Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
1. Scheme title and categoryChildhood Asthma Education Project
A community pharmacist intervention in schools that will contribute to a measurable improvement in the inhaler technique, adherence, and associated health outcomes, of children and young people (CYP) with asthma in primary and secondary school settings.
• To assess, and if necessary improve, inhaler technique for each CYP during one school-based pharmacy-led workshop and one follow-up workshop
• To show a reduction at 8-week follow-up in self- and/or parent-reported:
o Number of school days lost
o A&E attendances
o Emergency hospital admissions
o GP / OOH appointments
• To assess, and if necessary, improve condition control
• To show an improvement in quality of life – in terms of symptoms, activity limitation and emotional function – at follow-up
• To assess, and increase if necessary, the self- and/or parent-reported adherence of CYP to their asthma therapy
• To increase the confidence of CYP, parents and teachers in the use of inhalers
The scheme will be delivered with the support of Widnes Vikings, who will provide links with schools,
and player ambassador support for CYP with asthma.
The workshops aimed at primary school children will also make use of technology’s developed by Manchester University to use with flo-tone trainer devices (i.e. the Rafi –Tone App) which allows the children to monitor their own inhaler technique using an interactive App.
2. Summary of scheme, which patients/population groups is it targeting and forecast numbers of people who will be able to use/access the service
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
Prime Ministers Challenge Fund – Together for the health of Halton
Scheme specification template
The project proposes holding Community Pharmacist led inhaler technique workshops in primary and secondary schools. Noting the Asthma UK estimate of 2 children with asthma in each classroom[i], we will host workshops for a combined year 4-5 cohort (8-10 year-old students) and combined year 9-10 cohort (13-15 year-old students).Participating schools will also be offered a young person’s education event provided by Widnes Vikings, to be offered to the wider school population , that will focus on respiratory disease in general.
We aim to engage 4 primary schools and 4 secondary schools in this project. These schools will be purposively sampled, including schools with whom members of the project team have existing relationships. Within the sample there will be a diversity of deprivation (as determined by the full postcode of the school) across the Index of Multiple Deprivation quintiles and a geographical diversity across the Halton Local Authority areas.
When choosing the schools we will be closely guided by
· The data available on prevalence of asthma in children in the GP surgeries in Halton, and the surgeries proximity to local schools
· The data available on admissions to hospital related to Asthma, for children in Halton.
· The school nursing teams, and local authorities.
A letter will be written to the Head Teacher of prospective schools, outlining the project and gauging their interest. This will be followed up with a phone call. When a school agrees to participate, we will ask the Head Teacher to nominate a primary liaison teacher for the project team, who may or may not be themselves.
We propose to engage primary and secondary school CYP to show that it is possible for pharmacists to teach CYP at different stages of cognitive development, and at times of transition. We will not work with CYP, who will be taking national exams over Summer 2016 (SATS or GCSEs).
We will recruit CYP from the appropriate age groups with the help of the liaison teacher who may, in turn, draw upon other stakeholders. These are most likely to include Head Teachers; School Nurses; Parent Governors; Year Teachers and support staff. The project team will offer to present the project to the staff / governors at a special meeting before the project begins. The school will be required to have in place a ‘Managing Medical Conditions in schools’ policy .
An information pack from the project team will be sent by post from the school to all CYP in the specified classes who have been identified as CYP with asthma by the school. This will contain:
• An information sheet for the CYP (2 separate sheets will be developed for the different age groups and piloted with CYP)
• An information sheet for the parent/carer
• A parental permission form and a CYP assent form (none of the CYP will be able to give consent, but can and should give assent)
• A return envelope that should go to the school office.
The information sheet will show the date and time of the initial after-school workshop and the follow-up workshop. Once CYP and parent/carers return permission forms, the project team will know whom to expect. The permission form will also ask the parent/carer to tell the team what types of devices they use. It will include the address of their GP usual community pharmacy. The GP will then be notified of their patient’s participation in the project through a letter and copy of the information sheet.
In parallel, four local pharmacists and technicians will be trained in the delivery of the workshop. Each workshop will be delivered by two pharmacists and pharmacy technicians. This additional training will draw on the required expertise of how to relate to and engage CYP. To ensure that the project is successful, a fun and interactive approach will be taken, appropriate to each age group.
The project team and the community pharmacists engaged will work in a collaborative way with parents, school staff, school nurses, Staff from Widnes VIkings and appropriate staff from LAs, CCGs, GPs and practice nurses.
Workshop Format
Working in partnership with school nurses, teachers, and staff from Widnes Vikings community pharmacists will attend the schools at pre-arranged times to run a workshop for CYP, parents and school staff who are interested in finding out more about asthma and inhalers. The workshop format will be piloted in two schools (one primary and one secondary), with project team leaders present, and any revisions needed will be made.
The workshop content will be guided by staff as to the optimum length for the different age groups, but inevitably there will be administration time needed at the beginning and end of the direct engagement time. Staff will advise the team when the session should take place – it is not likely to be immediately after school (to protect the privacy of the participants), so it is likely to be later in the evening (6-8pm) or at a weekend. We anticipate that 10 CYP and their 10 parents, with up to 6 staff, will be a good size for the workshop audience.
