Rémi Gagnayre

The use of degrees of certainty to evaluate knowledge.

In patients with chronic diseases education should improve knowledge about the disease and increase certainty in knowledge. We present here a technique to measure changes in certainty after an educational intervention. For this purpose, before and after a course, patients answer a questionnaire in which answers are accompanied by an estimate of the degree of certainty. Answers are then assigned to areas of knowledge defined a priori: mastered (certainty > or = 90%, correctness > or = 90%), hazardous (certainty > or = 90%, correctness < or = 50%), uncertain (certainty < or = 50%, correctness > or = 90%) and residual. Finally differences in the distribution of answers among different areas are analysed statistically. Using this technique in a group of patients with type I diabetes who followed a course on insulin use, we found significant changes in the distribution of answers among different areas of knowledge. Thus changes in certainty can be analysed quantitatively and used to evaluate better the effect of therapeutic education.

Learning difficulties of diabetic patients: a survey of educators

This study was designed to shed light on the learning difficulties of diabetic patients. An open-ended questionnaire was sent to 85 health care professionals working in the field of diabetes and nutrition who had been trained in patient education techniques. They were asked to describe the skills that were the easiest to teach patients and those that patients mastered the best, as well as the skills they found hardest to teach patients, those that patients mastered the least and those that gave rise to errors persisting after the patients education was completed. On the whole, the results showed that the educators found it easy to teach techniques: patients mastered procedures well and made few mistakes. In contrast, diabetic patients seem to have problems learning skills, such as insulin dose adjustment, that require complex problem-solving (involving multiple variables). Based on these findings, the authors discuss the notions of learning complexity and the time needed for successful patient education.

Dermatite atopique : un référentiel d’éducation du malade

Resume Introduction L’education therapeutique s’applique a de nombreuses maladies chroniques. Elle vise a ameliorer la prise en charge de ces maladies en developpant les competences des malades. La dermatite atopique est un champ de developpement de l’education therapeutique. L’objectif de ce travail etait de definir les competences propres a la gestion de la dermatite atopique pouvant faire l’objet d’une education therapeutique et de reunir ces competences sous forme d’un referentiel adapte a l’usage. Materiel et methode Trente soignants ont participe a la redaction de ce referentiel (dermatologues, medecin specialiste d’education therapeutique, psychologue, infirmieres). Tous avaient une experience en education therapeutique au cours de la dermatite atopique. Resultats Quatre tranches d’âge ont ete retenues (avant 5 ans, de 6 a 10 ans, pre adolescent/adultes, parents d’enfant de moins de 5 ans). Pour chaque tranche d’âge, les competences attendues des malades ou parents d’enfant et les methodes d’apprentissage adaptees ont ete choisies. Les competences ont ete classees en trois champs differents : (i) les connaissances (savoir) sur la maladie, les traitements, les facteurs declenchants, (ii) les savoir-faire : realisation des soins par les malades ou par les parents, (iii) les savoir etre : savoir expliquer la maladie et les soins aux proches, savoir quand et qui contacter. Enfin, un guide pour le diagnostic educatif en 10 questions a ete etabli. Discussion Nous rapportons les modalites d’elaboration et le contenu d’un referentiel de competences pour les malades atteints de dermatite atopique. Il ne s’agit pas d’exiger pour chaque malade l’ensemble des competences listees dans ce travail mais de mettre a disposition des soignants un referentiel complet permettant de choisir les competences a travailler au terme d’un diagnostic educatif. Ce referentiel s’adresse aux malades atteints de formes moderees a severes de dermatite atopique en situation d’echec therapeutique. Il est utilisable par toutes les personnes qui prennent en charge le malade : medecin, infirmiere ou psychologue selon les items explores. Il constitue un support a l’elaboration, a la diffusion et a l’evaluation d’un programme d’education therapeutique dans la dermatite atopique.

Difficulties of diabetic patients in learning about their illness.

