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A South Australian population survey of the ownership of asthma action plans

Richard E Ruffin, David Wilson, Brian Smith and Robert J Adams
Med J Aust 1999; 171 (7): 348-351.
Published online: 4 October 1999
Research

A South Australian population survey of the ownership of asthma action plans

Richard E Ruffin, David Wilson, Anne Marie Southcott, Brian Smith and Robert J Adams

MJA 1999; 171: 348-351

Abstract - Introduction - Methods - Results - Discussion - References - Authors' details
- - More articles on Respiratory medicine


Abstract Objective: To examine the relationships between ownership of written asthma action plans, asthma morbidity, use of devices, and patients' perceptions of their asthma management.
Design and setting: A random population survey (in 1996) of the South Australian population aged 15 years or over, using interviewers to administer a questionnaire.
Participants: People who reported that they had current, doctor-diagnosed asthma.
Main outcome measures: Prevalence of written asthma action plans; night-time awakenings from asthma; ownership of peak flow meters; and people's perceptions of their asthma management.
Results: The ownership of asthma action plans by people with self-reported asthma was 33% and has declined since 1995 (42%; P < 0.001). Fifteen per cent were wakened weekly or more frequently by asthma symptoms. These people were more likely to have a peak flow meter and a written action plan, but less likely to consider they had been provided with enough information about their asthma, to feel comfortable managing their asthma, or to find it easy to see their doctor. Having a written asthma action plan was associated with regular corticosteroid use, understanding asthma, having enough information and owning a peak flow meter.
Conclusions: Ownership of asthma action plans in South Australia is suboptimal. Before we develop new strategies to improve asthma outcomes, we must determine whether there is a need to target people with less severe asthma and/or improve the use of guidelines by health professionals.


Introduction The Australian and New Zealand Asthma Guidelines, developed in 1989, provide a list of objectives that would be desirable to achieve for every person with asthma,1 and studies of the use of asthma management plans have shown improved health outcomes for people with asthma.2-4 In Australia there is evidence that the promotion of asthma plan guidelines by the Thoracic Society of Australia and New Zealand and the National Asthma Campaign has led to increased uptake of plans.1 In South Australia the prevalence of adults with asthma reporting that they had a written action plan almost doubled between 1992 and 1995.5 However, there is evidence that asthma management is not ideal.6-8In one study in Victoria, 45% of people who died of their asthma had been assessed as having only a history of mild or moderate asthma.6 In another study in Victoria that examined the asthma knowledge of asthma patients, the median score obtained was less than 50%.7

The effective implementation of asthma management plans in Australia to date has been seriously questioned by some investigators,8 and Bauman et al have concluded that the treatment and management of asthma is suboptimal.9

Our study aimed to provide representative population information on the ownership of written asthma action plans and the relationship to asthma morbidity and management factors.


Methods  

Survey The data for this study were collected in the 1996 South Australian Health Omnibus Survey,10 a representative survey of people aged 15 years or older (n = 3010; response, 71%) . The survey was a multistage, systematic, clustered area sample of people who live in metropolitan Adelaide and major country centres with a population of over 1000. The survey was selected from a random sample of Australian Bureau of Statistics collector districts. Within each collector's district a random starting point was selected and from this point 10 households were selected using a fixed skip interval. Hotels, motels, hospitals, nursing homes and other institutions were excluded. The person whose birthday was next in each selected household was interviewed in their home by trained health interviewers. There was no replacement for non-respondents. Up to five call-backs were made in an attempt to interview the selected person. The data were weighted by age, sex, and geographic region to the estimated resident population data so that the analysis would be representative of the South Australian population.

The part of the survey form dealing with asthma is shown in the Box. A person was classified as having current asthma if they answered yes to the first three questions.

Social class was determined by referring to the gradation of occupational prestige given in the Australian Standard Classification of Occupations.11

An asthma action plan was defined as "written instructions of what to do if your asthma is out of control."  

Data analysis Possession of an asthma management plan and frequency of wakening at night with asthma were used as the two dependent variables for univariate analyses,12 which examined the associations between these variables and reported asthma management, knowledge and attitudes to management.

