Running Head: INCREASING AWARENESS OF GASTRO-ESOPHAGEAL REFLUX DISEASE IN

ADULT PATIENTS AT A PRIMARY CARE CLINIC 1

Increasing Awareness of Gastro-Esophageal Reflux Disease

In Adult Patients at a Primary Care Clinic

Daniel G. Arsulo, RN, BSN

November 4, 2016
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Introduction

Gastroesophageal reflux disease is a common condition that affects approximately seven

million people in the United States. According to Amos (2012), sixty percent of the adult

population will experience some type of gastroesophageal reflux disease (GERD) within a 12

month period and weekly symptoms are expected in 20 to 30 percent. An estimated 18.3 million

patients had ambulatory care visits to healthcare professionals in emergency rooms, physicians’

offices, and clinics in 2004. That same year, approximately 3.1 million people were hospitalized in

the United States for GERD-related symptoms, complications, and treatment. Lower health-related

quality of life including reduced enjoyment of food, sleep problems, and work concentration

difficulties when symptoms were present were reported in individuals with GERD. The American

College of Gastroenterology estimated that $2 billion in lost productivity occurs each week of the

year due to the symptoms of GERD.

GERD is a condition where the reflux of gastric contents leads to troublesome symptoms or

complications. Acid reflux occurs when the lower esophageal sphincter (LES) relaxes transiently

as a result of vasovagal reflex, which is triggered by gastric distention. Some patients have

incompetent LES, which results to an increased reflux of acid when the intra-abdominal pressure

increases. Prolonged or frequent exposure of the esophagus to gastric acid damages the esophageal

mucosa. This gastric content is normally neutralized by esophageal peristalsis and bicarbonates

from the salivary secretions. The LES moves above the diaphragm in hiatal hernia which is

associated with higher amount of acid reflux and delayed gastric clearance in patients with GERD.

Some individuals have decreased peristalsis, which results in a longer exposure of the esophagus to

gastric acid. In other patients, gastric emptying is delayed due to gastroparesis or partial
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obstruction of the gastric outlet. Conditions that increase intra-abdominal pressure also contribute

to GERD. Most individuals only have mild disease but more serious complications develop in a

few patients (McPhee & Papadakis, 2016).

The management of GERD involves non-pharmacologic measures that involve lifestyle

modifications; endoscopic therapies; surgery for refractory cases; and medications, among which,

antacids, antagonists to histamine 2 receptors (H2 blockers) and proton pump inhibitors (PPI’s) are

the most commonly used; (Buttaro, 2013). These medications are very effective in managing

GERD symptoms but are not without side effects. One of the common misconceptions that patients

with GERD have is that these medications can be used to control their symptoms for as long as

necessary, without regard of their side effects. These side effects range from bothersome, such as

rebound hyperacidity with antacids, headache and loss of libido with the H2 blockers, to more

serious side effects that include osteoporosis with prolonged PPI use. Other unwanted side effects

that may occur with prolonged use of PPI’s, the first-line agents used for GERD, include

Clostridium difficile infections that may be due to bacterial overgrowth as a result of the reduced

gastric acidity. Fractures of the hip, wrist, and spine may occur due to the decreased absorption of

calcium as a result of the increased gastric pH. Community acquired pneumonia and iron

deficiency anemia have also been reported with prolonged PPI use. There is also a possibility of

gastric acid rebound and worsening of symptoms when PPI’s are discontinued (Ament, Dicola, &

James, 2012).

There are factors that increase the risk for GERD and simple lifestyle and dietary changes

can significantly reduce the symptoms and risk for this condition. There is extensive information

regarding GERD that is available to people who want to access them. However, a study conducted

by Cobb, et al (2010) showed that different ethnic groups have varying levels of knowledge
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regarding GERD, with these groups having different degrees of confidence in, and compliance

with the established information and recommendations about the disease. It is hoped that

increasing the patients’ knowledge about this condition will enable them engage in behaviors that

will help reduce their symptoms and reduce complications both from the condition and

medications used to control their symptoms.

