Abstract of dissertation entitled. An Evidence-Based Self Management Education Program to Improve Asthma

Transcription

1 Abstract of dissertation entitled An Evidence-Based Self Management Education Program to Improve Asthma Control and Quality of Life of Asthmatic Adult Patients Submitted by Fong Ka Lin For the degree of Master of Nursing at The University of Hong Kong in August 2015 Asthma is one of the most common chronic diseases in the world. In Hong Kong, there are more than 330,000 people suffering from asthma (The Hong Kong Asthma Society, 2013). Deterioration of asthma status or even death from asthma is highly preventable. In addition to the pharmacological treatment, studies showed that self-management education program for asthmatic adult patients can improve their asthma control and Quality of Life. However, it is revealed that the existing global and local education programs focus mainly on the clinical and preventive measures. They are not focus enough on patients self-management ability. Moreover, detailed and standardize guideline on the duration, format, resources and content for a

2 comprehensive education program are lacked. This dissertation aims at generating an evidence-base guideline for nurses to provide asthmatic adult patients with an organized and thorough self-management education program. In formulating the guideline, eight studies are first selected from the database. The quality of the selected studies is assessed by the appraising tools from Scottish Intercollegiate Guideline Network (SIGN). The content of the selected studies are summarize and synthesized. After assessing the implementation potential of the proposed guideline in local clinic setting, an evidence-based guideline with 3 main recommendations is generated with reference to the selected studies. To visualizing the interactions between stakeholders as well as testing the feasibility of the education program in local setting before actual implementation, an implementation plan is generated. It divided into two parts: communication plan and pilot testing. Finally, an evaluation plan is generated for identifying the main outcome and its measurement. With the guideline, it is anticipated that the self-management ability of adult patients towards asthma will increase, thus improving their asthma control and quality of life.

3 An Evidence-Based Self Management Education Program to Improve Asthma Control and Quality of Life of Asthmatic Adult Patients By Fong Ka Lin BN, RN An thesis submitted in partial fulfillment of the requirements for The degree of Master of Nursing at the University of Hong Kong August 2015

4 i Declaration I declare that the dissertation and the research work thereof represents my own work, except where due acknowledgement is made, and that it has not been previously included in a thesis, dissertation or report submitted to this University or to any other institution for a degree, diploma or other qualifications Signed Fong Ka Lin August 2015

5 ii Acknowledgements I would like to express my heartfelt gratitude to my supervisor, Dr. Vivian Ngai for her guidance to my thesis in these two years. She has given me many valuable comments and always response to my questions promptly and patiently. The dissertation could not be accomplished without her guidance. I would also like to express my sincere thanks to my classmates and colleagues for their support and sharing. Lastly, I would like to say thank you to my family member and friends, especially Mr Au Pak Kei and Ms Karen Ngai for their encouragement and support.

6 iii Content Declaration.... i Acknowledgements.. ii Table of Content..... iii Chapter 1 - Introduction Background Affirming the needs Research questions Aims and objectives Aim Objectives Significance... 7 Chapter 2 - CRITICAL APPRAISAL Searching Strategies Inclusion and exclusion criteria Searching process Data Extraction and recording Quality assessment of studies Overview of the studies Summary of quality assessment Result of Quality assessment Summary of data Aim of study Patient characteristics Studies design Outcome measurement Result Synthesis of data Target population Details on education program... 23

7 Outcome monitoring Conclusion Chapter 3 - Translation and Application Target settings and audience Target settings Target audience Transferability of the findings Similarity of settings and audience Philosophy of care Number of clients benefit from the program Duration of implementation and evaluation Feasibility Free to implement Administration support Interference to current clinic function Consensus among different parties Staff Training Availability of resources Availability of evaluation tools Cost-benefit ratio Potential benefit Potential risk Risk of maintaining current practice Cost Chapter 4 - Evidence-based Guideline Chapter 5 - Implementation and Evaluation Plan Communication plan Identifying the stakeholders Initiating the changes Guiding the change Sustaining the change Pilot test Setting, duration and enrollment strategies Evaluation... 47

8 5.3 Evaluation plan Nature of patients to be enroll Identifying outcome and timing on measurement Numbers of patients to be enroll Data analysis and outcome effectiveness Chapter 6 - Conclusion Appendix 1 - Literature search strategies Appendix 2 - Table of evidence Appendix 3 - SIGN methodology checklist: controlled trials Appendix 4 Cost of the education program Appendix 5 - Evidence-based guideline Appendix 6 - Content of self-management education program Appendix 7 - Run-down of self-management education program Appendix 8 - Daily record card Appendix 9 - Patient Education Checklist Appendix 10 - Patient Satisfaction Level Questionnaire Appendix 11 - Nurse Evaluation Questionnaire Appendix 12 - Patient Decline Log Appendix A - Levels of evidence Appendix B - Grades of recommendations Reference list

9 1 Chapter 1 - Introduction A significant number of patients suffered from asthma in Hong Kong. Their asthmatics conditions vary from time to time, affected by factors such as weather, recurrent respiratory infections and environment changes (Pocket guideline for asthma management and prevention, 2012). Despite the pharmacological treatment, it is observed that the lack of self-management skills in asthmatic adult patients also contribute to their high attack rate. Self-management referred to self-monitoring changes in severity, appropriate knowledge about asthma and its provoking factors, recognition of symptoms, knowledge of medications and adherence to inhaled medications (Huang, Yu & Wang, 2008). Self-management education program play a crucial role in prevention of the asthma attack and result in better asthma control and quality of life (QOL) in asthma patients (Urek, Tudoric, Plavec, Urek, R., Koprivc-Milenovic & Stojic, 2005). However, it is found that an organized and comprehensive self-management education program is lacked in Hong Kong s clinical settings. Therefore it is necessary to review on the present literatures and develop appropriate protocol.

