EXPENDABLES:

Topic
What is the patients perception of disease control of asthma compared with the guideline based
measures of control throughout North-west, North-central and South Trinidad in adult patients for the
year 2013?

Background
Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play
a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils, and epithelial cells. In
susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest
tightness, and cough, particularly at night and in the early morning
1
. These episodes are usually
associated with widespread but variable airflow obstruction that is often reversible either
spontaneously or with treatment. Based on this definition of asthma, the importance of airway
inflammation in its pathophysiology is key for the effective treatment of the disease. As a result, the
study of asthma pathogenesis and its treatment continues to focus on inflammation as a target to
control and regulate airflow obstruction and the resulting symptoms.
Acute symptoms of asthma usually arise from bronchospasm and require and respond to bronchodilator
therapy. Acute and chronic inflammation affecting airway calibre and airflow also leads to bronchial
hyper-responsiveness which results in susceptibility to bronchospasm. Treatment with anti-
inflammatory drugs can, to a large extent, reverse some of these processes. It is from this revelation,
that the guideline based measures of control for asthma was born.
The Global Initiative on Asthma (GINA) designed a standard set of guidelines for the control of asthma.
These guidelines have undergone various changes during its development described specifically from
opinion based (expert opinions based on clinical trials and mechanistic approaches) to evidence based
(provision of a logical and convenient framework from which the quality and relevance of clinical studies
may be assessed in an unbiased manner)
2
. These guidelines as articulated by GINA are systematically
developed statements designed to help practitioners and patients make decisions regarding the
appropriate health care for the management and treatment of asthma. These guidelines for the
management of asthma have proliferated across countries, but current practices indicate poor
adherence to national and international guidelines
3
. Although asthma guidelines may not be perfect,
they appear to be the most ideal mechanism available to assist physicians and patients to receive the
best possible care of asthma. The introduction of such guidelines into the Caribbean region
4
signals
awareness for the need for better asthma control in the region. The implementation of the guidelines
have generally been successful in that there has been a decrease in mortality and morbidity in countries
where asthma guidelines have been published and plans implemented despite the continued increase in
the prevalence of asthma
2
. An example of which resides in Brazil
5
, where asthma programs have shown
a considerable reduction in asthma hospitalisations among children living in deprived areas. There is
indeed a great need for asthma guidelines owing to the fact that many asthma deaths were shown to be
preventable due to suboptimal long-term medical care.

Rationale
As year 2 medical students, part of the Public Health curriculum requires us to perform a research
project on a chosen topic. The topic pertaining to asthma control was selected as it is very much a
relevant issue due to the fact that 80% of adult patients in specialty care have suboptimal asthma
control and are unaware of poor disease control
6
. The goal of this research project is to increase the
awareness of asthma in Trinidad and Tobago and to allow asthma to be regarded as an important
disease that can be controlled.
The intended population for this research is adult patients (18 years and over) suffering from asthma in
North Central, North West and South West Trinidad. The educational significance of the project is both
to increase knowledge on asthma and to empower patients that they can control their disease. The
purpose of this research is for its use in closing the intrinsic gap that exists between the publication of
guidelines and clinical practice, disseminating newly generated knowledge for the benefit of both health
professionals and patients. It would also contribute to reducing the occurrence of acute exacerbations
by sensitizing patients on the significance of the use of inhaled corticosteroids in reducing inflammation
of airways.
Potential problems that may arise while performing this research project are: the unwillingness of
patients to partake in the study and the inability to obtain a large enough population to represent the
intended audience for ideal analysis and withdrawal of statistics. These possible obstacles will be
overcome by respecting a patients decision to partake or not in the study and by making a conscious
effort to obtain a significantly large population of patients to withdraw sensible statistical data and to
make accurate conclusions by conducting research in three major hospitals in Trinidad: the Respiratory
Clinic at Port of Spain General Hospital and the Chest Clinics at Eric Williams Medical Sciences Complex
and San Fernando General Hospital.

Research Question
What is the patients perception of disease control of asthma compared with the guideline based
measures of control throughout North-west, North-central and South Trinidad in adult patients for the
year 2013?

Aim
To determine if there is a difference in patient perception of asthma control and objective measure of
control in adult patients in Trinidad.

Objectives
1. To investigate patient perception of asthma control utilising a Pilot-tested de novo
questionnaire.
2. To determine patient lung function through peak expiratory flow rate as a measure of FEV1.

Methodology
Study Design
All surveys conducted utilised the same protocol and was conducted in 3 main regional health facilities
the San Fernando Chest Clinic, the Mt Hope Chest Clinic and the Port of Spain Respiratory Clinic. This
was effective in that it provided a geographic cross section of Trinidads asthmatic population. Each
recruited patient would be administered a pilot-tested de novo questionnaire. [See Appendix]

Study Setting
Patients will be selected from the Chect Clinic at the Eric Williams Medical Sciences Complex and San
Fernando General Hospital, as well as the respiratory Clinic at Port of spain General Hospital. All the
clinics are based in public hospitals and provide care for residents of north-central, north-west and
south-west Trinidad respectively. Each clinic services patients with specialist care.
Pateients will be interviewed in a private room with the appropriate measuring apparatus (tape
measure, scale, peak flow meter).

Study Population
The study population of an epidemiological research project must state the unambiguous inclusion and
exclusion criteria.

Inclusion Criteria:
1. All patients with asthma that receive treatment at the respective clinics.
2. All asthma patients above the age of 18.
3. Males and females of all ethnicities.