Before conducting multiple logistic regression analyses, the explanatory variables were examined for collinearity or interactions. Stratified analyses were used to check homogeneity of associations across different levels of predictor variables. Smoking status and the information that people with asthma perceive they have for dealing with worsening asthma were found to interact, with an effect of these variables on worsening asthma. An interaction term for the two independent variables was included in the logistic regression analysis for frequency of wakening at night. This interaction term proved significant (P = 0.03), indicating the need to split the model and conduct separate logistic regression analyses of smokers and non-smokers.

Therefore, we conducted three logistic regression analyses, using "asthma plan", "waken weekly-non-smokers" and "waken weekly-smokers" as the three response variables. All variables found to be significant at the univariate stage (ie, P = 0.25)13 were entered into each logistic regression. Insignificant variables were progressively omitted until satisfactory models were found that explained possession of an asthma plan and frequency of wakening at night.


Results The prevalence of asthma was 11.6% (95% CI, 10.3%-12.9%). Of the 349 survey respondents with asthma, 33% (95% CI, 30.8%-35.2%) had a written asthma action plan and 15.2% (95% CI, 13.7%-15.7%) were awakened by asthma weekly or more frequently. Age, sex, migrant status, education level and socioeconomic status made no significant difference to the rate of possession of an asthma action plan or the rate of wakening with asthma weekly or more frequently.

Variables significantly

associated with ownership of an asthma action plan at the univariate level are shown in Table 1; those significantly associated with wakening with asthma at night are shown in Table 2.

In the multivariate analysis (Table 3), the variables that best described those who had an asthma action plan were: using corticosteroids, understanding the effects of worsening asthma, having a peak flow meter, and believing they have enough information to deal with worsening asthma. The variables that best described non-smokers who waken weekly or more often were: having a peak flow meter, having an asthma action plan, not believing they have enough information to deal with worsening asthma, and not feeling comfortable taking care of their asthma. Only one variable -- not finding it easy or convenient to access their doctor about asthma -- explained wakening weekly or more often for smokers.


Discussion The data obtained in this representative population study paint a bleak picture of the effectiveness of asthma management in Australia. As even people with mild asthma can die of the disease,6 every person with asthma may need an action plan. Yet, seven years after the promulgation of Australian guidelines on the implementation of asthma action plans,1 only 33% of people with diagnosed asthma had a written plan. The current level of plan ownership is significantly lower than the 42.1% (P < 0.001) reported 12 months earlier using the same survey methods.5 This may mean that vigilance regarding asthma management is declining.

Our study has some limitations. We have no objective data to identify levels of asthma severity and asthma control in the respondents. The validity of the perception questions as repeatable measures has not been verified. Because we focused on ownership of written action plans, our study does not tell us whether patients are making appropriate use of these plans or of verbal instructions.

In the multivariate analyses, only use of preventer medication, ownership of a peak flow meter and self-reported understanding of asthma were associated with plan ownership. This association could suggest that the more severe cases have better asthma management. Proof for this requires prospective measures (eg, lung function, medication doses) to assess the two critical factors of asthma severity and asthma control. Such knowledge could inform us of the potential need to target people with less severe asthma.

People with asthma with nocturnal symptoms were more likely than those without nocturnal symptoms to report possession of a peak flow meter, and to have asthma action plans, but were less likely to consider they had been provided with enough information about their asthma (non-smokers) or to find it easy to see their doctor (smokers) (Table 2). Thus, although asthmatics with a higher level of morbidity are more likely to receive physical materials to assist in self-care, they continue to have greater unmet needs for general practitioner access and information about asthma self-management.

What is the way forward? Randomised studies of the implementation of asthma plans show that good educational and skill objectives can be achieved.2,14-16 However, the complexity of the asthma management problem makes it impossible to provide for every contingency the patient might face in dealing with asthma. Asthma management decisions can be difficult, because the patient, the daily situation, the science base and the disease are constantly changing.2

The objectives of patient asthma management are the development of skills and positive attitudes to problem-solving, accompanied by sufficient knowledge to make sense of changing morbidity and symptoms. A controlled trial evaluation of a brief asthma education program (2.5 to 3 hours group work) demonstrated substantial changes in illness behaviour.2 These programs show that giving the patient the necessary skills cannot be achieved within the normal constraints of general practice. Randomised controlled trials of asthma clinics, where there is an emphasis on self-management, have demonstrated improvements in a range of morbidity and other health-related outcomes in a community-based setting.17 We must identify other ways of training the patient and focus the clinician on that part of the education program that can be managed in general practice. There is evidence that regular review improves asthma outcomes.18

It is pertinent to consider the possibility that inadequate use of guidelines by health professionals may be contributing to the fall in action plan ownership. Ways to improve use of guidelines need to include developments in information technology.

