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“EFFECTIVENESS OF PEAKFLOW SELF MANAGEMENT PLAN
ON QUALITY OF LIFE FOR ASTHMA PATIENTS IN
SELECTED COMMUNITY, COIMBATORE”
By
Mrs. NEETHI SELVAM. T, M.Sc (N)
A thesis submitted to
THE TAMIL NADU DR.M.G.R MEDICAL UNIVERSITY, CHENNAI
In fulfillment of the requirement for award of the degree of
DOCTOR OF PHILOSOPHY IN NURSING
JANUARY 2018
“EFFECTIVENESS OF PEAKFLOW SELF MANAGEMENT PLAN
ON QUALITY OF LIFE FOR ASTHMA PATIENTS IN
SELECTED COMMUNITY, COIMBATORE”
A thesis submitted to
THE TAMIL NADU DR.M.G.R MEDICAL UNIVERSITY,
CHENNAI
In fulfillment of the requirement for the award of the degree of
DOCTOR OF PHILOSOPHY IN NURSING
By
Mrs.NEETHI SELVAM., M.Sc (N)
Under the guidance of
Dr. JANANI SANKAR
MBBS.,DNB.,Ph.D.,M.A.M.S
Senior Consultant
Kanchi Kamakoti CHILDS Trust Hospital, Chennai
JANUARY 2018
CERTIFICATE
This is to certify that the thesis entitled “EFFECTIVENESS OF PEAKFLOW
SELF MANAGEMENT PLAN ON QUALITY OF LIFE FOR ASTHMA PATIENTS
IN SELECTED COMMUNITY, COIMBATORE” submitted by Mrs. NEETHI
SELVAM. T for the award of the degree of Doctor of Philosophy in Nursing, is a
bonafide record of research done by her during the period of study, under my supervision
and guidance and that it has not formed the basis for the award of any other Degree,
Diploma, Associateship, Fellowship or other similar title. I also certify that this thesis is
her original independent work. I recommend that this thesis should be placed before the
examiners for their consideration for the award of Ph.D. Degree in Nursing.
Research Guide
Dr. JANANI SANKAR, M.B.B.S., DNB, PhD, MA,MS.
Pedia Senior Consultant,
Kancha kamakoti CHILDS Trust Hospital,
Nungambakkam
Chennai - 600 018
Place :
Date :
CERTIFICATE
This is to certify that the thesis entitled “EFFECTIVENESS OF PEAKFLOW
SELF MANAGEMENT PLAN ON QUALITY OF LIFE FOR ASTHMA
PATIENTS IN SELECTED COMMUNITY, COIMBATORE” is a bonafide
work of Mrs. Neethi Selvam. T and submitted in fulfillment of the requirement for
the Degree of Doctor of Philosophy in Nursing to THE TAMILNADU
DR.M.G.R MEDICAL UNIVERSITY, CHENNAI under my guidance and
supervision.
Research Co-Guide
Dr. Lizy Sonia, M.Sc. (N), Ph.D (N),
Vice Principal, Apollo college of Nursing,
Vanagaram to Ambattur Road,
Ayanambakkam,
Chennai, 600095
Tamil Nadu, India
Place :
Date :
DECLARATION
I hereby declare that this thesis entitled ““EFFECTIVENESS OF PEAKFLOW
SELF MANAGEMENT PLAN ON QUALITY OF LIFE FOR ASTHMA PATIENTS
IN SELECTED COMMUNITY, COIMBATORE” is my own work carried out
under the guideship of Research Guide Dr. JANANI SANKAR, M.B.B.S., DNB,
PhD, MA,MS. Pedia Senior Consultant, Kancha kamakoti CHILDS Trust Hospital,
Chennai which is approved by the Research Committee, The Tamil Nadu Dr.
M.G.R Medical University, Guindy, Chennai.
I further declare that to the best of my knowledge the thesis does not contain any
part of any work which has been submitted for the award of any degree either in
this University or in any other University / Deemed University without proper
citation.
Mrs. Neethi Selvam.T
Research Scholar
Place :
Date :
ACKNOWLEDGEMENT
‘There are many plans in a man's heart; but the counsel of the LORD, alone that shall stand’
The investigator owes a deep sense of gratitude to the God Almighty for His powerful
and wonderful ways of leading me in her studies. His grace is sufficient for me to complete
the study successfully. I felt His leading hand in each and every step of this project. His ways
are marvelous, His ways are not our ways, His thoughts are not our thoughts.
My sincere and heartfelt thanks to the Management, Apollo College of Nursing,
Chennai for initiating Ph.D in Nursing and The Tamil Nadu Dr.M.G.R Medical
University, Guindy, Chennai for creating copious opportunities to learn.
I would like t o express my sincere and heartfelt gratitude to the fo r mer and the
present Vice Chancellor, Registrar and Academic Officer of The Tamil Nadu Dr.
M.G.R Medical University, Guindy, Chennai for providing me this prospect to pursue this
doctoral degree in this esteemed university and for being the source of support
throughout the period of study.
I whole heartedly express my sincere gratitude to Dr. Latha Venkatesan, Principal,
Apollo College of nursing, for her inspiring guidance, valuable suggestions, timely support
and constant supervision which made the study rewarding and successful.
I owe my sincere gratitude and deep regard to my Guide Dr. Janani Sankar, Pedia
Senior Consultant, for her valuable feedback and constant encouragement throughout the
duration of the project. My deep sense of gratitude to my co-guide Dr. Lizy Sonia, Vice
principal, Apollo College of nursing for her exemplary guidance. Her valuable suggestions
were of immense help throughout my thesis work.

I am highly indebted to Prof. Dr. Vijayalakshmi, HOD, Mental Health Nursing for her
guidance and support as well as for providing necessary information regarding the project &
also for her support in completing the project. I would like to express my special gratitude
and thanks to all the nursing and medical experts for giving me suggestions, attention and
time in content validity.
I am extremely thankful to Prof. P. Arumugam, biostatistician for rendering support in
statistical analysis. My sincere thanks to Prof. S.Valarmathi, Statistician for her help in
validating the tool.
I am grateful to Mrs. Fancy S, English editing a n d M r . R a v i C for editing this
report in tamil. I whole heartedly thank the author of Standardized AQLQ tool Professor E.
Juniper of Mapi Research Institute Research for her permission to use the UK English
version of the AQLQ and for the Tamil Translated copies sent by post . The researcher like to
thank the authors of WHO Well-Being Index (WHO-5), Psychiatric Research Unit and Dr. &
Mrs. Latha Venkatesan for her kindness in granting me permission to use her WBI Tamil
translated tool.
I express my sincere gratitude and regards to librarians at The Tamil Nadu Dr. M.G.R
Medical University Library, Guindy, Chennai a n d Mr. S.Siva Kumar and Mr.
B.Gopinath, librarians of Apollo College of Nursing, for extending support with adequate
references.
Most importantly, I express my profound gratitude to Mrs. Saramma Samuel, Principal,
R.V.S. College of Nursing in obtaining permission for the study to be conducted in
community and Mrs. Jaya Lakshmi, Nursing staff at community in helping with data
collection.
I also would like to extend my sincere thanks to Apollo family and all faculty of Apollo
college of Nursing for their kindness in giving me such attention and time. I have taken
efforts in this project. However, it would not have been possible without the kind support
and help of many individuals and organization. Each of the members of my Selection to
Dissertation Committee has provided me extensive personal and professional guidance and
taught me a great deal about both scientific research.
My thanks and appreciations to research participants and people who have willingly
participated in filling out the responses without which this research would be incomplete.
My thanks and appreciations also go to my friends and colleague in developing the
project and people who have willingly helped me out with their abilities. I wish to thank my
loving and supportive family for their commitment which made the study productive and all those
who directly or indirectly helped me and have contributed to the successful completion of this
endeavour.
Date : Signature of the Candidate
Place : Chennai Mrs. Neethi Selvam.T

