METHODS TO ASSESS ASTHMA SELF-REGULATION IN FEMALE

PATIENTS

Noreen M. Clark, Molly Z. Gong, Melissa A. Valerio,

Jimmy Yu, Xihong Lin, William F. Bria, Timothy B. Johnson

Supported by NHLBI Grant HL60884

May 22, 2001

BACKGROUND

Recent research suggests that self-regulatory management of asthma follows a sequential path.

A four-phase model of self-regulatory control of asthma was assessed in our research, using a qualitative data collection instrument, the Asthma Self-Regulatory Development Interview (ASRDI), used by Zimmerman and colleagues (1997).

PURPOSE

The general purpose of the study was to examine whether the ASRDI and four-phase model of self-regulation development used in childhood asthma could be used to assess self-regulation in women with asthma.

AIMS• assess asthma self-regulation phases using the

ASRDI

• explore modifying the ASRDI from a qualitative research instrument to a quantitative one

• evaluate the modified self-regulation assessment scale

SAMPLE

Data were collected by telephone from a total of 100 women,18 years of age or older, with a diagnosis of asthma.

White89%

6%5%

51-60

30% 41-50

26%

31 - 40

23%

61 - 70

13%

>70 years 1%

20 - 30 6%

< 20 1%

African - American Other

Ethnicity & Age

Annual Household Income & Education

< 20 K10%

60 - 80 K17%

80 - 100 K13%

> 100 K21%

20 - 40 K20%

40 - 60 K19%

< 20 K10%

60 - 80 K17%

80 - 100 K13%

> 100 K21%

20 - 40 K20%

40 - 60 K19%

4 Years College

34%

Post Grad17%

High SchoolGrad 29%

2 Years College

18%

4 Years College

34%

Post Grad17%

High SchoolGrad 29%

2 Years College

18%

< High School Grad 2%

At Home 21% Full

Time 52%Part

Time 27%

Marital & WorkingStatus

Single 14%

Married 73%

Divorced 10%

Widowed 3%

Medical Insurance

Yes

No

Yes

No98%

2%

METHODS

1. Assessed women’s asthma

self-regulation phases using the

Asthma Self-Regulatory

Development Interview (ASRDI)

THE FOUR PHASES OF ASTHMA SELF-REGULATION

(Zimmerman et al.)

Phase I - Asthma Avoidance

Phase II - Asthma Acceptance

Phase III - Asthma Compliance

Phase IV - Asthma Self-Regulation

Phase I – Asthma Avoidance:Less than three of the items in Phase II were passed

Scoring CriteriaPhase ASRDI items

PASS FAIL

II

1. Do you ever worry that you may notbe able to get to the doctor orhospital in time to get the care youneed for asthma? Why or why not?

Any mention ofworry

Fail to indicateworry

II

2. Do you feel that your asthma restrictsdaily activities or prevents you frombeing able to do the things you wouldlike to do? Please explain.

Any mention ofrestrictions

Fail to indicateasthma restrictions

II3. How serious can your asthma be?

Please explain.Mention limitationin lives or long-term consequences

Fail to indicate thatasthma ispotentially lifethreatening or haspotential long-termconsequences

II

4. Do you feel that your asthma couldpossibly be life threatening ifnothing is done to treat it? Why orwhy not?

Agree that asthmacan be lifethreatening

Disagreement thatasthma could be lifethreatening

Phase II – Asthma Acceptance:Three or all of the four items in Phase II were passed

Scoring CriteriaPhase ASRDI items PASS FAIL

III1. How important is it for you to

have regularly scheduledappointments with the doctorfor your asthma? Why?

Indicate that thepatient keepsregularly scheduleddoctor visits

Fail to indicate thatthe patient keepsregularly scheduleddoctor visits

III2. How important is it to take all

the medicines at the exactdosage that the doctor hasprescribed? Why?

Indicate adherence

Fail to indicateadherence to theprescribedmedicine

III

3. If the asthma medicine thatthe doctor prescribes doesn’tseem to help you, howimportant is it to continuetaking it? Why?

Indicateconsultation withthe doctor foralterations

Fail to indicateconsultation withthe doctor beforechanging medicine

Phase III - Asthma Compliance:Two or all of the three items in Phase III were passed

Scoring CriteriaPhase ASRDI items

PASS FAIL

IV1. Do you have any special method to

check for early signs of an oncomingasthma attack? What is it?

