Health Education & Behavior

It was hypothesized that a health education program for children with asthma aged 8-11 years that was delivered in elementary schools, would increase children's asthma management skills, self-efficacy and influence on parents' management decisions; re duce school absences and improve school performance. The study population con sisted of 239 low-income, predominantly Hispanic and black children from 12 elemen tary schools (six experimental and six control) in New York City. Parents did not attend educational sessions but received written materials. The program emphasized

A randomized clinical trial is in progress to evaluate an asthma educational program for Latino children and their parents. The intervention, "ACT—Asma Control y Trata miento Para Ninos," was adapted from ACT for Kids, an asthma self-management pro gram for English-speaking families. Results of a pilot study indicated that socioeco nomic status was a critical variable to be considered in the design of such programs. Latino children and parents encounter significant barriers to access and continuity of medical care. Therefore, the intervention was redesigned to include "linkages" using a nurse to reduce barriers and to coordinate care. The lesson plans emphasize concrete, experimental learning experiences, with repetition of key points in each session.

The concept of self-management for childhood asthma was introduced to Italy through a scientific exchange agreement with the United States. Two self-management programs, Living with Asthma (LWA) and Open Airways (OA), are being evaluated in three studies, two of which (Pilot and Atri-Viterbo) were conducted by the Respira tory Service of the Pediatric Department of the University "La Sapienza" in Rome and one by 14 Italian university pediatric respiratory centers (Project Italia).

In October 1985, 20 children and their 40 parents were enrolled in the Pilot Study. One hundred percent of the mothers and children and 70% of the fathers attended all of the sessions. Theoretical knowledge about asthma and knowledge of asthma self- management behavior were assessed three times by a questionnaire: at the beginning of the program, at the end of the program and one year later. Significant improvements in knowledge of asthma and in knowledge of asthma self-management behavior were demonstrated by both parents and children at the end of the program and one year later. Analysis of clinical symptoms and drug consumption indicated a statistically nonsignificant trend towards a reduction of asthma severity in the year after the program.

In the Atri-Viterbo study 8229 children were initially screened by a questionnaire. One hundred eighty-two children with asthma (2.4%) were identified and invited to participate in a self-management program. Open Airways was used in a shortened version. Only 29 families in Atri (22% of the eligible families) and 24 families in Viterbo (50%) ultimately agreed to participate in the program. A comparison of these families with those who did not participate showed that higher social status (p < 0.001) and more severe asthma (p < 0.05) were significantly associated with partici pation. Attendance by mothers and children was 78% in Atri and 61% in Viterbo. Only 5% of the fathers regularly attended the program. Parents who received the pro gram registered a statistically significant increase in knowledge of asthma and knowl edge of asthma self-management behavior relative to controls (+13% versus -4%; p < 0.05).

Fourteen university-based pediatric respiratory centers participated in Project Italia, in which the LWA and OA programs were compared in both full length and shortened versions (8 versus 4 h). Four hundred children and their families were en rolled in the study. Subsequently, 54% of the fathers, 75% of the mothers and 94% of the children attended 75% or more of the sessions. Experiences of many centers, how ever, suggest that one of the main problems is enrollment: Thus a remaining challenge is to find more effective methods of identifying, recruiting and educating those fami lies who most need education for childhood asthma. In general, results show that large epidemiological studies are necessary to better understand (1) how effective educa tional programs for asthma can be, and (2) how to increase their acceptability for those families who need them most.

The purpose of the study was to evaluate the efficacy of a structured education program on knowledge and psychomotor skills of subjects using inhaled beclometh asone dipropionate. The sample was comprised of 26 male outpatients with a mean age of sixty years (range 49 - 69 yrs) and mean educational level of 11 years (range 7 - 18 yrs). Subjects were tested to assess knowledge of drug action, self-administration, and side effects. Skill in self-administration was assessed by two independent raters who were blind to group assignment. Then, patients were randomly assigned to an experimental group (n=13), who received a structured educational program, or a con trol group (n=13), who received no structured educational interventions. Patients were retested four weeks after randomization.

