Effect of self regulatory education on women with asthma- 2003(2)
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Transcript of Effect of self regulatory education on women with asthma- 2003(2)
Effect of Self-Regulatory Education on Women with Asthma
July 12, 2003
Outlines
The research project
The intervention program
Baseline findings
Investigators
Noreen M. Clark, PhDPrincipal InvestigatorDean and Marshall H. Becker Professorof Health Behavior and HealthEducation, School of Public Health.
Timothy R. B. Johnson, MDCo-InvestigatorBates Professor, Diseases of Women &Children, Chair, Department of Obstetrics andGynecology, University of Michigan
William F. Bria, MDCo-Principal InvestigatorAssistant Professor, Pulmonary &Critical Care Medicine, University ofMichigan
Xihong Lin, PhDCo-InvestigatorProfessor, Biostatistics
Research Team
PI (Co-PI & Co-investigators) Oversees all aspects of the study
Project director-secretaryDaily operation
Data collection team5-6 graduate studentsRecruiting & interview
Intervention team2-3 health educators
Deliver program
Data analystManager/Analyst
Database / analysis
Background - Prevalence
Five million women are currently diagnosed with asthma (Crespo, 1997)
Asthma prevalence rate for women increased 82% compared to 29% for men (1982-1992, CDC)
Asthma mortality rate increased 59% for women compared to 34% for men (1982-1992, CDC)
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
Pre
vale
nce
Mo
rtal
ity
Women
Men
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)
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 of menstrual 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)
Factors Related to Women’s Traditional Tasks in Household
Cooking-related irritants and triggers include gas, wood smoke, cooking oils, food preservatives, monosodium glutamate, coloring agents.
Cleaning-related indoor allergens include house dust, domestic house-dust mites, fungi, molds, yeasts, sprays, cleaning products, and scented products.
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.
Specific Hypotheses
Decreased gender-related asthma management problems
Decreased symptoms
Reduced health care use
Reduced work absence
Improved quality of life
Study Design
A randomized controlled design utilizing an intervention group and a control group.
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
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
Data collection
Baseline Follow-up I: 12 months subsequent
to baseline (approximately 6 months subsequent to program completion)
Follow-up II: 12 months subsequent to there after.
Three time points:
Randomization After baseline data collection,
participants are randomly assigned to either the intervention or the control group. Women in the intervention group receive the “Women Breathe Free” telephone counseling program. Women in the control group will receive the program after it is evidenced to be effective and requested by the woman.
WOMENWOMENBREATHEBREATHE
FREEFREE
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
Asthma Education Kit
Workbook
Peak Flow Meter
PFM Video
Diary
Our Health Educators
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.
Self-regulatory problem solving steps
First step: select a problem
I have a problem with my diagnosis of asthma: Do I really have asthma?
I feel chest tightness and/or may wheeze whenever I cook, vacuum, or dust.
My asthma symptoms get worse when I have premenstrual syndrome.
Smoke may trigger my symptoms, and I live with someone who smokes. I’m afraid to tell them because I don’t want to hurt their feelings.
Second step:
Coach the participant to use diary and peak flow meter as observational tools to track related factors. The participant logs peak flow readings, hormonal cycles, symptoms, triggers, other medical conditions, medication use, tasks, activities & events every day for 4-6 weeks.
Women Breathe Free Program
Example – My Asthma Diary
My 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. 1/8/01 p.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
260300
230220
220240
250270
260250
220280
Nosymptoms
Somesymptoms
Severesymptoms
Menstrual bleeding Oral contraceptivesEstrogen R T (ERT)
SymptomsRunny nose,scratchy throat,heartburn.
Same as yesterdayplus headache. Noheartburn.
Cough, slight chesttightness, throatclearing, yellowmucus from nose,headache, cramps.
Nasal and chestcongestion,wheezing, woke upcoughing in night,breathless, cramps.
Tired, restless,heartburn, cough,wheeze, stuffynose, thick yellowgreen mucus.
Cough, urinaryleakage, chest tight,sinus drainage,headache.
Same as yesterdaybut no headache.
Medicine
Serevent 4puffs/dayFlovent 4puffs/daySingulair 10mg/dayClaritin 10mg/dayPrilosec 20mg/day
Same as Mon plus2 Advil 3 timestoday.
Same as yesterdaybut doubledFlovent. Used 2puffs albuterol 3times today.
Same as yesterday.Switched fromalbuterol puffer tonebulizer; 4treatments.
Same as yesterday.Called Dr., put onZithromax for sinusinfection. NoAdvil.
Same as yesterday.Day 2 of Z-Pak.
Same as yesterday.Day 3 of Z-Pak.
PossibleTriggers
Allergies? Cold?Drank 3 cups ofcoffee and ate spicyfood for dinner.
