Training Pharmacy Students to Manage Opioid Overdoses and Administer Naloxone

by Cole Sisson, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Kwon M, Moody AE, Thigpen J, Gauld A. Implementation of an Opioid Overdose and Naloxone Distribution Training in a Pharmacist Laboratory Course Am J Pharm Educ 2020; 84 (2): Article 7179.

Opioid overdoses caused almost 47,000 deaths in the US in 2018 and, according to the CDC, the number of deaths has been growing since 1999.¹ With the continuing increases in deaths due to prescribed and synthetic opioids, it is more important than ever that Americans be knowledgeable about and have access to overdose reversal agents like naloxone, which is a life-saving medication when administered correctly to those experiencing an overdose. Naloxone is commonly carried by emergency medical personnel and first responders, but the average person can be trained on its use.  Wide-spread availability of naloxone can expand the likelihood that someone will have access to this medication when needed. Naloxone dispensing and training is especially important in community settings like pharmacies, however many patients (and even some pharmacists) are reluctant to use naloxone due to a lack of confidence using an injectable medication and stigma related to opioid use. Integrating training about opioid overdoses and naloxone prescribing in pharmacy school curriculums can increase knowledge among new pharmacists entering the profession who can advocate for increased use and availability of these rescue medications.

At the Notre Dame of Maryland School of Pharmacy, Kwon and faculty colleagues designed, implemented, and evaluated an opioid overdose education and naloxone distribution (OEND) program.² They designed a program based on the 5 E’s learning method: Engage, Explore, Explain, Elaborate, and Evaluate.  To measure knowledge and attitudinal change, the investigators used the Opioid Overdose Knowledge Scale (OOKS) and Attitude Scale (OOAS) before and after the OEND program. The faculty engaged a class of P3 pharmacy students in a patient care laboratory session consisting of four parts: an interactive introductory presentation, a hands-on session with various placebo forms of naloxone, a large group review of the information learned in the first two parts, and then a patient counseling and overdose care scenario to test the newly learned skills. The students received prompt feedback after completing the scenarios. Afterward, the students took the post-test OOKS and OOAS evaluations.

Fifty-six students completed the OEND program. When compared to the baseline, the mean OOKS score increased significantly (p<0.001) in each knowledge domain including risk factors for overdose, signs of overdose, actions to care for an overdose victim, and general knowledge about naloxone. Similarly, the mean score in the OOAS evaluation increased significantly (p<0.001) from pre- to post-test, and the largest mean increases in the categories of self-perceived confidence in counseling and dispensing naloxone and counseling on how to rouse and stimulate someone experiencing overdose. As a longitudinal measure of knowledge retention, the pharmacy faculty also included naloxone counseling and overdose care in the final examination for the students that semester. The students were required to counsel a standardized patient on a randomly selected naloxone dosage form, and, in another station, care for a standardized patient who was experiencing an apparent overdose. The mean total score was very high on both of these stations and nearly all students achieved at or above the passing score. While this was not a direct re-administration of the standardized Opioid Overdose Knowledge Scale, it served as a good proxy for retained knowledge by the students.

This study evaluated the effectiveness of a well-designed instructional program and used standardized questionnaires (the OOKS and OOAS) to assess learning. The immediate results following the completion of the program showed significant increases in pharmacy student knowledge and attitudes related to managing an opioid overdose and dispensing naloxone.  While retention of this material was very strong, students were informed that these topics would be tested during the final examination, so it is possible that students did not retain this information so much as relearned it for the exam. This program was implemented with one student cohort at one pharmacy school, so additional studies will be needed to determine the generalizability of these findings to other colleges/schools of pharmacy. 

