- Email: [email protected]
Self-management of childhood asthma
Preface Self-management
of childhood
Robert A. Goldstein, M.D., Ph.D.,* Lawrence Sydney R. Parker, Ph.D.***
In the past decade there has been a renaissance of scientific interest and research into health education and programs of self-management, especially as they may apply to the control of chronic disabling diseases. Heightened public awareness of the precise role that individuals may play in promoting their own health has increased during this time through media exposure and improved patterns of life-style, which are presumed to be associated with enhanced quality of life and better health. It has not always been possible, however, to translate gains made by healthy people into similar progress for persons with chronic illness. In the middle 1970s research support became available for studies in a variety of areas. Such studies shared common goals and included the exploration of the means and methods of modifying behavior patterns in individuals in order that they might improve the quality of their lives and take advantage of advances in modem medicine. Changes observed to date include those related to our enhanced understanding of the harmful effects of cigarette smoking and improved compliance in taking medications to control hypertension. Among chronic disorders affecting children, asthma ranks as a prominent cause of morbidity and school absenteeism. It would appear to be one of the leading causes of admissions to hospital in the schoolage population, and although modem therapy has significantly reduced deaths from this disease, asthma continues to rank very high among causes of morbidity. Nationwide, approximately 15 million people, including adults, are afflicted with asthma and the disease appears to be especially prevalent in urban populations. On the basis of preliminary evidence that children with asthma could learn effective ways of managing
From the *National Institute of Allergy and Infectious Disease, Bethesda, Md., the **Center for Health Promotion Research and Development, University of Texas Health Science Center, Houston, Texas, and the ***National Heart, Lung, and Blood Institute, Bethesda, Md. 522
asthma W. Green, Dr.P.H.,** and
their disease with reduced reliance upon the health care system, the National Heart, Lung, and Blood Institute and the National Institute of Allergy and Infectious Diseases (NIAID), as well as other federal and nonfederal funding agencies, have helped to promote the development of programs whose goals are to encourage and facilitate the self-management of asthma. These programs have included educational reading materials and other learning aids and are aimed not only at children with asthma but also at their parents, teachers, and other health practitioners within the community. A variety of programs were reviewed at a meeting entitled Self-management Educational Programs for Childhood Asthma, held in Los Angeles in June of 1981 and sponsored by the NIAID in conjunction with the Asthma and Allergy Foundation of America and the Center for Interdisciplinary Research on Immunologic Diseases at the University of California, Los Angeles. At that time many programs were in a preliminary phase, with work still in progress and statistical analysis incomplete. Nevertheless, that conference brought together for the first time the principal investigators on these projects and other individuals throughout the United States who had dedicated themselves to working with asthmatic individuals, with the purpose of expediting the process of information dissemination. The programs presented at the 198 1 Conference will be described briefly. Although the programs presented at that earlier conference and reviewed in this report are not a comprehensive survey of all the asthma programs in the United States, they do constitute a broad sample of the programs available and they include those large research programs supported by the National Institutes of Health. Asthma Care Training (ACT), developed at UCLA, was comprised of five weekly 1 hr group sessions. There were separate sessions where children and parents met during an initial 45 min period followed by a group session where they could share their experiences. The educational technique relied heavily upon the thematic analogy of “you’re in the driver’s seat” and related management of asthma to safe as-
VOLUME NUMBER
72 5. PART 2
