Letters

Guided self management plans for asthma

Advice should be simple and patient focused

Focus groups may not accurately reflect current attitudes

Focus on regular follow up and repeated education may be more productive

Partnership approach leads to effective self management

Authors' reply

Advice should be simple and patient focused

EDITORThe study of Jones et al on the views of health professionals and patients about guided self management plans for asthma may be open to misinterpretation.¹ They conclude from exploratory work with focus groups that attempts to introduce self guided management plans for asthma in primary care are unlikely to be successfula conclusion unsupported by evidence.

Patients are managing their own care but without help from healthcare professionals, a finding that is supported by recent interviews undertaken by the National Asthma Campaign, which showed significant asthma morbidity and only 6% of patients recalling any kind of written advice on how to take asthma treatment.² An Australian study found greater use of self management plans in primary care.³

What the research of Jones et al tells us is the size of the problem involved in encouraging some asthma nurses and primary care doctors to take on the challenge. But in the light of the evidence, we should not be daunted by that task.⁴ We need to empower, rather than simply seek to educate, patients. We need to overcome the belief that self management plans are complex (it is unclear from the paper what complexity of self management was portrayed to the study participants). And additional barriersthat self management is not appropriate for most patients and the belief that education alone is the key to successare also not supported by evidence.⁵

The "Be in Control" initiative that was launched by the National Asthma Campaign on 30 January 2001 is designed to make self management easier for busy healthcare professionals. It should meet the plea from doctors and asthma nurses in the study who believe that advice should be simple and patient focused rather than simply generic.

As far as patients are concerned, we see nothing new in this study but note important omissions. Responses about denial and non-compliance are already well known, with some of this knowledge coming from previous work from Jones et al. But we also know from the campaign's telephone helpline and other surveys that people with asthma dislike the uncertainty associated with the condition. How they are helped to address that provides an important route to gaining acceptance for proactive self management. Each patient requires an approach that recognises his or her own particular circumstance. Not everybody needs a detailed personal asthma action plan, but everybody does need to know what to do in the event of deteriorating control of their asthma.

Martyn Partridge, consultant chest physician. 
Chest Clinic, Whipps Cross Hospital, London E11 1NR

Greta Barnes, director. 
National Asthma and Respiratory Training Centre, Warwick CV34 4AB

David Price, professor of primary care respiratory medicine. 
General Practice Airways Group, Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Aberdeen AB25 2AY

Jack Barnes, director of Research and Policy. 
National Asthma Campaign, London N1 0NT

Focus groups may not accurately reflect current attitudes

EDITORJones et al concluded that neither health professionals nor patients were enthusiastic about guided self management plans for asthma.¹ We think that aspects of the method adopted by Jones et al may have biased the outcome of their study.

Focus groups may not be the most efficient way of gathering data when the subject area is complex or participants hold many different, opposing, and interrelated attitudes towards the subject.² Thus, participants who may have had positive attitudes towards self management of asthma care may not have voiced these views if most were airing negative attitudes.

Varied locations were used for meetings and responses of participants may well have been influenced by where the interview was held. Oppenheim says that examples of inappropriate places to conduct interviews include a pub.³ Holding group discussions on guided self management plans for asthma with asthma patients, nurses, or doctors in a public house seems dubious.

The vignettes used by Jones et al seem to be based on transcripts collected by the same authors in an earlier paper.⁴ However, all three vignettes seem negatively biased against the patient or at least biased against asthma management. Instead of, "I don't need an asthma clinic," a more positive alternative taken from the previous study could have been, "I don't need the doctor as long as the medication is working. I'd let him know if there was a problem." The apparent bias may have triggered attitudes in the doctors and nurses towards the typical non-compliant patient rather than self management plans themselves. In turn, the wording of the vignettes may have resulted in putting the patients on the defensive (an "us and them" situation) rather than extracting attitudes towards self management plans. Also, why was there no mention of guided self management plans in the vignettes?

Jones et al reported that participants were given an additional explanation of self management plans consistent with the guidelines from the British Thoracic Society. Feedback from one participating doctor indicates that this was perceived as complexthis could have influenced the attitudes of participants towards their usefulness. These methodological issues suggest that this study may not accurately reflect attitudes towards guided self management plans for asthma.

Jennifer Cleland, clinical lecturer. 
jen.cleland{at}abdn.ac.uk

Mandy Moffat, doctoral student. 
m.moffat{at}abdn.ac.uk Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Aberdeen AB25 2AY

Focus on regular follow up and repeated education may be more productive

EDITORJones et al report that general practitioners and asthma nurses are ambivalent about the value of self guided management plans for asthma.¹ It is noteworthy that the nurses stressed the importance of patient education and ongoing monitoring. The doctors also stressed the need for continuing education and dialogue. The doubts expressed by the doctors and nurses appear to relate to the value of self management plans that instruct the patients to adjust to their medication according to peak expiratory flows and symptoms.

This begs the question whether guided self management plans confer any benefit over intensive education and regular review. Gibson et al examined this question in a systematic review.² The combination of education, self management, and regular review was compared with usual care in 22 studies. Self management was associated with a reduction in the number of admissions to hospital, unscheduled visits to the doctor, days off work, and nocturnal asthma. It is not clear, however, from these studies, whether the benefit was due to intensive education and regular follow up as opposed to the self management plans.

