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Importance of education in bronchial asthma treatment - gender differences

Article  in  Pneumonologia i alergologia polska: organ Polskiego Towarzystwa Ftyzjopneumonologicznego, Polskiego Towarzystwa Alergologicznego, i Instytutu Gruzlicy i Chorob Pluc ·
September 2015
DOI: 10.5603/PiAP.2015.0055

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 ORIGINAL RESEARCH

Beata Jankowska-Polańska 1, Justyna Pleśniak 2, Mariola Seń 2, Izabella Uchmanowicz 1,

Joanna Rosińczuk 3
1
Clinical Nursing Division, Public Health Faculty, Medical University of Wrocław, Poland
2
Department of Health Promotion, Public Health Faculty, Medical University of Wrocław, Poland
3
Department of Nervous System Diseases, Public Health Faculty, Medical University of Wrocław, Poland

Importance of education in bronchial asthma treatment

— gender differences
The authors declare no financial disclosure

Abstract
Introduction: Despite significant progress in understanding mechanisms and effective treatment there are still therapeutic failures
in patients treated for bronchial asthma. Education is vital in the therapeutic process. It improves the control of the disease at the
individual level by influencing the adherence and compliance.
Material and methods: The study included 100 patients suffering from bronchial asthma and treated according to GINA 2002
guidelines in Allergy Clinic. Asthma control test (ACT), analysis of patients’ medical documentation and a self-constructed qu-
estionnaire concerning health promotion and education were used in the study.
Aim of this work was to assess differences in the influence of education on results of bronchial asthma control between sexes.
Results: Average duration of asthma was similar in women and men (13.0 ± 11.16 vs.12.7 ± 9.74 years). Weaker asthma
control was found in women (ACT 17.7 vs. 20.4), as well as lower FEV1 values (80−50% of predicted value in 60.3% of women
vs. 43.25 of men). In women an analysis of correlation concerning patients’ knowledge and conducted health education with
asthma control revealed a statistically significant positive correlation of knowledge acquired from the allergologist with asthma
control, information about proceeding in acute attack, whereas negative correlation with asthma control with knowledge passed
on by family doctor was found. Among the male respondents positive correlations of knowledge with asthma control within the
scope of knowledge from allergologist and information concerning proceeding in asthmatic attack were found, while negative
correlation with information coming from family doctor was revealed.
Conclusions: Health education in patients with asthma should be conducted by a specialist in allergic diseases and well-prepared
healthcare professionals.

Key words: asthma control test, effective treatment, quality of life

Pneumonol Alergol Pol 2015; 83: 341–347

Introduction Although new mechanisms of treatment

have been discovered and the effects of bronchial
The second half of the 20 th century was asthma treatment have significantly improved,
marked by a disturbing increase in frequency of in many cases the administered therapy remains
allergic diseases, including bronchial asthma. ineffective. Many observations have shown that
Today, allergic diseases affect approximately the effects will not improve unless patient educa-
20 percent of the global population, and the rate tion and cooperation become the element of the
of bronchial asthma amongst adults is 5.4 percent treatment process. It is very important to educate
(4.9% in men and 5.8% in women) [1]. patients so that they and their family members

Address for correspondence: Beata Jankowska-Polańska, ul. Bartla 5, 51–618 Wrocław, e-mail: [email protected], tel. 79 347 70 07
DOI: 10.5603/PiAP.2015.0055
Received: 11.11.2014
Copyright © 2015 PTChP
ISSN 0867–7077

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Pneumonologia i Alergologia Polska 2015, vol. 83, no. 5, pages 341–347

