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The Use of Public Education in Practice

2001; American Academy of Pediatrics; Volume: 22; Issue: 3 Linguagem: Inglês

10.1542/pir.22-3-75

1529-7233

Miriam Bar-on,

Family and Patient Care in Intensive Care Units

Objectives After completing this article, readers should be able to: Public or patient education is one means of attaining the optimal physical, mental, and social health and well-being for infants, children, adolescents, and young adults, as stated in the American Academy of Pediatrics’ (AAP) mission statement. By definition, patient education is the process of influencing patient behavior and producing changes in knowledge, attitudes, and skills required to maintain or improve health. This usually is addressed on an individual basis and includes teaching and counseling to enable patients to stay healthy and manage illness better when it occurs. Public education, on the other hand, is a broader term that includes the pediatrician’s role in influencing the health status of the public through involvement with community groups and the media. Both types of education are important and merit pediatrician involvement. Questions arise as to the best and most effective ways to provide this education within the constraints of busy practices or other commitments.Public education can be incorporated into pediatricians’ daily activities in a variety of ways both inside and outside the office. Studies in the medical literature have reviewed the outcomes of public/patient education programs and their effectiveness in practice. This article examines various methods of public/patient education that may enhance pediatricians’ promotion of health and well-being for their patients. Although many of the methods discussed will be familiar, there is evidence in the literature that public/patient education is not adequately provided to patients.The office is the primary site of most pediatricians’ activities. Within this venue, several methods have been shown to be effective in educating patients and parents.Clear, spoken advice is a powerful agent for helping parents gain new knowledge. It has been demonstrated that specific, rather than general, advice is better for helping individuals learn and apply new information. Some studies have shown that specific verbal suggestions in combination with supportive counseling can lead to even greater acquisition of knowledge and skills and decrease parental anxiety. This is important because parental anxiety has been shown to lessen the information that parents retain after speaking with the pediatrician. One method of circumventing the anxiety-induced barriers to learning is for the pediatrician to explore parents’ understanding of their child’s condition, worries about the visit, and any other concerns. The effectiveness of verbal instructions can be enhanced with follow-up telephone calls after a visit. One study showed that telephone calls facilitated compliance in 90% of the experimental group compared with 55% of the control group. Reminder letters and cards containing important telephone numbers also helped increase compliance. Printed materials remain the mainstay of most patient and parent education programs, offering many advantages (Table 1). Handouts, which should expand on the spoken word, include:one-topic handouts, multiple-topic booklets,magazines, child-care books, and periodic newsletters, most of which are available from the AAP. Several child-care books familiar to all pediatricians (eg, Dr Spock, the “What to Expect…”, and the AAP child care series) provide information in an expanded form. One-topic, brief informational handouts have been demonstrated by Schmitt and associates to improve parents’ knowledge and outcomes such as compliance and satisfaction with care. Several studies also have documented that information handouts increased parents’ compliance with treatment recommendations. In addition, both Roberts and associates and Casey and colleagues showed in separate articles that providing parents with specific written information on a topic decreased the number of inappropriate telephone calls by 50% and unnecessary office visits by 50% to 75%. Published reports from the adult literature on the impact of written handouts found that adults appreciated them. They read them, retained the information (70% for greater than 12 mo), and generally were more satisfied with the care they received. Furthermore, written information not only decreased patients’ anxiety, but facilitated patient-staff interactions better than verbal instruction alone.Handouts also have been shown to be useful in building parenting skills longitudinally. In one study, parents received handouts correlating with the age of their infant over an extended period of time. The handouts addressed common parental concerns at each of the major health supervision visits and emphasized knowledge about development,parenting, health care, and emotional well-being. More than 70% of parents responding to follow-up evaluations reported improvements in knowledge about development, parent-child relationships, and self-confidence. Other studies have documented similar findings.Research clearly supports giving handouts to parents after a thorough discussion of the information during a patient visit; patient/parent awareness of and interest in a particular topic is critical for handouts to be effective. This capitalizes on the concept of the“teachable moment.” Personalizing handouts for families is another successful method of conveying and reinforcing information. Successful models of personalized handouts are the Injury Prevention Program and the Media History Form from the AAP, in which individual needs assessments are performed and information is provided based on these needs. Another example of personalized handouts comes from The Pediatric Advisor, which was constructed to allow pediatricians to personalize handouts for specific patients and to customize