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ORIGINAL ARTICLE
Year : 2006  |  Volume : 23  |  Issue : 1  |  Page : 3-7 Table of Contents   

Emotional aspects of bronchial asthma in Indian patients: Evaluation of an interventional strategy


1 Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh., India
2 National Institute of Nursing Education, Postgraduate Institute of Medical Education and Research, Chandigarh., India
3 Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh., India

Correspondence Address:
D Behera
Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh-160 012.
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.44422

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   Abstract 

In order to improve the self care abilities of the patients with bronchial asthma a 'Self Care Manual' (a Booklet of 26 pages) on bronchial asthma was prepared. An interview schedule was developed to evaluate the usefulness of the manual. The validity and reliability of both these instruments were established. Five hundred and twenty three diagnosed patients of bronchial asthma (260 in the study group to whom the self care manual was given and 263 controls to whom no specific instructions were given) were included in the study. Emotions like 'tension', 'excessive laughter', 'sadness', 'happiness' and 'anger' etc. that triggered the symptoms were studied. The effect of self care manual on other emotions (*a total of 8 items) like 'anxiety due to the disease', 'tension of taking medicine' and 'fear of death' etc. was also studied. Both groups were followed up at 2 weeks, 6 months and 1 year while the same interview schedule was administered on each visit. It was observed that the emotion scores decreased significantly in both the groups (8.08±5.5, 5.89±4.88, 1.44±4.63 and 1.19±4.01 in the study patients, whereas 8.50±6.30, 7.88±6.21, 7.35±6.03 and 5.97±5.81 in the controls) at 0 weeks, 2 weeks, 6 months and 1 year respectively. The emotion scores were significantly less in the study group as compared to controls (unpaired 't' = 3.57, 8.52 and 7.67) at 2 weeks, 6 months and 1 year respectively (p<0.001) Multiple logistic regression analysis showed that the odds ratio of study group patients showing significant improvement in emotion scores was 3.34 (95% CI, 1.78-6.25) and 4.26 (95% CI, 2.34-7.63) at 6 months and 1 year respectively as compared to controls.
We concluded that patient education (self care manual in the form of a booklet) made significant improvement in the emotions in patients with bronchial asthma.

Keywords: Bronchial asthma, emotions, self management, self care manual.


How to cite this article:
Behera D, Kaur S, Gupta D, Verma S K. Emotional aspects of bronchial asthma in Indian patients: Evaluation of an interventional strategy. Lung India 2006;23:3-7

How to cite this URL:
Behera D, Kaur S, Gupta D, Verma S K. Emotional aspects of bronchial asthma in Indian patients: Evaluation of an interventional strategy. Lung India [serial online] 2006 [cited 2019 May 22];23:3-7. Available from: http://www.lungindia.com/text.asp?2006/23/1/3/44422


   Introduction Top


Bronchial asthma is influenced by a number of biological, environmental, psychological and social factors. Asthma morbidity continues despite improvements in medication. Certain psychosocial factors may be important in the causation and/or aggravation of the disease [1] . Anxiety disorders are more common in asthmatic patients than in the general population. Diagnosis of asthma may itself be anxiogenic and simply having asthma may give patients an increased vulnerability towards the development of anxiety disorders [2] . Patients of bronchial asthma suffering from anxiety disorders usually hyperventilate, and many of them report phobic avoidance of certain situations, particularly where the breathing pattern is interrupted or the airway is momentarily occluded. These situations commonly include taking the shower, shaving, going to the toilet, eating alone, going in elevators or being outside of the home without an inhaler or a companion [2] . Certain high risk characteristics may be present that include depression, conflicts with parents and/or health professionals, reactions to losses (such as divorce or death in the family), sibling or parental problems and improper care and/or poorly compliant behaviour [3] .

The type of education and information provided by health care professionals have major influence on patient's understanding of treatment, as education alleviates anxiety by decreasing areas of unknown fears and fantasies [4] . The aim of the present study was to study emotions that trigger the symptoms in patients with bronchial asthma. It was hypothesized that patient education will improve the emotion scores of patients.


   Material and Method Top


Study setting and sample

The study was carried out in the outpatient clinics of the department of Pulmonary Medicine at the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh (India). The sample was drawn from patients with bronchial asthma. The diagnosis was established on the basis of consistent clinical history, examination and documented reversible airflow obstruction (as defined by at least 15% improvement in FEV 1 /FVC after administration of 200 µg salbutamol). A total of 523 patients of bronchial asthma fulfilling the inclusion criteria (age range of 18­60 years irrespective of the sex, willing to participate in the study, able to read Hindi (local dialect) and residing in or nearby Chandigarh (to ensure better follow up) were included in the study. Out of these, 260 patients were included in the study group to whom a Self Care Manual on bronchial asthma was given and 263 were included in the control group to whom no specific instructions were given.

