Educational self-help approaches in childhood asthma

Educational self-help in childhood asthma Edward

E. Bartlett,

approaches

Dr.P.H. Birmingham,

Ala.

Se(f-help is defined as “a process whereby (I layperson functions on his/her own behalf in health promotion and prevention and in disease detection and treatment .” Evidence that benefits are derived for patients who subscribe to the self-cure philosophy comes from research in the are(Is of (I) self-e&q, (2) information sharing, (3) patient satisfaction, and (4) patient invol\~ernent, This article presents jive criteria of educational selj:help. These criteria are: (I) encouragement of client responsibility. (2) full disclosure of information pertaining to the illness. (3) training of the putient in decision-making skills, (4) use of peer educutors, and (5) training of projkssionals to encourage se(flhelp attitudes and behaviors of their patients. The asthma projects presented at the June 1981 meeting in Los Angeles, entitled Self-management Educational Programs ,fix Childhood Asthma, ure reviewed in terms of the above jive criteria. Each program manijested varying numbers of criteria with diflerent levels of expertise. Findings suggest thtrt those programs that mo.st complete1.y incorporated these principles tended to IJCJ more e@ctive in favorably inj!uencing behavioral. physiologic, and ,jinancial outcomes. (J ALLEKGYCI.IN IMMUNOL 72.545-554. 1983.)

One of the seismic changesin the health field in the past 100 yr has been a shift in predominancefrom the acute illnesses to the chronic diseases.These chronic illnesses cannot be cured, only controlled. Generally, the most effective and economic approachesto the prevention and control of these problems are behavioral in nature: smoking cessation, dietary modification, stressmanagement,and adherenceto long-term therapeutic regimens. Asthma is no exception to this generalization. Despite exciting advancesin the last 20 yr in our understanding of its pathophysiology and chemotherapy, the greatesttherapeutic challenges(and problems) are behavioral-promoting the patient’s ability to prevent and control symptoms of asthma. For the child with newly diagnosed asthma, life undergoes an upheaval. At first the symptoms were attributed to a cold or bronchitis, then the diagnosis of asthma was made. Whatever it is called, its attacks are unpredictable, harrowing experiences.It becomes necessaryto watch for invisible phenomenalike pollen and dust. The child is treated differently by teachers, parents, and eventually playmates. Participation From the Division of Health Education-Health Behavior, School of Public Health and the Department of Family Practice, School of Medicine, University of Alabama in Birmingham. Reprint requests: Edward E. Bartlett, Dr.P.H., School of Public Health, University of Alabama in Birmingham, Birmingham, AL 35294.

in favorite activities like sports and dancing becomes difficult. When an attack occurs, the things the child is advised to do, such as use a bronchodilator, practice relaxation exercises, or drink coffee, always work too slowly and sometimesare only partly effective. At times the child and parents are so frightened by an attack that they visit the emergency room. These are the challenges that the child and the clinician face in the managementof asthma. The problem of nonadherence to the regimen is common in the care of patients with chronic illness, and it appears to be a major impediment to the achievement of desired therapeutic outcomes.l Indeed, several studies have examined nonadherenceto regimens by children with asthma.2-4To the extent that self-careeducation helps patients to becomemore informed of their diseaseand regimen and assistspatients and providers to develop therapeutic regimens that are mutually acceptable,it is plausible to suggest that educational self-care will improve adherenceto the regimen. In this presentationI discuss an important perspective that is germaneto the challenge of asthma control-educational self-care-and apply this perspective to the child asthma programs presented at the June 1981 meeting. A brief note on terminology

Clear thinking in this field hasbeen impeded by the tendency to use interchangeably words that have dis545