The workshop will start with an introduction to the service, which will be given by the pharmacist; this will explain the importance of good inhaler technique. Other elements of the workshop will include:
• An individual assessment of each CYP current condition control
• An individual assessment of the CYP respiratory technique and where appropriate advice and demonstration of the correct technique required. Podcasts, with an on-screen demonstration of correct technique may be used.
• Importance of ensuring CYP has the correct equipment in school at the start of each term (parent, CYP and teacher responsibility);
• ‘Red flag discussion’ which will include how to deal with asthma attacks / expiry dates of medication;
• The Vikings Coaches would then deliver active games around respiratory health messages.
o Don’t Start Smoking
o Antibiotics and Colds/Flu
o Why is exercise important?
o Player Ambassador support from members of the Widnes Vikings/ Liverpool Ladies team
• Provide each CYP with an Asthma UK pack, factsheets and podcast link;
• Q&A with the Pharmacist;
• ‘Quiz’ activities at milestones during the session (on computers if available in the workshop room) to gauge knowledge and adherence.
• The workshops aimed at primary school children will also make use of technology’s developed by Manchester University to use with flo-tone trainer devices (i.e. the Rafi –Tone App) which allows the children to monitor their own inhaler technique using an interactive App.
The CYP/parent pair will be encouraged to visit their own community pharmacy if they have any questions about the inhaler in the period after the first workshop. All community pharmacies in the study areas will be informed
If an intractable problem is identified with the device during the workshop, the CYP/parent pair will be shown alternatives and given a double-copy letter to take to their GP and regular community pharmacist which will ask them to consider a change of device.
The follow-up workshop will be held six-eight weeks later. This will give the CYP/parent pair the opportunity to show the pharmacy team how they have made progress, and will provide a forum for questions. Follow-up data collection in the quiz format will also be repeated. It is likely to be shorter in length than the first workshop. At the end of the second workshop, there will be a discussion about resources available to CYP and families, with a particular encouragement to visit the community pharmacist if they need further help and a final referral letter will be given to each family for their community pharmacy.
The CYP will receive a certificate of attendance at each session to add to their portfolio of achievements. This will maximise attendance from which our evaluation data will be drawn.
3. What benefits and impacts will the scheme bring to the targeted patient/public groups?
According to Asthma UK
· One in 11 children has asthma and it is the most common long-term medical condition.
· On average there are two children with asthma in every classroom in the UK.
· The UK has among the highest prevalence rates of asthma symptoms in children worldwide.
It is nationally acknowledged that the majority of patients, estimated by some authors at up to 90%, demonstrate a poor inhaler technique resulting in poor health outcomes and quality of life[ii] [iii]. When children do not use their inhalers correctly, they gain no - or at best a drastically reduced - benefit from the treatment, and this does not encourage adherence. Bad habits can be formed early in life that perpetuate into adulthood, with reduced quality of life.
Parents are partners in care, and work has shown that their knowledge is important in the overall chance of good outcomes. For 46 children aged 0-12 in one study in the Netherlands, it was found that in 87% of cases the parent decided when and how the inhaler device should be used, but mistakes were still being made. The authors recommended that parents should be involved when instructions for use were being given.
On average, there are 2 children with asthma in every classroom in the UK. As the main place that children spend time, there is a need to harness this environment to keep children with asthma well. A survey by Asthma UK found that 64% of children with asthma have at some point been unable to access a working inhaler in school, and 62% have had an asthma attack while at school. There have been recent changes to school medicine policies to enable salbutamol inhalers to be held as stock in schools for emergency use8. If staff and pupils do not know the correct technique, then the efficacy of this potentially life-saving medicine will be reduced.
Interventions with children regarding inhaler technique have been reported. The literature shows a better chance of correct inhaler technique for them where:
• There are repeated instruction sessions[iv]
• Where the patient has the opportunity to demonstrate their inhaler use[v]
• Where the children had the opportunity to ask their own questions about their medication
A paediatric medicine study from the Netherlands[vi] specifically compared the efficacy of a single instructional session from the GP with repeated pharmacy checks for newly-diagnosed patients aged 1-14 years6. They found that 79% of the pharmacy cohort performed essential steps correctly, as opposed to 39% of the GP session cohort (p<0.01). Moreover, a short video intervention about inhaler technique for children showed improvement over control immediately after seeing it, but not at follow-up11. The themes across all these papers seem to be that children would benefit from repeated inhaler technique instruction, that their parents should be involved, and that the school environment is also a place to promote more knowledge about these issues.
4. How will the scheme help contribute towards improving Halton residents’ access to a GP?
The scheme will improve the inhaler technique, and adherence to medication regimes, of CYP with Asthma, leading to an overall improvement in the control of their symptoms.
Improved control will reduce the need to access GP appointments due to deterioration in symptoms, reducing the demand on GP appointments.
The scheme will demonstrate the effect of a condition focused education programme for CYP in schools, the benefits of which could be sustained by future programmes for asthma education or education around other conditions.
5. How will be scheme success be evaluated and what key metrics will need to be collected?
All data will be recorded on a bespoke electronic PharmOutcomes service database to ensure consistency and the ability to produce individual reports. The preference is to complete the data input during the session before leaving the school where internet accesses is possible. If internet access is not available the data from the workshops will have to be collected on well-designed paper forms and stored securely on the school premises until such time as the pharmacy staff completing the sessions can collect and transport the data to the pharmacy, the data will subsequently entered onto the database by the pharmacist and their accompanying staff member and paper copies destroyed.