The development and comprehensibility of a pictorial asthma action plan☆
Introduction
There are 5.2 million people in the UK with asthma and 300 million globally [1] and very clear guidelines on how best to manage the condition. The first British Asthma Guidelines published in 1990 [2] stated that “as far as possible patients should be trained to manage their own treatment rather than be required to consult their doctor before making changes”. The international guidelines similarly suggest that the aim should be that of guided self-management, “that is giving patients the ability to control their own condition” [3]. Systematic reviews have confirmed that an important part of this process is the receipt by the patient of a written asthma action plan with advice as to when to increase their preventative therapy, when to start steroid tablets, and when to seek urgent medical attention [4] and yet relatively few patients receive such plans [5], [6], [7]. Some of the reasons for non-receipt may reflect poor dissemination of the content of guidelines, doctors not having faith in their ability to deliver this advice, lack of suitable pre-printed templates, a perception that patients do not wish to take control [8] or a belief that deterioration of asthma is too acute for patient action. There is clear evidence that most of these are false premises. Even patients who have not received action plans have been shown to find them acceptable [7] and 55% of adults with asthma are less involved in treatment decisions than they would wish [9]. Whilst only 20% of patients may have been given such plans, nearly two thirds wished to receive such advice [7] and this is true also for ethnic minorities [10]. In adults at least, most asthma exacerbations whilst severe are not acute [11], [12], [13], [14] and there is thus ample time for most patients to alter therapy, initiate new therapy or seek medical attention to prevent further worsening of their condition.
If plans are an important part of such education they need to be offered to patients in a manner that makes it easy for them to use. Health literacy is defined as the degree to which individuals have the capacity to process and understand basic health information and services needed to make appropriate health decisions [15]. Data from the US suggests that impairment is common and is frequently overlooked especially amongst African Americans and white non-Hispanics [16]. In the UK 15% of patients with rheumatoid arthritis in one study were functionally illiterate [17] and this figure was similar to that found in a US study specifically looking at those with asthma [18]. Such patients have been shown to benefit from tailored asthma self-management education [19]. Pictorial representations have been shown to improve recall of medical instructions in a clinical setting [20] and pictograms have been shown to be an effective tool, enhancing consultations and aiding understanding [21]. This study involves the development and validation of pictorial plans which have been based upon written materials already recommended within asthma guidelines [22].
Section snippets
Methods
This study involved initial production and revision of the images to be used within the asthma action plan and subsequent testing of their comprehensibility both simply and together in 3 different populations of patients with asthma.
Charing Cross Hospital Outpatients study group (n = 50)
50 patients with a diagnosis of asthma fulfilling the entry criteria were recruited to the study. The mean age was 48.2 years (S.D. 17.2) and 19 were males and 31 female. Patients had a wide educational background ranging from leaving school at age 14 years to postgraduate qualifications (Table 1). The patients were subsequently shown to be essentially literate according to the REALM questionnaire, all scoring above 45 on the REALM score (Table 1) [17]. Two stated that they had dyslexia.
Manchester Somali study group (n = 10)
10
Discussion
One barrier to the issuing of personalised asthma action plans may be that the concept and materials used may be perceived as being too complicated. Simple pictorial plans may have wider appeal and ensure wider applicability in minority groups and there is clear evidence that literacy is overestimated by doctors [16]. We have demonstrated in this study that pictograms designed specifically for an asthma action plan are well understood by a cross section of patients with varying cultural and
Conflict of interest
None of the authors have any conflicts of interest relevant to this study or the content of this report.
Acknowledgements
We acknowledge with considerable gratitude our Medical Artist colleague Mrs. A Wadmore for so patiently adapting and readapting the images until we and the patients were happy.
MRP instituted the development of the material. NJR undertook a major role in the development of the materials and in the testing of the materials in London. ZM and MJ undertook the study amongst Somalis in Manchester and P-S W and L-C L undertook the study in London. Both MRP and NJR jointly interpreted the results and
References (26)
- et al.
The Living and Breathing Study: a study of patients views of asthma and its treatment
Primary Care Resp J
(2004) - et al.
Perceptions of asthma in South Asians and their views on educational materials and self-management plans: a qualitative study
Patient Educ Couns
(2002) - et al.
Physician overestimation of patient literacy: a potential source of health care disparities
Patient Educ Couns
(2007) - et al.
Inadequate literacy is a barrier to asthma knowledge and self-care
Chest
(1998) - et al.
Using pictographs to enhance recall of spoken medical instructions
Patient Educ Couns
(1998) - et al.
The role of pictures in improving health communication: a review of research on attention, comprehension, recall, and adherence
Patient Educ Couns
(2006) - et al.
Global Initiative for Asthma (GINA) Program. The global burden of asthma: executive summary of the GINA Dissemination Committee report
Allergy
(2004) Guidelines for management of asthma in adults: 1—Chronic persistent asthma
Brit Med J
(1990)- Global Strategy for Asthma Management and Prevention. Global Initiative for Asthma (GINA), http://www.ginasthma.org;...
- et al.
Written action plans for asthma: an evidence-based review of the key components
Thorax
(2004)
Delivery of asthma care: patients’ use of and views on healthcare services as determined from a nation-wide interview survey
Asthma J
Acute asthma attacks: the patient's perspective
Asthma J
Qualitative study of views of health professionals and patients on guided self management plans for asthma
Brit Med J
Cited by (47)
Literature review and development of pictorial action plan to promote self-management of chronic obstructive pulmonary disease
2023, Patient Education and CounselingChoose to reuse! The effect of action-close reminders on pro-environmental behavior
2021, Journal of Environmental Economics and ManagementA scoping review of the use of visual aids in health education materials for persons with low-literacy levels
2021, Patient Education and CounselingCitation Excerpt :The remaining authors of studies did not present statistical differences in the evaluation of visual aids, but qualitatively described the preferred attributes of visual aids for persons with low-literacy. Guessability, familiarity, and position were described as important in South Africa (MIC) [93,99], the UK (HIC) (with immigrant populations from LMIC countries) [102], the Netherlands (HIC) [63] and the United States (HIC) [79] and cultural acceptability was described as important in South Africa (MIC) [94]. The seventh and final theme identified is the satisfaction and suitability of visual aids to their target population (n = 11) [57,64,72,76,80,84,86,92,94,100,101].
Development and Assessment of a Pictographic Pediatric Constipation Action Plan
2021, Journal of PediatricsCitation Excerpt :For this project, we adhered to the American National Standards Institute standard for adequate transparency: correct identification of each image by at least 85% of participants. Translucency refers to the strength of the relationship between the picture and its intended meaning.33 Translucency was evaluated by showing the parent the individual pictogram from the storyboard in conjunction with the appropriate, key clinical text to be paired with it on the USCAP.
A problem unstuck? Evaluating the effectiveness of sticker prompts for encouraging household food waste recycling behaviour
2017, Waste ManagementCitation Excerpt :Several authors have indicated that ensuring the final product is noticeable, simple and clear is important (Sussman et al., 2012). Adding pictures to written information may also improve effectiveness (Roberts et al., 2009), provided the images used are congruent with the text (Jae et al., 2008) and they do not ‘cloud’ the message (van Meurs and Aristoff, 2009). Some studies have shown that certain attempts to persuade using visual prompts can cause individuals to protest and engage in undesirable behaviours (Sussman and Gifford, 2012).
- ☆
Funding: This study was supported by a Trevor Clay Memorial Grant from the British Lung Foundation.