are able to eliminate improper practices, which plement uniform diagnostic, prophylactic and
often lead to otherwise preventable misevalua- treatment standards combined with the latest
tion of danger, delayed rescue and, ultimately, asthma research findings). The study measure-
fatal events, including death. An effective and ment tool was the specific Asthma Quality of Life
control-improving form of training requires in- Questionnaire (AQLQ (S)), Asthma Control Test
dividual cooperation with the patient, outlining (ACT), and own questionnaire for the assessment
the treatment plan and encouraging the patient of the level of patients’ knowledge and education
to a  guided self-treatment. Factors determining regarding their disease. The several-point scale of
a successful treatment include partnership, trust the AQLQ questionnaire enables the evaluation of
and good communication. The principal element physical activity of asthma patients, their ability
of education is to teach the patient to actively to avoid factors inducing shortness of breath,
participate in the treatment process and to switch night symptoms, fear of missing medications,
from being passive to active. The latest findings effects of symptoms on everyday life activities.
suggest that physician-patient partnership, mu- The questionnaire is composed of 32 questions on
tual understanding and individual and well- a 7-point scale, where 1 means maximum symp-
-discussed treatment plan significantly improve toms exacerbation or severely impaired function,
the course and control of the disease [2]. and 7 means that a function has not been impaired
Evaluation of treatment results based only at all. The total result of life quality assessment
on biological criteria has proved insufficient, and is expressed as the average from all questions [4].
the area of medical interest has expanded beyond Asthma Control Test is validated and widely
purely traditional medicine, to include also such used in every day clinical practice. The test in-
health measurements as those indicating the ac- cludes five questions measured in a 5-point scale.
tivity of patients in different life domains. The They assess asthma symptoms and medication
interest in quality of life stems from modernised utilization in the last four weeks [5].
approach to medicine, where the improved level The questionnaire regarding the level of
of functioning and self-assessment are equally knowledge and education was composed of
important or even more important than just the 6 questions, and allowed to evaluate the extent
effectiveness of therapy. These studies helped to to which the patient understands his/her dis-
understand that not only the classic, quantitative ease and knows the principles of self-treatment
therapeutic success indicators, such as survival and self-care and who and how often give them
rate, but also the qualitative parameters, such as medical information about asthma, ability to
symptoms frequency reduction, improved mood, cope with the disease, source of knowledge,
better psychological and physical status are clin- information received during out-patient visit
ically important [3]. A  better understanding of and circumstances to obtain information about
the influence of education, socio-demographic asthma. Survey also included socio-demographic
and clinical factors on the patient may determine data such as gender, age, marital status, financial
the most optimal method of bronchial asthma situation, professional, education, place of resi-
treatment and control. dence, factors affecting asthma and analysis of
The aim of the study was to evaluate gender medical records, allowing to collect clinical data
differences regarding the effect of education on of the patient. When using quality of life ques-
bronchial asthma control and quality of life. tionnaires it is possible to evaluate the subjective
dimension of health status. Quality of life is
Material and methods a measurable subjective criterion and an element
of medical technology. Studies of the quality of
For conducting the research a  permission life, which have now been performed on the basis
of Bioethics Committee of the Wroclaw Medical of standardised questionnaires for approximately
University No. 722/2012 was obtained. The study 10 years, have become a recognised tool in medical
evaluated a group of 100 patients with bronchial research. This stems from the need to obtain the
asthma, aged 18 to 80 years, under follow up fullest, quantifiable result of the patient’s health
at the specialist allergy outpatient clinics. The status. The statistical analysis was supported by
study covered a period from September 2009 to Microsoft Excel in combination with the Statis-
February 2010. One of the inclusion criteria was tica 9 PL package, and the following methods of
chronic anti-inflammatory treatment, in accor- statistical analysis were used: to test significance
dance with the GINA 2002 guidelines (Global — Student’s t-test for unrelated variables and Chi-
Initiative for Asthma; the main goal was to im- squared test for independent features; to test the

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 Beata Jankowska-Polańska et al., Education in the treatment of bronchial asthma