pects of driving an automobile. The stated goal included a reduction in the number and severity of asthmatic attacks as well as the elimination of unnecessary restrictions on the child’s daily activity. Teaching sessions were led by physicians and other professionals. The ACT program has continued to evolve since the conference. The design of the program permitted its use in physicians’ offices, clinics, ambulatory care centers, and schools. One of the guiding principles was that it be simple enough to be adaptable to a variety of settings. The Asthma Self-management Program, developed at Columbia University, targeted 4- to 16-yr-old patients, with emphasis on low-income populations of blacks and Hispanics attending clinics at four New York hospitals. Many of these target individuals had the typical urban and environmental difficulties at home. The program utilized urban hospital clinics. Health educators, graduate students, volunteers, and other individuals provided instruction. Six 50 min sessions were held during a 6 mo period and were offered in both English and Spanish. Program materials from Columbia University were especially suited to urban populations. At the National Asthma Center in Denver, Colorado, children between ages 5 to 17 yr were recruited from private physicians’ offices and offered a program consisting of eight sessions over a period of 3 mo. Early sessions included physician input and group discussions as well as individualized instruction where indicated. The overall emphasis was on behavioral and cognitive techniques. Although centralized at the National Asthma Center, a smaller community-based program also was developed. The American Institutes of Research in Palo Alto, California, worked in conjunction with Kaiser-Permanente Medical Group to develop a series of training manuals aimed at a target audience of 9- to 13-yrold patients who were exposed to eight 1 hr educational sessions. The sessions consisted of four peer and family support sessions and four behavioral modification sessions at weekly intervals. The group program was later reduced to four sessions. The program utilized instruction, game playing, and skill training combined with a series of audiovisual materials, written handouts, and homework. In addition, an individualized program was developed that was based on the same principles as the group program. Finally, at Children’s Hospital in Buffalo, New York, a family asthma program was developed with a target audience of 6- to I4-yr-old patients as well as parents, school nurses, teachers, and other individuals involved in the care of children with asthma. After a brief introduction parents and children were
Self-management
of childhood
asthma
523
separated for the bulk of the program, which was comprised of six 2 hr sessions held at weekly intervals. A variety of printed materials were used and education and training by physicians, nurses, social scientists, and exercise pulmonary physiologists were provided. The program was intended for use at the community level and did not require a hospital base. The most obvious similarities in these five highly developed programs include (1) the use of teaching materials that could be taken home, (2) the use of a variety of educators including physicians, nurse practitioners, psychologists, school teachers, and other interested individuals as instructors, and (3) target audiences that included not only children and parents but other individuals with whom the children would be in contact on a regular basis. The programs were not restricted to a clinic or hospital setting but could be conducted in almost any setting where the interested individuals could participate. Urban low-income, suburban, and middle-class audiences were all reached by one program or another. Although results are not complete in every instance, descriptions and publications of data are available in almost every one of these programs as of this time. In addition to an analysis of objective measures concerned with days missed from school and emergency room visits (which may or may not be the appropriate measure), other parameters such as those concerned with self-esteem, increased knowledge, and improved coping skills were also examined. The common theme remained prominent-that of improving and enhancing skills of self-management. Six other programs were presented at the June 1981 meeting. Because the research support was very different from that of the aforementioned group, it is convenient to discuss the programs separately. Camp Wheeze, supported by a group at Stanford University, provides children of ages 5 to 14 yr with summer day-camp sessions, which are followed by evening instructional sessions throughout the school year. Although developed for summer camp environment, the teaching program can be implemented in other community settings. The intervention schedule consists of five daily sessions, each with two 20 mm classroom sessions, as well as a directed recreational program. There are concurrent regular classes for the parents that are held with physicians and social workers. General educational instruction on the anatomy, physiology, definition, and treatment of asthma, along with psychosocial factors, is included. At Children’s Hospital in Pittsburgh, self-management of asthma is taught in an ambulatory care setting in the offices of private practitioners. The program consists of four 1 hr instruction sessions com-
524
Goldstein
et al
J. ALLERGY
CLIN. IMMUNOL. NOVEMBER
