Knowledge, attitude, and self-efficacy in asthma self-management and quality of life.

BACKGROUND: Cognitive variables such as knowledge, attitude, and self-efficacy affect asthma patients' abilities to be effective self-managers. OBJECTIVE: The objective of this cross-sectional analysis was to determine what patient and clinical factors were associated with these cognitive variables and to assess the contributions of these cognitive variables to clinical status. METHODS: Primary care asthma patients were interviewed using the three domains of the Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire (KASE), as well as established scales to measure social support, depressive symptoms, and ratings of asthma care. Clinical asthma status was measured with the Asthma Quality of Life Questionnaire (AQLQ). RESULTS: In total, 180 patients were enrolled, with a mean age of 43 years and 84% were women. Knowledge was low, with only 50% of patients answering half or more questions correctly (mean score = 52, possible range 0-100, higher is more knowledge). Attitude toward asthma was generally positive (mean score = 82, possible range 20-100, higher is more positive attitude) and self-efficacy was moderate (mean score = 76, possible range 20-100, higher is more self-efficacy). In separate multivariate analyses, younger age and higher education level were associated with more knowledge (p ≤ .005); more social support, fewer depressive symptoms, and more favorable prior results of asthma care were associated with more positive attitude (p ≤ .05); and favorable prior results, more satisfaction with asthma status, not having stress-related triggers, and not having had a recent emergency department visit for asthma were associated with more self-efficacy (p ≤ .07 for all variables). In additional multivariate analyses, more knowledge (p = .0005), more positive attitude (p = .02), and more self-efficacy (p = .01) were associated with better AQLQ scores. CONCLUSIONS: Different patient and clinical characteristics were associated with cognitive variables pertinent to self-management. These variables, in turn, were independently associated with asthma status. Thus, although fostering improvement in all three variables would be desirable, interventions that improve any of these variables potentially could be beneficial.

Randomized trial of self-management education in asthmatic patients and effects of depressive symptoms.

BACKGROUND: Self-management education is a cornerstone of routine asthma care. OBJECTIVES: To improve asthma knowledge and self-efficacy and to assess effects in patients with depressive symptoms. METHODS: In a randomized trial, controls received asthma brochures and social support through frequent follow-up visits. Intervention patients made a contract to adopt a behavior to improve asthma and received a workbook, weekly reinforcements for 12 weeks, and frequent follow-up visits. Outcomes were Asthma Quality of Life Questionnaire (AQLQ) and 36-Item Short Form Health Survey (SF-36) scores and emergency department (ED) visits and hospitalizations for asthma. RESULTS: Ninety patients were randomized to each group. Mean age was 43 years, 84% were women, and mean study time was 27 months. Intervention patients had more improvement in AQLQ scores at 5 months, but this difference was not sustained. For the entire period, AQLQ scores improved by a clinically important difference from 4.1 to a mean of 5.1 in both groups (P < .001) with no difference between groups (P = .91). In multivariate analysis, younger age, more education, better enrollment AQLQ score, more asthma self-efficacy and knowledge, and fewer depressive symptoms were associated with more improvement (P < .05 for all). Similar results were found for the SF-36. Thirty-one percent of patients had an ED visit, and 9% were hospitalized, with no differences between groups. In multivariate analysis, female sex, expecting to be cured of asthma, less asthma knowledge, and more depressive symptoms were associated with ED visits. Being in the intervention group attenuated the effects of depressive symptoms for all outcomes. CONCLUSIONS: Quality of life improved in both groups, with particular benefit in intervention patients with depressive symptoms.

Novel use of patient-derived vignettes to foster self-efficacy in an asthma self-management workbook.

This article describes the development of an interactive self-management workbook to increase asthma knowledge and self-efficacy. Its format encourages readers to write in their own personal experiences and perspectives. The knowledge component was developed from standard materials and organized into thematic chapters. The self-efficacy component was developed from interviews with patients in the outpatient setting, emergency room, and hospital; it consists of three sections explaining why confidence is necessary to be an effective self-manager and offers techniques to increase confidence. The component's cornerstone is vignettes of patients describing what triggers their asthma and what behaviors they use to successfully manage it. This novel approach to fostering self-efficacy allows patients to see themselves in others' success stories. Although not a substitute for self-management courses, the workbook promotes self-management by offering a practical and readily available option to in-person instruction and peer contact, which are accessible to only a small number of patients.

