A South Australian population survey of the ownership of asthma action plans

The part of the survey form dealing with asthma is shown in the Box. A person was classified as having current asthma if they answered yes to the first three questions.

Social class was determined by referring to the gradation of occupational prestige given in the Australian Standard Classification of Occupations.¹¹

An asthma action plan was defined as "written instructions of what to do if your asthma is out of control."  

Before conducting multiple logistic regression analyses, the explanatory variables were examined for collinearity or interactions. Stratified analyses were used to check homogeneity of associations across different levels of predictor variables. Smoking status and the information that people with asthma perceive they have for dealing with worsening asthma were found to interact, with an effect of these variables on worsening asthma. An interaction term for the two independent variables was included in the logistic regression analysis for frequency of wakening at night. This interaction term proved significant (P = 0.03), indicating the need to split the model and conduct separate logistic regression analyses of smokers and non-smokers.

Therefore, we conducted three logistic regression analyses, using "asthma plan", "waken weekly-non-smokers" and "waken weekly-smokers" as the three response variables. All variables found to be significant at the univariate stage (ie, P = 0.25)¹³ were entered into each logistic regression. Insignificant variables were progressively omitted until satisfactory models were found that explained possession of an asthma plan and frequency of wakening at night.

In the multivariate analysis (Table 3), the variables that best described those who had an asthma action plan were: using corticosteroids, understanding the effects of worsening asthma, having a peak flow meter, and believing they have enough information to deal with worsening asthma. The variables that best described non-smokers who waken weekly or more often were: having a peak flow meter, having an asthma action plan, not believing they have enough information to deal with worsening asthma, and not feeling comfortable taking care of their asthma. Only one variable -- not finding it easy or convenient to access their doctor about asthma -- explained wakening weekly or more often for smokers.

Our study has some limitations. We have no objective data to identify levels of asthma severity and asthma control in the respondents. The validity of the perception questions as repeatable measures has not been verified. Because we focused on ownership of written action plans, our study does not tell us whether patients are making appropriate use of these plans or of verbal instructions.

In the multivariate analyses, only use of preventer medication, ownership of a peak flow meter and self-reported understanding of asthma were associated with plan ownership. This association could suggest that the more severe cases have better asthma management. Proof for this requires prospective measures (eg, lung function, medication doses) to assess the two critical factors of asthma severity and asthma control. Such knowledge could inform us of the potential need to target people with less severe asthma.

People with asthma with nocturnal symptoms were more likely than those without nocturnal symptoms to report possession of a peak flow meter, and to have asthma action plans, but were less likely to consider they had been provided with enough information about their asthma (non-smokers) or to find it easy to see their doctor (smokers) (Table 2). Thus, although asthmatics with a higher level of morbidity are more likely to receive physical materials to assist in self-care, they continue to have greater unmet needs for general practitioner access and information about asthma self-management.

What is the way forward? Randomised studies of the implementation of asthma plans show that good educational and skill objectives can be achieved.^2,14-16 However, the complexity of the asthma management problem makes it impossible to provide for every contingency the patient might face in dealing with asthma. Asthma management decisions can be difficult, because the patient, the daily situation, the science base and the disease are constantly changing.²

The objectives of patient asthma management are the development of skills and positive attitudes to problem-solving, accompanied by sufficient knowledge to make sense of changing morbidity and symptoms. A controlled trial evaluation of a brief asthma education program (2.5 to 3 hours group work) demonstrated substantial changes in illness behaviour.² These programs show that giving the patient the necessary skills cannot be achieved within the normal constraints of general practice. Randomised controlled trials of asthma clinics, where there is an emphasis on self-management, have demonstrated improvements in a range of morbidity and other health-related outcomes in a community-based setting.¹⁷ We must identify other ways of training the patient and focus the clinician on that part of the education program that can be managed in general practice. There is evidence that regular review improves asthma outcomes.¹⁸

It is pertinent to consider the possibility that inadequate use of guidelines by health professionals may be contributing to the fall in action plan ownership. Ways to improve use of guidelines need to include developments in information technology.

Trostle has suggested that the inability of some people to comply with a treatment regimen is an unavoidable byproduct of collisions between the clinical world and other competing worlds of work, family, friends and recreation.¹⁹ Often, the process required to inform and empower the patient is more than an educational task. Some of the traditional models of patient education based on health beliefs or compliance frameworks have been seriously questioned.^20,21 Patients have to fit their medical problems and medical regimens into the context of their daily lives. In doing so they will vary their compliance with advice and instructions to accommodate the social, psychological, economic and physical influences which are part of their lives.²¹ We need research that clearly articulates the complexity and variability of how asthma management fits into the context of individual patients' lives.

The National Asthma Campaign has provided a guide for health professionals to assist with effective patient communication, which is a starting point for corrective strategies.²²

We therefore know what optimal management of asthma is, but its attainment is elusive. Future strategies must be guided by studies defining asthma severity and asthma control, studies identifying factors that influence the use of guidelines by professionals, and studies elucidating the context of asthma management for the individual.

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