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Keywords:

  • asthma;
  • competence;
  • individualized programme;
  • nursing;
  • older adults;
  • randomized controlled trial;
  • self-care;
  • self-efficacy

Abstract

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

Title. Individualized programme to promote self-care among older adults with asthma: randomized controlled trial.

Aim.  This paper is a report of a trial to examine the effectiveness of individualized self-care education programmes in older adults with moderate-to-severe asthma.

Background.  Asthma is a common chronic disease in adults and a major cause of frequent work absences, emergency room visits, and hospitalization. The results of studies of self-care education programmes have been largely supportive and suggest that they have positive outcomes for people with asthma. However, for older people with asthma, the effectiveness of computer-aided, self-learning video programmes has been controversial.

Methods.  Older adult patients with asthma (= 148) were randomly assigned to one of three groups: usual care, individualized education, or individualized education with peak flow monitoring, and followed for 6 months. Data were collected from January to December 2006. The variables studied included demographic data, asthma self-care competence, asthma self-efficacy, and asthma self-care behaviour.

Findings.  Patients in both individualized education groups reported higher asthma self-care competence scores (= 334·06 and 481·37, < 0·001) and asthma self-care and self-efficacy scores (= 104·08 and 68·42, < 0·001) than patients in the usual care group. In addition, patients who received individualized education with peak flow monitoring had statistically significantly higher asthma self-care behaviour and self-efficacy scores (< 0·001) and asthma control indicators (= 0·025) than the education alone group. No differences were found among the three groups in unscheduled health service usage.

Conclusion.  Our results suggest that individualized education helps older people with asthma to enhance their self-care behaviours, manage their disease, and increase their quality of life.


What is already known about this topic

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References
  • • 
    Asthma is a common chronic disease in adults and a major cause of frequent work absences, emergency room visits, and hospitalization.
  • • 
    The results of studies of self-care education programmes have been largely supportive and suggest that they have positive outcomes for people with asthma.
  • • 
    For older people with asthma, the effectiveness of computer-aided, self-learning video programmes has been controversial.

What this paper adds

  • • 
    Individualized education and using peak flow monitoring can improve self-care competency and prognosis for older adult people with asthma.
  • • 
    Older adults with asthma receiving usual care achieved competence in some areas of self-management, but those undertaking self-monitoring required more training and supervision.
  • • 
    A computer-aided self-learning video or asthma brochure could be useful in asthma programmes but these are inadequate substitutes for individualized education.

Implications for practice and/or policy

  • • 
    Individualized self-care educational programmes for older people with asthma should be designed to support effective self-management.
  • • 
    Self-care programmes should be systematically evaluated to ensure that they are meeting individual needs and are clinically effective and cost effective.

Introduction

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

Asthma is a common chronic disease in adults (Department of Health, Taiwan ROC 2005) that affects 1·7 million people (8% prevalence rate) in Taiwan (Jan et al. 2004). It is a major cause of frequent work absences, emergency room visits, and hospitalization (American Lung Association 2005). Furthermore, asthma-related hospitalizations, morbidity, and mortality have increased in Taiwan in the past three decades (Wu et al. 2004), with the death rate about twice that in the United States of America (USA) (Kuo et al. 2003). In addition to pharmacological therapy, education and self-management have become indispensable aspects of the treatment of asthma (Sin et al. 2005). Self-management education programmes enhance patients’ sense of self-control and personal responsibility for treatment, as well as helping them to consider healthcare providers as partners in managing their asthma (Put et al. 2003). However, there is still a long way to go before people with asthma can take control of their condition and lead active lives (Smith 2000), and effective education programmes are needed to improve self-management.

For people with asthma, ‘self-management’ refers to self-monitoring changes in disease severity, appropriate knowledge about asthma and its provoking factors, knowledge of medications, adherence to inhaled medication, recognition of symptoms, and self-adjustment of medical therapy (Klein et al. 2001, Durna & Ozcan 2003). Self-management decisions are generally based on symptoms and/or peak flow monitoring (PFM) (Powell & Gibson 2003, Wensley & Silverman 2004). In Taiwan, the majority of people with asthma base their disease management on symptoms rather than PFM.

