Characteristics and correlates of asthma knowledge among emergency department users in Harlem

Airway diseases and health literacy (HL) measurement tools: A systematic review to inform respiratory research and practice

OBJECTIVE

To identify and evaluate asthma/COPD measurement tools that assess any of the five health literacy (HL) domains: (1) access, (2) understand, (3) evaluate, (4) communicate, and (5) use, as well as numeracy.

METHODS

MEDLINE/Embase (via Ovid) databases from 1974 to 2016 were searched and complimented by grey literature. Study selection and data extraction were conducted by two reviewers independently.

RESULTS

We identified 65 tools including 40 asthma, 22 COPD, and 3 asthma/COPD focused tools. Thirty tools had been validated and two assessed all five domains. The 'understand' domain was captured in 49 tools, followed by 'access' in 29 tools, 'use' in 24 tools, 'evaluate' in 20 tools, and 'communicate' in 10 tools. Two tools assessed 'numeracy'. Tool content comprised disease physiology, triggers, symptoms, inhaler technique, self-management practices, and rehab programs.

CONCLUSIONS

This review highlights paucity of HL tools that have been validated and/or assess the 'communicate' domain and makes a valuable contribution to filling an existing research gap in the field of HL by determining the deficiencies of such tools.

PRACTICE IMPLICATIONS

Our review uncovers which HL domains are under-measured, justifying the need to develop an airways HL measurement tool which applies the 5-domain model for asthma/COPD management.

Knowledge on self-management and levels of asthma control among adult patients in Ho Chi Minh City, Vietnam

Background

Most asthma patients in Vietnam have poorly controlled asthma. Besides reasons related to the health care system and health care providers, knowledge on the self-management of patients has also contributed to this situation.

Purpose

To assess knowledge on asthma self-management among adult asthma patients in Ho Chi Minh City.

Patients and methods

A cross-sectional study with convenience sampling was conducted among 322 ambulatory patients using questionnaires filled in via a face-to-face interview. The questionnaires enquired about: 1) sociodemographic details, 2) the Global Initiative for Asthma 2017 criteria of asthma control, 3) the Asthma Control Test, and 4) the Asthma Self-Management Questionnaire (ASMQ). Knowledge on asthma self-management was determined by the ASMQ score. The relationship between this knowledge and demographic factors and asthma control levels was determined.

Results

The knowledge on asthma self-management was low, with a mean raw ASMQ score of 4.3 (maximum 14); this is equivalent to 30 in a transformed score (maximum 100). Only 0.3% of these patients had good knowledge, 16.2% had adequate knowledge, and 83.5% had poor knowledge. Of all participants, 52% stated erroneously that asthma can be cured, 30% were confused about control and rescue medications, 68% failed to correctly describe the inhalation technique, and only 15.5% could answer correctly about the management of an exacerbation. Although most participants had poor asthma control, the higher the patient’s level of control, the better the ASMQ score. Conversely, patients with better knowledge of asthma self-management (ASMQ score ≥50) had better asthma control based on the Asthma Control Test score. Also, a higher education level was associated with more knowledge on asthma self-management.

Conclusion

In these patients, the level of knowledge on asthma self-management was low and significantly correlated with the level of asthma control. There is a clear need to improve knowledge in order to improve asthma control in Vietnam.

Sociodemographic Factors Mediate Race and Ethnicity-associated Childhood Asthma Health Disparities: a Longitudinal Analysis

BACKGROUND

Race and ethnicity-based disparities in childhood asthma are well established. We characterized the longitudinal effects associated with being African-American/Black or Hispanic/Latino on a range of asthma outcomes, and the extent to which sociodemographic factors, caregiver health literacy, education level, and asthma knowledge mediate these associations.

METHODS

Children ages 8-15 and their caregivers (n = 544) in the Chicago Initiative to Raise Asthma Health Equity (CHIRAH) cohort completed interviews every 3 months for 1.5 years. Health literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM). Other covariates include sex, age, education level, income, smoke exposure, asthma duration, employment status, and insurance status. We conducted a series of models to evaluate these factors as mediators of the relationship between race/ethnicity and (1) asthma knowledge, (2) asthma-related quality of life, (3) asthma severity, and (4) asthma control based on NAEPP/EPR-3 2007 guidelines.