effect of independent variables on quality of life

Table 1. General and demographic statistics
factors — multiple regression; to determine the
correlation between independent variables and All Women Men p
asthma control — Pearson’s linear correlation test. subjects
The main inclusion criteria were signed informed No. of patients 100% 63% 37%
consent form and a  clinical condition allowing
Age (years) 0.09
unassisted completion of the questionnaire. Each
subject was assured of anonymity and informed Average 45.0 47.1 41.4
of the study purpose. SD 16.34 14.88 18.21
Education 0.32
Results Primary 12.% 11.11% 13.51%
Occupational 19.% 20.63% 16.22%
The study enrolled 63% of women (average
Secondary 33.% 26.98% 43.24%
age 47.1 ± 14.9 years, the average age of men was
41.4 ± 18.2 years. The main sociodemographic Higher 36.% 41.27% 27.03%
statistics characterising the subjects are presented Place of residence 0.79
in Table 1. Country 16.% 17.46% 13.51%
City/town 84.0% 82.54% 86.49%
Clinical analysis 2
BMI [kg/m ] 0,12
The average duration of asthma was similar
in women and men (13.0 ± 11.2 vs. 12.7 ± 9.7 Average 26.5 26.4 26.6
years, but the rate of acute events was higher SD 4.43 4.75 3.9
in women, respectively: everyday, including at Smoking 0.3
night 11.5% of women vs. 2.7% of men, and 3–4 No 57.% 61.9% 48.65%
times a week 12.7% of women vs. 8.1% of men.
Quit 30.% 28.57% 32.43%
The interviewed women scored lower in asthma
control (17.7 ± 5.2 vs. 20.4 ± 3.6) and had lower Yes 13.% 9.52% 18.92%
FEV1 values (80–50% of predicted value in 60.3% Years of smoking 0.46
of women vs. 43.25% of men). Results are pre- Average 14.2 13.3 15.5
sented in Table 2.
SD 9.7 8.53 11.13
The analysis of the level of knowledge of
asthma revealed that women were more informed No. of smoked 0.03
cigarettes [pcs]
than men. 61.9% women vs. 54.05% men think
to know enough about their asthma disease. Suf- Average 14.0 11.9 16.6
ficient information allowing the patient to cope SD 7.08 6.63 6.91
with the disease was found in 72% (73% women SD — standard deviation
vs. 70% men) of respondents, with the main
source of information from an allergist (94%),
the media (39%), and brochures and magazines a family practitioner (rxy < −0.36) and the media
(70%). 85,71% women and 70.27% men are aware (rxy < −0.26). Amongst the interviewed men a pos-
that more they know about the disease the better itive correlation of knowledge and asthma control
they control asthma symptoms. Unfortunately were found with regards to: knowledge obtained
only less than half of patients receive information from an allergologist (rxy < 0.40), education in
during each visit. Almost 16% women and 21% the principles of asthma and its mechanisms
men state that they have never been educated on (r xy < 0.38), and information on treatment in
asthma. Results are presented in Table 3. case of asthma attack (rxy < 0.31), and a negative
Correlation analysis regarding patients’ correlation with the knowledge obtained from
knowledge and health-related education with a  family practitioner (rxy < −0.42). Results are
asthma control in women has shown a statistical- presented in Table 4.
ly significant positive correlation of knowledge The analysis of quality of life based on asth-
obtained from an allergologist with asthma con- ma severity and its control showed that the se-
trol (rxy < 0.40), information regarding treatment verity of asthma was positively correlated with
in case of acute asthma attack (rxy < 0.36), and asthma control test, especially in the interviewed
a  negative correlation with asthma control was women (rxy < 0.42). The milder asthma symptoms
observed with the knowledge obtained from were, the better scores were achieved in the Asth-

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Pneumonologia i Alergologia Polska 2015, vol. 83, no. 5, pages 341–347

Table 2. Clinical characteristics of subjects

All subjects Women Men p

Years of disease 0.92
Average 12.9 13.0 12.7
SD 10.61 11.16 9.74
Asthma Control Test (ACT) 0.003
average 18.7 17.7 20.4
SD 4.88 5.24 3.65
No. of acute events
Everyday, incl. at night 23.% 30.06% 10.18%
3, 4 times a week 27.% 30.16% 21.62% 0.02
Once a week 20.% 17.46% 24.32%
Once a month or less 30.% 22.22% 43.25%
Main symptoms
Shortness of breath during a day 66.% 68.25% 62.16%
Morning cough 29.% 26.98% 32.43% 0.82
Waking-up at night due to shortness of breath 5.% 4.76% 5.41%
Visits in allergy outpatient clinic 0.43
2 times a month 10.% 12.7% 5.41%
Once a month 29.% 30.16% 27.03%
6 times a year 28.% 30.16% 24.32%
3 times a year 21.% 15.87% 29.73%
Less 12.% 11.11% 13.51%
Hospitalisation 0.84
1−2 times 39.% 41.27% 35.14%
3−5 times 6.% 6.35% 5.41%
6−10 times 4.% 3.17% 5.41%
More 4.% 3.17% 5.41%
FEV1/FVC 0.025
average 79.47 77.4 83
SD 12.17 11.71 12.28
FEV1 — acc. to category
> 80 46% 38.1% 56.76% 0.07
50–80 54% 60.32% 43.24% 0.1

