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Patient self-management programs have become an integral part of asthma treatment. The goal of such programs is to strengthen the partnership between patients and health care providers in controlling the condition. The present study analyzed how well patients maintained or relapsed in performing asthma self-management skills over time and across settings. It was conducted by contacting patients who had been involved in a successful self-management program an average of 6 years after their participation or an average of 7 years after they completed training. Seventy percent of the patients agreed to participate and complete, either by themselves or over the telephone, a structured interview regarding their experiences in performing asthma self-management. On the basis of their responses, 53 participants were categorized into two groups: continuers or relapsers, according to previously developed and published criteria for relapse. Characteristics that distinguished the two groups were described. As anticipated, those classified as continuers reportedly exhibited broader repertoires of self-management skills across an array of settings. They credited their performance with maintaining control over their asthma. However, two unexpected findings emerged in the study: First, all patients continued to use self-management skills to one degree or another 7 years after they had acquired these skills. Even patients who were categorized as relapsers regularly performed some self-management skills, often involving self-monitoring of their breathing. Second, half of the patients in the relapse group reported that their asthma was in remission and that they were asymptomatic. The self-management skills they reportedly used were performed to monitor and prevent a return of asthma.

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OBJECTIVE: The effect of experimenter expectancy was investigated on the resistance to respiratory air flow, measured as total respiratory resistance (Rt) in healthy individuals. METHOD: Each of three naive experimental assistants collected air flow resistance responses from 30 subjects who they had been told were either likely or unlikely to respond to the suggestion of breathing difficulty. RESULTS: The subjects were assigned to the two conditions at random. The subjects who were described to the experimenters as being likely to respond exhibited greater Rt increases to bronchoconstriction suggestion than did the subjects who were described as unlikely to respond. CONCLUSIONS: These findings confirmed the presence of a source of variance that has not been considered previously in suggestion studies.

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OBJECTIVE: The objective of the study was to train asthma patients to improve their ability to discriminate added resistive loads. METHODS: Training consisted of a task in which patients judged the relative difficulty of breathing through two circuits. Difficulty of breathing through the circuits was varied by addition of resistive loads. We assigned 45 patients randomly to one of three conditions: a feedback plus fading condition, a feedback condition, and a control condition. RESULTS: Feedback of accuracy of judgments coupled with fading resulted in reduction of difference threshold. Neither feedback alone nor a control condition in which patients were given experience in making judgments without feedback resulted in threshold change. CONCLUSIONS: Perception training with added resistive loads may help patients to detect an increase in air flow obstruction due to asthma before it becomes severe.

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Behavioral problems associated with asthma management were examined in a group of 100 adult Spanish outpatients with asthma (57 women, 43 men; 17-69 years of age). All of them completed a Spanish version of the Revised Asthma Problem Behavior Checklist (RAPBC). Data about duration, severity, and self-management of asthma (self-efficacy expectancies and health care utilization), as well as dyspnea and FEV1, were also recorded. The highest-reliability Cronbach alpha indices were for the criteria related to emotions and behaviors that could precipitate asthma attacks. Concurrent criterion validity was examined first by Pearson correlations between the RAPBC scores and clinical data about asthma (duration, FEV1, and dyspnea), and second, by examining the differences in RAPBC scores (ANOVAs) among three severity groups of patients. Severe patients reported more behavioral problems associated with poor life-styles and self-management of their asthma and showed more psychological and physical negative consequences related to asthma. In conclusion, while the RAPBC could be considered a valid instrument to assess the behavioral problems associated with asthma in Spanish patients, and shows a good concurrent criterion validity, its reliability (internal consistency) with respect to life-style and self-management behaviors related to asthma should be improved, to ensure its utility as a screening instrument for behavior-related problems in asthmatic Spanish patients.

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A number of reviews have described medication compliance and asthma. The consensus emerging from the analyses and discussion of the topic is that compliance to treatment regimens is generally poor. The current article describes several trees overlooked in the forest of data generated about compliance and asthma. The paper focuses on neglected issues concerning determinants of compliance, assessment, and changing noncompliant behavior. Based on available data, the conclusion is that it is time for health care personnel and patients to share the blame for the lack of medication compliance in asthma.

