One of the major public health problems facing Australia today is Asthma. It is disturbing that there has been an apparent increase in its prevalence and severity, and increased rates of hospital admissions. (E. J. Comino, 1996) For the diagnosed patient, the degree to which he or she suffers is related to severity of the condition, compliance with recommendations by medical experts, the immediate environment and the effectiveness of education programs. Like other major health problems, asthma has varying degrees of symptoms. As such, the degree and frequency of the symptoms limits many aspects of the asthmatics life.
To describe the main limitations suffered by those with chronic asthma, asthma must be defined. Asthma is a condition whereby the sufferer has difficulty breathing due to widespread narrowing of the airways of the lungs. This narrowing can be caused by a local inflammation of the air-ways, muscle contraction or the production of excess mucus with in bronchi. (R. Roberts, 1996) Most common is bronchial asthma. Medical definitions of asthma suggest that environmental triggers can substantially contribute to the occurrence of an asthma attack.
The review of asthma in Victoria (1988) by the Asthma Foundation of Victoria outlined infection, exercise, climatic conditions, exposure to airborne irritants and emotional upsets as the main trigger factors. However, doctors use a general classification to identify a patients pattern of asthma… classifying people who experience some symptoms of asthma on most days as having a chronic asthma condition. The classification system also extends to the categories of children, occupational asthma and asthma in later life.
Usually regular medication is required to keep the lungs functioning as normally as possible. Some chronic asthmatics have severe symptoms over a long period of time and may require long term or indefinite medication to be able to lead a normal life. (Lane, 1996) The most obvious limitations suffered relate to the asthmatics physiological dysfunction. However, physiological dysfunction can in turn contribute to greater social and psychological limitations. This area is related more specifically to quality of life and morbidity and will be discussed further on.
The main physiological limitation is related to the presence of the bronchial narrowing slowing the movement of air into and out of the lungs. Thus, there is difficulty both breathing in and out. Asthmatics commonly describe the feeling – tightness of the chest, congestion and wheezing. Although these symptoms can commonly occur in other chest diseases, in asthma it is a characteristic that can occur in an aggravated attack. This may be either brief episodes of chest tightness lasting a matter of minutes or a prolonged episode of wheezing lasting up to and hour, which can merge into a full blown attack of asthma.
Other physiological limitations relate to the sufferers sensitivity to known triggers factors and the consequential effect on their daily functioning. The Global Strategy for Asthma Management and Prevention (1995) states that triggers are risk factors that cause asthma exacerbation”s by inducing inflammation or provoking bronchio-constriction. This report also describes the main triggers as allergens, air pollutants, respiratory infections, exercise and hyperventilation, weather changes, allergies to foods, additives and drugs, and emotional stress.
For example it is well established that viral respiratory infections can exacerbate asthma, especially in children under the age of 10. (Busse, 1993) Because the triggers may vary from person to person and from time to time, it is important to take the sufferers natural history into account and identify each individuals triggers. Therefore, an individuals identified trigger can restrict the sufferers ability to function normally. For example – an asthmatic child may try to avoid exercise for fear that it may trigger an asthmatic attack.
This may in turn limit the sufferers physiological development over the long term and hence further contribute to the problem. (Global Strategy, 1995) Some psychological and social problems can also be considered as a consequence of the interaction with physiological limitations. The Global Strategy for Asthma Management and Prevention (1995) states that “asthma is a chronic disorder that can place considerable restrictions on the physical, emotional, and social aspects of the lives of patients and may have an impact on their careers”.
Chronic asthma sufferers have to live with the need for treatment and with the limitations that having asthma places on their everyday lives. It is in this context that the asthmatics life area”s are most likely to be handicapped. In general, the chronic asthmatics activity choices are particularly handicapped. …. especially physical education. Exercise incites airflow limitation in most children and young adults who have asthma. Exercise appears to be a specific stimulus for people with asthma because it seldom leads to airflow limitation in people without asthma. Global Strategy, 1995)
More specifically sports where sustained effort is needed over a considerable period (eg long distance running) are not recommended. From a psychological point of view, the development of a positive sense of self (ie self-esteem) can be adversely affected by asthma. In one study, nearly 41 percent of parents of children with asthma said that asthma caused their children to feel self-pity. These children also were found to have low self-esteem as well as poor relationships with their peers. (Charmaz, 1983) For an adult, occupation and social life may be handicapped.
A comparative study from Edinburgh (1996) between asthmatics and people with other forms of physical disability were found to have similar levels of anxiety or neuroticism. It was found most asthmatics exhibited varying levels of anxiety in relation to their beliefs and, in particular, their constant fear of another attack and anxiety over school and work prospects. (Lane, 1996). Similarly, fear also plays a predominant role in children who suffer from asthma…. with one in four Victorian children fearing not being able to breathe as a result of asthma (King, 1988).
