Asthma Self-Management Education Among Youths and Adults --- United States, 2003

Asthma is a prevalent chronic respiratory disease and major cause of morbidity in the United States (1). However, with appropriate medication, medical care, and self-management, most asthma symptoms are preventable (2). Recent evidence indicates that asthma self-management education is effective in improving outcomes of chronic asthma (3). Guidelines issued by the National Asthma Education and Prevention Program (NAEPP) specify essential components of asthma management, including patient education, objective monitoring of symptoms, and avoiding asthma triggers (3). Healthy People 2010 objectives include increasing the proportion of persons with asthma who receive formal patient education from 8% to 30% (objective 24-6) and who receive care according to NAEPP guidelines (objective 24-7) (4,5). The National Health Interview Survey (NHIS) routinely includes questions that assess asthma status. In 2003, the survey included a series of questions designed to reflect clinical best practices for asthma and to serve as a baseline assessment for progress toward national respiratory health objectives. These questions have not been repeated in any NHIS since 2003 but are scheduled to be included in the 2008 NHIS. To characterize asthma education among youths and adults with current asthma by selected demographic characteristics, CDC analyzed data from the 2003 NHIS. This report describes the results of that analysis, which indicated that the prevalence of asthma education varied by sex, age group, race/ethnicity, and health insurance status. The findings also suggest that a substantial proportion of youths and adults with current asthma lack the education necessary for effective self-management and control of asthma symptoms.

NHIS is an annual, in-person survey of the civilian, noninstitutionalized U.S. population based on a multistage sampling of households (6). A total of 43,101 sample adults and youths were included in the 2003 NHIS; an adult family member was selected to act as a proxy respondent for youths. Consistent with current Council of State and Territorial Epidemiologist recommendations, respondents were considered to have current asthma if they answered "yes" to both of the following questions: "Have you ever been told by a doctor or other health professional that you had asthma?" and "Do you still have asthma?" (7).

A supplement to the 2003 NHIS included a series of questions to assess components of effective asthma self-management (4). In that supplement, respondents were asked the following six questions regarding asthma self-management education: "Have you ever taken a course or class on how to manage asthma yourself?" "Has a doctor or other health professional ever given you an asthma management plan?" "Has a doctor or other health professional ever taught you how to monitor peak flow for daily therapy?" "Has a doctor or other health professional ever taught you how to recognize early signs or symptoms of an asthma episode?" "Has a doctor or other health professional ever taught you how to respond to episodes of asthma?" "Has a doctor or other health professional ever advised you to change things in your home, school, or work to improve your asthma?" Only respondents with current asthma who answered these questions are included in this report.

Prevalence estimates of asthma education for youths and adults by sex, age group, race/ethnicity, and health insurance status were calculated from the total number of respondents who reported current asthma. Samples were weighted to produce national estimates, and univariate and bivariate analyses were conducted; 95% confidence intervals were calculated, accounting for sample weights and complex sample design. Group differences (exclusive categories) were calculated by using chi-square tests; for insurance status (nonexclusive categories), pairwise differences between subgroups were determined using t tests. The significance level for all tests was p<0.05.

In 2003, an estimated 8.5% (n = 1,046) of U.S. youths (i.e., persons aged <17 years) and 6.4% (n = 2,048) of U.S. adults had current asthma. Overall, the prevalence of each component of asthma education analyzed in this report was significantly greater among youths than adults (Tables 1 and 2). The prevalence of various asthma education components for youths ranged from 40% who reported they had ever had an asthma management plan to 78% who reported they had ever been taught how to respond to an asthma attack (Table 1). Estimates for adults ranged from 12% who reported they had ever taken a class on asthma management to 65% who reported they had ever been taught how to respond to an asthma attack (Table 2).

Among youths, the prevalence of taking an asthma class or being taught to respond to an asthma attack was lower among non-Hispanic whites (12% and 76%) than among non-Hispanic blacks (23% and 80%, respectively) and other non-Hispanic races/ethnicities (21% and 92%, respectively). Among Hispanic youth subgroups, the only significant difference was in the proportion of persons taught to respond to an asthma attack (Mexicans, 69%, versus Puerto Ricans, 88%) (Table 1).

Among adults, significant differences were found by sex, by age group, and between Hispanic subgroups. The prevalence of asthma education for women was higher than that for men for four of six components: 1) ever had an asthma management plan, 2) taught to monitor peak flow, 3) taught how to respond to an asthma attack, and 4) advised to change aspects of home, school, or work. A greater proportion of persons aged 18--34 years, compared with persons aged >65 years, reported having been 1) taught how to respond to an asthma attack and 2) advised to change aspects of home, school, or work. A greater proportion of those aged 35--64 years had been taught to recognize early signs of an asthma attack, whereas a greater proportion of adults aged >65 years reported that they had an asthma management plan. Puerto Ricans reported significantly higher percentages for each component compared with Mexicans, with the exception of those who had ever taken a class on asthma management (Table 2).

