Bridging Knowledge Gaps in Anaphylaxis Management Through a Video-Based Educational Tool

Abstract

Introduction:

We aimed to develop and test the effectiveness of an education tool to help pediatric patients and their families better understand anaphylaxis and its management, and to improve current knowledge and treatment guidelines adherence.

Methods:

From June 2019 to May 2022, 128 pediatric patients with history of food-triggered anaphylaxis who presented to the allergy outpatient clinics at the study institution were recruited. Consenting families were asked to complete 6 questions related to the triggers, recognition, and management of anaphylaxis at the time of presentation to the clinic. Participants were shown a 5-min animated video on the causes, presentation, and management of anaphylaxis. At the end of the video, the participants were redirected to the same 6 questions to respond again. The scores were recorded in proportion of correct answers (minimum 0.0; maximum 1.0).

Results:

The mean age of the patients was 5.8 ± 4.5 years (range: 0.5–18.8 years). The majority were males (70 patients; 54.7%). The mean baseline prevideo education questionnaire score was 0.76 ± 0.2 (range: 0.3–1.0), whereas the mean follow-up score was 0.82 ± 0.2 (range: 0.3–1.0). This score difference of 0.06 was statistically significant (P < 0.001). There were no significant associations between change in scores and age or gender of the participants.

Conclusion:

Our video teaching method was successful in educating patients and their families to better understand anaphylaxis and its management at the moment of the clinical encounter. Retention of knowledge at long-term follow-up should be assessed.

Introduction

Anaphylaxis is the most severe form of allergic reaction. It is defined as a potentially life-threatening allergic reaction involving 2 or more organ systems, or hypotension, after exposure to an allergen.¹ It is estimated that up to 2% and 3% of North American and European populations are affected by anaphylaxis, respectively.^2–5 The rate of anaphylaxis is growing worldwide.^6–11 In Canada, up to 0.37% of pediatric emergency department visits were due to anaphylaxis.^12–14 Among children, food is the most common trigger for anaphylactic reaction.^12–15 Although >170 foods can induce an allergic reaction, the main food allergens are peanuts, tree nuts, milk, egg, wheat, soy, fish, shellfish, and sesame.^16–18

Understanding the clinical picture and management of anaphylaxis is crucial for the health care providers and the patients. Although Canadian guidelines for the diagnosis and management of anaphylaxis exist, a cross-sectional multicenter Canadian study has found that >25% of both groups of allergists and nonallergists would not administer epinephrine for patients presenting with severe anaphylaxis manifested by breathing difficulty or hypotension.^19,20

In addition, only one-third of primary care physicians in Canada prescribed epinephrine autoinjector for children who they have diagnosed with food allergy.¹⁵ This knowledge gap in understanding the diagnosis and management of anaphylaxis among health care providers has been well identified and studied in the literature as demonstrated in the previous examples. Nevertheless, there are sparse data on the effectiveness of educational programs aiming to improve knowledge gaps among patients with food allergy.

Educating the patients/families with food allergy on the causes and management of anaphylaxis is as important as educating the health care provides. We aimed to identify the knowledge gaps in the management of anaphylaxis among pediatric patients and/or their families. In addition, we aimed to develop and evaluate the effectiveness of an education tool to help pediatric patients and their families better understand anaphylaxis and its management.

Materials and Methods

This is a prospective study that was carried out from June 2019 to May 2022. The study was reviewed and approved by the institutional Research Ethics Board. Verbal and written consents were obtained from the participants.

A 5-min educational animated video was created and made available to the participants (Supplementary Videos S1 and S2). These videos were based on a unique set of data derived from the Cross Canada Anaphylaxis Registry study and are tailored to address knowledge gaps identified in Canadian households affected by anaphylaxis.^14,21,22 In these videos, we addressed the need to correctly recognize anaphylaxis, promptly administer epinephrine, need for continued vigilance to prevent recurrent reactions, and recommended careful assessment of precautionary labels.

During the study period, 128 consenting families of pediatric patients with history of food-triggered anaphylaxis who presented to the allergy outpatient clinics at the study institution were recruited. The patients and parents were asked to complete 6 questions related to the triggers, recognition, and management of anaphylaxis at the time of presentation to the clinic (Table 1).

Table 1.