RESULTS

African-American race and Hispanic/Latino ethnicity were significantly associated with all outcomes when compared to Whites. Adjusting for sociodemographic factors resulted in the most significant mediation of racial/ethnic disparities in all outcomes. Health literacy was a partial mediator of race/ethnic disparities in asthma knowledge and asthma-related quality of life. Asthma knowledge remained significantly associated with race and ethnicity, and race remained associated with asthma-related quality of life.

CONCLUSIONS

African-American race and Hispanic/Latino ethnicity are significantly associated with worse asthma compared to Whites in longitudinal analyses. Sociodemographic factors are potent mediators of these disparities, and should be considered when designing interventions to reduce asthma disparities. Health literacy and education level are partial mediators.

The Reliability and Validation of the Turkish Version of the Asthma Self-Management Knowledge Questionnaire

OBJECTIVES

There is no validated questionnaire in Turkish to assess asthma knowledge. In this study, we aimed to evaluate the reliability and validity of the Turkish version of the Asthma Self-Management Knowledge Questionnaire (AKQ) among asthmatic adults.

MATERIAL AND METHODS

The AKQ was translated into Turkish by two medical-text translators, followed by back translation and final review by two clinicians with experience in asthma management. The Turkish Asthma Self-Management Questionnaire was then applied to 202 adult asthma patients, and additional demographic and clinical features of the patients were collected for analysis.

RESULTS

The internal reliability of the 24-item AKQ was not high (Cronbach's alpha=0.55). Tukey's test of additivity was significant (p<0.001). This result revealed that all questions are consistent and measure the same concepts. Factor analysis demonstrated a probable structure of 10 factors that together explained 63.7% of total variance in results. Intra-class reliability of the AKQ was quite high.

CONCLUSION

This study shows that AKQ seems to be a suitable instrument to evaluate the effect of different components of asthma knowledge - such as triggers, medications, asthma exacerbations, and avoidance measures - in adult asthmatics.

Systematic review and content analysis of asthma knowledge questionnaires: A focus on the knowledge surrounding acute exacerbation management

OBJECTIVES

Asthma education is a key component of asthma management. Asthma education around the management of a person who is having an acute exacerbation of asthma (often referred to as asthma first aid (AFA) training) is important, particularly in a school setting. There is no gold standard assessment of asthma knowledge and also there is no specific tool to measure the knowledge of AFA. Our aim was to identify asthma knowledge questionnaires and perform a content analysis. We were interested in evaluating the number, the type and the format of AFA questions.

METHOD

A literature search was performed to identify the instruments which were able to assess asthma knowledge of people with asthma and/or caregivers of people with asthma. An electronic database search was performed in EMBASE, IPA, MEDLINE and PUBMED. Articles which described the development or psychometric testing of an asthma knowledge questionnaire were included. The content of questions in each instrument was analysed and categorised using the NVivo software, and a secondary analysis was performed to identify knowledge questions relevant to the management of an acute asthma exacerbation.

RESULTS

Forty-four papers with 37 different instruments met the inclusion criteria. The majority of the instruments contained a relatively low proportion of questions related to the management of acute asthma, i.e., only 162 of the 780 questions (21%). No questionnaire had sufficient specific emphasis on acute asthma management knowledge to test the impact of AFA training.

CONCLUSION

There is a scope to develop an up-to-date validated acute asthma management knowledge questionnaire for use in research and clinical settings.

Knowledge of actions of inhaled corticosteroids in patients who did not persist drug treatment early

OBJECTIVE

To evaluate, among new users of inhaled corticosteroids that did not persist treatment, knowledge of inhaled corticosteroids' actions and whether they were instructed on the use of their inhaler.

SETTING

Fifteen community pharmacies in The Netherlands. Methods Patients were interviewed by telephone. Their general practitioners provided diagnostic information and automated dispensing records were retrieved.