Similar OEND programs have been implemented and evaluated but none of the reports are as robust as the study by Kwon. Monteiro et al. evaluated an interprofessional workshop focused on increasing knowledge, skills, and attitudes of students towards opioid misuse.  The interprofessional teams included health professional students from medicine, nursing, pharmacy, physical therapy, and social work. While this study only assessed pre- and post- OOKS scores among the medical students, the results demonstrated significant improvements in knowledge.³ In another study, Schartel et al. evaluated the success of a program for P1 pharmacy students in a lab course.  However, they only taught students about and evaluated the use of one naloxone dosage form and, while knowledge improved significantly, they did not assess changes in student attitudes.⁴ 

Pharmacists are one of the most accessible health professionals and many patients ask a pharmacist about a health issue before seeing care from a physician. Implementing training programs in pharmacy curricula can help bridge the gaps in access and increase community awareness about managing opioid overdoses.  Training pharmacists to dispense and teach patients how to use naloxone products can help slow the escalating number of deaths in the US due to the opioid crisis. Interactive and well-designed programs like the one implemented by Kwon and colleagues are an effective way to increase both knowledge and attitudes towards opioid overdoses.

References

1. “Understanding the Epidemic” [Internet]. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention; 2020 [cited 2020Dec6]. https://www.cdc.gov/drugoverdose/epidemic/index.html
2. Kwon M, Moody AE, Thigpen J, Gauld A. Implementation of an Opioid Overdose and Naloxone Distribution Training in a Pharmacist Laboratory Course. Am J Pharm Educ 2020; 84 (2): Article 7179.
3. Monteiro K, Dumenco L, Collins S, et al. An interprofessional education workshop to develop health professional student opioid misuse knowledge, attitudes, and skills. J Am Pharm Assoc 2017; 57 (2): S113–S117.
4. Schartel A, Lardieri A, Mattingly A, Feemster AA. Implementation and assessment of a naloxone-training program for first-year student pharmacists. Curr Pharm Teach Learn. 2018; 10 (6): 717-722.

Supportive Counseling and Its Impact on Expecting Mothers

by Layla Langdon, Doctor of Pharmacy Student, University of Mississippi School of Pharmacy

Summary and Analysis of: Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304 

This article caught my attention because we have been studying women’s health and the impact of the mother’s behaviors and stress on a developing baby. Also, as a student pharmacist, I am very interested in pursuing a career in pediatrics, and a child’s health really starts in the womb. This study attempted to demonstrate the impact of an educational support program on a woman’s pregnancy-related and general stress as well as prenatal health behaviors. Pregnancy-related stress is often the result of worrying about maternal and fetal health, parental responsibility, physical symptoms, labor pain, childbirth, and the cost of raising a child.¹ All of these factors weigh on a woman and starts to take a toll on her health and can lead to a poor pregnancy outcome. Using supportive counseling to supplement usual antenatal care, this study aimed to reduce maternal stress and promote healthy behaviors that would benefit the mother and the developing child.

To test this theory, pregnant women between gestational age 6 and 32 weeks with no comorbidities were recruited to participate in this randomized, control study. The participating women were divided into two groups with 40 participants each. Women in both groups completed four questionnaires at baseline including the Revised Prenatal Distress (NUPDQ), Spielberger State-Anxiety Inventory (STAI-Y), Prenatal Health Behaviors Scale (PHBS), and the Perceived Stress Scale (PSS-14).  In addition, all of the women provided a saliva sample to measure salivary cortisol concentration. Each participant was advised to fast and avoid alcohol for at least 24 hours before the salivary sample was taken. Changes in the NUPDQ, STAI-Y, and PHBS were the primary outcomes for this study, and the PSS-14 and the salivary cortisol assay were considered secondary outcomes.

The control group received only usual antenatal care based on Iranian national guidelines. Each participant in this group received midwifery examinations, assessments of the mother’s and fetus’s health, and education about personal hygiene, sexual activity, signs of a high-risk pregnancy, common pregnancy complaints, nutritional and medicinal supplements, and use of fertility health services. In addition to usual antenatal care, the intervention group received weekly supportive counseling conducted by a female expert psychologist. These supportive counseling sessions consisted of face-to-face instruction with 12 to 14 women in each group. This gave the women the opportunity to interact with one another.  During these sessions, they discussed their stress and anxiety.  The instructor also designed group work and guided exercises to address unhealthy behaviors. The program targeted pregnancy-related worries such as health problems and costs, parental responsibility, physical symptoms, infantile health, parenting, labor pain, and childbirth phobia. Six weeks after completing the educational program, all participants in both groups again completed the four questionnaires and provided a salivary sample to measure their cortisol.

