Education of the patients with I stage of cholelithiasis at the health school

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Department of Propedeutic of Inner Diseases, Izhevsk State Medical Academy, Udmurt Republic

Izhevsk State Medical Academy, Department of Propedeutic of Inner Diseases, Udmurt Republic

EDUCATION OF THE PATIENTS WITH I STAGE OF CHOLELITHIASIS AT THE HEALTH SCHOOL

Khokhlacheva N.A. PhD, Professor,

Mikhaylova O.D. PhD, professor assistant,

Vakhrushev Ya.M. PhD, Professor, Glazyrina N.N.

Summary

Patients with stage I cholelithiasis were toughed at the school of health according to the special structured program. The psycho-emotional state, sanitary education and edical activity of patients were investigated in dynamics.

It was revealed that the training of patients at the school of health as part of complex therapy contributed to the better therapeutic effect, that was manifested in the early pain and dyspeptic syndromes reduction, the restoration of psycho-emotional balance. There was a positive dynamics of sanitary education and medical activity, that was expressed in increasing the knowledge level on the problem of cholelithiasis and readiness to apply this knowledge in practice.

Thus, we evaluate the therapeutic training of patients with stage I of CL at the school of health as clinically justified and promising direction of treatment of CL and prevention of gallbladder stone formation.

Key words: cholelithiasis, school of health, psycho-emotional status, health literacy, medical activity.

The main text

PROBLEM STATEMENT. Many risk factors for various diseases directly depend on the person [1,2]. Low medical culture of a significant part of the population is an important obstacle to the formation of active health promotion behavior [3,4].

As it turned out, health education - passive receiving of medical information - is not an effective way to promote healthy lifestyles. A very important role here belongs to the active educating to hygienic medical skills (trainings, role-playing games) for their subsequent use in life [5,6,7]. Such task is faced by schools of health for patients, that are widely introduced in the practice of health care in recent years [8,9]. This approach contributing to the improvement of the preventive direction with the using of resource-saving technologies, is also relevant due to realization of the national project "Health", started on 01.10.2018.

ANALYSIS OF RECENT RESEARCHES AND PUBLICATIONS.

The literature covers the organization of health schools for patients with various pathologies [10,11], but we have not found information about the organization of training for patients with cholelithiasis (CL). Meanwhile, this issue is extremely important and relevant today due to the ever wider and year-on-year increasing spread of this pathology [1,2,6].

FORMULATING THE PURPOSE OF THE ARTICLE. The training of patients in the school of health was organized with the aim to improve the effectiveness of therapy of cholelithiasis and to prevent the gallbladder stone formation. cholelithiasis health therapy medical

MATERIAL AND METHODS.

210 patients with I (pre-stone) stage of CL (classification of CSIIG, 2001) were examined. [12]. The study was spent during their hospitalization to the gastroenterology Department of Municipal Clinical Hospital due to various pathologies of the hepatobiliary system (biliary dysfunction, chronic non-calculous cholecystitis, non-alcoholic and alcoholic fatty liver disease).

The age median was 48 (32-65) years, there were 96 males and 114 females. Criteria for inclusion in the study were the next: age 20-65 years, the presence of biliary sludge on ultrasound examination (USE) of the gallbladder, the presence of an informed voluntary consent signed by patient (due to order No. 390n of the Ministry of Health and Social Development of the Russian Federation from 23.04.2012). Criteria for exclusion from the study: age less than 20 and more than 65 years, severe condition, cancer, mental disorders. This study was allowed by the ethical Committee of the Izhevsk State Medical Academy.

The diagnosis was verified by ultrasound investigation of the gallbladder. In addition to the clinical study (anamnesis, physical study), the study of psycho- emotional status of patients was performed. The levels of reactive anxiety (RA), as a state at the moment, and personal one (PA), as a stable characteristic of a person were investigated with the help of the Spielberg-Hanin test. The level of depression (D) was studied using the self-assessment scale of depression by V. Zung.

The examined patients were divided into two groups. The observation group (123 patients) together with base therapy in accordance with medical and economic standards (MES), were toughed at the school of health. The comparison group (87 patients) received only MES therapy. The groups were balanced by gender and age. The results were compared with the data of the control group, which included 50 healthy volunteers aged 30 to 60 years.