MAIN OUTCOME MEASURES

Knowledge of patients about the actions of inhaled corticosteroids.

RESULTS

230 (80.1%) of 287 patients were willing to participate. The majority (79.1%) of 230 patients was not aware of the anti-inflammatory actions of inhaled corticosteroids. Most patients were instructed on the use of their inhaler, predominantly by their physician (53%) or pharmacy (35.2%).

CONCLUSIONS

Although most patients reported inhaler instruction by at least one health care provider, the majority was unaware of inhaled corticosteroids' actions. Physicians and pharmacists should reconsider the instructions they provide especially to patients who should continuously use inhaled corticosteroids.

Development and validation of an asthma knowledge test for children 8-10 years of age

BACKGROUND

Although there are many instruments available to measure asthma knowledge in adult populations, a search of the literature identified the lack of valid and reliable instruments to assess the asthma knowledge of pre-adolescent children. The aim of this study was to develop and validate an asthma knowledge test for children 8-10 years of age.

METHODS

Three strategies were used to achieve the study objective: develop and design the asthma knowledge test; establish the content validity of test items; and conduct a pilot study to examine the validity, reliability and user friendliness of the instrument in a sample of 151 primary school children.

RESULTS

A 24-item asthma knowledge test was developed based on selected items from the Newcastle Asthma Knowledge Questionnaire and supplemented with items from other instruments. Test items were worded to ensure they could be understood by 8- to 10-year-old children, and content validity confirmed by an expert panel. A pilot study demonstrated that the test was user friendly, generated responses that reflected varying degrees of item difficulty and produced scores on the test that discriminated between 'known groups'.

CONCLUSION

Findings from this study indicate that an asthma knowledge test designed for primary school-age children has considerable promise. With further refinement and testing, this test will provide a valid and reliable measure of asthma knowledge in children with and without asthma that can be used in a wide range of childhood asthma studies.

Knowledge, attitude, and self-efficacy in asthma self-management and quality of life

BACKGROUND

Cognitive variables such as knowledge, attitude, and self-efficacy affect asthma patients' abilities to be effective self-managers.

OBJECTIVE

The objective of this cross-sectional analysis was to determine what patient and clinical factors were associated with these cognitive variables and to assess the contributions of these cognitive variables to clinical status.

METHODS

Primary care asthma patients were interviewed using the three domains of the Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire (KASE), as well as established scales to measure social support, depressive symptoms, and ratings of asthma care. Clinical asthma status was measured with the Asthma Quality of Life Questionnaire (AQLQ).

RESULTS

In total, 180 patients were enrolled, with a mean age of 43 years and 84% were women. Knowledge was low, with only 50% of patients answering half or more questions correctly (mean score = 52, possible range 0-100, higher is more knowledge). Attitude toward asthma was generally positive (mean score = 82, possible range 20-100, higher is more positive attitude) and self-efficacy was moderate (mean score = 76, possible range 20-100, higher is more self-efficacy). In separate multivariate analyses, younger age and higher education level were associated with more knowledge (p ≤ .005); more social support, fewer depressive symptoms, and more favorable prior results of asthma care were associated with more positive attitude (p ≤ .05); and favorable prior results, more satisfaction with asthma status, not having stress-related triggers, and not having had a recent emergency department visit for asthma were associated with more self-efficacy (p ≤ .07 for all variables). In additional multivariate analyses, more knowledge (p = .0005), more positive attitude (p = .02), and more self-efficacy (p = .01) were associated with better AQLQ scores.

CONCLUSIONS

Different patient and clinical characteristics were associated with cognitive variables pertinent to self-management. These variables, in turn, were independently associated with asthma status. Thus, although fostering improvement in all three variables would be desirable, interventions that improve any of these variables potentially could be beneficial.

Functional variants of the sphingosine-1-phosphate receptor 1 gene associate with asthma susceptibility

BACKGROUND

The genetic mechanisms underlying asthma remain unclear. Increased permeability of the microvasculature is a feature of asthma, and the sphingosine-1-phosphate receptor (S1PR1) is an essential participant regulating lung vascular integrity and responses to lung inflammation.