ma Control Test. Positive correlation in women Discussion

was also found between asthma severity and the
quality of life evaluated by AQLQ in the follow- The patient with asthma should receive
ing domains: symptoms (rxy < 0.42), limitation of written information on how the doses of the pre-
activity (rxy < 0.33), and emotional functioning (rxy scribed medications can be changed and to what
< 0.33). The milder asthma symptoms, the better extent. Self-control should never discharge the
scores were achieved in particular domains. No patient from following the basic rules, in partic-
correlation was observed between the severity of ular from attending the scheduled consultations
asthma or asthma control test and the quality of with an allergist, from regularly taking the med-
life in the interviewed men. Results are presented ications in doses prescribed during a visit or in
in Table 5. the self-control plan.

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 Beata Jankowska-Polańska et al., Education in the treatment of bronchial asthma

Table 3. Patients knowledge assessment and sources of its obtaining

  All Female Male p

Assessment of knowledge on the nature of asthma 0,41
High level of knowledge 59% 61.9% 54.05%
Average level of knowledge 25% 20.63% 32.43%
Lack of knowledge 16% 17.46% 13.51%
Ability to cope with the disease 0.27
Sufficient 72% 73.02% 70.27%
Average 18% 20.63% 13.51%
Lack of skills 9% 6.35% 15.21%
Source of knowledge
Allergologist 94% 93.65% 94.59% 0.85
Family doctor 26% 28.57% 21.62% 0.44
Nurse 11% 12.7% 8.11% 0.48
Media 39% 36.51% 43.24% 0.5
Magazine/brochure 70% 44.44% 45.95% 0.03
Other sources 16% 17.46% 13.51% 0.46
The impact of knowledge for life of the patient with asthma 0.13
Increases control symptoms 80% 85.71% 70.27%
Has no effect on the treatment 5% 4.76% 5.41%
I have no opinion 15% 9.52% 24.32%
Circumstances to obtain information about asthma 0.65
During a visit to the clinic 48% 49.21% 45.95%
Occasionally (depending on the visit) 32% 31.75% 32.43%
Nobody told me about the management of asthma 18% 15.87% 21.62%
Receives information only when I ask 2% 3.17% 0
Information received during out-patient visit about:
Principles of the treatment 57% 53.97% 62.16% 0.34
Living with chronic disease 51% 49.21% 54.05% 0.64
Using inhaled drug. 67% 73.02% 56.76% 0.1
Lifestyle modification 43% 42.86% 43.24% 0.97

The more the patient knows about the dis- We have found that quite a large population
ease, the better he/she can cooperate with the of asthma patients lives in urban areas. Other
therapeutic team and is able to help himself/ important factor influencing the course of the dis-
/herself to control the symptoms more effective- ease in our patients is smoking. The average du-
ly [6]. One of the most important elements of ration of smoking was 14.2 years and the average
self-treatment is to be able to quickly react in case number of smoked cigarettes was 14. Jassem [8]
of severe exacerbation. suggests that smoking may have a  pro-allergic
In our study the largest cohort were women and pro-inflammatory effect, as it damages the
(63%). According to the authors of “PTA and bronchial epithelium and impairs local protection
PTF Expert Panel Report” 2006, the prognosis for mechanisms. The negative impact of smoking
asthma is worse when the first onset of symptoms includes also its effect on molecular mechanisms
occurs during or after puberty, which happens inhibiting the beneficial effect of inhaled gluco-
more often in women [7]. corticosteroids.

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Pneumonologia i Alergologia Polska 2015, vol. 83, no. 5, pages 341–347

