effect of self-regulatory education on women with asthma-

8/9/2019 Effect of Self-Regulatory Education on Women With Asthma-

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Effect of Self-Regulatory

Education on Women

with Asthma

July 12, 2003


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Outlines

The research project

The intervention program

Baseline findings


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Investigators

Noreen M. Clark, PhDPrincipal Investigator

Dean and Marshall H. Becker Professorof Health Behavior and HealthEducation, School of Public Health.

Timothy R. B. Johnson, MDCo-Investigator

Bates Professor, Diseases of Women &Children, Chair, Department of Obstetrics andGynecology, University of Michigan

William F. Bria, MD

Co-Principal InvestigatorAssistant Professor, Pulmonary &Critical Care Medicine, University ofMichigan

Xihong Lin, PhD

Co-InvestigatorProfessor, Biostatistics


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Research Team

PI (Co-PI & Co-investigators)

Oversees all aspects of the study

Project director-secretary

Daily operation

Data collection team

5-6 graduate students

Recruiting & interview

Intervention team

2-3 health educators

Deliver program

Data analyst

Manager/Analyst

Database / analysis


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Background - Prevalence

Five million women arecurrently diagnosed withasthma (Crespo, 1997)

Asthma prevalence ratefor women increased 82%compared to 29% for men(1982-1992, CDC)

Asthma mortality rate

increased 59% for womencompared to 34% for men(1982-1992, CDC)

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

Prevalence

Mo

rtality

Women

Men


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Background

Morbidity & Hospitalization

Hospital admission for asthma:

Women 2 times more than men.(Skobeloff, 1996)

More symptoms and worse quality of

life reported by female asthma

patients compared to male patients.

(Osborn, 1998)


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Menstrual-Linked Asthma

30-40% of women with asthma report symptoms

worsening prior to or during menses. Significantly

reduced Peak Flow Rates, more medication and

health care use were found during this period ofmenstrual cycle. (Agarwal, 1997; Eliasson, 1986)

Disease is more severe in women with menstrual-

linked asthma.

Use of oral contraceptive medication may reduce

symptom variability in women with menstrual-linked

asthma.(Tan, 1997)


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Factors Related to Womens

Traditional Tasks in Household

Cooking-related irritantsand triggers include gas,wood smoke, cookingoils, food preservatives,

monosodium glutamate,coloring agents.

Cleaning-related indoorallergens include housedust, domestic house-

dust mites, fungi, molds,yeasts, sprays, cleaningproducts, and scentedproducts.


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The research project

Purpose

To evaluate an innovative

education program based on

self-regulation theory

designed to address the

unique needs of adult female

patients with asthma.


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Specific Hypotheses

Decreased gender-related asthma

management problems

Decreased symptoms

Reduced health care use

Reduced work absence

Improved quality of life


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Study Design

A randomized controlled

design utilizing an

intervention group and a

control group.


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Recruitment criteria 18 years of age or

older

A diagnosis of

asthma

A patient in one of

the clinics at

University of

Michigan Health

System


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IRBMED Approved

Recruitment Procedures

A list of female patients diagnosed with

asthma is provide by the UM Health

System Data Warehouse

An individual Invitation letter signed by

investigators and personal physician is

mailed to the potential participant

A phone call follows Consent forms are sent for signatures


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Data collection

Baseline

Follow-up I: 12 months subsequentto baseline (approximately 6

months subsequent to program

completion)

Follow-up II: 12 months subsequent

to there after.

Three time points:


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Randomization

After baseline data collection,

participants are randomly assigned to

either the intervention or the control

group. Women in the interventiongroup receive the Women Breathe

Free telephone counseling program.

Women in the control group will

receive the program after it isevidenced to be effective and

requested by the woman.


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WOMENWOMEN

BREATHEBREATHE

FREEFREE


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Components of the

intervention

Theoretical Framework-Social cognitive

theory (Bandura, 1986), and the principles of

self-regulation (Clark & Zimmerman, 1990,

Clark, 1992) applied

Gender-related management problems

addressed Peak flow meter and diary used

Telephone counseling sessions delivered


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Asthma Education Kit

Workbook

Peak Flow Meter

PFM Video

Diary


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Our Health Educators


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What the Health Educators Do

Introduce a problem solving process.