Development and testing of the Asthma Self-Management Questionnaire.

BACKGROUND: Assessing self-management knowledge can guide physicians in teaching patients necessary skills. OBJECTIVE: To develop and test the Asthma Self-Management Questionnaire (ASMQ). METHODS: The ASMQ was developed from patient interviews. Validity was evaluated by comparison with the established Knowledge, Attitude, and Self-Efficacy Asthma Questionnaire, and test-retest reliability was evaluated with repeated administration (mean, 5 days apart) in 25 patients (mean age, 41 years; 96% women). The ASMQ was further described in additional patients by comparison with cross-sectional self-management practices and longitudinal change in Asthma Quality of Life Questionnaire scores. RESULTS: The 16-item, multiple-choice ASMQ measures knowledge of preventive strategies, inhaler use, and medications and generates a score of 0 to 100, with higher scores indicating more correct responses. The ASMQ was correlated with the Knowledge, Attitude, and Self-Efficacy Questionnaire (r = 0.58) and had a Cronbach alpha of 0.71. The correlation between administrations was 0.78, and the intraclass correlation coefficient was 0.58. When given to another 231 patients (mean age, 41 years; 74% women), the mean (SD) ASMQ score was 60 (20). Patients with better ASMQ scores were more likely to own peak flow meters (P = .04) and to have received flu vaccines (P = .03). For 12 months, these patients received self-management information through workbooks and telephone reinforcement. Patients with higher ASMQ scores after 12 months were more likely to have clinically important improvements in quality of life compared with patients with lower ASMQ scores (65% vs 46%; P = .01). CONCLUSIONS: The ASMQ is valid and reliable and is associated with clinical markers of effective self-management and better asthma outcomes.

Beliefs about asthma medications: patients perceive both benefits and drawbacks.

Patients have diverse beliefs about asthma medications that may be influenced by asthma characteristics. The objective of this qualitative analysis was to identify patients' beliefs about asthma medications and to assess these beliefs according patient and asthma characteristics, including asthma severity and patient-reported medication adherence. From interviews with 52 patients (mean age 43 years, 87% women, 71% taking maintenance medications), 17 categories of beliefs about medications were discerned which were grouped into perceived benefits (e.g., permit activities, thwart symptoms) and perceived drawbacks (e.g., establish a medication routine, ensure supply). Beliefs were not mutually exclusive, with 56% of patients citing both benefits and drawbacks. Beliefs did not differ based on asthma severity or type of current therapy, however, patients who cited drawbacks were more likely to have worse self-reported Morisky Medication Adherence Questionnaire scores (possible range 0-4, higher is worse adherence) compared to those who did not cite drawbacks (1.9 +/- 1.3 vs 0.9 +/- 0.9; p = .02). Providers should be aware of patients' beliefs about medications in order to reinforce perceived benefits and address perceived drawbacks.

Comparison of energy expenditure from lifestyle physical activities between patients with rheumatoid arthritis and healthy controls.

OBJECTIVE: Low energy expenditure is a risk for cardiovascular morbidity. The goals of this study were to compare energy expenditure between patients with rheumatoid arthritis (RA) and healthy controls. METHODS: A total of 121 RA patients and 120 healthy controls in New York City completed the Paffenbarger Physical Activity and Exercise Index at time of enrollment (1999-2000) and 1 year later to measure energy expenditure from walking, climbing stairs, and exercise/sports. Analyses were adjusted for age, sex, education, pain, social support, and depressive symptoms and were compared with recommended thresholds of energy expenditure. RESULTS: Participants' mean age was 49 years, and 87% were women. Patients with RA expended fewer kilocalories per week than controls (mean +/- SD 1,474 +/- 1,198 versus 1,958 +/- 1,940, P = 0.003), with most of this difference from less walking as opposed to high-intensity activities. Although similar percents of RA patients and controls met national recommendations for total weekly energy expenditure (56% versus 64% for the lower [> or =1,000 kilocalories per week] threshold; P = 0.14, and 41% versus 48% for the higher [> or =1,400 kilocalories per week] threshold; P = 0.17), fewer RA patients met the recommendations (> or =700 kilocalories per week) for walking (32% versus 48%; P = 0.01). The strongest predictor of more energy expenditure at 1 year for both groups was more energy expenditure at enrollment. CONCLUSION: Most of the difference in energy expenditure between RA patients and healthy controls was due to less walking. Given that walking is an effective and relatively safe lifestyle activity, increasing walking should be a priority to improve cardiovascular risk in RA.