The results revealed there were significant improvements in the mean NuPDQ, STAI-Y, PHBS, and PSS-14 scores in the intervention group, including in the subscales of these instruments, when compared to the control group. Specifically, there were large effect size improvements in the medical and financial problems, infant health, physical symptoms, and labor and delivery subgroups of the NuPDQ and the four subgroups of the PHBS (See Table 1). The salivary cortisol levels improved in both the intervention and control groups but there were no significant differences in the mean change observed. 

Table 1. Mean Pre (T0) and Post (T1) Scores and Differences for Selected Outcomes Following an Educational Support Program for Pregnant Women

	Intervention			Control
	T0 Mean	T1 Mean	Change	T0 Mean	T1 Mean	Change
Primary Outcomes
NuPDQ	11.85	5.6	-6.97	9.42	11.32	2.62
STAI-Y	44.4	35.8	-7.2	40.65	41.82	.52
PHBS
Harmful Behavior of Health	4.17	2.42	-1.72	4.37	4.82	0.42
Health Promoting Behavior	20.2	23.67	3.53	20.45	20	-0.51
Harmful Physical activity of Health	5.52	3.6	-1.91	5.57	5.62	0.03
Health Promoting Physical activity	3.97	7.07	2.88	3.1	2.95	0.06
Secondary Outcomes
PSS-14	23.45	16.82	-7.20	21.82	21.77	-0.53
Serum Cortisol	23.32	20.25	-3.32	17.57	14.98	-2.61

One of the strengths of this study was the use of four different questionaries to evaluate the effect of supportive counseling on pregnancy-specific, general stress, and healthy behaviors. Another strength of this study is that the supportive counseling provided to the experimental group was provided in small groups with only 12 to 14 participants per group. This allowed each participant to develop relationships with other pregnant women who may be experiencing the same struggles. This study also aimed at improving each participant's self-esteem and maximizing their adaptive skills. These are important objectives because pregnant women often feel incapable of birthing and raising a child. The weaknesses of this study are that the questionnaires used were all based on self-evaluation. The authors do not discuss the sustainability of the program and don’t report outcomes after delivery – so the health outcomes of the babies is unknown. The findings of this study probably should not be generalized to complicated pregnancies.  While salivary cortisol was included as a measurement of stress, it does not correlate well with psychological stress.

In future studies, it would be helpful for each participant to complete a session with a mental health professional. This would allow a more personalize assessment and help the participants identify and analyze the specific stressors they are experiencing. Also, the addition of this session could be used as an external evaluation. Although this is a subjective measurement similar to the self-evaluations, an assessment performed by a mental health professional would be consistent for all participants. Future studies should gather data through the entire pregnancies, including delivery, plus three months postpartum.  This is important to truly determine the long-term effect of supportive counseling on pregnancy-related stress and outcomes.

A similar study analyzed the effect of a supportive intervention in pregnant women who were depressed using the Postnatal Depression Scale (EPDS >12).³ In this study, the intervention group received the same number of counseling sessions, six visits, but over eight weeks. That study also concluded that supportive counseling in addition to usual prenatal care improved outcomes. Specifically, the participants reported improvements in depressive symptoms, depressive severity, and quality of life. Another study found that supportive counseling improved the patient’s satisfaction during delivery.⁴ Although these studies had minor differences in terms of the number of counseling sessions provided, the program duration, and the number of participants, they all concluded that supportive counseling subjectively improved pregnancy-related stress 

While the supporting counseling program appears to have been effective, it would have been helpful if the intervention were described in more detail. This would allow other health professionals, such as pharmacists and nurses, to implement a similar program. However, this study is important because it demonstrated the benefits of adding supportive counseling to usual prenatal care. This may also improve the health of the fetus and allow for a smoother birthing experience. Overall, I believe that providing supportive counseling to pregnant women should be the standard of care during all pregnancies.