Guide through a period of self-

observation using PFM & Diary.Encourage to discuss questions and

observations with physicians to

enhance the patient-physician

partnership in asthma management.


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Self-regulatory problem solving steps

First step: select a problem

I have a problem with my diagnosis ofasthma: Do I really have asthma?

I feel chest tightness and/or may wheezewhenever I cook, vacuum, or dust.

My asthma symptoms get worse when Ihave premenstrual syndrome.

Smoke may trigger my symptoms, and I live

with someone who smokes. Im afraid to tellthem because I dont want to hurt theirfeelings.


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Second step:

Coach the participant to use diary and

peak flow meter as observational tools

to track related factors. Theparticipant logs peak flow readings,

hormonal cycles, symptoms, triggers,

other medical conditions, medication

use, tasks, activities & events everyday for 4-6 weeks.


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Women Breathe Free

ProgramExample My Asthma DiaryMy Name: Jane Doe My Birthday: //

My personal best peak flow reading (PBR) is: Green Zone: no symptoms or above 80% PBR Yellow Zone: some symptoms or 50-80% PBR Red Zone: severe symptoms or below 50% PBR

Day & Date Mon

a.m. 1/8/01p.m.

Tue

a.m. 1/9/01 p.m.

Wed

a.m.1/10/01 p.m.

Thur

a.m. 1/11/01 p.m.

Fri

a.m. 1/12/01 p.m.

Sat

a.m. 1/13/01 p.m.

Sun

a.m. 1/14/01 p.m.

Peak flow rates 300310

260

300

230

220

220

240

250

270

260

250

220

280

Nosymptoms

Somesymptoms

Severesymptoms

Menstrual bleeding Oral contraceptives

Estrogen R T (ERT)

Symptoms

Runny nose,

scratchy throat,

heartburn.

Same as yesterday

plus headache. No

heartburn.

Cough, slight chest

tightness, throat

clearing, yellow

mucus from nose,

headache, cramps.

Nasal and chest

congestion,

wheezing, woke up

coughing in night,

breathless, cramps.

Tired, restless,

heartburn, cough,

wheeze, stuffy

nose, thick yellow

green mucus.

Cough, urinary

leakage, chest tight,

sinus drainage,

headache.

Same as yesterday

but no headache.

Medicine

Serevent 4puffs/day

Flovent 4puffs/day

Singulair 10mg/dayClaritin 10mg/day

Prilosec 20mg/day

Same as Mon plus

2 Advil 3 times

today.

Same as yesterday

but doubled

Flovent. Used 2puffs albuterol 3

times today.

Same as yesterday.

Switched from

albuterol puffer tonebulizer; 4

treatments.

Same as yesterday.

Called Dr., put on

Zithromax for sinusinfection. No

Advil.

Same as yesterday.

Day 2 of Z-Pak.

Same as yesterday.

Day 3 of Z-Pak.

Possible

Triggers

Allergies? Cold?

Drank 3 cups of

coffee and ate spicy

food for dinner.

Time in damp

moldy basement,

used Lysol &Tilex.

Getting a cold?

Period due...

Definite cold

symptoms.

Premenstrual. Time

in dusty storeroom

at work. Feeling

moody & anxious.

Period started. Cold

worse. Changed

toner in printer at

work. Cooked and

baked in hot

kitchen.

Sinus infection.

Stressed, tired. Had

to clean house-- in-

laws coming.

Cold, laundry soap,

taking the basement

stairs a lot. Father-

in-law smoking in

house, mother-in-

laws perfume.

Cold/sinus

symptoms, stress,

fatigue.

Activities and

Events

Took kids to school

& back, worked,

cooked, ran

errands, exercised.

Same as yesterday

plus laundry, swept

basement, cleaned

bird cage, walked

dogs.

Kids, work, pet

care, cooking,

stayed up later than

usual.

Preparing for

family dinner on

Sat. Usual tasks at

home and work--no

exercise

Stayed home from

work-tried to rest

but had to clean

and cook. Napped.

Stripped the beds,

did the wash.

Hosted dinner for

in-laws.

Watched T.V.

Rested on the

couch, napped.