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We compared the effectiveness of personalized asthma self-management recommendations with that of a group self-management program. We assigned each of 34 asthma patients randomly to one of three conditions: individualized asthma self-management, group asthma self-management, and control. We derived individualized self-management recommendations from patient recordings of asthma occurrence, asthma precipitants, and peak expiratory flow rate made during a 3-month period. The group program we used was the Wheezers Anonymous program. As compared to a control group of patients who received no self-management training, the patients in both the individualized and group condition evidenced improvement of pulmonary function, as measured daily with a home peak flow meter. The improvement was equivalent for patients in the two conditions. Patients in the individualized condition also exhibited a drop in frequency of asthma attacks, but patients in the group condition did not. We concluded that individualized asthma self-management is effective in reducing symptoms of asthma.

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BACKGROUND: We performed a cost-benefit analysis of a previously described self-management program for adult asthma. METHODS: Direct and indirect cost data from 47 subjects who participated in the self-management program were analyzed. In particular, costs incurred by the subjects 1 year before participation were compared with costs incurred 1 year after participation. RESULTS: The cost-benefit analysis indicated that the program was beneficial, reducing the cost of asthma to each patient by $475.29. The benefit came primarily from reductions in hospital admissions (reduced from $18,488 to $1538) and income lost as a result of asthma (reduced from $11,593 to $4589). The asthma self-management program cost $208.33 per patient. Comparison of the program cost with the program benefit produced a 1:2.28 cost-benefit ratio, demonstrating that the program more than paid for itself. CONCLUSION: A self-management program for adult asthma effectively reduced the cost associated with asthma. The findings are especially salient because the subjects' asthma was generally under good medical control when they participated in the program. The savings were therefore not the result of improved medical treatment; medical treatment was a controlled parameter, not a variable, in the self-management study. The self-management program for adult asthma was cost-beneficial.

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BACKGROUND: We developed and evaluated a self-management program for adult asthma. In developing the program, we considered questions of format and behavior control. The format we selected included components known to be effective in educational settings. We regulated asthma management behavior through the introduction of environmental cues. METHODS: Seventy-six subjects, whose asthma was generally under medical control, were assigned randomly to either a treatment group or a waiting-list control group. Those in the treatment group were exposed to a 7-week program that incorporated proven features of providing effective training and establishing behavioral control. Subsequently, subjects in the control group received the treatment. Short-term evaluation of the treatment was made after the subjects in the experimental group were trained but before the control subjects were trained. Long-term evaluation was conducted after both groups of subjects were trained. RESULTS: Over the short term, self-management training led to fewer asthma symptoms and physician visits and improvement in asthma management skills and cognitive abilities. Over the long term, self-management training was related to lower asthma attack frequency, reduced medication use, improvement in cognitive measures, and increased use of self-management skills. CONCLUSIONS: The program improved asthma management in patients whose conditions were already under good medical control. The effects of the program were apparent a year after the conclusion of self-management training.

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The concept of assessing health-related quality of life has a brief and vibrant history. In this monograph, theoretical issues related to the term and the reasons assessment of quality of life is important are discussed. There is a great deal of ambiguity surrounding definitions of the concept. This equivocation is caused in part by the fact that thinking on both the concept of health-related quality-of-life assessment and the way in which it should be measured are still evolving. Methodologic concerns regarding the assessment of health-related quality of life are discussed, including ways in which the validity and reliability of measurement approaches are established. These characteristics are important because they are necessary to ensure that accurate information is obtained with whatever instrument or procedure is used. Many significant issues relate to the use of quality-of-life assessment, and these are delineated. Consideration and resolution of these issues are prerequisites to the introduction of a given assessment instrument or procedure into a study. A large section of this article is devoted to a review of selected measures of health-related quality of life. Three types of measures are discussed. The first type is referred to as general. These measures are designed to be used across different diseases, different treatments or interventions, and different groups of patients. The reliability and validity of general instruments or procedures, plus their history of empirical use, make them invaluable methods of measurement. The second type of measures is referred to as disease specific. These measures are designed to assess specific diagnostic or patient populations with the goal of detecting responsiveness or clinically significant changes. The ability to assess such changes in a particular patient population has led to major growth in the development and introduction of these instruments in the past few years. The final type of measure consists of batteries of separate instruments that are scored independently. The advantage of using this approach is that the battery can be put together to assess whatever aspects of health-related quality of life need to be measured. Examples of quality-of-life assessment in medical research include a discussion of how various procedures are used to measure the construct with asthma, chronic respiratory disorders, and human immunodeficiency virus (HIV) disease. All three types of assessment--general, disease specific, and batteries of measures--have been used in this respect. Newer methods of assessment, particularly disease-specific instruments and procedures, are also described.(ABSTRACT TRUNCATED AT 250 WORDS)