Subjects in the experimental and control groups did not differ significantly with re spect to their initial mean knowledge and performance scores. The post-test mean knowledge score was significantly higher when compared to initial score for each group. Mean knowledge score at post-test did not differ significantly between groups. However, when comparing post-test performance scores to initial scores the experi mental group had a significantly greater increase in mean score than the control group. It is concluded that a structured patient education program is an effective method for improving the psychomotor skills necessary for proper use of beclomethasone dipro pionate aerosol.

This article reviews replications and extensions of Living with Asthma, a self-man agement system developed and tested at the National Asthma Center in Denver be tween 1977 and 1980. Research on the system since the latter date has been con ducted within the conceptual framework provided by the social or cognitive learning model. This approach has switched experimenter effort away from developing and evaluating the acquisition of self-management skills toward assessing their performance by patients. Efforts to insure these skills are used effectively by patients to control their asthma, focusing particularly on the assessment of performance variables, are described.

The purpose of the AIR/Kaiser-Permanente asthma project is to evaluate various approaches to the education of adults with asthma, identifying those types of patients for whom particular approaches are most cost effective. Critical self-management prac tices for adults with asthma were identified using the critical incident technique. An individualized and a group administered educational program are being developed to teach the identified critical skills, using the instructional models previously employed in AIR WISE and AIR POWER programs for children with asthma.

Three hundred patients with moderate to severe asthma from Northern California Kaiser-Permanente Medical Group clinics will participate in a trial of these programs. Patients will be randomly assigned to one of four conditions: One of two educational programs, an information/attention control, or a data-only control condition. Data will be collected on all patients for 15 months; health care utilization data covering a two-year period will be available from medical records. Program effectiveness will be evaluated in terms of pre-post changes in the patients' knowledge, attitudes, self-man agement practices, medical condition, daily functioning, and utilization of services. Cost effectiveness will be evaluated, paying specific attention to the cost effectiveness of different educational approaches for different types of patients.

Most asthma self-management programs have focused on children, but the preva lence and impact, both personal and economic, of adult asthma is substantial. More over, failure to adhere to treatment regimens appears to be a significant problem in adult asthma. It appears important, therefore, to develop asthma self-management programs for adults. The UAB program is based on the Health Belief Model for health behavior and on the PRECEDE Model for patient education. A needs assessment and a review of existing educational materials were used to specify the content of a self- care workbook. This workbook seeks to increase cognitive skills, encourage daily self- assessment of asthma, demonstrate success in asthma self-management, and promote effective social support. The overall intervention integrates this workbook with sys tematic reinforcement of self-monitoring and self-management. A prospective con trolled study is comparing patients receiving this "special intervention" with "usual care" patients who receive only routinely available pamphlets providing information about asthma. Patients are randomly assigned to treatments by the closed envelope technique. Sample sizes were determined on the basis of statistical power. Outcomes in five areas are assessed: (1) health care utilization, (2) functional status, (3) knowl edge, (4) adherence, and (5) psychological reactions.

The public health benefits of research can be realized only if proven new techniques are translated into readily usable processes and materials and widely adopted by professionals and patients alike. To accomplish this, a systematic technology transfer process is needed.

One recent outcome of health behavior research has been identification of the skills needed by children and parents to effectively manage childhood asthma. Methods for teaching these skills were tested on hundreds of families in a variety of health care settings. They were then packaged in program manuals that guide health professionals through the teaching process and provide all necessary materials for conducting sessions. The resulting four programs teach attack prevention and control skills. They also emphasize coping skills and help families come to terms with the behavioral factors that impinge on asthma management and affect compliance with medical advice.

A technology transfer project for getting initial community adoption of these programs is described. The evolution of the project, including the development of the programs themselves, packaging considerations, establishment of a unique partnership for dissemination, development of a model workshop for stimulating health professionals, implementation of programs, and follow up and evaluation, is described. Successful elements are identified at each step.