10 2 1.1 Background Definition of Asthma Asthma is a chronic inflammatory disorder of the airways, which is diagnosed by taking medical history on sign and symptom, physical examinations together with lung function test (spirometry or peak expiratory flow) (World Health Organization WHO, 2013). According to Global strategies for asthma management and prevention (2012), the exact cause asthma is unknown. A combination of family history with risk exposure is the common cause of asthma. Exposures include external allergens and internal respiratory infections. Upon stimulations, the airway become narrower and the lining of the airway inflamed and swell with the production of excessive mucus secretion. The series of reaction in airway leads to asthma symptoms such as cough, chest tightness, wheezing and shortness of breath (Global strategies for asthma management and prevention, 2012). Night-time awakening is also one of the common conditions in asthma patients which would largely affect patients sleeping quality (Masoli, Fabian, Holt & Beasley, 2004). In additions, the tolerance to physical activities of patients decreases (WHO, 2013). All these would affect greatly patients quality of life.

11 3 Prevalence and impact of asthma Asthma is one of the most common chronic diseases in the world with approximately 235 million of people suffering from it globally (WHO, 2013). Asthma is a potentially life-threatening disease and is common both in children and adult. Asthma accounts for about 1 in every 250 deaths worldwide (Masoli et al., 2004) However, many of the deaths were preventable upon earlier detection and better long-term care (The Hong Kong Asthma Society, 2013). In Hong Kong, there are more than 330,000 people suffering from asthma, the prevalence rate is 7.2%, 5% and 5.8% in adult aged 19-21, and 70 or above respectively with mortality rate of around 5.6 per people (The Hong Kong Asthma Society, 2013). The rate is relatively high compared with other developed countries such as Australia and South Korea which is 3.8 and 4.9 per (Masoli et al., 2004). There are about 70 to 90 deaths caused by asthmatic attack every year, with 30% passed away in their prime (The Hong Kong Asthma Society, 2013). Socioeconomically, poor control of asthma leads to reduced activities days, which results in the frequent study or work absentees (Yilmaz & Akkaya, 2002). The number of disability-adjusted life years (DALYs) lost due to asthma worldwide is around 15

12 4 millions per year, which accounts for 1% of the all DALYs lost per year (Masoli et al., 2004). In additions, poor asthma control would also increase the utilization of health care resource and hence the health expenditure due to use of emergency care and admission to hospitals (Prabhakaran, Lim, Abisheganaden, Chee & Choo, 2006). According to Hong Kong Hospital authority Report (2009), there are 6945 of admission to public hospital in adult due to asthmatic attack in Poor control and management of asthma would lead to burden to the society. 1.2 Affirming the needs Huang et al. (2008) pointed out that poorly controlled adult asthma patients showed the characteristics of under-report symptoms, impaired perceptions of asthma severity, poor medication adherence and passive-mind. Other reasons for poor health outcome in asthma patients include lack of information, over-reliance on acute care and use of alternative unproven therapies (Choi & Chung, 2010).To improve the asthma control, in additions to effective treatment, competent self-management is crucial. Studies revealed that there was significant improvement in the educated group in improving patients asthma control and quality of life. However, it is found in my

13 5 local setting (chest clinic) that the management of asthma mainly focus on clinical management and pharmacological treatment with minimal self-management education provided, even to the newly diagnosis asthma patients. Although guideline have been developed in Global initiative for asthma (GINA) globally and Department of Health in Hong Kong locally on management of asthma, they are not self-management focused enough. For example, in the pocket guideline for asthma management and prevention developed by GINA (2012), although detailed clinical and preventive measures are listed, instructions on the duration, format, resources and content for a comprehensive education program are lacked. Same finding is observed in local guideline developed by the Department of Health (Professional development and quality assurance PDQA, 2008). In additions, the present self-management education programs are not standardized enough. They are of different format and teaching methods (Magar et al., 2005). To conclude, there is a need to establish a standard protocol for an organized and thorough self-management education program to asthma adult patients for better asthma control and QOL.