Exclusion Criteria:
1. Asthmatic children under the age of 18.
2. Asthmatic patients that do not consent to the survey.
3. Patients who were not able to complete oral interview interviews (dementia and/or language
barriers etc.)
4. There are also criteria for excluding patients from evaluating their lung function using Peak
Expiratory Flow. Patients will be excluded if there is pneumothorax, hemoptysis, unstable
cardiovascular status, recent myocardial infarction or pulmonary embolism, aneurysm (thoracic,
abdominal or cerebral), recent eye surgery, recent surgery (abdomen or thorax).
7

Contra-indication of Peak Expiratory Flow:
Any asthmatic patient who suffers from or is undergoing any of the following will be allowed to
participate in the questionnaire but will not participate in the PEF measurement:
1. Pneumothorax
7

2. Hemoptysis of unknown origin (may be aggravated by forced expiration)
7

3. Unstable cardiovascular status (forced expiration may worsen angina or cause changes in blood
pressure) or recent myocardial infarction or pulmonary embolism.
7

4. Thoracic, abdominal or cerebral aneurysn (increased thoracic pressure during PEF may cause
rupture)
7

5. Recent eye surgery
7

6. Presence of acute disease process that may affect performance (such as nausea and vomiting)
7

7. Recent surgery of thorax and abdomen.
7

8. Patients who have medical conditions other that asthma that would affect the peak flow
expiratory rate (cystic fibrosis, emphysema, chronic bronchitis, etc.)
9. Patients who were on Beta blockers

Sample Size
Approximately 80% of adult patients in specialty care have suboptimal asthma control and are unaware of poor
disease control.
6

Using the Equation: z
2
x p x (1-p)
d
2

Where; (Confidence level) z = 1.96
(Percentage Population) p = 0.80
(Confidence Interval) d = 0.03

Sample size was calculated to be 683 persons.

Data Collection
Data will be collected by administering a pilot-tested de novo questionnaire to patients.The peak
expiratory flow meter will be used to assess the patients lung function.

Method for Objective 1:
A questionnaire was developed. [See Appendix] The questionnaire will be pilot tested on twenty (20)
patients to ensure that it is understandable and also, that the responses the patients give are
synchronous with the information that we would like to elicit from them.
Before the interview, the patient will be informally assessed according to the inclusion-exclusion criteria
to determine whether they can participate. Also, they will be asked about any contra-indications for
peak expirtory flow determination.
The patients will be interviewed by asking the questions on the questionnaire in order and in a non-
suggestive manner. This is to eliminate any bias responses due to the interviewers intonation or tone
when asking the questions, especially with contraversial ones. The patients responses will be recorded
by checking boxes or by writing the patients actual responses.
The patients name will be recorded on the questionnaire and also be assigned an alpha-numeric code.
This code will be used henceforth with regards to the patient in order to preserve patient
confidentiality.
The patients lung function evaluation will be disclosed to them following the questionnaire. Finally, the
patient will be thanked for there time and kind assistance.

Method for Objective 2:
When the peak expiratory flow is to be determined, the patient will proceed if they are capable as
shown by the contra-indications to peak expiratory flow. If the patient is deemed unable to perform the
peak expiratory flow, it will be indicated on the questionnaire. The patient will be told how to do the
experiment in order to remove any errors in the procedure. They mouth-piece will be cleaned in front of
the patient, using cotton swabs and savlon, so that the patient is comfortable with the experiment and
apparatus to proceed. The patient will be asked to:
1. Inhale maximally.
2. Place the Peak Flow Meter into their mouth so that their lips form a seal around the rim.
3. They will then expel the air in as little time as possible.
4. The value on the peak flow meter will be recorded.
5. Steps 1-4 will be repeated two (2) more times. The best of the three values will be taken to
evaluate their lung function.
6. The mouthpiece will be cleaned.

Data Analysis
Data will be entered into a Excel spreadsheet and submitted to analysis using Statistical Program for
Social Sciences (SPSS).

Data Protection
Patient confidentiality will be secured by assigning each patient an alpha-numeric code, which will be
used following interview. Patients from Eric Williams Medical sciences Complex will be assigned the
number 1, those from Port of spain General Hospital will be assigned the number 2 and those from
san Fernando General Hospital, a 3. Following this numerical notation will be the Patients initials
followed by their birth date in the form DMMYY.
All information regarding patient records will be locked in the office of the supevisor and will only be
accessible by the group leader.
For example, Jane Doe (born 1
st
January, 1950) and a patient at Port of Spains clinic will be assigned the
alpha-numeric code: 2JD010150.


Expected Outcomes
It is predicted that the current practices of asthma control by the patients of Trinidad will indicate poor
adherence to national and international guidelines and that the awareness and complete understanding
of these guidelines by the majority of these individual patients would need to be increased. For these
reasons, it is expected to see continued increase in the prevalence of asthma. Thus, it is expected that
the results of this research will indicate poor perception of asthma control in Trinidad.

Dissemination of Findings Strategy
Information obtained from surveys carried out in different chest clinics in Trinidad will include
information about the asthma patients like the severity of symptoms, their frequency of hopsital visits,
patients knowledge on their inhaler medication as well as medical history. The survey also dives into
what the patient believes is his/her level of control. This information will be used to determine if
guidelines are being well implemented in Trinidad to provide the quality of asthma treatment as set out
by guidelines both internationally and regionally.
The findings of this survey would then be presented to various regional and national health authorities
so thatthe research activities of the University of The West Indies can be integrated and refrenced to
better provide medical treatment to asthmatic patients. In addition, these findings can be used as a
medium to assist other researchers and doctors in better evaluating patients perception of asthma
control and what can be done on their part to improve it. In this way, public health efforts toward
improving asthma control and clinical management can be achieved, and current efforts to shed light on
patient perception of asthma control can be strengthened.






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