Abstract
ABSTRACT
The present study was intended to assess the Effectiveness of Peakflow Self
Management plan on Quality of life for Asthma Patients in a Selected Community at
Coimbatore.
The objectives of the study were:
1. To assess the quality of life and general well being before and after peak
flow self management plan in control and experimental group of asthma
patients.
2. To assess the effectiveness of peak flow self management plan among

asthma patients by comparing the quality of life and general well being
between control and experimental group of asthma patients.
3. To assess the acceptability of asthma patients regarding peak flow self

management plan.
4. To find out the correlation between quality of life and its domain among
control and experimental group of asthma patients in pre test and post test.
5. To find the association between demographic variables with pre test and
post test quality of life in control and experimental group.
6. To find the association between clinical variables with pre test and post
test quality of life in control and experimental group.
Methods
The conceptual frame work of the current research was based on Bandura’s self efficacy
theory. The sample size of the study was 200 asthma patients in a community at
Coimbatore. A quasi experimental study with time series design was used. The
samples were selected through purposive sampling technique and selected samples
were assigned to control and experimental group (100,100). The subjects in the
experimental group received peak flow self management plan. A pre test and post test
assessment at the time of interview, 2 months, 4 months and 6 months were done for
the asthma patients in control and experimental groups which was compared before
and after the intervention to test the effectiveness of the nursing intervention (peak
flow self management plan)
The instruments used for the study consisted of proforma to assess demographic and
clinical variable proforma, standardized Asthma Quality of Life Questionnaire to
assess symptoms, activity limitation, emotional function and environmental stimuli
ultimately assessing the quality of life as well as well being Index to assess the well
being of asthma patients in control and experimental group and satisfaction scale to
assess level of acceptability of asthma patients and observation schedules of peak
flow diary and peak flow graph for experimental group.
Descriptive statistics (frequency, percentage, mean, standard deviation) and inferential
statistics (chi square, paired, independent t-test, repeated measures of ANOVA and
Karl pearson’s correlation) were used to summarize the data and to test the research
hypothesis.
Major findings of the study

 With regard to demographic variables, majority of the asthma patients
were males (54%, 72%), married (57%,66%), from rural back ground
(69,74), from joint family (84%,79%) in control group and
experimental group respectively. Among clinical variables, majority of
the asthma patients had industry around home (81%, 77%), used LPG
Gas for cooking (71%,82%), had family history of first degree relative
with asthma (67%,72%), had no habit of smoking (61%, 48%), with

moderate asthma (49%,64%), had consultation with physician one
month back (58%,51%), had no presence of co-morbid illness
(46%,57%) and had not used peak flow metre (77%, 94%),
 In pre-test, the mean AQLQ scores of control group and experimental
group were almost same (95.90, 96.6/224) with t’value 0.88 showed
that there is no significant difference at (P>0.05), however in post test
I, II, III, with the interval of 2 months, there was marked increase in
AQLQ score only in experimental group (127.73, 144.14, 161.17) and
it was statistically significant at (P<0.001). There was also significant
difference between control and experimental group.
 With regard to general well-being index scores also, during pretest, the
experimental group had M=29.32/100 that gradually increased to 49.4,
61.2, 80.8 during post test I, II, III respectively and it was statistically
significant at (P<0.01).
 On comparison of AQLQ score of pre-test, post-test 1, post-test II and
post-test III, repeated measures of ANOVA showed significant
difference between the two groups. The experimental group had an
improvement in AQLQ score and well being that was statistically
significant (P<0.001).
 During pretest, no demographic variables had association with quality
of life (P>0.05) in both groups, and among clinical variables asthma
severity, habit of smoking and whether or not they had industries
around their homes at that time in control group were statistically
strongly significantly associated with quality of life (P<0.01). And in

experimental group, only the severity of asthma was statistically
significantly associated with their quality of life (P<0.05).
 During post test II also, no demographic variables had association with
quality of life (P>0.05), except with age that had statistically strongly
significant association with the quality of life with age of both the
control and experimental groups and occupation status was statistically
significant only in control group. Among the clinical variables, the
asthma patients’ habit of smoking and asthma severity had statistically
very highly significant associations with their quality of life and
medications had a statistically significant association with their quality
of life in control group (P<0.01). And in experimental group, the
asthma patients’ time of last consultancy with a physician, whether or
not they had industries around their homes, what kind of cooking fuel
they used had statistically highly significant associations with their
quality of life, and the presence of co-morbid illnesses had a
statistically significant association with their quality of life (P<0.01).
 With regard to homogeneity, except gender all other demographic
variables such as age, education, occupation, marital status, monthly
income, residence and type of family were not statistically significantly
differed (P>0.05). The two groups (control and experimental) were
homogeneous groups and they were comparable groups in respect of
their demographic characteristics.
In this study, with regard to Quality of Life among asthma patients was poor before
intervention on peak flow self management plan in control (M=95.90/224) and

experimental group (M=96.6/224) that showed no significant difference at (P>0.05).
However during post test I, II, III after intervention, the AQLQ scores determining the
quality of life of asthma patients were higher in experimental group (M=127.7,
M=144.1, M=161.1) than the control group (M=98.3, M=100.7, M=103.09) that was
statistically significant (P <0.001). This attributes to the effectiveness of peak flow
self management plan in improving the quality of life for asthma patients.
With respect to the well being of asthma patients, the well being was poor before
intervention on peak flow self management plan in control (M=30.36/100) and
experimental group (M=29.3/100) that showed no significant difference at (P>0.05).
However during post test I, II, III after intervention, the well being scores determining
the well being of asthma patients were higher in experimental group (M=49.48,
M=61.28, M=80.80) than the control group (M=35.52, M=40.96, M=45.20) which
was statistically significant (P <0.001). This attributes to the effectiveness of peak
flow self management plan in improving the well being of asthma patients.
There was no significant correlation between quality of life (AQLQ) and its domains
during pretest and post test I and was significantly correlated among the domains in
post test II and III in control group. Same way there was no significant correlation
between quality of life (AQLQ) and its domains during pretest, post test I (except
activity with emotional), post-test II, as well as post-test III among the domains in in
experimental group.
Thus the findings of the present study attributed to the effectiveness of peak flow
self management plan in improving the quality of life and well being of asthma
patients. This stresses the importance of peak flow self management for better asthma
control that can be included in asthma care and strategy.

Conclusion
Peak flow self management is an effective method for monitoring the lung status and
record symptoms for moderate to severe asthma who require daily asthma
medications. It helps to detect an attack and begin treatment early thereby prevent
asthma episode and severity as well as the physical and emotional effects such as
breathing difficulty or panic state. The findings of the present study has generated
knowledge in the field of nursing practice in asthma care and treatment. The study
findings are also supported by the studies conducted in India and abroad. Thus self
managing asthma correctly allow asthma patients to avoid serious attack and avoid a
severe asthma emergency enabling them to lead an active, healthy and improved
quality of life.
Key words: Peak flow Self management, Asthma control, Quality of life,
TABLE OF CONTENTS
Chapter Title Page No.

No.
I Introduction 1-19
Background of the study 1-7
Need for the study 7-12
Statement of the Problem 11
Objectives of the Study 11-12
Operational Definitions 12-13
Null Hypotheses 13-14
Assumptions 14
Delimitations 15
Projected outcome 15
Conceptual Framework applied in this study 16-18
Summary 19
II Review of Literature 20-62
Literature reviewed related to the work 20- 51
Development of Nursing Evidence Based Protocol 51-61
Summary 62
III Methodology 63-81
Research Approach 63
Research Design 64-66
Variables of Study 67-68
Research Setting 68
Chapter Title Page No.
No.
Population 68
Sample and Sample size 69-70
Sampling technique and method of sample selection 70-71
Selection and Development of study instruments 71-74
Psychometric properties of the instruments 74-75
Reliability 75
Ethical considerations 76
Intervention protocol 76-79
Pilot study 79
Data collection procedure 79
Summary 81
IV Analysis And Interpretation 82-138
Presentation of Data Analysis 84-137
Summary 138
V Discussion 139-153
Summary 153
VI Summary and Recommendations 154-165
Summary of the study 154
Nursing Implications 160-164
Recommendations for Future Research & Conclusion 164-165
References 166-178
Annexures
LIST OF TABLES
S.No Titles Page No
1 Individual Evidence Summary of RCT’s based on 56-61

effectiveness of peak flow self management plan on quality of
life
2 Frequency and Percentage Distribution and homogeneity of 84-85

Demographic variables in control and experimental groups
of Asthma Patients.
3. Frequency and Percentage Distribution and homogeneity of 86-87
clinical variables in control and experimental groups of
Asthma Patients.
4 Comparison of Mean, Standard Deviation and Mean 89

Difference between Tests of AQLQ in Control Group Of
Asthma Patients.

difference between Tests of AQLQ in Experimental group of
Asthma patients.

