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.
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