Furthermore, the relationship between asthma and emotional andor severe behavior problems is documented in a 1995 study by R,Bussing et al. In particular they tend to suffer from limited school functioning, inability to attend school and need for special school or special classes. In Australia, school loss caused by asthma accounted for approximately 965,000 days annually. (Aust Bureau Statistics, 1991) In particular poor academic performance and greater risk to learning difficulties were found to be the greatest negative consequences. (Fowler, 1992)
The asthma sufferer can have a limited choice of occupations, because they are exposed to an increasingly large number of potential irritants in their working lives. In particular if specific allergies are known to exist then an occupation that exposes them to the allergens must be avoided. For instance, those sensitive to pollen should not become gardeners or those who have recurrent shortness of breath, should not become marine biologists. (Lane, 1996) 3. What can an individual do to prevent the occurrence of unnecessary as asthma attacks, or to minimize the seriousness of those that do occur?
In 1989 an Australian Asthma management (AMP) plan was set up as a guideline for health professionals. The guideline was set up as a common consensus among health experts to help tackle the irregular diagnosis and treatment of asthma. More particularly, to help combat the increase of asthma induced admissions to hospitals due the occurrence of unnecessary asthma attacks. This report outlined 6 important steps to aid the doctor and the sufferer as to the basis of good asthma management.
They include (1) Assess the severity of asthma; (2) achieve best lung function (3) maintain best lung function by identifying and avoiding triggers; (4) maintain best lung function with optimal medication; (5) develop an action plan; and (6) educate and review regularly. (Woolcock, 1989) Current research by Beilby (1997) highlighted that having an action plan can play a vital role in preventing hospital admissions and death from asthma. An asthma action plan is a co-ordinated method of management that covers all aspects a persons asthma – medication, triggers factors, lung function measurements, etc.
To ensure greater adherence, both the patient and the doctor should fill out an asthma management chart together. It encourages self management and focuses on the importance of identifying the main trigger factors and monitoring the warning signs of an asthma attack. Essentially this involves a regular check on airway function by the use of a peak flow meter and the additional measurement of lung capacity twice a day those with severe asthma. Use of symptomatic (quick working) medication such the bronchodilator ventolin aerosol type to maintain best lung function, is recommended to reduce the seriousness of an acute attack.
Doctors prescribe preventative medication such as Intal (sodium cromogylcate), anti-allergy injections and inhaled steroids for people who have severe asthma. Long term use of preventative medicine is used in conjunction with bronchodilators. After several months on preventative medicine, asthmatics find they are able to reduce their use of bronchodilators dramatically. (Prendergast, 1991) Identifying trigger factors such as allergens, infection, exercise, weather changes and emotional stress is also important.
The use of a bronchodilator or Intal, before being exposed to an identified trigger factor, can reduce the likelihood of an asthmatic reaction. The asthma management chart also describes what to do if following warning signs are observed : (1) the bronchodilator doesn”t bring expected relief, (2) a decrease in the peak expiratory flow, (3) Increased breathlessness and variation in peak flow rates during the day, (4) more frequent wheezing and a persistent dry cough and (4) disturbed sleep. (Prendergast, 1991)
Asthmatics who live in highly polluted areas and are surrounded by electrical appliances, high tech equipment and power lines can benefit from air ionisers and a purifiers. Individuals can also prescribe to alternative treatment (for instance the Buteyko method), various breathing exercises, physical exercise (such as swimming), a healthy diet, and natural remedies such a homeopathic and acupuncture. It has been found that these treatments should complement orthodox medication and also help reduce the reliance on it. Roberts (1996) suggest that there is evidence that the Buteyko method is effective in treating chronic asthma.
Devised by professor Beteyko of Siberia, this program consists of specific relaxation techniques and shallow breathing to correct breathlessness and wheezing. For those who are prone to exercise induced asthma choosing the right type of exercise is important … particularly choosing a sport that requires longer and slower breathing and/or short bursts of effort. Examples include gymnastics, cricket and basketball. Swimming with its controlled breathing pattern is also recommended as it promotes chest development, flexibility and, therefore better breathing. (Roberts, 1996)
There has been extensive research into new drug treatments of asthma by pharmaceutical companies and universities over the last 20 years. One such new effective drug to emerge is a Leukotiene receptor antagonists (LTRA). It was recently introduced into Australia this year and the USA 3 years ago. In people with asthma, leukotrienes play a key role in causing the inflammation, bronchoconstriction, and mucous production that lead to coughing, wheezing, and shortness of breath. LTRA”s prevent leukotrienes from attaching to the proinflammatory receptors on circulating and lung cells, which contribute to asthma symptoms.
