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To cite this article: Kyrie L. Shomaker MD & Stephanie H. DeVeau-Rosen MD (2016) Feasibility
of a worksheet for facilitating self-management in children with asthma, Journal of Asthma,
53:4, 419-426, DOI: 10.3109/02770903.2015.1101472
Article views: 42
Eastern Virginia Medical School and The Childrens Hospital of The Kings Daughters, Norfolk, VA, USA
Abstract Keywords
Background: Few tools exist to facilitate recommended self-management support for children Education, health behavior, motivational
with asthma. We sought to examine the feasibility, acceptance and preliminary results of a interviewing, patient-centered care,
novel worksheet designed to provide such support for children and their caregivers presenting pediatric
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for asthma care. Methods: A 12-topic asthma worksheet was modeled on currently available
self-management tools and based on the behavior change theory and motivational History
interviewing techniques. Children 118 years old with asthma and their caregivers were
recruited from an allergy clinic and an inpatient ward to pilot test the worksheet by choosing Received 17 March 2015
three topics, generating self-management goals for each topic and assessing their self-efficacy Revised 22 July 2015
for behavior change. Physician documentation of the visit was reviewed for comparison. Accepted 25 September 2015
Telephone follow up of self-management goals occurred 1 week after the visit. Results: Forty- Published online 21 January 2016
one of 46 eligible subjects agreed to participate (89%). Average completion time was 5:47 min
(range 3:3013:00). Most of them (98%) found the worksheet easy to understand, with minor
modifications suggested. Topics most commonly selected were distinct from topics docu-
mented by physicians in the subsequent encounter (p50.01). Subjects generated 121 total self-
management goals; 93% were at least moderately confident they could meet the goals. All 15
subjects reached by phone (37%) had achieved at least one goal at follow-up. Conclusions:
A worksheet designed for self-management support of children is brief, feasible and acceptable
in the clinical environment. This tool captures unique patient-centered preferences for behavior
change, and shows promise for facilitating goal-setting and self-management education in the
routine clinical care of pediatric asthma.
Introduction
outcomes, is an effective approach to behavior change that has
Currently 7 million children in the US suffer from asthma [1]. been used to overcome phobias, reduce criminal recidivism
National surveillance data indicate poor control of asthma in and curb the transmission of guinea worm [9]. The focus on
up to two-thirds of these children [2]. Exacerbation of behaviors, rather than outcomes, overcomes the obstacles to
symptoms leading to school absenteeism, urgent care and success that occur when a person does not know how to
emergency department visits, hospitalization and even death achieve the desired outcome. In the case of pediatric asthma,
continue despite the publication of updated guidance on the vital behaviors include adherence to controller medica-
evidence-based management of asthma in 2007 [3,4]. tions, avoidance of smoke exposure and other triggers,
In order to achieve better asthma control, children and their allergen avoidance, environmental modification, cleaning
families must change their lifestyle, adopting behaviors and planning ahead [3,10].
associated with improved health. Simply imparting know- Self-management support and motivational interviewing
ledge to patients on the importance of lifestyle change does are effective techniques for facilitating behavior change in the
not account for the complexity of behavior change, and fails healthcare setting [3,5,11]. A critical analysis of pediatric and
to positively affect asthma outcomes [3,58]. Even when adult asthma by the Agency for Healthcare Research and
patients receive and comprehend effective health counseling, Quality recommended self-management with a variety of
they must learn these new behaviors, and then determine how educational techniques that include childrens caregivers [5].
