Pamela Willson, PhD, RN, FNP-BC, CNE, NE-BC, FAANP

Director of Graduate Programs and Leadership and Administration in Nursing

Texas State University, School of Nursing, Round Rock, TX, USA

Susan K. Lee, PhD, RN, CNE

Associate Program Director, Assistant Faculty, Healthcare Disparities, Diversity, and Advocacy

UT-MD Anderson Cancer Center, School of Health Professions, Houston, TX, USA

Dr. Willson is the corresponding author:

E-MAIL: paw66@txstate.edu

Mobile: 512-365-0979

ABSTRACT

Customized asthma patient education is a patient-centered approach that supports patient and caregiver engagement. Patient asthma self-management skills are enhanced when educational sessions reflect the learner’s cultural diversity, personal health beliefs, and social determinants of health. Provider resources are explored. [40 words]

            Keywords: self-management, asthma, patient education, teaching-learning strategies

            Asthma education is a standard of patient care. Multiple studies have demonstrated that providing patient education improves quality of life, asthma control, and results in fewer visits to emergency rooms.  In the publication EXHALE Technical Package, from the Centers for Disease Control and Prevention (CDC) (2018), multiple evidence-based strategies to improve patient’s asthma control and to reduce health care costs are described. Customizing the program’s components begins with expanding access to and delivery of asthma self-management education. Asthma education must include barriers to patient engagement, including social determinants of health (SDOH) (Healthy People, 2020).

Implementing asthma patient education within the primary care setting, assures patients receive high-quality education but may be challenging when matching the content to the characteristics of provider’s patients. This step may involve developing new educational materials or amending structured education materials such as those offered by the Asthma and Allergy Foundation of America (AAFA) to address the patient’s unique characteristics. The aim of this report is to provide physicians, physician assistants, and nurse practitioners with evidence-based strategies to improve patient outcomes through customized patient education. Steps will be outlined for the provider to address teaching skills for behavioral change (psychoeducation) in patient education for asthmatics.

            Being an effective teacher is more than having extensive knowledge of the topic. It includes delivering content to the learner that is understandable and relevant. Asthma self-care needs to include a change in cognition or behavior patterns, while the teacher makes connections, is flexible, and inspires the learner. Education includes changing attitudes and beliefs; developing coping, emotional support, problem-solving; and crisis-intervention skills (Walsh, 2010). Framed on Cognitive Theory (Berlin, 2002) how a person feels, and thinks is reflected in their behavior. The healthcare provider may address cognitive deficits to encourage problem-solving skills development. Common program elements that contribute to positive asthma patient outcomes include:

  • Teaching concrete practical strategies that enhance self-esteem (e.g., social support, self-care resources),
  • Building stress resilience (e.g., coping and problem-management skills), and
  • Enhancing communication (e.g., barrier, stigma, and fear reduction).

Program Components

            The Registered Nurses’ Association of Ontario’s (RNAO) Adult Asthma Care: Promoting Control of Asthma clarifies recommendations for education (RNAO, 2017). The RNAO advises that behavior change programs for asthma prevention should be led by skilled educators who provide (1) asthma self-management education, (2) demonstrate correct inhaler techniques, and (3) who explain and use an asthma action plan. Team members should receive instruction to support the quality of their teaching and screening. The primary care provider should make sure that the teaching team receives adequate training and periodically assesses group and individual patient education quality. Certification as an asthma/respiratory educator, as well as standardized training and quality control of spirometry testing (RNAO, 2017, p. 52) may also be advantageous. There are many provider resources for the latest in asthma management and prevention (see Table).

Table. Information for international and national asthma clinical care guidelines

Date, Age Group Organization Web address
2017 Adult & Children American Thoracic Society
Severe asthma, using exhaled nitric oxide in practice, exercise-
induced asthma,
obesity and asthma,
asthma attacks
https://www.thoracic.org/statements/allergy-asthma.php  
2018 Adult & Children Centers for Disease Control and Prevention (CDC)
Vital Signs: Asthma in Children – U.S. 2001-16EXHALE Technical
PackageHome
characteristics &
Asthma Triggers –
checklistAsthma slideshow
https://www.cdc.gov/asthma/healthcare.html  
2019 Adult & Children older than 5 years Global Initiative for Asthma (GINA)
Pocket guide for
asthma management
and prevention  
https://ginasthma.org/wp-content/uploads/2019/04/GINA-2019-main-Pocket-Guide-wms.pdf  
2011 Adult & Children National Institutes
of Health, National
Heart, Lung, and Blood Institute (NIH, NHLBI)
Guidelines from the
National Asthma
Education and
Prevention Program;
Asthma
Care Quick Reference: Diagnosing and
managing asthma
patient education for
self-management
Action
plan Home care
https://www.nhlbi.nih.gov/sites/default/files/media/docs/asthma_qrg_0_0.pdf             www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.pdf    