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tinct meanings. Two of those words are “medical” and “health.” The rampant confusion is evidenced by the synonymous use of the terms “medical care” and “health care, ’ ’ ‘ ‘medical personnel ’ ’ and “health personnel, ’ ’ “medical history” and “health history 9” and so forth. Clear thinking will be served best if “medical” is restricted to indicate “pertaining to physicians. ” Thus “medical personnel” would refer to physicians, “medical care” would be what physicians do, while health care would be what all health practitioners (nurses, physicians, health educators, dietitians, pharmacists, etc.) render. One phrase that suffers from convoluted usage is “medical outcomes. ” Ostensibly this refers to outcomes that are a result of activities that only physicians do or that are of interest solely to them. In common parlance, however, “medical outcomes” refers to such physiologic outcomes as peak expiratory rate, blood pressure, or extent of symptomatology. To imply that physicians are concerned only with such variables is, I believe, to consign them to a sterile role that ignores the patient’s emotional status, satisfaction with care, and social milieu. Depending on the intended meaning, “physiologic outcomes ’ ’ or “health outcomes” might be more appropriate. A second source of confusion is found in the terms “health education ” and “health information. ” One often hears of such information dissemination techniques as pamphlets and booklets equated with health education. Health education practice encompasses the use of a broad range of educational-behavioral strategies, including peer group discussions, organizational development, community organization, behavioral contracting, self-monitoring, stimulus control, and contingency management.5 Health education encompasses much more than health information. Third, one often hears the term “compliance” used to refer to the extent to which the patient follows the physician’s advice. Noncompliance carries heavy pejorative baggage with it, depicting the patient in a largely passive role and connoting that it is the patient’s fault. 1 recommend the term “nonadherence” because it is less value laden and more scientifically neutral. More precise use of these words will contribute to better thinking, more useful research, and sounder policy making. The development

of educational

self-help

If one can consider the development of self-management in psychology as one manifestation of professional concern for strengthening client involvement and self-determination, the self-help movement can be viewed as the lay complement of self-managemerit. Although people have engaged in self-help

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practices since antiquity, it has not been until the last 10 or 15 yr that the lay revival of this concept has stimulated extensive scientific attention. Because of the traditional commitment of health educators to client self-determination, informed decision making, and voluntary behavior change, the self-care movement has been of singular interest to the health education profession. The self-help philosophy emphasizes the client’s strengths and self-responsibility.“, ’ Self-care (the subset of self-help pertaining to health) has been defined as “a process whereby a layperson functions on his/her own behalf in health promotion and prevention and in disease detection and treatment at the level of the primary health resource in the health care system. “6 According to the logic of self-care, the provider-consumer dichotomy is broken down because the consumer is the provider for most illnesses.R In fact, studies have found that 75% or more of all health care is rendered by lay “providers. ’ ‘$ Levin et al.” have suggested the following implications of the self-help philosophy for patient-professional relationships: (1) The decision to contact the professional care-giver is largely, but not totally, at the initiative of the patient; (2) it is often the product of a lay referral process; (3) a good part of the care for a given complaint takes place prior to sharing responsibility with the physician; (4) treatment decisions may be determined by the patient (particularly, patient requests for prescriptions); (5) patients vary with regard to adherence to the professional treatment plan; and (6) patients habitually participate in evaluation of professional care (efficacy and outcomes). The management of chronic illness such as asthma presents a particularly fertile ground for the development of self-care skills on a progressive and continuous basis. Some examples of clinical applications of self-care are the development of patients’ skills in decision making and in locating relevant health information, the fostering of mutually supportive patient/ provider relationships, and the encouragement of patients to read their health records. The reader who is accustomed to more traditional forms of the patient/provider relationship might reasonably ask, “What evidence exists to suggest any tangible benefits for patients who subscribe to the self-care philosophy?” Because of the scanty research devoted to this topic, the answer is incomplete. Yet much of the evidence that we do possess is encouraging . The following sections discuss several theoretical and empirical bodies of research that amplify the self-care theme: the self-efficacy theory, patient satisfaction, sharing information with the patient, and active patient involvement. Self-eficacy theory. Probably the most compelling

