An evaluation of a pictorial asthma medication plan for Pacific children

Asthma has a considerable influence on the lives of many New Zealand children and their families. Uncontrolled disease can negatively impact day-to-day activities, such as school attendance and participation in sports, and may lead to acute attacks. These are not only frightening, but can also result in visits to general practice or accident and emergency facilities.1The burden of disease falls disproportionately on children from Pacific communities. Pacific children, along with Māori, have a higher asthma prevalence and their acute symptoms are often more severe when compared with other ethnicities.2 They are also overrepresented in preventable asthma-related hospital admissions.3 This is a significant health inequity and an ongoing challenge for the health sector.The exact reason for poor asthma outcomes in Pacific children is unclear. Evidence suggests that Pacific families lack an understanding about asthma medicines use and how to recognise the signs and symptoms of worsening asthma.4 These factors are likely to contribute to poor asthma management and symptom control and may be mitigated with appropriate education.3For all ethnicities, asthma education has traditionally relied upon the use of written asthma action plans, despite there being limited evidence of their effectiveness.5 Utilisation rates of such plans may also be decreasing in New Zealand.6Data about the use and utility of asthma education resources in Pacific children is lacking. The only published study that has evaluated asthma self-management plans in Pacific people was in a Tongan community-based programme.7 Although older children were enrolled in this study, the overall emphasis was on adults and no specific conclusions were made with respect to the child participants.The Paediatric Society of New Zealand's childhood asthma guidelines has recommendations around providing asthma education to Pacific families. They stress the importance of educating about ‘everyday' asthma inhaler use (e.g. ‘preventers', ‘controllers'), ensuring language is not a barrier, and suggest that ‘action plans with pictures of medicines rather than words may help'.8,p41 No such asthma resource has been available to health workers in New Zealand. Furthermore, no studies have been published yet about the use of ‘pictorial' asthma action plans in children - of any ethnicity. There is a single study that evaluated a pictorial asthma plan, but this was designed only for use in adults.9Recently, the Pharmaceutical Management Agency (PHARMAC) launched Space to Breathe, an initiative that uses a personalised asthma action plan with images of the child's inhalers.10However, it has not been formally evaluated, the resources are predominately textual, and are unavailable in the first language for Pacific families. The ‘one-size-fits-all' approach of the written asthma action plans that are commonly available in New Zealand could be a potential barrier to effective asthma self-management support in the Pacific community.We have developed www.pamp.co.nz a web-based tool that health professionals can use to produce personalised pictorial asthma resources in English and three Pacific languages. The focus of the Pacific Asthma Medication Plan, or PAMP, is on the child's ‘everyday' inhalers. Pre-printed information sheets about the signs and symptoms of asthma are also available in the first language. These resources are laminated together with fridge magnets attached for families to take home.The objective of this study was to evaluate: the utilisation and acceptability of the resources, the effectiveness of the PAMP to reinforce the importance of the ‘everyday' inhalers and to act as a reminder to use them regularly, changes in ‘everyday' inhaler use patterns, and the effectiveness of the asthma signs and symptoms sheets to inform and improve self-efficacy. The primary outcome variable was continued use of the resources after 6 months.Methods This was a quantitative, prospective study conducted at two sites from June 2009 to May 2010: West Fono Health Trust (a large Pacific Health primary care provider in West Auckland servicing 360 enrolled asthmatic children aged 2-16 years), and the Rangitira Unit, Waitakere Hospital (a 15-bed children's ward). Inclusion criteria were Pacific children aged 2-15 years prescribed ‘preventer' or ‘controller' asthma medications. To generate a PAMP using the online tool, details were entered about the child (age, gender), prescribed asthma inhalers (one ‘reliever' with variable fields for dose and frequency; up to two ‘everyday' inhalers with variable fields for dose and a default frequency of twice a day), health professional (name, location, phone number), and expiry date of the plan. These were printed in colour in the patient's choice of language/s (English, Samoan, Tongan or Tuvaluan), then laminated with a pre-printed signs and symptoms sheet (also in the chosen language/s) on the reverse, and fridge magnets attached (Figure 1). Figure 1. PAMP (English and Samoan) and asthma signs and symptoms sheet Participants were given the resources as part of the routine face-to-face asthma education provided during their visit; six