Difference of AQLQ Scores between Control group and
Experimental group of Asthma patients.
7 Comparison of Mean and Standard Deviation between Tests 94

of Well Being Index Scores of Control Group.
8 Comparison of Mean and Standard Deviation between Tests of 95

Well being Index scores in Experimental group of Asthma
patients.
9 Comparison of Mean, and Standard Deviation of Well being 96

Index Scores between Control group and Experimental group
of Asthma patients
10 Comparison of Domain Wise AQLQ Scores between Control 98

and Experimental group in Pretest of Asthma Patients
11 Comparison of Domain wise AQLQ Scores between Control 100

and Experimental Group in Post test I of Asthma Patients.
12 Comparison of Domain wise AQLQ between Control And 102

Experimental Group in Post test II of Asthma Patients
13 Comparison of Domain wise AQLQ scores between Control 104

and Experimental Group in Post test III of Asthma Patients
14 Assessment of Quality of life of Control and Experimental 106

group from Pre -test to Post-test III
15 Assessment of Well being of Control and Experimental group 107

from Pre-test to Post-test III
16 Comparison of AQLQ Scores between Pre-test and Post-tests 108

in Control and Experimental group of Asthma patients using
ANOVA.
17 Level of Acceptability of Peak flow Self Management Plan in 111
Experimental Group of Asthma Patients
18 Correlation between the Domains of AQLQ in Control group 112

of Asthma patients in Pre-test (n=100).

of Asthma patients in Post-test I (n=100)

of Asthma patients in Post-test II

of Asthma patients in Post-test III.
22 Correlation between the Domains of AQLQ in Experimental 117

group of Asthma patients in Pre-test

group of Asthma patients in Post-test I.

group of Asthma patients in Post-test II.
25 Correlation between the Domains of AQLQ in Experimental 120-121

group of Asthma patients in Post-test III.
26 Association between Pre Test Mean Scores of AQLQ (Asthma 122-123

quality of life questionnaire) and Selected Demographic
Variables among Asthma Patients in Control group.
quality of life questionnaire) and Selected Clinical Variables
among Asthma Patients in Control group

quality of life questionnaire) and Selected Demographic
Variables among Asthma Patients in Experimental group

quality of life questionnaire) and Selected Clinical Variables
among Asthma Patients in Experimental group
30 Association between Post-test II Mean Scores of AQLQ 131-132

(Asthma quality of life questionnaire) and Selected
Demographic Variables among Asthma Patients in Control
group.

(Asthma quality of life questionnaire) and Selected Clinical
Variables among Asthma Patients in Control group.

(Asthma quality of life questionnaire) and Selected
Demographic Variables among Asthma Patients in
Experimental group.

(Asthma quality of life questionnaire) and Selected Clinical
Variables among Asthma Patients in Experimental group.
LIST OF FIGURES
S. No Title Page No
Conceptual Framework on Effect of peak flow based on Bandura’s self

1 18A
regulatory (cognitive Theory )model
2 PRISMA Flow Diagram 55
3 Schematic Representation of the Research Design 66
4 Mean scores of AQLQ of Experimental group from Pre test to 91

Post test III
5 Mean scores of AQLQ of Control group and Experimental 93

1 Mean scores of AQLQ of Experimental group from Pre
group from Pre test to Post test III
test to Post test III
6 2 scoresMean
Mean scores
of Well beingofIndex
AQLQfrom
of Control
Pre testgroup andTest
to Post Experimental
III between 97
group from
Control and Pre test to Post
Experimental test III
Group.
Mean Scores of Domain wise AQLQ in Control and Experimental 99

group in Pre Test
7
8 Mean Scores of Domain wise AQLQ in Control and Experimental 101

group in Post test I.
9 Mean Scores of Domain wise AQLQ in Control and Experimental 103

group in Post Test II
10 Mean Scores of Domain wise AQLQ in Control and Experimental

group in Post Test III
105
11 Trends of AQLQ improvements from Pre-test to Post-test III between 109

the Control and Experimental groups of Asthma patients.
12 Trends of Well being improvements from Pre-test to Post-test III 110

between the Control and Experimental groups of Asthma patients.
LIST OF ANNEXURES
S. No. Title
A Part Time Provisional Registration Certificate - Ph.D Degree
B Confirmation of Provisional Registration
C Constitution of Doctoral Advisory Committee - Certificate
D Institutional Ethics Committee Approval Certificate
E Plagiarism check Certificate, Plagiarism Analysis Report by Urkund,

Screenshot of Plagiarism Analysis
F Certificate for English Editing
G Certificate for Tamil Editing
H Letter granting permission to conduct the study from Deputy Director of Health
services
I Grant of permission to use the Johns Hopkins Nursing Evidence Based Practice
Models and Tools
J Evidence of permission to use Standardized AQLQ Questionnaire
K Evidence of WHO requiring no permission for using Standardized Well being Index
(English)
L Evidence of permission to use Standardized WHO Well being Index (Tamil

Translation)
M List of experts who validated the tool
N Letter seeking permission to conduct research study

O Request for opinions and suggestions of experts for content validity, Criteria
Checklist for Evaluation, Content Validity Index and Content Validity
Certificate
P Research participant consent form
Q Tool in English
R Tool in Tamil
S Information Booklet on asthma in English
T Information Booklet on asthma in Tamil
U Peak flow self management plan Intervention protocol
V Thesis related Publications
W Ph.D Synopsis Submission Application Form
X Photos
Y Master Coding Sheet

ABBREVIATIONS
1. DALYs Disability-Adjusted Life Years
2. PFM Peak Flow Meters/Peak Flow Monitoring
3. GINA Global Burden of Asthma Report
4. COPD Chronic Obstructive Pulmonary Disease
5. AQLQ Asthma Quality of Life Questionnaire
6. WBI Well Being Index
7. EMBASE Excerpta Medica Data BASE
8. PRISMA Preferred Reporting Items for Systematic Reviews and Meta –
9. ACS Analyses
Asthma Control Score
10. OR Odds Ratio
11. PEFR Peak Expiratory Flow Rate
12. CUE Computer Using Educator
13. CI Confidence Interval
14. RR Relative Risk
15. RCT Randomoized Controlled Trial
16. FEV1 Forced Expiratory Volume in one second
17. WHO World health organization
18. ICS Inhaled Corticosteroid
19. ASQ Asthma Status Questionnaire
20. GINA Global Initiative for asthma
21. SFC Salmeterol/ Fluticasone Combination
22. SAL Salmeterol
23. ER, ED Emergency Room / Department

24. CINAHL Cumulative Index to Nursing and Allied Health Literature
25. BMI Body Mass Index
26. US United States of America
27. UK United Kingdom
28. PFB Peak Flow Based
29.. NAP No Action Plan
30. SB Symptom Based