The organization of the school of health was guided by the Order of MH of the Russian Federation № 455 from 23.09.2003 “ Improvement of activity of health organizations for disease prevention in the Russian Federation” and Order of Ministry of Health UR № 449 dated 13.09.2011 "Organization of health schools activity on issues of formation of healthy lifestyle". The duration of the training cycle was 10 lessons for 50-60 minutes. Classes were carried out by the method of active learning. The distribution of time was as follows: 30 % - information lecture, 30 % - discussion, 30 % - practical work (case-method, role-playing games), 10 % - individual consultations.

The effectiveness of health school education was evaluated by the levels of health literacy (HL) and medical activity (MA) determined before and after the cycle of classes. The criteria for assessing the levels of GL and MA were the results of tests and questionnaires developed according to the conceptual model of health literacy proposed in the European survey of population health literacy (2012). They included questions on risk factors for CL and the ability to apply the information in practice.

The calculation of the required number of observations was based on the calculation of the sample size with the level of statistical power of the study p=0.80 and was performed using statistical software packages Statistica 6.1 (Stat Soft), allowing to estimate the sample population as corresponding to the normal distribution. Randomization of patients was carried out at the stage of group formation using the method of simple randomization with random number tables. To determine the relationship between the analyzed qualitative characteristics, the criterion x2 was used. The data in the table are presented as average values (M) with the determination of their errors (± m). The reliability was evaluated by the Student's criterion, the difference is considered reliable in p < 0.05.

RESULTS AND DISCUSSION

At USE biliary sludge in the cavity of the gallbladder (suspension of hyperechogenic particles, putty bile, microlithiasis) was found in 100% of patients, it was the criterion for inclusion in the study. In anamnesis, pain abdominal syndrome was revealed. As a rule, the pain was localized in the right hypochondrium, was dull, oppressive, intensified after eating, less often the pain was acute, colic-like. Among the symptoms of biliary dyspepsia prevailed eructation, slight nausea, bitter taste in the mouth, unstable stool with alternation of diarrhea and constipation.

In the examined patients, both reactivity to external and internal stimuli (RA) and the level of personal anxiety (PA), characterizing the tendency to perceive a large range of situations as threatening, were significantly increased; the level of depression (D) as one of the manifestations of psycho-emotional disadaptation, was high (table 1). These results are consistent with the previously described in the literature data obouthigh anxiety of patients with pathology of the biliary system [13].

To develop a structured training program for the cycle among the patients of the observation group, a survey was conducted, that revealed that 74 patients (60.16%) preferred a conversation with a doctor to all other sources of information about their health. 89 patients (72,35%) wanted to receive detailed information about proper nutrition in CL,64 patients (52,03%) - about rational moving activity and 47 patients (38,21%) needed data about the harmful effects of smoking and alcohol for health. The main source of medical information for the majority of respondents was the media (TV and radio programs, newspapers, computer sites). 75 patients (60.97%) smoked and (or) used alcohol.

Insufficient was the level of medical activity (MA) of patients (negligent attitude to their health, non-compliance with medical recommendations'). So, in case of complaints only 47 patients (38.21%) addressed to the doctor in time, the rest ones - only when independent treatment was ineffective. Only 54 patients (43,90%) exactly followed to doctor's recommendations.

Based on the results of the survey, a training program for course was developed, that aimed to improve the prevention of gallbladder stone formation. Classes at the school of health were held in a group consisting of 8-12 people. The group was a "closed group", i.e. new patients did not join it in the learning process. The program of the cycle included the following topics: anatomy and physiology of the gallbladder, the concept of CL and its complications, diet and rational work and rest regimen, necessary for the prevention of gallbladder stone formation, non-drug therapy of CL, the negative role of alcohol and smoking in the development of CL. To increase adherence to treatment two lessons were conducted in conjunction with a psychotherapist. During classes patients were encouraged to express their views on the issues discussed, to discussions, to exchange life experiences (positive or negative), thus patients received psychological support. At the end of the lesson, the results were summed up together, the key points of the topic were once again emphasized, the doctor and the accomplices noted the successes of each person.

