A Cognitive-Behavioral Approach to Asthma Patient Education

Vol. 11 •Issue 4 • Page 47
A Cognitive-Behavioral Approach to Asthma Patient Education

During the last 30 years, pharmaceutical research has developed a wide variety of rescue and controller medications that allow effective pharmacologic treatment of asthma.1-3 Despite the development of these medical options, asthma morbidity and mortality rates have continued to rise.

National guidelines for asthma management have been established4 and numerous asthma education programs for patients have been developed.5-8 The effectiveness of these programs depends on the participants acquiring knowledge about asthma and making behavioral changes to control their asthma.

Acquiring asthma knowledge can be defined as learning and remembering information about asthma topics, such as triggers, peak flows and medication, while behavioral changes can be defined as adopting specific ongoing asthma self-management behaviors, such as removing a trigger, measuring peak flow or adhering to medication recommendations. The low asthma medication compliance rate reported in the literature indicates traditional asthma education is having a limited effect on knowledge acquisition and/or behavioral change.9,10

In theory, the likelihood of a participant acquiring knowledge and changing behaviors in an asthma education program is dependent on factors related to the participants, the structure of the educational program and the techniques used in the educational program. We hypothesized that an asthma education program optimizing these factors would improve the quality of life for asthmatic participants.


Fifteen Caucasian, nonsmoking adult asthma volunteers (11 women) were recruited from North Central Illinois. All participants stated that a medical doctor had diagnosed them with asthma, and they were very interested in making behavioral changes relative to their asthma. The average age of participants was 58.3 years old (range 34 to 75 years old) and the average number of allergy/asthma medications being taken by the participants was three. The study was conducted free of charge during the summer of 1998 and the summer of 1999. The 1998 phase of the study included nine participants while the 1999 phase of the study included six participants. Of the 15 participants, two did not complete the program.

Upon enrollment, participants signed consent forms and completed an allergy/asthma intake form that identified triggers of their asthma. Next, physiological measurements were obtained for each participant, including blood pressure, pulse, respiration and peak flow. Each participant filled out a 20-item asthma quality-of-life (QOL) survey11 in which items were grouped in four subscales: breathlessness, mood, sociability and concern for health. (See Table 1.)

Table 1: Quality of Life Survey
The following response options were applied to each question: “Not at all = 1,” “Mildly = 2,” “Moderately = 3,” “Severely = 4,” and “Very severely = 5.” Participants were asked to check the response that matched how they felt during the two weeks preceding the pre-test and post-test.
Breathlessness Subscale (Alpha = 0.85)
I have been troubled by episodes of shortness of breath.
I have been troubled by wheezing attacks.
I have been troubled by tightness in my chest.
I have been restricted in walking down the street on level ground or doing light housework because of asthma.
I have been restricted in walking up hills or doing heavy house work because of asthma.
Mood Subscale (Alpha = 0.78)
I have felt tired or had a general lack of energy.
I have been unable to sleep at night.
I have felt sad or depressed.
I have felt anxious, under tension or stressed.
Sociability Subscale (Alpha = 0.76)
Asthma has interfered with my social life.
I have been limited to going to certain places because they are bad for my asthma.
I have been limited in going to certain places because I have been afraid of getting an asthma attack and not being able to get help.
I have felt generally restricted.
I have been restricted in the sports, hobbies or other recreations I can engage in because of my asthma.
Concerns for Health Subscale (Alpha = 0.66)
I have felt that asthma is preventing me from achieving what I want from life.
I have been frustrated with myself.
I have felt that asthma is controlling my life.
I have been worried about my present or future health because of asthma.
I have felt dependent on my asthma sprays.
I have worried about asthma shortening my life.

Following completion of the education program, the physiological measurements were repeated and the QOL survey was administered again for the 13 participants who completed the program. Within-subject t-tests were computed for each of the physiological variables and the four QOL subscales. Finally, participants were asked to write down at least two strengths of the education program.

The nine participants in 1998 went through a six-week program (1.5 hours/week) while the six participants in 1999 went through a seven-week program (two hours/week). The program length and session duration was increased for 1999 because all 1998 program participants recommended that an extra session and 30 minutes more each week would be highly beneficial to the participants.

The faculty was composed of a research psychologist who is a life-long asthmatic, a registered nurse and a certified social worker; guest faculty included two allergists and a respiratory therapist. The content of the program changed weekly and was based on handouts and readings from an asthma guidebook.12 Additionally, one session was devoted to humor therapy.


