More than 300 million people currently suffer from asthma worldwide. It is the most common chronic disease among children (WHO, 2008). In Saudi Arabia, there is a lack of statistics about the asthma, however, an estimated number can be assumed through Abou Zaid et al study. According to Abou Zaid et al (2009), there are around 7 percent of the children and adolescents in the south region only suffering from bronchial asthma. That percentage was based in one city (AlTaif) from the Saudi Arabia regions (south region). Moreover, that study was based on a city that does not have polluted environment such as the capital city and the surrounding areas. That city AlTaif, this city is known with the high altitude city and clean environment due to the staggering distance from the polluted industries. From that point, it can be seen that the percentage of the children who have asthma will be higher in the capital cities or in the industrial environments due to the excessive present of the pollution and the asthma triggers (Abou Zaid et all, 2009).
Asthma is a chronic inflammatory disease of the airways that a recurrent symptoms. It’s resulting from the interaction between the inflammatory cells and the tissue cell that cover the airways. The inflammatory process during asthma is leading to the asthma pattern such as the difficulty of breathing, wheezing, coughing and chest tightness (Henson& Johnston. 2002).
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The enhancements of pediatric asthma have clearly linked to the sensitivity of airways. This sensitivity can lead to the asthma onset. The allergic inflammation of the airways can be stimulated by the allergens (Henson& Johnston. 2002).asthma in children can be caused by many factors. Several factors that might increase the risk of development of asthma such as: genetic, gender, environment and prematurity when delivery (Henson& Johnston. 2002). Smoking for women during pregnancy has been linked strongly to asthma in children (Henson& Johnston. 2002). This will be an issue with the women who smoke in Saudi Arabia.
Primary Health Care Centers in Saudi Arabia have been lacking in asthma care knowledge structures (equipment and medication) (Alhaddad et al. 1997). In addition, there were a large number of asthma prescriptions from the primary health care centers that had no documentation of the dosage for the asthma inhalers and this showed how poor the documentation has been from the asthma medicines prescribers. Moreover patients who were ordered asthma steroids have shown a poor compliance with the prescriptions. All of that has led to more primary health care centers visits and more hospitalizations. The studies also showed there were only 35% of the prescriptions were in the preventive therapy. That means the other prescription were either higher than the preventive therapy or lower than the recommended preventive therapy (Aldashash, Almukhtar. 2003).
The significance of the proposal:
The clients who have poor compliance and with no educational tools, the hospital visits and hospitalization by them will increase and remain in the high level. However, if the clients have been given booklets which teach them how to handle the asthma attacks and how to prevent them, the hospital visits may be decreased with the proper motivation and education.
Aims and objectives for the project:
This proposal is targeting the children with asthma to decrease the hospital visits by them. It will also improve the awareness for the children’s guardians and what is an asthma booklet for children may promote the quality of the children’s lives and it also may decrease the hospitalization. That booklet are also aiming to maintain the self management for children with asthma it will increase the public awareness in what to do if someone had an asthma attack by providing the children and their guardians the sufficient education.
The strategies of the project:
Making the booklet.
This strategy is the main concept to start the implementation process. In addition, this booklet should start with giving the clients useful information related to their needs. The ways to make the client satisfy with this booklet, all the information are in need to be simple to understand. Up to date information needed to fill out this booklet to make the client able to relate it to the recent self management approaches. The booklet will be very handy to the client who cannot or do not have the ability to check the information via online. All the updated and needed data will be available at the booklet for the reader to read it and to ask about anything that they want or they need to know about the booklet.
Process of implementation.
Asthma self management booklet needs to be implemented in strong used methods to be able to gain the fruits of successes. Knox (2000) has suggested that the implementation process need to be based on many theories to give it the ability to adapt on the various changes in the client’s needs or barriers such as eye sight problems and literacy. The elected theory will be adapting Lewin’s theory. Lewin’s theory has been elected because of it is the easiest theory to be controlled and monitored. In addition, Lewin’s theory is capable to be adjusted to suit the wanted changes more than the other theories (Knox, 2000).