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Third step:

Identifying self-management asthma

goal (short and long term goals)

Long-term goal: to clean the

house without wheezing.Short term goal: to vacuum the

house without symptoms

Examples of Goals


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Fourth step: Developing my plan

Steps to reaching my short-term goal are:

1. Buy masks & dust proof vacuum bags.

2. Wear mask every time I vacuum.

3. Have someone vacuum for me.

Developing a plan for reaching the

goal (lists of barriers and strategies to

reach the goal)


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Developing my plan:

Barriers Strategies

Did not know where to

purchase masks & vacuumcleaner bags

Ask my asthma coach or

look at information inworkbook under supplies

Forget to wear mask Hang mask on vacuumcleaner handle

Feel someone may not beable to do a good job

Instruct & trust otherpeople can do a good job


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Other self-regulatory steps

Exploring a reward

Developing a health-related

contract


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Preliminary Evaluation

Among a total of 166 program participants,80% (n=131) completed required 4 diaries,83% (n=109) completed 8 or more diaries,

87% (n=113) completion with 4 categories,94% completion of peak flow entry.

I was a reluctant participant with mild

asthma but found the program helpful inidentifying when to use medication. I amnow more likely to use my inhaler than Imight have been without the program.


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Baseline Findings


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Sample demographics

(n=439)Age8%

17%

24%

25%

17%

9%

18-30

31-40

41-50

51-60

61-70

>71


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Sample demographics

Annual Household Income

4%6%

16%

20%

14%

12%

17%

11%

100,000

refusal


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Sample demographics

2%

26%

21%

30%

21%

< High School

High School

2-year College

4-year College

Post Grad

Education Level


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Sample demographics

Race/Ethnicity

85%

2%

8%

2%

1%

2% Caucasian/White

AfricanAmerican/BlackAsian/Pacific Islander

Hispanic/Latino

Native American

Other


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Asthma severity

Percent ofWomen

Mildintermittent 52.62

Mildpersistent

14.35

Moderatepersistent

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Severepersistent

14.58

Classified by NAEPP

criteria, Guidelines and

Diagnosis and Treatment

of Asthma, NHLBI, NIH,

1997


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Co-Morbidities Reported

Reflux: 72%

Reflux

No Reflux

Overweight

Obese

Over Obese

Normal Weight

Over weight (BMI=26-30): 28%,

Obese (BMI 31-35): 30%

Over obese (BMI > 35): 9%


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Co-Morbidities Reported

Urinary

incontinence: 54%

Urinary

Incontinence

No Urinary

Incontinence

Migraines: 34% MigrainesNo Migraines


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Health care utilization during

the past 12 months One fourth of the

women had at least

one ED visit.

8% were

hospitalized

35% had one or

more unscheduled

urgent visit to adoctors office.

0 %

5 %

1 0 %1 5 %

2 0 %

2 5 %

3 0 %

3 5 %

EDVisit

Hospitalized

Unscheduled

Visit

W o m e


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Factors Associated with

Persistent Disease1. Low annual household income, a lower level of

education, and not working for pay were associated

with persistent asthma, whereas, age, marital status,

and ethnicity were not.

2. Women with persistent asthma were more likely to

have high BMI, maintain a low level of exercise, have

lower self-esteem, had more social support compared

to women with intermittent disease.


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Hormone Related Findings

54% women currently menstruate. Among those:

15% noticed symptoms worsening during the week

prior to the period. Over half of the women reported PMS symptoms.

The more severe the asthma symptoms, the more

severe the PMS symptoms (r=0.364, p


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Urinary incontinencewas

significantly associated with older age, not working for pay, ever been

pregnant, history of smoking, and a

higher body mass index.more days of daytime and nighttime

symptoms and more hospitalizations andclinic visits.

lower self-esteem, social support, andoverall quality of life.


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Overweight was significantly

associated with: Older age (p=.05), lower level of education

(p=.0001), and household income (p=.002),being unmarried (p=.02), and African American(p=.04);

More days of daytime (0=.06) and nighttimesymptoms (p=0.08), more hospitalization(p=.0001), ED visit (p=.0029), urgent office visits(p=.008), scheduled office visits (p=.03), andvisits to follow-up an asthma attack (p=.009);

Urinary incontinence (p=.0001), migraineheadache (p=.03), and reflux (p=.02);

Lower level of quality of life (p.0002) and self-esteem (p=.001)


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Limitations

This study sample includes a

number of women with high levels

of education and income.

The findings reported here are from

preliminary analysis.


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Thank You!

effect of self-regulatory education on women with asthma-

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