Chapter – I
Introduction
CHAPTER - I
INTRODUCTION
Back Ground of the Study
Human beings have number of basic needs that are vital for his living, and the
most essential need is oxygen. They can live without food or water for few hours or
even days but cannot live without air. But in asthma airway spasm and airflow
restriction makes breathing difficult leading to air hunger. Bronchial asthma was
officially named as specific respiratory disorder by Hippocrates in 450 BC. In fact the
term Asthma comes from Greek Aazein, meaning to pant, to exhale with the open
mouth, sharp breath.1 Asthma has puzzled and confused physicians from the time of
Hippocrates to the present day.
Asthma is a chronic disease of the small airways. The hallmarks of asthma are
chronic inflammation, reversible obstruction and airflow limitation. It is a potentially
life-threatening or serious airway disease that imposes a substantial burden on
patients, their families and the community. Maintaining patent airway has always
been vital to life, but asthmatic patients are incapable of keeping their airways clear
though air is available in the atmosphere.
While communicable diseases describes mortality and morbidity from major
diseases and risk factors to health, "Chronic non communicable diseases are bringing
greater disease burden, accounting for more than half of the global mortalities and
global morbidity".2 Sir George Alleyne, calls it the silent tsunami." WHO Director-
General warned that asthma is on the rise "everywhere" and referred to it as a
festering sore.2 Asthma is also an epidemic. It has become a disease of interest
worldwide because of its impact on individuals and societies.
1
Asthma is a familiar and growing disease today, and has increasing
prevalence, but its story goes back to the ancient world, as we know from accounts in
ancient texts from China, India, Greece and Rome. It was treated with acupuncture
and Ayurveda.3 There is higher prevalence of asthma in developed than in developing
countries and its prevalence increases by 50% every decade. Globally, it affects 5-
10% of population.4 In Saudi Arabia, asthma prevalence has been reported in the
proximity of 20% with regional variations. About 8-14% of Saudi children have
asthma, and physician-diagnosed asthma in adolescent age of 16 − 18 years is 19.6%.
In Australia, where asthma was made a national health priority, the 2010
statistics showed that its prevalence in children under 14 years of age reached
18.4%. About 8.3% of US population have asthma and the number of asthmatic
patients has increased from 20 million in 2001 to 26 million in 2011. In North
America, 10% of the population have asthma. 5
In developing regions, Africa, Central and South America, Asia, and the
Pacific however, asthma prevalence is rising sharply with increasing urbanisation and
westernisation. High prevalence rates have been reported in Peru (13.0%), Costa Rica
(11.9%), and Brazil (11.4%). Most of the Asian countries including India and China,
although reporting relatively lower prevalence rates than those in the West, account
for a huge burden in terms of absolute numbers of patients. 6
In Asia, increased prevalences are likely to be particularly dramatic in India
and China. For example, a 2% increase in prevalence in China would lead to an
additional 2 million asthma sufferers. Asthma incidences in India have increased
significantly over the years in the country. India has an estimated 15-20 million
asthmatics. As per National Family Health Survey of India, 2468 persons per 100,000
population are reported to be suffering from asthma, which is considerably higher in
2
rural areas (2649 per 100,000 population) than in urban areas (1966 per 100,000
population).7 During the world Asthma Day (May 3’ 2011), city Pulmonologists said
the prevalence of asthma has increased by 7% in Coimbatore over the last decade. It
has shot up from one to seven percent across India. The industrial city of Coimbatore
dotted with spinning mills, dyeing units, foundries, automobile spare parts and
manufacturing units, has recorded highest increase.8
The increased incidence of asthma worldwide has been attributed to the
modernization of societies. Changes in lifestyle, food habits, environmental exposure
and cigarette smoking are contributing factors to increased number of asthmatic
patients. The percentage of children with asthma has increased over the last few years.
Overall, females have higher current asthma prevalence than males, although among
children aged 0–17, boys seem to have a higher prevalence than girls. 8
The number of disability-adjusted life years (DALYs) lost due to Asthma
worldwide have currently been estimated at about 15 million per year. Worldwide,
asthma accounts for around 1% of all DALYs lost, thus reflecting the high prevalence
and severity of asthma. Asthma continues to be a serious public health problem. The
burden of illness from asthma is high and increasing. Asthma is under diagnosed and
poorly treated, although the use of inhaled corticosteroids has made a positive impact
on outcomes.9
Nevertheless there are problems with the delivery of care, which include
under-treatment with corticosteroids, limited knowledge, and poor asthma
management skills amongst patients with severe asthma. There has been a great
interest in developing treatment guidelines for asthma in many countries. The focus in
all asthma treatment guidelines is to control asthma symptoms by involving patients
in their treatment planning and execution. Though effective screening, evaluation, and
3
management strategies for asthma are well established in high-income countries, these
strategies have not been fully implemented in India as evidence had previously
suggested that asthma is not to be treated independently but fitted into the general
spectrum of respiratory diseases. Therefore, asthma education has become the main
component of the treatment plan. Studies have shown that simple educational sessions
for asthmatics could have positive impacts on patients' adherence to treatment and
control of symptoms.
According to a review conducted to analyze costs and the cost-effectiveness of
self-management based on peak flow monitoring interventions in asthma, home peak
flow monitoring increases patients' self-management and could lead to cost savings.
Twenty-one studies were included in this review. Data were extracted, and
methodological and economic quality were assessed. These studies presented
economic information regarding self-management interventions based on peak flow
monitoring in asthmatics. The mean methodological quality was 4.6 (maximum 8),
and the mean economic quality was 12.0 (maximum 15). In eighteen studies, the
interventions led to net savings compared with usual care or less intensive
intervention. Only three studies found the total costs to be higher in the intervention
group. In thirteen of the seventeen studies that analyzed health outcomes, at least one
of the reported health outcomes improved statistically significantly after the
intervention. The results emphasize the need for guidelines to increase the
comparability of cost-effectiveness evaluations relating to asthma. 10
The management of asthma relies on a patient's ability to monitor their
asthma regularly. Self-monitoring includes assessing the frequency and severity of
symptoms such as wheezing and shortness of breath and measurement of lung
function with a peak flow meter. Patients are required to take their regular
4
medications along with the home monitoring of peak flow. There are two types of
medicines for asthma: aanti-inflammatory drugs used as. controllers and quick relief
or emergency drugs used as bronchodilators. Education is a light that shows the
mankind the right direction to surge. Education directed toward asthma self-
management emphasizes patient participation in symptom monitoring and control.
Educational programs on self management can reduce morbidity.
Self management is to empower patients with the knowledge and skills they
need to treat their own illness. Self-management support programs assume a complex
sequence of effects. Developers expect these programs to change patients’ behavior
by increasing the patients’ self-efficacy and knowledge. Improved behavior is
expected to lead to better disease control which should, in turn, lead to better patient
outcomes and reduced utilization of health care services, particularly preventable
emergency room visits and hospitalizations, and ultimately to reduced costs.
Peak flow monitoring of asthma came into vogue with the advent of asthma
self-management programs. Because it offered an objective way to gauge asthma
severity, it promised improvement in the accuracy of asthma monitoring over that
attainable by symptom monitoring.11 The benefits of peak flow monitoring in asthma
self-management provide, at best, no more than a small increment in effectiveness
beyond that afforded by symptom monitoring.
Benefits of using a peak flow meter include: Patients can tell what is going on
in his bronchial tubes rather than just guessing how he feel. He can find out if the
treatment is effective. He will know whether he need to change his treatment. It’s a
written record he can show his health professional.
5
These benefits can help patients feel more in control, have fewer emergency
visits, and spend less money on uncontrolled asthma. In managing chronic asthma,
long-term daily peak flow rate monitoring may assist with the following measures:
Detecting early changes in asthma that may require therapy, Evaluating
responsiveness to changes in therapy, Giving a quantitative measurement of
improvement and Identifying temporal relationships between environmental and
occupational exposures and bronchospasm.
The most frequent use of peak flow rate measurement is in home monitoring
of asthma, where it can be beneficial in patients for both short- and long-term