Significance and Statement of the Problem

A private practice clinic in Las Vegas sees an average of 5 patients with GERD or

symptoms of heartburn each day. Most of these patients are on proton pump inhibitors to manage

their symptoms, with a significant portion of these patients having been on this class of

medications or other over-the-counter antacids or several months. A lack of knowledge about

GERD is identified as a major factor in the inadequate control of GERD symptoms. Some patients

have very little knowledge about the risk factors for GERD and what they can do to prevent it. On

the other hand, there are also patients who are very well aware of the risk factors but do not have

the motivation to eliminate these factors. Some of the reasons for the lack of effort in the part of

the patients to eliminate these common modifiable risk factors include adequate control of their

symptoms with the use of pharmacologic measures, lack of knowledge about the side effects of

long-term use of these commonly used medications, and lack of knowledge of the potential effects

of inadequately managed symptoms of GERD.

Inadequate management of GERD can result in unwanted complications that can prove to

be serious health risks for the patients affected by it. Medications used to manage GERD also have

potential side effects that can lead to other health issues. Reduction of symptoms of GERD which

can help minimize patients’ reliance on pharmacologic measures can be accomplished by lifestyle

changes that patients with GERD can adopt. This program aims to increase the patients’ awareness
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of GERD, its causes, complications both from the condition and treatment, and measures that can

be taken to reduce its symptoms.

This program will attempt to answer whether providing information to adult patients who

can understand and read English in a chosen medical clinic will increase their knowledge about

GERD as compared to those who do not receive the same information during their visit to that

particular clinic.

The Conceptual Framework

The Health Belief Model, which is a psychosocial model that explains the correlation

between an individual’s health perceptions and the individual’s health preventative behavior

(Douglas & Pacquiao, 2010), is most suitable in tackling the challenges of promoting health

practices that will reduce the risk for GERD and heartburn. Good health will be equated to the

absence of GERD symptoms and complications from either the disease or the medications used to

treat the condition. It is anticipated that the participants’ health behavior, in terms of practicing

lifestyle behaviors that reduce the risk for GERD, will be achieved if they perceive the absence of

symptoms and complications as a sign of good health. The constructs of the Health Belief Model

will be incorporated into this program as follows:

 Perceived susceptibility: Providing participants with data showing how GERD affects

different individuals from different backgrounds, stressing the effects of inadequate control of this

condition, as well the unwanted effects of long-term use of medications used to control the

symptoms of this condition.

 Perceived severity: Providing participants with information about the complications that

may arise due to inadequate control of this condition, as well the complications of long-term use of
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medications used to control the symptoms of this disease. The consequences of inadequately

controlled symptoms, as well as potential side effects from prolonged use of medications to control

the symptoms, will be emphasized.

 Perceived benefits: Providing participants with information that will help reduce the risk

for GERD and the symptoms associated with it, with emphasis on preventing symptoms of the

disease and the complications that may arise from it or the medications that are used to control it.

 Cues to action: Providing brochures that provide important information about the disease,

its complications, and the different ways to minimize the risk for GERD and manage its symptoms.

 Self-Efficacy: Encouraging participants to share their means of managing their symptoms

and highlighting their ability to manage their symptoms effectively.

Information will be gathered from patients with symptoms of heartburn or are taking PPI’s or

H2 blockers who come to the clinic to determine their learning needs based on the five constructs.

Information to be provided in the program will be based on those needs to achieve good outcomes.

Related Literature

GERD is a condition that is prevalent globally, and evidence suggests that its prevalence in

developing countries is increasing. According to the World Gastroenterology Organization (2015),

there is a significant geographic variation in the prevalence estimates for GERD, but it remains

consistently lower than 10% in East Asia. This high prevalence of GERD translates to substantial

effects on society due to its bothersome symptoms, with impacts on work productivity and the

quality of life of the affected individuals.

