Journalof Asthma, 33(2), 1 13-1 18 (1996)

Evaluation of Individualized Asthma

Self-Management Programs

Harry Kotses,' Cynthia Stout: Karen McConnaughy:

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John A. Winder; and Thomas L. Creerl

'o\iio University
Athens, Ohio
2Applied Materials
Santa Clara, California
3Allergy and Asthma Research Center
Toledo, Ohio
For personal use only.

ABSTRACT
We compared the effectiveness of personalized asthma self-management rec-
ommendations with that of a group self-management program. We assigned
each of 34 asthma patients randomly to one of three conditions: individualized
asthma self-management, group asthma self-management, and control. We
derived individualized self-management recommendations from patient record-
ings of asthma occurrence, asthma precipitants, and peak expiratory flow rate
made during a 3-month period. The group program we used was the Wheezers
Anonymous program. As compared to a control group of patients who received
no self-management training, the patients in both the individualized and group
condition evidenced improvement of pulmonary function, as measured daily
with a home peak flow meter. The improvement was equivalent for patients in
the two conditions. Patients in the individualized condition also exhibited a drop
in frequency of asthma attacks, but patients in the group condition did not. We
concluded that individualized asthma self-management is effective in reducing
symptoms of asthma.

INTRODUCTION One procedure involves tailoring to meet the

needs of a specific population. Programs inthis
Personalization of asthma self-management category have included training for preschool
training has been approached in several ways. children (1,2) and training for inner-city chil-

Address correspondence to: Harry Kotses, Department of Psychology, Ohio University, Athens, OH 45701.

113
Copyright 0 1996 by Marcel Dekker, Inc.
 114
dren (3,4). A second personalization procedure
consists of tailoring for the individual patient,
rather than a population, but focuses on only a
few elements of self-management. Programs in
this mold have included tailoring for medica-
tion use (5,6),utilization of peak flow informa-
tion (6), emergency plans, and personal fitness
recommendations (7). These two procedures,
tailoring for populations and tailoring a few
self-management elements, represent a limited
approach to personalization.Although helpful,
this kind of tailoring stops short of providing
each patient a comprehensiveasthma self-man-
agement program suited to his or her needs.
More ambitious tailoring addresses the needs
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of the individual and takes into account all
aspects of self-management.A few programs of
this type have been developed. They differ
from one another in the way information for
tailoring was gathered. Three procedures have
been used to collect information on which to
base tailored programs: interviewing the pa-
tient; training the patient to identify important
self-management measures; and deriving a
For personal use only.
program statisticallyfrom patient recordingsof
both asthma exacerbations and asthma trig-
gers. Each procedure has strengths and weak-
nesses.
Interviewing the patient to obtain informa-
tion useful in tailoring has been the most pop-
ular personalization procedure. Its strength is
the ease with which information for tailoring is
gathered. A potential drawback is that even
when interviewed skillfully, patients might be
unable to provide the information needed for
effectivepersonalization of training. Interview
information was used to tailor three asthma
sel.&managementprograms (8-10). In each case,
personalized programs for patients were mod-
ifications of programs intended for group use.
To various degrees, these programs were effec-
tive in controlling symptoms of asthma, but
tailoring was evaluated independently in only
1case (10).
Training patients to identify important
asthma self-management elements has been
used twice as a component of group programs
(11,12). Its contribution to the effectiveness of
the program was not evaluated. The procedure
involved having the patient take note of events
consistentlyassociated with asthma. To gather
Kotses et al.
information, the patient completed a question-
naire about each asthma exacerbation. Training
included discussion of rules for determining
events related to asthma and recommendations
for tailoring self-management routines in ac-
cordance with the information obtained. A
strength of this approach to tailoring is that it
can detect a wide range of asthma management
problems. Weaknesses include a lengthy data
collection period and a considerable documen-
tation requirement.
Like programs that rely on the patient to
identify important self-management elements,
programs statistically derived from patient re-
cordings are sensitive to a wide range of prob-
lems and require a lengthy developmental pe-
riod and extensive documentation. Programs
statistically derived from patient recordings
have been tested on only one occasion and
with only a few subjects. Compared to con-
trols, patients who both recorded events re-
lated to their asthma and were given tailored
programs based on their recordings improved
in several indices of asthma (13). The present
study was an extension of that research. We
compared the effectiveness of personalized
self-management programs based on patient
recording procedures with that of an estab-
lished group asthma self-managementprogram,
the Wheezers Anonymous program (14).
METHOD
Subjects and Design
The participants were 45 asthma patients
from the Toledo, Ohio, area who responded to
advertisements for research subjects. During
the course of the study, 11subjects terminated
their participation, leaving 34 patients to com-
plete the experiment. Our sample consisted of
27 female patients and 7 male patients. Their
average age was 42 years; they had been experi-
encingasthma onaverage for 16.5years. Self-re-
ported asthma severity in our sample was mod-
erate: 4 individuals reported suffering from
mild asthma, 27 from moderate asthma, and 3
from severe asthma. A total of 30 patients took
daily medication for the control of their asthma,
and 4 patients used medication as needed.
 Individualized Asthma Self-Management 115

