Asthma self-management: do patient education programs always have an impact?

BACKGROUND: During the past 15 years, programs to improve self-management practices in adults with asthma have reported improvement in functional status and reduction of inappropriate use of health care services. However, these programs usually represent an ideal approach, applying multiple patient education methods. Consequently, when these programs are found to be efficacious, it is important to replicate the programs as well as to evaluate less complex methods that may be more appropriate for nonacademic health care settings. METHODS: We compared the following 3 standardized self-management treatments in a randomized, controlled trial: (1) a replication of the self-management program developed at a university medical center that was previously shown to be efficacious; (2) a modified version of this program including only the core elements; and (3) a usual-care program. Outcome measures included medication and inhaler regimen adherence, asthma symptoms, respiratory illness, functional status, and use of health care resources. RESULTS: All 3 groups improved on measures of respiratory illnesses, use of health care services, and functional status. Patients in both education groups did no better than the usual-care group. CONCLUSIONS: The results are inconsistent with the results of the first asthma self-management study at this institution and with those of efficacy studies of similar programs. Two factors, selection of the patient population and historical changes in asthma treatment, most likely contributed to the lack of impact of the self-management programs. As a result of the improved standards for usual care due to both factors, the opportunity to effect patient outcomes was substantially reduced.

Ideal residency curriculum in reproductive endocrinology and infertility.

OBJECTIVE: Knowledge in reproductive endocrinology and infertility is fundamental to the delivery of quality women's health care. In 1991, the American Fertility Society formed a resident education committee to gather data on the current status of reproductive endocrinology and infertility training and develop an ideal curriculum. METHODS: Program directors and reproductive endocrinology and infertility faculty from 288 residencies in obstetrics and gynecology were surveyed about training in reproductive endocrinology and infertility; 257 (89%) of the program directors (survey I) and 203 (82%) of the reproductive endocrinology and infertility faculty (survey II) responded. An ideal curriculum has been developed from consensus discussions, review of survey data, and polling of experienced educators. The curriculum was reviewed and approved by the board of directors of both the Society for Reproductive Endocrinologists and the American Fertility Society. RESULTS: The curriculum is divided into subject matter and therapeutics, which are prioritized into three levels of knowledge: critical core curriculum, less critical material, and material with which residents should have familiarity and general knowledge. In addition, other recommendations and suggestions are made regarding the number of rotations, duration of rotations, and teaching methods. CONCLUSION: The ideal curriculum may serve as a guide to assist program directors in the formulation of the most effective residency training in reproductive endocrinology and infertility. The curriculum can help prioritize what should be taught and where an emphasis can be placed. There is not enough time or resources to teach residents all aspects of reproductive endocrinology and infertility.

Predictors of smoking cessation during pregnancy.

AIMS: The purpose of this study was to determine predictors of smoking cessation from a sample of pregnant Medicaid recipients. Of special interest was whether patient stage of change, based on the transtheoretical model, was predictive of smoking behavior change during pregnancy. PARTICIPANTS/SETTING: The sample was drawn from a cohort of pregnant smokers who were participants in a prospective, randomized clinical trial conducted in four public health maternity clinics in Birmingham, Alabama, USA. DESIGN/MEASUREMENTS: The 435 participants entered prenatal care on or before their 24th week of gestation and had saliva collected for cotinine assays at baseline and follow-up. In this secondary analysis, descriptive statistics defined the sample, cross-tabulation procedures identified a preliminary set of predictor variables, and discriminant function analyses predicted group membership--quitter or smoker. FINDINGS/CONCLUSIONS: Discriminant function analyses revealed that patient baseline cotinine value, duration of smoking habit, self-efficacy, exposure to environmental tobacco smoke, and exposure to patient education methods were predictive of non-smoking status assessed during the third trimester of pregnancy.

How to implement an asthma education program.

Given that poor asthma management leads to such devastating rates of morbidity and mortality in this country, efforts must be made to increase the knowledge, skills, and behaviors of persons with asthma. The suggestions and recommendations provided here represent a blend of academic opinion and practical advice on methods to implement an asthma education program. In developing an asthma education program, consideration must be given to what content should be included, how and by whom that content should be taught, and when education should take place. The identification of a key clinical staff member to take the lead in translating these and other asthma education guidelines will be a critical next step for clinicians committed to developing an effective asthma education program.

Contraceptive female sterilization in Alabama: a replication of the WHO study.