Semi-structured interview schedule

An elaborative interview schedule was prepared which was demonstrated to have validity and reliability. It consisted of socio-demographic information (25 items) and general information (18 items) on the patients. Eight items elaborated the occurrence of various emotions related to asthma, like tension because of the disease, frustration and worrying of the cost of medicine etc. Each type of emotion was put on four point continuum; 'Never', 'Sometimes', 'Often' and 'All the time' with '0' score to 'Never' and '3' score to 'All the times'. The score ranged from 0 to 24. Information was also sought regarding other emotions (tension, excessive laughter, sadness, anger etc.) which triggered asthma attacks in our patients.

Self care manual

A self care manual (a booklet of 26 pages) on bronchial asthma, initially prepared in English was translated to Hindi (the local language of people) in the form of text and pictures. The text contained the information like 'What is asthma, how it develops, the various triggering factors, signs and symptoms, control of emotions, use of inhalation devices, P.E.F.R., management according to traffic lights, home management of acute attack and preventive measures etc. [5],[6],[7],[8],[9],[10],[11],[12],[13],1[4],[15],[16] Its validity and reliability were also established. This manual was prepared after consulting the relevant literature and under the guidance of experts from the related disciplines (Pulmonary Medicine, Internal Medicine, Psychiatry and Nursing Education). Language and text of the booklet was adopted and modified as per the requirements keeping in mind the aims and objectives of the study protocol. The booklet was used in the present study with an aim to improve the knowledge of patients regarding the disease and thereby reducing the adverse emotional responses.

Study Protocol

After the initial interview (pre test at 0 week), each patient in the study group was given the self care manual which they could carry home. All the patients from both the groups were asked to come for follow up at 2 weeks, 6 months and 1 year. The same interview schedule was administered on all follow up visits.

Data analysis

Analysis was carried out by x 2 test, unpaired 't' test, Friedman's ANOVA and multiple logistic regression. Demographic variables of the two groups were compared by using x 2 for categorical variables and unpaired 't' test for continuous data. Friedman's ANOVA was applied to check the variations of individual emotion over a period of time (pre test, post test 1, post test 2 and post test 3). Multiple logistic regression was applied to find out the influence of independent variables such as age, sex, marital status, education, occupation, place of residence, type of family, family history and duration of disease on the improvement in emotion scores of the study group patients.


   Results Top


Demographics

Of the 523 enrolled patients (260 in study group and 263 in control group), the number of patients who completed their follow ups in study and control groups were: 240 (92.31%) and 240 (91.25%) at 2 weeks, 212 (81.54%) and 210 (79.85%) at 6 months and 204 (78.46%) and 194 (73.76%) at 1 year respectively.

In both groups, there were more female patients (131 i.e. 64.22% in study group and 100 ie. 51.55% in the control group) compared to male patients. The mean age of the study group was 36.72±11.53 years and for the control group it was 34.34±12.86 years.

According to the duration of the illness, most i.e. 74(36.27%) from the study group and 73(37.63%) from the control group were having asthma for the last 1 to 5 years. The two groups were comparable on majority (20 out of 25) of the socio-demographic variables.

There was no relationship of emotion scores with income, type of family, family history of asthma and rural/urban background of the patients. The housewives in both the groups had the highest emotion scores and also the patients with longer duration of asthma had higher emotion score at 6 months and 1 year follow ups as compared to those with lesser duration of asthma. It was also observed that emotion scores were lower in the study group as compared to the control group at follow up visits.

Emotions as triggers

In the study, 129 (60.3%) and in the control group 104 (53.6%) patients had their symptoms triggered/aggravated by various emotions. As shown in [Table 1], tension was the major emotional trigger followed by excessive laughter, sadness and a mixture of being happy and sad. Only 1 patient in the control group had anger as a trigger. Significantly, more patients in the study group had started avoiding the incriminating emotion(s) whereas the percentage of patients avoiding emotions at follow up did not change significantly in control group.

The various other emotional reactions of the patients studied were: Concerned about having to use medication, concerned about having asthma, frustrated due to asthma, anxiety due to asthma, afraid of getting out of breath, depressed, fear of death and tension of expenditure on treatment. The severity of each type of emotion of the patients in the year preceding their participation in the study and their follow up during the study period of one year was analysed using a four-point scale (already discussed under methods). The number of patients with higher (more severe) emotion scores decreased on each subsequent visit in study group thereby increasing the number of patients with milder levels of emotions. These trends were similar in all the emotions except in case of 'anxiety due to asthma' where the number of patients with grade zero increased from 49 patients at the first visit to 85 patients at the second visit, 133 at third visit and 49 (as at baseline) at last visit. These trends (decrease in emotion score) were similar in both groups (P<0.001), but were more marked in the study group. In both the groups, patients having 'fear of death' had no significant difference on any follow up visit (F=NS).

