Asthma education information source preferences and their relationship to asthma knowledge.
Abstract: This study recounts the findings from a year-long survey of Brooklyn residents. Survey respondents were questioned about their knowledge of asthma signs, triggers, symptoms and their attitudes and beliefs about asthma. If they had asthma or were responsible for a child or adult who had asthma they were asked questions to determine how well that asthma was controlled. They were also questioned about their preferred sources of asthma information. Descriptive and inferential statistics indicate that the survey respondents (mostly African American, middle aged, females) were generally knowledgeable about asthma, although they shared some misconceptions about asthma treatments and triggers. They showed a marked preference for obtaining their asthma information from traditional Western medicine providers rather than friends, family members, alternative or complimentary medicine providers or spiritual leaders. This information is useful in guiding investments of time and resources for asthma education programs addressing such audiences. It is also useful for planning health care education programs for a variety of disorders, including high blood pressure and diabetes.

Keywords: asthma education, peer counselors, asthma information sources, asthma knowledge, minority health education, asthma survey, asthma education resources
Article Type: Report
Subject: Health education (Demographic aspects)
Health education (Information management)
Asthma (Care and treatment)
Author: Zahradnik, Anne
Pub Date: 12/22/2011
Publication: Name: Journal of Health and Human Services Administration Publisher: Southern Public Administration Education Foundation, Inc. Audience: Academic Format: Magazine/Journal Subject: Government; Health Copyright: COPYRIGHT 2011 Southern Public Administration Education Foundation, Inc. ISSN: 1079-3739
Issue: Date: Winter, 2011 Source Volume: 34 Source Issue: 3
Topic: Event Code: 260 General services Computer Subject: Company systems management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 304051558
Full Text: INTRODUCTION

The specific recommendations in Action Against Asthma (Anonymous, 2000) include "Help Health Care Providers Practice Up-to-date Asthma Care, and Educate Patients and Their Families" (p. 36). The National Asthma Education and Prevention Program Coordinating Committee's Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma (2007) also includes a section specifically addressing patient education, emphasizing the need for a partnership in asthma care. Yet, according to the US Department of Health and Human Services (2002) only about eight percent of asthma patients receive formal patient education. Clearly, despite the high human and social costs of asthma, the need for effective asthma education is still not being met on a wide scale.

Large amounts of time and money have been invested in asthma education. Many research projects have also evaluated the effectiveness of asthma education programs. However, to date, little attention has been placed on discovering the methods by which asthma patients, and the parents of juvenile asthma patients, prefer to learn about asthma.

Purpose of the Study

While there are many high-quality, pre-packaged asthma education systems, one of the concerns in launching the Brenda Pillors Asthma Education (BPAE) Program was that the program provide asthma education in the format that would be the optimum match for the Brooklyn audiences. The experienced respiratory therapists in the program felt confident of what they should cover when counseling clients but program administrators wanted to double check our assumptions about where and how that information should be presented. Our target audience was largely African American (US Census, 2011), which the literature (Watson, Gillespie, Thomas, Filuk, & McColm, 2009; Bryant-Stephens, & Li, 2004; Partidge, et al, 2008 and Hobiner & Fouladi, 2008) indicates we could reach most effectively through community-based lay educators. The literature also directed us toward establishing communication channels through faith-based organizations (Israel, et al, 2010) to enhance our credibility and acceptance into the community.

Setting up a faith-based peer educator system is time consuming and costly, however, so we were concerned about investing in such a system without double checking the appropriateness of those assumptions for our particular set of clients. We decided the best way to find out where and how people in Brooklyn would prefer to learn about asthma was simply to ask them. While the BPAE launched a proactive, multi-faceted asthma education program in eight Brooklyn schools and community centers, attending 45 health fairs in six different Brooklyn sub-boroughs, we also spent a year surveying health fair attendees about the sources they preferred to use for asthma information. What we found ran contrary to the results reported in the literature.