The aim of this report is to shed light on the difficulties experienced by diabetic patients in learning about their illness. One hundred and thirty-eight diabetic people (97 IDD and 41 NIDD) were questioned at two survey locations, one national (63) and one regional (75), by means of a closed answer questionnaire. One hundred and four (75%) had attended a formal programme of diabetes education. They were asked which points in their diabetes education they had best understood and which they had least understood. The main results show that, globally, they easily acquire the manual skills. Conversely, numerous learning difficulties are associated with the skills required to solve problems and make decisions, such as adaptation of doses of insulin. These results are comparable to those obtained in a previous study in which professional carers were asked about their difficulties in educating their patients.

Educating diabetic patients about insulin use: changes over time in certainty and correctness of knowledge.

AIM Diabetic patients should understand their disease correctly and be sure of what they know, but certainty is rarely considered by educators. Furthermore little is known about how certainty changes with time after an educational intervention. To clarify this, in 38 patients with type 1 diabetes (0.3-36 years duration) we analysed the effect of a course on insulin use by administering a questionnaire before the course, after the course and 1 and 3 years later. METHODS Answers, accompanied by a subjective estimate of the degree of certainty, were assigned to mastered knowledge (certainty>or=90%, correctness>or=90%), hazardous knowledge (certainty>or=90%, correctness<or=50%), uncertain knowledge (certainty<or=50%, correctness>or=90%) and residual knowledge (total-[mastered+hazardous+uncertain]). Answers were then counted and changes in distribution among areas were analysed by the chi2 test. We also followed the fate of wrong answers. RESULTS The course increased mastered knowledge, while other types of knowledge decreased. With time mastered knowledge decreased, patients losing both correctness and certainty. The loss affected declarative knowledge, based purely on theory, more than procedural knowledge, which concerns the way things are done. Wrong answers, mostly given with high degree of certainty, were heterogeneous since some became correct after the course, some remained wrong, some became wrong after the course, some became mistaken after having been corrected earlier. CONCLUSIONS The analysis of certainty helps in evaluating patients knowledge; programmes tending to improve procedural knowledge are more likely to have long lasting effects; wrong answers need to be considered on a individual basis.

Patient resources in the therapeutic education of haemophiliacs in France: their skills and roles as defined by consensus of a working group

Summary.  The activities of ‘expert patients’ or ‘patient tutors’, who help educate their peers, are gaining recognition in the health care system. This study investigates the role played by such patients in therapeutic education programmes organized by caregivers to validate the role of patients in implementing the therapeutic education of haemophilic patients and to define the skills required for such activities. This study employs the consensus methodology recommended by France’s National Authority for Health. The working group includes seven caregivers from Hemophiliac Treatment Centers (HTCs) and three patients from the French Association of Hemophiliacs (FAH). The role of patients in haemophilia education is recognized. Patients participating in the education of their peers are referred to as ‘patient resources’. A patient resource should be an adult, a volunteer and live in the same region as his peers. Candidates are chosen by the FAH and the HTCs to serve based on their motivation to facilitate the education of other patients as well as on their psychological and pedagogical aptitudes. A patient resource participates in the conception and administration of therapeutic education programmes. He also mediates between the caregivers and the patients. He ensures that the patients understand the material and are able to apply their knowledge in daily life. His activities are governed by professional ethics. Seven categories of skills were defined, permitting the group to determine precisely which skills are required to function as a patient resource. Supervision of the patients is planned to reinforce reflexive practices in the patients. Evolution of the health care system has led patients to become involved in therapeutic education. This phenomenon calls for a framework to be developed and an evaluation of its eventual effects.

