|Year : 2015 | Volume
| Issue : 1 | Page : 16-22
Asthma control and self-management: The role of asthma education
Ghazi Abdulrahman Alotaibi
Department of Respiratory Care, College of Applied Medical Sciences, University of Dammam, Dammam, Saudi Arabia
|Date of Web Publication||13-Feb-2015|
Ghazi Abdulrahman Alotaibi
Department of Respiratory Care, College of Applied Medical Sciences, University of Dammam, P.O. Box 40269, Dammam - 31952
Source of Support: None, Conflict of Interest: None
Asthma is a common chronic airway disease that afflicts both adults and children. Worldwide, about 300 million people suffer from asthma. There has been a great interest in developing treatment guidelines for asthma in many countries. The focus in all asthma treatment guidelines is to control asthma symptoms by involving patients in their treatment planning and execution. Therefore, asthma education has become the main component of the treatment plan. Studies have shown that simple educational sessions for asthmatics could have positive impacts on patients' adherence to treatment and control of symptoms. We searched most common medical and health databases for related research studies that were published since 2001. The retrieved articles were carefully scrutinized for inclusion in this review. This review focuses on level of asthma control as reported in the literature and provides an overview of effectiveness of asthma education programmes on controlling asthma symptoms. With all available knowledge and technology, it seems that the goal of controlling asthma is yet to be achieved. Asthma education should be integrated in treatment plan and conducted at all points of patients' care.
Keywords: Asthma, asthma control, asthma education, self-management, written action plan
|How to cite this article:|
Alotaibi GA. Asthma control and self-management: The role of asthma education. Saudi J Health Sci 2015;4:16-22
| Introduction|| |
Asthma is a chronic disease of the small airways. The hallmarks of asthma are chronic inflammation, reversible obstruction and airflow limitation.  Asthma has become a disease of interest worldwide because of its impact on individuals and societies. Globally, it affects 5-10% of population.  About 8.3% of US population have asthma.  In Saudi Arabia, asthma prevalence has been reported in the proximity of 20% with regional variations.  About 8-14% of Saudi children have asthma, and physician-diagnosed asthma in adolescent age (16 − 18 years) is 19.6%.  In Australia, where asthma was made a national health priority, the 2010 statistics showed that its prevalence in children under 14 years of age reached 18.4%.  The increased incidence of asthma worldwide has been attributed to the modernization of societies. Changes in lifestyle, food habits, environmental exposure and cigarette smoking are contributing factors to increased number of asthmatic patients. In the US, the number of asthmatic patients has increased from 20 million in 2001 to 26 million in 2011. 
Asthma represents a worldwide socioeconomic burden on every health care delivery system. In the US, the cost of asthma is estimated to be around $56 billion each year.  Cost of care for asthmatic children in the US is approximately 90% higher than caring for children without asthma.  In a systematic review of the economic burden of asthma, hospitalization costs up to 86% of all asthma-related cost, and poor asthma control was associated with increased cost of care.  Although difficult to measure, the indirect cost of asthma is immense. Missed work days, absence from school, low productivity, emotional and social impacts are examples of indirect costs of asthma. Data form the US-based National Asthma Control Programme (NACP)  indicated that about 50% of children miss at least 1 day of school each year because of asthma. In adult with asthma, one-third will miss at least 1 day of work each year.
Treatment of asthma focuses primarily on pharmacotherapy. Long-acting beta agonists and inhaled corticosteroids are the main medication categories used for asthmatics. Asthma self-control and written action plan have become increasingly important in asthma management, as the philosophy of treatment shifted towards patients' engagement in treating his/her own disease. There are various methods of engaging patients in the treatment plan. Asthma education has been implemented at different points of care with variable outcomes.
| Methods|| |
In this writing, we review the status of asthma control as reported in the literature and give an overview of effectiveness of asthma educational programmes at different clinical settings. A literature search was performed to identify related research studies published between 2001 and 2014. The following medical and health databases were searched: EBSCO, ProQuest, SAGE, ScienceDirect, Scopus, GALE and PubMed. Summon search engine was also used to retrieve research works published in the subscribed databases. The following terms were used during searching process: Asthma control, asthma symptoms, asthma education, asthma self-management, asthma action plan and asthma guidelines. Combination of terms feature was also used to narrow search results. A total of 80 articles were initially retrieved and reviewed for inclusion. After careful revision, 46 articles were included in this review, in addition to asthma guidelines issued by several health organizations.