14 6 1.3 Research questions A searchable and answerable question is formulated with PICO format. The clinical question is: Can a self-management education program improve the asthma control and quality of life of the asthma adult patients when compared with those patients receive usual care? 1.4 Aims and objectives Aim To develop an evidence-based self-management education program to improve the asthma control and quality of life of the asthma adult patients Objectives (i) To select a sample of studies as evidences (ii) To assess the quality of, summarize and synthesize the data of the selected studies (iii) To assess the implementation potential of an evidence-based self-management

15 7 education program to asthmatic adult in local settings (iv) To generate implementation plan and perform evaluation 1.5 Significance From patient s perspective A self-management education program allows patients to have a more thorough understanding on asthma and its corresponding skills. Patients sense of self control can be increased. It also allows patients to develop problem solving behavior, as well as taking self-initiatives for better asthma control (Huang et al., 2008). With the well-controlled asthma status, patient can be more active in life and have better QOL (Yilmaz et al., 2002). From nurses perspective The evidence-based self-management education program can boost professionalism and autonomy among nurses. Nurses can provide patients with appropriate knowledge based on the evidence-based protocol competently. In additions to general knowledge, patients specific needs are identified and personalized care is developed. Partnership can be developed between nurses and patients in the management of asthma (Urek et

16 8 al., 2005). With the improved asthma control and QOL through preventive measures, the nursing and medical workload would be improved. From socio-economic point of view The rate of using acute health care due to unplanned asthmatic attack would decrease and hence the health expenditure due to asthma can be reduced in long-run (Gallefoss & Bakke, 2001).

17 9 Chapter 2 - CRITICAL APPRAISAL Upon identifying the needs of an evidence-based self-management education program to the asthmatic adult patients, critical appraisal was performed in this chapter. The appraisal starts with setting up inclusion and exclusion criteria in selection of studies, followed by a detailed description of the searching process to obtain a sample of studies in the database. The data of selected studies was then be extracted and recorded in the form of table of evidence with quality assessment be performed. Data of the studies were summarized and synthesized finally. 2.1 Searching Strategies Inclusion and exclusion criteria Inclusion criteria 1. Patients aged 18 or above with persistent asthma 2. Studies publicized in year 2000 or above with English literacy 3. RCTs and Quasi-experimental studies Exclusion criteria 1. Home-visit, internet or telephone-based intervention

18 Searching process A total of 4 electronic databases were used in the searching process on 1 st March, 2014 to 28 th July, They were PubMed, CINAHL, Cochrane Library and ProQuest. The keywords include 'asthma', 'adult', 'self- management', 'education, asthma control and quality of life. The selection of studies was followed by deleting the duplications and screening through the title and abstract for elimination. The searching was then further limited according to the inclusion and exclusion criterion mentioned in and revising the full text. A total of 9 studies were identified, seven from PubMed, one from CINAHL and one from manual search of reference lists of the selected studies. Two studies (Marabini, Brugnami, Curradi & Siracusa, 2002 & Marabini et al., 2005) were found to be the same study in different time phrase. Finally, eight studies are selected. Please refer to appendix 1 for the details of searching strategies. 2.2 Data Extraction and recording Data of the selected studies are extracted and recorded in form of table of evidence (See appendix 2). Key information of the table of evidence include study design, subject characteristics, intervention and control descriptions, length of follow-up,

19 11 outcome measures and effect size. 2.3 Quality assessment of studies The methodology checklist for controlled trial from the Scottish Intercollegiate Guidelines Network (SIGN) was used to assess the quality of the selected studies. The checklist divided into two sections, aiming at assessing the internal validity, possible bias and overall effect of the studies. Please see appendix 3 for the checklists of the selected studies Overview of the studies Of all selected studies, six of them are RCTs (Gallefoss et al., 2001; Janson, McGrath, Covington, Cheng & Boushey, 2009; Magar et al., 2005; Marabini et al. 2005; Put, van den Bergh, Lemaigre, Demedts & Verleden, 2003; Urek et al., 2005) and two of them are quasi-experimental (Choi et al., 2010; Yang, Chiang, Yao & Wang, 2003). For the quasi-experimental study, both of them performed pre-test and post-test evaluation, and only Yang et al. (2003) divided the patients into experimental and control group. The studies were performed in Korea (Choi et al., 2010), Norway (Gallefoss et al., 2001), United State (Janson et al., 2009), France (Magar et al., 2005),

20 12 Italy (Marabini et al., 2002 and 2005), Croatia (Urek et al., 2005) Belgium (Put et al., 2003) and Taiwan (Yang et al.,2003). No local study was found. The sample size ranged from 23 to 238. All selected studies evaluated the effectiveness of the self- management education program on patients QOL whereas six studies evaluated on asthma control ( Janson et al., 2009; Urek et al., 2005; Magar et al. 2005; Gallefoss et al., 2001; Put et al., 2003; Choi et al., 2010) Summary of quality assessment RCTs For the six RCTs, patients were randomized to intervention group and control group. Patients in intervention group received self-management education and those in control group received usual care. The method of randomization varied. Three studies used computer allocation method (Janson et al., 2009; Urek et al., 2005; Marabini et al., 2005).Other three studies used scratch a box (Magar et al., 2005), random number table.(gallefoss et al., 2001) and drawing envelope (Put et al., 2003). Magar et al. (2005) mentioned use of box and Gallefoss et al. (2001) and Put et al. (2003) mentioned use of sealed envelope as concealment method. Other studies did not mention the use of concealment method.