The two major techniques used every week to increase the likelihood of knowledge acquisition and behavioral change were small group discussions and the practice of behavioral change, which included a four-step sequence of goal-setting, practice, self-reflection and feedback. Small group discussions were learner-centered interactive dialogues among the faculty and the participants. The faculty integrated short oral presentations with the handouts and readings and encouraged participants to describe personal experiences relevant to the presented material.

Goal-setting occurred at the end of each session and involved identification of both one behavior to change over the ensuing week and the criteria for behavioral change success.13,14 Participants then practiced the identified behavior for one week. Self-reflection occurred at the beginning of the next meeting, where participants discussed their behavioral change successes and/or failures with the group. After each participant self-reflected, the faculty provided positive emotional feedback.

The four-step sequence was frequently integrated with group discussions and readings. For example, when the discussion was about hydration and lung physiology, the group set the goal of drinking at least 64 oz. of fluid a day. When the group discussions and readings centered on mind/body medicine and psychoneuroimmunology, the goal was to practice relaxation for 20 minutes each day using an audiotape developed by the social worker.


For participants who completed the program, there were statistically significant mean improvements for three of the four QOL subscales: sociability, health concern and total QOL. (See Table 1.)Results also indicated significant improvement in participants’ peak flow monitoring. Before the program, participants were taking their peak flow reading approximately two times a week. After the program, participants were taking their peak flows approximately 13 times a week.

There were no statistically significant changes in heart rate or blood pressure following the completion of the program. Although mean peak flow rate increased from pre-test to post-test (348 Lpm to 361 Lpm, respectively), this increase was not statistically significant.

The findings in this pilot study suggest that an asthma patient education program that integrates interactive small group discussions and the practice of relevant behavioral changes can improve the QOL for adults with asthma. In addition, participants reported two major qualitative program strengths: The opportunity to learn about medication options (69 percent) and the opportunity to learn how other people cope with asthma .(85 percent).

The program’s success can be attributed, at least in part, to the enrollment of highly motivated participants. A key variable that predicts behavioral change is the motivation of the individual to change his or her behavior.15-17 For any particular behavior change, individuals are at one of five stages: precontemplation, contemplation, preparation, action or maintenance. The participants in this asthma education program were interviewed at the beginning of the program and indicated they were very interested in making behavioral changes to improve their health. Thus, the participants were probably at the action stage of behavioral change. (See Table 2.)

Table 2: Prochaska’s Transtheoretical Theory Applied to Asthma Management
Change Level Cognitive Process Possible Impact on Asthma
Precontemplation Not considering change Little medication compliance
Frequent hospitalizations
Contemplation Decides that cost of change outweighs benefits of change Sporadic medication compliance
Complains about health system
Preparation Ready to change Asks doctor for more information
Investigates possible behavioral changes
Action Actively pursuing change Goes to asthma education class
Reads books
Looks up Internet information
Takes yoga class
Maintenance Made change and wants to continue Continues asthma education
Changes lifestyle
Notes major health improvement

Another key factor was the structure of the program. The program was consistent with the structure of successful patient education programs in cardiology, oncology and psychiatry.18-23 In those programs, knowledge acquisition and behavioral change were best accomplished when small groups met for one to two hours on multiple occasions.

Unfortunately, most patients with asthma receive asthma education in office settings where he or she might listen for five minutes to a lecture from a health care provider. Such single-session, brief-duration education rarely leads to important knowledge acquisition and/or behavioral change outcomes. Even when there is a community-based asthma education program, frequently it’s a single-session, long-duration program with little interaction between the large group of patients and the faculty.


In addition to having motivated participants and a solid structure, the program used two effective educational techniques: interactive group discussions and behavior change practice.

Research on physician education has indicated that interactive problem-based learning discussions with a small group can lead to changes in how physicians write prescriptions.24 Research with patients who have asthma has shown that small groups and/or families can be used to change .behaviors.25-29 We believe that our interactive small group discussions led to knowledge acquisition and behavior change. The following story illustrates this point:

During the second week of the 1999 program, participants were asked to read a book chapter on medications. The following week, a local allergist interactively discussed the National Institute of Health’s medication guidelines with the group. One participant whose asthma was getting worse stated that she was using her albuterol inhaler 10 times a week and only occasionally taking her corticosteroid inhaler. Once this participant was properly educated on the disease and NIH guidelines, she decided to schedule an appointment with the local allergist. After this consultation, she immediately began using her corticosteroid inhaler on a daily basis, which led to a rapid improvement in her asthma.

