METHODS TO ASSESS ASTHMA

SELF-REGULATION IN FEMALE
PATIENTS

Noreen M. Clark, Molly Z. Gong, Melissa A. Valerio,

Jimmy Yu, Xihong Lin, William F. Bria, Timothy B. Johnson

Supported by NHLBI Grant HL60884

May 22, 2001
 BACKGROUND
Recent research suggests that self-
regulatory management of asthma follows a
sequential path.
A four-phase model of self-regulatory control
of asthma was assessed in our research,
using a qualitative data collection instrument,
the Asthma Self-Regulatory Development
Interview (ASRDI), used by Zimmerman and
colleagues (1997).
 PURPOSE
The general purpose of the study
was to examine whether the ASRDI
and four-phase model of self-
regulation development used in
childhood asthma could be used to
assess self-regulation in women
with asthma.
 AIMS
• assess asthma self-regulation phases using the ASRDI
• explore modifying the ASRDI from a qualitative research
instrument to a quantitative one
• evaluate the modified self-regulation assessment scale
 SAMPLE

Data were collected by telephone from a

total of 100 women,18 years of age or
older, with a diagnosis of asthma.
 Ethnicity & Age
>70 years
1%
African - < 20
American Other 1%
20 - 30
6%
5% 61 - 70
6%
13%
31 - 40
White 51-60 23%
89%
30% 41-50
26%
 Annual Household Income
& Education
< High School
Grad 2%
< 20 K
> 100 K 10% Post Grad
21% 17%
20 - 40 K High School
20% Grad 29%
80 - 100 K
13% 4 Years
40 - 60 K College 2 Years
60 - 80 K 19% 34% College
17% 18%
 Marital & Working
Widowed
Status
3%

Single At
14% Home
21%
Divorced Full
10% Time
Part 52%
Time
Married 27%
73%
Medical Insurance
2%

Yes

No
98%
 METHODS

1. Assessed women’s asthma

self-regulation phases using the
Asthma Self-Regulatory
Development Interview (ASRDI)
THE FOUR PHASES OF ASTHMA
SELF-REGULATION
(Zimmerman et al.)

Phase I - Asthma Avoidance

Phase II - Asthma Acceptance
Phase III - Asthma Compliance
Phase IV - Asthma Self-Regulation
 Phase I – Asthma Avoidance:
Less than three of the items in Phase II were passed
Scoring Criteria
Phase ASRDI items
PASS FAIL
1. Do you ever worry that you may not
be able to get to the doctor or Any mention of Fail to indicate
II hospital in time to get the care you worry worry
need for asthma? Why or why not?

2. Do you feel that your asthma restricts

daily activities or prevents you from
Any mention of Fail to indicate
II being able to do the things you would
restrictions asthma restrictions
like to do? Please explain.

Fail to indicate that

asthma is
3. How serious can your asthma be? Mention limitation
potentially life
II Please explain. in lives or long-
threatening or has
term consequences
potential long-term
consequences
4. Do you feel that your asthma could
possibly be life threatening if Agree that asthma Disagreement that
II nothing is done to treat it? Why or can be life asthma could be life
why not? threatening threatening

Phase II – Asthma Acceptance:

Three or all of the four items in Phase II were passed
 Scoring Criteria
Phase ASRDI items
PASS FAIL
1. How important is it for you to Indicate that the Fail to indicate that
have regularly scheduled patient keeps the patient keeps
III appointments with the doctor regularly scheduled regularly scheduled
for your asthma? Why? doctor visits doctor visits

2. How important is it to take all Fail to indicate

the medicines at the exact adherence to the
III dosage that the doctor has
Indicate adherence
prescribed
prescribed? Why? medicine

3. If the asthma medicine that

Indicate Fail to indicate
the doctor prescribes doesn’t
consultation with consultation with
III seem to help you, how
the doctor for the doctor before
important is it to continue
alterations changing medicine
taking it? Why?

Phase III - Asthma Compliance:

Two or all of the three items in Phase III were passed
 Scoring Criteria
Phase ASRDI items PASS FAIL
1. Do you have any special method to Specify early symptoms Fail to specify early
IV check for early signs of an oncoming of an attack symptoms of an
asthma attack? What is it? attack
Specify the rescue
2. Do you have any special procedure
medicines that must be Fail to specify the
IV that you follow starting at the first sign
administered at the first rescue medicines
of an asthma attach? What is it?
sign of an attack

3. Do you have a systematic plan to Stepped plans that have Fail to indicate a
adjust your medicine if the pattern of been worked out with the stepped medication
IV your symptoms gets better or worse? doctor plan with the doctor
What is it?