The mean emotion score in the study group was 8.08±5.50 at 0 week and 5.89±4.88, 1.44±4.63 and 1.19±4.01 at 2 weeks, 6 months and 1 year follow up (F=72.28, p<0.001) respectively. In the control group, the mean emotion score was 8.50±6.30 at 0 week and 7.88±6.21, 7.35±6.03 and 5.97±5.81 at 2 weeks, 6 months and 1 year follow up visit (F=6.03, p<0.001) [Figure 1] respectively. Comparing the emotion scores of the study and control group patients, it was found that their scores were comparable at first visit (0 week-unpaired 't'=0.69, p=ns). However the emotion scores were significantly less in study group as compared to control group at all the subsequent follow up visits (Unpaired 't'=3.57, 8.52 and 7.67 at 2 weeks, 6 months and 1 year respectively, p<0.001).

Logistic Regression

Multivariate logistic regression was applied to study the improvement in emotions (decrease in emotion scores) in the study group as compared to controls after adjusting for various confounding variables (age, sex, years of education, duration of asthma, occupation, income, type of family, residence of the patients and the family history of asthma). The odds ratio of cases showing significant improvement in study group was 3.34 (95% CI, 1.78-6.25) and 4.26 (95% CI, 2.38-7.63) at 6 months and 1 year respectively (p<0.001), [Table 2] as compared to controls.


   Discussion Top


Younger patients in the study group had significantly more emotion score at first visit. However those aged more than 20 years in the study group had significantly lesser emotion scores at 6 months and 1 year compared to the control group patients (P<0.001). Female control patients had significantly higher emotion score. Cote et al [17] reported more women with possible and definite anxiety (61% and 68%) respectively. In the present study, control group patients with lower grades of education were more emotional about their disease. Brooks et al [18] have emphasized that patients who have more knowledge of their disease and/or feel more able to control it are less likely to experience panic-fear or irritability symptoms when they have attacks. In our study group, patients with lesser income had significantly higher emotional scores.

Tension, excessive laughter and sadness were the major emotional triggers in this study. An earlier study had reported that 21 patients (70%) had precipitation of asthma by emotions, only 5 reported precipitation by allergen or infection. While 18 patients reported anger to be responsible, anxiety/worry was reported to be responsible in 7 patients and pleasure and sadness in 2 patients each. [19] Another enquiry into precipitating factors of asthma revealed that 56% of the patients reported asthmatic attacks precipitated by emotions. [20]

Observations from the present study showed that the number of patients with higher (more severe emotions) emotion scores decreased on each subsequent visit in study group. In one study, exposure to asthma self management program reduced some of the psychological morbidity associated with asthma. For instance feeling of anger (F=22.1, P<0.01) and irritation (F=27, P<0.01) were reduced and these gains were maintained in the long run. [21] Another study reported that there was an increase in the proportion of patients with asthma who were not angry about their condition in the intervention group from 50% to 53% immediately after intervention and 73% at 6 months. There was a fall in number of such patients in the control group from 62% to 53%. Despite a slight increase in the proportion of patients who were 'optimistic' immediately after intervention from 63% to 68%, the difference was not significant. At 6 months there was a significant decrease in the proportion of patients feeling 'optimistic' about their asthma outcome 37% in the intervention group (P=0.001) and 51% (P=0.03) in the control group. [22]

The findings of the present study are in agreement with an earlier study which noted a significant improvement in psychosocial disturbances score in the intervention group (from 7.21±4.07 at baseline to 4.0±4.38 at 10 months follow up). A fall in this emotion was also observed in the control group (from 6.75±4.65 at baseline to 3.96±3.34 at 10 months follow up) although differences between the two groups were not significant. [23] Others [24],[25] have reported that interventions aimed to provide information alone have generally shown improvement in knowledge with no change in the rate of illness or in behavior during illness. Furthermore, the Grampian Asthma Study of Integrated Care found no significant difference in psychological outcomes such as anxiety, depression, self-efficacy or social and physical functioning between the groups. [26]

There were certain limitations in our study. The intervention was only in the form of a booklet on patient education. Neither specialized psychosocial intervention was made nor additional drugs were given. Also, no detailed psychiatric evaluation was done. Learning about one's disease is always likely to help particularly in patients suffering from chronic diseases. Our intervention did make a significant difference for the control of emotion scores in patients when compared with control patients at all follow up visits. Identification of psychological factors may be helpful to find out high risk subgroups and in these selected patients psychiatric intervention may be beneficial in addition to medical treatment. Role of patient education is apparent from this study as from many others also.