Several types of asthma education programmes have been developed for older people with asthma, with different treatment components (Janson et al. 2001, Ignacio-Garcia et al. 2002, Schermer et al. 2002, Griffiths et al. 2004, Wensley & Silverman 2004, Magar et al. 2005, Urek et al. 2005, Schatz et al. 2006). The various approaches have included individual oral instructions, written information, or group classes on the pathophysiology of asthma and use of medication (Ignacio-Garcia et al. 2002, Schermer et al. 2002, Griffiths et al. 2004, Magar et al. 2005, Urek et al. 2005, Schatz et al. 2006), using a specialist-liaison model of care (Ignacio-Garcia et al. 2002, Janson et al. 2003, Griffiths et al. 2004, Magar et al. 2005), and individualized, written action plans based on personal best peak expiratory flow (Urek et al. 2005). Outcome variables have included increased knowledge, self-care behavioural change, decreased time off work or school, unscheduled health service usage, symptom-free days, number of night-time awakenings, medication use, improvements in quality of life, and improvements in biological markers, lung function and asthma control indicators (Janson et al. 2001, Ignacio-Garcia et al. 2002, Schermer et al. 2002, Griffiths et al. 2004, Wensley & Silverman 2004, Magar et al. 2005, Urek et al. 2005, Schatz et al. 2006, Huang 2007).

In Taiwan, many intervention studies have focused on children with asthma, but only three studies have targeted adults with asthma (Jen 1999, Pan et al. 2002, Yang et al. 2003). In all three studies one session of education was provided, either for individual patients (Pan et al. 2002) or for groups (Jen 1999, Yang et al. 2003). After 1 month, all the interventions were evaluated in terms of asthma-related knowledge (Jen 1999, Pan et al. 2002, Yang et al. 2003), behaviour (Jen 1999, Pan et al. 2002), self-efficacy (Pan et al. 2002), and quality of life (Yang et al. 2003).

Asthma is prevalent among older people but they often under-report symptoms and attribute breathlessness to age and other comorbidities (Cortes et al. 2004, Cousens et al. 2007). Other difficulties include impaired perception of asthma severity, poor medication adherence, physical disability, cognitive dysfunction, and a passive self-management approach (Cortes et al. 2004, Cousens et al. 2007). These all contribute to poorer asthma outcomes among older people. Asthma is a chronic condition requiring the ability to self-manage symptoms. Few educational programmes have focused on the learning needs of older people with asthma (Cortes et al. 2004). The management of asthma among older people is likely to improve if their specific needs are addressed with a written asthma self-management plan and appropriate care (Janson & Roberts 2003, Barua & O’Mahony 2005). Also, increased attention must be focused on strengthening the patient-provider therapeutic relationship to improve asthma outcomes (Barua & O’Mahony 2005).

Guided self-care is a cornerstone of asthma care for all age groups. Based on the literature, a specialist-liaison model of follow-up care would be appropriate for older people with asthma in Taiwan and an educational programme with an individualized care plan and written educational content using big characters and clear coloured pictures. As most of the older people in Taiwan do not use PFM and often under-report symptoms, we were interested in whether basing self-management on PFM or symptoms would be better for older people with asthma in Taiwan.

Thus, the purpose of the trial reported in this paper was to compare the effectiveness of two individualized self-care education programmes (with and without PFM) with usual care (asthma education including a computer-aided, self-learning video) in older adults with moderate-to-severe asthma. Effectiveness was assessed by 6-month changes in asthma self-care competence, self-care behaviours, self-efficacy, asthma control indicators, lung function, unscheduled health service usage, and medication use.

The study

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

Aim

The aim of this study was to examine the effectiveness of individualized self-care education programmes in older adults with moderate-to-severe asthma.