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body of literature, conceptually and theoretically, is Bandura’s self-efficacy theory. loa I1 Bandura poses the apparent enigma that whereas theories of human behavior are increasingly formulated in cognitive terms, the approaches to facilitating behavior change are based more on performance-based procedures. To reconcile this divergence of theory and practice, Bandura proposes the existence of the “self-efficacy” construct, which mediates between cognitive and behavioral change. Self-efficacy refers to the expectations that a person has concerning whether a given behavior can be successfully performed (e.g., manage wheezing attacks, interact effectively in social contexts, and do relaxation techniques). Expectations of self-efficacy determine whether coping behavior will be initiated, how much effort will be expended, and how long it will be sustained in the face of obstacles. Bandura outlines four ways to influence a patient’s self-efficacy: (1) enactive-successful performance of the behavior itself increases a person’s confidence in his/her ability to repeat the behavior; (2) vicarious-observation of a credible role model performing the behavior can augment self-efficacy; (3) persuasive-exhortations and encouragement can alter feelings of self-efficacy; and (4) emotive-high states of emotional arousal can impair self-efficacy (although recent research indicates that under some circumstances emotional arousal can have a beneficial effect). The enactive, vicarious, and persuasive models represent influences of decreasing strength and suggest different educational-behavior strategies that might be used to help children to manage their asthma. Self-efficacy theory indicates that an important effect of patient education programs is to heighten a person’s efficacy expectations. By their very nature, practices and policies of health care personnel that foster dependence of the patient (e.g., discouragement of independent performance of self-care activities such as monitoring one’s lung function) will impair his or her sense of ability to accomplish those activities successfully. Conversely, activities that encourage independent action will enhance self-efficacy expectations. Thus the self-efficacy theory provides a theoretical buttress for the notion of an “activated” patient. Self-efficacy theory has obvious implications for the management of children with asthma, many of whom simply lack the feeling of self-confidence that their illness can be controlled. Sharing injbrmation with the patient. The problem of inadequate and distorted provision of information to the patient has been documented repeatedly and convincingly in the literature.12-31 In the case of childhood asthma, Clark et al.% have reported that

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almost half of all respondents in their project believed they received too little information from their caregiver. These distorted communications take the form of exaggeration of the degree of uncertainty or consequences of an untreated illness,“” failing to explain the severity of an intractable or incurable disease,3” and nurses absolving responsibility to tell the patient the diagnosis or prognosis in the face of medical authority .3s It has been suggested that miscommunication serves the purpose of heightening the mystique of medical procedures and of securing the patient’s acquiescence to undergo procedures that may be costly, painful, inconvenient, or disfiguring.““-:‘” The self-care philosophy advocates that the patient is entitled to a full disclosure of information pertaining to the prognosis and alternative treatments. Naturally, some patients will want more information than others, and additional information should not be forced upon the asthmatic child or the parent who already has enough facts to make up his or her mind. This full disclosure is based upon the ethical commitment of a democratic society to informed decision making, upon the legal doctrine of informed consent, and upon the mutual desire to improve the patient/ provider relationship. Studies on patient satisfaction. Inadequate and distorted communications not only violate the goal of informed decision making, but impair patient satisfaction with care. Clinical significance of patient satisfaction is indicated by its consistently predictive relationship to adherence with the therapeutic regimen.40 A number of studies have identified a variety of physician communication skills that influence patient satisfaction. For example, the seminal study by Korsch et al.= found that patients, in fact, were more satisfied with their physicians when they were friendly and understood the patient’s concerns. Fisher41 found that greater personal interest shown for patients was associated with greater satisfaction. Stiles et a1.4’ found that allowing the patient to describe the problem in his or her own words had a significant correlation with satisfaction (r = 0.30). DiMatteo et a1.43found patients to be significantly more satisfied when their physician listened to them, took enough time with them, and cared for them. Bartlett44 measured a significant correlation of 0.24 between physician interpersonal skills and patient satisfaction. Ley et al. 45found that patients who received a single 5 min educational visit every 10 days while in the hospital were significantly more satisfied than were the control patients. Increased satisfaction was found from information giving in other studies conducted in ambulatory4G and hospita14’ settings.