Asthma as an international health concern
Asthma has become a major public concern because of its impact on patients' health, economy and society. As a response to the global and local challenges of asthma, many countries have initiated programmes to promote research studies related to asthma diagnosis and treatment. The national asthma education and prevention programme (NAEPP) was initiated by the US National Institute of Health (NIH) to raise awareness of patients and health-care workers about asthma.  NAEPP collaborates with medical organizations and government departments to reach out to public and health professionals. The NAEPP produced an evidence-based guideline on the diagnosis and management of asthma. In their 2007 expert panel report (EPR-3), they proposed four components of asthma care, (1) Assessment and monitoring, (2) education, (3) control of environmental factors and (4) pharmacologic therapy. Also the Centre for Disease Control and Prevention (CDC) in the US launched in 1999 the National Asthma Control Programme (NACP) to coordinate national public health response to control asthma.  NACP has become an invaluable source of epidemiological data on asthma in the US. In the UK, the British Thoracic Society developed the British guidelines on the management of asthma in 1999 with update every 2 years. In section 9 of the British asthma guidelines, patient education and self-management of asthma are regarded as grade A recommendation.  This grade of recommendation is given to findings that were produced from high quality research with direct applicability to target population. In Australia, the Asthma Council produced the Australian Asthma Handbook, which provides evidence-based management strategies for asthma. The Handbook recommends three components of asthma self-management, (1) Written action plan, (2) monitoring of symptoms and (3) education and follow-up.  In Saudi Arabia, the Saudi Initiative for Asthma (SINA) was initiated by the Saudi Thoracic Society to develop guidelines for the diagnosis and management of asthmatic adults and children.  SINA guidelines have gained popularity nationally and regionally in helping physicians, nurses and respiratory therapists to use evidence-based management strategies for asthma treatment.
Asthma symptoms: What is the level of control?
The current trend in the management of asthma emphasizes the importance of controlling symptoms and preventing exacerbation of attacks. To achieve optimal asthma control, asthmatic patients must involve in treatment plan. Patients are expected to avoid triggers, monitor asthma symptoms and make necessary behavioural changes as dictated by the written action plan. Therefore, asthma education has become an essential component of asthma management. The EPR-3 recommends, in its asthma guidelines, that health-care workers provide proper education and counselling to patients and family on asthma management and action plans.  In their 2014 updated guidelines, Global initiative for asthma (GINA)  and SINA  highlighted the importance of asthma education, written action plan and triggers avoidance as primary components of asthma management. SINA guidelines state that 'Asthma education should be conducted by a well-trained health-care worker.' According to SINA guidelines, the principal objective of asthma treatment is to control symptoms and reduce the number of hospital visits.
Since inpatient hospitalization and emergency department (ED) visits are the main sources of increased asthma financial and social burden,  better asthma control should translate into a considerable reduction in cost of caring for these patients. Asthmatic patients are expected to make lifestyle changes to avoid asthma triggers because asthma triggers are major contributors to poor asthma control. In fact, severely uncontrolled asthma contributes to about 40% of asthma-related cost.  This is the rationale for extensive focus on 'asthma control' in recommendations and guidelines developed by asthma organizations. In a retrospective study of more than 100,000 patients with asthma to investigate indicators of asthma control in the US over a 3-year period (2008-2010), Julia et al.  found that 51% of individuals diagnosed with asthma had at least one exacerbation in the last year, and 46% of asthmatics reported use of a quick-relieve inhaler for asthma symptoms in the last 3 months. Another important finding of this study was that only 22% of asthmatic in the US used long-term control medications. These results clearly indicate that asthma control in the study sample, and by generalization to the US population, is suboptimal. In Australia, the Centre for Asthma Monitoring reported that in asthmatic patients above 15 years of age, only 14.4% have written asthma control plan.  The same centre reported that 88% of south Australian adults with asthma complained of asthma symptoms in 2009. In Canada, asthma was reported to be poorly controlled in 53% of patients.  In Sweden, the proportion of patients who had asthma control was not only low (37%) in 2001, but it did not significantly improve in 2005 (40%).  Similar findings of poorly controlled asthma symptoms were reported by a large study that involved 29 countries. 