Psychosocial variables and fatigue: a longitudinal study comparing individuals with rheumatoid arthritis and healthy controls.

OBJECTIVE: In individuals with rheumatoid arthritis (RA) and healthy controls, at enrollment and one year later, we evaluated relationships between diverse psychosocial characteristics and fatigue in multivariate analyses. METHODS: Participants with RA and controls completed the Fatigue Severity Scale (FSS) at enrollment and again after one year. All participants also completed measures of depressive symptoms, anxiety, role satisfaction, social support, social stress, disability, physical activity, and sleep quality at enrollment. RESULTS: A total of 122 individuals with RA and 122 controls of similar age, sex, education, employment, and marital status were enrolled. Those with RA had more fatigue compared to controls (FSS scores 4.2 +/- 1.2 vs 3.4 +/- 1.1; p < 0.0001) (possible range 1-7, higher score = more fatigue). In cross-sectional multivariate regression analysis for the RA group, more fatigue was associated with more anxiety, more disability, less social support, and more social stress (p

Barriers and facilitators to healthy physical activity in asthma patients.

Preliminary evidence indicates that asthma patients limit exercise and healthy lifestyle activities to avoid respiratory symptoms. This self-imposed decrease in activity, even among those with mild disease, may predispose to long-term general health risks. The objectives of this qualitative study were to determine patients' views about exercise and lifestyle activities and to determine if these views varied depending on asthma characteristics. During in-person interviews, 60 patients were asked open-ended questions about asthma and perceived barriers and facilitators to exercise and lifestyle activities, particularly walking. Responses were coded and corroborated by independent investigators and then compared according to asthma severity, knowledge, self-efficacy, and attitudes. Although most patients acknowledged the importance of exercise, many either limited or did not participate in exercise because of asthma and other conditions. Patients cited both internal and external barriers to exercise, such as lack of motivation, time constraints, and extreme weather affecting asthma. Patients identified multiple facilitators, such as social support and the desire to be healthy. Lifestyle activities were preferred over formal exercise regimens. Patients with more severe disease were more likely to believe that exercise was not good for asthma. Patients with less knowledge, less self-efficacy, and worse attitudes toward asthma also were more likely to have negative perspectives about exercise. In conclusion, for many patients, asthma is a deterrent to physical activity and predisposes to inactivity. Developing interventions to foster prudent lifestyle activities and exercise among asthma patients should be a priority to decrease long-term health risks.

Longitudinal study of negative workplace events among employed rheumatoid arthritis patients and healthy controls.

OBJECTIVE: Most studies of employment in patients with rheumatoid arthritis (RA) have focused on job loss. Less is known about workplace events in patients who continued to work. The goal of this longitudinal study was to compare the incidence of negative workplace events between employed patients with RA and healthy controls. METHODS: Participants completed the work domains of the Psychiatric Epidemiology Research Interview Life Events Scale and the Inventory of Small Life Events Scale measuring major and minor workplace events. Events were compared between groups according to psychosocial, clinical, and job characteristics. RESULTS: A total of 122 patients with RA and 122 healthy controls were enrolled with similar demographic and occupational characteristics. There were no differences in percentages of patients and controls who had at least 1 major (35% versus 31%) or 1 minor (48% versus 55%) negative event. For patients with RA, negative events were associated with having more pain, more fatigue, more social stress, and less job autonomy (P < or = 0.05). For controls, in addition to social stress, negative events were associated with job characteristics, functional status, and social support (P < or = 0.05). CONCLUSION: A comparable number of patients with RA and controls had negative workplace events. In addition to the well-known contributions of job autonomy and pain, social stress and fatigue also were found to be important variables related to negative events in patients with RA. These potentially modifiable variables have not been fully evaluated with respect to long-term employment in these patients.