Table

The dynamics of psycho-emotional status in the learning process at the School of Health

Note: n - number of observations; P¹- reliability with respect to the control level; P² - reliability with respect to the level before treatment

Indicators of psycho-emotional status of patients were studied in the dynamics of treatment (table).

The inclusion of therapeutic training in the treatment regimen (observation group) contributed to a distinct decrease in D, PA and RA, that reflected the normalization of the psycho-emotional background.

It is important that during the training the level of RA decreased more than PA level, that probably indicated the normalization of the patient's situational response to such stressful situations as illness and fear, due to lack of necessary and adequate medical information. The level of PA remained higher than control values (the same was noted by us in earlier studies [14,15]), may have been associated with the increasing responsibility of the patient for his health in obtaining reliable knowledge about the CL and methods of preventing gallbladder stone formation. In the group of comparison it was not noted the dynamics of indicators of the psycho-emotional status.

Figure 1 Changes in the level of hygienic literacy of patients during treatment

Normalization of psycho-emotional background contributed to a more manifested dynamics of clinical symptoms. Thus, abdominal pain and biliary symptoms in the observation group were stopped to 3-5 days of treatment, and in the comparison group - to 7-10 days.

In the course of training, patients improved their knowledge on the CL problem (health literacy), as evidenced by improved test results (Fig.1). Those who studied at the health school began to orient better in matters of rational nutrition - by 62% (%2=19,35, p=0,01), the negative impact of smoking and alcohol on the biliary tract - by 69% (x2=20,98, p=0,01), the benefits of motor activity - by 71% (x2=34,9, p=0,001), possible complications of CL - by 70% (%2=5,4, p=0,04).

Getting knowledge about the CL and preventive measures of gallbladder stone formation contributed to the increase of MA, that was expressed in the willingness to apply the knowledge in practice. Due to results of a survey lessons at school of health has led to increased patients motivation to the keeping the recommended health procedures, for compliance with proper diet and rational motor activity: 48 of the 56 patients who consumed alcohol (85,71%, x2=27,35, p=0.001), decided to stop its use, 46 of the 62 smoking patients (74,19%, x2=16,81, p=0.001) wished to refuse from smoking, 67 patients (54,47%, x2=6,7, p=0.05) decided to increase motor activity and 56 patients (45,52%, x2=5,87, p=0.05) - to balance the nutrition. A similar trend was observed after training in schools of health of patients with other system organs pathology [14,15].

The methodology of the educational process made it possible to evoke interest to learning, as a result of it 104 patients (84.55%) wished to take a second course of classes to obtain a deeper knowledge about CL, 95 patients (77.23 %) began to independently study popular scientific medical literature.

Follow-up after 1 year (Fig.2) after discharge from the hospital showed that the level of preservation of self-control and compliance with a healthy lifestyle among patients of the observation group was higher than in the comparison one.

68% and 62% of observation group patients, respectively, refused to take alcohol and smoking, while in comparison group 31% and 25% ones, respectively, could give up these bad habits (x2=6.2, p=0.03 and X2=9.7, p=0.03). 82% of patients in the observation group and 35% in the comparison group followed the correct diet (x2=11.4, p=0.02). The rules of rational motor activity were observed by 79% respondents and 42% ones, accordingly (x2=5.5, p=0.04).

Figure 2 Patient compliance with a healthy lifestyle in the remote period.

Conclusion

The use of the developed structured program of active training of patients with early stage of CL as part of the complex therapy contributed to the improving of the therapeutic effect, that was manifested in a faster reduction of pain and dyspeptic syndromes, in the restoring of psycho-emotional balance. After the training it was marked the positive dynamics of HL and MA, which was expressed in increasing of the knowledge level on the problem of CL and willingness to apply this knowledge in practice. Motivation to maintain healthsaving behavior remained after 1 year after training.

Thus, the therapeutic training of patients with stage I of CL at the school of health seems to us clinically justified and perspective direction of CL treatment and prevention of gallbladder stone formation.

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