548 Bartlett

Linn”” studied 1739 patient encounters in 11 ambulatory care centers and found that giving advice to the patient significantly improved the patients’ general satisfaction with care. Stiles et al.& found that when the physician gave advice to patients at the end of the visit, there was a correlation of 0.45 (p < 0.05) with the patient’s satisfaction with “cognitive” aspects of the visit. Liptak et al. 4g found that physician’s communications regarding infant feeding, emergency care, immunizations, etc., was significantly associated (p < 0.05) with maternal satisfaction with medical care. DiMatteo et a1.4”found an association of 0.26 (p < 0.001) between a patient report that “physician explains condition to me” and the patient’s intention to see the same physician in the future. Bashshur et al.“” found a positive correlation between provision of information regarding the insurance plan and patient satisfaction. Similar relationships also have been reported by Cartwright, ” Duff and Hollingshead,52 and Freeman et al.5’” This literature indicates the importance of physician interpersonal and teaching skills, which in turn influence patient satisfaction and adherence. Yet surprisingly little research has examined the effects of information sharing on the satisfaction of children who have a chronic illness such as asthma. Active patient involvement. The self-help educational approach advocates active patient involvement in preventive and therapeutic measures. Active patient involvement includes such activities as soliciting patients’ questions, asking what the patient thinks the problem may be, involving the patient in the selection of the most desirable therapeutic course, and encouraging patients to take their own measurements of health status and progress (e.g., lung function, blood pressure, and blood sugar levels). What evidence exists to support the benefits of patient involvement? Early studies found that increasing involvement enhanced worker productivity54 and resulted in a greater degree553 56and persistence 57of attitude change. Two classic health education studies found significantly more behavioral improvements among persons who participated in peer group discussions (high-involvement method) than in those who listened to lectures (low-involvement method) that covered the same information.58’ jy For example, in the Bond5s study, 59% of the women in the discussion groups reported that they performed breast self-examinations 13 mo later compared with 39% in the lecture group. In a less intensive application of the active involvement principle, Levy et al. fifl found that simply asking persons whether they could report the results of post-

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immunization symptoms was significantly more effective in inducing this behavior than was telling them to do so. Some studies have compared the effectiveness of interpersonal versus nonpersonal (i.e. , pamphlets, videotapes, etc.) approaches to patient education and have found that the personal approaches are more effective than are mediated methods,“” Ii2 except in the possible case in which impersonal methods were so new as to create a “novelty effect.” From his review of the literature on completion of referrals for hypertension screening, Flyn#” concluded, “The common element found to be effective in all studies was personal contact with an individual assigned specifically to deliver educational messages. The effect appeared to be independent of the length of time of the contact with the educator, concurrent use of other media, or the specific content of the contact.” Presumably, personalized patient education is more effective, in part, because it requires more active involvement of the patient. A number of explanations have been proposed to explain the effectiveness of the principle of active involvement. It is possible that the person who actively participates in an activity receives more experiential information. Reinforcement theory suggests that an active participant in a group discussion may be positively reinforced by the group, resulting in attitude change. Cognitive dissonance theory suggests that a person who voluntarily performs a behavior will subsequently modify his attitudes to become more consistent with the behavior. Finally, reactance theory indicates that persons respond to perceived coercion and loss of freedom by offering resistance.“” Increasing involvement may reduce the perception of coercion and increase cooperative behavior. Additionally, the use of communication methods that preclude interaction minimizes the opportunity for the patient to ask questions and for the therapist to observe gestures and expressions that signal confusion or misunderstanding .61 Other qproaches. Other strategies that have the potential for contributing to our understanding of educational self-care are improvement of patient/provider agreement66* “’ and contracting.68, 6g An example of contracting might be for a parent to agree to take the child to the movies if the child undertakes certain behaviors such as avoiding allergens, doing deepbreathing exercises, and taking medications. Educational

self-help

criteria

Based on the above discussion of scientific support for the notion of educational self-help, I will suggest

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five self-help criteria. These criteria serve as the basis of the review of the child asthma programs in the subsequentsection. Development of client responsibility. This is probably the most fundamental of all the educational selfcare principles. It indicates that the patient is accorded at least part of the responsibility for his or her health and for the therapeutic outcome. It implies that the client plays an active role and is involved in the therapeutic decision-making process. This can be accomplished, in part, by telling the patient the findings of the physical examination, the differential diagnosis, and the alternative coursesof treatment. Given the fact that there are often several therapeutic modalities available (e.g., use of theophylline versus cromolyn, continuous versus intermittent therapy), the patient’s input in selection of the most convenient and effective treatment should be solicited. If client responsibility is one of the pivotal concepts of self-care, it is also the least understood. The misunderstandingis suggestedby the logical inconsistency of ordering a person to be independent and selfresponsible or blaming him when he fails to control contingencies beyond his control. Clearly, the notion of self-responsibility cannot be imposed or mandated from without. Thus programs that delineate a list of behaviors that the patient must perform in order to be “self-responsible” are in fact promoting client dependenceand passivity. Those who advocate patient education efforts that aim to strengthen client self-responsibility must have an appreciation for the difficulty of the task. They must acknowledge that patients vary widely in their desires for self-responsibility and in their ability to assumeit. In a society that glorifies quick-fix medical miracles, many patients initially are reluctant to assume greater decision making and self-responsibility in their health care. On the other hand, somepersons respond enthusiastically to such approachesbut may become frustrated to discover unexpected institutional, financial, environmental, or social barriers to practice of theseapproaches.The key here is the provision of support and encouragementover a period of time. Full disclosure of information pertaining to the illness. Patients should be given the opportunity to avail