 

References

1. Esfandiari M, Faramarzi M, Nasiri-Amiri F, et al. Effect of supportive counseling on pregnancy-specific stress, general stress, and prenatal health behaviors: A multicenter randomized controlled trial [Internet]. Patient Education and Counseling 2020;103 (11): 2297-2304.
2. Nast I, Bolten M, Meinlschmidt G, Hellhammer DH. How to Measure Prenatal Stress? A Systematic Review of Psychometric Instruments to Assess Psychosocial Stress during Pregnancy. Paediatric and Perinatal Epidemiology. 2013;27(4):313–22.
3. Neighmond P. To Prevent Pregnancy-Related Depression, At-Risk Women Advised To Get Counseling [Internet]. National Public Radio. NPR; 2019 [cited 2020Oct19].
4. Segre LS, Brock RL, O'Hara MW. Depression treatment for impoverished mothers by point-of-care providers: A randomized controlled trial. J Consult Clin Psychol 2015; 83 (2): 314-24.
5. Pasha H, Basirat Z, Hajahmadi M, Bakhtiari A, Faramarzi M, Salmalian H. Maternal expectations and experiences of labor analgesia with nitrous oxide.. Iranian Red Crescent Med J 2012; 14 (12): 792-7.

Understanding Patient Medication Experiences through Theater

by Alexandra Frazier, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of: Cernasev A, Kuftinec S, Bortz R, Schommer JC, Ranelli PL. Using Theater as an Educational Tool for Understanding Medication Experiences from the Patient Perspective [Internet]. Am J of Pharm Educ. 2020; 84(4): Article 7606. doi:10.5688/ajpe7606

As student pharmacists, a great deal of our education is dedicated to learning how to provide medication counseling and handle patient interactions in various pharmacy practice settings. This training not only involves learning how to provide the essential information patients need to use medications wisely but also delivering that information with empathy, listening actively to patients, and applying motivational interviewing techniques. Though pharmacy students are trained on how to assist patients struggling to acquire medications, students in other healthcare professions do not always receive formal instruction about how to assist patients experiencing access barriers. Healthcare professionals should be knowledgeable about the issues that may arise when medications are prescribed to patients, be prepared to handle these situations efficiently, and be able to express empathy for patients in difficult situations.

This unique study examined the effectiveness of theater as an educational tool for healthcare professionals.¹ The American Alliance for Theatre and Education (AATE) defines drama-based learning strategies as “an improvisational, non-exhibitional, process-centered form of drama in which participants are guided by a leader to imagine, enact, and reflect upon human experiences.”² I was captivated by this study because it allowed healthcare practitioners to gain perspective into patients’ experiences in an innovative way.¹

From April 2015 to March 2016, adults in the U.S. completed the self-administered the National Consumer Surveys on the Medication Experience and Pharmacist Roles. Comments from this survey were compiled detailing participants’ medication experiences. These comments were then used as the inspiration for a theatrical script written by Syl Jones and performed by Mixed Blood Theatre. The play, Go Ask Alice, included a total of seven scenes that explored multiple patient scenarios as well as a mock drug advertisement. There were two performances of Go Ask Alice – one in Minneapolis, Minnesota on November 29, 2016, and the other in Duluth, Minnesota on November 30, 2019. The play lasted ~60 minutes and was followed by a talk-back session facilitated by one of the authors that lasted ~30 minutes. These talk-back sessions were not led by any guided questions but instead allowed audience members to discuss the play openly with one another. Members of the audience were asked to complete a survey before the performance, immediately after the talk-back session, and then three weeks later. These assessments each contained the same seven statements regarding patient medication experiences and asked participants to rate their agreement with each statement. The two additional questionnaires were administered after the play which contained demographic questions and open-ended questions asking for feedback on the experience. The findings from the seven statements were summarized with descriptive statistics and inductive thematic analysis was performed on the open-ended questions.¹