Are schoolteachers able to teach first aid to children younger than 6 years? A comparative study

Objectives This study was designed to assess the knowledge acquired by very young children (<6 years) trained by their own teachers at nursery school. This comparative study assessed the effect of training before the age of 6 years compared with a group of age-matched untrained children. Setting Some schoolteachers were trained by emergency medical teams to perform basic first aid. Participants Eighteen classes comprising 315 pupils were randomly selected: nine classes of trained pupils (cohort C1) and nine classes of untrained pupils (cohort C2). Primary and secondary outcome measures The test involved observing and describing three pictures and using the phone to call the medical emergency centre. Assessment of each child was based on nine criteria, and was performed by the teacher 2 months after completion of first aid training. Results This study concerned 285 pupils: 140 trained and 145 untrained. The majority of trained pupils gave the expected answers for all criteria and reacted appropriately by assessing the situation and alerting emergency services (55.7−89.3% according to the questions). Comparison of the two groups revealed a significantly greater ability of trained pupils to describe an emergency situation (p<0.005) and raise the alert (p<0.0001). Conclusions This study shows the ability of very young children to assimilate basic skills as taught by their own schoolteachers.

Analyse des tensions perçues par les soignants hospitaliers dans la pratique de l’éducation thérapeutique : implications pour leur supervision

La mise en œuvre des programmes d’éducation thérapeutique en France suscite chez les soignants des tensions. Ces tensions résultent du décalage perçu entre la réalité des pratiques d’éducation thérapeutique et les représentations qu’ils en ont. Cette étude descriptive qualitative vise à caractériser la nature de ces tensions. En 2009, 27 entretiens semi-directifs ont été réalisés auprès de soignants du Centre Hospitalier Universitaire de Nantes (France). A partir de la théorie ancrée, l’analyse des entretiens a mis en évidence 3 types de tensions : tensions dialogiques, tensions cognitives et tensions d’impuissance d’action. Cette étude interroge les conditions d’une supervision des soignants.

Le conducteur pédagogique : une aide pour mener des séances d’éducation thérapeutique

L’éducation thérapeutique du patient fait aujourd’hui partie intégrante de la prise en charge des patients ayant des maladies chroniques comme en témoigne le guide méthodologique de l’HAS et de l’Inpes et les recommandations de la HAS [1]. Cette prise en charge éducative nécessite que les soignants bénéficient d’une formation méthodologique adaptée [1]. Ceci a été possible dans la mucoviscidose, grâce aux efforts consentis par l’association Vaincre la Mucoviscidose. Pour aider ces soignants à mettre en œuvre des séances éducatives, nous avons rédigé des conducteurs pédagogiques : ils permettent de préciser, à partir du référentiel de compétences et d’objectifs d’éducation du patient, déterminés pour la mucoviscidose en 2007 [2], ce que fait le soignant dans son animation en regard de ce que le patient fait pour apprendre.

Knowledge, Representations, Attitudes, and Behaviors of Women Faced With Taking Medications While Breastfeeding: A Scoping Review

Background: Breastfeeding is a major public health issue in terms of its benefits to both mothers and infants. Despite recommendations, breastfeeding initiation and duration are low in many industrialized countries. Although human milk is viewed as the most appropriate food for infants, when it is perceived as contaminated, doubts about its quality can lead to negative behaviors concerning breastfeeding. This is especially true when mothers are taking medication. Research aim: The aim of this review is to evaluate the data in the literature on the knowledge, representations, attitudes, and behaviors of women with regard to taking medication while breastfeeding. These elements should aid our understanding of how the mothers’ behaviors are constructed in this situation. Methods: The authors conducted a scoping review to map and analyze the available data from literature sources regarding breastfeeding mothers’ knowledge, representations, attitudes, and behaviors about medicines. A staged approach to the scoping review was used. Results: Eighteen studies met the selection criteria. They described safety behaviors like noninitiation, duration reduction, breastfeeding cessation, and refusal to take medication in order to breastfeed. Most showed a conflict between taking medication and breastfeeding. Because the knowledge, representations, and attitudes behind such behaviors have received very little study, it is difficult to explain how these behaviors are constructed. Conclusion: The results of this review confirm the need for a qualitative study to explore the knowledge, representations, and attitudes of breastfeeding women faced with taking medications, so that we can understand their connection with observed behaviors and take appropriate educational action.