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Journal of Asthma

ISSN: 0277-0903 (Print) 1532-4303 (Online) Journal homepage: http://www.tandfonline.com/loi/ijas20

Feasibility of a worksheet for facilitating self-


management in children with asthma

Kyrie L. Shomaker MD & Stephanie H. DeVeau-Rosen MD

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

To link to this article: http://dx.doi.org/10.3109/02770903.2015.1101472

Published online: 29 Jan 2016.

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http://tandfonline.com/ijas
ISSN: 0277-0903 (print), 1532-4303 (electronic)

J Asthma, 2016; 53(4): 419426


! 2016 Taylor & Francis. DOI: 10.3109/02770903.2015.1101472

MANAGEMENT AND CONTROL

Feasibility of a worksheet for facilitating self-management in children


with asthma
Kyrie L. Shomaker, MD and Stephanie Hom DeVeau-Rosen, MD

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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goals, barriers to reaching goals and plans for overcoming


to guide the discussion, empowering them with the tools to
barriers; and self-assessments of belief (How much do you
make life-changing decisions. Motivational interviewing is
think these goals will improve your/your childs asthma?)
best known for its role in smoking cessation but it has also
and confidence (How confident are you that you can meet
been utilized in other settings, including promotion of
these goals?) each measured on a 16 Likert scale.
healthy dietary modifications such as increasing intake of
Worksheet text along with pre-visit and post-visit survey
fruits and vegetables, and short term reduction in viral
assessment questions are shown in Table 1.
load and unprotected sexual acts by HIV positive youth
The worksheet was evaluated for face validity by a group
[1517].
of 10 physicians with expertise in pediatric asthma and
Tools designed to aid practitioners adoption of self-
chronic disease management. Feedback to improve clarity
management techniques into routine care have become
was incorporated. The resulting worksheet read at the seventh
increasingly available, including visual aids for negotiating
grade literacy level.
an agenda, goal-setting and rating confidence and readiness
to change [1820]. Despite strong evidence supporting self- Setting
management tools and motivational interviewing as a
means of improving patient outcomes, reducing disease The Childrens Hospital of The Kings Daughters in Norfolk,
morbidity and decreasing healthcare costs in adults, few Virginia serves the greater Hampton Roads/Tidewater region,
such tools exist for pediatrics and none exist for pediatric encompassing more than 20% of Virginias pediatric popu-
asthma. lation [22]. Pilot testing took place between May and July of
The aim of this study was to trial a newly designed 2014. As asthma patient volumes are typically lower in
Asthma Self-Management Worksheet for Patients/ summer months, both the inpatient ward and the outpatient
Caregivers, which was modeled on available self-manage- allergy clinic were selected as sites for subject recruitment.
ment tools for other chronic conditions and focused on
asthma-related vital behaviors. We hypothesized the work- Subjects
sheet would be an engaging and understandable tool to use for English-speaking patients aged 1218 years and parents or
negotiating behavior change relating to asthma, and feasible guardians of children aged 111 years with attending
enough to introduce into a routine care setting. Further, we physician-diagnosed asthma were eligible for enrollment in
hypothesized that introducing a worksheet with clearly the study. All eligible subjects presenting between the hours
defined goals for behavior change would permit tracking of 8:00 am and 5:00 pm from Monday through Friday of each
patient-centered progress in disease management over time, week were given the opportunity to participate. Each subject
as recommended by the National Asthma Education and was enrolled only once. Consent was obtained from all
Prevention Program (NAEPP) and Institute for Healthcare parents or guardians who participated, or whose children
Improvement (IHI). participated, in the study. Assent was obtained from children
aged 1218 years. No incentives were provided. Subjects
Methods were informed that their participation would not impact their
subsequent care or become part of their medical record.
This study used a non-experimental design to pilot test a
novel asthma worksheet in a convenience sample of children
Worksheet administration
presenting for asthma care. This study was approved by the
Institutional Review Board of Eastern Virginia Medical A single research assistant enrolled patients and administered
School. the pre-visit survey questions, worksheet, and post-visit
DOI: 10.3109/02770903.2015.1101472 Self-management worksheet for pediatric asthma 421
Table 1. Study questions.