themselves of independent sources of information without invoking the displeasure of the physician. If the outside information appearsto contradict the advice from the physician, the patient should feel at liberty to discuss the seeming incongruity. In this atmosphere of mutual trust and respect, a satisfying patient/professional relationship can flourish. Full disclosure can be accomplished through

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(1) provision of medical textbooks and articles in the clinic, (2) advising patients where such information can be obtained (e.g., library, bookstore, or hospital wellness center), and (3) sharing the health/medical record with the patient. 7”-72 We are familiar with office practices that have improved information sharing by means of setting up a patient library; dictating the SOAP* note in the presence of the patient; sending a copy of the progress note to the patient to review; having the nurse initially review any questionsthe patient has for the physician and writing them down so they are not forgotten; encouraging patients to bring in newspaperclippings of relevant health stories and discussing apparentdiscrepancies between the newspaper article and the physician’s advice; and establishing a relaxed, unhurried atmospherein the office. Training in decision-making skills. The concept of an “‘activated” patient implies the need to be able to make appropriate health decisions. Decision making involves the ability.to analyze, evaluate, and synthesize information (including often contradictory information coming .from physicians, nurses, parents, and peers);to extrapolatetrends in order to anticipate consequences(e.g., wheezing attacks becoming more frequent as the allergy seasonapproaches);to weigh the probabilities and consequencesof various courses of action (e.g., use of relaxation techniques versus medication); to postpone immediate gratifications; and to avoid impulsive behavior (e.g., panic-fear reaction). Thus decision making is a skill that is considerably’more complex than is simple memorization of a variegated collection of health facts. For example, one asthma education program for early childhood included formal training in decision-making skills as part of its curriculum.73 Janis and Mann74have developed the “decisional balance sheet” method of training people in decisionmaking skills. This involves an enumeration of the costs and benefits of each alternative in terms of consequencesboth for oneself and for others. Several approachesto training patients seen in office practice in decision-making skills are described later in this article. Use of peer educators. The influence of peersin the support of desired behavior change is suggestedby the general literature of sociology and social psychology and more recently in Bandura’s’Owork on social learning theory. The emergenceof peer support groups has been a common phenomenon in the self*The Subjective, Objective, Assessment and Plan is the format used in problem-oriented medical records.

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help movement, especially in groups concerned with women’s health. Two earlier studies of adults who have asthma indicate the effectiveness of peer education. In one project, a group of adults with asthma attended a single discussion group to learn ways to control prodromal symptoms of an asthmatic attack.75 It was found that the experimental patients subsequently had less than half the number of emergency room visits than had the randomly assigned patients in the control group who received the usual care. In a second study, asthmatic patients received counseling from nurses on ways to prevent and control asthma attacks; some of these nurses had asthma also.“’ It was found that patients who were randomly assigned to receive education from a nurse with asthma were significantly less likely to require a return visit to the emergency room than were those who had spoken to a nurse who did nut have asthma. These studies indicate that peers (in terms of having the same illness), whether they are professional or laypersons, are effective in helping to control asthma. Although we possess far more knowledge and experience about adult peer groups than about child peer groups, 76 recent studies have found that adolescent peer educators can be very effective in preventing the initiation of cigarette smoking.77-79 Training health professionals to encourage selfhelp attitudes and behaviors of their patients. Effective self-help programs require not only activated patients but also supportive and understanding professionals. Physicians who endorse the self-care philosophy advocate the development of a nonauthoritarian relationship with the patient, discourage excessive dependence on the health provider, and build upon and emphasize the patient’s strengths in the management of illness. The number of programs in medical schools and residencies that train physicians in interpersonal skills and health education have mushroomed dramatically since the 196Os.*OThese programs teach skills such as showing empathy, eliciting information, assessing and managing patient nonadherence, and communicating information about the disease and the regimen.81 They use such instructional methods as lectures, modeling, role plays, simulated patients, videotape review, and feedback. Evaluations of these programs indicate that they are generally effective in influencing medical students’ knowledge, attitudes, and behavior, at least on a short-term basis.82 Virtually all of these studies were conducted with medical students and residents. Nonetheless, the studies lend a note of cautious encouragement to the idea