bined with two 2 hr group discussion and question classes. Instructional booklets concerned with asthma, allergy, and environmental hazards are provided. The target audience is children from 2 to 14 yr of age as well as their parents. Two other programs were concerned with the inpatient instruction of children with asthma who were medically unable to be managed as outpatients. The Children’s Hospital in Los Angeles, in conjunction with the Sunair Home for Asthmatic Children, Tujunga, California, treated children ages 6 to 13 yr who had severe, chronic asthma and who could not otherwise be managed. Printed materials were provided in another inpatient setting at the Blythedale Hospital in Tarrytown, New York, within a chronic care facility. A variety of educators including family counselors, teachers, physical therapists, and recreation specialists, along with regular medical care personnel, provided a series of individual and group instruction sessions as well as other learning activities. These activities for the most part were tailored for the individual and therefore could not be compared with other programs. Programs for very wide dissemination have also been developed. The American Lung Association presented “Superstuff, ’ ’ a packaged educational program for patients and families, through physicians’ offices and local lung associations. No special educators were required. The program was free standing and depended on self-instruction. Winning Over Wheezing, another free-standing program, was developed initially in Denver and further in Hawaii and is intended for nationwide distribution by the William H. Rorer Company. Applied on a local scale, it was used in conjunction with community teaching sessions. It becomes obvious in reviewing these 11 programs that there is a wide diversity in the available material and the stated goals. Many similarities were evident in these widely varied intervention programs. Generally speaking, each included education about asthma, peer and family support, and behavior training sessions of some sort. Intervention programs were conducted in a variety of settings. Clearly a great deal of enthusiastic effort has gone into the development and application of these educational materials. It has been difficult to evaluate and analyze the results of these interventions in an objective and meaningful fashion. A major purpose of the original conference was to provide a forum for discussion and to gather for the first time information on all of these activities in order to bring attention to self-management educational programs for childhood asthma.
1983
The follow-up workshop in June of 1983, reflected in the articles that follow, was aimed not at simply redescribing programs but at evaluating various aspects of the programs. Although data suggested the effectiveness of these efforts, critical review and evaluation were considered necessary in order to provide useful and meaningful information to those individuals who would conduct activities of this nature. Thus in addition to an evaluation of various aspects of these programs, it was the purpose of this series of articles to provide the reader with an overall view of what behavioral self-management is, how it is utilized, how effective it is, how to identify good features in self-management programs, and how one can determine which patients will benefit from these programs. This workshop brought together experts, many of whom have not been involved directly in the development and application of programs on self-management of asthma but rather who have a broader view of the topic; that has been intentional. The format was designed to provide a broad review of topics and research from related fields pertinent to self-management by experts in those related fields. Each critical review is followed by a response by an individual directly involved in asthma programs to provide discussion of the theories and issues as they apply to self-management of asthma. The articles address the full range of clinical, behavioral, educational, organizational, and methodologic issues in self-management research and the prospects of transfering the technology of self-management education into health care settings. For the purposes of this workshop, self-management was defined as those organized methods of developing the capacity of the child and his or her parents to prevent asthma attacks and to manage attacks once they occur, while encouraging the child to live as normal a life as possible. “Asthma in Childhood,” by Elliot F. Ellis, M.D., offers a primer on asthma with emphasis on current application of knowledge in the medical management of asthma, epidemiology of asthma, and aspects of the natural history of asthma that have particular relevance for self-management. It discusses individual behaviors that an asthmatic child needs to know and perform to control the asthma condition and how these behaviors have been clinically defined. Henry Levison, M.D., and Alan Isles, M.D., provide a response that addresses controversies in the pharmacotherapy of asthma. “Educational Self-help Approaches in Childhood Asthma,” by Edward E. Bartlett, Dr.P.H., examines specific theories in health education as they apply to