Trostle has suggested that the inability of some people to comply with a treatment regimen is an unavoidable byproduct of collisions between the clinical world and other competing worlds of work, family, friends and recreation.19 Often, the process required to inform and empower the patient is more than an educational task. Some of the traditional models of patient education based on health beliefs or compliance frameworks have been seriously questioned.20,21 Patients have to fit their medical problems and medical regimens into the context of their daily lives. In doing so they will vary their compliance with advice and instructions to accommodate the social, psychological, economic and physical influences which are part of their lives.21 We need research that clearly articulates the complexity and variability of how asthma management fits into the context of individual patients' lives.

The National Asthma Campaign has provided a guide for health professionals to assist with effective patient communication, which is a starting point for corrective strategies.22

We therefore know what optimal management of asthma is, but its attainment is elusive. Future strategies must be guided by studies defining asthma severity and asthma control, studies identifying factors that influence the use of guidelines by professionals, and studies elucidating the context of asthma management for the individual.


References
  1. Woolcock A, Rubinfeld AR, Seale P, et al. Asthma management plan, 1989. Med J Aust 1989; 151: 650-653.
  2. Yoon R, McKenzie DK, Bauman A, Miles DA. Controlled trial evaluation of an asthma program for adults. Thorax 1993; 48: 1110-1116.
  3. Comino EJ, Mitchell CA, Bauman A, et al. Asthma management in eastern Australia. Med J Aust 1996; 164: 403-406.
  4. Beasley R, Cushley M, Holgate ST. A self-management plan in the treatment of adult asthma. Thorax 1989; 44: 200-204.
  5. Adams R, Ruffin R, Wakefield M, et al. Asthma prevalence, morbidity and management practices in South Australia, 1992-1995. Aust N Z J Med 1997; 27: 672-679.
  6. Robertson C, Rubinfeld AR, Bowes G. Deaths from asthma in Victoria: a twelve-month survey. Med J Aust 1990; 152: 511-517.
  7. Rubinfeld AR, Dunt DR, McLure BG. Do patients understand asthma? A community survey of asthma knowledge. Med J Aust 1988; 149: 526-530.
  8. Bauman A, Young L, Peat JK, et al. Asthma under-recognition and under-treatment in an Australian community. Aust N Z J Med 1992; 22: 36-40.
  9. Bauman A, Mitchell CA, Henry RL, et al. Asthma morbidity in Australia: an epidemiological study. Med J Aust 1992; 156: 827-831.
  10. Wilson D, Wakefield M, Taylor A. The South Australian Health Omnibus Survey. Health Promotional J Aust 1992; 2: 47-49.
  11. Kelley JL, Evans MDR. Using ASCO for socio-economic analysis: assessment and conversion into status and prestige indices. Canberra: Research School of Social Sciences, Australian National University, 1988.
  12. SPSS for Windows. Release 8.0 [computer program]. Chicago, IL: SPSS Inc, 1998.
  13. Hosmer DW, Lemeshow S. Applied logistic regression. New York: John Wiley, 1989.
  14. Wilson-Pessano SR, McNabb WL. The role of patient education in the management of childhood asthma. Prev Med 1985; 14: 670-687.
  15. Clark NM, Feldman CH, Evans D, et al. Managing better: children, parents and asthma. Patient Educ Counsell 1986; 8: 27-38.
  16. D'Sousa WD, Crane J, Burgess C, et al. Community-based asthma care: trial of a "credit card" asthma self-management plan. Eur Respir J 1994; 7: 1260-1265.
  17. Lahdenso A, Haajtela T, Herrala J, et al. Randomised comparison of guided self-management and traditional treatment of asthma over one year. BMJ 1996; 312: 748-752.
  18. Asthma management handbook 1998. Melbourne: National Asthma Campaign, 1998.
  19. Trostle JA. Medical compliance as an ideology. Soc Sci Med 1988; 18: 1299-1308.
  20. Carter WB. Psychology and decision making: modelling health behaviour with multiattribute theory. J Dental Educ 1992, December: 800-807.
  21. Morris SL, Schulz RM. Medication compliance: the patients' perspective. Clin Ther 1993; 15: 593-606.
  22. Asthma adherence: a guide for health professionals. Melbourne: National Asthma Campaign, 1999.