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that self-help programs can help practicing physicians to better support the self-help practices of their patients. Indeed, we know many physicians whose enjoyment of the practice of medicine (and the size of their practices) is substantially enhanced because they assume a more relaxed, “give-and-take” attitude with their patients. Critique

of programs

On the basis of the foregoing principles for educational self-care, recent child asthma programs and studies are now reviewed. A remarkable diversity was noted to exist in terms of educational-behavioral methods (lectures, peer group discussions, printed materials, and skills training), settings (clinics, private physicians’ offices, residential treatment centers, and community settings), intensity of the intervention, duration of the program, target group (children, parents, and health professionals), evaluation design, and educational-behavioral expertise. This diversity, very appropriate in a field during its early stages of development, allows gross comparisons to be made of the effectiveness and efficiency for a broad range of health education programs. Because a complete description of each program was not available, it would be unfair to critique each program individually according to all the criteria. The following discussion, therefore, makes general comments regarding the application of each criterion in the asthma programs and cites the exemplary projects. Encouragement of client responsibility. Most of the programs emphasized the role of patient self-responsibility in the control of asthma. Most notable in this regard was the project developed in the Asthma Care Training Program at the University of California, Los Angeles. Patient involvement and self-responsibility were overriding themes in those five weekly sessions. Using the slogan “You’re in the driver’s seat, ” the classes employed traffic analogies to convey the concept that the children could take charge of the disease rather than be controlled by it. A number of program descriptions mentioned the importance of self-responsibility but did not seem to have a clear-cut idea of how to develop this attitude in children. Some insights into this program are offered by self-efficacy theory,‘” which suggests that the most effective means to strengthen self-responsibility is to induce children to perform the appropriate self-management behaviors and to experience the subsequent relief from symptoms. Less effective but possibly more practical ways to teach self-responsibility are to

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have the children observe role models that successfully cope with symptoms or to use verbal persuasion techniques. Full disclosure of information. The dissemination of factual information about the anatomy, physiology , prevention, and control of asthma was an important component of all programs. The information was conveyed through group lectures, individual instruction, group discussions, and a melange of audiovisual aides (booklets, posters, puzzles, etc.). Although the exact duration varied among the programs, a typical project was the Asthma Education Initiative in New York City32 that included six 50 min sessions for parents on the following topics: (1) helping the child take medication, (2) setting realistic limits for the child’s activities, (3) taking care of an attack at home, (4) getting information from the doctor, (5) keeping the child healthy, and (6) helping the child to do well in school. Although the children and parents no doubt gained more access to information pertaining to asthma than had been gained previously, most of the projects used methods of information transfer that retained control of the information by the provider rather than approaches such as sharing the health record with the patient or family, making primary sources of information (e.g., scientific textbooks or journal articles) available for perusal, or encouraging the obtaining of a second opinion from other physicians. Training in decision-making skills. Three programs addressed decision-making and problem-solving skills in their curricula. The UCLA project devoted one of their five sessions to teaching the decisionmaking process. The Three Little Pigs story, a tic-tactoe grid, and a road map were used to illustrate the following steps: (1) identify the problem, (2) suggest alternative solutions, (3) predict outcomes, both positive and negative, (4) anticipate feelings/values, (5) select a solution and act on it, and (6) evaluate the solution. The program at the National Asthma Center in Denvers3 devoted its final session to the subject of problem solving. With the view that the class presented a chance to review what had been taught previously, participants were presented with hypothetical problems (e.g., what to do during a camping trip when you discover that the asthma medications were left at home), and various solutions were discussed (brew a cup of hot coffee). In Pittsburgh, Fireman et al.84 covered five decision-making skills in their patient education program: (1) observational skills-able to observe situations that might lead to an attack; (2) discrimination