We assigned the patients to one of three
conditions: an individualized asthma self-man-
agement condition, a group asthma self-man-
agement condition, and a control condition.
Group assignments were made randomly with
the restriction that conditions be equated for
number of subjects. The patients in each condi-
tion participated in three experimental phases:
baseline, intervention, and follow-up.Of the 34
patients in our sample, 11 were in the individ-
ualized condition, 11 in the group condition,
and 12 in the control condition.
Procedure
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control of asthma through the use of standard-
ized video and audio materials and discussions
facilitated by a group leader. It includes peak
flow monitoring. Administration of the pro-
gram required two sessions each of which was
approximately 2.5 h in length. Patients in the
control condition had no specific requirements
during the intervention period.
From information collected during the inter-
vention period, we tested, for eachpatient in the
individualized condition, the relationship be-
tween the occurrence of asthma and the other
variables recorded during the intervention pe-
riod: A.M. and P.M. PEFR and each potential trig-
ger. We did this by a two-step process: chi-

Patients collected baseline data for a period
of 30 days prior to intervention. On a daily
basis, they monitored frequency of A.M. and
P.M. asthma attacks, A.M. and P.M. peak expir-
atory flow rate (PEFR),activity limitations, and
visits to emergency care facilities. They kept a
record of these events on asthma diaries given
to them prior to the beginning of the study.
Each diary included a definition of an asthma
For personal use only.
square analysis followed by logistic regression
analysis. We used chi-square analyses to elimi-
nate variables completely unrelated to asthma.
We uscd logistic regression analyses to deter-
mine the degree of association between asthma
and all remaining variables. The self-manage-
ment program we gave to a patient in the indi-
vidualized condition consisted of discussion of
those variables related (p < .20) to his or her

attack. Patients were given instruction on the
use of the mini-Wright meter (model PF-239),
and they were told that the PEFR provided an
accuratemeasure of the condition of their respi-
ratory system.
A 90-day intervention period followed the
baseline period. During the intervention pe-
riod, patients in the individualized self-man-
agement condition kept a daily record of the
following information: their A.M. and P.M.
asthma attacks, their A.M. and P.M. PEFR scores,
and their contact with at least 18 common
asthma precipitants.* The intervention for pa-
tients in the group self-management condition
consisted of the Wheezers Anonymous Pro-
gram (14), an adult program derived from two
pediatric asthma self-management programs:
Living with Asthma (15)and the Family Asthma
Program (16).The Wheezers Anonymous Pro-
gram outlines general recommendations for the
asthma. We used a wide region of rejection in
our statistical tests because we wanted ourself-
management programs to include even those
factors remotely related to asthma.We discrussed
the factors related to each patient’s asthma in a
60-min session.Our discussions included use of
PEFR as an early warning sign for asthma onset
and methods for avoiding precipitants. In addi-
tion, we gave those patients whose asthma was
related to emotion an audio tape of progressive
relaxation instructions. Figure 1shows the con-
tent of the self-management program of each
patient in the individualized condition. Finally,
all patients in the individualized condition re-
ceived instructions for reducing asthma exacer-
bations.
At the completion of the intervention pe-
riod, all participants entered a 30-day follow-
up period during which they kept a daily re-
cord of their A.M. and P.M. asthma attacks, A.M.

*We identified the 18 precipitants in research with another population of asthma patients. We asked each member of a
group of 48 patients to list all of his or her asthma precipitants.The 18 precipitants accounted for 81% of the precipitants
mentioned by the group. As a group, patients in the present experiment failed to indicate experience with three (aspirin;
freshly mowed hay or grass; and laughing or crying) of the original 18 precipitants. But patients in the present experiment
added suspected precipitants to the original 18 we listed. Each of 3 patients added one precipitant.The three precipitants
added to the final list were alcohol, missed medication,and contact with mold. The appearanceof alcohol may have resulted
from its association with either smoke or fatigue.
 116 Kotses et al.

