| | Kid Cards: Teaching Children About Their MedicinesSection EditorMary Margaret Gottesman, PhD, RN, CPNP, FAAN Ohio State University College of Nursing Columbus, Ohio The incidence of chronic health conditions among children has increased two-fold over the last decade (Hockenberry, 2002). These conditions require medications throughout life to prevent or delay progression of the disease process. Thus, increasing the health literacy of these children is essential to providing health care knowledge that is understood and valued by the child. Comprehension of their health care condition, treatment plan, and consequences is essential to ensure that adherence to the medication regimen will continue throughout their lives. Previous research supports the use of direct, developmentally appropriate, child-centered health care education (Pantell et al 1982, Perrin et al 1991, Sanz 2003, Sleath et al 2003, Tates and Meeuwesen 2000). Other research has concluded that both medicine use and treatment adherence might be improved with direct child-appropriate education (Boorady 2006, O’Brien and Bush 1993, Tieffenberg et al 2000). In other studies, teaching children about their medication regimen has correlated with improved knowledge and decreased anxiety, fear, and negativity (Knight, Wigder, Fortsch, and Polcari, 1990). Developing the health literacy of children is an important aspect of their ongoing transition toward adulthood and a critical element in the development of self-management skills. In 2004, Surgeon General Carmona stated that a health-literate individual is more apt to know the answer when asked how to keep themselves well (Agency for Health Care Research and Quality [AHRQ], 2004). This statement has resulted in interventions aimed at increasing health literacy among all Americans. Currently, there is a burgeoning movement among medical professionals to address the heath literacy of their patients, including pediatric patients. Teaching health information to children empowers them to actively participate in their current care and provides self-management skills that will assist them in keeping themselves well throughout their lives. Currently, there is a paucity of medication administration instructional information appropriate for children. Providing medication information that the child fully understands may result in better treatment adherence, fewer adverse effects, and increased knowledge. The United States Pharmacopeia (USP), in a 1998 position paper, outlined 10 principles to be used when teaching children and adolescents about medications. These principles encourage developmentally based medication education for children, starting with what children want to know. This paper also recognizes the need to directly address children, rather than exclude them either actively or passively from the medication teaching process (USP, 1999). Using data from focus groups of children in grades 2 to 5, the USP identified concepts that children understand. These include information regarding where medicines go in the body and how doctors know that medications work (Bush, 1998). Pfizer (1999) developed a booklet entitled “Talking to Children About Their Medication” with content developed from the USP recommendations. This booklet teaches children to ask medication-specific questions, such as “Why do I have to take this medicine,” “How long will I have to take this medication,” “How will it make me better,” “ What will it taste like,” and “What side effects can happen?” The USP has also suggested that the use of pictures within the educational program is beneficial; although Hameen-Anttila and colleagues (2004) claim that the usefulness of pictures has been exaggerated. MacPhee (2002) proposed that using the USP handout might enhance pediatric patients’ interest in their medications. Clinical anecdotal evidence, supported by research done by Eggleston and associates (1998), indicate that some pediatric patients self-medicate. A concern is that the child who may be self-medicating may know little or nothing about the medications they are taking except for the color or taste. Knowledge regarding medications should assist in transitioning the pediatric patient to adult care with effective self-management skills. Conceptual framework  Using Piaget’s Theory of Cognitive Development, children between the ages of 7 and 11 are typically in the concrete operational phase, acquiring the skills that allow them to become logical and coherent (Hockenberry, 2002). Children at this stage are able classify, sort, and organize facts about the world. Thus, they may use this knowledge to problem-solve. Reasoning at this stage is inductive and overall thought becomes less self-centered. It is appropriate to teach children information about their chronic illness in this developmental stage and reasonable to expect them to comprehend their health care condition, its treatment(s), and consequence(s), including potential complication(s). Appropriate educational interventions include building on their past experiences and using their memory to retain information. They must also become discriminate with respect to how the information applies directly to them. Symbols, drawings, and age-appropriate wording were used to develop the medication education card for this study. The education card was developed using the theory as a framework and the principles outlined by the USP (1999) to guide content. A sample card is presented in the Figure. Methods Children with bleeding disorders routinely receive aminocaproic acid (Amicar®) to prevent excessive bleeding, especially from the mucous membranes. Bleeding disorders are a group of life-long, chronic conditions that will always require medical attention and may be impacted by self-medication skills. Thus, these children represent a population who could benefit from increased medication knowledge. A brief pilot study assessed the impact of medication cards on knowledge among children aged 7 to 11 years receiving aminocaproic acid. Study Personnel and Setting Each advanced practice nurse (APN) employed at the study setting is responsible for providing health education. Medication cards, written at a 9th grade reading level, are widely available within the hospital and on the Web site. While appropriate for parents and many teens, these cards do not encourage a child to become informed about his or her medications. The medication card developed for the study provides information regarding the purpose, administration method, available form, and side/adverse effects associated with aminocaproic acid. Once developed, readability statistics were determined using the spelling and grammar feature of Word®. This feature combines the use of passive sentences, the