Adults with Asthma

Asthma Self-treatment Intervention

Article Citation:
van der Palen J, Klein JJ, Zielhuis GA, van Herwaarden CLA, Seydel ER. Behavioural effect of self-treatment guidelines in a self-management program for adults with asthma. Patient Education and Counseling 2001;43:161-9.

Intervention Setting:
Classroom

Target Population:
Adults with clinically diagnosed of asthma identified through an outpatient clinic database of a large teaching hospital in Enschede, The Netherlands

Program Description:
This study assessed whether including self-treatment guidelines (action plans) in a self-management program for adults who have asthma leads to greater behavioral changes than a program without these guidelines. All participants received self-management training and education by a nurse specialist in three 90-minute small group sessions with 5-10 patients and their partners. The instruction included information about the pathophysiology of asthma, the role of medication and side effects, allergic and nonallergic triggers, and symptoms. All patients were instructed in the correct use of their inhaled medication and the use of a peak flow meter. Patients were encouraged to ask questions and discuss personal matters related to their disease. The only difference between the two groups was that the intervention (self-treatment) group (group S) also received instructions about the self-treatment of exacerbations during the third session and the control group did not. Before the intervention and after 1 year, patients were asked to keep a diary for 2 weeks reporting on symptoms, medication use, and peak expiratory flow (PEF) rates.

Evaluation Design:
Randomized controlled trial with a 1-year follow-up. Patients were randomized into a self-treatment group or an active control group.

Sample Size:
A total of 245 adults aged 18–65 years who had been in a stable phase of their disease during the past 6 weeks and had been using inhaled steroids for at least 3 months.

Outcome Measures/Results:
Outcome measures included reported compliance with medication, self-reported compliance with self-treatment guidelines (action plans), inhalation technique, self-efficacy expectations, outcome expectations, intentions toward self-management and social support, asthma-specific knowledge, and hypothetical self-treatment and self-management behavior. More than 90% of all patients showed good medication compliance at baseline and after 1 year. Correct inhalation technique at baseline applied to 73% of participants; after 1 year this had increased to 82.5%. A small (3.5%), but statistically significant, improvement in generalized self-efficacy was found only in the intervention group. Both groups showed large improvements in asthma-specific self-efficacy expectations. Small (4%), but statistically significant, increases in outcome expectations for both groups also were found. Social support at follow-up was higher for the intervention group than for the controls. For the intervention group only, during the last 2 weeks of the study, there was an increase in the proportion of patients who adjusted their medication in response to an increase in symptoms or a decline in PEF. Only intervention group patients showed improvements in both self-treatment and self-management behavior when presented with a hypothetical scenario of a slow-onset exacerbation.

Editor’s Notes:
The program is underway in private pulmonary health-care practices in parts of Germany. The program was evaluated in Germany and approved for reimbursement by insurance companies by the German government in a region of that country that borders on The Netherlands.

Availability of Protocol/Materials:
Materials are not available in English and are not available for widespread distribution.

Case Study:
None

Chronic Disease Self-management Program

Article Citation:
Lorig KR, Sobel DS, Ritter PL, Laurent D, Hobbs M. Effect of a self-management program on patients with chronic disease. Effective Clinical Practice 2001;4(6):256-62.

Intervention Setting:
Classroom workshop offered in community settings, such as senior centers, churches, libraries, and hospitals

Target Population:
Adults with one or more chronic diseases; i.e., lung or heart conditions, diabetes or arthritis, insured by Kaiser Permanente and physically able to attend the seven-session program

Program Description:
Self-management education programs emphasize the patients’ role in managing their illness, including medical management, maintenance of life roles, and management emotions such as fear and depression. Self-management programs also provide patients with the knowledge, skills, and confidence to manage disease-related problems. The Chronic Disease Self-Management Program (CDSMP) is a 17-hour, 7-week, small-group intervention attended by people with different chronic conditions. It is taught by two trained leaders, one or both of whom may be non-health professionals with a chronic disease. The instructors work from a highly structured manual to deliver the material. The program is based on self-efficacy theory and emphasizes problem solving, decision-making, and confidence building. It incorporates skills mastery, reinterpretation of symptoms, modeling, and social persuasion to increase a sense of personal efficacy. The course content was published in “Living a Healthy Life with Chronic Conditions”, which also served as a reference book for participants. Each class comprised 8-20 participants of various ages and diagnoses and their interested family members. Topics included making an action plan, managing symptoms through relaxation, managing anger, fear, and frustration, participating in fitness/exercise, managing fatigue, eating healthy, communicating, understanding medications, making treatment decisions, informing the health care team, and working with health care professionals. The course included guided mastery of skills through weekly action planning and feedback of progress, modeling of self-management behaviors and problem-solving strategies, and social persuasion through group support and guidance for individual self-management efforts.

Evaluation Design:
A pre-post cohort study

Sample Size:
A total of 613 volunteer patients recruited from various Kaiser Permanente hospitals and clinics participated in the study. Sixty-eight classes were held at 21 sites: 14 in California, three in Colorado, and one each in North Carolina, Ohio, Georgia and Washington State.