The Anaphylaxis Knowledge Questionnaire

Questions
1. How soon does an allergic reaction start after eating the culprit food?
a. Immediately or within 2 h of eating the food
b. 24 h after eating
c. 36 h after eating
d. 48 h after eating
2. What symptoms can you see in anaphylaxis?
a. Difficulty breathing
b. Nausea and vomiting
c. Low blood pressure
d. All of the above
3. Which of the following does not belong to the 8 most common allergens?
a. Shrimp
b. Egg
c. Cashew
d. Rice
4. What is the most common cause of anaphylaxis in Canadian children?
a. Milk
b. Peanuts/tree nuts
c. Eggs
d. Shellfish
5. Which of the following is the best treatment for anaphylaxis?
a. An antihistamine, like Benadryl^®
b. An asthma medication, like Ventolin^®
c. An epinephrine autoinjector, like an Epipen^®
d. All of the above
6. After treating anaphylaxis with epinephrine, what is the next step?
a. Call 9-1-1 and go to the emergency department
b. Call your family doctor
c. Watch and wait at home
d. Give Benadryl

Brand names of medications used in the questions are of the medications most commonly used in Canada.

This questionnaire was developed by a group of pediatric allergists and was preassessed in 5 families to ensure clarity of the questions. The questionnaire aimed to assess the main knowledge gaps related to the causes and management of anaphylaxis. The participants were then shown the animated video. At the end of the video, the participants were redirected to the same 6 questions, in the same order, to reassess their knowledge improvement. Their answers were scored in proportion of correct answers (minimum 0.0; maximum 1.0).

Data were analyzed using the SPSS software (version 23.0; SPSS, Inc., Chicago, IL). A descriptive analysis was carried out first. Then the paired samples t-test was used to assess the change in the questionnaire score before and after watching the educational video. The Mann–Whitney U-test was used to assess the association between a quantitative variable (change in questionnaire score) and a binary qualitative variable that was not normally distributed (gender). In contrast, Spearman correlation test was used to assess the association between 2 quantitative variables (change in questionnaire score and age) that were not normally distributed. A P value of <0.05 was considered as the cutoff level of statistical significance.

Results

The background characteristics of the participants are summarized in Table 2. The mean age of the patients was 5.8 ± 4.5 years (range: 0.5–18.8 years). The majority of the patients were males (70 patients; 54.7%).

Table 2.

Age and Gender of the Participants (N = 128)

Characteristic	Result
Age (years)
Mean ± SD	5.8 ± 4.5
Range	0.5–18.8
Gender, n (%)
Female	58 (45.3)
Male	70 (54.7)

SD, standard deviation.

Figure 1 shows the knowledge score before and after watching the educational video. The mean baseline knowledge score was 0.76 ± 0.2 (range: 0.3–1.0), whereas the mean score after watching the educational video was 0.82 ± 0.2 (range: 0.3–1.0). This score difference of 0.06 was statistically significant (P < 0.001). There were no significant associations between change in scores before and after watching the video and age (P = 0.935) or gender (P = 0.867) of the participants.

FIG. 1.

Knowledge score about anaphylaxis before and after watching the educational video.

Table 3 gives results of each question of the questionnaire before and after watching the video. The lowest number of participants who answered a single question correctly was for question 2, which was concerning the symptoms of anaphylaxis. This number (51 participant; 39.8%) improved after watching the video to 70 (54.7%); however, it remained the lowest among all other questions. In contrast, question 6 concerning the postanaphylaxis care had the highest number of correct answers before (122; 95.3%) and after (125; 97.7%) watching the video.

Table 3.

Frequency and Percentage of Participants with Correct Answer for Each Question (N = 128)

Questions	Frequency and percentage of correct answers, n (%)
Questions	Before	After
1. How soon does an allergic reaction start after eating the culprit food?	84 (65.6)	83 (64.8)
2. What symptoms can you see in anaphylaxis?	51 (39.8)	70 (54.7)
3. Which of the following does not belong to the 8 most common allergens?	124 (96.9)	124 (96.9)
4. What is the most common cause of anaphylaxis in Canadian children?	109 (85.2)	123 (96.1)
5. Which of the following is the best treatment for anaphylaxis?	110 (85.9)	119 (93.0)
6. After treating anaphylaxis with epinephrine, what is the next step?	122 (95.3)	125 (97.7)

Discussion

This study demonstrates that, among pediatric patients and their caregivers who presented to our allergy clinics for food allergy, knowledge about the diagnosis and management of anaphylaxis is suboptimal. Our simple animated educational video successfully improved their knowledge about this critical condition. However, almost one-fifth of the patients/caregivers did not exemplify improvement even after watching the video. This highlights the importance of having various validated educational tools for patient education.