monitoring. When properly performed and interpreted, peak flow rate measurement
can provide the patient and the clinician with objective data upon which to base
therapeutic decisions.
Guided self-management is a cornerstone of asthma care for all age groups.
When compared with “usual care” in a recent systematic review, self-management
training backed by a written action plan reduced hospitalizations, unplanned doctor
visits, emergency room attendance, work absence, and nocturnal asthma in adults.
The introduction of self-management training programs reduces direct and indirect
health-related costs.
Research studies to compare the use of patient-performed peak expiratory flow
(PEFR) and symptom monitoring as asthma self-management tools have shown that
PEFR self-monitoring is a more useful asthma tool than symptom self-monitoring.
The study recommends the use of peak flow meters (PFM) as an important
part of self-management plans after a trial with 92 adult asthma patients in a primary
6
care setting to compare the effectiveness of action plans using either peak flow
monitoring or symptoms to guide self-management. The study has found significant
improvements within groups for FEV1.12
Management of asthma based on PEFR measurements can result in early
recognition and prompt treatment of asthma exacerbations and PEFR monitoring in
the setting of a comprehensive self-management program can lead to fewer symptoms
of asthma, fewer emergency examinations, fewer hospitalizations, lower requirements
of inhaled β-antagonists and oral corticosteroid therapy, and better pulmonary
function.13 As a nurse it is important to help the asthma patients in order to improve
the quality of life and promote their health to the fullest of living. So the investigator
would like to apply the knowledge in the field of improvement in asthma control,
outcomes and management.
Need For The Study
Asthma is a chronic inflammatory condition that makes it hard to get air in and
out of lungs during asthma attacks. Asthma can be a life-threatening disease if not
properly managed. In an asthma attack, 3 things happen: the wall of the airway gets
swollen and inflamed, the muscles surrounding the airway have spasm and mucus fills
the air passages. These 3 things make the airway narrower, so it is harder to get air
through, and less oxygen reaches the blood. When people have an asthma attack, they
can feel chest tightness, throat tightness, wheezing and can cough a lot. The resulting
airway obstruction and bronchial constriction may lead to oxygen insufficiency and
respiratory failure.14,15
7
Wilson, et al. took bronchoscopic biopsies from major airways of 12 patients
with asthma and 11 control patients and evaluated bronchial vessel numbers and size,
using computerized image analysis, the airways of asthmatic patients were
significantly more vascular with more vessels than the controls. 16 Despite of advanced
studies in asthma causes and pathogenesis the exact cause of asthma is unknown.
People with asthma have inflamed and sensitive airways that become clogged with
sticky mucus in response to certain triggers. 17
In the recent years, the morbidity and mortality of population due to asthma is
increasing despite the advances being made in understanding of this disease and
availability of improved medications and information on treatment. World-wide,
deaths from this condition have reached over 180,000 annually. Asthma creates a
substantial burden on individuals and families as it is more often under-diagnosed and
under-treated. Asthma exacerbations result in approximately 5,000 deaths per year
and are largely preventable. Death rates are higher among minorities, especially those
who live in inner-city housing.
In India, according to WHO an estimated 57,000 deaths were attributed to
Asthma in 2004 and it was seen as one of the leading cause of morbidity and mortality
in rural India. According to the global burden of asthma report (GINA), over 50
million suffer from asthma in Central and Southern Asia and an absolute 2% increase
in the prevalence of asthma in India would result in an additional 20 million people
with this disease.18 According to the Asthma and Allergy Foundation of America,
asthma control is difficult for 25 million asthma sufferers in the US alone, it is one of
the most common and costly diseases and there is no cure for asthma. 19
8
With the projected increase in the proportion of the world‘s urban population
from 45% to 59% in 2025, there is likely to be a marked increase in the number of
asthmatics worldwide over the next two decades. It is estimated that there may be an
additional 100 million persons with Asthma by 2025 suggesting asthma prevalence
increase globally by 50% every decade.20
In addition to its prevalence and cost of its treatment asthma represents a
world wide socioeconomic burden on health care delivery system. The National
Institute of Allergy and Infectious Diseases reports (2007) spending related to asthma
at $19.7 billion. In the US, the cost of asthma is estimated to be around $56 billion
each year.21 In a systematic review of the economic burden of asthma, hospitalization
costs up to 86% of all asthma-related cost, and poor asthma control was associated
with increased cost of care. 22 They impose direct costs through consumption of
resources through hospitalizations, physician visits, and medications. Although
difficult to measure, the indirect cost of asthma is immense. Missed work days,
absence from school, low productivity, emotional and social impacts are examples of
indirect costs of asthma. During an asthma flare up, patients struggle to breathe in air
having sensation of air hunger, that terribly upset and so they experience fear that they
are going to die. The very feeling that another asthma episode could start at any time
may cause a person to feel anxious constantly. 23
Asthma also affect individual’s quality of life. It is associated with poorer
quality of life, with disease severity and the level of control both having an impact. It has
varying degrees of impact on the physical, psychological and social wellbeing of
people living with the condition. People with asthma are more likely to report a poor
quality of life. This is more pronounced among people with severe or poorly
9
controlled asthma.24,25 A 2012 survey of 2,686 Australians aged 16 years and older
with current asthma found that asthma was not well-controlled in 45% of people with
current asthma. More than half of this group were not using a preventer inhaler, or
were using it infrequently.
Michele Dunne and Mary Hughes conducted a study where in 31 participated
out of which 21 were female aged 22-76 years in 8 venues. They found that asthma
had a significant impact on quality of life because of symptoms suffered, amount of
medication required and the constant fear of exposure to triggers or events. The
unrelenting pressure of managing their asthma took a toll on the participants, as they
felt that their lifestyle had changed dramatically and they had lost some or all control
over their health and well-being. Many reported high levels of anxiety, and many
turned to alternative medicine to regain a sense of control. Many were frustrated that
despite following instructions from their doctor, they did not feel better. Symptoms
were frequent and could be overwhelming when trying to manage their daily lives. 26
Adding personalized care by educating asthma sufferers about how to self-
manage their disease could save money, and improve quality of life for asthmatics.
Since the disease is complex and may be difficult to manage, active participation of
the patient in both the daily self-management of the disease as well as the treatment of
acute episodes is critical.
Reduction or complete ablation of asthma symptoms is the goal of therapy.
Nevertheless majority of patients with asthma live in rural areas. As poverty levels are
higher in rural areas when compared to urban, it is imperative that primary health care
providers should focus mainly on preventive rather than curative care of the disease.
10
Low health literacy has been known as a contributor to poor health access,
health outcomes and increased health costs. Hence great emphasis is placed on
educating asthmatics to use action plans to achieve better control of symptoms. The
use of peak flow meters (PFM) has been recommended as an important part of self-
management plans and for steroid resistant patients of age 5 and older with moderate
or severe asthma. It is less time consuming as they need not take appointment with
physician avoiding emergency consultations and prevents asthma episodes.
Recent studies shows that routine use of peak flow monitoring may be useful,
but it is not the only way to guide patients in self-management of exacerbations. In
this context the investigator found the necessity to guide in asthma self management
plan and in monitoring the effect of peak flow self management in selected
community at Coimbatore for patients with asthma thus facilitate patients’ improved
quality of life.
Statement of the Problem
A study to assess the “Effectiveness of Peak flow Self-Management plan on
Quality of life for Asthma Patients in Selected Community” at Coimbatore.
Objectives
7. To assess the quality of life and general well being before and after peak
flow self management plan in control and experimental group of asthma
patients.
11
8. To assess the effectiveness of peak flow self management plan among
asthma patients by comparing the quality of life and general well being
between control and experimental group of asthma patients.
management plan in experimental group.
11. To find the association between demographic variables with quality of life
in control and experimental group of asthma patients.
12. To find the association between clinical variables with quality of life in
control and experimental group of asthma patients.
Operational Definitions
Peak Flow Self management Plan