Design

This study was a prospective, randomized control trial conducted in northern Taiwan between January and December 2006. We compared the effectiveness of three interventions (usual care, education alone, and education plus PFM) on self-care competence, self-care behaviours, self-efficacy, asthma control indicators, lung function, unscheduled health service usage, and changes in medication use of older adult patients with moderate-to-severe asthma over 6 months.

Participants

In a pilot study, the mean score for self-care behaviour at pretest was 65·4 (sd = 7·402), and at post-test was 71·6 (sd = 10·968). With a medium effect size, α = 0.05 and two-sided test, 54 patients were needed in each group to have 80% power to detect a between-group difference. However, to make some allowance for dropout over the 6 months of the study, a larger sample was needed.

A research assistant (RA) approached older adults with asthma in the chest outpatient department (OPD) of a 3900-bed teaching hospital in northern Taiwan and explained the trial to them. Patients were included if they met the following criteria: ≥18 years of age, diagnosed by a physician according to the Global Initiative for Asthma guidelines with moderate-to-severe asthma for at least 6 months, needing to use inhaled medicine, having received regular treatment for at least 3 months, and able to communicate in Mandarin or Taiwanese. The RA obtained written informed consent for each patient. Of 173 patients recruited for this trial, 25 withdrew during the 6-month follow-up. Therefore, the final sample consisted of 148 patients (Figure 1).

image

Figure 1.  Participant enrolment and flow for the trial.

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Randomization

The first author used a computer-developed random table to assign patients to the three intervention groups. Allocation was concealed from the recruiting RA. The RA collecting data and the second author who assessed and analysed the outcomes were blinded to group assignment, but first author was not blinded.

Interventions

Usual care group

Patients in the usual care group received the routine OPD asthma education programme, which included a computer-aided, self-learning video on asthma pathology and symptoms, management of an acute episode, long-term control of asthma, medication use, and use of a peak flow meter. Patients in this group were not given a PFM, brochures or written summaries nor did they receive any telephone contact.

Education alone group

Patients in this group received individualized education alone for 6 months. This programme was provided by a nurse who had 6 years of experience in chest and emergency care of older adults and who telephoned patients once a week for 6 months.

The nurse collaborated with patients, their family members, and healthcare team to design an individualized education plan based on their baseline information. In addition, these patients received an educational brochure on self-care for people with asthma. This information included an asthma treatment plan; asthma pathology, definition, diagnosis, and symptoms; information about assessing the severity, preventing and signs of acute episodes and managing these episodes; and a manual about medications, asthma and exercise, and comprehensive treatment. All patients were asked to record their day- and night-time asthma symptoms. The severity of asthma symptoms was rated on a scale from 1 to 3 (green, yellow, and red).

The educational brochure was designed with coloured pictures, step-by-step instructions, and used few words with big characters. This approach enabled patients with less education and impaired vision to participate in the trial. In addition, the nurse gave patients and/or family members a written copy of their asthma management plan and a list of ongoing concerns. Through follow-up telephone calls, the nurse addressed the concerns of patients and family members, monitored patients’ progress, and collaborated with physicians to modify therapies.

Education plus PFM group

Patients in this group received the same intervention by the same nurse as those in the education alone group, plus training on how to use a peak flow meter. The nurse provided patients with a peak flow meter and taught them individually how to manage their own asthma, based on values obtained in the mornings and evenings.

Assessment

Patients in all the three groups were assessed for outcomes (see below) at baseline, 1, and 6 months by an RA blinded to their group allocation. Assessment data were collected in a health education room at the OPD. Data were also collected at baseline on age, gender, education, marital status, income, and asthma-related history.

Outcomes

The main outcome variables were asthma self-care competence (knowledge and skills), self-care behaviours, and self-efficacy. These outcomes were measured by two subscales (knowledge and skills) of the Asthma Self-Care Agency scale, the Asthma Self-Care Behaviour Scale, and the Asthma Self-Efficacy Scale, respectively, developed by the investigator (Huang 2007). Scale development was based on a comprehensive literature review, clinical experience, and observation; scale validity was established by content validity index (CVI) (0·92–0·99), test-retest reliability, and internal consistency (Huang 2007).