Fleisch Reading Ease, and the Fleisch-Kincaid Grade Level to determine the readability of a document. Six children randomly chosen at the study site also reviewed the medication card as did the hematology/oncology clinical pharmacist. Sample Institutional Review Board approval was obtained prior to data collection. This approval included a review of the medication card and open-ended response study questions. On Friday, each APN reviewing the upcoming weekly appointment schedule identified potential participants. Potential participants included those children (1) between the ages of 7 to 11 years, (2) taking aminocaproic acid, (3) able to speak, read and write in English, (4) having a parent/guardian present who could provide consent, (5) able to assent, (6) available for follow-up data collection using a telephone interview, and (7) receiving primary care for a bleeding disorder only at the study site. Individuals excluded from participation included those whose health care condition was fragile, changing, or unstable and for whom study participation was judged to be burdensome. All health care professionals at the study site discussed each potential study participant. If appropriateness was questioned by any health care professional, the potential participant was excluded from the study. Procedure Once identified, the study was explained verbally to each potential participant and his or her parent or guardian during a routine clinic visit. Study participation commenced only after consent and assent were obtained and occurred in three phases. The first phase consisted of the APN assessing the child’s knowledge regarding aminocaproic acid, verbal education of the child by the APN assisted by the Kid Card, self-disclosure of demographic data, and provision of the Kid Card to the child. The second phase of data collection obtained longitudinal data through the use of a follow-up phone call occurring 2 weeks post intervention. Data collected at this time surrounded the purpose, side effects and adverse effects, and administration method of Amicar. The last phase of data collection was an additional phone call 2 weeks later, where the same questions were asked. Thus, the study data assessed knowledge retention and its accuracy over a 1-month timeframe. Data were treated nominally, indicating whether knowledge was retained (positive response) or lost (incorrect or not remembered). All data were entered into SPSS prior to analysis. Analysis Nine children participated in this study. These participants ranged from 7.03 to 11.08 years of age (mean 8 years, 8 months; standard deviation 1.86). There were 7 males (78%) and 2 females (22%), with 8 (89%) of the participants self-reporting their ethnicity as Caucasian and 1 (11%) self-reporting African American as their ethnicity. Each participant received the drug aminocaproic acid prophylactically for prevention of coagulation complications associated with a bleeding disorder. Nonparametric statistics were used to analyze these data. This technique is appropriate with small sample sizes (Siegel and Castellan, 1988). All data were treated as nominal and collected longitudinally from one sample population. As such, the choice of analyses is limited to descriptive and binomial statistics (Siegel and Castellan, 1988). Developing discrete categories based upon responses from each question, with 1 serving as knowing the appropriate information and 2 as not knowing the correct information, analysis reveals that only knowledge of the administration method item was statistically significant across each data collection interval (P = .039) (Table). Results These results indicate that these participants knew the method by which aminocaproic acid was administered. This knowledge was retained throughout the data collection interval of this study. While knowledge pertaining to the medication side effects was statistically significant at the time of initial data collection, this knowledge dissipated over time. Other interview questions failed to obtain statistical significance. While the generalizability of these pilot results should be used with caution, they do indicate that drug education needs to be performed and reinforced regularly with this population. Limitations The results from a pilot study should be interpreted with caution. The participants in this study were from one study site and receiving care from a small number of health care professionals. Extrapolating these results to other health care conditions, or other medications, should be avoided. Discussion The results of this study indicate that medication education is appropriate for children between the ages of 7 to 11 years. This education needs reinforcement at future encounters to ensure knowledge retention. This pilot study demonstrated that the development of Kid Cards aimed at the information children in this age group want to know about their treatment can increase their retention of some aspects of medication-related information. Obtaining data from children with chronic illness provides evidence-based care that is valued, appropriate, and feasible. United States Pharmacopeia 1998 Funding for this study was provided through a grant from a private funding source, Dee Lyons. The authors would like to thank Stacey Shoman, RN, for her assistance in the development of the Kid Card and all the nurses in the Hematology/Oncology Section for their assistance during data collection. References Agency for Health Care Research and Quality 2004. 1.Agency for Health Care Research and Quality. (2004). AHRQ Briefing 8/08/04. Retrieved January 10, 2006 from http://www.kaisernetwork.org. Boorady 2006. 2.Boorady, R. (2006). Talking with kids when medication is prescribed. Retrieved January 10, 2006 from http://www.med.nyu.edu/cigbin/it/web/printablecgi?url+http%3A//www.aboutourkids.org. Bush 1998. 3.Bush, P. (Ed.) (1998). Guide to developing and evaluating medicine education programs and materials for children and adolescents. Retrieved February 2, 2006 from http://www.usp.org. Eggleston et al 1998. 4.Eggleston P, Malveaux F, Butz A, Huss K, Thompson L, Kolodner K, et al. Medications used by children with asthma living in the inner city. Pediatrics. 1998;101:349–354. Hameen-Anttila et al 2004. 5.Hameen-Anttila K, Kemppainen K, Enlund H, Bush P, Marja A. Do pictograms improve children’s understanding of medicine leaflet information?. Patient Education and Counseling. 2004;55:371–378. Abstract | Full Text |
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PII: S0891-5245(06)00553-0 doi:10.1016/j.pedhc.2006.08.013 © 2006 National Association of Pediatric Nurse Practitioners. Published by Elsevier Inc. All rights reserved. | |
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