OBJECTIVE

We explored the contribution of polymorphisms in the S1PR1 gene to asthma susceptibility.

METHODS

A combination of gene resequencing for single nucleotide polymorphism (SNP) discovery, case-control association, functional evaluation of associated SNPs, and protein immunochemistry studies was used.

RESULTS

Immunohistochemistry studies demonstrated significantly decreased S1PR1 protein expression in pulmonary vessels in lungs of asthmatic patients compared with those of nonasthmatic subjects (P < .05). Direct DNA sequencing of 27 multiethnic samples identified 39 S1PR1 variants (18 novel SNPs). Association studies were performed based on genotyping results from cosmopolitan tagging SNPs in 3 case-control cohorts from Chicago and New York totaling 1,061 subjects (502 cases and 559 control subjects). The promoter SNP rs2038366 (-1557G/T) was found to be associated with asthma (P = .03) in European Americans. In African Americans an association was found for both asthma and severe asthma for intronic SNP rs3753194 (c.-164+170A/G; P = .006 and P = .040, respectively) and for promoter SNP rs59317557 (-532C/G) with severe asthma (P = .028). Consistent with predicted in silico functionality, alleles of the promoter SNPs rs2038366 (-1557G/T) and rs59317557 (-532C/G) influenced the activity of a luciferase S1PR1 reporter vector in transfected endothelial cells exposed to growth factors (epidermal growth factor, platelet-derived growth factor, and vascular endothelial growth factor) known to be increased in asthmatic airways.

CONCLUSION

These data provide strong support for a role for S1PR1 gene variants in asthma susceptibility and severity.

Measuring patient knowledge of asthma: a systematic review of outcome measures

BACKGROUND

Asthma self-management education is a key component of international guidelines. No gold standard patient centred outcome measure exists for asthma knowledge. Our aim was to identify high-quality, validated, and reliable outcome measures suitable for use in either the research or clinical setting.

METHODS

A systematic review was performed to identify outcome measures able to assess asthma knowledge in people with asthma. An electronic database search was made of MEDLINE, BNI, CINAHL, CDSR, DARE, Health Technology Assessment, NHS Economic Evaluation Database, EMBASE, AMED, PsychInfo and ISI. A review of grey literature was also performed. Articles were included if they described the development and psychometric testing of an asthma knowledge measure. The quality of each outcome measure was assessed according to published guidance. Content validity, construct validity, criterion validity, internal consistency, responsiveness, floor and ceiling effects, reproducibility, and interpretability were evaluated and given a rating of either "positive," "intermediate," or "negative."

RESULTS

Eighteen outcome measures met the inclusion criteria. None of these had a positive rating for all eight psychometric properties. Three outcome measures achieved either a positive or intermediate rating for content validity, construct validity, internal consistency, and reproducibility. As none of the articles had sufficient data regarding floor and ceiling effects, responsiveness, or interpretability, these properties could not be assessed.

CONCLUSION

We have been unable to identify any high-quality patient-centered asthma knowledge outcome measures. Any conclusions drawn from trials using such measures should therefore be interpreted with caution.

Development and testing of the Asthma Self-Management Questionnaire

BACKGROUND

Assessing self-management knowledge can guide physicians in teaching patients necessary skills.

OBJECTIVE

To develop and test the Asthma Self-Management Questionnaire (ASMQ).

METHODS

The ASMQ was developed from patient interviews. Validity was evaluated by comparison with the established Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire, and test-retest reliability was evaluated with repeated administration (mean, 5 days apart) in 25 patients (mean age, 41 years; 96% women). The ASMQ was further described in additional patients by comparison with cross-sectional self-management practices and longitudinal change in Asthma Quality of Life Questionnaire scores.