A total of 225 health professions students attended the two performances; 161 participants completed the post-performance survey and only 58 completed the 3-month follow-up survey. There was a significant increase in the survey scores before vs. after the performance. Some of the key results of this survey are detailed in Table 1. During the qualitative analysis, the responses to the open-ended questions were merged into six categories then ultimately two themes: 1) barriers faced by patients when seeking health care services and 2) major hindrances and contributors to the patients’ medication experience. Overall, the results show that theatrical performance may be an effective educational tool to understand the human experience from a patient’s perspective.¹

Table 1: Pre- and Post-Performance Survey Results

Survey Item	Before Performance, Mean (SD)	After Performance, Mean (SD)	P-value
I am able to fully empathize with patients	3.6 (0.9)	3.9 (0.9)	<.001
I am fully aware of all the challenges patients experience with taking their medications	3.0 (1.1)	3.4 (1.1)	<.001
I am fully aware of the attitudes patients hold toward their medications	2.8 (0.9)	3.5 (1.0)	<.001
I am fully aware of all the challenges patients experience with filling their medications	3.0 (1.0)	3.6 (1.1)	<.001
I am fully aware of the roles of medications in society	3.3 (0.9)	3.6 (0.9)	<.001
I fully understand the process of prior authorizations	2.9 (1.2)	3.5 (1.1)	<.001
I fully understand the effect of the medication experience on a patient’s family	2.9 (0.9)	3.5 (1.1)	<.001

 

One of the biggest strengths of this study is the longitudinal assessment of audience members’ perspectives before and after the performance as well as three months following the play. This was an effective way to discern the audience’s initial perceptions and how Go Ask Alice affected their understanding of patients’ medication experiences. The post-performance talk-back session could be seen as both an advantage and disadvantage. The session allowed audience members to explore their feelings and reactions to the play, which would be advantageous for learners. However, this discussion could have influenced the results of the surveys by emphasizing all the aspects of patient experience that audience members were supposed to get from the play but did not. Another disadvantage of this study is the cost and access! The two performances cost roughly 25000.  Only 225 were in attendance and the two plays were held in a relatively small geographical area (both in Minnesota). Because of this, Go Ask Alice was not widely available. A wider audience (from different geographic areas) may not have the same of reaction to the play. There was also some concern from the audience that too much medical jargon was used in the script.

I feel like the analysis method used to evaluate the rate of agreement with the seven statements was appropriate, as was the use of a thematic analysis for the evaluation of the open-ended questions. For this qualitative analysis, one researcher read the comments several times and identified the main codes and categories. After this, a second researcher evaluated the codes and categories.  If needed, the second researcher debated the coding and classifications with the first researcher.  Based on both the results of this study and my personal experience with drama-based educational techniques, I do believe theater is an effective way to teach healthcare providers to see experiences from patients’ perspective. Moreover, this is an entertaining way to present information when real-life experience may not be a practical option.

Another study explored the negative impact of medication-related burden (MRB) and patients’ lived experience with medication (PLEM) therapies or medical conditions.³ This study concluded that because of the impact MRB has on patients’ beliefs and behaviors toward medications, healthcare practitioners need to have better insights into PLEM to improve patients’ medication therapy and outcomes.³ Though theatre models have been used to educate healthcare students in various situations, there is little literature on the appeal of such techniques to trainees.⁴ Another study concluded that the drama-based learning technique used had a generally positive influence on medical students’ perceptions.⁴

Because patient-centered care has the potential to strongly impact patient health outcomes, healthcare providers need to understand the struggles patients might face and be able to express empathy.⁵ This study explored an innovative teaching method that allowed audience members to understand and experience medication issues from a patient perspective.¹ Based on the feedback received from the audience, it seems that the educational tool was successful in achieve its goal but it’s impact was limited to a small audience.¹ In the future, such plays could be recorded for mass viewing or even adapted into active learning exercises for re-enactment by students in the health professions. Future healthcare professionals may benefit from the incorporation of drama-based learning strategies into their curricula, especially in areas where understanding the patient’s perspective is critically important.