Secondary outcome variables included four asthma control indicators: peak expiratory flow rate (PEFR), forced expiratory volume of the first second after a deep breath (FEV1), forced vital capacity (FVC), and FEV1/FVC. Data were also collected on unscheduled health service usage and changes in medication use.

Asthma self-care competence.  Asthma self-care competence, which included knowledge and skills related to asthma self-care, was measured by the knowledge and skills subscales of the Asthma Self-Care Agency Scale (Huang 2007). The knowledge subscale contains 22 multiple-choice questions (six for medicine, three for self-monitoring, nine for environment controls, one for regular check-ups, and five for exercise). Each question has only one correct answer. To avoid guessing answers, the choice ‘I do not know’ is included as a possible response. Scores range from 0 to 22, with higher scores indicating better knowledge. For the present trial, test-retest reliability (r) was 0·83 and Cronbach’s alpha was 0·84. The skill subscale assesses two self-care skills: testing for peak expiratory flow rate (5 points), and taking fixed amounts of inhaled medicine (3 points). Scores range from 0 to 8, with higher scores indicating more correct skills for self-care. In this trial Cronbach’s alpha was 0·89 and the test-retest reliability (r) was 0·83.

Asthma self-care behaviour.  Asthma self-care behaviour was measured by the Asthma Self-Care Behaviour Scale (Huang 2007), which contains 21 items (two for medicine, five for self-monitoring, seven for environment control, two for regular check-up, and five for exercise) that are all rated on a 5-point Likert scale (5 = always to 1 = never). Scores range from 21 to 105, with higher scores indicating better self-care behaviour. The test-retest reliability was 0·93 and Cronbach’s alpha was 0·83 in this trial.

Asthma self-efficacy.  Asthma self-efficacy was measured by the Asthma Self-Efficacy Scale (Huang 2007), which contains 5 items (medicine, self-monitoring, environment control, regular check-up, exercise) that are all rated on a 5-point Likert-type scale (5 = absolutely confident to 1 = absolutely no confidence). Scores range from 5 to 25, with higher scores indicating better self-efficacy. The test-retest reliability was 0·81 and Cronbach’s alpha was 0·84 in this trial.

Lung function.  Lung function was measured by spirometry using a body plethysmograph and evaluated in terms of PEFR, FEV1, FVC, and FEV1/FVC.

Asthma control indicators.  Asthma control was measured by the Asthma Control Test, a 5-item questionnaire used to assess shortness of breath, patient-rated control, use of rescue medication, asthma interference with work/school, and asthma interference with sleep (Nathan et al. 2004). Symptoms are coded as uncontrolled (0) and controlled (1), so total scores range from 0 to 5. Higher scores indicate better control. Cronbach’s alpha was 0·84 in a previous trial (Nathan et al. 2004) and 0·77 in the present trial.

Unscheduled health service usage and changes in medications.  Self-reported use of unscheduled health services were recorded as unplanned doctor visits, emergency room visits, or hospitalizations. Changes in prescribed medicine use were monitored by medication type and dosage.

Ethical considerations

The trial was approved by the appropriate ethics committee. Participants were recruited as described above, were assured of confidentiality and given the option to decline participation or withdraw from the trial at any time.

Data analysis

Statistical analyses were performed using spss 12.0 (SPSS Inc., Chicago, IL, USA). Analysis of variance, chi-square statistics, and Fisher’s exact test were used to test for differences among the groups at baseline. Analysis of covariance (ancova) was used to evaluate the statistical significance of differences in the various outcome variables among the groups after controlling for the baseline value of each outcome at 6 months. Test-retest reliability was determined over a 2-week period with 10 volunteers. Internal consistency was examined by Cronbach’s alpha.