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

Table 2. Subject characteristics.

Inpatient ward (n 15) Allergy clinic (n 26)


Overall (n 41)
% (n) % (n) 95% CI % (n) 95% CI p
Patient age, mean in years 8.2 5.2 3.56.9 10 8.311.6 50.01a
b
Relationship of subject to patient
Self 22 (9) 0 (0) 020 35 (9) 1954
Mother 63 (29) 80 (12) 5593 54 (14) 3571
Father 10 (4) 13 (2) 438 8 (2) 224
Grandparent 5 (2) 7 (1) 130 4 (1) 0.719
b
Number of subjects completing each portion of the study
Worksheet 100 (41) 100 (15) 80100 100 (26) 87100
Telephone follow up 37 (15) 47 (7) 2570 31 (8) 1650

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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Subjects asthma knowledge ratings increased significantly


description of a new technique rather than testing for
from the pre-visit to the post-visit survey (p 0.01; Table 3).
outcomes. Demographics, worksheet duration, topic selec-
Increases in numerical Likert scale values were greatest in
tion, themes of self-management goals and barriers and
subjects recruited from the clinic compared to the ward
answers to Likert scale questions are quantified and
(average +0.7 points per subject versus +0.1) and subjects
reported descriptively. Demographics between subjects
who were patients versus caregivers (+0.7 versus +0.4); all
recruited from the inpatient ward and those recruited
subjects who were themselves patients were recruited from
from the allergy clinic were compared using the Wilson
the clinic.
score for proportions. Subjects ratings of their overall
asthma knowledge in the post-visit survey were compared
Preliminary outcomes
to their pre-visit survey answers using the paired t-test with
a 95% confidence interval. Concordance between topics Frequency of worksheet topic selection and related behavior
selected by subjects and those found in the patients changes selected by subjects as self-management goals are
physician documentation was analyzed with the McNemars shown in Table 4. The most frequently selected topic overall
test when there were more than 20 discordant pairs; was Topic 10 (Avoid known allergens). The topics chosen
otherwise the Fishers exact test was used. p Values 50.05 least frequently were Topic 1 (Regular medical check-ups
were considered significant. Calculations were performed for child) and Topic 4 (Keep home and car smoke free).
using OpenEpi software (Atlanta, GA) version 3.03a, Subjects recruited from clinic and subjects who were
updated 05/04/2015. themselves patients were more likely to select Topics 9
(Keep furry pets out of bedroom) and 12 (Clean up
Results food spills, seal up holes) than subjects recruited from the
wards and subjects who were caregivers. Subjects recruited
Worksheet feasibility and acceptance
from the wards were more likely to select Topic 1 (Regular
Forty-one of 46 eligible subjects agreed to participate (89%). medical check-ups for child) than subjects recruited from
Two potential inpatient ward subjects (4%) declined and an the clinic.
additional three (7%) were encountered on the wards without Interestingly, on one occasion an 8-year-old patient too
a parent present to consent. The 41 remaining subjects young to complete the worksheet but old enough to under-
completed the worksheet. Of these, 40 had physician docu- stand it indicated he wanted his mother to select Topic 4
mentation of the subsequent visit available. Fifteen subjects (Keep home and car smoke-free) despite her selecting
completed telephone follow up. Demographics of the study alternate topics.
subjects are shown in Table 2. Forty-one subjects listed a total of 121 specific self-
The average time required for worksheet completion was management goals using the worksheet, comprising 40 of the
5:47 min (Table 3). Ninety-eight percent of subjects found the 64 unique behavior changes provided as possibilities (Table 4;
worksheet easy or very easy to read. One 6-year-old Topics 6 and 7 provide the same suggestions). The goals
child did not like the illustration accompanying the topic generated by subjects were concordant with the topics they
Yearly flu shot. Ten subjects (24%) required additional had selected 83% of the time. In 15% of cases, goals were
explanation of the term barriers to reaching goals. Parents related to a different topic on the worksheet; only 2% of self-
spontaneously reported interest in seeing if my goals show management goals were not topic-related. For topics with
improvement, that they learned a lot and that the many potential behavior change options, subjects chose a
worksheet was helpful, particularly five (12%) who variety of self-management goals, some of which were more
reported unwittingly using a humidifier before learning that specific than the illustrated topic itself, such as checking
DOI: 10.3109/02770903.2015.1101472 Self-management worksheet for pediatric asthma 423
Table 3. Worksheet feasibility and acceptance.