References:

1. Cernasev A, Kuftinec S, Bortz R, Schommer JC, Ranelli PL. Using Theater as an Educational Tool for Understanding Medication Experiences from the Patient Perspective [Internet]. Am J of Pharm Educ. 2020; 84(4): Article 7606.
2. DBI Network: Activating learning through the arts [Internet]. Austin: The University of Texas at Austin; c2020. Drama-based Pedagogy; 2020. Available from: https://dbp.theatredance.utexas.edu/about
3. Mohammed MA, Moles RJ, Chen TF. Medication-related burden and patients’ lived experience with medicine: a systematic review and metasynthesis of qualitative studies [Internet]. BMJ Open. 2016; 6: e010035. doi: 10.1136/bmjopen-2015-010035
4. Keskinis C, Bafitis V, Karailidou P, Pagonidou C, Pantelidis P, Rampotas A, Sideris M, Tsoulfas G, Stakos D. The use of theatre in medical education in the emergency cases school: an appealing and widely accessible way of learning [Internet]. Perspect Med Educ. 2017; 6: 199-204.
5. Stewart M, Brown JB, Donner A, McWhinney IR, Oates J, Weston WW, Jordan J. The Impact of Patient-Centered Care on Outcomes [Internet]. J of Fam Prac. 2000; 49(9): 796-804.

The Importance of Educating Caregivers Too

by Lydia Kneemueller, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:  Alnazly EK. The impact of an education Intervention in caregiving outcomes in Jordanian caregivers of patients receiving hemodialysis: A single group pre-and-post test. International Journal of Nursing Sciences 2018; 5(2): 144-150.

I feel that caregiver education is often overlooked.  I think it’s equally important that we address the needs of caregivers as well as patients. As baby boomers continue to age, the needs of caregivers will only increase and the current pandemic has only made their burden greater. I found a study that specifically addresses caregiver education.  The study looked at the level of stress that caregivers experience and evaluated the impact of an educational program on caregiver burden and perceptions of life.¹

This study was carried out in Jordan at four outpatient hemodialysis facilities located in three different cities.¹ Each caregiver filled out a questionnaire about socio-demographics which also included questions about their health such as headaches, difficulty sleeping, hypertension, and heartburn. In addition, the participants completed a 15-item questionnaire to measure the burden of physical and emotional caregiving tasks on a 5-point scale. Lastly, participants had a 15-item questionnaire that was used to measure caregiver perception of their life, in which a score of 4 or greater indicates the caregiver’s perception of life has changed for the better.¹

During the educational program, caregivers were provided information about how to perform caregiving tasks such as diet and nutrition, food recipes, weight control, blood pressure monitoring, infection, fistula care, quinine catheter care, skin hygiene, bleed precaution, medications, fall prevention, available resources, and involving other family members in patient care¹. Methods of teaching included lectures, small group discussions, return demonstration, videos on DVDs, and written materials which were developed at a 5th-grade reading level. The instruction was provided during one 4-hour session. After the session, behavioral skills were observed using simulations and scored using a checklist. The caregiver burden assessment was administered two weeks after the educational session in order for caregivers to have time to implement the newly acquired skills.

During this study, 169 caregivers completed the pre and post questionnaires. The participants had between 1 and 15 years of experience serving as a caregiver, most were female (55.6%), and their ages ranged from 26 to 70 years old. Many of the caregivers indicated they had a high level of difficulty meeting the patient’s dietary needs.  They also expressed concerns about finances and finding help with caregiving tasks.

Following the education intervention, there was a positive change in the caregiver perception scores which suggests that the instructional activities likely had a positive impact on the caregiver’s life perceptions.  See Table 1. In fact, almost all scores significantly improved. The only scores that did not increase to above 4 were the time for social activities (pre 2.30 to post 3.65) and financial well-being (pre 2.86 to post 3.99). It is clear that the intervention provided a positive increase in scores on all change in life perception characteristics evaluated. 