This patient’s behavioral change was not based on obedience, compliance, adherence or clinical monitoring. Instead, the behavioral change was based on the participant acquiring knowledge that asthma is an inflammatory disease and that inhaled corticosteroids treat the inflammation. The behavioral change became intrinsically motivating to her because her health improved after the change. Research in asthma supports the idea that intrinsic motivation is the best method for obtaining long-term behavioral change.30

A second major purpose of the interactive group discussions was to provide emotional support for each of the participants. Using communication skills similar to those of other asthma researchers,28,31 the staff actively listened to the self-disclosures of the participants. Eventually, the participants became more comfortable with each other, and toward the end of the program, social support began to lead to friendships and intra-participant support. There is growing evidence that social support, relaxation training and humor therapy can play important roles in the management of several diseases, including cancer, depression, heart disease and asthma.18,19,21-23,32-42


The other major educational technique used in our program was the practice of behavior change using the aforementioned four-step process. Behavioral change may be obtained if an individual learns how to monitor the behavior, sets short range attainable sub-goals to motivate and direct their efforts, and enlists positive incentives and social supports to sustain the effort needed to succeed.37

Behavioral change also involves improvements, plateaus, setbacks and recoveries. People often have to go through several cycles of mastery and relapse before they finally succeed. An individual who has high self-efficacy will ultimately persevere even when they initially fail at the task.

In this study, the goal-setting technique was derived from research in organizational psychology13 and from a successful weight loss program.14 Participants worked with the staff in identifying behavior changes and setting criteria for successful performance. This process meant participants were more likely to engage in the behaviors than if the staff had simply ordered the group to perform a behavior.

By practicing the behavior change each day at home and then self-reflecting at each meeting, participants became more aware of the factors that led to successful behavioral changes. At the weekly meetings, the staff used communication skills and emphasized the importance of having attempted the behavior change rather than focusing on the specific results.

Discussion of the experiences of those participants who succeeded in meeting the target goal served as motivation for other members of the group. For those participants who failed to reach the target goal, the faculty used a positive supportive attitude to maintain the participants’ self-efficacy and probability for future success. One other major source of behavior change motivation for the participants came from a faculty member who had asthma and also attempted the weekly behavioral change goals. Research43 indicates that role modeling is an excellent technique for changing behavior.


Although the results of the pilot study are promising, there were weaknesses in both the experimental design and the results. One weakness was the lack of statistically significant changes in the physiological data to support the QOL results. The fact that the length of the program was only a few weeks rather than a few months may be the reason no physiological improvement was noted. In addition, the small sample size might have lacked statistical power to detect significant physiological differences. In future studies we plan to have a long-duration program with a control group and will look for significant physiological changes in lung function. We also plan to use a different asthma QOL survey.44

Also, we didn’t formally assess knowledge acquisition or behavioral change. In future studies, we will use a stages of change model to quantitatively assess where participants are when they enter and leave our program. We will specify in a more exact manner the weekly successes and failures of group members in attaining the specified behavioral change goals. We will evaluate other behavioral changes, such as peak flow monitoring and trigger removal, which might benefit our participants. We also will give participants knowledge tests at the beginning and end of the program.45

Lastly, in this short study, we didn’t measure long-term indicators of asthmatic health such as hospitalization rates and school absenteeism rates.46,47 Because this was a pilot study and the setting was at a small liberal arts college with few medical resources, health care outcomes could not be measured. We look forward to running our program within health care organizations that have the necessary resources to measure these long-term indicators of asthma health. We believe our program will lead to health care cost reductions due to reductions in emergency room visits and/or hospitalizations. We also plan to develop programs for children and high-risk groups.48-51 n

Dr. Tousman is a life-long asthmatic and associate professor of psychology at Rockford College, Rockford, Ill., and a board member of the Association of Asthma Educators. Dr. Zeitz is director of the division of allergy, asthma and immunology at the University of Illinois College of Medicine at Rockford. Bristol is director of health services at Rockford College.

For a list of references, please call Debra Yemenijian at (610) 278-1400, ext. 1153, or visit www.Respiratory-care-sleep-medicine.advanceweb.com/mrreflist.html.

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