VOLUME NUMBER
72 5, PART 2
Self-management
pediatric asthma programs. Michele C. Hindi-Alexander, Ph.D., details some pragmatic issues to consider when designing educational programs for children with asthma. “The Application of Theory in Childhood Asthma Self-help Programs, ” by John G. Bruhn, Ph.D., addresses the following questions: How is theory currently used in self-management research? What theories or new developments in health education and behavioral science are potentially useful to self-management research? Commentary is provided by Noreen M. Clark, Ph.D., of the University of Michigan. ‘ ‘Methodologic Problems in the Evaluation of Selfmanagement Programs,” by W. James Popham, Ed.D., and Elanna S. Yalow, Ph.D., asks: What problems are encountered in self-management research and evaluation of such subjects as experimental design, control groups, experimental bias, effects of attention, effects of monitoring, and sample size? What problems are encountered in measurement of knowledge, behavioral attitude, process measures, and outcome measures including number of attacks,
Bound
volumes
available
of childhood
asthma
525
use of health care resources, and days lost from school? Sandra R. Wilson, Ph.D., responds from the perspective of a researcher in the asthma self-manage-
ment field. “Self-management Psychology and the Treatment of Childhood Asthma,” by Carl E. Thoresen, Ph.D., and Kathleen Kirmil-Gray, Ph.D., discusses theoretic aspects of self-management behavior psychology. Thomas L. Creer, Ph.D., examines self-management psychology as it applies to the asthmatic patient. “Implementing Asthma Self-management Educa-
tion in Medical Care Settings-Issues and Strategies,” by Patricia Dolan Mullen, Dr.P.H., and Lawrence R. Mullen, J.D., asks what health care system variables, economic variables, settings for health care delivery, and health care personnel affect the implementation of self-management and the use of the health care system by asthmatic patients. Charles E. Lewis, M.D., responds from the perspective of an experienced physician and health services research investigator in pediatric asthma self-management programs.
to subscribers
Bound volumes of THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGYare available to subscribers (only) for the 1983 issues from the Publisher, at a cost of $47.50 ($57.10 international) for Vol. 71 (January-June)and Vol. 72 (July-December). Shipping chargesare included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stampedin gold on the spine. Payment must accompany all orders. Contact Mr. Deans Lynch at The C. V. Mosby Co., 11830 Westline Industrial Dr., St. Louis, MO. 63146. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.
of childhood
Robert A. Goldstein, M.D., Ph.D.,* Lawrence Sydney R. Parker, Ph.D.***
In the past decade there has been a renaissance of scientific interest and research into health education and programs of self-management, especially as they may apply to the control of chronic disabling diseases. Heightened public awareness of the precise role that individuals may play in promoting their own health has increased during this time through media exposure and improved patterns of life-style, which are presumed to be associated with enhanced quality of life and better health. It has not always been possible, however, to translate gains made by healthy people into similar progress for persons with chronic illness. In the middle 1970s research support became available for studies in a variety of areas. Such studies shared common goals and included the exploration of the means and methods of modifying behavior patterns in individuals in order that they might improve the quality of their lives and take advantage of advances in modem medicine. Changes observed to date include those related to our enhanced understanding of the harmful effects of cigarette smoking and improved compliance in taking medications to control hypertension. Among chronic disorders affecting children, asthma ranks as a prominent cause of morbidity and school absenteeism. It would appear to be one of the leading causes of admissions to hospital in the schoolage population, and although modem therapy has significantly reduced deaths from this disease, asthma continues to rank very high among causes of morbidity. Nationwide, approximately 15 million people, including adults, are afflicted with asthma and the disease appears to be especially prevalent in urban populations. On the basis of preliminary evidence that children with asthma could learn effective ways of managing
From the *National Institute of Allergy and Infectious Disease, Bethesda, Md., the **Center for Health Promotion Research and Development, University of Texas Health Science Center, Houston, Texas, and the ***National Heart, Lung, and Blood Institute, Bethesda, Md. 522
asthma W. Green, Dr.P.H.,** and