disable who fail to cooperate with the physician is an

Table 4. Correlations between health promotion, educa-
especially serious problem in the context of proper
tion and asthma control in men and women
use of inhaled medications that are the first-choice
Asthma control of asthma treatment [7]. Another important factor
which may affect asthma control in these patients is
All Women Men poor socioeconomic status, and the fact that because
subjects
of high medication prices they can afford only some
Knowledge of how to cope 0.04 0.08 −0.12 of the prescribed medications.
with asthma
Quality of life assessment amongst the respon-
Knowledge from allergologist 0.12 0.40* 0.40* dents revealed higher quality of life scores for men
Knowledge from family −0.37* −0.36* −0.42* than women. This may be due to comorbidity, higher
practitioner rate of symptoms exacerbation, and the resulting
Knowledge from a nurse −0.22 −0.23 −0.15 poorer asthma control in women. The analysis
Knowledge from the media −0.21* −0.26* −0.19 of the level of knowledge of asthma revealed that
Knowledge from brochures −0.17 −0.11 −0.17 women were more informed than men. Sufficient
and magazines information allowing the patient to cope with the
Education in asthma 0.12 0.02 0.38* disease was observed in 72% of respondents, with
principles the main source of information being an allergist
Education in treatment 0.11* 0.36* 0.31* (94%), the media (39%), brochures (38%), and
in case of asthma attack magazines (32%). The correlation analysis of knowl-
Education in the usage 0.00 0.07 0.02 edge and health education with asthma control has
of inhalation medications shown a statistically significant positive correla-
Education in lifestyle −0.09 −0.05 −0.21 tion of knowledge obtained from an allergist with
* indicates statistically significant values asthma control, information regarding treatment
in case of acute asthma attack both in men and
women, and a  negative correlation with asthma
Table 5. Correlations between asthma severity, quality control was found with knowledge obtained from
of life and asthma control in men and women a family practitioner and the media amongst both
men and women. This may be due to the fact that
Asthma severity the information provided by family practitioners is
All Women Men incomplete. Early diagnosis and asthma prophylaxis
subjects are the main goals of treatment but they may be
Asthma Control Test 0.35* 0.42* 0.23 achieved only if family practitioners are included
Symptoms (AQLQ) 0.32* 0.42* 0.16
in the treatment process. Rising asthma rates should
motivate family practitioners to become more alert
Limitation of Activity (AQLQ) 0.21* 0.33* 0.00
during regular patient visits, and more especially
Emotional functioning (AQLQ) 0.25* 0.33* 0.11 so because patients rarely suspect their symp-
Environmental stimuli (AQLQ) 0.14 0.22 0.02 toms of being asthma-related. Steciwko et al. [10]
* indicates statistically significant values; AQLQ — Asthma Quality of Life are advocates of continuous skills improvement
Questionnaire
of family practitioners regarding allergic diseases,
asthma and the methods of treatment in accordance
Patients often do suffer from very low self-es- with the latest research findings. Guidelines regard-
teem and lack of social usefulness. Poor financial ing the diagnosis and treatment of allergic diseases
situation as the result of unemployment caused and asthma, published in regularly updated reports,
by the patient’s inability to work also negatively such as GINA or ARIA (Allergic Rhinitis and its
impact mental condition [9]. Impact on Asthma) should be communicated to
Our study has found that age had a negative family doctors in a form of simple algorithms [10].
effect on asthma control, probably due to certain The effectiveness of treatment of a chronic disease
specific therapeutic problems, such as greater depends on the level of physician-patient cooper-
risk of adverse drug effects, especially in case of ation, and good cooperation means that patients
comorbidity. The medications, especially inhaled are provided with accurate and clear information
medications, are often misused by elder patients, about their disease. Asthma control, on the other
while longer duration time of the disease makes the hand, can be practiced on the basis of knowledge
number of hospitalisation and medical intervention obtained from an allergist and training provided by
greater. Patients with cognitive deficits or manually health care professionals. Training on the correct

346 www.pneumonologia.viamedica.pl
 Beata Jankowska-Polańska et al., Education in the treatment of bronchial asthma

use of inhaled medication or a nebuliser is espe- Conclusions

cially important. Many studies have evaluated the
effects of different forms of education. Gawlewicz Health education with asthma should be con-
et al. [11] have noticed that the methods which pa- ducted by a specialist allergologist and well-prepared
tients choose are often not the most effective ones. healthcare professionals. Being able to properly react
In addition to that, methods aiming to inform only in case of asthma attack is the most important aspect
have the potential to raise patients’ awareness but of that education for both women and men.
do not necessarily cause lung function or the need The knowledge of the principles of asthma
of medical assistance to improve. Improvement in and its management positively impacts quality of
asthma treatment can be achieved by using inter- life and the level of asthma control in both sexes.
active educational methods in conjunction with
individual advice. For example, three educational Conflict of interest
meetings held by a specially trained nurse may be
enough to reduce the number of patients readmit- The authors declare no conflict of interest.
ted to the A&E department due to loss of asthma
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