RESULTS

The 16-item, multiple-choice ASMQ measures knowledge of preventive strategies, inhaler use, and medications and generates a score of 0 to 100, with higher scores indicating more correct responses. The ASMQ was correlated with the Knowledge, Attitude, and Self-Efficacy Questionnaire (r = 0.58) and had a Cronbach alpha of 0.71. The correlation between administrations was 0.78, and the intraclass correlation coefficient was 0.58. When given to another 231 patients (mean age, 41 years; 74% women), the mean (SD) ASMQ score was 60 (20). Patients with better ASMQ scores were more likely to own peak flow meters (P = .04) and to have received flu vaccines (P = .03). For 12 months, these patients received self-management information through workbooks and telephone reinforcement. Patients with higher ASMQ scores after 12 months were more likely to have clinically important improvements in quality of life compared with patients with lower ASMQ scores (65% vs 46%; P = .01).

CONCLUSIONS

The ASMQ is valid and reliable and is associated with clinical markers of effective self-management and better asthma outcomes.

An evaluation of pediatric asthma educational resources

The purpose of this study was to evaluate newly developed educational resources for children with asthma. Children with asthma, their parents, and pediatric health care professionals were invited to review age-appropriate asthma resources. Key findings revealed: (1) the perceived usefulness of these resources, particularly for creating discussion opportunities between children and their caregivers through implemented resource use; (2) the need for health education materials to balance goals of depth of information versus child enjoyment in order to increase effective knowledge transfer and application; and (3) a renewed call for future educational resources to be both relevant and interactive in their outreach and engagement of children, potentially involving mediums of advanced technology. Clinical experience and the literature note a current lack of pediatric asthma education materials. The positive findings of this review of novel educational materials in asthma address an important gap relative to pediatric practice, resource evaluation, and knowledge translation.

Characterizing community-based asthma knowledge in Chicago and its high risk neighborhoods

The goal of this study was to characterize asthma knowledge in high risk neighborhoods compared to a random sample of residents in the Chicago area. The Chicago Community Asthma Survey-32 (CCAS-32) was administered to 1006 Chicago-area residents and 388 residents in 4 high-risk Chicago inner-city neighborhoods. There was a significant difference in asthma knowledge between groups. The general Chicago-area respondents have an average desirable response rate of 71.6% versus 64.7% for respondents in high-risk communities (p < 0.0001). For some aspects of asthma knowledge, e.g., nocturnal cough, cockroach allergen, and vaporizer use, general knowledge was similarly low. For other aspects, such as the need for asymptomatic asthma visits and chest tightness, there were larger gaps between residents of high risk communities and the general community. High-risk neighborhoods in Chicago had lower asthma knowledge compared to the general Chicago community. This discrepancy may be contributing to the disparities seen in asthma morbidity. Public health efforts to increase asthma knowledge in these high risk minority communities may help reduce these disparities. Important misconceptions exist about asthma triggers, signs and symptoms, especially among lower income African American communities, that should be addressed by physicians.

Asthma patients' knowledge, perception, and adherence to the asthma guidelines

Asthma patients' knowledge and perceptions about asthma management regimens have been shown to correlate with the quality of their asthma management and outcomes. This study addresses adult ambulatory asthma patients' knowledge and perception of the asthma management guidelines issued by the National Asthma Education and Prevention Program. We interviewed 76 patients at three adult medicine outpatient clinics. Of 37 patients who knew about peak flow monitoring, 21 found it to be useful, only 10 were using it regularly, and 7 had a notation about it in their chart. Eight patients knew about patient self-assessment forms, 6 found them useful, 3 had used one recently, and only 1 patient had one in the chart. Six patients knew about asthma action plans, 4 of them thought that these plans were useful, but only 1 patient was actively using it. This study demonstrates major gaps in the asthma patients knowledge, perceptions, and their adherence to recommendations and also with the documentation in the medical record.