Results

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

Comparison of three groups at baseline

The majority of patients were 65 years or older, male, with ≤6 years education, married, living with their nuclear family, and had more than enough income (Table 1). More than half had a smoking history, no emergency room visits or hospitalizations in the past year, a more than 5-year asthma history, were diagnosed with severe asthma, and took one kind of medicine at two dosages each time. The groups were well-balanced for baseline demographic characteristics and lung function parameters, as well as for asthma self-care competence, self-care behaviours, and self-efficacy.

Table 1.   Baseline demographics (= 148)
VariableIntervention group
Usual care (= 50) Education (= 49)Education  + PFM (= 49)
n%n%n%
  1. PFM, peak flow monitoring.

Age, years
 19–440024510
 45–64204021431939
 ≥65306026532551
Gender
 Female112217351224
 Male397832653776
Education, years
 01122510612
 ≤6244823472347
 9–1291816331531
 >12612510510
Marital status
 Single243612
 Married489646944898
Smoking
 No438644904082
 Yes714510918
Asthma duration, years
 <2102081748
 2–571410201633
 >5–<10133415311531
 10–20481122412
 >201224510814
Asthma severity
 Moderate204013261633
 Severe306036743367

Impact of educational programmes on outcomes

Except for the lung function parameter PEFR, all outcome indicators at 6 months were statistically significantly better for patients in the individualized educational groups than for those in the usual care group.

Self-care competence

In terms of self-care competence, the average knowledge scores for the two individualized educational groups increased from 15·92 (sd = 3·74) and 16·26 (sd = 3·15) at baseline to 21·37 (sd = 1·11) and 21·47 (sd = 0·94) 6 months later, whereas scores for patients in the usual care group over the same period rose from 15·40 (sd = 4·21) to 18·38 (sd = 2·67). Differences among the three groups were shown by ancova to be statistically significant (F = 334·06, P < 0·001); education alone was statistically significantly different from usual care (P < 0·001), whereas education plus PFM was not statistically significantly different from education alone (P > .05). These results indicate that the increased knowledge of patients in the two individualized education groups at 6 months follow-up was statistically significantly higher than that of the usual care group (Table 2).

Table 2.   Effects of individualized interventions on 6-month outcomes for older people with asthma by group
Group variablesUsual care group, mean (sd) (= 50)Education alone group, mean (sd) (= 49)Education + PFM group, mean (sd) (N = 49)F value2 minus 13 minus 2
P value95% CI for differenceP value95% CI for difference
  1. PFM, peak flow monitoring; PEFR, peak expiratory flow rate; FEV1, forced expiratory volume of the first second after a deep breath; FVC, forced vital capacity.