21 13 For blinding process, double blinding was difficult to perform to the patients and investigators who received and provided education program respectively. Janson et al. (2009) blinded the investigators who contributed to data management and assessment and Put et al. (2003) blinded the researcher who conducted the program and performed assessment. The remaining four RCTs did not mention about the blinding process. The intervention group and control group were similar at the start of study in five RCTs as shown by no significant difference between groups in baseline measurement (Janson et al., 2009; Urek et al., 2005; Marabini et al., 2005; Put et al., 2003; Gallefoss et al., 2001). Peakflow (Janson et al., 2009) and the proportion of both sex (Urek et al., 2005) was reported significance difference between groups in baseline measurement. Appropriate adjustment was made in the statistical analytic process in the above two studies afterward. One RCT (Magar et al., 2005) did not mentioned about the similarity between groups at baseline. However, patients recruited in this study were of common characteristics as described in inclusion and exclusion criterion, as well as similar baseline scores in QOL and asthma control. Therefore, it was suggested that the intervention group was similar to control group in this study.

22 14 In all six RCTs, the only difference between groups was the treatment under investigation. The drop out or lost to follow-up rate ranged from 0% to 18.9%. Power analysis was mentioned in two RCTs to reach a power of 80%. (Janson et al., 2009; Magar et al., 2005) The sample size of former study reached the calculated sample size but Magar et al. (2005) did not. However, owing to the relative large in sample size of Magar et al. (2005) and the size was very close to the expected value, the sample power was estimated to be adequate. Only one RCT mentioned the intention to treat (ITT) analysis (Janson et al., 2009). All six RCTs recruited patients from outpatient settings. Urek et al. (2005) also recruit patients in in-patient wards. Three studies performed the study in a single clinic setting (Marabini et al., 2005; Put et al., 2003; Gallefoss et al., 2001). One RCT conducted the study in four clinic settings (Magar et al., 2005). It did not mention if the study compared result between sites. However, the result would not be affected significantly owing to the randomize nature and similar characteristics between groups. Janson et al. (2009) did not mention if the study conducted in single clinic setting.

23 15 Quasi-experimental Two quasi-experimental studies with pre-test and post-test design were identified (Choi et al., 2010; Yang et al., 2003). Yang et al. (2003) involved both intervention and control group while Choi et al. (2010) involved only intervention group. Power analysis was not mentioned in both studies. In Yang s study, there was no significant difference between groups expect age and disease severity, which was later adjusted in statistically analytic process. No blinding process was mentioned and the only difference between groups was the intervention under investigation. The dropout rate of both studies was 0%. Both of them carried out the program in the same clinic setting. P value smaller than 0.05 was defined as statically significant in all selected studies. Regarding the outcome measurement, valid and reliable tools were used in all selected studies which will described in detail in chapter and Result of Quality assessment Based on the criteria in the SIGN checklist, one study was rated 1++ (Janson et al., 2009). Five studies were rated 1+ (Urek et al., 2005; Magar et al., 2005; Marabini et al., 2005; Put et al., 2003; Gallefoss et al., 2001). Among the two quasi-experimental

24 16 studies, one study was rated 2++ (Yang et al., 2003) and the remaining rated 2+ (Choi et al., 2010). 2.4 Summary of data Aim of study The aim of all selected study was to investigate the effectiveness of self-management education program in improving QOL of asthma patients. Six studies ( Janson et al., 2009, Urek et al., 2005; Magar et al. 2005; Gallefoss et al., 2001; Put et al., 2003; Choi et al., 2010) also aimed at improving patient s asthma control Patient characteristics All of the selected studies involved adult patients. The age ranged from 18 to 72 years old. In four studies, the mean age ranged from 43.4 to 59 ( Urek et al., 2005; Marabini et al., 2005; Choi et al., 2010; Yang et al., 2003). Five studies (Janson et al., 2009; Marabini et al., 2005; Choi et al., 2010; Yang et al., 2003; Put et al., 2003) recruited similar proportion of patients for both sex, with around 50% in each gender. The intervention group with individual education and control group of Urek et al. (2005),

25 17 both intervention and control groups of Gallefoss et al. (2001) had higher female patients of 65%, 80%, 61% and 79% in proportion respectively. Magar et al. (2005) did not mention the gender information. The levels of severity in asthma recruited in the studies varied. Three of the studies followed the GINA guideline on the classification of asthma severity (Urek et al., 2005; Magar et al., 2005; Marabini et al., 2005) while the remaining studies classified by FEV1 values and asthma symptoms without stating the corresponding guideline Studies design Except Choi et al. (2010) which recruited patients in hospital setting, all studies recruited patients in outpatient clinic. Urek et al. (2005) also recruited patients from inpatients wards. The education program of all studies took place in single outpatient clinic, except Magar et al. (2005) which conducted in four clinic settings. Regarding the mode of delivering education, Janson et al. (2009), Put et al. (2003) and Choi et al. (2010) conducted individualized education program whereas Yang et al. (2003) carried out group education program. Urek et al. (2005) include three arms in the study; individual education program, group education program and usual care. One study involved mainly individual education with a one hour group session