Time in dampmoldy basement,used Lysol &Tilex.Getting a cold?Period due...
Definite coldsymptoms.Premenstrual. Timein dusty storeroomat work. Feelingmoody & anxious.
Period started. Coldworse. Changedtoner in printer atwork. Cooked andbaked in hotkitchen.
Sinus infection.Stressed, tired. Hadto clean house-- in-laws coming.
Cold, laundry soap,taking the basementstairs a lot. Father-in-law smoking inhouse, mother-in-law’s perfume.
Cold/sinussymptoms, stress,fatigue.
Activities andEvents
Took kids to school& back, worked,cooked, ranerrands, exercised.
Same as yesterdayplus laundry, sweptbasement, cleanedbird cage, walkeddogs.
Kids, work, petcare, cooking,stayed up later thanusual.
Preparing forfamily dinner onSat. Usual tasks athome and work--noexercise
Stayed home fromwork-tried to restbut had to cleanand cook. Napped.
Stripped the beds,did the wash.Hosted dinner forin-laws.
Watched T.V.Rested on thecouch, napped.
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
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)
Developing my plan:
Barriers Strategies
Did not know where to purchase masks & vacuum cleaner bags
Ask my asthma coach or look at information in workbook under supplies
Forget to wear mask Hang mask on vacuum cleaner handle
Feel someone may not be able to do a good job
Instruct & trust other people can do a good job
Other self-regulatory steps
Exploring a reward
Developing a health-related contract
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 in identifying when to use medication. I am now more likely to use my inhaler than I might have been without the program.
Baseline Findings
Sample demographics (n=439)
Age
8%
17%
24%25%
17%
9%
18-30
31-40
41-50
51-60
61-70
>71
Sample demographics
Annual Household Income
4% 6%
16%
20%
14%
12%
17%
11%<10,000
10,001-20,000
20,001-40,000
40,001-60,000
60,001-80,000
80,000-100,000
>100,000
refusal
Sample demographics
2%
26%
21%30%
21%< High School
High School
2-year College
4-year College
Post Grad
Education Level
Sample demographics
Race/Ethnicity
85%
2%
8%
2%1%
2% Caucasian/White
AfricanAmerican/BlackAsian/Pacific Islander
Hispanic/Latino
Native American
Other
Asthma severity
Percent of Women
Mild intermittent
52.62
Mild persistent
14.35
Moderate persistent
18.45
Severe persistent
14.58
Classified by NAEPP criteria, Guidelines and Diagnosis and Treatment of Asthma, NHLBI, NIH, 1997
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%
Co-Morbidities Reported
Urinary incontinence: 54%
UrinaryIncontinence
No UrinaryIncontinence
Migraines: 34%Migraines
No Migraines
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 a doctor’s office.
0%5%
10%15%20%25%30%35%
ED V
isit
Hos
pita
lized
Uns
ched
uled
Visi
t
Women
Peak Flow Meter Usage
Almost 80% of the women owned a peak flow meter.
Less than 7% of the women used it every day.
30% used their peak flow meter only when they felt an asthma attack was coming on.
0%10%20%30%40%50%60%70%80%
Ow
ned
Use
d D
aily
Use
d be
fore
asth
ma
atta
ck
Women
Factors Associated with Persistent Disease
1. 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.
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<.0001)
30% women reported they were bothered by symptoms of asthma during sexual activity. The more severe the asthma symptoms, the more bothersome during sexual activity (r=0.361, p<.0001)
Hormonal factors and health care utilization
# ofHospitalizations
# of ED Visits # of UnscheduledDoctor Visits
Est. RRp-
valueEst. RR
p-value
Est. RRp-
value
Currently menstruates 0.374 1.45 0.217 0.096 1.10 0.634 0.156 1.17 0.228
Noticed that asthmasymptoms change duringthe menstrual cycle
1.893 6.64 0.000 0.764 2.14 0.001 0.41 1.51 0.012
Reported PMS 0.125 1.13 0.000 0.038 1.03 0.066 0.069 1.06 0.000
Menstruation and Asthma Health Care Utilization
Urinary incontinence was 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 and clinic visits.
lower self-esteem, social support, and overall quality of life.
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 nighttime symptoms (p=0.08), more hospitalization (p=.0001), ED visit (p=.0029), urgent office visits (p=.008), scheduled office visits (p=.03), and visits to follow-up an asthma attack (p=.009);
Urinary incontinence (p=.0001), migraine headache (p=.03), and reflux (p=.02);
Lower level of quality of life (p.0002) and self-esteem (p=.001)
Limitations
This study sample includes a number of women with high levels of education and income.
The findings reported here are from preliminary analysis.
Thank You!