Prompt use of epinephrine in cases of anaphylaxis reaction is highly important. A recent systematic review and meta-analysis have showed that using epinephrine in the prehospital setting for managing anaphylaxis remains poor globally.²³ Health care providers should invest in strategies to increase patient awareness and education to optimize the care provided during anaphylaxis. We believe that the video used in this study is a reasonable tool for bridging the knowledge gap in this condition; however, transferability to real-life knowledge and practice of epinephrine use needs to be investigated.

Our findings indicate families' awareness on the most common food allergens as demonstrated in question number 4 in our questionnaire. We believe that high awareness to all common food allergens is crucial for reducing the risk for inadvertent reactions given that studies by our group and others revealed increased risk of certain food allergens, such as tree nut, and that recurrent reactions are less common for peanut versus other common food allergens potentially due to higher awareness for peanut avoidance.^10,24

Videos are valuable educational tools that are being widely used in the health care setting nowadays. Such videos have shown to be time efficient and effective in conveying health information.^25,26 Patients and caregivers find health education videos highly acceptable and useful in delivering the information.^26–28 In fact, properly designed videos have shown to change adult and pediatric patients' behavior with various conditions.^29–34 For example, the use of educational videos among asthma patients improved their knowledge of the disease and their use of pressurized metered dose inhaler–spacer technique, as well as reduced their emergency department visits when used in the outpatient setting.^29,30

In Australia, an educational video on the types of contraception delivered to young women through social media resulted in improved self-reported contraceptive knowledge and increased their preference to use intrauterine device for family planning.³¹ In addition, video-based education was found to reduce patient anxiety and increase compliance with treatment among patients receiving radiosurgery and radiation therapy.³² Similar findings were seen among patients undergoing skin biopsy, where those who had prebiopsy video education reported lower pain and anxiety levels than patients who did not see the video.³³

Similarly, expectations for functional outcomes of rectal cancer treatment positively changed with video-based education about the condition and its treatment among patients with this disease in Canada.³⁴ Based on the examples presented previously and the results of our study, health care providers should invest in creating professional educational videos to supplement traditional patient education modalities. Future studies should also evaluate whether the use of epinephrine for the treatment of anaphylactic reactions in the prehospital setting by patients and caregivers improves after using our educational video.

Although our study showed important findings, several limitations exist. First, our study did not look into the long-term retention of knowledge among the participants. Therefore, the questionnaire should be administered again to the participants at least 1 year after their enrollment to see whether there is any difference in the questionnaire scores. Second, our survey did not investigate changes in use of epinephrine. It would be interesting to see whether the patients/caregivers self-reported practice of epinephrine use would change after watching the video.

Moreover, other educational videos demonstrating how to use epinephrine injections should be developed and evaluated, as skills in addition to knowledge are important in successful self-management. Also, we did not obtain information about the background knowledge/education of the caregivers. Caregivers who are health care workers or have history of allergy and anaphylaxis might have had better scores in our questionnaire. In addition, our sample is of patients who have already experienced an anaphylactic episode before being referred to our clinic. This could have affected the patients’/caregivers' baseline knowledge and expectation of management, and might explain why some participants had a high baseline prevideo score in our study.

Finally, it remains unclear why some participants did not improve their knowledge after watching the video. Assessing the participants' knowledge after watching the video multiple times is needed, and a comparison with other educational strategies is crucial. It would also be interesting to study the value of sharing this video with families who are at risk of anaphylaxis but did not experience it yet.

Conclusions

The video teaching strategy used in this study was successful in educating patients and their families to better understand anaphylaxis and its management at the moment of the clinical encounter. The test will be repeated at a 1-year interval to determine their retention of knowledge.

Footnotes

Authors' Contributions

J.K. contributed to all steps of the project, including planning, data collection, data analysis, results interpretation, and article preparation, and read and approved all contents of the article. S.G. and B.T. participated in project planning, data collection, and results interpretation, and read and approved all contents of the article. A.B., S.D.S., V.G.L., R.A., C.M., M.V., J.M., J.G., and X.Z. participated in project planning and results interpretation and read and approved all contents of the article. M.B.S. the senior author supervised all steps of the project and article preparation, and read and approved all contents of the article.