26 18 (Marabini et al., 2005). Two studies involved mainly group session with individual patient assessment (Magar et al., 2005; Gallefoss et al., 2001). For the studies conducted individual education, all studies provided three education sessions, except Put et al. (2003) conducted in six sessions. Two of them lasted for 30 minutes each session (Janson et al., 2009; Choi et al., 2010) whereas Urek et al. (2005) and Put et al., (2003) lasted for one hour each session. The range of total intervention hours for individual education was 1.5 to 6 hours. For the studies conducted group education, the duration varied. Urek et al. (2005) launched three 4-hour classes and Yang et al. (2003) launched four 1-hour classes. The range of total intervention hours for group education was 4-12 hours. For the studies having mixed education, both Magar et al (2005) and Gallefoss et al. (2001) involved one hour individual assessment session with two 2-hour to 2.5 hour group classes. One study provided three individual sessions (five hours in total) with one hour being the group class (Marabini et al., 2005). The range of total intervention hours for mixed education was 5 to 6 hours. The main educators were nurses in five studies (Janson et al., 2009; Urek et al., 2005; Magar et al., 2005; Gallefoss et al., 2001; Choi et al., 2010) with collaboration with chest physicians (Urek et al., 2005; Magar 2005) or other health allies such as

27 19 physiotherapy (Margar et al., 2005; Gallefoss et al., 2001), chest therapists (Janson et al., 2009), spirometry technicians (Urek et al., 2005) or pharmacists (Choi et al., 2010). Two studies involved only chest physician as educators (Marabini et al., 2005; Yang et al., 2003). Put et al., (2003) did not mention the qualifications of educators. Regarding the content of education, all studies taught patient with the basic knowledge of asthma. Six studies mentioned about the teaching of asthma trigger and its avoidance (Janson et al. 2009; Magar et al., 2005; Marabini et al., 2005; Urek et al., 2005; Put et al., 2003; Yang et al., 2003). Five studies mentioned the teaching of the proper use of peak flow meter and its monitoring, as well as the proper use of inhaled medications (Janson et al. 2009; Magar et al., 2005; Marabini et al., 2005; Urek et al., 2005; Choi et al., 2010). Six studies provided patients with action plan for the case of exacerbations (Janson et al., 2009; Urek et al., 2005; Magar et al., 2005; Marabini et al., 2005; Gallefoss et al., 2001; Choi et al., 2010). The action plan includes guideline on adjustment of asthma medications, except in Janson et al. (2009) Outcome measurement Regarding the outcome measurement, the main outcomes are QOL and degree of asthma control.

28 20 Quality of life For health related QOL, it was measured by Modified short version of living with asthma (ms LAUQ) in two studies (Urek et al., 2005; Choi et al., 2010), Asthma Quality of Life Questionnaires (AQLQ) in three studies (Marabini et al., 2005; Put et al., 2003; Yang et al., 2003). Janson et al. (2009) and Gallefoss et al. (2001) adopted the St George s Respiratory Questionnaie (SGRQ), a validated questionnaire by Marks, Dunn andwoolcock (1992) and QVSA questionnaire was used in Magar et al. (2005). The psychometric properties of the questionnaires will be discussed in Asthma control PERF was measured in five studies (Janson et al., 2009; Urek et al., 2005; Put et al., 2003; Marabini et al., 2002; Choi et al., 2010). Three studies measured the asthma control by daily record card (DRC). It required patients to self-scoring and record indicators such as number of nighttime awakening and rescue medications use daily (Janson et al., 2009; Urek et al., 2005; Choi et al., 2010). Magar et al. (2005) measured the asthma symptoms by asking the patients to keep a daily dairy stating the time course of their asthma symptoms and their healthcare consumption, as well as self-administered questionnaires during follow up. Put et al. (2003) measured by asthma control checklist which involved self-scoring on frequency of symptoms such

29 21 as airway obstruction, fatigue and irritation by patients at baseline and end of program. All control groups received usual care during the study period Result Quality of Life Except Yang et al. (2003) and Janson et al. (2009), six out of eight studies measured significant improvement between groups. Asthma control Regarding the asthma control, six studies showed significant improvement in one or more items in asthma symptoms and asthma control indicators between groups (Janson et al., 2009; Urek et al., 2005; Magar et al., 2004; Gallefoss et al., 2001,; Put et al., 2003; Choi et al., 2010).The asthma symptoms and indicators included numbers of night-time awakening, numbers of symptom free days and use of rescue medications. Regarding PEFR, the individual education group in Urek et al. (2005) and Put et al. (2003) showed significant improvement between groups. Choi et al. (2010) showed significant improvement in PEFR between pre and post-test. No significant different

30 22 observed for PEFR between groups in two studies (Janson et al., 2009; Marabini et al., 2005), as well as the intervention group with group education in Urek et al. (2005). 2.5 Synthesis of data By summarizing the selected studies, some key elements for an effective self- management education program are identified Target population The level of severity in asthmatics varied in the selected studies. Four studies recruited patients with all levels of asthma (Choi et al., 2010; Marabini et al., 2005; Magar et al., 2005; Yang et al., 2003). Two studies recruited patient with mild to moderate asthma (Put et al., 2003; Gallefosset al., 2001). Urek et al. (2005) and Janson et al. (2009) involved moderate and moderate to severe asthmatics respectively. Upon summarizing the studies, it is found that education program was beneficial to patients of different permanent asthmatic status. Therefore, patients of all degree of persistent asthma should be involved in the self-management education program. Patients of poor compliance can also be recruited, so that they can be educated before asthma status getting worse (Choi et al., 2010).