It refers to using and monitoring of self-management of Peak Flow expiratory
rate with the use of peak flow metre and asthma information booklet as taught by the
investigator and marking of peak flow readings in the peak flow diary and graph and
the color zones as follow:
 >80-100% Above 460 EU normal zone, green color
 50-80% From 287 - 460 EU caution zone, yellow color
 <50% upto 287 EU danger zone. Red color
Peak flow metre
It is a calibrated instrument used to measure lung capacity in monitoring
breathing disorders such as asthma.
12
Asthma patients
It refers to the patients diagnosed by the physician to have current asthma.
Quality of life
It refers to the personal satisfaction obtained by asthma patients with the
cultural or intellectual conditions as measured by WHO well being index and asthma
quality of life questionnaire.
Effectiveness
It is the desired effect of peak flow self-management plan on quality of life of
asthma patients and beneficial outcome expected by the investigator as evidenced by
less absenteeism from work place, reduced emergency visits and doctor consultations.
Selected Community
In this study it refers to the semi urban area of Somanur town which the
investigator has selected to conduct the study for patients with asthma.
Hypotheses
Null Hypotheses
H01: There will be no significant difference between the mean AQLQ score and well
being index score between control and experimental group of asthma patients before
and after intervention.
H02: There will be no significant difference in the mean AQLQ score and well being
index score between first and subsequent observations in control and experimental
group of asthma patients.
13
H03: There will be no correlation between quality of life and its domains among
H04: There will not be significant association between AQLQ scores and selected
demographic variables in control and experimental group of asthma patients.
H05: There will not be significant association between AQLQ scores and selected
clinical variables in control and experimental group of asthma patients.
Assumptions
 Asthma is primarily a disease of chronic airway inflammation. Patients with
asthma experience breathing difficulty and wheezing due to inflamed, swollen
airways.
 Inflammation producing mucus and the muscles of the airway being under
spasm blocks the airway leading to narrowed air passages causing respiratory
failure.
 Recurrent asthma symptoms frequently cause sleeplessness, daytime fatigue,
reduced activity levels and school and work absenteeism.
 People with asthma are more likely to report a poor quality of life. This is
more pronounced among people with severe or poorly controlled asthma.
 Peak flow self management plan intervention can influence the outcome of
asthma patients such as productivity, fewer asthma episodes, reduced
morbidity and disability thus improving the quality of life.
14
Delimitations
 The study is delimited to only adults with chronic asthma or chronic
obstructive pulmonary disease (COPD) not suffering from other serious
diseases.
 Only patients with the age group of 20-70 years is selected.
 The study is done among the patients marking on the peak flow diary
maintained at home for peak flow monitoring.
Projected Outcome
Though asthma has a significant impact on quality of life because of
symptoms suffered, amount of medication required and the constant fear of exposure
to triggers or events, a peak flow-based asthma education and self-management plan
program would be the most cost-effective alternative in reducing costs associated with
emergency visits and hospitalizations due to asthma exacerbation. Use of written
action plans, combined with regular contact to reinforce self-management, improves
airway reactivity and reduced health care utilization. Therefore the present study
findings with simple educational plan for asthmatics could have positive impacts on
patients' adherence to treatment and control of symptoms. Further asthma patients will
demonstrate better asthma control with few symptoms and no night waking or
limitation of activity and thus improved quality of life.
15
Conceptual Framework
Conceptual framework provides a clear description of variables, suggesting
ways or methods to conduct the study and guide the interpretation, evaluation and
integration of significant findings. This study is aimed at determining the effect of
peak flow self management for asthma patients on quality of life in selected
community at Coimbatore.
Self-Efficacy Theory
The study is based on the Bandura’s self efficacy model. 27 Bandura defines
self-efficacy as 'an individual's perception of his/her own capabilities to produce
designated levels of performance'. Self-efficacy level has been used as a predictor of
health behaviours change in smoking cessation, weight loss and diet control and
avoidance of triggers.28
Three implications of self-efficacy theory are of important interest to asthma
education.
First, the theory stipulates that individuals will show strong commitment to
achieve goals if they believe in their capabilities. Here, the asthma patients on
receiving asthma information and peak flow monitoring techniques on how to monitor
their lung function will show commitment to follow the instructions provided by the
investigator in using the peak flow meter and maintaining the peak flow diary there by
peak flow self-management plan in managing asthma symptoms.
Second, verbal persuasion of individuals about their abilities increases the
likelihood of engagement in goal achievement. The investigator on providing the peak
flow diary and asthma information booklet motivates the asthma patient providing
16
positive encouragement so that he will be able to recognize his abilities that would
increase chances for goal achievement.
Thirdly, when individuals observe others succeeding in goal attainment, their
belief in themselves increases. So in this study the asthma patients were taught in a
group enhancing them to attain positive goals on asthma control as individuals
succeed when they observe others.
Health behavior change
This is a component in Bandura’s self -efficacy model. Social-cognitive
models of health behavior change cast self-efficacy as predictor, mediator, or
moderator.29
As a predictor, self-efficacy is supposed to facilitate the forming of behavioral
intentions, the development of action plans, and the initiation of action. In this study,
the asthma patients were given written action plan. The asthma action plan showed
daily treatment, such as what kind of medicines to take and when to take them. This
plan described how to control asthma long term and how to handle worsening asthma,
or attacks. The plan also explained when to call the doctor or go to the emergency
room. Patients were taught on using peak flow meter and recording of peak flow
readings in a diary.
As mediator, self-efficacy can help prevent relapse to unhealthy behavior. The
asthma patients followed the instructions regarding peak flow monitoring and
maintained diary. They also followed the education provided by the investigator from
information booklet on how to identify triggers and avoid asthma exacerbations in
order to prevent and recognize poor lung function. Patient's self-confidence was
raised while they practiced the health measures. Hence they are capable of controlling
17
their disease. In addition, unhealthy behaviors such as activity limitation, absenteeism
in school/ work, asthma flare ups, emergency physician visits and hospitalization,
improved sleeplessness and night awakenings and fatigue were prevented.
As a moderator, self-efficacy can support the translation of intentions into
action. In this study it refers to the improved health behavior and positive image that
the asthma patients developed. Thus they had good asthma control, improved quality
of life and well-being having less absenteeism, fewer asthma flare ups, less
emergency physician visits and less hospitalization, improved sleep and activity and
less night awakenings and less fatigue and less fear.
18
Fig. 1 Conceptual frame work based on Cognitive Theory by Bandura’s self-efficacy Model
18A
Summary
This chapter has dealt with the back ground of the study, need for the study,
statement of the problem, objectives of the study, operational definitions, null
hypothesis, assumptions, delimitations, projected outcome and conceptual frame
work.
19
Chapter -II
Review of Literature
CHAPTER - II
REVIEW OF LITERATURE
The review of literature is a summary of current knowledge about a particular
practice problem. A literature review is an organized written presentation of what has
been published on a topic by the scholars.
An extensive search of research and non research literature was performed in
electronic search engines such as PubMed / Medline, EMBASE, PsychInfo and
Cochrane Central Register of Controlled trials for trials / studies reported in English.
Also direct searches of specific journals and backward searches through reference
lists of related publications were done.
Review of literature for the present study aimed to synthesize existing
evidence of studies on various study designs, with a special focus on randomized
controlled trials on the use of pharmacologic and non-pharmacologic interventions to
manage asthma symptoms and patient’s adherence to asthma treatment and
written action plan as well as educational intervention for asthmatic patients. The
review also focused on peak flow self management intervention in asthma control
and quality of life.
Literature reviewed related to the research work and Development of Nursing
Evidence Based Practice Protocol was applied. The Nursing Evidence Based Practice
Protocol include Nursing Evidence Based Practice question development, PRISMA
Flow Diagram, and Individual Evidence Summary.
20
Review of literature for the present study is also organized under the following headings:
 Prevalence and risk factors of asthma
 Asthma control and management