Our survey was largely based (with permission) on the previously validated Chicago Community Asthma Survey (CCAS-32). That survey includes sets of questions to help determine the extent of the respondents' knowledge of asthma signs, symptoms and triggers. For those respondents who self-reported as having asthma there is also a battery of questions to determine how well their asthma is controlled. Parents of children with asthma, or guardians of people with asthma, were queried about how well their child's or family member's asthma was controlled. To help meet our goal of discovering optimum communication channels for our target audiences, we added a set of questions about preferred sources of asthma information to the CCAS-32 survey.

Research Questions

Our central research question was to determine preferences for sources of asthma information amongst members of our target audiences in Brooklyn. We were also curious to learn if there was a correlation between the types and number of sources a patient or parent consulted and their knowledge of asthma signs, symptoms, and triggers. Lastly, we wanted to learn if there was a correspondence between the type of source, and/or number of sources, a person relied upon and how well their asthma was controlled.

Limitations

The survey environment influenced our convenience sample. We surveyed people who were in proximity to the Brenda Pillors Asthma Education Program booth at health fairs and community events. Some events were held inside buildings, such as a church or YMCA. In those situations, that meant our convenience sample was affected by selection bias. Presumably, people who were motivated enough to attend a health fair would be motivated to become more knowledgeable about asthma. Most events, however, were held in areas with more open access. While we were based from a table at a health fair, many of the respondents were simply walking past on the sidewalk, or were at the shopping mall on other errands, when they were randomly intercepted by our surveyors. In retrospect, it would have been beneficial to have added a question asking if the person was there specifically to attend the health fair or for another reason. Nonetheless, our sampling method was consistent from site to site and throughout the year, resulting in a sufficiently representative population to perform statistical analysis.

Definitions and Terms

Race or ethnicity categories in the survey were self-identified by the respondents. We did not use a checklist that would constrain their answers to a pre-defined set. Instead we asked the open-ended question of "What race(s) or ethnicity(ies) do you identify with?" Thus, racial designations were applied as self-reported by the respondents. Multiple answers were permitted. That technique resulted in 17 different racial or ethnic designations.

REVIEW OF THE LITERATURE

Importance of Measuring Asthma Knowledge, Attitudes, and Perceptions

In 1999, Grant, et al stated, "A number of survey instruments have been used to characterize knowledge, attitudes, and beliefs about asthma among people with asthma. However, there appear to be no published survey instruments specifically designed to gain insights into the perception of the general public." (p.178S).

In 2006, Tumiel-Berhalter & Zayas, were still recommending that learning about lay perceptions of asthma and its management is a worthwhile effort. They stated that if healthcare professionals had a better understanding of how their patients perceive asthma and its management, patient education and care would be improved. A variety of research strategies have been employed in pursuit of this information. For example, Koenig's 2004 and 2007 articles on low-income parents' perspectives on managing their children's asthma used an in-depth interview approach. Koenig interviewed each family as many as five times over three to six months, having them give narratives about their perspective on managing their children's illness. She concluded that different parental coping styles would be best met with individually developed management plans. In a study of barriers to asthma management (Laster, Holsey, Shendell, McCarty, & Celano, 2009) found that beliefs and perceptions around the use of daily controller medications, held by both children and their caregivers, were a significant barrier to asthma care and self-management.

Forms, Functions, and Expectations for Asthma Education Materials

Brown, et al, (2005) began with the premise that most health communication is evaluated in terms of program outcomes. They proposed instead that the health communications process should be viewed from the information consumer's point of view.

That reflects the attitude behind this study. Rather than base our program decisions on the standard assumptions, we were motivated to first ask the health information consumers themselves how they would like to learn about asthma. We also wanted to gauge how accurate and complete their baseline information was.