their disease with reduced reliance upon the health care system, the National Heart, Lung, and Blood Institute and the National Institute of Allergy and Infectious Diseases (NIAID), as well as other federal and nonfederal funding agencies, have helped to promote the development of programs whose goals are to encourage and facilitate the self-management of asthma. These programs have included educational reading materials and other learning aids and are aimed not only at children with asthma but also at their parents, teachers, and other health practitioners within the community. A variety of programs were reviewed at a meeting entitled Self-management Educational Programs for Childhood Asthma, held in Los Angeles in June of 1981 and sponsored by the NIAID in conjunction with the Asthma and Allergy Foundation of America and the Center for Interdisciplinary Research on Immunologic Diseases at the University of California, Los Angeles. At that time many programs were in a preliminary phase, with work still in progress and statistical analysis incomplete. Nevertheless, that conference brought together for the first time the principal investigators on these projects and other individuals throughout the United States who had dedicated themselves to working with asthmatic individuals, with the purpose of expediting the process of information dissemination. The programs presented at the 198 1 Conference will be described briefly. Although the programs presented at that earlier conference and reviewed in this report are not a comprehensive survey of all the asthma programs in the United States, they do constitute a broad sample of the programs available and they include those large research programs supported by the National Institutes of Health. Asthma Care Training (ACT), developed at UCLA, was comprised of five weekly 1 hr group sessions. There were separate sessions where children and parents met during an initial 45 min period followed by a group session where they could share their experiences. The educational technique relied heavily upon the thematic analogy of “you’re in the driver’s seat” and related management of asthma to safe as-
VOLUME NUMBER
72 5. PART 2
pects of driving an automobile. The stated goal included a reduction in the number and severity of asthmatic attacks as well as the elimination of unnecessary restrictions on the child’s daily activity. Teaching sessions were led by physicians and other professionals. The ACT program has continued to evolve since the conference. The design of the program permitted its use in physicians’ offices, clinics, ambulatory care centers, and schools. One of the guiding principles was that it be simple enough to be adaptable to a variety of settings. The Asthma Self-management Program, developed at Columbia University, targeted 4- to 16-yr-old patients, with emphasis on low-income populations of blacks and Hispanics attending clinics at four New York hospitals. Many of these target individuals had the typical urban and environmental difficulties at home. The program utilized urban hospital clinics. Health educators, graduate students, volunteers, and other individuals provided instruction. Six 50 min sessions were held during a 6 mo period and were offered in both English and Spanish. Program materials from Columbia University were especially suited to urban populations. At the National Asthma Center in Denver, Colorado, children between ages 5 to 17 yr were recruited from private physicians’ offices and offered a program consisting of eight sessions over a period of 3 mo. Early sessions included physician input and group discussions as well as individualized instruction where indicated. The overall emphasis was on behavioral and cognitive techniques. Although centralized at the National Asthma Center, a smaller community-based program also was developed. The American Institutes of Research in Palo Alto, California, worked in conjunction with Kaiser-Permanente Medical Group to develop a series of training manuals aimed at a target audience of 9- to 13-yrold patients who were exposed to eight 1 hr educational sessions. The sessions consisted of four peer and family support sessions and four behavioral modification sessions at weekly intervals. The group program was later reduced to four sessions. The program utilized instruction, game playing, and skill training combined with a series of audiovisual materials, written handouts, and homework. In addition, an individualized program was developed that was based on the same principles as the group program. Finally, at Children’s Hospital in Buffalo, New York, a family asthma program was developed with a target audience of 6- to I4-yr-old patients as well as parents, school nurses, teachers, and other individuals involved in the care of children with asthma. After a brief introduction parents and children were
Self-management
of childhood
asthma
523