  2. Prebronchodilation.

  3. Postbronchodilation.

  4. F-test for all three groups: *P < 0·05; **P < 0·01; ***P < 0·001.

Competence   334·06***0·002·28–3·410·73−0·67–0·472
Knowledge
 Pre15·40 (4·21) 15·92 (3·74)16·26 (3·15)     
 Post 118·74 (2·47)21·18 (1·18)21·68 (0·52)     
 Post 218·38 (2·67)21·37 (1·11)21·47 (0·94)     
Skills   481·37***0·07−0·16–0·0060·55−.057–0·106
 Pre7·80 (0·61) 7·65 (0·69)7·61 (0·73)     
 Post 17·90 (0·36)7·90 (0·37) 7·88 (0·53)     
 Post 27·92 (0·34)7·98 (0·14)8·00 (0·00)     
Self-care   104·08***0·0011·23–16·570·003·40–8·77
Behaviours
 Pre65·34 (7·17) 66·00 (7·96)65·86 (9·83)     
 Post 167·84 (8·66)80·24 (8·79)86·61 (8·19)     
 Post 268·96 (8·58)83·24 (8·29) 89·24 (8·03)     
Self-efficacy   68·42***0·001·48–2·760·001·31–2·59
 Pre16·54 (2·11)16·73 (2·80) 17·16 (2·64)      
 Post 116·66 (2·34)18·90 (2·29)21·10 (1·94)     
 Post 217·08 (2·63)19·88 (2·20)21·88 (2·25)     
PEFR   2·530·08−17·41–30·730·11−4·30–44·23
 Pre263 (101·3)275 (93·32)297 (103·88)     
 Post 1276 (113·5)296 (81·11) 335 (115·0)     
 Post 2301 (110·7)318 (90·43)358 (106·63)     
FEV1 (%)   5·78**0·02  0·67–7·740·31−5·39–1·72
 Pre51·82 (17·07)51·71 (15·40)50·88 (20·60)     
 Post 152·30 (17·90)53·96 (16·13)53·24 (21·00)     
 Post 252·48 (17·62)56·59 (16·17)54·00 (21·13)     
FEV1 (%)   1·270·35−1·98–5·550·52−2·56–5·03
 Pre61·10 (15·92)59·76 (16·87)60·12 (16·04)     
 Post 162·49 (16·17)63·10 (16·70)63·12 (16·74)     
 Post 259·96 (21·25)63·12 (21·48)62·14 (21·74)     
FVC (%)   9·92***0·011·59–9·460·56−5·14–2·78
 Pre56·54 (17·95)58·22 (14·61)59·84 (18·97)     
 Post 156·76 (18·16)60·39 (14·48)61·06 (20·06)     
 Post 255·50 (17·05)62·37 (14·01)62·47 (19·32)     
FEV1/FVC   1·271·00−6·20–5·890·57−9·39–2·76
 Pre67·84 (10·47)68·12 (11·92)65·77 (13·71)      
 Post 167·50 (10·67)67·89 (11·75)67·59 (11·75)     
 Post 269·20 (11·45)69·05 (11·72)68·06 (13·66)     
FEV1/FVC    0·601·00−5·40–6·741·00−9·19–5·01
 Pre68·98 (10·75)67·96 (13·20)65·96 (13·34)      
 Post 168·85 (10·95)68·87 (11·62)68·63 (13·61)     
 Post 270·14 (12·15)70·81 (11·82)69·72 (13·39)     
Control indicator   16·42***0·23−0·72–0·170·030·07–0·96
 Pre3·32 (1·58)3·59 (1·41)3·12 (1·45)      
 Post 13·40(1·44)3·55 (1·37) 3·43 (1·27)     
 Post 23·36(1·35)3·24 (1·53)3·49 (1·31)     

Average skill scores were shown by ancova to be statistically significantly different among the three groups (F = 481·37, P < 0·001); skill scores in the two individualized education groups were slightly higher than those in the usual care group, but this difference was not statistically significant (P > 0·05) (Table 2).

Self-care behaviours

Self-care behaviours among the three groups changed statistically significantly over time (Table 2) as demonstrated by ancova (F = 104·08, P < 0·001). These behaviours also changed statistically significantly between the education alone and usual care groups (P < 0·001), and between the education plus PFM and education alone groups (P < 0·001) at 6 months. The mean self-care behaviour score of the education plus PFM group was higher than that of the education alone group, and the education alone group had a higher mean score than the usual care group (Table 2).

Self-efficacy

Mean total self-efficacy scores for patients in the education alone and education plus PMF groups rose from 16·73 (sd = 2·80) and 17·16 (sd = 2·64) at baseline to 19·88 (sd = 2·20) and 21·88 (sd = 2·25) at 6 month follow-up, whereas scores for patients in the usual care group rose from 16·54 (sd = 2·11) to 17·082 (sd = 2·63). Self-efficacy among the three groups was shown by ancova to be statistically significantly different (F = 68·42, < 0·001); education alone and usual care differed statistically significantly (P < 0·001), and education plus PFM differed statistically significantly from education alone (P < 0·001) at 6 months. The mean self-efficacy score of the education plus PFM group was statistically significantly higher than that of the education alone group, and the education alone group had a higher score than the usual care group (Table 2).