to incorporate the new behaviors into daily life. Self-management support is one of the six core components
Focusing change efforts on vital behaviors, or those of the Chronic Care Model (CCM), an integrated framework
behaviors known to be necessary and sufficient for positive for healthcare delivery which has been associated with long-
term improvements in quality of care and outcomes for
patients with chronic disease [12]. A Cochrane review of 36
Correspondence: Kyrie L. Shomaker, MD, Associate Professor,
Department of Pediatrics, 601 Childrens Lane, Norfolk, VA 23507, adult asthma trials compared self-management education,
USA. Tel: +1 757-668-8177. E-mail: kyrie.shomaker@chkd.org including regular medical reviews, peak expiratory flow or
420 K. L. Shomaker & S. H. DeVeau-Rosen J Asthma, 2016; 53(4): 419426
symptom monitoring and a written action plan, with usual Worksheet development
care, which included a variety of interventions. Self-manage-
The Asthma Self-Management Worksheet for Patients/
ment education was found to improve patient quality of life
Caregivers was modeled after self-management support
and reduce hospitalizations, emergency room visits, unsched-
tools available online, which incorporate a patient-centered
uled visits to the doctors office, missed school or workdays
agenda-setting tool, collaborative and realistic goal develop-
and nocturnal asthma symptoms compared to usual care [13].
ment, anticipatory problem-solving and assessments of
Another systematic review compared 84 articles to determine
conviction and confidence as described in the Chronic
whether self-management training could improve outcomes in
Care Model and motivational interviewing techniques
adult patients with type 2 diabetes. Short-term follow-up of
[8,11,1820]. In addition, the concept of vital behaviors
these patients demonstrated improved patient knowledge,
was incorporated into the worksheet by reviewing American
frequency and accuracy of self-monitoring of blood glucose
Academy of Pediatrics (AAP) and NAEPP educational
levels and glycemic control [14]. Thus, self-management
materials for important themes contributing to asthma control,
education has proven helpful in a variety of chronic disease
then converting themes into actionable topics to portray in the
settings.
agenda-setting portion of the worksheet [3,9,21]. For
Motivational interviewing is a technique designed to
example, the theme of avoiding passive smoke exposure was
stimulate behavior change, often used to facilitate self-
modified into the actionable topic Keep home and car
management support. Participants work with a counselor to
smoke-free.
assess their readiness to change and sort through the
The worksheet consists of a table with twelve color-
hesitancies that prevent them from doing so. This method
illustrated topics; prompts for listing three self-management
of conversation is patient-centered and enables participants
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Question Category
Pre-visit survey questions
What is your relationship to the patient? Demographics
How well do you understand what you can do to improve your (your childs) asthma? (1 Not very well Knowledge
at all to 5 Extremely well)
Asthma Self-Management Worksheet for Patients/Caregivers (Timed)
What is the patients age? Demographics
In the following table, circle three items that you would like to learn more about at todays visit. Topics
1. Regular medical checkups for child
2. Take controller medicine twice a day
3. Use spacer with inhaled medicine
4. Keep home and car smoke-free
5. Carry rescue medicine with you
6. Use mattress and pillow covers
7. Wash and dry bedding on hot cycle
8. Yearly flu shot
9. Keep furry pets out of bedroom
10. Avoid known allergens
11. Keep household fumes away
12. Clean up food spills, seal up holes
Please list your three asthma self-management goals. Self-management goals
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Please list any barriers you may have in reaching these goals. Barriers
Please list your plan for overcoming the barriers you listed. Barriers
How much do you think these goals will improve your (your childs) asthma? Belief
(1 definitely wont to 6 definitely will)
How confident are you that you can meet these goals? Confidence
(1 not at all confident to 6 extremely confident)
Post-visit Survey Questions
Since completing the worksheet, how well do you understand what you can do to improve your (your Knowledge
childs) asthma? (1 Not very well at all to 5 Extremely well)
How easy to read was the worksheet you just completed? (1 Very difficult to 5 Very easy) Worksheet feedback
Which pictures or words, if any, were confusing to you? Worksheet feedback
survey questions to each subject in the clinic or ward prior to routine medical care. Written self-management goals, barriers
her physician visit that day. Patient age and location of to change and plans to overcome barriers were subsequently
enrollment were recorded. Completion of the worksheet reviewed for themes by each of the authors.