Asthma control has been studied in Saudi Arabia. AL-Jahdali et al.  evaluated asthma control for 1,060 asthmatic patients in five medical centres in Riyadh using Asthma Control Test (ACT) scores. They found that only 5% of surveyed patients had completely controlled asthma, 31% well-controlled and 64% had uncontrolled asthma symptoms. Gender difference in asthma control was evident in this study as only 30% of females had controlled asthma as compared to 44% of male asthmatics. In another study, AL-Jahdali et al.  surveyed 450 adult asthmatic patients in two major hospitals in Riyadh and found that 40% of them did not receive any formal education on asthma control. They also reported that about 50% of studied patients were unable to use inhaler devices properly leading to poor asthma control and increased ED visits. Incorrect use of inhalers has been associated with poor asthma control in several studies. ,, In another gulf state, Oman, a study by Al-Busaidi and Soriano  reported that more than 50% of surveyed patients had poor or not well controlled asthma. [Table 1] summarizes asthma control studies from several countries.
In order to help patients follow treatment steps in a standardized manner, the asthma written action plan was introduced as an important component of asthma treatment. Asthma action plan comprises written instructions that help patients understand severity of disease symptoms and act upon the degree of symptoms. According to the National Asthma Council of Australia, the use of written action plan has been found to reduce hospital visits and absenteeism from work.  Douglas et al.  interviewed 62 adult patients who visited ED for asthma exacerbation and found that the most common reason for them not to have a written action plan was that their doctors did offer or discuss it with them. In a randomized controlled trail, Ducharme et al. studied the effect of providing a written action plan for 219 children. The experimental group had higher adherence to the treatment regimen and medical follow-up as compared to the group that did not receive asthma action plan.  Abramson et al.  conducted an interesting research to study contribution of using written action plan to death from asthma. They found that the use of the written action plan was associated with 70% reduction in risk of death.
Corsico and his colleagues conducted an epidemiological study in 12 countries (including USA, UK, Australia and several European countries), to assess patients adherence to asthma treatment.  The study revealed that only 56% of study sample reported adherence to treatment regimen. This study also unveiled two interesting findings about factors related to the issue of adherence. First, negative patient's belief about medications was associated with poor adherence. Second, better patients' follow-up with health-care providers predicts good adherence. The main objective of asthma education programme is to educate patients about his/her asthma medications and clarify common misconceptions about side effects of medications. This, in turn, should improve patient's follow-up with their doctors and their adherence to the prescribed treatment regimens.
Asthma control in young asthmatic patients has been reported to be sub-optimal. This can be attributed to two factors. First, young patients (school age and adolescents) are more likely to be embarrassed about using their asthma medications in front of their peers.  Therefore, medications may not be used when symptoms of the disease become worse, reducing the level of symptoms control. Secondly, school-age patients and adolescents depend on their parents with regard to treatment plan and use of medications. If parents are not well-educated about asthma self-management and action plans, their children are less likely to control symptoms of the disease. Importance of parents' education about asthma was highlighted in the study of Barton et al.  They studied 85 children and young adults (age 10-24 years) and found that as parents become more knowledgeable about asthma, their children and adolescents' knowledge about the disease increases.
Asthma education programmes
Asthma education programmes (AEPs) aim to help patients recognize disease symptoms, follow treatment plan, control environmental triggers and to seek medical care when symptoms get worse. It is well-documented in public health and health promotion field that structured health education programmes, given to the right participants in the right settings, improve health behaviours, social support and health internality.  Effectiveness of AEP has been investigated in numerous research studies. Takemura et al.  tested the effect of a structured educational programme on the use of inhalation devices and reported that implementation of the programme for asthmatic patients led to proper use of inhaler devices and better adherence to treatment. In a systematic review of 38 research studies including 7,843 children with asthma, AEP was found to reduce risk for ED visits (RR 0.73) and hospital admissions (RR 0.79).  AEP have been implemented in schools targeting children with asthma, as prevalence of the disease is in the rise for the school-aged population. Coffman et al.  reviewed 25 randomized controlled trials of school-based AEP and found that majority of studies reported significant improvement in self-efficacy, self-management and knowledge about asthma of school-age asthmatics as compared to control group. However, findings were not consistent regarding effect of school-based AEP on quality of life, school absences and disease symptoms.