handouts to meet the needs of individual practices. There also are several Web sites that offer patient handouts that can be personalized, but often cannot be customized. These include but are not limited to MDConsult™, Beansprout.com, and KidsGrowth.com.It is important to make handouts “user friendly,” particularly in terms of the literacy and language barriers of patients in an individual practice. In the United States, approximately 20% of the adult population is considered functionally illiterate (defined as reading below the 8th grade level). Studies have shown that many commonly used handouts are written for individuals whose reading levels are greater than the 9th grade. Language barriers affect approximately 10% of United States citizens. These individuals have expressed frustration about the lack of handouts written in their primary language. A simple solution to these two barriers is to develop handouts that are written below the 8th grade reading level(preferably closer to the 5th grade level) and that incorporate shorter sentences with good structure (eg, avoid passive verb tenses, eliminate multiple preposition phrases), use simpler vocabulary, and include illustrations.This type of education can take the form of either topic-specific education sessions for patients and parents or group well child care. Group patient education sessions have been shown to increase physician productivity and to meet the needs of patients and parents on specific topics. Many studies have documented the effectiveness of group teaching programs on asthma for children and adults. In addition, women who attended antenatal breastfeeding workshops had increased confidence levels about breastfeeding and continued to breastfeed for an extended time, even if they experienced difficulties. Group well child care was started in 1977 by Stein and was highly promoted in the 1980s to increase the amount of patient education provided to parents during health supervision visits. Practices that provide this type of care select small cohorts of patients of the same age and conduct group health supervision visits that usually last about 1 hour. They emphasize anticipatory guidance, safety and prevention issues, and psychosocial concerns. The physical examinations and immunizations are performed privately. Evaluations of this method of providing health supervision documented increased parental compliance with visits and less seeking of advice between visits. Using this method of care enabled the physician to spend 1 hour with a number of families addressing specific areas of concern rather than the estimated 16 minutes per traditional individual visit where it was shown that parents were less likely to voice concerns. More than 95%of parents preferred group to individual visits. To improve the health and well-being of children, pediatricians need to reach beyond the confines of the office. They need to become involved in the community, establishing their credibility as persons who care about children and their families and who can take action on their behalf. The most effective method of becoming involved in the community has been shown to be working with an established organization to design, fund, and implement a community service project. Such organizations include local Parent-Teacher Associations, youth service programs (eg, Girl/Boy Scouts, YMCA, Girl’s/Boy’s Clubs), the state AAP Chapter/Pediatric Society, community service organizations (eg,Junior League, Jaycees), or agencies devoted to the betterment of children’s health (Ronald McDonald House Charities, the Cystic Fibrosis Foundation). Following the successful implementation of a project, invitations to join the board of a community organization often are extended, which provides the opportunity to become a leader and share one’s knowledge of children’s issues. There are few better-qualified individuals to speak to the issues affecting children than pediatricians.Becoming a member of community organization boards enables the pediatrician to help set the organizations’ health agendas and advocacy efforts. How does one determine a health agenda? One study from England demonstrated that during a 2-week period, pediatricians in a practice were able to identify 60 problems that needed to be addressed by keeping detailed clinical diaries. They classified the problems into levels at which advocacy was required, such as the individual level, public health level within the community, public health level within the city, and public health level nationally. If generating a list of community health problems is not feasible, the AAP has a national agenda that can be extrapolated into individual communities. Topics such as access to care, handgun violence, and care for children who have disabilities are at the forefront of the AAP’s agenda.Participation on community organization boards and in community activities allows the pediatrician to develop personal relationships with nonmedical community leaders. These relationships usually become strong and productive over time, establishing the pediatrician’s role as an educator on and an advocate for children’s health issues. Pediatricians can use their influence to increase services, promote prevention activities, and change community attitudes that affect health risks to children, especially in areas such as violence.Technology-based education takes two forms. The first uses the computer to support software, such as an interactive program or game to teach patients in a manner that is appealing to children and adolescents. Many programs have been developed, including Asthma Command, the Baby Game, and Romance, that have capitalized on the computer game craze to standardize educational interventions while providing a stimulating experience for affected patients. It has been hypothesized that the attraction of these games is their interactive nature, which provides instantaneous feedback on any decision made by a player. The feedback usually indicates whether