Specify early symptomsof an attack

Fail to specify earlysymptoms of anattack

IV2. Do you have any special procedure

that you follow starting at the first signof an asthma attach? What is it?

Specify the rescuemedicines that must beadministered at the firstsign of an attack

Fail to specify therescue medicines

IV3. Do you have a systematic plan to

adjust your medicine if the pattern ofyour symptoms gets better or worse?What is it?

Stepped plans that havebeen worked out with thedoctor

Fail to indicate astepped medicationplan with the doctor

IV4. Do you have any special procedure for

observing changes in your symptomsafter you take asthma medicine? Whatis it?

Indicate the necessity ifpersonally monitoringspecific symptoms

Fail to indicate thenecessity ifpersonallymonitoring specificsymptoms

Phase IV – Asthma Self-Regulation:Three or all of the four items in Phase IV were passed

Two differences were identified when using ASRDI to measure self-regulation phases in women with asthma versus children with asthma. 1. The four self-regulatory phases are not as sequential in women with asthma as in children with asthma. Over 25% of the women who correctly answered questions related to a higher ASRDI phase did not pass a lower or previous phase.

Examples of Women’s Scores and Phases

Phase Subject1

Subject2

Subject3

Subject4

Subject5

Subject6

Subject7

Subject8

0 1 1 0 0 0 0 01 1 0 1 0 0 0 00 1 1 1 0 0 0 1I/II

0 1 1 1 1 1 0 00 0 1 0 1 1 0 01 0 1 1 1 0 1 1III0 0 1 1 1 1 1 10 0 0 1 1 0 1 00 1 1 0 1 1 1 00 1 0 1 1 1 0 0IV

0 0 1 1 0 0 1 0Phase I II III IV I or V? I or II? I or IV? I or III?TotalScore

2 6 8 8 7 5 5 3

2. When using the ASRDI with women versus children, some responses could not be clearly scored as ‘pass’ or ‘fail’ only. Finer levels of classification of ASRDI responses appear to be needed for women with asthma.

Example 1 - First item in Phase I or II

Do you ever worry that you may not be able to get to the doctor orhospital in time to get the care you need for asthma? Why or whynot?

Yes/ No Responses Comments

No“The rescue inhalers havealways worked.”

Clearly responds notworried

Yes

“I had a very bad attack twoyears ago and did not knowwhat brought it up.”

Clearly respondsworried

No

“I haven’t had anything reallybad happen. So, I try not toworry.”

Does not clearlyrespond (worried or notworried)

Did notanswerwithyes/ no

“I was worried when I had onereal bad attack. I am notworried because I know what todo. I’d call the doctor orambulance.”

Does not clearlyrespond (worried or notworried)

Example 2 - Third item in Phase III

If the asthma medicine that the doctor prescribes doesn’t seem to helpyou, how important is it to continue taking it? Why?

Howimportant

Why? Comments

Very

“Will continue to take medicineuntil I can get to the doctor’soffice to change it.”

A good responsereflecting a ‘Yes’

Not at all“If it’s not working, I just won’ttake it.”

A clear response of ‘No’

Very“I’d keep increasing dosageuntil it works.”

Not a correct 'Yes'response

Kind of“I’d continue (taking it) becauseof hope that it would make mefeel better eventually.”

An unclear response

To allow for greater variation in

responses, we developed a Numerical

Coding and Scoring System. We

classified responses into five categories,

from the most self-regulatory-like

response (5) to the least (1), for each item

in each phase.

Women Numerical Coding andScoring System

Phase Lowest Highest

I/II 4 20

III 3 15

IV 4 20

Overall 11 55

NUMERICAL CODING & SCORING SYSTEM

Code

Do you every worry that you may not be able to get to thedoctor or hospital in time to get the care you need forasthma? Why or why not?

5

Very worried – Cannot breathe. Have no control overasthma. Health services not quickly available or easy to getto.

4Worried – If do not have medicines with them or if it a badtime of the year for their asthma, including bad seasons.

3

Somewhat worried – Know asthma can be serious.Currently not very worried because think their asthma ismanaged or controlled.

2 A little worried – Try not to worry about asthma.

1Not at all worried – Asthma is never that bad. Don’t needER.

Codes - First item in Phase I or II

Codes - Third item in Phase III

CodeIf the asthma medicine that the doctor prescribes doesn’tseem to help you, how important is it to continue taking it?Why?

5Very important - continue taking it until to consult with thedoctor

4Important - some medicine takes time to work. Hope it’llwork eventually. Did not mention to consult the doctor.