Management guidelines for GERD in different geographical regions vary according to

context and resources available in these regions. Diversion of research and clinical resources from
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more pressing problems in developing countries is a concern with guidelines that focus on high-

tech investigations, which are common in developed countries. However, inappropriate

investigations and resource utilization also happen even in developed countries. These emphasize

the need to establish guidelines that highlight context-sensitive management options that also

consider available local resources and healthcare support system for all geographical regions

regardless of that region’s economy (World Gastroenterology Organization, 2015).

The epidemiology of GERD and reflux-like symptoms need to be comparable worldwide if

there is to be a standardized approach to this condition. In addition, the full ranges of diagnostic

tests and medical treatment options have to be uniformly available. It is very challenging to

provide a single, gold standard approach to the management of GERD due to the wide variation of

epidemiology of GERD and the availability of resources for the diagnosis and management of this

condition (World Gastroenterology Organization, 2015).

The management of GERD is a multifaceted approach that combines lifestyle changes,

medications, endoscopic therapies, and surgery. Lifestyle changes that include decreased meal

size, smoking cessation, reduced consumption of alcohol, weight loss, and avoidance of dietary

fats and carbonated drinks, may benefit patients but are not enough to control the symptoms is

used alone (Buttaro, 2013). Although these changes cannot be used alone in managing symptoms

of GERD, they help in reducing the frequency of heartburn (Mayo Clinic, 2014).

A study about GERD in minority populations conducted by Cobb, et al (2010), found that

all populations studied need more education about GERD. The physical, psychological, social, and

economic impact on affected individuals is significant, so are their associated complications. An

increased awareness of GERD may enable patients to recognize symptoms which may be

indicative of GERD, in addition to informing them of beneficial lifestyle changes that include diet
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and substance use, practices that help reduce the severity and frequency of their symptoms, use of

appropriate medications, and seeking medical care promptly. The study also found that a particular

patient population with the highest prevalence rate and reported symptoms more frequently had

less awareness of GERD. This further stresses the importance of educating patients as this lack of

knowledge may result in a significant delay in seeking treatment until the condition has worsened.

Education is important for patients with GERD. Bennett, et al (2009), utilized pre-testing,

providing education, and post-testing to the participants of a study that they conducted. Results

showed that providing education to patients with GERD improved their post-test scores and

reduced the frequency of their heartburn. The study also provided the pharmacists, who were the

main providers of medication-based education in the study, an opportunity to assess the patients’

knowledge and behavior associated with lifestyle modification. It also allowed them to build

professional relationships with the participants, which could have positively affected the patients’

knowledge and promote the lifestyle change.

Available literature support that GERD is a significant problem that affects many

individuals. Yet, many of these individuals who have GERD symptoms know little about this

condition. Studies conducted by Kadam and Salunkhe (2015), and Bennett, et al (2009), showed

that providing education to individuals, even using different methods of instruction, improved their

knowledge about the targeted conditions. This approach may produce similar results if tried on

participants in the chosen clinic.

Project Proposal

Target Population and Setting

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The proposed clinic is private practice and will be the site of the intervention and patients

who have experienced heartburn or are on medications to control symptoms of GERD will be

included. This proposed clinic serves a predominantly Asian population, but includes other

patients of different culture and background, in the central area of Las Vegas. The clinic provides

services to an average of 35 patients a day. The participant’s demographic information will be

collected for the purpose of the study and will not be shared with other entities not related to this

project. The surveys and intervention will be conducted while the recruited participants are waiting

to be seen by the provider, which is about 30 minutes to an hour on average, and will not prolong

the participants’ stay in the clinic. No identifying data will be collected from the participants of

this intervention which only involves surveys and teaching in the form of an information brochure.

There is no policy and procedure established in this clinic regarding providing education about

GERD to patients who come to this clinic.

Proposed Solutions

This project will utilize the use of a pre-intervention survey to determine the patient’s

knowledge about GERD; providing an instructional brochure that will provide information about

GERD, its causes, complications from both the condition and its treatment, and measures to reduce

its symptoms; and lastly, administering a post-intervention survey to determine if the intervention

increased the participants’ knowledge about the condition. This project will adapt the strategy

taken by Kadam and Salunkhe (2015) that studied the effectiveness of self instructional module in

increasing the patient’s knowledge regarding the hazards of smokeless tobacco. That study showed

that this technique is effective in increasing the subjects’ knowledge about the targeted condition,

with an actual gain of 34% as indicated by the post-test. It is hoped that this project, which will use

the same technique, will yield similar results.