The prevalence of female sterilization for contraceptive purposes has grown rapidly throughout the world, and is especially high in the United States. Yet the psychosocial impact of female sterilization is incompletely understood. Much of the previous research has been retrospective and has lacked comparison groups of women using other methods. Better designed, prospective studies have been needed, and the World Health Organization's Collaborative Prospective Study of Female Sterilization was conducted to address this need. No evidence was found in the WHO study of a significant impact of tubal ligation compared to other contraceptive methods on mental health, menstruation, or sexual satisfaction. The present study, a replication of the WHO study, compared 323 Alabama women undergoing elective contraceptive sterilization with 318 women using other techniques to control fertility. In general, the results supported the WHO study conclusions. Although sterilization produced a small increase in menstrual distress in Alabama, there were no significant differences between sterilization and comparison women in mental health or sexual satisfaction.

The University of Alabama Teenage Access Project: a model for prevention, referrals, and linkages to testing for high-risk young women.

The Teenage Access Project (TAP) was supported by the Special Projects of National Significance Program to expand and ensure access to health and support services for disadvantaged, human immunodeficiency virus (HIV)-positive, and at-risk adolescent and young adult women aged 10-21 years by: (a) preventing further HIV transmission through empowerment and reduction of risk behavior, (b) providing HIV counseling and testing to increase screening of young women, and (c) facilitating referrals to medical and psychosocial services through the TAP activities. TAP served 403 young people (82% African-American and 83% young women). The basic elements of the TAP service model components were: (a) outreach to community agencies serving high-risk, disadvantaged young women; (b) My Individual Responsibility Reduces Our Risk (MIRROR), a six-module risk-reduction and empowerment activity specifically designed for young women in Jefferson County, using a small group format; and (c) the Adolescent Testing Center (ATC), a center for age and culturally appropriate HIV testing, pre- and posttest counseling, risk assessment, and referrals. HIV testing and pre- and posttest counseling were provided confidentially in both clinical and community settings. More than 200 participated in the MIRROR activity. A total of 101 young women received HIV counseling and testing services.

AIDS knowledge among black drug users: an issue of reliability.

This study examined the reliability of an inventory measuring AIDS-related knowledge among 553 black drug users. Data were collected from a socially high-risk community in Birmingham, Alabama. The KR-20 reliability scores were computed from the inventory for each drug-use group. The KR-20 reliabilities ranged from .39 to .57. These findings may suggest that the inconsistent reports of the predictive power of AIDS knowledge among drug users reported in previous studies might be related to the low internal consistencies of the inventory.

Asthma education, monitoring and environmental control.

Asthma treatment in the last 10 years has benefited greatly from the first and second reports of the National Asthma Education and Prevention Program expert panel. Newer approaches to medical therapy have been accompanied by more aggressive attempts to involve patients in the management of their disease. In fact, it is widely recognized that the patient has a very important role in asthma management. As indicated by the section title, symptom and peak flow monitoring, along with environmental control, are essential topics for patient education. This review covers the three related areas of education, monitoring and environmental control, as well as the associated salient issues addressed in recent asthma prevention and control literature. The first section covers essential elements of asthma education. A review of current research and recommendations includes a brief synopsis of the expert panel recommendations for patient and family education and summarizes recent controlled trials of asthma self management interventions for both children and adults. The results of these trials raise the question of incremental gains in patient outcomes seen with increasing intensity of asthma self management interventions. Suggestions for future directions for self management research are included in this and the following two sections. The second section focuses primarily on research related to the role of self monitoring in asthma care and the relative advantages of using a peak flow meter and/or symptoms to assess the need for a step up in treatment. The final section addresses environmental control as it relates to self management and looks at the burgeoning literature on the role of household environmental monitoring and control for the prevention of sensitization and subsequent morbidity from exposure to allergens and irritants. The importance of the patient and family in environmental control is emphasized.

Self-management and other behavioral aspects of asthma.

We review recently published literature on behavioral aspects of asthma, including program descriptions, reviews, and original research reports. Most of the literature on behavioral aspects of asthma has been in the area of self-management, including education, medication use, and peak flow monitoring. Recent studies of these factors have shown promising trends in reducing morbidity and in improving health care utilization outcomes. Medication adherence continues to be problematic, and its complexity is increased when comparing inhaled with oral medications and bronchodilators with anti-inflammatory agents. Psychobiologic factors that have been recently studied include perceptions of airway changes and the role of emotional responses in asthma self-management. Because the behavioral aspects of asthma play such a significant role in asthma treatment, further study is needed to determine how changes in patient behavior can improve patient quality of life.

Prepare graduate students for teaching responsibilities.