This literature review has only focused on the recent articles that only done in 2009 and 2010. These articles are not about the Kingdom of Saudi Arabia due to the lack of the recent resources that have mentioned the asthma education in Saudi Arabia. These articles were taken from the search engine CINHAL based on key words asthma and education. The search was limited on the articles that have been published in years 2009 and 2010. Only 32 hits were found: 13 of them were in English but those articles were based on the church communities. Thus, those articles have been excluded due to the inconvenient to the topic to apply it in Saudi Arabia. In addition, 6 of the articles were written by a foreign language Portuguese language so these articles have been excluded too. That will leave only 13 recent articles to use in this literature review. The literatures will be mentioned under the following sub headings
Asthma in connection with communities:
Asthma self care management is more beneficial for the client when it is connected with the community (Otsuki et al 2009; Millard et al 2009; Krieger et al 2009). The purpose of connecting the asthma self management plan is to get the maximum support to the clients and to the plan itself. This will give the wanted plan with the maximum validity. When talking about using the communities to give a great aid to the asthma self management plan from allowing a large informatics resource to be focused on that plan (Clark et al 2010). The management needs to be supported by giving guardians need to be included in that education to allow them to be a good participant in the asthma self management plan for the children (Tolomeo 2009; Zhao et al 2009).
When the asthma self management plan has been separated from the community. The wanted education plans will be disrupted by the invalid information and will be lacking of resources such as clients and trainers. This will lead to failing in that education plans (Farber, 2009).
Asthma in connection with medical facilities:
Asthma is a medical problem. This medical problem will require a medical attention. When a clients education have been provided without any connection to any medical facilities, then the asthma education will contains a lot of fraud information. From that point, asthma self care management plan should have some connection with the medical facilities to be able to be suitable to be carried out with attention from the medical staffs. In addition, the medical facilities will lubricate the educational process to the client by allowing them to feel the difference before and after using the suggested self management education plan (Praeger 2009; Farber, 2009).
Asthma education for undergraduate nurses:
The way to make the educator nurse able to deliver a good education to the clients is to allow the nurses to get more methods to educate the clients when they are taking their degrees. In another words, allow the asthma self management methods to be taught in the tertiary schools to the nurses to increase the flexibilities to the nurses to adapt the methods to teach the clients more effectively and to create the realism in the education plan (Richard, 2009).
Reducing clients with asthma hospitalization:
When the clients are getting an insufficient education, the emergency visits by the clients will be increased (Flores et al 2009). Vice versa, if the health education have become more effective to the clients, that will lead to promote their health. When their health status has been promoted, the visit to the emergency room will be reduced (Zhao et al 2009)
Clients with asthma in schools:
When the clients who diagnosed with asthma are having an episode of asthma, then the absence of school will occur and the emergency visits will increase (Murdock et al 2010). Increasing the community awareness and the asthma self management education will promote the clients health status and that will decrease the absence from schools (Otsuki et al 2009). Moreover, when using an education techniques to the children clients, an appropriate technique should be used to avoid the incompliance from the children such as ignorant or depression (Murdock et al 2010). One study done by Tolomeo has reported that only 15 % of children who diagnosed with asthma that have received a complete asthma education (2009). That is less percentage than what has been reported by Apter et al (2001). However, another study done by Millard et al has argued that the affect of asthma absence in schools were highly over estimated (2009). However, there still gaps between the recommended asthma care plan and the current plan that has been used in the schools (Frankowski, 2009). In addition, Frankowski recommended Physician Asthma Care Education (PACE) to increase the effort in communication while providing the client the asthma self management plans (2009).
The content of the booklet with the rationale:
The content of the booklet will use the simple English to make it easy to be understood by the client and the client guardian if any. In addition, it will be written as a dot point to make it easy to be absorbed by the clients mind. The booklet will contain some of the pictures to make it easy to explain the contents to the clients. The booklet will contain six sections; those sections will be clearly identified below.
This section is talking about the asthma disease and includes sufficient information about the asthma. It is also include the sign and symptoms of asthma.
The aim of this section is to give the client enough information about the asthma to determine the reality of the disease and how to identify the sign and symptoms. This will be useful to the client and their guardian to be able to identify the initial information about what is asthma and what is it doing to the client health status. In addition, this section is including some information about how to control the asthma. In specific this booklet is aiming to motivate the self management for the clients to promote their health by promoting their self control for the asthma. Moreover, if the booklet has engaged the client and their guardians by acknowledging them to the sign and symptoms of asthma on sets, then the booklet has allowed the client to be more confident in managing his health condition and that will reduce the depression to the client (Murdock et al 2010).
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The aim is achieved by including an explanation on what are the asthma and the pathology for the asthma. This definition is to make it clear to the client in what is exactly going on in the clients lungs. The booklet did also include some of the sign and symptoms for asthma and some definitions for the difficult words such as wheezing. Wheezing is the whistling or squeaky sound that’s appears when the asthmatic person are breaths (LBI 2007). Moreover, the booklet has identified when the clients need to contact their doctors and when they need their medications. In addition, the booklet has shown some information about how to control the child asthma. All the information that has been written in the booklet was from up to date references.