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The Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire (KASE-AQ) is a paper-and-pencil instrument that was developed to allow physicians, behavioral scientists, and other health care personnel to assess asthma patients' knowledge regarding asthma, their attitudes about their asthma (including their willingness to cooperate with the physician in managing asthma), and their self-efficacy regarding their perceived ability to control the disorder. The KASE-AQ assesses changes in these patient variables following a particular intervention. The KASE-AQ proved to be reliable and internally consistent, and a factor analysis revealed presence of three subscales in the questionnaire (knowledge, attitude, and self-efficacy about asthma). Following asthma education and self-management training, experimental group subjects showed significant improvements in knowledge, attitude, and self-efficacy. Waiting-list control subjects showed similar improvements following training. Both groups' scores at 3-month follow-up remained significantly higher than their baseline scores on all 3 variables.

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In two discrimination training studies, we noted improvements in the ability of healthy individuals to discriminate between respiratory sensations. We trained individuals to discriminate between respiratory sensations elicited during inspiration in Experiment 1 and during expiration in Experiment 2. We elicited respiratory sensations by having participants breathe through circuits that differed in their resistance to air flow. Training, in both experiments, was conducted within the context of a task in which individuals judged which member of a series of respiratory circuit pairs was easier to breathe through. To improve the accuracy of judgments, we gave participants feedback of their performance, and we faded air flow resistance. The latter procedure consisted of presenting circuit pairs in order of increasing similarity. Individuals who received performance feedback with fading of air flow resistance demonstrated reliable improvements in discrimination from pre- to posttraining in both experiments, but controls, who received either performance feedback or practice in discrimination did not. These findings may contribute to improving awareness of respiratory sensations in asthma patients, and thereby bolster efforts to manage asthma.

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The paper describes the development and testing of a paper-and-pencil instrument, the Life Activities Questionnaire for Childhood Asthma, that can be applied to assess activity restriction in children with asthma. It describes how items for the instrument were selected to ensure the validity of the developed instrument. The method by which the reliability of the questionnaire was established is also discussed. The result is a valid and reliable instrument that should have wide applicability in measuring activity restriction because of childhood asthma. The developed instrument has potential use in clinical settings, research, and policy making.

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Several areas of research on childhood asthma are discussed within a transactional model of asthma. The model emphasizes the multidirectional influences that affect the severity of asthma and associated behavioral disability. The initial focus is on how the clinical presentation and morbidity of asthma are affected both by somatic predisposition and by interactions with multiple internal and external elements. Specific elements include emotional factors, neuroimmunology, temperament, and medication side effects. Second, the impact of asthma on the child, his or her family, and segments of the community are described, as are consequences of the disorder on quality of life. Third, there is a synopsis of preventative interventions for reducing the medical and behavioral impact of childhood asthma. The motif is that the interaction of medical and behavioral procedures can improve the management of asthma while consequences of the disorder are mollified. Finally, as examples of a transactional model of asthma, self-management programs for teaching children to become partners with their physicians in establishing and maintaining control over the disorder are described. A representative of self-management--the ACT (Asthma Care Training) program--is described, along with the impact such programs have on children, their families, and institutions. The conclusion emphasizes that asthma is a complicated and unpredictable disorder that puzzles physicians, behavioral scientists, and patients. Although new treatments may be over the horizon, controlling childhood asthma and its consequences currently rests on the cooperation and increased interaction of medical and behavioral scientists.

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The development, testing, and applicability of an instrument, the Life Activities Questionnaire for Adult Asthma is described that can be used to assess activity restriction in adults with asthma. It explains how items for the instrument were selected to insure the validity of the developed instrument. The reliability of the questionnaire is also discussed. The result is a valid and reliable paper-and-pencil instrument that should have wide applicability as a component of quality of life measurement. This instrument has potential for functional use in clinical settings, research environments, and policy-making procedures.

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