4. Do you have any special procedure for Indicate the necessity if Fail to indicate the
observing changes in your symptoms personally monitoring necessity if
IV after you take asthma medicine? What specific symptoms personally
is it? monitoring specific
symptoms
Phase IV – Asthma Self-Regulation:
Three or all of the four items in Phase IV were passed
Two differences were identified when
using ASRDI to measure self-
regulation phases in women with
asthma versus children with asthma.
1. The four self-regulatory phases are not as
sequential in women with asthma as in
children with asthma. Over 25% of the
women who correctly answered questions
related to a higher ASRDI phase did not pass
a lower or previous phase.
Examples of Women’s Scores and Phases
Phase Subject Subject Subject Subject Subject Subject Subject Subject
1 2 3 4 5 6 7 8
0 1 1 0 0 0 0 0
1 1 0 1 0 0 0 0
I/II
0 1 1 1 0 0 0 1
0 1 1 1 1 1 0 0
0 0 1 0 1 1 0 0
III 1 0 1 1 1 0 1 1
0 0 1 1 1 1 1 1
0 0 0 1 1 0 1 0
0 1 1 0 1 1 1 0
IV
0 1 0 1 1 1 0 0
0 0 1 1 0 0 1 0
Phase I II III IV I or V? I or II? I or IV? I or III?
Total
2 6 8 8 7 5 5 3
Score
2. When using the ASRDI with
women versus children, some
responses could not be clearly
scored as ‘pass’ or ‘fail’ only. Finer
levels of classification of ASRDI
responses appear to be needed for
women with asthma.
 Example 1 - First item in Phase I or II
Do you ever worry that you may not be able to get to the doctor or
hospital in time to get the care you need for asthma? Why or why
not?
Yes/ No Responses Comments
“The rescue inhalers have Clearly responds not
No always worked.” worried
“I had a very bad attack two Clearly responds
Yes years ago and did not know worried
what brought it up.”
“I haven’t had anything really Does not clearly
No bad happen. So, I try not to respond (worried or not
worry.” worried)
Did not “I was worried when I had one Does not clearly
answer real bad attack. I am not respond (worried or not
with worried because I know what to worried)
yes/ no do. I ’d call the doctor or
ambulance.”
 Example 2 - Third item in Phase III

If the asthma medicine that the doctor prescribes doesn’t seem to help
you, how important is it to continue taking it? Why?

How Why? Comments

important
“Will continue to take medicine A good response
Very until I can get to the doctor’s reflecting a ‘Yes’
office to change it.”

“If it’s not working, I just won’t A clear response of ‘No’

Not at all
take it.”

“I’d keep increasing dosage Not a correct 'Yes'

Very response
until it works.”

“I’d continue (taking it) because

Kind of of hope that it would make me An unclear response
feel better eventually.”
To allow for greater variation in
responses, we developed a Numerical
Coding and Scoring System. We
classified responses into five categories,
from the most self-regulatory-like
response (5) to the least (1), for each
item in each phase.
NUMERICAL CODING & SCORING
SYSTEM

Women Numerical Coding and

Scoring System
Phase Lowest Highest
I/II 4 20

III 3 15

IV 4 20

Overall 11 55
 Codes - First item in Phase I or II

Do you every worry that you may not be able to get to the
Code doctor or hospital in time to get the care you need for
asthma? Why or why not?
Very worried – Cannot breathe. Have no control over
5 asthma. Health services not quickly available or easy to get
to.
Worried – If do not have medicines with them or if it a bad
4 time of the year for their asthma, including bad seasons.
Somewhat worried – Know asthma can be serious.
3 Currently not very worried because think their asthma is
managed or controlled.

2 A little worried – Try not to worry about asthma.

Not at all worried – Asthma is never that bad. Don’t need
1 ER.
 Codes - Third item in Phase III
If the asthma medicine that the doctor prescribes doesn’t
Code seem to help you, how important is it to continue taking it?
Why?

Very important - continue taking it until to consult with the

5
doctor

Important - some medicine takes time to work. Hope it’ll

4
work eventually. Did not mention to consult the doctor.