Patient education has long been considered a fundamental and important part of asthma management. The Expert Guidelines for the Diagnosis and Management of Asthma (1997) emphasized education's critical role. However, asthma education faces diverse and manifold logistic barriers, including time, funding, literacy, access, and motivation (Peterson, 2001). To confuse the subject further, research on the effectiveness of patient education and patient education accompanied by case worker attention has shown mixed results on the type and degree of their influence on patients' asthma control. In a Canadian study, Watson, Gillespie, Thomas, Filuk, & McColm (2009) concluded that participants benefited in several ways from their small-group, interactive asthma education program. Participants experienced significantly reduced need for hospital-based asthma services, reduced their use of oral corticosteroids, had fewer visits to primary care physicians, and their primary caregivers missed fewer work hours.

Krishna, et al. (2003), however, found a positive correlation between asthma knowledge and asthma control when they tested for possible effects of an Internet-based, interactive asthma education tool. Comparing the treatment group to a control group who received traditional, paperbased asthma education, they found the educational program significantly increased asthma knowledge, and was positively correlated with decreased asthma symptom days, fewer urgent physician visits, lower use of quickrelief medications, and decreased emergency department visits.

While there is an intuitive connection between higher levels of asthma knowledge and improved asthma control, that connection is not supported in all studies. Coffman, Cabana, Halpin, & Yelin (2008) reported on their meta-analysis of 36 studies regarding the effectiveness of asthma education as judged by hospitalizations, emergency department visits, and urgent physician visits for asthma. They found asthma education programs inconsistently influenced important factors such as physician visits, hospital visits and hospitalization rates.

In an urban, school-based asthma education program, Magzamen, Patel, Davis, Edelstein, & Tager (2008) found participants had reduced symptoms, fewer activity limitations, and less health care utilization. In a rural-based study, Hobiner & Fouladi (2008) found changes in scores for children's asthma knowledge and self-management, self-efficacy in symptom management and use of their metered dose inhaler. They determined that using lay health educators was an effective way to improve children's asthma knowledge and self-management skills.

METHOD

The survey for this study is based on the tested and validated Chicago Community Asthma Survey (CCAS-32) (Grant, et al, 1999 and Weiss, et al, 1999). The CCAS-32 includes 21 dichotomous items to test factual asthma knowledge, and 11 Likert-scale items to gauge asthma-related attitudes and beliefs. Nine areas covered in the survey include, "... symptoms, stigma/acceptability, seriousness/severity, perceptions of susceptibility, consequences, barriers to care, perceptions of quality of life, treatment and healthcare utilization, and triggers." (p. 184S). The BPAE study added two additional question sets: One section specifically asked about preferred sources of asthma information. Another section of questions (answered only by those who self reported as being diagnosed with asthma or were parents or guardians of people with asthma) gauged asthma control. The questions to gauge asthma control were derived from the EPR3 Standards.

ZIP postal codes were also collected from respondents, along with basic demographics of age, education, gender and self-reported racial identity. Respondents, who are described in detail in the results, were largely African American females.

Data was collected at 16 Brooklyn health fairs and community events over the course of a full year. Faculty and graduate students in Public Administration and Respiratory Care programs from Long Island University's Brooklyn campus, conducted 300 surveys, 278 of which were complete and were used in this analysis. At each event the Brenda Pillors Asthma Education (BPAE) program (also associated with Long Island University's Brooklyn Campus) had an asthma education table. A convenience sample was used, as surveyors asked people who browsed the health fair, and others who were not attending the health fair but just happened to be walking past, to complete the survey. A $15.00 incentive was offered for completion of the survey. The survey was administered in English only.

As part of the educational function of the BPAE, a spirometry test performed by a respiratory therapist was offered to survey respondents. Results of such tests were recorded on the respondents' surveys. The majority of spirometry results conducted in the field were not reproducible and were thus unreliable. Analysis of the respondents' asthma control was therefore based on their self-reported answers to the set of asthma control questions.