Asthma education has been conducted in different patient settings using different learning approaches. Osman et al.  designed a short (40-60 min) self-management educational programme for 280 asthmatic patients during hospital admission and found that morbidity after discharge (daytime wheezes, night disturbances and activity limitation) has significantly reduced after implementation of the programme. Also, readmission rate has significantly decreased [17% vs. 27%, odds ratio (OR) 0.5, confidence interval (CI) 0.3 − 1.0] in self-management group when compared to patients on standard care. Because patients differ in important characteristics that could interfere with the learning process, tailoring the programme to address patient's needs, literacy level and culture could produce better outcomes. Based on this premise, Thoones et al.  studied the efficacy of tailored versus traditional AEP. The tailored programme was designed based on information needed by asthmatic patients as determined by a panel of experts. The authors reported better patient satisfaction and better interaction between patients and health-care providers when tailored programme was used.
Educating asthma patients should be offered in all clinical settings, including ED. Visiting the ED is quite common for asthmatic patients. Therefore, the ED can be used as a point of delivering asthma educational sessions. To assess effectiveness of providing education in this setting, Williams et al.  implemented a simple educational intervention for asthmatic patients and their parents during ED visits and found that the group who received an educational session had significant improvement in outpatient follow-up rate (50% vs. 20.8%, P < 0.001) as compared with a group of asthmatic children who presented to the ED but did not receive educational intervention.
AEPs should address medical, social and psychological aspects of treatment. Doctors, respiratory therapists, social workers and psychologists can tackle different aspects of the disease to produce a comprehensive treatment plan. This interdisciplinary approach of asthma education was assessed by Walders et al.  They performed a randomized control trail using written asthma management plan for both study groups. The intervention group received asthma education sessions, asthma risk profile assessment and problem solving therapy to patient's family. Both, experimental and control groups, had significant reduction in asthma symptoms and improved quality of life, but the intervention group showed decreased utilization of medical resources as indicated by 32% reduction in ED or inpatients use of resources. This study showed that involving different health care disciplines in asthma education can be of great benefit to the program.
Using a non-traditional approach to teaching during asthma education has been shown to produce positive results. In a randomized control trial, Watson et al.  compared the effect of small group, interactive asthma education with usual asthma management care as prescribed by patients' primary care physician. Patients who received small group interactive asthma education made fewer ED visits, and the likelihood of requiring emergency care was reduced by 38% (RR 0.62, P < 0.004) as compared to the routine care group. Asthma symptoms for patients in the study group and missed work days for their parents were less with comparison to control group.
In the era of computer and mobile technology, some health-care providers and researchers have utilized available technology as means of delivering asthma education. Burns et al.  pilot-tested web-based asthma self-management programme in 51 adult asthmatic patients and found that this form of delivery increased patients' asthma knowledge, improved asthma control and enhanced quality of life. Also, interactive smartphone applications have been used to improve communication between asthmatic patients and health care providers. Preliminary studies on using smartphone applications to support asthma action plan showed promising results. It has been reported that patients who used asthma action smartphone applications had better compliance with self-management advice, fewer asthma symptoms and better interaction with health-care providers. ,
Despite the good results obtained with these teaching approaches, well-structured AEP are apparently underutilized. In the US, less than half of children and less than one-third of adult with asthma get an asthma control plan.  In Saudi Arabia, 40% of asthmatic patients do not receive any formal education on how to use their medications. 
| Self-Efficacy Theory and Asthma Management|| |
Over many years of treating and containing asthma, it seems that the medical community has overlooked the importance of psychological factors and patient's engagement in treating his/her own disease. Patient self-efficacy as described by Bandura ,, has an important practical implication for successful AEP. Bandura  defines self-efficacy as 'an individual's perception of his/her own capabilities to produce designated levels of performance'. Self-efficacy level has been used as a predictor of health behaviours change in smoking cessation, weight loss and diet control programmes. 
