The development and comprehensibility of a pictorial asthma action plan

Abstract

Objective

Written action plans are regarded as an important part of asthma self-management education and yet they may not be understood by those with limited literacy skills. This study was designed to produce an understandable pictorial asthma action plan.

Methods

With advice from a group of doctors and nurses a “standard” written action plan was translated by a medical artist into a series of pictorial images. These were assessed using the techniques of guessability and translucency by a series of adults attending a specialist asthma clinic in London and the same process was subsequently used to assess comprehensibility of the images and plans amongst a group of Somalis living in Manchester, UK and Malaysians in Seremban, Malaysia.

Results

Guessability testing showed that the majority of pictograms were well understood by each of the study groups. Translucency testing revealed close agreement with intended meaning for the majority of the images. One image, depicting extra use of reliever medication scored less well in all populations; two other images scored less well in the Somali and Malaysian groups and reflect less use of certain inhaler devices in other countries. The overall plan was well understood by all patients who were able to adequately recount the appropriate actions to take in different clinical scenarios.

Conclusion

We have developed a pictorial asthma action plan understandable by 3 different populations of patients with asthma.

Practice implications

Pictorial representations have been shown by other studies in other situations to be an effective method of reinforcing the spoken word. The pictorial asthma action plan developed for this study has been shown to be comprehensible, personalised to the individual in the usual fashion. It is now suitable for further evaluation in clinical practice.

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].