1. Effect of Self-Regulatory Education on Women with Asthma July 12, 2003

2. Outlines  The research project  The intervention program  Baseline findings

3. Investigators

4. Research Team PI (Co-PI & Co- investigators) Oversees all aspects of the study Project director- secretary Daily operation Data collection team 5-6 graduate students Recruiting & interview Intervention team 2-3 health educators Deliver program Data analyst Manager/Analyst Database / analysis

5. Background - Prevalence  Five million women are currently diagnosed with asthma (Crespo, 1997)  Asthma prevalence rate for women increased 82% compared to 29% for men (1982-1992, CDC)  Asthma mortality rate increased 59% for women compared to 34% for men (1982-1992, CDC)

6. Background – Morbidity & Hospitalization  Hospital admission for asthma: Women 2 times more than men. (Skobeloff, 1996)  More symptoms and worse quality of life reported by female asthma patients compared to male patients. (Osborn, 1998)

7. Menstrual-Linked Asthma  30-40% of women with asthma report symptoms worsening prior to or during menses. Significantly reduced Peak Flow Rates, more medication and health care use were found during this period of menstrual cycle. (Agarwal, 1997; Eliasson, 1986)  Disease is more severe in women with menstrual- linked asthma.  Use of oral contraceptive medication may reduce symptom variability in women with menstrual-linked asthma.(Tan, 1997)

8. Factors Related to Women’s Traditional Tasks in Household  Cooking-related irritants and triggers include gas, wood smoke, cooking oils, food preservatives, monosodium glutamate, coloring agents.  Cleaning-related indoor allergens include house dust, domestic house- dust mites, fungi, molds, yeasts, sprays, cleaning products, and scented products.

9. The research project Purpose  To evaluate an innovative education program based on self-regulation theory designed to address the unique needs of adult female patients with asthma.

10. Specific Hypotheses  Decreased gender-related asthma management problems  Decreased symptoms  Reduced health care use  Reduced work absence  Improved quality of life

11. Study Design  A randomized controlled design utilizing an intervention group and a control group.

12. Recruitment criteria  18 years of age or older  A diagnosis of asthma  A patient in one of the clinics at University of Michigan Health System

13. IRBMED Approved Recruitment Procedures  A list of female patients diagnosed with asthma is provide by the UM Health System Data Warehouse  An individual Invitation letter signed by investigators and personal physician is mailed to the potential participant  A phone call follows  Consent forms are sent for signatures

14. Data collection  Baseline  Follow-up I: 12 months subsequent to baseline (approximately 6 months subsequent to program completion)  Follow-up II: 12 months subsequent to there after. Three time points:

15. Randomization  After baseline data collection, participants are randomly assigned to either the intervention or the control group. Women in the intervention group receive the “Women Breathe Free” telephone counseling program. Women in the control group will receive the program after it is evidenced to be effective and requested by the woman.

16. WOMEN BREATHE FREE

17. Components of the intervention  Theoretical Framework-Social cognitive theory (Bandura, 1986), and the principles of self-regulation (Clark & Zimmerman, 1990, Clark, 1992) applied  Gender-related management problems addressed  Peak flow meter and diary used  Telephone counseling sessions delivered

18. Asthma Education Kit  Workbook  Peak Flow Meter  PFM Video  Diary

19. Our Health Educators

20. What the Health Educators Do  Introduce a problem solving process.  Guide through a period of self- observation using PFM & Diary.  Encourage to discuss questions and observations with physicians to enhance the patient-physician partnership in asthma management.

21. Self-regulatory problem solving steps First step: select a problem  I have a problem with my diagnosis of asthma: Do I really have asthma?  I feel chest tightness and/or may wheeze whenever I cook, vacuum, or dust.  My asthma symptoms get worse when I have premenstrual syndrome.  Smoke may trigger my symptoms, and I live with someone who smokes. I’m afraid to tell them because I don’t want to hurt their feelings.

22. Second step:  Coach the participant to use diary and peak flow meter as observational tools to track related factors. The participant logs peak flow readings, hormonal cycles, symptoms, triggers, other medical conditions, medication use, tasks, activities & events every day for 4-6 weeks.

