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Asthma Management: Barriers to Care

By Thomas J. Kallstrom

Often respiratory therapists find that their asthma patients don't comply with their asthma management program.   In this article in AARC Times, the respiratory therapist's professional publication, learn how therapists are recognizing and tackling barriers to care for asthma patients.

You would think that providing care and education to a patient or family member would be simple. But as respiratory therapists know, that is usually just not the case. There are so many intricacies to ensuring that the proper message is received by our patients. Once they go home and self manage, we lose a level of control over their asthma management; therefore, it is so important that we get it right during every interaction we have with them. Some of the barriers that need to be overcome are the patients’ ability to take basic asthma management knowledge and then to integrate it into their activities of daily living, literacy level, environmental triggers, support system, and, of course, economic concerns.

Literacy level
Literacy is a growing problem in the United States. It is wrong to assume that patients will understand all that we tell them and then be able to take that information and merge it into their activities of daily living. I found this to be true with an inner-city asthma disease management program I developed in Cleveland a few years ago.

Our program allowed a respiratory therapist to evaluate, educate, and intercede in the patient’s home. It was the home environment component that was critical to the success of the program. What we found was that patients with asthma who were asked to take an examination had a high level of knowledge of the disease. However, successfully communicating that knowledge was very difficult for many. Certainly this is not a literacy problem but more of a behavior management problem.

We were able to tailor a program that allowed us to take an educational concept and show patients and family members how that new piece of information could be implemented. A typical patient was one who had presented with severe asthma. She was an adult who was unable to manage her disease appropriately. In the year preceding the program, she had numerous unscheduled physician visits and ER visits, as well as a stay in the ICU. She had a peak flowmeter and was very proficient on how to use it. Her particular barrier was that she had no idea what to do with the reading she got, and she didn’t understand the zone concept. Her physician had only provided her with the device and taught her the technique, but not much beyond that. Realizing this, I developed a zone management plan and an action plan for her. Over time, she was able not only to master the action plan but also had concrete evidence in a diary that using the peak flowmeter actually allowed her to better gauge her condition. All it took was an asthma educator to walk her through the process. Her “barrier to care” was insufficient education, not necessarily low literacy.

Caregivers cannot just assume a person is literate. There are often telltale signs that could signal a lack of understanding when we educate the patient. A patient may refuse to read aloud a document in front of the asthma educator, perhaps giving the excuse that they forgot their glasses that day. Or a visual affirmation (e.g., a nod of the head) during the education that occurs at an inappropriate time is another sign that the patient is not necessarily perceiving the information being discussed. This is why patients should be asked to recap what was told to them so that the educator can be assured that the information was understood. If the patient has a lower literacy level, it is essential that the educator recognize this and adjust the message accordingly. Left ignored, there is a good chance that the patient not only will have a lower level of satisfaction of their care but also will be less likely to actually participate in the decisions of their ongoing care.1

Environmental triggers
Environmental triggers are another major health care concern for our patient with asthma. The first thing that needs to be done is to recognize what (if any) triggers reside in the home, school, or work environment. Commonly seen triggers are the presence of warm-blooded animals, dust mites, cockroaches, second-hand smoke, and molds. A cause-and-effect needs to be established, and allergy testing should be indicated. Once the offending substance is identified, the educator can then teach patients about it and offer remediation education.

Support system
Certainly, unless there is a support system for patients, they may have a more difficult time managing their disease.2 This support is generally a social support system like a parent or spouse. However, often, especially with the adult patient, the support may come from friends or neighbors. The key to success is a participatory social support system.

Economic concerns
One of the most difficult barriers to review with the patient is the cost of care. A large number of Americans no longer carry medical insurance or they have inadequate coverage. Even if a patient is covered, there may be economic decisions that need to be made regarding purchase of medications, delivery devices, monitoring devices, etc. If a patient has to pay “out of pocket” for a peak flowmeter or a spacer, it may not always be purchased. This is an area in which the asthma educator must work with patients and share with them local and national resources on how to obtain free or discounted medications and devices. It is important for the asthma educator to tell the patient about potential aid that they may be qualified to receive. The list of barriers certainly is much longer than the ones highlighted here, and they are specific to each patient. That is why it is important for the clinician to look for the obvious and not-soobvious signs that their patients have barriers to care. Perhaps by spending time with our patients, we can start to chip away at these persistent barriers or even remove them. •

References
1. Mancuso CA, Rincon M. Asthma patients’ assessments of health care and medical decision making: the role of health literacy. J Asthma 2006; 43(1):41-44.
2. Patterson R, McGrath KG. The “Peter Pan” syndrome and allergy practice: facilitating adherence through the use of social support. Allergy Asthma Proc 2000; 21(4):231-233.

Available resources
An asthma certification preparation course is available in Dallas, TX, Feb. 24-25. This popular course has prepared hundreds of respiratory therapists intending to take the National Asthma Education Certification Board (NAECB) exam. Other cities will be announced shortly. Log on to www.aarc.org for more information. Join the Asthma Disease Management Roundtable free at www.aarc.org/community/asthma_roundtable/ to network with other members interested in asthma care through an electronic mailing list.

About the author
Thomas J. Kallstrom, BS, RRT, AE-C, FAARC, is associate executive director and chief operating officer of the AARC. He is also a member of the NAEPP Coordinating Committee and is a certified asthma educator.