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To improve patients’ awareness of GERD, its causes, complications both from the

condition and treatment, and measures that can be taken to reduce its symptoms, the following

steps will be taken for the project:

 Formulate a questionnaire that will determine the patient’s knowledge about GERD, its

causes, complications both from the condition and treatment, and measures that can be taken

to reduce its symptoms.

 Construct a brochure that contains information about GERD, with emphasis on its causes,

complications both from the condition and treatment, and measures that can be taken to

reduce its symptoms.

 Obtain permission from the chosen clinic to implement the project.

 Recruit participants who are in the waiting room before they see the provider. Participants

must be able to give verbal consent, are not mentally incapacitated, and are able to read,

understand, and speak English.

 Obtain a verbal consent from the project participants.

 Administer a pretest to the participant in the waiting room of the chosen clinic, using the

questionnaire as described above, to determine the extent of the patient’s knowledge about

GERD.

 Provide the patient the brochure as described above while in the waiting room and allow

them time to read the material.

 Conduct a post-test after the patient had time to read the material provided.

 Perform a statistical analysis of the data collected.

 Evaluate the effectiveness of the intervention as indicated by the difference between the

scores in the pre-test and post-test.

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Project Implementation

The implementation of this project will involve three steps. First, information needed by

the patients will be identified by the author during history taking in patient encounters, to

determine the needs of most patients as regards information about GERD. Strengths in terms of

accurate information will be identified, as well as common misconceptions and complete lack of

knowledge about certain aspects of the condition. The input from the provider regarding the other

areas of need on GERD education will be solicited and incorporated in the construction of the

survey questionnaire and information brochure.

The second step is the administration of the pre-test and distribution of information

brochures after permission from the clinic and participant’s verbal consent are obtained. The pre-

test, which is formulated by the author, will include basic information that the patient should know

about GERD, learning outcomes as dictated by the learning needs of the patients will direct the

kind of questions that will be used in the tests. The information brochure, which will be created by

the author, using information gathered from similar brochures from existing studies, textbooks, and

guidelines, will address the learning outcomes as determined by the patients’ learning needs and

will cover the causes of the condition, measures to reduce the symptoms of the condition, and

complications that may arise from inadequate management of the patients’ symptoms, as well as

those that may arise from treatment modalities of the condition. The Health Belief Model

theoretical framework will be utilized to improve the patients’ preventative behavior by improving

their health perception through increased understanding of GERD. This part of the intervention

will be conducted by the author in the waiting room of the chosen clinic, and will include patients

who meet the criteria and agree to participate in the intervention program.
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A post-intervention survey will be conducted by the author after the participants have read

the information brochure. The questionnaire will contain the same materials found in the pre-

intervention questionnaire and will be conducted at the same clinic during the same visit. The

intervention program and surveys involved are expected to be completed four days after its

commencement.

The last step of the project is the evaluation of the program. Statistical analysis will be

performed, using the data gathered, to determine if the difference between the surveys scores,

before and after information is provided in the form of the brochure, is statistically significant.

This will be performed by the author after sufficient data from 50 participants have been gathered.

The success of the intervention will be indicated by a statistically significant difference between

the pre-intervention and post-intervention mean scores.

Budget Considerations

The project requires a small budget to implement. Information to be included in the

brochure is available from textbooks, journals, and reliable websites and will not incur any cost.

The information brochure will be developed by the author, utilizing existing brochures that have

been employed in past studies, in addition to the sources mentioned earlier, and will not have

added cost to the project. The survey questionnaires will be created by the author, with no added

cost to the project. Expenditures for this project will come mainly from printing and reproduction

of the questionnaire and information brochure, which is estimated to be $150.00. The project will

be conducted by the author while the patients are in the waiting room and waiting to see the

provider. Staff at the clinic will not participate in conducting the intervention, thus, there will be no

additional cost from staff hours.