Peak flow self management and quality of life
 Online Asthma Information
 Correlation between Asthma symptoms and lung function
Prevalence and risk factors of asthma
Aggarwal1 et al (2006) estimated the Prevalence and Risk Factors for
Bronchial Asthma in Indian Adults. A Multicentre Study was conducted at
Chandigarh, Delhi, Kanpur and Bangalore through a two stage stratified urban/ rural
sampling and uniform methodology using a previously validated questionnaire on
73605 respondents. Besides demographic data, information on smoking habits,
domestic cooking fuel used, atopic symptoms, and family history suggestive of
asthma was also collected. Univariate and multivariate logistic regression modelling
was performed to calculate odds ratio of various potential risk factors. One or more
respiratory symptoms were present in 4.3-10.5% patients. Asthma was diagnosed in
2.28%, 1.69%, 2.05 and 3.47% respondents respectively at Chandigarh, Delhi,
Kanpur and Bangalore, with overall prevalence of 2.38%. Female sex, advancing age,
residence in urban area, lower socio-economic status, history suggestive of atopy,
history of asthma in a first degree relative, and all forms of tobacco smoking were
associated with significantly higher odds of having asthma. 30,31
Basagaña et al (2004) conducted a study on Socioeconomic Status and
Asthma Prevalence in Young Adults of 20-44 years of age in which Asthma
prevalence was higher in lower socioeconomic groups, and patients of low
21
educational levels had a higher risk of asthma. They suggested the role of early-life
events such as maternal diet or the fetal and post natal environment is one possibility.
Child hood and adult hood obesity, inactivity, and diet are also risk factors for asthma.
31
Agrawal et al (2013) estimated the prevalence of self-reported asthma in adult
Indians and examined several risk factors influencing disease prevalence. 99, 574
women and 56, 742 men aged 20–49 years were included in India’s third National
Family Health Survey, 2005–2006. The prevalence of self-reported asthma was 1.8%
(95% CI 1.6–2.0) among men and 1.9% (95% CI 1.8–2.0) among women, with higher
rates in rural than in urban areas and marked geographic differences. After adjustment
for known asthma risk factors, women were 1.2 times more likely to have asthma than
men. Daily or weekly consumption of milk or milk products, green leafy vegetables
and fruits were associated with a lower asthma risk, where as consumption of
chicken/meat, a lower body mass index (BMI; <16 kg/m2, OR 2.08, 95% CI 1.73–
2.50) as well as a higher BMI (>30 kg/m2, OR 1.67, 95%CI 1.36–2.06), current
tobacco smoking (OR 1.30, 95%CI 1.12–1.50) and ever use of alcohol (OR 1.21,
95%CI 1.05–1.39) were associated with an increased asthma risk. 32
Burke et al (2003) conducted a study to assess the Family history as a
predictor of asthma risk. Their search identified 33 studies from all geographic
regions of the world for review. Family history of asthma in one or more first-degree
relatives was consistently identified as a risk factor for asthma. In ten studies,
sensitivity and predictive value of a positive Family history of asthma were
calculated. Sensitivity ranged from 4%-43%, positive predictive value from 11%-
37%, and negative predictive value from 86%-97%. Although a positive Family
22
history predicts an increased risk of asthma, it identifies a minority of children at
risk.34
Ledford et al (2013) conducted a review on Asthma and comorbidities, and it
was found that obesity likely affects asthma symptoms and possibly its pathogenesis.
Treatment of asymptomatic gastroesophageal reflux does not improve asthma. It was
concluded that Evidence-based medicine is lacking as most asthma studies exclude
comorbidities; and that additional studies are needed. 35
Cerveri et al (2012) conducted a study to investigate changes in smoking
habits and their effects on forced expiratory volume in 1 s (FEV 1) in patients with
asthma in comparison with the rest of the population, focusing on the healthy smoker
effect. Patients were 9092 without asthma and 1045 with asthma at baseline who
participated in both the European Community Respiratory Health Survey I (20-44
years old in 1991-1993) and II (1999-2002).
At follow up, smoking was significantly less frequent among patients with
asthma than in the rest of the population (26 vs.31%; p<0.001). Patients with asthma
who were ex smokers at the beginning of the follow up in the 1990s had the highest
mean score (number of reported asthma-like symptoms, range 0-5), probably as a
result of healthy smoker effect (2.80 vs. 2.44 in never smokers, 2.19 in quitters and
2.24 in smokers p<0.001). The influence on smoking on (FEV1) decline did not
depend on asthma status. Smokers had the highest proportion of patients with chronic
cough/phlegm (p<0.01). One out of 4 patients with asthma continues smoking and
reports significantly more chronic cough/phlegm than never smokers and ex-smokers.
This stresses the importance of smoking cessation in all patients with asthma, even in
those with less severe asthma.36
23
Saxena T et al (2011) conducted a retrospective study on Mild cool air a risk factor
for asthma exacerbations at Mittal Hospital & Research Centre and J. L. N. Medical
college hospital at Rajasthan by collecting data for the period of four years from
January 2006 to December 2009. This record included symptoms, history of exposure
to various risk factors, and PEFR. Environmental data was also collected. On the basis
of record monthly attack rate was calculated. Maximum attack rate (> 90%) was
found in October, November, early winter and February and March during all the four
years studied except in October 2009. A common precipitant present during these
months was mild cool air when the environmental temperature of 23-27o. Attack rate
was very less above and below of this temperature. No clear association was present
with any other known precipitants. It was concluded that inhalation of mild cool air
23-27oc may be an important risk factor besides other risk factors for asthma
exacerbation.37
Asthma control and management
Hasegawa et al (2012) conducted a study on Asthma control and management
changes in Japan. A questionnaire survey to investigate the changes in asthma control
and management for every two-year period using the data from 1998 to 2008. The
number of cases surveyed each year was about 3,000 (2,593-3,347 cases). The
changes in the data from 1998 to 2008, including asthma attacks and symptoms rate,
indicated the improvement of asthma control with the spread of medication according
to the guidelines; of particular note, there was a 24.1% increase in the usage rate of
inhaled corticosteroids during the study period. 38
Andrews et al (2014) conducted a study on Asthma self-management in
adults: A review of current literature to establish an understanding of current
24
published literature on asthma self-management programs in adults and to identify
any reported attributes or components which serve to either assist or obstruct the
uptake of self-management strategies. Electronic data sources including Scopus,
Proquest 5000, CINAHL, PubMed and Web of Science were accessed and literature
searches were conducted. Sixty four articles were included in this review due to their
relevance to the major components of asthma self management, as defined by the
Australian Asthma Management Handbook. A major conclusion from this review was
that the uptake of asthma self-management strategies is poor despite global
recommendations for over twenty years; and that a likely reason for this is that
generic asthma self-management advice does not engage the individual with asthma. 39
BoLundbäck and EvaRönmar (2009) conducted a 3-year “real-life” study,
during which patients' medication was increased and decreased to achieve sustained
asthma control. Patients (282) were randomised to receive treatment with SAL
(salmeterol) 50 μg, FP (fluticasone propionate, 250 μg, or SFC (Salmeterol/
fluticasone combination) 50/250 μg via a Diskus inhaler, bid. A 12-month double-
blind period was followed by a 2-year open phase. The physician increased or
decreased patients’ medication to achieve and maintain asthma control at regular
clinical assessments using criteria based on the asthma treatment guidelines. On
completion 73% (168/229) of the patients were receiving SFC to maintain control of
their asthma, compared with 21% (49/229) receiving FP and 5% (12/229) receiving
SAL. Odds ratio for requiring increased treatment were 2.66 (p = 0.002) for patients
initially randomised to FP and 9.38 (p < 0.0001) SAL, compared with SFC. Time
until 25% of patients first required an increase in study medication was 6 months for
patients initially treated with SAL compared to 12 months for FP and 21 months for
SFC. Symptoms and use of rescue medication improved first, followed rapidly by
25
PEF with the greatest improvements occurring over the first year. Airway hyper
responsiveness continued to improve throughout the study. The majority of patients
achieved and maintained control of asthma over a 3-year period with physician-driven
medication changes. Patients treated with SFC were more likely to achieve control
than patients treated with FP or SAL alone. 40
Asthma control has been studied in Saudi Arabia. Al-Jahdali et al
(2008) 41 evaluated asthma control for 1,060 asthmatic patients in five medical centres