 
   References Top

1.Campbell DA, Yellowlees PM and McLennan G. Psychiatric and medical features of near fatal asthma. Thorax 1995; 50: 254-259.  Back to cited text no. 1    
2.Yellowlees PN and Kalucy RS. Psychological aspects of asthma and the consequent research implication: Chest 1990; 97: 628.634.  Back to cited text no. 2    
3.Mascia A, Frank S, Berkman A. et al. Mortality versus improvement in severe chronic asthma: Physiological and psychological factors. Ann Allergy 1989; 62:311-317.  Back to cited text no. 3    
4.Wilson SR, Scamagas P and German DF et al. A controlled trial of two forms of self management education for adults with asthma. Am. J Med 1993;94:564-576.  Back to cited text no. 4    
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7.Gupta SK, Mazumdar KS, Gupta S, Mazumdar AS and Gupta S. Patient education programme in bronchial asthma in India: Why, How, What and Where to communicate? Indian J Chest Dis Allied Sci 1998; 40: 117-124.  Back to cited text no. 7    
8.Custovic A and Woolcock A. Reducing allergen exposure in asthma patients. The Practitioner 1999; 243: 232-235.  Back to cited text no. 8    
9.Neville R. Self management plans in asthma. The Practitioner 1998; 242:212-215.  Back to cited text no. 9  [PUBMED]  
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13.National Heart, Lung and Blood Institute, National Institutes of Health. International Consensus Report on diagnosis and treatment of asthma. Eur Respir J 1992; 5:601-641.  Back to cited text no. 13    
14.Brewis RAL. Patient education, self-management plans and peak flow measurements. Respiratory Medicine 1991; 85:457-462.  Back to cited text no. 14    
15.Worth H. Patient education in asthmatic adults. Lung (Suppl) 1990; 463-468.  Back to cited text no. 15    
16.Newman SP, Pavia D, Clarke SW. Simple instructions for using pressurized aerosol bronchodilators. Journal of the Royal Society of Medicine 1980; 73: 776-779.  Back to cited text no. 16  [PUBMED]  [FULLTEXT]
17.Cote J, Kartier A and Robichaud P et al. Influence on asthma morbidity of asthma education programs based on self­management plans following treatment optimization. Am J Respir Crit Care Med 1997; 155: 1509-1514.  Back to cited text no. 17    
18.Brooks CM, Richards JM, Bailey WC, Martin B, Windsor RA and Soong SJ. Subjective symptomatology of asthma in an out patient population. Psychosomatic Medicine 1989; 51: 102-108.  Back to cited text no. 18    
19.Desai NG, Gandhi HA and Shah AD. Emotional factors in bronchial asthma. Indian J Psychiat 1981; 32: 104-108.  Back to cited text no. 19    
20.Ramachandran V, Thiruvengadam KV and Zackria MG. Parental loss and emotional factors in bronchial asthma. Indian J Psychiat 1977; 19: 44-47.  Back to cited text no. 20    
21.Bauman AE, Criag AR, Dunsmore J, Browne G, Allen DH and Vandenberg R. Removing barriers to effective self­management of asthma. Patient Education Counselling 1989; 14: 217-226.  Back to cited text no. 21    
22.Abdulwadud O, Abramson M, Forbes A, James A and Walters EH. Evaluation of a randomized controlled trial of adult asthma education in a hospital setting. Thorax 1999; 54: 493-500.  Back to cited text no. 22    
23.Yoon R, McKenzie D, Bauman A and Miles D. Controlled trial of an asthma education program for adults. Thorax 1993; 48: 1110-1116.  Back to cited text no. 23    
24.Moldofsky H, Broder I, Davies G and Leznoff A. A videotape educational program for people with asthma. Can Med Ed. J 1979; 120: 669-672.  Back to cited text no. 24    
25.Darr MS, Self TH, Ryan MR, Vanderbush RE and Baswell RL. Content and retention evaluation of an audiovisual patient education program on bronchodilators. Am J Hosp Pharm 1981; 38: 672-675.  Back to cited text no. 25    
26.Grampian asthma study of integrated care (GRASSIC). Integrated care for asthma: a clinical, social and economic evaluation BMJ 1994; 308: 559-564.  Back to cited text no. 26    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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