Data Cleaning and Analysis

Surveys were coded and entered into an Excel[R] database throughout the year. Once the data was entered and double checked, it was converted into SPSS[R]. All analyses and statistical tests were completed in SPSS version 18.

RESULTS

Overview of Survey Respondents

The average age of survey respondents was 42.9 years. The largest age group was 41-50 years (27%), followed by 31-40 years (23%). Figure 1 below provides an overview of all age respondent age groups.

Figure 2 provides a description of respondents' self-reported race or ethnicity. Rather than provide a predetermined list of possible answers, respondents were asked which race(s) or ethnicity(ies) with which they identified. Multiple answers were permitted. Seventeen different responses were tabulated in Figure 2.

[FIGURE 2 OMITTED]

Overview of Responses to Questions on Asthma Symptoms and Triggers and Attitudes toward Asthma

The survey respondents were first asked 21 questions about asthma signs, triggers, and symptoms with a yes/no or true/false dichotomous answer option. Then they were asked a series of questions about their attitudes and beliefs toward asthma and asthma patients.

The original Chicago study, (Weiss, et al, 1999) reported a mean correct response rate for the dichotomous items of 71.9%. In Chicago, >80% of the respondents provided correct answers to 10 of the 21 true/false questions. Misconceptions were common in the Chicago responses. Fewer than half of the respondents knew that asthma cannot be cured. Less than one third knew that using a vaporizer is not a good way to treat asthma. Chicago responses to the Likert-scale items tended to hover near the center of the scale, indicating a lack of certain opinions.

The Brooklyn respondents had a mean correct response rate of 73.8% for the dichotomous items, slightly higher than the Chicago group. In Brooklyn, however, >98% of the respondents provided correct answers to 10 or more of the 21 true/false questions. See Figure 3, below. The mode for number correct was 16. Common misconceptions included not understanding that cockroaches play a role as an asthma trigger, thinking that asthma can be cured, believing that a vaporizer is a good way to treat asthma, and thinking that mosquito bites are an asthma trigger. As in Chicago, the Brooklyn respondent Likert Scale items tended to hover near the center of the scale (averages ranged from 3.1 to 4.4) indicating a lack of strong opinions overall.

Number and Types of Sources of Information about Asthma

As explained earlier, a primary motivation for this study was to determine where our clients and potential clients preferred to find information on asthma. To that end, survey respondents were presented with a list of nine possible sources of information about asthma. They were asked "Where would you go for information about asthma?" and directed to indicate all that apply.

Most respondents reported they check multiple sources for information about asthma. The average number of preferred sources was five. The mode was six sources. The breakdown of number of sources is diagrammed in Figure 4 below. Not only were the respondents interested in checking multiple sources for information on asthma, results for respondents' preferred sources of information are quite dramatically skewed toward traditional medicine sources.

Contrary to literature that indicates a preference for peer educators or a reliance on spiritual leaders for health education, our respondents showed a strong preference for traditional Western medicine sources for asthma information.

Next steps in the analysis explored possible relationships between accuracy of asthma knowledge and the number and types of information sources consulted. For the eleven asthma knowledge questions, there was not a strong correspondence between the number of answers the respondent got correct and the number of sources the respondent reported consulting for asthma information. There was, however, a correspondence between the number of answers the correspondent got correct and the type of source he or she reported using.

This cross tabulation indicates that, in general, people who reported trusting a physician or nurse answered more asthma knowledge questions correctly.

Cross-tabulating education levels did not demonstrate any relationship between the average number of correct answers and the respondent's education level.

Preferences for information sources also did not demonstrate any trends related to respondents' education level. All education levels showed a preference for learning about asthma from a doctor or nurse. The largest differences of opinion were in response to questions about referring to non-Western medicine sources such as herbalists or traditional healers, and in response to the question about consulting spiritual leaders.

Anecdotally, many of the respondents with higher education levels did not just say they would not consult a spiritual leader for asthma information. They accompanied their "no" with a sarcastic remark, or replied in an incredulous tone. While this reaction was not coded, it occurred frequently enough to convince the surveyors that such sources would lack credibility on this particular topic with those audience members.