The second section:
The aim of this section is acknowledging the client about the different kind of asthma medication and the purpose for them. This page will allow the client to gain the adequate knowledge about what is the medication and why those medications have been prescribed for the client. This also will allow the medical team to educate the client about the medication. By engaging the clients and their guarding in the asthma self management plan and provide them with sufficient education then the booklet is actually insuring that the clients are getting the adequate asthma education (Tolomeo, 2009). In addition, if the clients are aware of the asthma onset sign and symptoms then the client also aware about how to use the supplied medication to solve the onset, then the pressure to the client from the sickness itself will be reduced and the client will not be more depressed about their medical conditions (Murdock et al 2010).
This aim is achieved by explaining that there are two kind of asthma medication: the reliever one “puffer” and the preventive medication (LBI 2007). The medication will be varying from each client. That is why there were no specific brand name to the inhalers has been mentioned in details. All the details that have been written in the booklet were general due to the avoidance of getting biased or malfunctioned.
This section contains some useful pictures that explain to the client how to use the different kind of inhalers. This will promote the client knowledge about the proper way to use the inhalers to insure the maximum benefits from the medication.
This section was established in this booklet to educate the client about what are the asthma triggers and how to solve or eliminate them to be more in control for their asthma situations.
This section is mainly about the asthma management plan during emergency action plan. This section can be filled by the physician to make the client able to handle emergency situations and when to know when their health status are dropping down or getting better. This section is essential to the booklet due to the highly urgent need to the client to know their emergency action plan. In addition, this section is giving the clients and the reader more information on how to scale the clients with asthma health status regarding the asthma point of view. When the client is able to measure the peak flow and know what the vital variance to determine their asthma status, then they will know when to seek help or when they are in the risk free zone. That will allow them to take in charge for their health and will give them an advance notice when to be worried and need to seek attention or help for the medical staff. This also will allow the client to know when they need to book themselves an appointment in the medical facilities in advance. This issue may lead to less waiting hours in the primary health care clinics from the asthma perspective. That will lead to less hospitalization and might reduce the mortality rate for the clients.
This section is about the useful community services in Saudi Arabia. This will help he client to seek the adequate sufficient information about asthma when needed. It is also including some of the valid web site links for those community services to be able to locate them in their areas or have the contact numbers for them. According to Knox (2000), explained that the clients are reading about their condition more than what they used to, especially when they are looking for a solution to a problem that they have. When the clients are suffering from a specific problem, they would require looking for the solution and wanting a valid resource for them to be able to find the solution.
The implementation process:
Every implementation process would require a leadership or changing agent. While there is no leadership or no change agent the implementation will eventually fails due to there will be no control for the outcomes. In addition, the leadership or the change agent needs to be armed with skills to be able to control the implementation process and need to have adequate expertise about what is the change and what the favor from the implementation. The leadership shall identify the changes and how it will affect the organization. In addition, the leadership will have the leading skills to lead the other staffs to be able to reduce or eliminate the fears from the changes and the uncertainty while making the changes. Moreover, this leadership will visualize the recent valid change process to be able to implement them to the changes that the leadership will require (Swanburgs, 2005). The leaders ship should be honest responsible and have the flexibility to admit their own mistakes. Moreover, the leaderships need to be qualifies persons whom can built a business on a trust and can reach to important goals (Swanburgs, 2005).
The process of making the implementation more flexible and effective is to make it based on more than one change theory (Knox. 2000). The implementation of the booklet will basically base on Lewin’s force field model of change. Lewin’s model is consisting of three stages: unfreeze stage, moving stage and freeze stage (Swanburgs, 2005). However, other change process theories might be included in this project.
The implementation process will consider that there will be no harm that will occur to the clients and there will be no harm for the distributers or the medical staffs (Swanburgs, 2005). If any harm was noted to any of the parts the implementation process will immediately terminated and that incidence will get investigated to see where the implementation process were deviated from the track and to discuss whether or not that harm will affect the future of the implementation process. The harm might happen when the clients or their guardian are not understanding the booklet and might misuse it.