Provider Skills

Provider skills in patient education are built on the foundation of expert knowledge of the disease pathology, risk factors, prevention, and medical management, and demand that the educator fashion the educational strategies to meet the patients’ needs. Patients spend little time with their primary care provider and/or education team; the majority of the time, the patient is managing asthma care themselves.The value placed on patient’s experiences and knowledge should be supported (Cooper-Stanton, 2019) and empowered through teaching self-management skills. Entering a collaborative process fosters self-responsibility while considering the patient’s situation. Teaching content and teaching/learning strategies should be designed with consideration of the patient’s SDOH factors, such as education; income; racial or ethnic group; religion; socioeconomic status; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or discrimination. The population groups most affected by SDOH include children and adolescents, disabled, elderly, medically underserved, racial or ethnic minorities, rural or urban dwellers, and women (Healthy People 2020). Social and economic factors influence a person’s ability to take part in healthy behaviors (i.e., diet, exercise, smoking cessation), which, if not addressed collaboratively in the goal setting and action planning phases, may prove unsuccessful and result in reduced quality of life (Artiga & Hinton, 2018).  Common barriers to attending asthma educational sessions are insufficient knowledge of available services, anxiety, cost, work conflicts, transportation, and cultural influences (Healthy People 2020). Lack of education poses barriers to a patient’s health as their environment may be unsafe, unsanitary, or substandard. These environmental factors have multi-generational impact, rooted in social and economic disadvantages (Chetty, Hendren, Kline, & Saez, 2014). Home visits to identify asthma triggers and to provide self-management education have revealed SDOH barriers to patient engagement and control, such as housing conditions, social stressors, work, and family obligations that affect the patient’s ability to manage asthma (Bryant-Stephens, Reed-Wells, Canales, et al., 2016).  

Collaborative goal setting and action plan development based on the patient’s successful past experiences are emboldening and inspire self-management. Empowerment is facilitated with structured support, such as structured teaching/learning sessions (e.g., three one-hour classes on asthma prevention). Electronic medical record (EMR) teaching documentation templates can be used to track the patient’s progress through the multiple sessions, communication with the team, and for billing. Problem solving for behavior change requires a patient-centered collaborative approach where the health care provider and patient work as a team to generate possible solutions to asthma.

Program Evaluation

            Regardless of how the educational program is taught, participant evaluation will provide insight for program improvement. Patient outcomes can easily be measured using a standardized instrument. One to consider using is the Mini Asthma Quality of Life Questionnaire (Mini AQLQ) (Juniper, Cox, Ferrie, & King, 1999). The Mini AQLQ is a 15-item tool that takes about 3-4 minutes for the patient to complete (for further information see: http://www.qoltech.co.uk/miniaqlq.html ). The Mini AQLQ measures asthma symptoms, activities, emotions, and environment and can be administered prior to the learning activity, as well as at varying post-program intervals (e.g., 1-month, 6-months). A 0.5 increase in Mini AQLQ score is considered clinically important improvement and low domain scores may point to areas for educational content revisions. For example, a low environmental score may be addressed with a home or virtual visit to identify asthma triggers.

Summary

            This report aimed to provide primary care providers with evidence-based strategies to improve patient outcomes through customized asthma patient education. Patient educator resources were presented that enhance the design, development, and quality of asthma patient education that is matched to unique patient learning and behavioral change needs. A collaborative patient-centered approach to asthma patient education engages the individual to take an active role in their care, empowers the learner while teaching self-management skills, and facilitates support. [1091 words]

REFERENCES

Artiga, S., & Hinton, E. (2018) Beyond health care: The role of social determinants in promoting health and health equity, Kaiser Family Foundation: Issue Brief. Retrieved from: https://www.kff.org/disparities-policy/issue-brief/beyond-health-care-the-role-of-social-determinants-in-promoting-health-and-health-equity/

Asthma and Allergy Foundation of America (AAFA). (n.d.). Asthma and Allergy Educational Materials and Tools for Patients and Caregivers. Retrieved from: https://www.aafa.org/programs-for-patients-and-caregivers/

Bryant-Stephens, T., Reed-Wells, S., Canales, M., et al. Home visits are needed to address asthma health disparities in adults. Journal of Allergy and Clinical Immunology, 138(6):1526-1530.

Centers for Disease Control and Prevention [CDC]. (2018). EXHALE: Technical Package to Control Asthma (Resource Document). Asthma and Community Health Branch, Division of Environmental Health Science and Practice. National Center for Environmental Health. Retrieved from: https://www.cdc.gov/asthma/pdfs/EXHALE_technical_package-508.pdf

Chetty, R., Hendren, N., Kline, P., & Saez, E. (2014). Where is the land of opportunity? The geography of intergenerational mobility in the United States. The Quarterly Journal of Economics 129(4), 1553–1623. doi:10.1093/qje/qju022.

Cooper-Stanton, G. (2019). How can self-management and patient education bring empowerment?

British Journal of Nursing28(7), 470. https://doi-org.libproxy.txstate.edu/10.12968/bjon.

2019.28.7.470

Healthy People 2020. (2010). Social Determinants of Health.

https://www.healthypeople.gov/2020/topicsobjectives/topic/social-determinants-of-health. Accessed August 28, 2019.

Juniper, E.F., Guyatt, G.H., Cox, F.M., Ferrie, P.J., & King, D.R. (1999). Development

and validation of the Mini Asthma Quality of Life Questionnaire. European Respiratory Journal, 14, 32 -38.

Registered Nurses’ Association of Ontario (RNAO). (2017). Adult asthma care:

Promoting control of asthma. Retrieved from: https://rnao.ca/bpg/guidelines/adult-asthma-care

Walsh, J. (2010). Psychoeducation in mental health. Chicago, Il: Lyceum Books, Inc.

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