Author Disclosure Statement

None of the authors have any conflict of interest to disclose.

Funding Information

This project received support from AllerGen, the Allergy, Genes, and Environment Network, which is a national research network funded by Innovation, Science and Economic Development Canada through the Networks of Centres of Excellence (NCE) Program.

Supplementary Material

References

Sampson

, Muñoz-Furlong

, Campbell

, et al. Second symposium on the definition and management of anaphylaxis: Summary report—Second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. J Allergy Clin Immunol, 2006; 117(2):391–397; doi: 10.1016/j.jaci.2005.12.1303

NIAID-Sponsored Expert

Panel

, Boyce

, Assa'ad

, et al. Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol, 2010; 126(6 Suppl.):S1–S58; doi: 10.1016/j.jaci.2010.10.007

Worm

, Moneret-Vautrin

, Scherer

, et al. First European data from the network of severe allergic reactions (NORA). Allergy, 2014; 69(10):1397–1404; doi: 10.1111/all.12475

Umasunthar

, Leonardi-Bee

, Turner

, et al. Incidence of food anaphylaxis in people with food allergy: A systematic review and meta-analysis. Clin Exp Allergy, 2015; 45(11):1621–1636; doi: 10.1111/cea.12477

Panesar

, Javad

, de Silva

, et al. The epidemiology of anaphylaxis in Europe: A systematic review. Allergy, 2013; 68(11):1353–1361; doi: 10.1111/all.12272

Capps

, Sharma

, Arkwright

. Prevalence, outcome and pre-hospital management of anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK. Resuscitation, 2010; 81(6):653–657; doi: 10.1016/j.resuscitation.2010.01.021

Dyer

, Lau

, Smith

, et al. Pediatric emergency department visits and hospitalizations due to food-induced anaphylaxis in Illinois. Ann Allergy Asthma Immunol, 2015; 115(1):56–62; doi: 10.1016/j.anai.2015.05.006

Poulos

, Waters

, Correll

, et al. Trends in hospitalizations for anaphylaxis, angioedema, and urticaria in Australia, 1993–1994 to 2004–2005. J Allergy Clin Immunol, 2007; 120(4):878–884; doi: 10.1016/j.jaci.2007.07.040

Gupta

, Sheikh

, Strachan

, et al. Time trends in allergic disorders in the UK. Thorax, 2007; 62(1):91–96; doi: 10.1136/thx.2004.038844

10.

Miles

, Gabrielli

, Clarke

, et al. Rates of anaphylaxis for the most common food allergies. J Allergy Clin Immunol Pract, 2020; 8(7):2402.e3–2405.e3; doi: 10.1016/j.jaip.2020.03.014

11.

Patek

, Owda

, Menoch

MJA

. Anaphyl-crisis: Rising rates of pediatric anaphylaxis. Pediatr Emerg Care, 2022; 38(9):e1529–e1532; doi: 10.1097/PEC.0000000000002771

12.

Ben-Shoshan

, La Vieille

, Eisman

, et al. Anaphylaxis treated in a Canadian pediatric hospital: Incidence, clinical characteristics, triggers, and management. J Allergy Clin Immunol, 2013; 132(3):739.e3–741.e3; doi: 10.1016/j.jaci.2013.06.016

13.

Hochstadter

, Clarke

, De Schryver

, et al. Increasing visits for anaphylaxis and the benefits of early epinephrine administration: A 4-year study at a pediatric emergency department in Montreal, Canada. J Allergy Clin Immunol, 2016; 137(6):1888.e4–1890.e4; doi: 10.1016/j.jaci.2016.02.016

14.

Lee

, Enarson

, Clarke

, et al. Anaphylaxis across two Canadian pediatric centers: Evaluating management disparities. J Asthma Allergy, 2016; 10:1–7; doi: 10.2147/JAA.S123053

15.

Singer

, Kosowan

, Soller

, et al. Prevalence of physician-reported food allergy in Canadian Children. J Allergy Clin Immunol Pract, 2021; 9(1):193–199; doi: 10.1016/j.jaip.2020.07.039

16.

Gupta

, Warren

, Smith

, et al. Prevalence and severity of food allergies among US adults. JAMA Netw Open, 2019; 2(1):e185630; doi: 10.1001/jamanetworkopen.2018.5630

17.