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Expected Outcomes

In a different project that utilized the same technique as conducted by Kadam and

Salunkhe (2015), an instructional module to increase the participants’ awareness about the hazards

of oral tobacco was utilized. The outcome of the program resulted to an actual gain of 34%,

indicating that the technique is effective in increasing the participants’ knowledge about the

targeted information. It is expected that a similar outcome can be achieved, using the same

technique, to increase the participants’ knowledge about GERD, its causes, complications both

from the condition and treatment, and measures that can be taken to reduce its symptoms.

Evaluation Plan

The program should be evaluated if it is to be sustained or improved. Success or failure of

the program can initially be determined using the results of the pre-intervention and post-

intervention survey scores. However, long-term benefits from this program can be determined

during subsequent patient visits. Since no personally identifying information will be collected,

follow-up with specific patients cannot be conducted. Information about presence of GERD

symptoms or relief of these symptoms can be elicited from all patients during history-taking on

their follow-up visits. Relief of symptoms will be emphasized as patients are more likely to

remember the information and comply with recommendations from experts if they associate their

efforts with a positive change in their condition.

Conclusion

GERD is a highly prevalent condition that affects a significant portion of our population.

GERD symptoms are often mild but can cause significant discomfort and complications in some
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patients. However, despite this condition's prevalence, many individuals affected by it remain

inadequately informed about this condition. This lack of information places some patients at risk

for poor control of symptoms and complications both from the disease itself and from the

medications that are used to treat it. Although lifestyle changes alone are not adequate to manage

this condition, it has been shown that some behaviors reduce the frequency of GERD symptoms.

Individuals with GERD may benefit from knowing the behaviors in which they can engage to help

reduce these symptoms and prevent complications that may arise from GERD, as well as minimize

the side effects from the medications that are used to treat it.

Studies have shown that providing patients with instructional materials improve their

understanding of targeted conditions. One study on increasing the patients’ knowledge on GERD

showed that the patients who received this intervention not only increased their knowledge about

GERD but also experienced symptoms less frequently. This intervention program will utilize the

methods that were employed in these studies in the hopes of achieving similar results, that is,

increase the patients’ knowledge about GERD, which will help empower them to manage their

conditions better.
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References

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inhibitors. American Family Physician. Retrieved from

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Amos, J (2012). Acid Reflux (GERD) Statistics and Facts. Healthline. Retrieved from

http://www.healthline.com/health/gerd/statistics

Bennett, M., Finley, K., Giannamore, M., & Hall, L. (2009) Assessing the impact of lifestyle

modification education on knowledge and behavior changes in gastroesophageal reflux

patients on proton pump inhibitors. Journal of American Pharmacists Association.

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Buttaro, T. (2013). Gastroesophageal reflux disease. In Primary Care: A Collaborative Practice.

St. Louis, MO: Elsevier/Mosby

Cobb, N., Goldfarb, N., Katz, P., Romney, M., Spodik, M., Toner, R., & Yuen, E. (2010).

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Douglas, M., & Pacquiao, D. (2010). Core curriculum for transcultural nursing and health care.

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ch3-main-constructs.shtml#top_anchor
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Kadam, P. & Salunkhe, A. (2015). A study to evaluate the effectiveness of self instructional

module on oral health hazards among smokeless tobacco users in selected rural area of

Karad Taluka. International Journal of Science and Research. Retrieved from

http://www.ijsr.net/archive/v4i2/SUB151411.pdf

Mayo Clinic Staff (2014). Lifestyle and home remedies. Mayo Clinic.

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home-remedies/CON-20025201

Papadakis, M (2016). Gastrointestinal disorders. In Current Medical Diagnosis and Treatment.

McGraw-Hill Education/Medical

World Gastroenterology Organisation (2015). GERD global perspective on gastroesophageal

reflux disease. World Gastroenterology Organisation Global Guidelines. Retrieved from

http://www.worldgastroenterology.org/UserFiles/file/guidelines/gastroesophageal-reflux-

disease-english-2015.pdf