Table 1:  Changes in Caregiver Perceptions (Pre vs. Post Scores)

Characteristic	Difference in Scores
Self Esteem	+ 1.55
Physical Health	+ 2.31
Time for family activities	+ 1.84
Ability to cope with stress	+ 1.06
Relationship with friends	+ 1.46
Future outlook	+ 1.64
Level of energy	+ 1.36
Emotional well-being	+ 1.12
Roles in life	+ 1.13
Time for social activities	+1.35

 

One of the weaknesses of this study is that since hemodialysis is life-long, these results may not be the same for caregivers who care for patients with short-term health conditions. Moreover, hemodialysis requires very hands-on, intense caregiving skills similar to the level of care that patients with cerebral palsy and dementia require. This study also did not have a control group, so while the pre and post-intervention assessments showed an improvement, there was no control group to compare the effectiveness of the educational program.  Because the patients were not blinded and likely want to please the investigators, their responses may have been biased.  The three assessments were appropriate to measure and could be applied to caregivers in all levels of care.

Another study that provided education to caregivers of patients with dementia had a similar impact on caregiver burden.² The dementia study was a randomized, controlled study that evaluated the effects of an education program that consisted of 5 weekly sessions that covered topics about treatment, ways to improve patient communication, and methods to help control patient’s unusual behaviors.² Family members who participated in the education program had a significant reduction in caregiving burden one month following the educational program, whereas the group that did not have any education had increased levels of burden. In another study, an assessment of the effectiveness of educational intervention for improving the complementary feeding (weaning) practices of primary caregivers of children was evaluated.³ The findings showed that caregivers randomly selected for the educational intervention demonstrated improvements in complementary feeding and hygiene practices.³

These studies demonstrate the importance of educating our caregivers and that such interventions can positively impact caregiver burden and quality of life. These studies have made me realize how important it is to educate not only patients but also their caregivers — to make sure they understand the medications and how to perform caregiving activities. Improving the lives of caregivers hopefully results in better patient care which is my goal as a student pharmacist.

References

1. Alnazly E K. The impact of an education Intervention in caregiving outcomes in Jordanian caregivers of patients receiving hemodialysis: A single group pre-and-post test. International Journal of Nursing Sciences 2018; 5(2): 144-150.
2. Pahlavanzadeh S, Heidari FG, Maghsudi J, Ghazavi Z, Samandari S.(2010). The effects of family education program on the caregiver burden of families of elderly with dementia disorders.Iran J Nurs Midwifery Res. 2010; 15(3): 102-108.
3. Arikpo, D., Edet, E. S., & Chibuzor, M. T. (2018). Educational interventions for improving primary caregiving complementary feeding practices for children ages 24 months and under. Cochrane Database of Systematic Reviews. doi:10.1002/14651858.cd011768.pub24.

Reducing the Stress of Parents of Children with Type 1 Diabetes

by Katherine Blackburn, Doctor of Pharmacy Candidate, University of Mississippi School of Pharmacy

Summary and Analysis of:   Whittemore R, Coleman J, Delvy R, et al. An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress. The Diabetes Educator 2020;46(1):62-72.

Most parents' lives are full of stress with demands from multiple sources. Their work-life can demand one thing while their children's lives require something else. When do parents even find time to cook dinner? For parents of children living with a chronic illness, such as type 1 diabetes, their stress levels are much higher when compared to the average parent. However, it is vital that parents of children with type 1 diabetes learn how to manage their stress so that their stress does not adversely affect their child's life and care. A recently published study evaluated the benefits of a six-month educational program, called Type 1 Teamwork.¹ The investigators measured parental stress before and after using this innovative online program.