This stage will include the gathering of all the recent asthma brochures and investigate what are the brochures that are out dated. All the out dated brochures need to be collected and announced to the client to not use them. After that, an introduction for this booklet needs to be done in small community such as rural area. The supposed area in Kingdom of Saudi Arabia is AlMajmaah due to it contains only three Primary Health Clinics and two hospitals. The introduction for the booklet will be started on the asthma inpatients in one of the hospital and for this trail the elected hospital will be King Khalid Hospital because of there is special department for asthma patients in there and there is Special Ward for clients with asthma there. That ward consists of 12 beds especially for children whom diagnosed with asthma so the trial can be easily controlled. Prior to distributing the booklet, the project leadership will collect the sufficient data about the status of those children and what they have received from the education point of view. The culture habits such as raising sheep’s or camels should be considered and investigated whether or not it triggers the asthma attacks. That will need to be investigated by the physicians. The other educational elements should be considered such as literacy, education level, any cultural impairment such as lack of transportation or lack of guardians, any physical impairment such as eye sight or deafness. After collecting and analyzing the data, the leadership will establish basic team to assist the leadership in applying the changes. This team will be armed with experience and it will contain trustable persons that are accountable for the successful of the supposed change aims. After the investigation has been collected and analyzed, some of the inpatient clients will be elected for the first trial. The election will be based on the children whom with low complications to decrease the chance for the failure of this trail. Those selected subjects and the selected team will receive an intensive course for the use of the booklet and the benefits for the booklet. That course will not be established unless a formal consent has been gained from the hospital administration and from the guardians of the children. The intensive course will be held for one week and it will contain the needed educational material such as the booklet, some posters and brochures to maximize the knowledge that will be gained by the mentioned subjects. This trial was inspired by Roger s’ theory (Swanburgs, 2005). After the intensive course the booklet will be handed on to the clients and observation for the real benefits that gained after handing the booklet will be monitored.
In this stage the leadership and the nominated team will start distributing the booklet among the whole AlMajmaah inpatient children whom are suffering from asthma especially the recent diagnosed children. When introducing and distributing for the booklet a classes will be held in all the inpatients wards that contains children whom diagnosed with asthma to brief them of the benefits of using the booklet and how to use them. The mentioned classes will run for a period of a month. After the mentioned month, an evaluation process will run for the whole two hospital and investigation about the actual benefits that been gained from that booklet. The booklet may need modification or alteration to make the booklet more suitable for the use by the clients. When there is any alteration for the booklet the previous implementation steps will be carried out again to insure the smoothness of the changing process. After finishing the alteration for the booklet and the successful of the trails, the booklet will be recommended to the Ministry of Health to implement it for the whole Saudi Arabia medical facilities and that the aim of this project.
When completing the booklet trials and insuring the maximum validity of the booklet contents, then the booklet should get the official shape and recommended to the Ministry of Health to be able to make it the primary distributed booklet for children with asthma in Saudi Arabia.
Discussion and limitation:
The most significant barrier for this booklet would be adapting the medical team and the public about the best safe way to use the booklet, this can be covered by established a educational facilities or teams to keep educating the public how to use the booklet and an intensive program to teach the medical teams as well. In addition, some of the information might be not valid or useless after a while, that can be cover by creating an evaluation teams to keep this booklet up to date. Moreover, the booklet maybe in need for more information or more sections and that can be dealt with by the evaluation teams. The booklet may suffer from the lack of compliance from the patients, that can be dealt with educate the patient of the importance of following the instruction that been given by the medical team. Moreover, some patient may manipulate the information’s in the booklet or adding more information that might bias the booklet that might be solved by educating the patient in how dangerous it would be if they done so and how inappropriate treatments might result from that. However, some of the departments in Saudi Arabia have adopted some of the asthma education techniques such as King Fahd National Guard Hospital. KFNGH has created a link via web site to allow the clients to calculate the severity of their asthma if they have it.
This booklet may be used as a data base style so the clients will require a USB device to carry their entire case file and their required information. The booklet can be as well a digital booklet so the client can check it out via online or using the new devices such as i pad or iPod. The booklet will include in the future more sections to get the booklet further in the way to reach to the holistic approach.
In conclusion, asthma is a chronic health issue that affects many people from all around the world. Many asthma self management education method has been used around the globe. Moreover, the asthma education is one of the essentials to reduce the clients’ emergency room visits and hospitalization. Education will require connecting it with the community and medical facilities to get the maximum benefits to the plan. In addition, one of the education methods that can be used to educate the clients is the asthma self management booklet. This booklet need to have up to date information to be able to assist the clients to promote their health.th booklet will contain six section that have been detailed above. The implementation of the booklet will go via three stages unfreeze, move then freeze. All the implementation stages should be monitored thoroughly to maintain the success. This booklet may reach to preferred destination and may not. If it reached to the final hoped destination then the booklet will require evaluate and frequent update.
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