separated for the bulk of the program, which was comprised of six 2 hr sessions held at weekly intervals. A variety of printed materials were used and education and training by physicians, nurses, social scientists, and exercise pulmonary physiologists were provided. The program was intended for use at the community level and did not require a hospital base. The most obvious similarities in these five highly developed programs include (1) the use of teaching materials that could be taken home, (2) the use of a variety of educators including physicians, nurse practitioners, psychologists, school teachers, and other interested individuals as instructors, and (3) target audiences that included not only children and parents but other individuals with whom the children would be in contact on a regular basis. The programs were not restricted to a clinic or hospital setting but could be conducted in almost any setting where the interested individuals could participate. Urban low-income, suburban, and middle-class audiences were all reached by one program or another. Although results are not complete in every instance, descriptions and publications of data are available in almost every one of these programs as of this time. In addition to an analysis of objective measures concerned with days missed from school and emergency room visits (which may or may not be the appropriate measure), other parameters such as those concerned with self-esteem, increased knowledge, and improved coping skills were also examined. The common theme remained prominent-that of improving and enhancing skills of self-management. Six other programs were presented at the June 1981 meeting. Because the research support was very different from that of the aforementioned group, it is convenient to discuss the programs separately. Camp Wheeze, supported by a group at Stanford University, provides children of ages 5 to 14 yr with summer day-camp sessions, which are followed by evening instructional sessions throughout the school year. Although developed for summer camp environment, the teaching program can be implemented in other community settings. The intervention schedule consists of five daily sessions, each with two 20 mm classroom sessions, as well as a directed recreational program. There are concurrent regular classes for the parents that are held with physicians and social workers. General educational instruction on the anatomy, physiology, definition, and treatment of asthma, along with psychosocial factors, is included. At Children’s Hospital in Pittsburgh, self-management of asthma is taught in an ambulatory care setting in the offices of private practitioners. The program consists of four 1 hr instruction sessions com-
524
Goldstein
et al
J. ALLERGY
CLIN. IMMUNOL. NOVEMBER
bined with two 2 hr group discussion and question classes. Instructional booklets concerned with asthma, allergy, and environmental hazards are provided. The target audience is children from 2 to 14 yr of age as well as their parents. Two other programs were concerned with the inpatient instruction of children with asthma who were medically unable to be managed as outpatients. The Children’s Hospital in Los Angeles, in conjunction with the Sunair Home for Asthmatic Children, Tujunga, California, treated children ages 6 to 13 yr who had severe, chronic asthma and who could not otherwise be managed. Printed materials were provided in another inpatient setting at the Blythedale Hospital in Tarrytown, New York, within a chronic care facility. A variety of educators including family counselors, teachers, physical therapists, and recreation specialists, along with regular medical care personnel, provided a series of individual and group instruction sessions as well as other learning activities. These activities for the most part were tailored for the individual and therefore could not be compared with other programs. Programs for very wide dissemination have also been developed. The American Lung Association presented “Superstuff, ’ ’ a packaged educational program for patients and families, through physicians’ offices and local lung associations. No special educators were required. The program was free standing and depended on self-instruction. Winning Over Wheezing, another free-standing program, was developed initially in Denver and further in Hawaii and is intended for nationwide distribution by the William H. Rorer Company. Applied on a local scale, it was used in conjunction with community teaching sessions. It becomes obvious in reviewing these 11 programs that there is a wide diversity in the available material and the stated goals. Many similarities were evident in these widely varied intervention programs. Generally speaking, each included education about asthma, peer and family support, and behavior training sessions of some sort. Intervention programs were conducted in a variety of settings. Clearly a great deal of enthusiastic effort has gone into the development and application of these educational materials. It has been difficult to evaluate and analyze the results of these interventions in an objective and meaningful fashion. A major purpose of the original conference was to provide a forum for discussion and to gather for the first time information on all of these activities in order to bring attention to self-management educational programs for childhood asthma.