No significant differences were observed in asthma education for youths by health insurance status. In contrast, a significantly higher proportion of adults with private insurance compared with those with no insurance reported 1) having ever had an asthma management plan, 2) being taught to monitor peak flow, 3) taking a class on asthma management, and 4) being taught how to respond to an asthma attack (Table 2). Adults with private health insurance had significantly higher proportions of asthma education than those with Medicare with regard to 1) being taught to recognize early signs of an asthma attack, 2) being taught how to respond to an asthma attack, and 3) being advised to change aspects of home, school, or work. Compared with those without health insurance, a higher proportion of people with Medicaid reported having an asthma management plan, and a higher proportion of adults with Medicare reported having an asthma management plan or taking a class on asthma management.

Reported by: ME King, PhD, RA Rudd, MSPH, Div of Environmental Hazards and Health Effects, National Center for Environmental Health, CDC.

Editorial Note:

The results of this study indicated that the prevalence of asthma self-management education among youths with current asthma was both higher and more consistent across all demographic groups when compared with adults with current asthma. Despite this finding, only 40% of youths had ever had an asthma management plan, and only 16% had taken a class on asthma management. For both youths and adults, substantial opportunities exist for improving asthma care through additional patient education and provider training according to national guidelines (4).

In 1997, the NAEPP expert panel of the National Heart, Lung, and Blood Institute issued best-practice guidelines for asthma care in the United States (3,5). According to these guidelines, every patient with asthma should have a written asthma management plan, including instructions for recognizing and responding to attacks. Patient and provider education for asthma self-management also should include information on methods for monitoring symptoms objectively using a peak-flow meter and for controlling exposure to environmental factors that can trigger asthma, such as tobacco smoke, cockroaches, cat and dog allergens, and dust mites (3,5).

The supplemental questions added to the 2003 NHIS reflect clinical activities recommended by NAEPP as essential components of asthma management (3). These clinical activities are the foundation of effective asthma care and the basis for Healthy People 2010 respiratory health objectives (4). Tracking disease-management indicators with surveys such as NHIS is a useful method for assessing the application of current clinical guidelines in the United States. The results of this analysis are similar to those from other studies (8,9) that have suggested national clinical care asthma guidelines are not being implemented adequately among persons with current asthma.

The findings in this report are subject to at least two limitations. First, although these 2003 data are the most recent data available and can be used to establish a historical baseline for asthma self-management at the national level, their date of collection precludes drawing definitive conclusions about asthma self-management practices in 2007. Second, respondents might have recalled asthma education inaccurately, resulting in an overestimation or underestimation of the actual prevalence of asthma education.

This report provides a preliminary picture of the prevalence of asthma self-management education in the United States, suggesting that the majority of adults and youths with current asthma would benefit from additional information and training. These findings can be used in coordination with state and local surveillance data to better identify asthma-related health disparities, to support asthma-control measures, and to provide a baseline for future studies. Asthma-control programs should work to improve the ability of health-care providers to provide asthma education and should support services based on NAEPP standards for patients. National trends in asthma education should continue to be monitored periodically to determine progress toward Healthy People 2010 objectives.

References

1. Mannino DM, Homa DM, Akinbami LJ, Moorman JE, Gwynn C, Redd SC. Surveillance for asthma---United States, 1980--1999. MMWR 2002;51(No. SS-01).
2. Sheffer AL, ed. Fatal asthma. New York, NY: Marcel Dekker; 1998.
3. National Institutes of Health, National Asthma Education and Prevention Program. Expert panel report 3: guidelines for the diagnosis and management of asthma. Expert panel report 3. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute; 2007. Available at http://www.nhlbi.nih.gov/guidelines/asthma/index.htm.
4. US Department of Health and Human Services. Healthy people 2010 (conference ed, in 2 vols). Washington, DC: US Department of Health and Human Services; 2000. Available at http://www.health.gov/healthypeople.
5. National Institutes of Health, National Asthma Education and Prevention Program. Expert panel report: guidelines for the diagnosis and management of asthma: update on selected topics 2002. Bethesda, MD: National Institutes of Health, National Heart, Lung, and Blood Institute;2002. Available at http://www.nhlbi.nih.gov/guidelines/archives/epr-2_upd/index.htm.
6. CDC. National Health Interview Survey: research for the 1995--2004 redesign. Hyattsville MD: CDC. Vital Health Stat 1999;2(126):1--129.
7. Council of State and Territorial Epidemiologists. Annual position statement 1998-EH/CD-1: asthma surveillance and case definition. Available at www.cste.org/ps/1998/1998-eh-cd-01.htm.
8. Gipson JS, Millard MW, Kennerly DA, Bokovoy J. Impact of the national asthma guidelines on internal medicine primary care and specialty practice. Proc (Bayl Univ Med Cent) 2000;13:407--12.
9. Cabana MD, Rand CS, Becher OJ, Rubin HR. Reasons for pediatrician nonadherence to asthma guidelines. Arch Pediatr Adolesc Med 2001;155:1057--62.

Table 1


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Table 2


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Date last reviewed: 9/5/2007