P8Ilenl

Animal dander
Anxiety I anger
Cigarette smoke
Cooking odors
Dust
Exercise
Fatigue
Humidity
Infection
Missed medication
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Mold
PEFR variability
Perfume I chemical fumes
Pollen
Pollution
Temperature change
Temperature extremes
For personal use only.

Wind

Figure 1. Content of individualized asthma self-management program for each patient.

and P.M. PEFR, activity limitations, and number
of visits to emergency care facilities. The fol-
low-up period was identical in recording re-
quirements to the baseline period.
RESULTS
We predicted that improvements in asthma
from baseline to follow-up would be limited
to patients given self-management training, in
either individual or group form. Accordingly,
we compared the baseline score with the fol-
low-up score of each dependent variable. We
conducted all statistical tests on an a priori
basis. We noted improvements in patients in
both the individualized and the group self-
management condition in A.M. PEFR: the pa-
tients in the individualized condition im-
proved from an average of 327 L/M at baseline
to 359 L/M at follow-up, F(1,30) = 5.67, p < .05,
and the patients in the group condition im-
proved from an average of 387 L/M at baseline
to 418 L/M at follow-up, F(1,30) = 5.76, p < .05.
(The data of one patient in the individualized
condition were eliminated from these analyses
because the patient’s PEFR scores were excep-
tionally low, on the order of 70 L/M.) For
asthma attack frequency, however, the only
improvement we noted was in patients in the
individualized asthma self-management con-
dition. On average, patients who received in-
dividualized training experienced a drop in
A.M. asthma attack frequency of about 3.9 at-
tacks per month, from 10.5 attacks during
baseline to 6.6 attacks during follow-up,
F(1,31) = 5.90, p < .05. An analogous drop of
1.5 attacks per month, from 10.1 to 8.6 attacks
per month, in patients assigned to the group
self-management condition was not statisti-
cally significant. Patients in neither self-man-
agement condition exhibited changes in either
P.M. asthma attacks, P.M. PEFR, activity
limitiations, or frequency of visits to emer-
 Individualized Asthma Self-Management 117

Table 1. Means and Standard Deviations of All Dependent Variables

During Both Baseline and Follow-up by Group
~~

VARIABLE GROUP BASELINE FOLLOW-UP

A.M. I 327.00 f 91.60 359.00 f 186.60*
PEFR W 387.40 f 127.70 4 1 8 . 1 0 f 124.00*
C 31 0.30 f 105.20 326.80 f 1 1 5.30
P.M. I 366.20 f 85.60 372.50 f 105.00
PEFR W 41 2.20 f 128.70 429.30 f 120.60
C 336.80 f 107.1 0 340.1 0 f 103.90
A.M. I 10.54 f 8.67 6.63 f 10.40*
Attacks W 10.09 f 8.47 8.63 f 10.49
C 9 . 6 6 f 7.20 11.41 f 10.63
P.M. I 9.45 f 6.93 9.72 f 9.75
Attacks W 9.09 & 10.64 8.81 f 10.90
C 9.58 f 8.45 9.25 f 10.40
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Activity I 2 . 5 4 f 6.31 0.9Of 0.30

limitations W 3 . 5 4 f 7.06 0
C 3.91 f 4.52 2.25 f 4.75
Emergency I 0.82 f 2.72 0
visits W 0 0.91 f 0.30
C 1 . 4 2 f 3.52 0.33 f 0.09
I, individualized self-management training; W, group self-management training;
C, control.
* p < .05.
For personal use only.