(Received 19 Apr, accepted 26 Aug, 1999)


Authors' details The Queen Elizabeth Hospital, Adelaide, SA.
Richard E Ruffin, FRACP, MD, Head, Division of Medicine, and Michell Professor of Medicine, University of Adelaide;
Anne Marie Southcott, MB BS(Hons), FRACP, Acting Director, Respiratory Medicine;
Brian Smith, PhD, FRACP, Director, Clinical Epidemiology and Health Outcomes Unit, and Senior Lecturer, University of Adelaide.

Centre for Population Studies in Epidemiology, Department of Human Services, Adelaide, SA.
David Wilson, PhD, MPH, Head.

Channing Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Robert J Adams, MB BS, FRACP, Research Fellow.

Reprints: Professor R E Ruffin, Department of Medicine, University of Adelaide, The Queen Elizabeth Hospital Campus, 28 Woodville Road, Woodville, SA 5011. rruffinATmedicine.adelaide.edu.au






Survey questions

Have you ever had asthma?
Was your asthma confirmed by a doctor?
Do you still have asthma?

If answer yes to these questions, then:

Do you have an asthma action plan (written instructions of what to do if your asthma is out of control)?
Do you have a home nebuliser for asthma treatment?
Interviewer: if "yes" prompt "have you used it in the last 12 months?"

What preventive (not reliever) medicine do you use regularly for your asthma?
None - Intal - Becotide - Becloforte Pulmicort - Tilade - Other (specify)

Which of the statements shown on this card do you feel are true of your preventer medication?
Works by relieving narrowed breathing tubes quickly
Needs to be used when you feel unwell
Works by slowly reducing inflammation in the breathing tubes
Must not have the dose changed
Don't know

How often do you awaken during the night with asthma?
Nightly - Most nights - About twice a week - Weekly - Monthly - Less often than monthly
Only at certain times of the year (ie seasonal)
Never

In the last 12 months have you had any hospital admissions for asthma where you stayed at least one night in hospital?

In the last 12 months have you had any days lost from work, school or home duties from asthma?

How many days would you estimate?

What would you do if you had a bad attack of asthma and six puffs of your reliever (eg, ventolin, respolin) had not helped?

Which of these statements shown on this card most closely matches what you would be likely to do?
Wait another two hours and take more reliever medication
Seek medical advice
Take another six puffs of reliever medication and see what happens
Call an ambulance
Get someone to take you to hospital
Do something else (specify)

What feelings would you have if you had to get help for a bad attack of asthma? Which of the statements shown on this card most closely match how you would be feeling?
You feel that you have failed
You would feel embarrassed
You do not want to bother others
It is the right thing to do
You know you will be OK because of past experience
Something else (specify)

I am now going to read out a number of statements and show you a card for each of them. Could you please tell me which number from 1 to 5 best reflects the way you feel.

I am the sort of person who understands all about my asthma
Always - Often - Sometimes - Rarely - Never - Don't know/other

If I took care of my asthma myself, most of the time, I would . . .
Manage well
Manage sometimes
Not manage at all
Don't know/other

If I were having a severe attack of asthma I would feel comfortable about going to a doctor or hospital
Very comfortable
Comfortable
Don't mind
Uncomfortable
Not comfortable at all
Don't know/other

Going to see a doctor for help with my asthma is
Easy and convenient
Not easy nor convenient
Don't know/other

I have information to use (such as "Asthma Action Plan" or other instructions) to deal with worsening asthma.
Yes, all I need
Some
No, none at all
Don't know/other

Other questions were asked about smoking status, educational level and migrant status.