Somehow - depends, not sure, why the medicine does not

work, try to find a reason: other triggers? Cold? Did not
3
say to continue take it or did not mention to consult the
doctor. Or stop taking it before talk to the doctor.

2 Stop taking it with some reasons, such as, side effects

Stop taking it. Switch to another medicine without
1
consultation with the doctor.
DATA ANALYSIS

&

RESULTS
 Factor Analysis

Num e r ica l
Coding &
ASRDI Fa ct or 1 Fa ct or 2 Fa ctor 3 Fa ctor 1 Fa ctor 2 Fa ct or 3
Scor ing
Syst e m

II.2 0.80411 -0.15622 -0.25349 II. 3 0.78404 0.17264 0.07457

II.1 0.69494 -0.0443 0.01539 II. 1 0.77724 0.04207 0.21302
II.4 0.57099 0.08623 0.19139 II. 4 0.76145 0.2568 0.16061
II. 3 0.46137 0.19424 0.29325 II. 2 0.72635 0.0223 0.12186
III. 3 0.43487 0.0963 0.21474 III. 2 0.20709 -0.00526 0.79616
IV. 1 -0.22655 0.7439 -0.01231 III. 1 0.31751 0.09742 0.69602
IV. 4 0.00785 0.6937 0.02812 III. 3 -0.01433 0.39476 0.65492
IV. 3 0.09031 0.67229 -0.20705 IV. 1 0.12502 0.76096 0.03904
IV. 2 0.27989 0.5232 0.07509 IV. 2 0.27862 0.7458 0.05785
III. 1 -0.01021 -0.08755 0.80413 IV. 3 0.02122 0.71295 0.06317
III. 2 -0.0002 -0.07203 0.79289 IV. 4 0.07112 0.69839 0.2556
 Association between women’s asthma
regulation phases and asthma outcomes
using the ASRDI scoring system:

ASRDI Number of Number of Overall score Number of ED Overall score of

nighttime gender related of visits in the quality of life
Scoring symptoms problems management past 12 months
System behavior

Phase N Age Mean SD Mean SD Mean SD Mean SD Mean SD

1 46 46.4 31.87 56.64 3.96 2.54 88.11 27.61 0.065 0.25 24.59 7.55

2 4 39.8 25.25 21.65 4.5 4.04 27.89 1.77 1.25 1.89 32.00 3.37

3 21 47.4 60.81 32.75 6.67 3.04 102.62 24.02 0.52 0.98 42.86 11.36

4 28 49.7 43.21 35.00 5.66 2.88 128.59 17.09 0.69 1.17 38.17 10.93

p-values (ANOVA) 0.1056 0.0024 0.0001 0.0034 0.0001

 Association between women’s asthma
regulation phases and asthma outcomes
using the new coding system:

New Number of Number of Overall score Number of ED Overall score of

nighttime gender related of visits in the quality of life
Coding symptoms problems management past 12 months
System behavior

Phase N Age Mean SD Mean SD Mean SD Mean SD Mean SD

1 25 45 34.2 72.87 3.76 2.65 80.56 23.01 0 NA 23.92 6.12

2 24 46.6 37.08 31.15 4.71 3.22 84.54 24.32 0.5 1.142 29.71 11.49

3 37 48.5 51.47 37.55 5.58 2.66 117.76 18.21 0.47 0.951 37.13 12.13

4 13 49.4 30.46 21.78 6.54 3.23 137.46 15.73 0.69 1.032 42.08 10.00

p-values (ANOVA) 0.3531 0.0214 0.0001 0.0794 0.0001

 Further Quantitative Plan

Phase ASRDI items Closed Question Responses

5 4 3 2 1
1. Do you worry that
you may not be able
to get to the doctor Some- Not at
Very A little
I/II or hospital in time to
worried
Worried what
worried
all
get the care you worried worried
need for asthma?

3. If the asthma
medicine that the
doctor prescribes Some- Not at
A little
doesn’t seem to help Very what all
III you, how important important
Important
impor-
impor-
impor-
tant
is it to continue tant tant
taking it until you
contact your doctor?
TENTATIVE CONCLUSIONS
1. The four-phase self-regulation model
and asthma self-regulatory development
interview items can be adapted to
assess self-regulation in women with
asthma.
2. The modified quantitative scoring
system can be both effective and
efficient to assess self-regulation in
women with asthma.