31 Details on education program Individual education was performed in four studies (Janson et al., 2009; Urek et al., 2005; Choi et al., 2010; Put et al., 2003). In Urek et al. (2005) which include individual intervention, group intervention and control group. It was found that patients received individualized education showed best overall improvement in both QOL and asthma control. Put et al. (2003) showed significant improvement in patient s QOL, asthma control and knowledge immediate and three months after education. Janson et al. (2009) showed significant improvement in patient s perceived symptom control score and Choi et al. (2010) showed significant improvement in QOL and symptom control. One-to -one basis of individual education program allowed patients to express their key area of concern over asthma and health professionals could provide education accordingly. The duration and frequency of program should be appropriate so that it can be long enough to promote behavioral changes, enhance skills and knowledge but not be too long to avoid absenteeism. After reviewing the selected studies, one hour per session was estimated to be appropriate (Urek et al., 2005; Choi et al., 2010; Put et al., 2003). The program can be divided into three sessions (Janson et al,. 2009; Urek et al., 2005; Choi et al,. 2010; Marabini et al,. 2005; Magar et al., 2005; Gallefoss et al., 2001) in

32 24 about three months (Urek et al., 2005; Put et al., 2003; Marabini et al., 2005). The total teaching hours will be three. Individual education of teaching hours in three months were showed significant in improving patients quality of life and asthma control (Janson et al. 2009; Urek et al., 2005; Choi et al., 2010). Four studies used trained nurses or experienced chest nurses as major educators (Janson et al., 2009; Urek et al. 2005; Magar et al., 2005; Choi et al., 2010.). Training is recommended for nurse educators on appropriate interview technique and implementations of appropriate teaching methods for asthmatics accordingly (Urek et al., 2005). The content of education program is recommended to promote self-management of the asthma patients. It should perform in an interactive ways so as to encourage a more active role in asthma related self-care from patients (Urek et al., 2005). The content should include asthma pathophysiology, asthma symptoms, importance of medication adherence, proper use of inhaled medications and asthma triggers and avoidance as taught in majority of the selected studies. The use of peak-flow monitoring(janson et al., 2009; Urek et al., 2005; Choi et al., 2010; Marabini et al., 2005; Magar et al., 2005) and use of action plan (Janson et al., 2009; Urek et al., 2005; Magar et al., 2005; Marabini et al., 2005; Gallefoss et al., 2001; Choi et al., 2010)

33 25 should also include in the content. To fulfil patients information need, it is necessary to identify their high risk behavior and provide information and resources accordingly (Choi et al., 2010; Put et al., 2003) Outcome monitoring Quality of life Regarding QOL measurement, having mentioned in part , the measuring tools varied in the selected studies. Four questionnaires were identified in the selected studies. SGRQ used in Janson et al. (2009) and Gallefoss et al. (2001) is a 72-items questionnaire with total score of 100. According to American Thoracic Society (2015), SGRQ measure three components: Symptom, activity limitation and impact. It is reproducible, internal consistent and validate with intraclass correlations of to and significant correlations between total score and presence of symptom, activity, and impact domains. QVSA used in Magar et al. (2005) is a questionnaire with score ranged from 0% to 100%. However, the literature (Lennox & Lebrun, 1998) found in reference list of Magar et al. (2005) on QVSA is non-english version and no further information can obtained. Modified short version of Living With Asthma Questionnaire (ms-lwaq) (Ried et al. 1999) used in Urek et al. (2005) and Choi et al. (2010) is a validate and reliable tools with Cronbach alpha >0.72. It is measured by 21

34 26 true or false questions and divided into four subscales of affect, leisure, seriousness consequence. Asthma Quality of Life Questionnaire (AQLQ) (Juniper et al., 1992) measured QOL by 32 questions in four domains (symptoms, emotion, activities and environmental triggers) (Marabini et al. 2005; Yang et al., 2003; Put et al. 2003). AQLQ is recommended. It is a reliable and valid measurement tool. According to Juniper et al. (1992 and 1993), AQLQ contains comprehensive domains to detected changes in patients who had natural fluctuations in asthma or who responded to treatment (p < 0.001) and to differentiate these patients from those who remained stable (p < 0.001). It is reproducible among patients and there were significant longitudinal and cross-sectional correlations between asthma quality of life and other measures of clinical asthma and generic quality of life such as spirometry reading (Juniper et al., 1992). Asthma control Except Magar et al. (2005), Gallefoss et al. (2001) and Yang et al. (2003), the remaining five studies measured PERF as asthma control parameter. PERF is a discrimative and sensitive parameter of asthma control (Urek et al., 2005). It is recommended to measure three times to obtain the highest value each time, prior to the use of bronchodilator. To prevent the impact of circadian pattern, it was