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skills-able to notice changes that would indicate an impending or actual attack; (3) decision-making skills-able to make decisions to take action themselves or to seek help to prevent or stop an attack; (4) communication skills-able to tell parents, physicians, or others what is happening just before and during an attack; and (5) self-reliance skills-developing a strong positive attitude regarding their ability to do things for asthma management. These diverse approaches to teaching decisionmaking and problem-solving skills deserve replication and further refinement. Use of peer educators. Several of the programs used peer discussion groups as one component of the patient education program. For example, the National Asthma Center project in Denver encouraged frank discussions, peer support, and sharing of advice on how to cope with asthma as part of its eight sessions. The peer and family support intervention conducted at Kaiser-Permanente Medical Care Group in association with the American Institutes of Research allowed children to share problems and solutions encountered in asthma management, to accept greater responsibility for control of his or her asthma, and to report personal progress to the group at subsequent sessions. Subject areas covered during the five sessions of the group included dealing with emotions and resisting peer and adult pressure. The positive findings of the evaluations of these two projects suggest that use of peer educators may have great promise in the prevention and control of asthma. Training health professionals to develop self-help attitudes and behaviors in patients. Two of the projects explicitly cited the necessity of physician support for self-care concepts and practices (Asthma Care Training at UCLA and the Sunair Home for Asthmatic Children). The Sunair residential program suggested that physicians receive training or at least informal encouragement for such attitudes. This project recommended that the physician question both the patient and the parent regarding the frequency and severity of attacks, their effects on daily activities, medication adherence, and need for hospitalization. Yet it was unclear who recommended these questions to the physicians, in what context, and with what results. Also, it was uncertain how asking these questions would contribute to the stated goals of increasing patients’ selfesteem, involvement, and sense of responsibility. The reasons that the other projects did not address the physicians’ role in promoting self-management and self-care behaviors are not clear; those involved

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in future projects may wish to include this as one component of their intervention scheme. An emerging rapprochement health education and behavioral psychology?

between

The parallels between the self-help and self-management schools of thought are highlighted by similarities between the self-help criteria proposed in this article and the self-management criteria developed by Thoresen and Kirmil-Gray (see article in this issue). Four out of the five self-help criteria are echoed in the self-management criteria: E&t~lttionctl self help 1. Development of client responsibility 2. Full disclosure of information 3. Training in decisionmaking skills 4. Use of peer educators 5. Training health professionals to develop self-help attitudes and behaviors

Behavior-r11self-management 9. Promotion of personal responsibility for health

5. Teaching more than adherence to treatment 8. Promotion of maintenance and generalization of skills relates to many of the nine self-management criteria

Although the educational self-help criteria derive from a philosophical stance on the role of the “activated” health consumer and the self-management criteria come from a theoretical school in psychology, they complement each other nicely. Perhaps this reflects broader trends taking place in the fields of health education and psychology. The early years of behavioral psychology were characterized by a rigid adherence to a black box model of human behavior that ignored the role of thoughts, feelings, attitudes, and motivations. In contrast, health education practice of the same era employed primarily a cognitive approach at one extreme (characterized by heavy reliance on pamphlets, films, and the mass media) and community organization approaches at the other. The didactic approaches were relatively successful in inducing such simple, onetime behavior changes as obtaining immunizations and receiving tuberculosis screening tests. Community organization was directed typically at the mobilization of medical resources or at environmental sanitary reforms. Toward the middle of the century, the disease burden began to shift from the acute to the chronic illnesses. The prevention and treatment of these diseases posed behavioral challenges of a much greater magnitude: smoking cessation, weight loss, coping with an incurable disease, and adherence to long-term therapeutic regimens. Simple instructional approach-