Mean (range) 95% CI


Time required in minutes 5:47 (3:3013:00) 5:116:22
How easy to read was the worksheet you just completed? % (n)
1 Very difficult 0 (0)
2 Difficult 0 (0)
3 Neutral 2 (1)
4 Easy 17 (7)
5 Very easy 81 (33)
How well do you understand what you can do to improve Pre-visit Survey Post-visit Survey p
your (your childs) asthma? % (n) % (n)
1 Not very well at all 5 (2) 0 (0)
2 A little 5 (2) 2 (1)
3 Some 10 (4) 5 (2)
4 Pretty well 51 (21) 39 (16)
5 Extremely well 29 (12) 54 (22) 0.01a
a
p value calculated by paired t-test of the pre-visit versus post-visit survey distribution.

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

Table 5. Examples of barriers to change.

Themes Examples of barriers Examples of plans to overcome barriers


Household modification sometimes AC doesnt work use a clean fan
washing curtains is difficult vacuum and steam
Smoking avoidance trying to stop my husbands smoking in car seeking professional help
Allergen avoidance I dont know how to monitor pollen count Learn how to monitor pollen count and what number
to watch for
Medication adherence skipping his medicine when I think hes okay I need to give medicine
I forget to take medicine sometimes put medicine by laptop each day
Positive self-talk and planning plan ahead
reinforce decisions
make the time
talk to his teacher and nurse

Frequency of Topic Selection/Documentation


Figure 1. Frequency of topics selected for 35
further asthma education, by patients (or their
parents) compared to physicians. *Difference 30
is statistically significant at the p50.001
25
level; yDifference is statistically significant at
the p50.015 level. 20
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*
15 * *

10 * *

5 *

Patient selections Physicians documenting

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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the physician. Use of the worksheet facilitated discovery of


abundant data regarding ongoing trigger exposure which in Incorporating a self-management worksheet for pediatric
some cases did not appear to be disclosed during the asthma into a clinical encounter is brief and feasible in the
subsequent encounter with the physician. Whereas documen- clinical setting without significant costs. Using an illustrated
tation from each clinical encounter revealed active medical worksheet to negotiate a patient-centered agenda engaged
management of a variety of asthma-related issues, topics patients and parents in considering behavior change and
selected by patients led, by design, to behaviors subjects could setting self-management goals that were complementary to
modify independently. Ideally, future studies would use the physician recommendations. Broader study of this worksheet
worksheets goals, barriers and measures of belief and in clinical settings should determine its effectiveness with
confidence to track subjects self-efficacy over time. different patient populations, and whether the tool can be self-
Questions remain about the optimal administration of such administered or is better administered by staff trained in
a worksheet in the clinical practice environment. The IHI motivational interviewing techniques. Integration of such a
suggests setting an agenda with the patient during the clinical worksheet into the medical record is recommended to
visit, and that, in the assignment of roles to members of the facilitate tracking of behavior change goals and their impact
healthcare team, non-clinicians can be as effective at on clinical outcomes over time.
motivating and coaching as physicians [19]. Although
certified asthma educators are an appealing choice, there Acknowledgements
are less than 4000 certified educators nationally meaning The authors wish to thank Ms. Ashley Stevenson for her work
many practices will not have a certified educator on staff [29]. as the research assistant for this project.
We used a research assistant to deploy the worksheet in the
study environment. Though some portions of the worksheet Declaration of interest
could be completed independently, or electronically, a staff
member with some training in motivational interviewing The authors report no conflicts of interest. The authors alone
techniques and self-management support would be desirable are responsible for the content and writing of the paper.
in helping patients through some of the more difficult aspects
of worksheet deployment, such as the prompt to generate References
potential barriers to change, measurements of belief and 1. Akinbami L, Moorman J, Bailey C, Zahran H, King M, Johnson C,
confidence and follow up on goals between visits. Liu X. Trends in asthma prevalence, health care use, and mortality
in the United States, 20012010. Department of Health and Human
Services Centers for Disease Control and Prevention. Hyattsville
Study limitations (MD): National Center for Health Statistics; 2012:18.
2. Cui W, Zack M, Zahran H. Health-related quality of life and asthma
The small sample size of this pilot study, taking place over among United States adolescents. J Pediatrics 2015;166:358364.
one summer season at one institution, addressed feasibility 3. Expert Panel Report 3: guidelines for the diagnosis and manage-
but prevented us from performing any subgroup analyses ment of asthma (EPR-3 2007). Bethesda, MD: U.S. Department of
Health and Human Services; National Institutes of Health; National
about the effectiveness of the asthma worksheet amongst Heart, Lung, and Blood Institute; National Asthma Education
subjects from various clinical environments, socio-economic/ and Prevention Program, 2007 Contract No.: NIH Publication
race backgrounds and degrees of asthma severity. The No. 07-4051.
worksheet should be studied in a larger population of patients 4. CDCs National Asthma Control Program. Asthma self-manage-
ment education and environmental management: approaches to
over a longer timeframe, preferably within the patients enhancing reimbursement. 2013:138. Available from http://
medical home and within the context of other existing www.cdc.gov/asthma/nacp.htm [last accessed 15 Mar 2015].
426 K. L. Shomaker & S. H. DeVeau-Rosen J Asthma, 2016; 53(4): 419426