3

Somehow - depends, not sure, why the medicine does notwork, try to find a reason: other triggers? Cold? Did notsay to continue take it or did not mention to consult thedoctor. Or stop taking it before talk to the doctor.

2 Stop taking it with some reasons, such as, side effects

1Stop taking it. Switch to another medicine withoutconsultation with the doctor.

DATA ANALYSIS

&

RESULTS

Factor Analysis

ASRDI Factor 1 Factor 2 Factor 3

Numerica l Coding & Scoring System

Factor 1 Factor 2 Factor 3

II.2 0.80411 -0.15622 -0.25349 II. 3 0.78404 0.17264 0.07457

II.1 0.69494 -0.0443 0.01539 II. 1 0.77724 0.04207 0.21302

II.4 0.57099 0.08623 0.19139 II. 4 0.76145 0.2568 0.16061

II. 3 0.46137 0.19424 0.29325 II. 2 0.72635 0.0223 0.12186

III. 3 0.43487 0.0963 0.21474 III. 2 0.20709 -0.00526 0.79616

IV. 1 -0.22655 0.7439 -0.01231 III. 1 0.31751 0.09742 0.69602

IV. 4 0.00785 0.6937 0.02812 III. 3 -0.01433 0.39476 0.65492

IV. 3 0.09031 0.67229 -0.20705 IV. 1 0.12502 0.76096 0.03904

IV. 2 0.27989 0.5232 0.07509 IV. 2 0.27862 0.7458 0.05785

III. 1 -0.01021 -0.08755 0.80413 IV. 3 0.02122 0.71295 0.06317

III. 2 -0.0002 -0.07203 0.79289 IV. 4 0.07112 0.69839 0.2556

Association between women’s asthma regulation phases and asthma outcomes using the ASRDI scoring system:

ASRDIScoringSystem

Number ofnighttimesymptoms

Number ofgender related

problems

Overall scoreof

managementbehavior

Number of EDvisits in the

past 12 months

Overall score ofquality of life

Phase N Age Mean SD Mean SD Mean SD Mean SD Mean SD

1 46 46.4 31.87 56.64 3.96 2.54 88.11 27.61 0.065 0.25 24.59 7.55

2 4 39.8 25.25 21.65 4.5 4.04 27.89 1.77 1.25 1.89 32.00 3.37

3 21 47.4 60.81 32.75 6.67 3.04 102.62 24.02 0.52 0.98 42.86 11.36

4 28 49.7 43.21 35.00 5.66 2.88 128.59 17.09 0.69 1.17 38.17 10.93

p-values (ANOVA) 0.1056 0.0024 0.0001 0.0034 0.0001

Association between women’s asthma regulation phases and asthma outcomes using the new coding system:

NewCodingSystem

Number ofnighttimesymptoms

Number ofgender related

problems

Overall scoreof

managementbehavior

Number of EDvisits in the

past 12 months

Overall score ofquality of life

Phase N Age Mean SD Mean SD Mean SD Mean SD Mean SD

1 25 45 34.2 72.87 3.76 2.65 80.56 23.01 0 NA 23.92 6.12

2 24 46.6 37.08 31.15 4.71 3.22 84.54 24.32 0.5 1.142 29.71 11.49

3 37 48.5 51.47 37.55 5.58 2.66 117.76 18.21 0.47 0.951 37.13 12.13

4 13 49.4 30.46 21.78 6.54 3.23 137.46 15.73 0.69 1.032 42.08 10.00

p-values (ANOVA) 0.3531 0.0214 0.0001 0.0794 0.0001

Further Quantitative Plan

Closed Question ResponsesPhase ASRDI items5 4 3 2 1

I/II

1. Do you worry thatyou may not be ableto get to the doctoror hospital in time toget the care youneed for asthma?

Veryworried

WorriedSome-what

worried

A littleworried

Not atall

worried

III

3. If the asthmamedicine that thedoctor prescribesdoesn’t seem to helpyou, how importantis it to continuetaking it until youcontact your doctor?

Veryimportant

Important

Some-what

impor-tant

A littleimpor-

tant

Not atallimpor-tant

TENTATIVE CONCLUSIONS

1. The four-phase self-regulation model and asthma self-regulatory

development

interview items can be adapted to assess self-regulation in women

with asthma.

2. The modified quantitative scoring system can be both effective and efficient to assess self-regulation in women with asthma.