is able to master this sequence and perform it correctly after the initial instruction, and nearly four in five asthmatic patients use their inhalers incorrectly (Root & Small, 2019). As a result of insufficient health literacy and incorrect inhaler techniques, patients turn up at the hospital for readmission that could have been avoidable, had they demonstrated sufficient skills in disease self-management (Press et al., 2017). Hence, the adoption of pMDI-VHC as the means of treating asthma symptoms necessitated the introduction of health literacy interventions to educate asthma patients about the correct inhaler techniques.
The Teach-to-Goal method is an approach to educating patients with limited health literacy devised to improve their outcomes by teaching them sufficient self-management skills. The method has its foundation in the theory of learning mastery developed in the 1960s (Root & Small, 2019). The essence of this approach is teaching the patients self-care skills during the consistently repeated sessions until they reach the behavioral goals – hence, Teach-to-Goal. The emphasis on consistent and repeated training is especially important for patients with low health literacy, as it often coincides with language barriers and insufficient income levels. Language barriers impede communication between healthcare providers and patients and often leave the latter unable to fully comprehend written or spoken instructions. Insufficient income and the consequential lack of insurance coverage limit the patient’s access to healthcare services and certain materials. In the case of asthma, patients of lower socioeconomic status may not have access to the spacers attached to the inhaler and ensure accurate dosage. Considering these factors, the importance of proper inhaler technique becomes even greater, and the Teach-to-Goal method appears to be a preferable way of educating the patients about it.
Significance of the Problem
The incorrect usage of the inhaler by children with asthma is a significant health issue because of several factors. While it has no direct effect on morbidity, the importance of promoting health literacy with regards to asthma control and self-management is directly proportional to the prevalence of the disease (Root & Small, 2019). Environmental factors may cause an asthmatic exacerbation in the area studied, thus making the improvement of health literacy all the more important. Asthma-related deaths are infrequent and, with rare exceptions, preventable if the patients possess sufficient skills in self-management and control. Thus, improving the inhaler techniques in children with asthma is also relatively important in terms of mortality, low as it may be. Finally, as mentioned above, patients of lower socioeconomic status may have no access to the spacers ensuring accurate dosage. In the absence of economically unaffordable materials, mastering the correct use of the inhaler becomes the only reasonable alternative. As a result, insufficient health literacy in children with asthma and, particularly, incorrect inhaler techniques is a significant problem in terms of morbidity, money, and, to a certain degree, mortality.
The purpose of implementing the Teach-to-Goal method in educating children under 18 about the correct techniques of inhaler usage is to improve asthma control and self-management skills. First and foremost, the outcome should manifest in the form of better results in pulmonary function tests (Root & Small, 2019). Apart from that, the patients receiving Teach-to-Goal training are expected to demonstrate better results in other clinical tools for assessing asthma control. These include the Childhood Asthma Control Test (C-ACT), Asthma Control Questionnaire (ACQ), and Test for Respiratory and Asthma Control in Kids (TRACK) (Dinakar & Chipps, 2017). The use of the Teach-to-Goal method with its emphasis on repeated raining through multiple sessions should allow mitigating communication difficulties due to language barriers by demonstrations and consistent instructing. The promotion of correct inhaler techniques should also circumvent the limitations of insurance coverage for patients of lower socioeconomic status by using the skills developed to compensate for the unavailable materials, such as spacers.
PICOT Formatted Question
The population of interest for this evidence-based research is patients under 18 diagnosed with asthma. The problem is the prevalence of the incorrect inhaler techniques further exacerbated by the rates of asthma due to environmental factors, language barriers impeding education and health literacy, and socioeconomic status of patients limiting their access to healthcare services and related materials. The intervention proposed is using the Teach-to-Goal method to improve inhaler techniques in children with asthma, thus promoting their outcomes and reducing the rates of readmission due to insufficient control and self-management skills. The Teach-to-Goal method, as compared to usual care, puts an increased emphasis on standardized training during repeated sessions to achieve behavioral goals with regards to self-management and control skills. The desired outcome of the intervention is improving asthma control in patients under 18, assessed through the pulmonary function tests as well as C-ACT, ACQ, and TRACK scores. The time necessary to implement the intervention is estimated as six months. Therefore, the PICOT formulated question for this evidence-based research is:
In children 7-10 years old with persistent asthma, what is the effect of achieving the correct six steps pMDI-VHC technique on improving asthma control compared with the incorrect use of inhalers in a 6-month time frame?
Conceptual Definitions of Concepts
Asthma control – the degree to which the symptoms of asthma are mitigated by the interventions and the therapeutic goals are met.
Asthma self-management – a set of activities an asthmatic patient undertakes to perform everyday activities successfully.
Correct inhaler use – a six-step sequence that ensures the distribution of a necessary dose of a medication and its subsequent assimilation when using pMDI-VHC.
Health literacy – the degree to which a person is able to obtain, communicate, process, and understand health information and services.
Teach-to-Goal method – a multisession educational strategy that focuses on consistent training of disease control and self-management skills until the patients achieve the desired behavioral goals.
Dinakar, C., & Chipps, B. E. (2017). Clinical tools to assess asthma control in children. Pediatrics, 139(1), e20163438.
Myers, R., & Murray, R. K. (2019). Overcoming health literacy barriers to improve asthma inhaler therapy adherence. Annals of the American Thoracic Society, 16(2), 182-186.
Perss, V. G., Kelly, C. A., Kim, J. J., White, S. R., Meltzer, D. O., & Arora, V. M. (2017). Virtual Teach-To-Goal adaptive learning of inhaler technique for inpatients with asthma or COPD. The Journal of Allergy and Critical Immunology: In Practice, 5(4), 1032–1039.e1.
Root, J., & Small, L. (2019). Improving asthma control in children using the Teach-to-Goal method. Pediatric Nursing, 45(5), 250-257.