portion of the study was timed with a stopwatch. For each of
the three topics selected by the subject, the research assistant Review of physician documentation
read aloud from a brief educational script prepared for that
topic from AAP and NAEPP materials, containing back- We reviewed physician documentation of the medical
ground information on the importance of that topic for asthma encounter one week after the patients visit. The pre-printed
control and a variety of potential behavior changes relevant to asthma action plan, with checkbox prompts for follow-up,
that topic. For example, background information for the topic triggers, controller and rescue medication use, was not
Keep home and car smoke free contained facts such as reviewed for this purpose. Phrases indicating discussion of
Children who come from homes where people smoke make any of the 12 topics on the asthma worksheet were extracted
more than twice as many emergency hospital visits as children and categorized according to topic by the authors. Topics
who are not exposed to smoke and suggested additional documented by physicians during the patients medical
behavior changes such as remove ashtrays from your encounter were compared with worksheet topics selected by
home, and avoid taking your child to homes where that patients subject for concordance.
people smoke [3,21]. The subject was prompted to write
down one behavior change (self-management goal) she could
Telephone follow up
undertake pertaining to the topic. This process was repeated
for each of the three topics selected. The subject was then Subjects were contacted by telephone 1 week after worksheet
guided through the remainder of the worksheet and post-visit completion. They were asked whether the worksheet had
survey questions. Post-visit survey questions asked about the helped prepare them for talking with the doctor (yes or no),
effect of the worksheet on overall asthma knowledge and whether they remembered which three topics they circled
(measured from 15 on a Likert scale) compared to the pre- on the worksheet (possible score 03). Subjects were then
visit survey, and explicitly requested feedback on the work- asked about each written goal, Tell me about how [self-
sheet itself by rating the ease of readability and an open-ended management goal X] has worked for you since your (your
response to the question, Which pictures or words, if any, childs) visit? to assess completion (possible score 03).
were confusing to you? Each subject retained a color copy Three attempts were made to contact each subject before they
of her completed Asthma Worksheet, and then proceeded with were considered lost to follow up.
422 K. L. Shomaker & S. H. DeVeau-Rosen J Asthma, 2016; 53(4): 419426
CI confidence interval.
a
p Value calculated by the Wilson score.
b
Chi-square calculation could not be performed due to small numbers within each subgroup.
Statistical analysis dry air improves dust mite control from Topics 6 and 7. All
topics were selected by at least five subjects, suggesting that
A power calculation was not performed to identify a
all topics were conveyed comprehensibly.
minimal sample size as the goal of the pilot was
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Table 4. Preliminary outcomes: selection of worksheet topics and most frequent self-management goals.
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Worksheet topic
Recommended behavior changes chosen as self-management goals Theme
a
1. Regular medical checkups for child (5) Assessing and monitoring asthma control
Schedule a follow-up visit for asthma within 1-6 months (4)
2. Take controller medicine twice a day (8) Medication adherence
Take inhaled corticosteroids every day as recommended (7)
3. Use spacer with inhaled medicine (9) Medication technique
Use your spacer each time you take a puff from your inhaler (6)
4. Keep home and car smoke-free (5) Avoiding passive smoke exposure
Do not allow smoking in your car (2)
5. Carry rescue medicine with you (8) Managing asthma symptoms
Ask for a written plan to allow child to receive medications at school (4)
6. Use mattress and pillow covers (13) Reducing dust mite exposure
Use hot cycle for washing and drying linens, because dust mites can
survive in warm soapy water (4)
Avoid humidifiers and vaporizers (4)
7. Wash and dry bedding on hot cycle (15) Reducing dust mite exposure
Use hot cycle for washing and drying linens, because dust mites can
survive in warm soapy water (7)
8. Yearly flu shot (12) Preventing respiratory infections
Make sure child gets flu shot this fall (9)
9. Keep furry pets out of bedroom (10) Reducing pet dander
Keep your pet out of childs bedroom (6)
10. Avoid known allergens (23) Minimizing pollen and mold exposure
Check pollen counts and air quality reports on the internet (8)
11. Keep household fumes away (8) Avoiding odors, fumes, and nitrogen dioxide
If you cook with gas, keep kitchen ventilated at all times (use an exhaust fan) (2)
Buy unscented tissues, detergents, and household supplies (2)
Avoid using ammonia-based cleaning products, room deodorizers, incense,
mothballs, and heavily-perfumed soaps in the home (2)
12. Clean up food spills, seal up holes (7) Reducing cockroaches and other indoor pests
Use sticky traps instead of aerosol insecticides (3)
a
Numbers in parentheses represent number of subjects selecting each topic and recommended behavior change as a self-management
goal.
pollen counts and air quality reports online (Topic 10, Avoid
asthma, and all were at least somewhat confident they
known allergens).
could meet these goals.