Ben-Shoshan

, Harrington

, Soller

, et al. A population-based study on peanut, tree nut, fish, shellfish, and sesame allergy prevalence in Canada. J Allergy Clin Immunol, 2010; 125(6):1327–1335; doi: 10.1016/j.jaci.2010.03.015

18.

Soller

, Ben-Shoshan

, Harrington

, et al. Overall prevalence of self-reported food allergy in Canada. J Allergy Clin Immunol, 2012; 130(4):986–988; doi: 10.1016/j.jaci.2012.06.029

19.

Cheng

. Emergency treatment of anaphylaxis in infants and children. Paediatr Child Health, 2011; 16(1):35–40.

20.

Desjardins

, Clarke

, Alizadehfar

, et al. Canadian allergists' and nonallergists' perception of epinephrine use and vaccination of persons with egg allergy. J Allergy Clin Immunol Pract, 2013; 1(3):289–294; doi: 10.1016/j.jaip.2013.03.006

21.

Asai

, Yanishevsky

, Clarke

, et al. Rate, triggers, severity and management of anaphylaxis in adults treated in a Canadian emergency department. Int Arch Allergy Immunol, 2014; 164(3):246–252; doi: 10.1159/000365631

22.

Kimchi

, Clarke

, Moisan

, et al. Anaphylaxis cases presenting to primary care paramedics in Quebec. Immun Inflamm Dis, 2015; 3(4):406–410; doi: 10.1002/iid3.78

23.

Miles

, Ratnarajah

, Gabrielli

, et al. Community use of epinephrine for the treatment of anaphylaxis: A review and meta-analysis. J Allergy Clin Immunol Pract, 2021; 9(6):2321–2333; doi: 10.1016/j.jaip.2021.01.038

24.

O'Keefe

, Clarke

, St Pierre

, et al. The risk of recurrent anaphylaxis. J Pediatr, 2017; 180:217–221.

25.

Wilson

, Park

, Curtis

, et al. Media and memory: The efficacy of video and print materials for promoting patient education about asthma. Patient Educ Couns, 2010; 80(3):393–398; doi: 10.1016/j.pec.2010.07.011

26.

Botngård

, Skranes

, et al. Multimedia based health information to parents in a pediatric acute ward: A randomized controlled trial. Patient Educ Couns, 2013; 93(3):389–393; doi: 10.1016/j.pec.2013.04.017

27.

Geryk

, Arrindell

, Sage

, et al. Exploring youth and caregiver preferences for asthma education video content. J Asthma, 2016; 53(1):101–106; doi: 10.3109/02770903.2015.1057847

28.

Frydenberg

, Oborne

, Polley

, et al. Paediatric asthma education: Implementation of video-based education for families. J Paediatr Child Health, 2022; 58(5):868–872; doi: 10.1111/jpc.15862

29.

Krishna

, Francisco

, Balas

, et al. Internet-enabled interactive multimedia asthma education program: A randomized trial. Pediatrics, 2003; 111(3):503–510; doi: 10.1542/peds.111.3.503

30.

Shaw

, Le Souëf

, Turkovic

, et al. Pressurised metered dose inhaler-spacer technique in young children improves with video instruction. Eur J Pediatr, 2016; 175(7):1007–1012; doi: 10.1007/s00431-016-2738-2

31.

Mazza

, Buckingham

, McCarthy

, et al. Can an online educational video broaden young women's contraceptive choice? Outcomes of the PREFER pre-post intervention study. BMJ Sex Reprod Health, 2022; 48(4):267–274; doi: 10.1136/bmjsrh-2021-201301

32.

Esen

CSB

, Yazici

, Hurmuz

, et al. The effect of video-based education on anxiety of patients receiving stereotactic radiosurgery and stereotactic body radiation therapy. J Cancer Educ, 2022; doi: 10.1007/s13187-022-02135-1

33.

Savaş Erdoğan

, Falay Gür

, Doğan

. Effect of video-based patient information on patients' anxiety and pain levels before skin biopsy: A randomized controlled study. Postgrad Med, 2021; 133(8):988–993; doi: 10.1080/00325481.2021.1969718

34.

Streith

, Yip

SJY

, Brown

, et al. Effectiveness of a rectal cancer education video on patient expectations. Colorectal Dis, 2022:24(9):1040–1046; doi: 10.1111/codi.16143

Supplementary Material

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