35 27 recommended to measure PERF in similar time of the day, in morning and evening (Urek et al., 2005; Choi et al., 2010; Put et al., 2003). PERF can also acts as a mean for patients to monitor their asthma status, giving them a sense of self control. Other objective indicators such as night-time awakening were used in six studies to monitor asthma status (Janson et al., 2009; Urek et al., 2005; Magar et al., 2004; Gallefoss et al., 2001; Put et al., 2003; Choi et al., 2010). The above indicators were recorded in form of daily record card (DRC) in three studies (Janson et al., 2009; Urek et al., 2005; Choi et al., 2010). The advantage of DRC was to avoid record bias and also act as a mean to self-monitoring of the asthma symptoms. 2.6 Conclusion Asthma is common chronic illness globally and locally. It is potentially life-threatening. However, it is found that asthma attack is preventable and can be well-controlled with appropriate self- management education program. In chapter one and two, critical appraisal and review have been conducted on the existing studies with an aim of providing evidence for implementing a self-management education program for adult asthmatics in the local setting in coming chapters.

36 28 Chapter 3 - Translation and Application Implementation potential In this chapter, the implementation potential of the proposed evidence-based education program is assessed. Target settings and audience are first be defined. The program is then assessed in terms of transferability of the findings to local settings, feasibility and cost-benefit ratio of the program (Pilot & Beck, 2008). 3.1Target settings and audience Target settings The target setting is TB & chest service of Department of Health which includes 12 full-time chest clinic and 5 part-time chest clinic. All of them are outpatient clinic. The education program is first implemented in one of the full-time chest clinic as pilot. There are totally two medical officers, one nursing officer, 8 registered nurses and 4 enrolled nurses in the target clinic.

37 Target audience Inclusion criterion 1. Aged 18 or above with persistent asthma Exclusion criterion 1. With infectious Tuberculosis (TB) status as screened by sputum smear laboratory test 2. With mental or psychiatric disorder that affect ability to understand or comply with the program 3.2 Transferability of the findings Similarity of settings and audience In addition to TB patients, chest clinic encounters numbers of patients with chest problem like asthma. The aim of chest clinic is to provide medical service for patients with chest problem in out-patient settings. Similar to the proposed education program, all of the studies except Choi et al. (2010), recruited patients in outpatient settings. The target setting in general is similar to that in the selected studies.

38 30 According to the registration database in the selected chest clinic, there are about 97% of the patients aged 20 or above. Among them, 72% are aged 40 or above. The proportion of male and female is around one to one. All of the selected studies recruited patients aged 18 or above, ranging from 18 to 72. Their mean age ranged from 43.4 to 59. Majority of the selected studies recruited similar proportion of both sex, around one to one (Janson et al., 2009; Marabini et al., 2005; Choi et al., 2010; Yang et al., 2003; Put et al., 2003). According to the selected studies, the education program was significant in improving the asthma control and quality of life of adult patients with mild, moderate and severe persistent asthma. Although only two of the selected studies conducted in Asia, Korea and Taiwan (Choi et al., 2003; Yang et al., 2010), other studies conducted in western countries shared similar characteristics as Hong Kong in terms of prevalence of asthma in adult (prevalence of asthma patients in Hong Kong, Belgium, France and Italy is 6.2%, 6.8%, 6.0% and 4.5% respectively in 2004) and maturity of medical services (GINA, 2012). In general, the demographic characteristics of the patients in the reviewed studies are similar to that in target clinic.

39 Philosophy of care The proposed program aims to increase the self-management ability of asthma patients in asthma monitoring and control of symptoms through education program, so as to yield a better quality of life. It is coherent to the goal of the selected studies which aimed at finding out the effectiveness of self-management program in increasing asthma control and quality of life. Moreover, the mission of chest clinic is to safeguard the health of the people of Hong Kong through promotive, preventive, curative and rehabilitation services (Department of Health, 2014). Therefore the proposed education program, the mission of target settings and the selected studies shared similar philosophy of care Number of clients benefit from the program According to the registration record of general office, there were patients aged 20 or above attended the selected chest clinic from November 2013 to October Since no formal statistics on the number of asthma patients attended is available, the number of attendance of asthma patients is done based on clinical observation. It is estimated that there are about 264 asthma patients attending the clinic per year. The program aims at recruiting 30 patients and 150 patients in pilot and actual

40 32 implementation phrase respectively Duration of implementation and evaluation It is estimated that the total duration of the pilot program is 26 week, which included 4 weeks of preparation time, 20 week of implementation time and 2 week for evaluation and analyzing process. The pilot study is then followed by the actual implementation after refining, the duration of the actual implementation is 1 year followed by 3 weeks of evaluation period. To conclude, the clinic settings and targeted audience, philosophy of care and duration of program of the selected studies are largely similar to that in local clinic environment, suggesting high transferability of those studies into the targeted local settings. 3.3 Feasibility Feasibility to implement the proposed program are assessed in terms of freedom to implement, administration support, interference to current clinic function, consensus, staff training, availability of resources and evaluation tools (Polit & Beck,2008).