Barriers to complying with self-management goals were
elicited for 21 subjects (45%) and were categorized into five
Review of physician documentation (n 40)
major themes (Table 5). Twenty subjects were able to
generate plans to overcome these barriers. The remaining Topics selected most frequently by subjects were distinct from
subjects cited no barriers to completing their self-manage- the topics documented by their physicians during the
ment goals. subsequent clinical encounter (Figure 1, p50.001).
Eighty-nine percent of all subjects believed their self- Physician documentation on the wards focused on follow-up
management goals would improve their (or their childs) (13/15), controller (10/15) and rescue medication (7/15) use,
424 K. L. Shomaker & S. H. DeVeau-Rosen J Asthma, 2016; 53(4): 419426
*
15 * *
10 * *
5 *
with occasional reference to avoidance of specific triggers performed in conjunction with a clinical encounter, and is
(3/15). In the clinic, allergens and triggers were routinely accepted enthusiastically by most children and their care-
documented, as were follow-up (18/25), controller (20/25) givers. Only 4% of eligible subjects chose not to participate,
and rescue medication (16/25) recommendations; allergists and 85% of subjects completed the worksheet in less than
also documented recommendations for the medical manage- 7 min.
ment of acute asthma exacerbations (6/25) and comorbid The brevity of the worksheet, suggesting feasibility for
conditions such as allergic rhinitis (17/25), sinusitis (1/25) incorporation into clinical workflow, is critical because
and food allergy (9/25). Two children being considered for asthma education requires repetition to affect outcomes
immunotherapy had parents who disclosed ongoing smoke [3,23]. Many effective pediatric asthma self-management
exposure in the home and car by completing their worksheet; programs, including classes, camps and home evaluations
this exposure was not captured in the physician with environmental modifications, have a role in improving
documentation. outcomes but are limited geographically, time-intensive
(typically 5.5 h), and require considerable resources on the
Telephone follow-up (n 15) part of the staff implementing the program [3,4,8,24,25]. By
Of the 15 subjects reached by telephone 1 week after scripting the recommendations provided for subjects selected
completing the worksheet, 93% (14/15) reported that the topics, we were able to facilitate evidence-based education
worksheet helped them feel more prepared in talking with consistent with NAEPP guidelines at a higher rate than is
their doctor. Sixty percent (9/15) were able to spontaneously described in current clinical practice, without a significant
recall at least one of their self-management goals. All had investment in training or personnel [7,26].
completed at least one of their self-management goals, 60% Though we had hoped the worksheet could be used for
(9/15) had completed two goals and 27% (4/15) had tracking behavior change goals across clinical practice
completed all three goals. environments, the results suggest that its feasibility may be
greater in the outpatient clinic than in the hospital setting.
On the inpatient ward, two parents declined to participate
Discussion
and an additional three were unavailable. Inpatient ward
In this pilot study, we demonstrated that a worksheet designed patients were younger, on average, than the clinic patients,
for pediatric asthma self-management support is brief, can be and as a result, fewer were able to complete the worksheet
DOI: 10.3109/02770903.2015.1101472 Self-management worksheet for pediatric asthma 425
themselves and receive self-management support directly. components of the Chronic Care Model to determine optimal
Topic selections were focused more often on attaining deployment and any effects on process and clinical outcomes.