Lung function

Changes over time in PEFR, FEV1 (pre- and postbronchodilation), FVC, and FEV1/FVC for the three groups are listed in Table 2. Statistically significant differences among groups were shown by ancova (F = 5·78, 9·92, and 13·70, P < 0·001) for prebronchodilation FEV1, FVC and both FEV1/FVC at 6 months. The education alone and usual care groups were statistically significantly different for prebronchodilation FEV1, FVC and postbronchodilation FEV1/FVC (P < 0.05, 0.001, and 0.05, respectively), but the education plus PFM and education alone groups were not statistically significantly different (P > 0·05) on any lung function parameters (Table 2).

Asthma control indicators

The three groups were shown by ancova to be statistically significantly different (F = 16·42, P < 0·001) for control indicators. Patients who received the education plus PMF intervention reported statistically significantly higher asthma control indicator scores than the education alone group (P < 0·05) (Table 2).

Unscheduled health care usage

During the 6-month trial, the frequency of unscheduled health care visits in the usual care group was eight chest OPD visits and five emergency room (ER) visits, in the education alone group was six chest OPD visits and four ER visits, and in the education plus PFM group was four chest OPD visits and one ER visits. Overall, 13, 10, and five patients in the usual care, education alone, and education plus PFM groups, respectively, made unscheduled health care visits. No statistically significant differences were found among the three groups.

Medications

During the 6-month study, the average number of medication types taken by patients in the education plus PFM group decreased statistically significantly more than that for the other two groups (= 0·033) (Table 3). In addition, the dosage of medication taken by the three groups was not statistically significant (P > 0·05).

Table 3.   Medication use at 6-month follow-up (= 148)
VariableTimeUsual care (= 50)Education (= 49)Education + PFM (= 49)P value
Mean (sd)
  1. PFM, peak flow monitoring.

  2. Type analysed by ancova. Dosage analysed by Fisher’s exact test: ([DOWNWARDS ARROW]) decreased; (—) same; ([UPWARDS ARROW]) increased.

Medication type
 Pre 1·26 (0·44)  1·27 (0·45)  1·16 (0·37) 0·405
 Post 1·26 (0·44)  1·37 (0·48)  1·12 (0·33) 0·033
Medication dosage     n (%)     
 [DOWNWARDS ARROW][UPWARDS ARROW][DOWNWARDS ARROW][UPWARDS ARROW][DOWNWARDS ARROW][UPWARDS ARROW]
 Post0 (0)50 (100)0 (0)0 (0)46 (94)3 (6)2 (4)46 (94)1 (2)0·064

Discussion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

This trial demonstrated that when older adult patients with moderate-to-severe asthma received individualized education plus PFM with follow-up planning, they had better asthma self-care competency (knowledge and skills), self-care behaviours, self-efficacy, prebronchodilation FEV1, FVC, asthma control indicators, and took fewer medications than patients receiving usual care. No statistically significant differences were found among the three groups on PEFR, postbronchodilation FEV1, FEV1/FVC, unscheduled health care usage and dosage of medication at 6-month follow-up.

Study limitations

This trial has several limitations. First, participants were recruited from only one medical centre. The results from a multi-site trial would be more generalizable. Second, these older people could have had comorbid respiratory conditions that were not assessed in this study. The sampling technique did not control for presence of other respiratory disorders in group assignment, which could have affected study outcomes. Third, participants were followed up over a relatively short period. A longer study would allow better estimation of the effects of education on long-term asthma control. Fourth, we randomly allocated participants into three different groups at the same period. Thus, medication treatment, adherence to medication, and the impact of seasonal variation on asthma control were confounding factors in this study. Fifth, the study was also under-powered because we did not retain the required 54 patients in each group. Finally, it is unclear how much additional time and costs were incurred by these two individualized educational approaches. A cost-effectiveness study may be needed.