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

J Qual Saf 2003;29:563574.


Interventions to modify health care provider adherence to asthma
12. Coleman K, Austin B, Brach C, Wagner E. Evidence on the chronic
guidelines: a systematic review. Pediatrics 2013;132:517534.
care model in the new millenium. Health Affairs 2009;28:7585.
27. Riekert K, Borrelli B, Bilderback A, Rand C. The development of a
13. Gibson P, Powell H, Wilson A, Abramson M, Haywood P, Bauman
motivational interviewing intervention to promote medication
A, Hensley M, et al. Self-management education and regular
adherence among inner-city, African-American adolescents with
practitioner review for adults with asthma. Cochrane Database Syst asthma. Patient Educ Counsel 2011;82:117122.
Rev 2002;3:CD001117. 28. Sleath B, Carpenter D, Slota C, Williams D, Tudor G, Yeatts K,
14. Norris S, Engelgau M, Narayan K. Effectiveness of self- Davis S, et al. Communication during pediatric asthma visits and
management training in type 2 diabetes. Diabetes Care 2001;24: self-reported asthma medication adherence. Pediatrics 2012;130:
561587. 627633.
15. Lindson-Hawley N, Thompson T, Begh R. Motivational interview- 29. Certificant Corner. National Asthma Educator Certification Board;
ing for smoking cessation. Cochrane Database Syst Rev 2015;3: 2013. Available from: https://naecb.com/certificant-corner.php [last
CD006936. accessed 22 July 2015].
16. Resnicow K, Jackson A, Wang T, De A, McCarty F, Dudley W, 30. Brueton V, Tierney J, Stenning S, Harding S, Meredith S,
Baranowski T. A motivational interviewing intervention to increase Nazareth I, Rait G. Strategies to improve retention in
fruit and vegetable intake through black churches: results of the Eat randomised trials. Cochrane Database Syst Rev 2013;Art. No.:
for Life trial. Am J Public Health 2001;91:16861693. MR000032.
17. Mbuagbaw L, Ye C, Thabane L. Motivational interviewing for 31. Pill R, Stott N, Rollnick S, Rees M. A randomized controlled trial
improving outcomes in youth living with HIV. Cochrane Database of an intervention designed to improve the care given in general
Syst Rev 2012;9:CD009748. practice to Type II diabetic patients: patient outcomes and
18. Stott N, Rollnick S, Rees M, Pill R. Innovation in clinical method: professional ability to change behaviour. Fam Pract 1998;15:
diabetes care and negotiating skills. Fam Pract 1995;12:413418. 229235.

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