Outcome Measures/Results:
Outcome measures included health behavior, perceived self-efficacy, health status and health-care use, which were assessed at baseline and at 1 year post intervention by self-administered questionnaires. At 1 year, seven of the nine health status measures – fatigue, shortness of breath, pain, social activity limitation, illness intrusiveness, depression, and health distress – improved significantly. Participation in the program also was associated with improvements in all health behaviors (exercise, cognitive symptom management, and improved communications with physicians) and in self-efficacy. The number of unscheduled emergency department visits decreased significantly, and visits to physicians and days in the hospital were fewer.

Availability of Protocol/Materials:
The Stanford Patient Education Research Center owns and provides the CDSMP. Approximately 2500 individuals had participated in the program through 2000. A week-long train-the-trainer course is offered for health care organizations that desire to deliver the CDSMP. The Center maintains a website at http://patienteducation.stanford.edu/.

Case Study:
None

Teach Your Patients about Asthma

Article Citation(s):
Marabini A, Brugnami G, Curradi F, Casciola G, Stopponi R, Pettinari L, Siracusa A. Short-term effectiveness of an asthma educational program: Results of a randomized controlled trial. Respiratory Medicine 2002;96:993-8.

Intervention Setting:
Classroom

Target Population:
Adults aged >18 years with long-term persistent, but stable, asthma in the 3 months before recruitment who were outpatients attending the asthma clinic at the Institute of Occupational Medicine at the University of Perugia, Italy

Program Description:
This intervention was undertaken to determine the effectiveness of an education program in a group of outpatients who had asthma and its impact on their quality of life (QoL). Spirometry was completed and peak expiratory flow was measured at enrollment and at 3 months after the initial evaluation. Patients were randomly selected to an intervention (education) group or to a control (usual-care) group. Patients in the education group participated in three 2-hour asthma education sessions that included:

1. basic information about asthma;
2. information about asthma medications (bronchodilators and anti-inflammatory agents);
3. use of inhalers and peak flow meters;
4. identification of asthma-warning signs;
5. avoidance of and/or reduction of exposure to asthma triggers; and
6. development of action plans and emergency plans.

Each patient was given written instructions about managing asthma attacks according to the asthma management zone system. Participants received handouts covering key points of each lesson to reinforce learning. Patients in the control group received instructions from the same physician/instructor on medication use, the influence of allergenic and nonallergenic triggers, and proper use of the inhalers. The physician also answered specific questions by usual-care patients. The Asthma Quality of Life (QoL) questionnaire was administered to each patient at baseline and at the 3-month follow-up visit. The QoL questionnaire comprised 32 questions in four domains: activities, emotions, symptoms and environmental triggers. QoL was expressed as a score ranging from 1 (total impairment) to 7 (no impairment). A difference in score of ≥ 0.5 was considered clinically relevant for overall QoL and for each domain.

Evaluation Design:
A randomized controlled study approach was used.

Sample Size:
The study comprised 77 adults.

Outcome Measures/Results:
Outcome measures included QoL, symptom-free days, medication use, days of work or school missed, and forced expiratory volume at 1 second (FEV1). The educational program effectively improved QoL, mainly in patients with moderate-to-severe asthma. Improvements in the overall QoL score and the symptoms domain of the QoL instrument were observed in all patients in the intervention group, whereas the environment domain improved only in participants with moderate-to-severe asthma. Three months after initial evaluation, participants in the intervention group significantly improved their overall QoL (from 5.7 ± 0.8 to 6 ± 0.7, p < 0.01) and the symptoms domain (from 5.8 ± 1.1 to 6.2 ± 0.8, p < 0.005). QoL did not significantly change in the control group. At the 3-month follow-up, intervention participants had a higher score than usual-care participants in overall QOL and in the "environment" and the "symptoms" domains. Also at the 3-month follow-up, intervention group participants who had moderate-to-severe asthma had a significantly improved overall QoL score (from 5.6 ± 0.8 to 6 ± 0.7; p < 0.05), symptoms domain (from 5.7 ± 1.1 to 6.2 ± 0.8; p < 0.01), and activities domain (from 5.1 ± 0.9 to 5.4 ± 0.9; p < 0.05). By contrast, in control group participants who had moderate-to-severe asthma, QoL scores at the 3-month follow-up remained unchanged. Intergroup analysis at the 3-month follow-up showed that intervention group participants who had moderate-to-severe asthma had a higher overall QoL score and environment and symptoms domain scores than control group participants. QoL of participants with mild asthma did not change from baseline to the 3-month follow-up in either group. After stratification for asthma severity, only baseline FEV1 in participants with moderate-to-severe asthma was significantly higher in the intervention group than in controls. After adjustment for baseline FEV1, at the 3-month follow-up, FEV1 was higher in the intervention group than in the controls group (p < 0.05). No differences were found in subjects with mild asthma. The education program did not effect changes in number of symptom-free days, use of rescue medications, or days absent from school or work.

Materials available:
Materials are not available in English. Inquiries about this study should be directed to Dr. Alessandra Marabina, modall@unipg.it.