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es that implied that the patient should follow the regimen “because the doctor says so” did not work. Hence, health education practice has expanded its scope to address the myriad psychological, sociological, and environmental variables that impinge on the desired health behavior. This development has greatly increased the complexity of the work of the health educator, who must now be sophisticated in a broad range of methods including individual counseling, peer group discussions, behavior modification, mass media, organizational development, and community organization.5, H5Pointing up the difficulties in distinguishing between educational and behavioral methods, at least two authors have referred to this assortment of techniques as “educational-behavioral strategies. 1186, 87 There are other developments that point up the convergence of the two disciplines. A review of one definition of behavior therapy reveals8”: “Behavior therapy involves environmental change and social interaction rather than the direct alteration of bodily processes by biological procedures. The uirn is primaril> educationul. The techniques facilitate improved selfcontrol [emphasis added]. ” According to this definition, behavior therapy might be considered a specialized application of health education. In a separate analysis, Green”’ compared principles of behavioral therapeutics and of educational learning. He discovered a substantial overlap in terms of identification of the behavioral objectives, feedback given over a period of time, individualization of the program, and internal motivation. The emergence of the educational self-help and self-care movement with its attendant emphasis on client involvement and self-determination closely parallels the growth of the behavioral self-management school of psychology. Both health education, an applied discipline, and psychology, a theoretical discipline, can play complementary roles to contribute to enhanced health outcomes of patients and clients. SUMMARY Effective patient education programs require firm footing in the behavioral sciences and in their conceptual and philosophic foundations. Such foundations permit knowledge to be cumulative rather than sporadic and lessons learned in one project to be intelligently applied to another. Principles and approaches of educational self-care were reviewed, five educational self-care principles were presented, and the extent to which recent asthma projects exemplified these criteria was discussed. The programs manifested the criteria with different degrees of thoroughness. Preliminary evaluation find-

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ings suggested that those programs that best incorporated these principles tended to be more effective in favorably influencing a broad range of behavioral, physiologic, and financial outcomes .RR An excellent start has been registered in improvement of the educational and behavioral aspects of care for children with asthma, and the findings from several projects are very encouraging. Further research and experience in this realm no doubt will help improve the health of children with asthma. Surely, they deserve our best efforts. REFERENCES 1. Haynes RB, et al: Compliance in health care. Baltimore, 1979, Johns Hopkins University Press. 2. Cooper B. Patterson R: The corticosteroid dose graph. J ALLERGY CLIN IMMUNOL S&635, 1976. 3. Eney RD. Goldstein EO: Compliance of chronic asthmatics with oral administration of theophylline as measured by serum and salivary levels. Pediatrics .57:513, 1976. 4. Rubenstein HS: Behavior in a medical clinic of patients with well controlled bronchial asthma. Lancet 1: 1011, 1976. 5. Bartlett EE: Selection of educational strageties. In Green LW, et al, editors: Health education planning: a diagnostic approach. Palo Alto, Calif., 1980, Mayfield Publishing Co. 6. Levin LS, et al: Self-care: lay initiatives in health. New York, 1976, Prodist, p. 11. 7. Fonaroff A, Levin LS, editors: Issues in self-care. Health Educ Monogr 5:206-10, 1977. 8. Levin LS: The layperson as the primary care practitioner. Public Health Rep 91:206, 1976. 9. Pratt L: The significance of the family in medication. J Comparative Fam Stud 1:13, 1973. 10. Bandura A: Social learning theory. Englewood Cliffs, N.J., 1977. Prentice-Hall, Inc. I 1. Bandura A: Self-efficacy: toward a unifying theory of behavior change. Psycho1 Rev 84: 191, 1977. 12. Reeder LG, et al: What patients expect from their doctors. Mod Hosp. 89:88, 1957. 13. McGhee A: The patient’s attitude to nursing care. Edinburgh, 1961, E & S Livingstone. 14. David MS, Eichhom RL: Compliance with medical regimens: a panel study. J Health Sot Behav 4:240, 1963. 15. Raphael W: Patients and their hospitals. London, 1969, King Edward’s Hospital Fund. 16. Hugh-Jones P, et al: Patients’ views of admission to a London teaching hospital. Br Med J 2:660, 1964. 17. Skipper JK, et al: Some possible consequences of limited communication between patients and hospital functionaries. J Health Hum Behav 5:34, 1964. 18. Glaser BG, Strauss AL: Awareness of dying. Chicago, 1965, Aldine Publishing Co. 19. Ley P, Spelman MS: Communications in an out-patient setting. Br J Sot Clin Psycho1 4:114, 1965. 20. Ley P, Spelman MS: Communicating with the patient. St. Louis, 1967, Warren H Green, Inc. 2 1. Skipper JK: Communication and the hospitalized patient. In Skipper JK, Leonard RC, editors: Social interaction and patient care. Philadelphia, 1965, J. B. Lippincott Co. 22. Korsch B, et al: Gaps in doctor-patient communications. 1. Doctor-patient interaction and patient satisfaction. Pediatrics 42:855, 1968.

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