1983
The follow-up workshop in June of 1983, reflected in the articles that follow, was aimed not at simply redescribing programs but at evaluating various aspects of the programs. Although data suggested the effectiveness of these efforts, critical review and evaluation were considered necessary in order to provide useful and meaningful information to those individuals who would conduct activities of this nature. Thus in addition to an evaluation of various aspects of these programs, it was the purpose of this series of articles to provide the reader with an overall view of what behavioral self-management is, how it is utilized, how effective it is, how to identify good features in self-management programs, and how one can determine which patients will benefit from these programs. This workshop brought together experts, many of whom have not been involved directly in the development and application of programs on self-management of asthma but rather who have a broader view of the topic; that has been intentional. The format was designed to provide a broad review of topics and research from related fields pertinent to self-management by experts in those related fields. Each critical review is followed by a response by an individual directly involved in asthma programs to provide discussion of the theories and issues as they apply to self-management of asthma. The articles address the full range of clinical, behavioral, educational, organizational, and methodologic issues in self-management research and the prospects of transfering the technology of self-management education into health care settings. For the purposes of this workshop, self-management was defined as those organized methods of developing the capacity of the child and his or her parents to prevent asthma attacks and to manage attacks once they occur, while encouraging the child to live as normal a life as possible. “Asthma in Childhood,” by Elliot F. Ellis, M.D., offers a primer on asthma with emphasis on current application of knowledge in the medical management of asthma, epidemiology of asthma, and aspects of the natural history of asthma that have particular relevance for self-management. It discusses individual behaviors that an asthmatic child needs to know and perform to control the asthma condition and how these behaviors have been clinically defined. Henry Levison, M.D., and Alan Isles, M.D., provide a response that addresses controversies in the pharmacotherapy of asthma. “Educational Self-help Approaches in Childhood Asthma,” by Edward E. Bartlett, Dr.P.H., examines specific theories in health education as they apply to
VOLUME NUMBER
72 5, PART 2
Self-management
pediatric asthma programs. Michele C. Hindi-Alexander, Ph.D., details some pragmatic issues to consider when designing educational programs for children with asthma. “The Application of Theory in Childhood Asthma Self-help Programs, ” by John G. Bruhn, Ph.D., addresses the following questions: How is theory currently used in self-management research? What theories or new developments in health education and behavioral science are potentially useful to self-management research? Commentary is provided by Noreen M. Clark, Ph.D., of the University of Michigan. ‘ ‘Methodologic Problems in the Evaluation of Selfmanagement Programs,” by W. James Popham, Ed.D., and Elanna S. Yalow, Ph.D., asks: What problems are encountered in self-management research and evaluation of such subjects as experimental design, control groups, experimental bias, effects of attention, effects of monitoring, and sample size? What problems are encountered in measurement of knowledge, behavioral attitude, process measures, and outcome measures including number of attacks,
Bound
volumes
available
of childhood
asthma
525
use of health care resources, and days lost from school? Sandra R. Wilson, Ph.D., responds from the perspective of a researcher in the asthma self-manage-
ment field. “Self-management Psychology and the Treatment of Childhood Asthma,” by Carl E. Thoresen, Ph.D., and Kathleen Kirmil-Gray, Ph.D., discusses theoretic aspects of self-management behavior psychology. Thomas L. Creer, Ph.D., examines self-management psychology as it applies to the asthmatic patient. “Implementing Asthma Self-management Educa-
tion in Medical Care Settings-Issues and Strategies,” by Patricia Dolan Mullen, Dr.P.H., and Lawrence R. Mullen, J.D., asks what health care system variables, economic variables, settings for health care delivery, and health care personnel affect the implementation of self-management and the use of the health care system by asthmatic patients. Charles E. Lewis, M.D., responds from the perspective of an experienced physician and health services research investigator in pediatric asthma self-management programs.
to subscribers
Bound volumes of THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGYare available to subscribers (only) for the 1983 issues from the Publisher, at a cost of $47.50 ($57.10 international) for Vol. 71 (January-June)and Vol. 72 (July-December). Shipping chargesare included. Each bound volume contains a subject and author index, and all advertising is removed. Copies are shipped within 30 days after publication of the last issue in the volume. The binding is durable buckram with the journal name, volume number, and year stampedin gold on the spine. Payment must accompany all orders. Contact Mr. Deans Lynch at The C. V. Mosby Co., 11830 Westline Industrial Dr., St. Louis, MO. 63146. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular journal subscription.