Grouping the information sources into broad categories of sources, however, does indicate trends in source preferences. For example, the higher the reported level of education the more the respondent preferred to consult traditional Western medicine sources of health information and the less they preferred to consult an herbalist, a traditional healer, or a spiritual leader. By contrast, respondents who said they had completed grammar school as their highest level of education reported consulting traditional Western medicine sources, but they were much more likely to also consult friends and family members, an herbalist or traditional healer, or a spiritual leader for information.

Spearman's Rho correlation was used to further analyze relationships indicated by the descriptive statistics. Spearman's Rho was used because the interval variables were not normally distributed. There was a moderate but statistically significant correlation at the 0.01 level between the number of sources a person reported using and the number of correct answers they made. Other moderate correlations, significant at the 0.01 level, included:

* Number correct and reliance on a physician or pediatrician for information

* Number correct and reliance on a school nurse for information

* Number correct and reliance on the emergency department doctor or nurse for information

* Number correct and reliance on the Internet for information

* Number correct and reliance on pamphlets, brochures, or books for information.

Lower strength correlations existed between the number of correct answers and reliance on a friend, a spiritual leader, or an herbalist or other traditional healer for asthma information. The very lowest correlation strength was between the number of correct answers and reliance on their mother or another older woman for information.

These correlations indicate that people who are more motivated to search out asthma information from multiple sources are more likely to have accurate information. That is not surprising. They also indicate, however, that the people with the least accurate asthma information are relying on the very sources many asthma education professionals recommend using as peer counselors.

SUMMARY AND CONCLUSIONS

Clearly, an absolutely vital step in setting up a community- or faith-based peer counseling system is extensive prior training for the peer counselors. Based on the results of this survey, however, the time and effort required to establish a widespread community- or faith-based asthma education system would not necessarily be a good investment for communicating with an urban, female, African American, educated group. Our survey respondents did not prefer community or faith-based information sources. They prefer to get their information from mainstream medical sources and publications. The route to improving the quality and quantity of information they receive, then, would be through improving the asthma knowledge of the health care providers they consult.

While the findings indicated that more educated people used health care providers as resources and were more knowledgeable, they also indicated that less well-educated people (who participated less in our health fairs) rely more on peer counselors and spiritual leaders. The time and effort to set up community and faith-based asthma education programs would be worthwhile for audiences with lower education levels. Asthma education programs, therefore, should focus their resources as most appropriate for their particular audiences rather than assume faith-based peer counseling is the optimum strategy for all audiences.

This information may also logically be applied when communicating health information to people suffering from other disorders, such as diabetes and high blood pressure. Large investments of time and money are being made to improve knowledge of disease signs, symptoms, and triggers, and improved self-care can improve patient and family quality of life and reduce hospitalizations. Such investments, however, are optimized by more closely matching information sources to audience preferences.

Acknowledgements

Funding for this research was provided by a Congressional Earmark sponsored by Congressman Edolphus Towns, along with Senators Charles Schumer and Hillary Clinton, and a Worksite Wellness Grant from the New York State Department of Health. A sincere thank you is owed as well as to the public administration and respiratory care graduate students from Long Island University, Brooklyn, who tirelessly and cheerfully assisted in survey administration.

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ANNE ZAHRADNIK

Marist College
This conventional public health mindset is that
   professionals create information that they
   believe the targeted market segments need or
   want. However, in this age of consumerism,
   public health organizations and professionals
   must think of consumers as problem solvers in
   pursuit of information to help them create
   health, not merely as recipients of what
   professionals think is right for them. (p. 164).


Figure 1

Breakdown of respondents' ages.

61-70      8%

71+        4%

15-20      2%

51-60     16%

21-30     20%

41-50     27%

31-40     23%

Note: Table made from pie chart.