Back to text

1: Variables associated with ownership of an action plan*

VariableSubjects (n = 349)%Odds ratio

Wrong about CS effect10332.01.0
Correct about CS effect16244.41.7 (0.98-2.94) P = 0.04
Don't use CS regularly14721.81.0
Use CS regularly20241.62.56 (1.54-4.26) P < 0.01
No home nebuliser28229.11.0
Have home nebuliser6750.72.51 (1.41-4.48) P < 0.01
No peak flow meter29626.61.0
Have peak flow meter5371.76.99 (3.50-14.14) P <0.01
Don't always understand asthma8516.51.0
Understand asthma26438.63.19 (1.65-6.27) P < 0.01
Not enough information11715.51.0
Enough information23255.56.77 (3.98-11.56) P <0.01
Feel bad getting help4721.31.0
Getting help OK30235.12.26 (1.04-4.90) P = 0.04
No hospital admission within 12 months 33432.1 1.0
Hospital admission1560.03.17 (1.00-10.32) P = 0.05
No days lost from work/school30231.11.0
Days lost from work/school4746.81.95 (1.00-3.79) P = 0.05

CS = corticosteroids. * Variables tested but not found to be significant were: sex, age, migrant status, educational level, socioeconomic status, weight, access to doctor, uncomfortableness dealing with asthma, perception of dealing with asthma, comfortableness in going to hospital if required, exercise, smoking status, and smoking bans at home. Only those who regularly used preventive medicine for their asthma (n = 265) were asked about its effects.
Back to text

2: Variables associated with the likelihood of wakening with asthma on a weekly basis or more frequently*

VariableSubjects (n = 349)%Odds ratio

Wrong about CS effect1038.71.0
Correct about CS effect16225.83.63(1.60-8.45) P < 0.01
No home nebuliser28212.81.0
Have home nebuliser6730.81.96 (0.96-3.95) P = 0.04
No peak flow meter29612.81.0
Have peak flow meter5330.83.02 (1.45-6.27) P < 0.01
Not easy to see doctor6033.31.0
Easy access to doctor28911.80.27 (0.13-0.53) P < 0.01
Uncomfortable taking care of asthma 4836.2 1.0
Comfortable taking care30112.30.25 (0.12-0.52) P < 0.01
Perception of self-management good 3813.7 1.0
Perception poor31129.42.62 (1.09-6.25) P = 0.0 3
No days lost from work/school30213.61.0
Days lost from work/school4727.72.42 (1.11-5.25) P = 0.02

CS = Corticosteroids. * Variables tested but not found to be significant were: sex, age, migrant status, educational level, socioeconomic status, weight, regular use of corticosteroids, not always understanding asthma, not having enough information, feeling bad getting help, comfortableness in going to hospital if required, exercise, smoking status, smoking bans at home, and having an asthma action plan. Only those who regularly used preventive medicine for their asthma (n = 265) were asked about its effects.
Back to text

3: Logistic regression analyses of variables associated with ownership of an asthma management plan and frequency of wakening at night with asthma (n = 349)

VariableOdds ratio

Asthma plan
No peak flow meter1.0
Have peak flow meter4.32 (2.91-8.43)
Don't always understand asthma 1.0
Understand asthma2.01 (1.01-4.02)
Not enough information1.0
Enough information4.32 (2.11-8.85)
Don't use corticosteroid regularly1.0
Use corticosteroid regularly2.08 (1.21-3.58)
Waken weekly (non-smokers)
No peak flow meter1.0
Have a peak flow meter7.32 (2.59-20.07)
Not enough information1.0
Enough information0.12 (0.04-0.39)
Uncomfortable taking care of asthma1.0
Comfortable taking care0.30 (0.14-0.77)
No asthma action plan1.0
Asthma action plan2.79 (1.09-7.15)
Waken weekly (smokers)
Not easy to see doctor1.0
Easy to see doctor0.28 (0.10-0.79)

All results significant, P < 0.05.
Back to text

Received 19 September 2018, accepted 19 September 2018

  • Richard E Ruffin
  • David Wilson
  • Brian Smith
  • Robert J Adams


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