weeks later they completed a structured questionnaire about the resources, either in person at West Fono Health Trust, or by phone. For the purposes of follow-up, patients visiting the Rangitira Unit were excluded if they were not enrolled at West Fono Health Trust. The dates of initial visit and follow-up, the family's ethnicity, and language versions of the resources provided were also recorded. Consultations were conducted in English by a registered health professional. The questionnaire answers were collated and statistical analysis carried out using SAS v9.1.3 software for Windows. An additional audit was conducted 6 months after study completion to see if the families were still using the resources. Adult and child versions of the participant information sheet and consent form were pre-tested for comprehensibility using key informant interviews with six Pacific families; these were available in English only. These documents were tested at a focus group of West Fono Health Trust staff who also assisted with writing the asthma resources in the first language; the choice of languages was aligned with the demographics of the local population. Both groups provided feedback on the layout and design of the asthma resources. The clinical content was compiled by the Quality Use of Medicines Team at Waitemata District Health Board (DHB) and the asthma educators at West Fono Health Trust; this was endorsed by a consultant paediatrician, a paediatric clinical pharmacist, paediatric nursing staff, and Pacific Support Services at Waitakere Hospital. Changes in ‘everyday' inhaler use before and after receiving the asthma resources were investigated using repeated measure analysis to adjust for child to child variability; inhaler use was coded as: ‘never' = 0; ‘few times a week' = 3-5 (midpoint of 4 was used); ‘most days' = 6-7 (midpoint of 6.5 was used). The study had ethics approval from the Northern X Regional Ethics Committee, Auckland (NTX/08/09/088). Results None of the study participants were recruited at the Rangitira Unit during the 11-month study period because there were no hospital admissions of West Fono Health Trust enrolled children who met the inclusion criteria. A total of 52 children were recruited, but four children were excluded (two were from non-Pacific families; two had incomplete consent forms); the remaining 48 participants completed the structured questionnaire. Along with parental consent, five older children also gave their assent to participate. The primary visit and follow-up was performed by either of two registered practice nurses who had completed an accredited asthma education course; one nurse enrolled 45 of the participants. Table 1 describes the patient demographics and utilisation of resources. There were similar numbers of boys and girls, with an average age of 6 years. Samoan made up the largest specific ethnicity (n = 31) in the whole group. The median time to initial follow-up was 48 days. A total of 67 sets of asthma resources were given to 48 families (45 English and 22 first language versions). Table 1. Patient demographics, distribution and utilisation of resources Gender of children and age (median; range) All participants (n=48) 6 years (2-14) Female (n=23) 7 years (3-14) Male (n=25) 6 years (2-13) Ethnicity; number of families Samoan 31 Cook Island Maori 4 Niuean 4 Tongan 3 Fijian 2 Tuvaluan 2 Unspecified† 2 Ethnicity; language version; no. of families who received the resources Samoan Samoan + English 16 English only 13 Samoan only 2 Cook Island Maori English only 4 Niuean English only 4 Tongan Tongan + English 2 Tongan only 1 Fijian English only 2 Tuvaluan Tuvaluan + English 1 English only 1 Unspecified† English only 2 No. of English + first language versions given to families 67 versions to 48 families (English 45; first language 22) Median time between first meeting and follow-up questionnaire 48 days (range 37-119)* † Patients listed as ‘Other Pacific' * Includes five families that took longer than 60 days to follow-up Table 2 details the questions and responses in the questionnaire. There were minor omissions in nine questionnaires; all available responses were included in the analysis. The questionnaires were completed by the child's parent or caregiver. Table 2. Questions and responses from structured questionnaire Questions† Choices No. of responses % of responses Q1. Are you still using the asthma medication plan? Yes, we are still using the plan 45/45# 100 No, we are not using the plan 0 0 Q2. Where did you keep the asthma medication plan that we gave you? Fridge 45/47 96 Bedroom 1/47 2 Drawer 1/47 2 Q3. Have you ever been given another type of asthma medication plan, or asthma action plan before? No, this is the first time (go to Q5) 39/45 87 Yes, we have been given one before 6/45 13 Q4. How does the asthma medication plan we gave you compare to ones you've used before? Better* (from Q3) 6/6 100 Same* 0 0 Worse* 0 0 Q5. About the number of words used on the asthma medication plan, which of the following do you agree with? About right 46/47 98 Not enough words 1/47 2 Too many words 0 0 Q6. About the number of pictures used on the asthma medication plan, which of the following do you agree with? About right 46/47 98