Figure 3

Correct responses by percent, Highest possible score = 21.

Number correct

16 to 21     51.9
11 to 15     46.4
8 to 10      0.02

Note: Table made from bar graph.

Figure 4

Number of sources respondents reported relying upon for
information about asthma.

1     2%
2     4%
3     7%
4     9%
5    11%
6    13%
7    16%
8    18%
9    20%

Note: Table made from pie chart.

Figure 5

Breakdown of respondents' preferred sources of information

Information source                   Respondents who said they
                                     would use this source. N- 272.
                                     Multiple answers permitted.

General physician or pediatrician    91%
School nurse                         58%
My mother or another older           29%
woman
Emergency department doctor or       79%
nurse
Friends who have children with       50%
Asthma
Internet                             68%
Herbalist or traditional healer      25%
Pamphlets, brochures, or books       65%
Spiritual leader                     13%

Figure 6
Number of correct asthma knowledge questions crosstabbed
with type of information source.

                [greater
                than or
                equal to]
                5 correct   6 correct   7 correct   8 correct

Phys or Ped     73%         71%         32%         90%

School nurse    45%         38%         50%         63%

Mother/old er   18%         33%         34%         33%

ED Doc/Nur      63%         67%         66%         78%

Friends         55%         43%         38%         60%

Internet        45%         71%         59%         70%

Herb/Trad       27%         19%         28%         31%

Pubs            45%         48%         53%         61%

Spirit leader   18%         5%          6%          15%

Ave # sources   3.91        4.15        4.22        5.04
used

Phys or Ped     9 correct   10 correct   11 correct

School nurse    93%         86%          81%

Mother/old er   59%         49%          75%

ED Doc/Nur      33%         19%          25%

Friends         83%         79%          69%

Internet        49%         46%          31%

Herb/Trad       70%         63%          50%

Pubs            19%         23%          25%

Spirit leader   70%         72%          50%

Ave # sources   13%         18%          6%
used
                4.88        4.62         4.40

Figure 7

Education level cross-tabbed with correct asthma
knowledge questions.

Education
level            Ave. #
completed        correct   Range     Mode   N=

Grammar school   8.7       6 to 10   10     12

High school or   8.6       3 to 11   9      95
GED

Some college     8.1       2 to 11   9      75

Graduated        8.4       4 to 11   10     53
college

Graduate         8.2       4 to 11   10     21
school

Note: Not all survey respondents answered this question

Figure 8
Education level cross-tabbed against information sources.

                                         Some
               Grammar       HS or GED   college
               school N=13   N=101       N= 78

Phys or Ped    85%           89%         90%

School nurse   62%           55%         65%

Mother/older   38%           28%         28%

ED Doc/Nur     92%           76%         83%

Friends        62%           44%         54%

Internet       46%           59%         74%

Herb/Trad      31%           23%         28%

Pubs           62%           58%         68%

Spirit         31%           11%         15%
leader

               Grad.
               College   Postgrad
               N=53      N=20

Phys or Ped    94%       95%

School nurse   53%       65%

Mother/older   36%       25%

ED Doc/Nur     68%       90%

Friends        53%       45%

Internet       77%       75%

Herb/Trad      19%       25%

Pubs           72%       80%

Spirit         6%        5%
leader

Note: Multiple answers permitted.

Figure 9
Education level cross-tabbed with grouped information sources.

                  Grammar               Some      Grad.
                  school    HS or GED   college   College   Postgrad
                  N=13      N=101       N= 78     N=53      N=20

Traditional Western medicine information sources

Phys or Ped       80%       73%         79%       72%       83%

School nurse

ED Doc/Nur

Friends and family

Mother/older      50%       36%         41%       44%       35%

Friends

Written word

Internet          54%       58%         71%       51%       78%

Pubs

Other than mainstream Western tradition sources

Herb/Trad         35%       17%         22%       12%       15%
Spirit leader
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