General principals of management: education

Asthma education is an essential part of the treatment of this disease. Health care professionals must establish a partnership with the patient with asthma and the patient's family to devise a plan of care with which the patient voluntarily will comply. The partnership with the patient begins at the first encounter and continues throughout the therapeutic relationship. Each member of the health care team can be instrumental in reinforcing the crucial information the patient must know to be an informed participant in his or her care. Nursing professionals are in a particularly advantageous position to foster this partnership because of their patient-focused outlook and the quality of time spent with patients. When the partnership is based on mutual trust and cooperation, the clinician can direct asthma care that is consistent with current expert guidelines. Educational interventions should be meaningful to the patient, learner centered to incorporate the patient's needs, and sensitive to the patient's cultural influences. The patient and his or her significant social and family support should be actively involved. The clinician should be alert to the patient's readiness to learn and tailor the message to suit the setting in which it is delivered. The patient should receive information that allows his or her participation in goal setting for treatment. Essentials to be included are the significance of the diagnosis, basics about inflammation as the primary cause of symptoms, the difference between controllers and relievers, how to use the medications and monitoring devices, how to reach the provider, and the need for continuous ongoing interaction with the clinician. Goals set in the partnership are objectified in the asthma action plan or guided self-management plan. The success of the treatment can be assessed from the patient's improved asthma control and reduced reliance on emergency treatment. Every health care provider is a potential wealth of patient education. Every patient encounter is an opportunity to reinforce knowledge and proficiency in asthma management. Nursing professionals can play a fundamental and crucial role in asthma education by maintaining the focus of the medical treatment on the priorities in asthma care--the learning needs and goals of the patient.

Relations among asthma knowledge, treatment adherence, and outcome

BACKGROUND

Asthma knowledge is frequently assumed to be a prerequisite for optimal asthma treatment. However, the validity of existing asthma knowledge questionnaires has not been rigorously examined, and no contemporary measure of asthma knowledge has received widespread acceptance.

OBJECTIVE

To construct and examine the psychometric properties of an asthma knowledge instrument, and its association with demographic and psychosocial variables, asthma medication adherence, and treatment outcome.

METHODS

A 25-item Asthma Knowledge Questionnaire was developed with input from national pediatric asthma experts. Parents of 155 children with asthma completed the Asthma Knowledge Questionnaire as well as demographic, family functioning, and home environment measures. Asthma outcomes and adherence with inhaled medication was measured across 12 months.

RESULTS

Despite the many steps taken to develop a strong measure of asthma knowledge, reliability was relatively poor. There was also no association between asthma knowledge and treatment adherence or outcomes. Furthermore, asthma knowledge was not a unidimensional construct and was not a simple function of education.

CONCLUSIONS

Findings from this study, in combination with previous studies of asthma knowledge questionnaires, suggest that the construction of a simple self-report asthma knowledge instrument for use as a primary outcome measure demonstrating mastery of asthma self-management skills may not be achievable.

Patterns and predictors of asthma-related emergency department use in Harlem

STUDY OBJECTIVES

To assess the roles of poor access to care, psychological risk factors, and asthma severity in frequent emergency department (ED) use.

DESIGN

A cross-sectional survey.

SETTING

Harlem Hospital Center ED and outpatient chest clinic.

PARTICIPANTS

Three hundred seventy-five adult residents of Harlem, a predominantly African-American community in New York City.

MEASUREMENTS

Asthma severity was assessed by self-reported symptoms using National Asthma Education and Prevention Program guidelines, health-care utilization, and psychometric scales.

RESULTS

Respondents with more severe asthma were more likely to have a primary asthma care provider, and to have had more scheduled office visits for asthma in the year prior to the interview (mean number of visits for patients with severe asthma, 3.6 visits; moderate asthma, 2.4 visits; and mild asthma, 1.7 visits). Despite having a regular source of care, 69% of respondents identified the ED as their preferred source of care; 82% visited the ED more than once in the year prior to interview (median, four visits). Persons with moderate or severe asthma were 3.8 times more likely to be frequent ED users compared to those with mild asthma (odds ratio [OR], 3.8; 95% confidence interval [CI], 2.2 to 6.6). This was the strongest predictor of frequent ED use. Other predictors of ED use were number of comorbid disorders (OR, 1.5; 95% CI, 1.1 to 2.1) and self-reported global health in the year prior to the ED visit (OR, 1.8; 95% CI, 1.2 to 2.7). Psychological characteristics were not predictive of frequent ED use when controlling for disease severity.

CONCLUSIONS

Frequent ED users present with serious medical conditions. They do not substitute physician care with ED care; they augment it to address serious health needs.