Discussion of results

We found that patients who completed both programmes of individualized self-care education had statistically significantly increased general asthma-related knowledge, behaviour, and self-efficacy, consistent with previous reports (Put et al. 2003, Sin et al. 2005). In contrast, patients in the usual care group improved, but not as much as those in the other two groups. These patients, who received standard medical care with only a computer-aided self-learning video programme at the chest OPD, showed smaller but statistically significant improvements in their asthma self-care knowledge, behaviour, and self-efficacy. Thus, our results documented that all three kinds of programmes can improve self-care competence, self-care behaviour, self-efficacy, and lung function in older people.

Moreover, our trial results with individualized interventions supports previous reports (Pan et al. 2002, Gibson & Powell 2004, Griffiths et al. 2004, Magar et al. 2005, Urek et al. 2005) that such interventions are more effective than group education for older adult people with asthma. The majority of participants in our trial were 65 years or older, and with >5-year asthma history. These characteristics suggest that they would have asthma-related knowledge and use self-management strategies. The merit of this trial is that it involved three forms of self-care education used in everyday clinical practice. Older adults with persistent, moderate-to-severe asthma who attended education groups with the most individually oriented comprehensive form of education, achieved the best results regarding self-care competence, self-efficacy, and asthma control. A computer-aided self-learning video or asthma brochure could be useful in asthma programmes but these are inadequate substitutes for individualized education.

This trial suggests that a specialist-liaison model (used for both individualized education groups in this trial) facilitates higher self-care behaviours once knowledge is present. This model may be a successful approach with people with asthma to promote self-care behaviour and improve lung function. Our results are similar to those in several previous reports (Ignacio-Garcia et al. 2002, Janson et al. 2003, Yang et al. 2003, Griffiths et al. 2004, Magar et al. 2005) that using a liaison model of care can improve knowledge, lung function, and reduce unscheduled care, number of days off work or school, and acute episodes.

The episodic nature of asthma as a chronic disease presents challenges for self-management as patients lose interest in their condition once they are asymptomatic. An important consideration in education programmes is to have a constant effort by personnel who maintain frequent contact and provide reassurance, comfort, and consistency to the patient. However, the Taiwan healthcare system does not provide the financial support for self-management to be effective. We need to find the means to make asthma education and self-care with reinforcement by providers a priority. As asthma self-management is complicated for patients, certified asthma educators should work in OPD to improve the success of self-management.

Participants in this trial who received education plus PFM had better outcomes than those who received education alone and used symptoms to manage their asthma. More than 80% of participants did not use PFM at the beginning of this trial. Even those who did use PFM did not regularly check their peak flow meters due to impatience or the belief that they knew their disease pretty well and could handle it according to how they ‘felt’. Another factor that might explain this reluctance to use PFM is the National Insurance policy in Taiwan, which makes medical resources easily available; therefore, people feel confident that during acute episodes medical care will be easily available and symptoms will be effectively relieved. However, using PFM is recommended to improve the intentions of older adult people with asthma to take charge of their own health and to become more competent in self-care. In fact, PEFR is recommended by several authors (Ignacio-Garcia et al. 2002, Powell & Gibson 2003, Wensley & Silverman 2004, Urek et al. 2005) as an especially good indicator of asthma activity, and regular PEFR monitoring as highly important for reducing morbidity and optimal utilization of anti-asthma medication. They also agree that all educational programmes should cover PEFR monitoring and consequent planning of asthma treatment.

Conclusion

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

Our results suggest that self-care educational programmes should be individualized in order to be effective in promoting self-care by older people with asthma. A computer-aided self-learning video or asthma brochure could be useful in asthma programmes, but these are inadequate substitutes for individualized education.

Funding

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Author contributions

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References

TT and YT were responsible for the study conception and design. TT and CH performed the data collection and made critical revisions to the paper for important intellectual content. TT provided statistical expertise. TT and YT performed the data analysis and were responsible for the drafting of the manuscript. TT provided administrative, technical or material support and supervised the study.

References

  1. Top of page
  2. Abstract
  3. What is already known about this topic
  4. Introduction
  5. The study
  6. Results
  7. Discussion
  8. Conclusion
  9. Funding
  10. Author contributions
  11. References
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