This question can be addressed by studies where both groups have regular follow up and ongoing education and where the only difference between the two groups is the use of a guided self management plan. The few studies that have done this did not show any additional benefit from self management plans.^3-5 Ayres et al randomised 120 patients to dose adjustments made by a physician or to a self management plan.³ Both groups were seen at intervals of six weeks. At the end of six months there was no difference between the groups in symptoms or lung function.

The Grampian asthma study of integrated care (GRASSIC) study randomised 569 patients to conventional monitoring or self monitoring with a peak flow meter.⁴ The latter group was given guidelines on adjusting medicines according to their peak flow. All patients were reviewed at intervals of three months. At one year there was no difference between the groups in lung function, use of medication, or admissions to hospital. The views reported by Jones et al are supported by the published evidence. Selected patients may benefit from guided self management plans, but for the most part it may be more productive to focus on regular follow up and repeated education.

Peter Black, associate professor. 
Department of Medicine, University of Auckland, Private Bag 92019, Auckland, New Zealand

Partnership approach leads to effective self management

EDITORThe emerging challenge for health policymakers is to maintain the quality of life and functional capacity of those with a chronic illness, within economic constraints and despite system barriers. The organisation and principles of primary care seem ideally suited to adopting self management approaches in the care of people with chronic diseases. The study by Jones et al is important in raising several issues in relation to self management in primary care.¹ Their conclusions, however, must be viewed in the context of the chosen intervention and limitations of study design.

Jones et al point out that an ongoing partnership needs to be formed with patients, but they then trial a guided self management approach that is developed by clinicians and has little ownership by either the practitioners implementing the programme or the recipients of the programme.

Similarly, concepts such as compliance do not reflect patient centred medicine or a partnership approach, but rather a directed, traditional medical model approach. Compliance implies the extent to which a patient follows medications and recommendations.² Non-adherence should not be regarded as a defiant behaviour but as a person's conscious and often reasoned decision not to follow a prescriptive regimen or change a behaviour. In addition to the limitations inherent with this particular self management plan, the selected study design restricts the generalisability of the findings. In particular the finding that guided self management plans for adults with mild to moderate asthma are unlikely to be accepted or sustained in primary care needs to be interpreted cautiously.

Thoonen and van Weel in their editorial report that ownership of guidelines is essential to guaranteeing implementation.³ This is true not only for general practitioners and nurses, but also for patients. Criticism should be perhaps aimed at the fact that the self management intervention was a written guide that was not owned by any of those working together. Some patients do not want to self manage, but everyone should be given the opportunity if that is what they wish. The belief that healthcare providers can choose who will benefit is not substantiated by the literature. Approaches such as the transtheoretical model could benefit general practitioners and other healthcare professionals as it underscores the necessity to tailor programmes to the actual needs of patients through discussion with them to achieve the best outcome possible.⁴

What is ultimately necessary is not for the imposition of well intentioned externally designed plans, but rather the acquisition of skills and knowledge by providers and consumers that is supported by a self management culture that integrates with existing practice.

Pradeep Jayasuriya, acting medical director. 
pradeep.jayasuriya{at}racgp.org.au

Sally Roach, senior research officer. 
Linda Thoms, research officer. 
Royal Australian College of General Practitioners, WA Research Unit, Shenton Park, Western Australia 6010, Australia

Authors' reply

EDITORIn our paper we set out to seek the views of health professionals and patients on guided self management plans for asthma. We do not think that methodological flaws were incurred because of our use of focus groups. These have been widely used and developed in health services research,¹ and the National Asthma Campaign has released a video on focus group methods. The interaction between participants makes them especially appropriate for the study of attitudes and experiences around specific topics.

Successful focus groups are facilitated by skilful moderation in congenial settings.² For some patients this was a quiet back room in a public house. The vignettes used the actual words employed by the respondents in our earlier work where there was no mention of guided self management plans. In all cases, the topic had to be directly raised by the moderator, which reflects both limited experience of guided self management plans and the perception that they were essentially phenomenon encountered in secondary care.

What we found was a fundamental mismatch between the views of the health professionals and patients. The key issue now is how to address this, and most of the correspondence seems to allude to this. The recently launched initiative by the National Asthma Campaign, "Be in Control," will help to simplify the task , but we need to take this further. We need to pilot and develop a guided self management plan that is developed in a patient centred model, rather than one designed in a medical model (the only ones currently available). The information balance between patients and health professionals is recognised in this study; technical knowledge resides in one party (a doctor or nurse) and preference resides in the other (the patient). Sharing information alone is, however, not sufficient, and this is not synonymous with sharing decisions. They are separate goals within the consultation and require different skills.²

Risk communication is vital in asthma care, and this requires an open two way exchange of information and opinion about risk, so that management decisions can be based on better understanding of the options and outcomes.³ This process is unlikely to occur within the predominantly doctor centred model of asthma care, and the process of shared decision making is integral to the wider concept of a patient centred approach within the consultation.⁴ We need to work together in developing and testing ongoing programmes of research using a patient centred approach to guided self management in asthma. This has already worked successfully in diabetes care, and recent evidence suggests that patients want a patient centred approach. ^{5 6} Now is the time to use existing knowledge and skills to empower patients as well as arming the all important asthma nurses with the tools for the job.

Alan Jones, senior lecturer. 
University of Wales College of Medicine, Gorseinon General Practice Research Unit, Swansea SA4 2US

Roisin Pill, professor. 
Department of General Practice, University of Wales College of Medicine, Health Centre, Cardiff CF23 9PN

Stephanie Adams, lecturer. 
School of Social Science and International Development, University of Swansea, Swansea SA2 8PP

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