follow-up than on other specific behavior changes. Though our findings suggest enthusiastic adoption by patients
Further study is needed to determine if this worksheet and families, over 60% were lost to telephone follow-up, and
provides additional benefit beyond the written home telephone recall of goals at one week was poor. High levels of
management plan of care in a hospital environment where belief and confidence at study enrollment may have biased the
higher stress and unfamiliar medical personnel are more follow-up results we obtained [30]. Studying the worksheet on
likely to be encountered. a larger scale, incentivizing study completion, investing more
Subjects committed to 40 unique self-management goals resources in follow-up assessment and ultimately, integrating
representing all 12 illustrated topics, indicating the worksheet the worksheet into the patients primary care medical home
was both efficient and successful in establishing patient- and/or electronic medical record would allow for more
centered preferences for behavior change. Negotiating a accurate monitoring of process outcomes, adherence to
patient-centered agenda for change is a motivational inter- behavior change goals and sustainability of this intervention
viewing technique that has been associated with improved over time [19,31]. One research assistant administered the
asthma outcomes, as it facilitates initial change and adherence worksheet and requested assessments of its feasibility,
to change [8,27,28]. Similar advice originating from a potentially introducing response bias depending on the
physician often provokes resistance [8]. perception of the subject even though the assistant was not
In our preliminary results, we found that the data obtained, the principal investigator.
and recommendations provided, via the worksheet were
distinct from and complementary to those documented by Conclusions
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5. Bravata D, Sundaram V, Lewis R, Gienger A, Gould M, McDonald 19. Schaefer J, Miller D, Goldstein M, Simmons L. Partnering in self-
K, Wise P, et al. Asthma Care. Rockville (MD): Agency for management support: a toolkit for clinicians. Massachusetts:
Healthcare Research and Quality, 2007 Contract No.: AHRQ Cambridge University Press; 2009:126.
Publication No. 04(07)-0051-5. 20. Boulter S, Crystal Y, Duncan P, Keels MA, Ramos-Gomez F.
6. Boyd M, Lasserson T, McKean M, Gibson P, Ducharme F, Haby M. Oral health self management goals for parents/caregivers.
Interventions for educating children who are at risk of asthma- American Academy of Pediatrics; 2011; Self-Management Tool.
related emergency department attendance. Cochrane Database Syst Available from: https://www2.aap.org/oralhealth/RiskAssessment
Rev 2009;2:CD001290. Tool.html [last accessed 11 Mar 2014].
7. Roger A, Vazquez R, Almonacid C, Padilla A, Serrano J, Garcia- 21. Welch M. Allergies and asthma: what every parent needs to know.
Salmones M, Molina F, et al. Knowledge of their own allergic 2nd ed. Elk Grove Village (IL): American Academy of Pediatrics;
sensitizations in asthmatic patients and its impact on the level of 2011:174 p.
asthma control. Arch Bronconeumol 2013;49:289296. 22. Report on the Health of Children in Hampton Roads. Consortium
8. Borrelli B, Riekert K, Weinstein A, Rathier L. Brief motivational for Infant and Child Health (CINCH)/Center for Pediatric Research,
interviewing as a clinical strategy to promote asthma medication 2005. Available from: www.chkd.org/cinch [last accessed 15 Mar
adherence. J Allergy Clin Immunol 2007;120:10201030. 2015].
9. Grenny J, Patterson K, Maxfield D, McMillan R, Switzler A. 23. Coffman J, Cabana M, Halpin H, Yelin E. Effects of asthma
Influencer: the new science of leading change. 2nd ed. New York: education on childrens use of acute care services: a meta-analysis.
McGraw Hill Education; 2013:299 p. Pediatrics 2008;121:575586.
10. Raymond K, Fiese B, Winter M, Knestel A, Everhart R. Helpful 24. Clark N, Mitchell H, Rand C. Effectiveness of educational
hints: caregiver-generated asthma management strategies and their and behavioral asthma interventions. Pediatrics 2009;123:
relation to pediatric asthma symptoms and quality of life. J Pediatr S185S192.
Psychol 2012;37:414423. 25. Elliott J, Marcotullio N, Skoner D, Lunney P, Gentile D. Impact of
11. Glasgow R, Davis C, Funnell M, Beck A. Implementing practical student pharmacist-delivered asthma education on child and
interventions to support chronic illness self-management. Jt Comm caregiver knowledge. Am J Pharm Educ 2014;78:16.
26. Okelo S, Butz A, Sharma R, Diette G, Pitts S, King T, Linn S, et al.
Downloaded by [Laurentian University] at 18:44 06 May 2016