درمان آسم با یک مدل خود مدیریتی رفتار بیماری در محیط داروخانه جامعه استرالیا

Asthma affects a considerable proportion of the population worldwide and presents a significant health problem in Australia. Given its chronic nature, effective asthma self-management approaches are important. However, despite research and interventions targeting its treatment, the management of asthma remains problematic. This study aimed to develop, from a theoretical basis, an asthma self-management model and implement it in an Australian community pharmacy setting in metropolitan Sydney, using a controlled, parallel-groups repeated-measures design. Trained pharmacists delivered a structured, step-wise, patient-focused asthma self-management program to adult participants over a 9-month period focusing on identification of asthma problems, goal setting and strategy development. Data on process- clinical- and psychosocial-outcome measures were gathered. Results showed that participants set an average of four new goals and six repeated goals over the course of the intervention. Most common goal-related themes included asthma triggers, asthma control and medications. An average of nine strategies per participant was developed to achieve the set goals. Common strategies involved visiting a medical practitioner for review of medications, improving adherence to medications and using medications before exercise. Clinical and psychosocial outcomes indicated significant improvements over time in asthma symptom control, asthma-related self-efficacy and quality of life, and negative affect. These results suggest that an asthma self-management model of illness behaviour has the potential to provide patients with a range of process skills for self-management, and deliver improvements in clinical and psychosocial indicators of asthma control. The results also indicate the capacity for the effective delivery of such an intervention by pharmacists in Australian community pharmacy settings.