23. Women Breathe Free Program

24. Third step:  Identifying self-management asthma goal (short and long term goals)  Long-term goal: to clean the house without wheezing.  Short term goal: to vacuum the house without symptoms Examples of Goals

25. Fourth step: Developing my plan  Steps to reaching my short-term goal are: 1. Buy masks & dust proof vacuum bags. 2. Wear mask every time I vacuum. 3. Have someone vacuum for me.  Developing a plan for reaching the goal (lists of barriers and strategies to reach the goal)

26. Developing my plan: BarriersStrategies Did not know where to purchase masks & vacuum cleaner bags Ask my asthma coach or look at information in workbook under supplies Forget to wear maskHang mask on vacuum cleaner handle Feel someone may not be able to do a good job Instruct & trust other people can do a good job

27. Other self-regulatory steps  Exploring a reward  Developing a health-related contract

28. Preliminary Evaluation  Among a total of 166 program participants, 80% (n=131) completed required 4 diaries, 83% (n=109) completed 8 or more diaries, 87% (n=113) completion with 4 categories, 94% completion of peak flow entry.  I was a reluctant participant with mild asthma but found the program helpful in identifying when to use medication. I am now more likely to use my inhaler than I might have been without the program.

29. Baseline Findings

30. Sample demographics (n=439) Age

31. Sample demographics Annual Household Income

32. Sample demographics Education Level

33. Sample demographics Race/Ethnicity

34. Asthma severity Percent of Women Mild intermittent 52.62 Mild persistent 14.35 Moderate persistent 18.45 Severe persistent 14.58 Classified by NAEPP criteria, Guidelines and Diagnosis and Treatment of Asthma, NHLBI, NIH, 1997

35. Co-Morbidities Reported  Reflux: 72%  Over weight (BMI=26- 30): 28%,  Obese (BMI 31-35): 30%  Over obese (BMI > 35): 9%

36. Co-Morbidities Reported  Urinary incontinence: 54%  Migraines: 34%

37. Health care utilization during the past 12 months  One fourth of the women had at least one ED visit.  8% were hospitalized  35% had one or more unscheduled urgent visit to a doctor’s office.

38. Peak Flow Meter Usage  Almost 80% of the women owned a peak flow meter.  Less than 7% of the women used it every day.  30% used their peak flow meter only when they felt an asthma attack was coming on.

39. Factors Associated with Persistent Disease 1. Low annual household income, a lower level of education, and not working for pay were associated with persistent asthma, whereas, age, marital status, and ethnicity were not. 2. Women with persistent asthma were more likely to have high BMI, maintain a low level of exercise, have lower self-esteem, had more social support compared to women with intermittent disease.

40. Hormone Related Findings  54% women currently menstruate. Among those:  15% noticed symptoms worsening during the week prior to the period.  Over half of the women reported PMS symptoms. The more severe the asthma symptoms, the more severe the PMS symptoms (r=0.364, p<.0001)  30% women reported they were bothered by symptoms of asthma during sexual activity. The more severe the asthma symptoms, the more bothersome during sexual activity (r=0.361, p<.0001)

41. Hormonal factors and health care utilization Menstruation and Asthma Health Care Utilization

42. Urinary incontinence was significantly associated with  older age, not working for pay, ever been pregnant, history of smoking, and a higher body mass index.  more days of daytime and nighttime symptoms and more hospitalizations and clinic visits.  lower self-esteem, social support, and overall quality of life.

43. Overweight was significantly associated with:  Older age (p=.05), lower level of education (p=.0001), and household income (p=.002), being unmarried (p=.02), and African American (p=.04);  More days of daytime (0=.06) and nighttime symptoms (p=0.08), more hospitalization (p=.0001), ED visit (p=.0029), urgent office visits (p=.008), scheduled office visits (p=.03), and visits to follow-up an asthma attack (p=.009);  Urinary incontinence (p=.0001), migraine headache (p=.03), and reflux (p=.02);  Lower level of quality of life (p.0002) and self- esteem (p=.001)

44. Limitations  This study sample includes a number of women with high levels of education and income.  The findings reported here are from preliminary analysis.

45. Thank You!