gency care facilities. Individuals assigned to
the control condition evidenced changes in
none of the dependent variables from the base-
line to the follow-up period. The group means
and standard deviations of each dependent
variable are shown in Table 1.
DISCUSSIO N
Personalized asthma self-managementpro-
grams derived statisticallyfrom patient record-
ings can be effective. The personalized pro-
grams in the aggregate were at least as effective
as the group program. Detracting from the ap-
peal of the personalized programs is that they
required more patient effort and, overall, more
patient contact than the group program. Nev-
ertheless, a personalized asthma self-manage-
ment program, similar to those we used, could
be offered by a physician to patients willing to
record asthma-related events during a period
of several months.
Personalized asthma self-management pro-
grams have several advantages over group pro-
grams. First, because they do not require the use
of educational facilities, they may be conducted
during officevisits.Second,because they donot
contain material irrelevant to the patient, they
may appeal to patients more than do programs
that aim for general applicability. Third and
most important, personalized self-management
is consistent with medical practice in that treat-
ment recommendationsfollow fromevaluation
of a condition. In contrast, group programs omit
the diagnostic step. Group programs are more
akin to educational practice than they are to
medical practice.
One additional, negative feature of the sys-
tem of personalization we used is extensive de-
pendence on complex statistical calculations.
The use of these procedures hinders the ease
with which the system may be implemented.
Development of simpler statistical procedures
for determining the content of self-management
programs is a necessary prerequisite to general
use. Once these simpler procedures are devel-
oped, implementation of a system of personal-
ized asthma self-management training will be
within the reach of all.
 118
REFERENCES
1. Mesters I, Pieterse M, Meertens R Pediatric asthma, a
qualitative and quantitative approach toneeds assess-
ment. Patient Educ Couns 1723 (1991).
2. Mesters I, Meertens R, KokG, Parcel G S Effectiveness
of a multidisciplinary education protocol in children
with asthma (0-4 years) in primary health care. j
Asthma 31347 (1994).
3. Shields MC, Griffin KW, McNabb W L The effect of a
patient education program on emergency room use
for inner-city children with asthma. A m ] Public Health
80:36 (1990).
4. Taggart VS, Zuckerman AE, Lucas S, Acty-Lindsey A,
Bellanti JA: Adapting a self-management education
program for asthma for use in an outpatient clinic.
Ann Allergy 58:173(1987).
J Asthma Downloaded from informahealthcare.com by University of Otago on 01/06/15
5. @man LM, Abdalla MI, Beattie JAG, Ross SJ,Russell
IT, Friend JA, LeggeJS, Douglas JG: Reducing hospital
admissions through computer supported education
for asthma patients. Br Med j 308568 (1994).
6. D-Souza W, Crane J, Burgess H, Karu HT, Fox C,
Harper M, RobsonB,Howden-ChapmanP, Crossland
L, Woodman K, Pearce N, Pomare E, Beasley R: Com-
munity-based asthma care: Trial of a "credit card"
asthma self-management plan. Eur Respir 7:1260
(1984).
7. Byme DM, Drury J, Mackay RC, Robinson S, Faranda
For personal use only.
C, MacAdam DB: Evaluation of the efficacy of an
instructional programme in the self-management of
patients with asthma. j Adu Nurs 28637 (1993).
8. Bailey WC, Richards JM, Brooks M, Soong S, Windsor
RA, Manzella BA: A randomized trial to improve
Kotses et al.
self-management practices of adults with asthma.
Arch Intern Med 1501664(1990).
9. FiremanP,FridayGA,GiraC,VirthalerWA,Michaels
L Teaching self-management skills to asthmatic chil-
dren and their parents in an ambulatory care setting.
Pediatrics 6 8 3 1 (1981).
10. Wilson SR, Scamagas P, German DF, Hughes GW,
Lulla S, Coss S, Chardon L, Thomas RG, Starr-
Schneidkraut N, Stancavage FB, Arsham GM. A
controlled trial of two forms of self-management
education for adults with asthma. A m I Med 94564
(1993).
11. Creer TL, Backiel MA, Bums KL, Leung P, Marion RJ,
Miklich DR, Morrill C, Taplin PS,Ullman S Living
with Asthma. I. Genesis and development of a self-
management program for childhood asthma. )Asthma
25335 (1988).
12. Kotses H, Burnstein IL, Burnstein DI, Reynolds RVC,
Korbee L, Wigal JK, Ganson E, Stout C, Creer TL: A
self-management program for adult asthma. Part I.
Development and evaluation. J Allergy Clin Zmrnunol
95529 (1995).
13. Kotses H, Stout C, Wigal JK, Carlson B, Creer TL,
Lewis P:Individualized asthma self-management: A
beginning. ] Asthma 28287 (1991).
14. Snyder SE, Winder JA, Creer TL: Development and
evaluation of an adult asthma self-management pro-
gram: Wheezers Anonymous. J Asthma 24:153 (1987).
15. Creer TL, Backiel M, Ullman S, hung P:Living with
Asthma. Parts I and 11. National Institutes of Health,
Bethesda, MD, publication no. 86-2364, April 1986.
16. Hindi-Alexander M, Cropp GJA: Community and
family program for children with asthma. Ann Allergy
46:143 (1981).