Type 1 Teamwork offers on-demand, online seminars and other activities focusing on the transfer of care responsibilities to the child, effective communication skills, and stress management. The study was a randomized control trial that recruited parents or guardians of a child between the ages of 11 and 16 with type 1 diabetes who were willing to commit to the six-month study and spoke fluent English. The eligible participants were randomly assigned to participate in the Type 1 Teamwork program or a control group. The participants in the Type 1 Teamwork group were immediately granted access to the online programming featuring diabetes information, tips for diabetes management, and skills for efficient communication between parents and children.  One of the goals of this program was to reduce parental stress. The program requested parents log into the portal once a week to review educational materials. The control group was given access to the Type 1 Teamwork program after completion of the study. To determine the primary outcomes of reducing parenting stress, the researchers utilized the Pediatric Inventory for Parents (PIP) and the Perceived Stress Scale. On both of these inventories, a higher score means a higher stress level. In addition to reducing parenting stress, researchers also analyzed parent anxiety, parent depressive symptoms, parent support for their child's autonomy, family conflict, and the child's A1C levels. To analyze the results, researchers used histograms and quantile-quantile plots to establish normality. For the primary outcome, they used an unadjusted, repeated measures regression model comparing parent's stress reported at baseline, three-months, and six-months in the two groups.¹

At baseline, 36% of parents participating in the study exhibited elevated depressive symptoms while 40% of parents exhibited elevated state anxiety symptoms. The average child’s baseline A1C was 7.9%. Parents reported that 75% of children used an insulin pump and 69% used a continuous glucose monitor to manage their diabetes. Researchers found that using Type 1 Teamwork deceased parent’s overall stress, improved communication between family members, and helped parents delegate responsibilities to their child to optimize their care. Parents also reported lower emotional distress and decreased struggles with parental roles and communication. However, because this was an online program focused on alleviating parenting stress, the program did not address ways to lower depression and anxiety symptoms other than encouraging parents to seek other treatment. While there were several benefits to participating in the Type 1 Teamwork program, the average A1C did not change over the six-month study.¹

One of the main strengths of this study was its broad eligibility criteria. These criteria allowed for people of all backgrounds, races, and geographic locations. However, most of the participants were married white women with a relatively high income. A potential weakness is the lack of objective verification – all results were self-reported by the parents.  Since the participants were not blinded, they may have been biased toward reporting positive results.¹ Though the study has weaknesses, I believe utilizing on-demand, online programs like Type 1 Teamwork can help reduce parental stress and can teach them new ways of communicating with their children.¹

In another study that examined parenting stress of fathers of children with type 1 diabetes, the investigators found that stress exhibited by the father can adversely impact both the mother and child’s stress response.² These fathers were also given the Pediatric Inventory for Parents to evaluate their overall stress levels; however, their results were much lower than the women in this study. In a third study completed in Germany, parents who attended weekly meetings with other families who also have children with Type 1 Diabetes exhibited lower psychological stress and improve parenting behaviors.³

High levels of parental stress can not only impact the parent’s mental health but also affect the care their child receives. Online programs, such as Type 1 Teamwork, offer support for parents and their children from the comfort of their home and at a time that is convenient, thereby reducing barriers to participation.¹ Educators should be aware of programs available for parents of children with Type 1 Diabetes to provide support materials they can review and choose from, such as the Diabetes Empowerment Foundation, which offers material for the person with diabetes, parents, and partners.⁴ Educators need to consider the circumstances each parent faces as well. Do they have a support system present? Are they the main caregiver for their child? Does the parent have time to incorporate meetings into their schedule? Are they financially stable? It is important to consider all factors of the patients when making recommendations because if educators overwhelm them with too much information, it can cause their stress levels to increase even more.

References

1. Whittemore R, Coleman J, Delvy R, et al. An eHealth Program for Parents of Adolescents With T1DM Improves Parenting Stress. The Diabetes Educator 2020;46(1):62-72.

2. Mitchell SJ, Hilliard ME, Mednick L, et al. Stress among Fathers of Young Children with Type 1 Diabetes. Fam Syst Health 2009; 27(4):314-324.

3. Sabmann H, de Hair M, Danne T, Lange K. Reducing stress and supporting positive relations in families of young children with type 1 diabetes: A randomized controlled study for evaluating the effects of the DELFIN parenting program. BMC Pediatrics 2012;12:152.

4. Diabetes Empowerment Health, Support & Wellbeing [Internet]. 2019 [cited 2020 Oct 9]. Available from: http://www.diabetesempowerment.org