Leukotriene research is the direct result of a Nobel Prize-winning discovery made by scientist Beng Samuelsson in 1979. (Lipworth, 1999) However, there needs to be further research into the efficacy and its side effects. 4. How effective are the educational programs undertaken by organizations such as Asthma Victoria? Current statistics indicate that there has been a reduction of asthma mortality and morbidity in Australia over the past 10 years. The fall in deaths from 964 in 1989 to 715 in 1997 may indicate that some of Australia”s strategies for asthma management have been successful. (NAC, 1998)
The Australian Asthma Management Program provides a systematic and methodical approach to asthma care. Nevertheless, it was not formulated as an evidence based document. This means that its recommendations (devised in 1989) were not based on systematic reviews or had been ranked according to the strength supporting them. However, today there have been a number of studies reviewing the effectiveness of the AMP. One such report by the National Asthma Campaign (1999), commented on the crucial role of education in improving the management of asthma rather than the token gesture of handing over a leaflet at the end of a patient consultation.
This was in relation to the 6th step – educate and review regularly and highlights the importance of education programs undertaken by organizations such as the Australian National Asthma Campaign, Asthma Victoria, the Thoracic society of Australia and New Zealand and other relevant educators. The 1990 and 1993 national surveys of 22,000 adults and 16,000 children conducted by the National Asthma Campaign (NAC) showed improved asthma management practices in the three year period.
Although the changes are not necessary the direct result of the National Asthma Campaign, it is considered to be consistent with the campaign and other agencies having been successful in promoting awareness and optimal management of asthma. (Comino, 1996) One of the goals of the NAC was to reduce the reliance on daily medication and hence increase the use of preventative therapy (such as inhaled corcosteroids) for patients with moderate or severe asthma; together with written action plans based on symptom severity and measurements of lung function.
Use of preventative medication was found to have increased among both children and adults. The study highlighted also that there was a significant decline in the use of daily inhaled bronchodilator drugs among children and also inappropriate medications such as antibiotics and oral prescriptions. In addition this study also showed that in 1993 survey, doctors measured lung function significantly more often than in 1990; with similar increases observed in the use of peak flow meters and written action plans.
These results suggest that the Australian Asthma Management Programs are relatively effective. However, the study also points to the fact that limitations still exist. In particular there is a lack of communication and joint management strategies between specialists and GP”s, hospitals and the community; whilst the use of action plans still has considerable room for further improvement. Nonetheless, not all studies on education programs show positive conclusions.
A British research paper ‘Greenwich Asthma Study” of 1291 asthmatics conducted in 1993 and 1996 found that their model of service delivery was not effective in improving the outcome of asthma in the community. The intervention program used was based on the British Thoracic Society”s guidelines and was conducted by specialist nurses in community based settings. There were similarities in the methodology and intervention measurement. However, they concluded that no evidence was found for an improvement in asthma related quality of life among newly surveyed patients in intervention practices compared with control practices.
Altogether this highlights that the variability of the asthma educational programs undertaken by various major organisations make it difficult to comparatively evaluate. A comprehensive world wide study, ‘Objectives, methods and content of patient education programs for adults with asthma: systematic review of studies published between 1979 and 1998″ found that there was great difficulty in identifying the most effective components of asthma educational programs.
The main reason cited was that education programs for adults with asthma vary widely. Most reports did not specify the general (56%) and educational objectives (60%) of the intervention. Important training characteristics were often not available: duration of education (45%) and number of sessions (22%), who delivered education (15%), whether training was conducted in groups or was individualised (28%). (Sudre, 1999) Such variability suggests a lack of consensus on what educational components actually work.
With insufficient documentation of asthma education programs for adults, replication is limited. In conclusion there is some evidence to suggest that written treatment management plans are most effective in improving the quality of life for people with asthma. In the Australian context the National Asthma Campaign has clearly documented program goals. However, the limitations lie in its lack of empirical evidence. In addition the reliability of the research documents in general has been brought into question by the Sudre (1999) study.
Therefore it is difficult to demonstrate the most effective management plan for asthma sufferers. This issue is currently being addressed by the National Asthma Campaign and the Asthma Foundation of Victoria. The Asthma foundation is currently conducting a study into the effectiveness of their schools based program. Hopefully, this and other studies will help fill the gap associated with the effectiveness of asthma education programs. And hence secure the continuation and development of asthma education in the community.
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