the player responded correctly or incorrectly when offering a solution to a problem. Evaluations of these educational games have shown that knowledge and behavior have been affected, and in some cases the morbidity of the disease process has been decreased. It is important that pediatricians be knowledgeable about computer programs that might be beneficial for their patients (Table 2). Physicians might have demonstration programs available in their offices with which patients and parents could play to determine if they meet the individual learning needs of affected families.The second form of technology involves the computer as a vehicle to reach the Internet, an extremely accessible source of health information to which people increasingly are turning. More than 90,000 sites refer to the specialty of pediatrics in some form. Health-related sites are among the most frequently accessed information resources on the Web, and new sites are put up daily that provide advice on many child-related health issues. Some health-related sites are created and maintained by hospital staff, some by individual doctors, some by parents who have an interest in a particular field, and some by commercial firms to advertise a product. A significant problem with the Internet relates to the quality and validity of the information available because peer review, as used for medical journals, is not employed. Much of the information may be helpful and correct, but a large amount is incorrect or incomplete. Additionally,it has been shown that the reading level of various health-related sites is higher than that of most parents.An important function of the Internet, with its abundant health information, should be to lessen anxiety by making parents better informed. Studies assessing the usefulness of checklists as tools for parents to help them determine the quality and reliability of pediatric sites have shown that there are no effective means to screen these sites. It is crucial for pediatricians to recommend reliable Web sites to patients and their families when asked. Sites developed and maintained by reputable organizations such as the AAP or local children’s hospitals have been shown to be the most reliable.Pediatricians could have specific sites “bookmarked” on their computers to demonstrate to patients or for parents to browse in the waiting room or they could have handouts with researched sites listed(Table 3). To facilitate patient education and strengthen the connections between pediatricians and patients, the AAP has joined with the clinical leadership of the nation’s major medical societies to develop Medem. As an e-health network, Medem offers and guarantees the quality of their online comprehensive, clinical health care information. Its first product, Your Practice Online™, offers to group and individual medical practices customizable Web sites, enabling pediatricians to combine their general practice and patient education materials with the AAP’s patient information and Medem’s interactive tools. These tools will help pediatricians to create a fully personalized Web site that can meet the needs of their patients. The content architecture and navigational system allow patients to drill deeper into a topic for increasing medical detail. Further information on Medem can be accessed at www.medem.com.Newspapers, newsmagazines, radio shows, and television programs all have the power to reach large audiences. Campaigns promoting specific health education issues, such as cardiovascular disease prevention, healthy eating, and bicycle helmet use, have had large media components. Elements of the media campaigns included public service announcements, news stories, and articles in the newspapers. Several studies evaluating the effect of mass media in promoting specific health issues have demonstrated that this is an effective method of disseminating information. Other studies have shown that behaviors were changed by a media campaign.It is important for pediatricians to establish good contacts with reporters for local newspapers, radio stations, or television stations. Most newspapers and television news bureaus have health reporters who need to be made aware of issues that affect children. Pediatricians should respond to reporters’ inquiries quickly (usually the same day) because reporters frequently have deadlines. Pediatricians also can provide reporters with handouts, addresses of Web sites, and other pertinent resources to reinforce significant information. As with community-based education, the pediatrician needs to establish himself or herself as an expert in child health who has ready access to relevant data. In addition, if possible, the pediatrician should have patients available for photographs, videotaping, and interviews. Personal statements are essential in a good news story and may entice the reporter to develop a complete story. With certain issues, a multimedia approach is the best strategy to reach the broadest audience.In addition to working with the media on major child health issues or campaigns, pediatricians should try to provide material regularly for child health stories. Recurrent contact with a specific radio or television station can lead to the development and airing of a weekly or monthly broadcast. Local newspapers also welcome pediatricians as columnists. In this manner, children’s health can be brought to the public frequently. Educating the community through broadcasts and newspaper stories and columns not only promotes child health care, but it promotes pediatricians and their advocacy and caring for children.Pediatricians educate their patients daily. Developing or adapting patient handouts for their practices, incorporating community activities into their schedules, becoming familiar with technological advances, and teaming up with the local media are all methods through which they can educate patients and the community at large. As experts in child health, pediatricians should capitalize on this expertise.