During graduate training, students often undertake some teaching responsibilities, which provides useful experience for a future career in academia. However, they receive little guidance to prepare them for this role. This article describes some of the attempts that have been made to overcome this deficiency, with emphasis on the specially developed teaching course offered to graduate students at the University of Kentucky; this provides instruction on planning, implementing and evaluating instruction, and classroom training in instructional skills. Evaluation suggests that the programme is relevant and effective, and provides a useful model for other medical schools.

Depressive symptoms as correlates of polydrug use for blacks in a high-risk community.

BACKGROUND: This study examined the relationship between depressive symptoms and polydrug use (alcohol, marijuana, and cocaine) among blacks in a high-risk community. METHODS: A street sample (N = 570) from four high-risk communities in Birmingham, Alabama, was collected through personal interviews. Interviewers asked respondents about their drug use behavior during the past 30 days, as well as about their depressive symptoms during the past week. RESULTS: Odds ratios and logistic regressions, adjusted for age and sex, were used to assess the relationship between depressive symptoms and drug and polydrug use (drug use involving cocaine). Results showed that depressive symptoms are significantly associated with polydrug use. However, depressive symptoms were not associated with alcohol use or with the combination of alcohol and marijuana use. CONCLUSIONS: Depressive symptoms are related to polydrug use involving cocaine, though the causal relationship is uncertain. Previous reports on depressive symptoms and alcohol or marijuana may be inconclusive.

Drug use and HIV risk--related sex behaviors: a street outreach study of black adults.

BACKGROUND: Our street outreach project investigated the relationship between use of noninjecting drugs (alcohol, marijuana, cocaine) and human immunodeficiency virus (HIV) risk-related sex behaviors of black adults. The study focused on three HIV-related risks: multiple sex partners, unprotected sex, and drugs during sex. METHODS: Data for this study were collected in a street outreach community survey for a drug abuse and HIV intervention study in Birmingham, Ala. A total of 780 black men and women completed the survey. RESULTS: High-risk sex behaviors were far more prevalent among cocaine users than marijuana or alcohol users. A greater number of cocaine users reported having multiple sex partners, not using condoms, and using drugs during sex. Female cocaine users showed the same risk level for HIV infection as male cocaine users. CONCLUSIONS: Increased risk of HIV infection through sexual transmission is associated with use of noninjecting cocaine for both men and women. Condom use should be considered as a major component of HIV prevention programs.

Scale for assessing functional impairment in adults with asthma.

Improved outcome measures for asthma research, especially measures of functional status and quality of life, have become increasingly important. This research describes one such measure, the University of Alabama at Birmingham (UAB) Functional Impairment Scale. This scale consists of eight items to assess the impact of asthma on various aspects of daily living. The psychometric properties of the UAB Scale were assessed in two samples. The coefficient alpha reliabilities were high in both samples (.83 and .84), and the item-total correlations indicated all items were measuring the same trait. The score distributions covered the entire range of possible scores, and the central tendencies and dispersions confirmed the presence of enough variation to detect differences in functional impairment among individuals. Correlations between the UAB Scale and other asthma-related measures support construct validity. All of these results support the potential usefulness of the UAB Scale.

Assessing adherence to asthma medication and inhaler regimens: a psychometric analysis of adult self-report scales.

Poor adherence to recommended regimens is a substantial problem in the clinical management of adults with asthma and other chronic diseases. Research on adherence assessment is complicated by methodological difficulties including limitations associated with the use of self-report measures. In this study, psychometric techniques were used to analyze two self-report scales for assessing adherence to recommended medication and inhaler use regimens in adults with asthma. Results indicated that the two scales had standard deviations large enough to detect variation adherence, had adequate reliability, and reflected the impact of an intervention designed to improve adherence. The results supported the usefulness of these scales for research on adherence. Additional analyses indicated that the two scales could be combined if the research goal required an overall measure of adherence.

Use of focus group methodology to develop an asthma self-management program useful for community-based medical practices.

Health education programs developed in academic medical centers are not optimally disseminated to community clinical settings. Strategies are needed to translate the findings of research on health education programs into programs useful in a wide range of health care settings. Focus group techniques were used to provide data for revising a successful university-based asthma self-management program to make it more practical for use by community physicians. Physicians representing a variety of specialties attended the sessions and provided feedback on the utility of various components of the original program. The discussions revealed that many physicians felt they did not have the time or resources to conduct the original program and identified elements viewed as impractical. This physician input contributed significantly to the development of a revised program with a briefer, less costly intervention. The revised program was later evaluated by focus group participants. Eighty-eight percent of those who evaluated the revised program agreed they would be able and willing to use the program in their own practices. As a formative evaluation tool, the focus group technique made available useful information that would have been difficult to obtain through evaluation forms alone.