Asthma is a major health problem and its impact is both physical and psychological, extending beyond the well-being of individuals, to their families and the community. Worldwide, the prevalence of asthma makes it one of the most commonly occurring chronic diseases (The Global Initiative, 2005). Recently published figures indicate the prevalence of diagnosed asthma ranging from 2.7% of the population in Germany, to 7.1% in the United States of America (The Global Initiative, 2005). In Australia, asthma affects 10–12% of adults and 14–16% of children (The Australian Institute of Health and Welfare, 2005). Consequently, it is one of the most common reasons for hospital and medical practitioner visits (Britt et al., 2003). However, despite active campaigning, training and promotion by Federal bodies such as the Australian National Asthma Council, and State-based Asthma Foundations, asthma management practices in Australia are suboptimal. It has been suggested that new strategies are needed within primary care to ensure that asthma care meets current standards of best practice (Coughlin, Wilson, & Gibson, 2000; Reid, Abramson, Raven, & Walters, 2000; Ruffin, Wilson, Southcott, Smith, & Adams, 1999). Self-management of chronic illness is becoming increasingly important in the community as life expectancy increases and the population becomes more susceptible to diseases such as circulatory and respiratory disorders. Effective self-management of asthma is a complex process that is influenced by patients’ attitudes and beliefs about their asthma, their perceived competence and confidence in their ability to self-manage their illness, and perceptions of high-quality healthcare provider (HCP) support (Battersby, Ask, Reece, Markwick, & Collins, 2004; Bender, 2002; Horne & Weinman, 2002). Individuals need to engage in various cognitive and behavioural processes, ranging from a simple recognition that there is an absence of any asthma symptoms on a given day, to a complex array of almost hourly assessments of symptoms, identification of known triggers of asthma, and subsequent modifications of medications and behaviour. The uptake of complementary therapies (Blanc, Ware, Katz, Smith, & Yelin, 1997; Ernst, 1998) and inappropriate use of reliever medications (e.g. Short-acting beta-2 agonist inhalers) for the treatment of asthma (Cerveri et al., 1999; Reid et al., 2000) reflects the desire by people to self-manage their illness. For many, however, attaining optimal asthma self-management can be a difficult task (Clark & Partridge, 2002). Some of this difficulty may be due to the episodic nature of asthma and patients’ reluctance to take preventer medication when they are symptom-free. Thus, providing skills and guidance is essential for lifelong and appropriate asthma management. Recent research into the psychosocial aspects of asthma management has centred around patient perceptions and beliefs about asthma (Goeman et al., 2002; Horne & Weinman, 2002), the development of asthma-related measuring instruments (Hicks & Harris, 2001; Marks, Dunn, & Woolcock, 1992; Tobin, Wigal, Winder, Holroyd, & Creer, 1987) or the delivery of an intervention based on HCP-directed methods to encourage changes in patient illness behaviour (Narhi, Airaksinen, & Enlund, 2002; Put, van den Bergh, Lemaigre, Demedts, & Verleden, 2003; Thoonen et al., 2002). Although these intervention studies have sought to equip the patient with the desired asthma self-management skills, there do not appear to be any intervention studies designed to test a theoretical model of self-management in asthma care. Given the focus on improving primary-care management of asthma, pharmacists often represent an underutilised resource. Pharmacists have high levels of therapeutic knowledge and skills, and are very often the first point of contact for people with asthma. Pharmacy-based asthma interventions in Australia so far have included the identification, education, management, review and appropriate referral of people at risk, and have demonstrated significant improvements in clinical, psychosocial and economic outcomes (Burton et al., 2001; March, Gilbert, Roughead, & Qunitrell, 1999; Saini, Krass, & Armour, 2004). A pharmacy-based asthma self-management intervention has also been undertaken in England (Barbanel, Eldridge, & Griffiths, 2003) resulting in significant improvements in intervention group participants’ asthma symptoms at 3-month follow-up. However, while the facilitation of self-management skills was included in some of these studies it was not the main focus, and the process did not reflect a strong theoretical basis. In the current study we sought to redress this imbalance by focusing almost entirely on patient self-regulation of asthma management behaviour, using a theoretical framework to underpin the intervention, within a community pharmacy healthcare setting. The current study tested an intervention based on a self-management model of illness behaviour (Bandura, 2005; Horne & Weinman, 2002; Leventhal, Brissette, & Leventhal, 2003; Maes & Karoly, 2005; Wright, Barlow, Turner, & Bancroft, 2003) in an asthma population in Australia. This model comprises a structured, step-wise and facilitative process whereby the HCP adopts a patient-centred approach. The patient is helped to identify areas of asthma control that are problematic and to then set goals to address the most pressing of those problem areas. The patient is encouraged to devise strategies that will help him or her attain the set goals. By working with goals that are personally relevant to the patient the level of personal investment is maximised, thus potentiating behaviour change (Bandura, 1997). Mastery of these important behaviours is facilitated by regular contact with the HCP who provides feedback and support. This process is further supported by the provision of a workbook that contains medical information about the condition in lay language, and space for the patient to write in problem areas of asthma control, as well as their goals and strategies. This is an important component of implementing this type of intervention as the steps in the self-regulatory process are reinforced, through a written medium, and the workbook provides guidance for the patient both between visits to the HCP and at follow up appointments. Importantly, the strength of this model is that it enables the acquisition of process skills that empower the individual to modify his or her behaviour in order to achieve a desired change. The participant learns to break down a problem area of asthma control into its component parts, and then develops problem-solving skills in an explicit and structured fashion. This is done in a supportive environment in which personal rather than clinical relevance is paramount. It is in these aspects that the current study differs from asthma intervention studies conducted in the past. An asthma intervention was thus developed, based on a theoretical model of self-management of illness behaviour, and was implemented in a community pharmacy setting. The aim of this study was to evaluate this intervention in terms of its process (e.g. goal setting), clinical (e.g. asthma control) and psychosocial (e.g. asthma self-efficacy) outcomes.

This project tested a self-management model of illness behaviour in Australian community pharmacy and showed that this type of intervention has the potential to deliver significant health outcomes for the patient with asthma. Recently conducted studies in Australia indicate that pharmacists are well-placed to deliver interventions such as these, and that patients report high levels of satisfaction with such services (Blumenschein, Johannesson, Yokohama, & Freeman, 2001; Gallefoss & Bakke, 2000; Osman, Bond, Mackenzie, & Williams, 1999). Thus, community pharmacies may be an ideal environment in which to further explore the benefits of programs based on models of illness self-management. However, as leaders in the field of self-regulation have recently commented, continued research into this area is important because despite an extensive knowledge and research base, understanding the processes underlying health and illness behaviours requires further investigation ( Bandura, 2005; Carver & Scheier, 1998; Leventhal & Mora, 2005; Maes & Karoly, 2005). Future research could usefully focus on the interaction between levels of personal control and behaviour change on barriers to achieving optimal asthma self-management practices.