Three implications of self-efficacy theory are of important interest to asthma education. First, the theory stipulates that individuals will show strong commitment to achieve goals if they believe in their capabilities. Second, verbal persuasion of individuals about their abilities increases the likelihood of engagement in goal achievement. Thirdly, when individuals observe others succeeding in goal attainment, their belief in themselves increases. These concepts can be utilized in AEP to potentiate outcomes of the programme. Educational sessions should be targeted towards raising patient's self-confidence and positive self-image leading to the belief that he or she is capable of controlling his/her own disease. Successful actions should be encouraged and used as catalysts for more positive actions. Additionally, educating asthmatic patients in a group may produce better results as each patient is encouraged by and learn from each other.
In an interesting study, Lavoie et al. studied the association between asthma self-efficacy and asthma control.  They reported that low level of asthma self-efficacy was associated with poor asthma control and quality of life. The authors called for the need to incorporate self-efficacy techniques in asthma education and self-management programmes.
| Summary and conclusions|| |
Even though we now understand the disease and treatment options more than any time in history, asthma prevalence and consequent morbidity are in the rise. It is estimated that there are now 300 million people with asthma worldwide.  This number is expected to reach 400 million by 2025.  This increase in asthma prevalence will impose further economic, social and personal burdens on individuals and societies. It is our belief that management strategies of asthma have to be reviewed to consider a comprehensive approach to treatment that takes medical, social and personal aspects of treatment into consideration. While educating asthmatic patients about their disease and basic management improve adherence to therapy and consequently result in better asthma control, available data drawn from well-conducted research indicate that asthma control has not reached the optimum level. A large study involving 1,477 randomly selected asthmatic patients reported a strong and directional relationship between patient's knowledge about asthma and degree of asthma control.  As asthmatic patients take better control of their symptoms, their lifestyles change and overall health status improve. , Apparently, asthma education has not been fully utilized by health-care providers when treating asthmatic patients. Asthma organizations in many countries have developed treatment guidelines for asthma. With no exception, all asthma guidelines give emphasis to asthma education as an integral part of asthma treatment plan. In fact, To et al.  have developed 15 performance indicators of primary care for asthma. The number one performance indicator was 'Asthma education by a certified asthma educator'. Educating asthmatic patients should be performed at all points of patients encounter, whether in out-patient clinic, patient wards or during ED visits. Asthma education has been successfully conducted in out-of-hospital settings, like schools or patient's home. Provision of AEP that are cultural-sensitive to customs, beliefs and common misconceptions is more effective than generic programmes that overlook cultural effect on compliance. Also understanding and/or having the same culture as patients have been found to improve performance of asthma educators and produced some positive patient outcomes. 
Some demographic studies , reported a higher prevalence of asthma in females, low education and poor patients. This has implications for health-care planners and policy-makers. Access to health care and AEPs should be prioritized to those subsets of patients. Low health literacy has been known as a contributor to poor health access, health outcomes and increased health costs.  Apter et al.  studied the association of health literacy to asthma self-management in 284 adult patients and found that higher health literacy was linked to better asthma control and adherence to therapy.
Finally, we conclude with following two notions. First, it is evident from the literature that there is an inconsistency in following asthma management guidelines by health-care providers. In particular, the asthma education component is obviously underutilized. Health-care providers dealing with asthmatic patients (pulmonologists, family physicians, emergency physicians, respiratory therapists and nurses) should have clear familiarity with asthma management strategies and treatment guidelines. Secondly, programmes dedicated for preparing asthma educators should be encouraged and supported. Some countries have established special certification schemes for asthma educators. The National Asthma Educator Certification Board (NAECB) in the US is responsible for providing the Certified Asthma Educator credentials for health professionals who pass an examination. In Saudi Arabia, the Saudi Society for Respiratory Care (SSRC) has developed a well-structured 2-day AEP for respiratory therapists, pulmonary physicians, primary care physicians, nurses and health educators. The goal of this programme is to provide participants with up-to-date information and skills on asthma education. The course ends with an examination to assess gained knowledge and skills of participants. Passing this examination qualifies participants to be a Certified Educator on Asthma (CEA) by SSRC. Such educational programmes and qualifications promote knowledge and skills of asthma education, encourage health-care providers to involve in such activities and establish asthma education as an important subspecialty in treating patients with asthma.
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