41 Free to implement One of the major works of nurses in chest clinic is to provide health education to patients. Nurses have high autonomy in initiating or refining the education program. Nurses get the right to implement and terminate the proposed education program upon getting consensus with the nursing officer (NO) and senior nursing officer (SNO) Administration support The SNO and NO of chest clinic are open-minded and eager to change. They encourage frontline staff to give opinions for better nursing quality. One of the examples is the monthly sharing session in the target clinic. Recently, lots of efforts have been made to improve the service of clinic and nursing care such as revision of the nursing protocol with evidence-based approach, encouragement of research among nurses as well as the establishment of IT system in chest services. Support would be gained from the administrative level of the clinic, however, adequate time should be allowed for getting approval Interference to current clinic function Upon introducing the program, the workload and pressure of nurses will be increase

42 34 in short-run. Time and man-power is needed for setting up the program and training. To ease the problem, the logistic of the program should be well-planned and kept simple. The program conducts on less buzy scheduled Wednesday and Friday, with four quotas in morning and three in afternoon session. Each session is conducted by a nurse. All nurses are trained to be educators to prevent over-workload of particular nurses. In additions, to prevent overload of nurses, part-time nurse will be recruited on Wednesday and Friday during the implementation phrase to replace from the routine work. Part-time nurse is also required during the preparation and evaluation phrase. Furthermore, nurses might reluctant to change owing to lack of insight about the benefit of program. Therefore, details and aims of the program should be explained clearly to the nurses. Moreover, sufficient training time is allowed for nurses for higher competency. In long-run, the number of unplanned attendance due to poor asthma control and hence workload of staff would be decreased. Also, the morale and autonomy of nurses would also increase Consensus among different parties Consensus among different parties involved in the education program is needed before implementation. Another discipline involved is physicians of the target clinic. In general, the physicians are open-minded and helpful in providing opinions.

43 35 Agreement need to be made regarding the temporary change of follow up schedule from three monthly to monthly once the patient recruited to the education program. In addition, physicians can also pay an effort to persuade patients to enroll into the program Staff Training Staff training is a key component in implementing an education program. Nurses in chest clinic get practical asthma related knowledge on the use of peak flow meter, performing lung function test, use of inhaler and smokerlyzer. The training is recommended to focus more on theoretical knowledge on asthma, underlying principle of medications, interpretation of different reading as well as the details on the logistics of education program. All nurses are trained. They are trained in one 60-minutes session by two trained nurse and the training is performed after work to minimize the interference to the clinic function. One-hour time off will be given back to each involved nurses Availability of resources Well prepared equipment is also crucial for launching an education program. The

44 36 program is launched in the interviewing room of the target clinic. Equipment such as lung function machine, Isobooth for better ventilation to prevent from air-borne disease during lung function test, smokerlyzer, spacer and inhaled medications are available in target setting. The main equipment need to be newly prepared is the peak flow meter which will be issued to each patient joining the program. Patients are recommended to use the issued peak flow meter daily for self-monitoring of their asthma status. More details on the use of peak flow meter will be explained in Appendix 6. Other materials need to develop include information kit for nurses and patients, checklist for the progress of education program, as well as the daily record card for patients Availability of evaluation tools To measure the outcome of the program, appropriate evaluation tools are needed. Valid evaluation tools are identified for measuring outcomes (asthma control and Quality of life) in the proposed program. The evaluation tools for measuring asthma control are peak flow meter reading and daily record card. Asthma Quality of Life Questionnaire (AQLQ) (Juniper et al., 1993) is recommended for the measurement of quality of life of the patients in the program. Details for selecting the tools please refer to chapter

45 37 To conclude, the proposed program is feasible to conduct in the target setting. 3.4 Cost-benefit ratio With reference to Polit & Beck (2008), one of the major components in assessing the implementation potential of a proposed program is cost-benefit ratio. It can be assess through analyzing the potential benefit, potential risk and summarizing the material and non-material cost of the proposed program Potential benefit The major benefit of the proposed education program is to increase the asthma control and quality of life of the participants. In long term, with the enhancement of the self-management skill, the number of unplanned clinic visit and hospital admission can be decreased, resulting in decreased health care expenditure and decreased workload of the nurses. Being the educators of the program, a trustful relationship built between patients and nurses, together with the high autonomy of the nurse role, the morale of nurses will increase.

46 Potential risk The proposed program imposed nearly no risk to the patients. The major risk is an increased number of defaulted patients due to increased time spent in clinic. To minimize the risk, the program should be well-designed to convenient the patients. For example, the education program is arranged in the same day with the consultation date. In addition, as discussed in previous chapter, the duration and frequency of program should not be too long to avoid absenteeism. Three 1 hour sessions in three months is appropriate Risk of maintaining current practice There are more than 330,000 people suffering from asthma in Hong Kong (The Hong Kong Asthma Society, 2014). According to Lai, Kim, Kuo, Spencer & William (2006), the health cost for asthma in Hong Kong is about US$1010 per patient every year. The direct costs of asthma include emergency visit, hospital admission and ambulance use. According to the Hospital Authority Statistical Report (2012), there was 8912 admission due to asthma attack. With reference to developed countries such as British and Austria, the length of stay is approximately 3 and 2.5 days respectively (Soyiri, I. N., Reidpath, D. D. & Sarran, C., 2011; Asthma in Australia, 2011). The cost of