in Riyadh using Asthma Control Test (ACT) scores. They found that only 5% of
surveyed patients had completely controlled asthma, 31% well-controlled and 64%
had uncontrolled asthma symptoms. Gender difference in asthma control was evident
in this study as only 30% of females had controlled asthma as compared to 44% of
male asthmatics. In another study, Al-Jahdali et al (2013)42 surveyed 450 adult
asthmatic patients in two major hospitals in Riyadh and found that 40% of them did
not receive any formal education on asthma control. They also reported that about
50% of studied patients were unable to use inhaler devices properly leading to poor
asthma control and increased ED visits. Incorrect use of inhalers has been associated
with poor asthma control in several studies. 43,44,45 In another gulf state, Oman, a study
by Al-Busaidi and Soriano (2011)46 reported that more than 50% of surveyed
patients had poor or not well controlled asthma.
In a retrospective study of more than 100,000 patients with asthma to
investigate indicators of asthma control in the US over a 3-year period (2008-2010),
Julia et al (2014) found that 51% of individuals diagnosed with asthma had at least
one exacerbation in the last year, and 46% of asthmatics reported use of a quick-
relieve inhaler for asthma symptoms in the last 3 months. Another important finding
of this study was that only 22% of asthmatic in the US used long-term control
26
medications. These results clearly indicate that asthma control in the study sample,
and by generalization to the US population, is suboptimal.47
Apter et al (2013) studied the association of health literacy to asthma self-
management in 284 adult patients and found that higher health literacy was linked to
better asthma control and adherence to therapy. 48 In Canada, asthma was reported to
be poorly controlled in 53% of patients. 49 In Sweden, the proportion of patients who
had asthma control was not only low (37%) in 2001, but it did not significantly
improve in 2005 (40%).50
Rabe et al (2004) conducted a study on World wide severity and control of
asthma in children and adults: The global asthma insights and reality surveys. A
cross-section of households in 29 countries in North America, Europe, and Asia were
surveyed to identify from the general population asthmatic patients with symptoms
within the last year or who were taking current asthma medication. A standard
questionnaire was administered to 7786 adults, and 3153 children with asthma
Objective and subjective patient perception of asthma control and severity were
assessed, including access to medical care, health care use, missed work-school, and
medication use.
The current level of asthma control worldwide falls far short of the goals for
long-term management in international guidelines. A significant proportion of patients
continue to have symptoms and lifestyle restrictions and to require emergency care.
The proportion of adult asthmatic patients who were current smokers was also high.
However, the use of anti-inflammatory preventative medication, even in patients with
severe persistent asthma, was low, ranging from 26% in Western Europe to 9% in
Japan, as was the use of objective lung function testing. The correlation between self-
27
perceived severity of asthma and objective assessment of severity on the basis of
GINA criteria was consistently poor in all areas. It was concluded that there is direct
evidence for suboptimal asthma control in many patients worldwide, despite the
availability of effective therapies, with long-term management falling far short of the
goals set in the GINA guidelines.51
Cazzoletti et al (2007) conducted a study to assess asthma control in several
European centers according to the Global Initiative for asthma (GINA) to investigate
its determinants. In the European Community Respiratory Health Survey II (1999-
2002), 1241 adults with asthma were identified and classified into inhaled
corticosteroid (ICS) users and non-ICS users in the last year. Control was assessed in
both groups by using the (GINA) proposal (controlled, partly controlled, and
uncontrolled asthma), and it was related to potential determinants.
Results were only 15% (95% CI, 12% to 19%) of patients who had used ICSs
in the last year and 45 % (95% CI,41%-50%) of non ICS users had their asthma under
control; individuals with uncontrolled asthma accounted for 49% (95%CI, 35%-90%;
Italy). Over weight status, chronic cough and phlegm and sensitization to
Cladosporium species were associated with poor control in ICS users. About 65% and
87% of ICS users with uncontrolled and partly controlled asthma, respectively, were
on a medication regimen that was less than recommended by the GINA guidelines.
Six of 7 European asthmatic adults using ICSs in the last year did not achieve good
disease control. Majority of poorly controlled asthma were using anti asthma drugs in
a suboptimal way.52
Kotwani A and Shendge S (2013) conducted a study on Assessment of
Adherence to Inhaled Corticosteroid Treatment for Asthma: A Cross-Sectional Study
28
from Delhi The study aims were to (i) evaluate patients’ self-reported adherence to
ICS therapy, (ii) identify possible reasons for non-adherence, and (iii) identify
possible correlations between ICS adherence, medicine beliefs and socio-
demographic factors of asthma patients.
Adults with previously diagnosed asthma (n=200) presenting to the emergency
room (March 2009-December 2009) of a public chest hospital in Delhi for asthma
exacerbation completed an interviewer-administered questionnaire on socio-
demographics, clinical history, self-reported adherence, beliefs about causes of
disease, medicine beliefs and medication adherence after stabilization of their
condition.
The mean duration of registration with the study hospital was 5.4±4.4 years
and all were prescribed ICS treatment. Self-report on adherence: 49% took medicines
even without symptoms; 91.0% reported they forgot to take their medicine “some or
lot of times”; 84.0% avoided medicines “some of the times”. Important reasons for
avoiding medicines were no symptoms (59.5%), cost (34.5%), fear of getting
dependent (29%), side effects (17%) and social inhibition (14.5%). Correlation
between self-reported adherence and demographic factors, such as age, sex, education
and income was calculated. The commonly endorsed causes for asthma were pollution
(33.5%), poor medical care in the past (15.5%), heredity (8.5%), cold climate (7.5%),
and diet (5.5%). Non-adherent behaviors were associated with doubts about the
necessity of medication and concerns about its potential side effects with long-term
use (r=-0.299, p<0.001).53
Corsico (2015) and his colleagues conducted an epidemiological study in 12
countries (including USA, UK, Australia and several European countries), to assess
29
patients adherence to asthma treatment. The study revealed that only 56% of study
sample reported adherence to treatment regimen. This study also unveiled two
interesting findings about factors related to the issue of adherence. First, negative
patient's belief about medications was associated with poor adherence. Second, better
patients' follow-up with health-care providers predicts good adherence. The main
objective of asthma education programme is to educate patients about his/her asthma
medications and clarify common misconceptions about side effects of medications.
This, in turn, should improve patient's follow-up with their doctors and their
adherence to the prescribed treatment regimens. 54,55
In order to help patients follow treatment steps in a standardized manner, the
asthma written action plan was introduced as an important component of asthma
treatment. Asthma action plan comprises written instructions that help patients
understand severity of disease symptoms and act upon the degree of symptoms.
According to the National Asthma Council of Australia, the use of written action plan
has been found to reduce hospital visits and absenteeism from work.
Douglass et al (2002) interviewed 62 adult patients who visited ED for asthma
exacerbation and found that the most common reason for them not to have a written
action plan was that their doctors did offer or discuss it with them. 56
In a randomized controlled trail, Ducharme et al (2011) studied the effect of
providing a written action plan for 219 children. The experimental group had higher
adherence to the treatment regimen and medical follow-up as compared to the group
that did not receive asthma action plan. 57 Abramson et al (2001) conducted an
interesting research to study contribution of using written action plan to death from
asthma. They found that the use of the written action plan was associated with 70%
reduction in risk of death.58
30
In Australia, the Centre for Asthma Monitoring reported that in asthmatic
patients above 15 years of age, only 14.4% have written asthma control plan. The
same centre reported that 88% of south Australian adults with asthma complained of
asthma symptoms in 2009.
Horne et al (2002) conducted a study on Self-regulation and Self-
management in Asthma: Exploring the Role of Illness Perceptions and Treatment
Beliefs in Explaining Non-adherence to Preventer Medication. He evaluated the
degree to which variations in reported adherence to preventer medication for asthma
could be explained by two sets of beliefs: perceptions of asthma and perceptions of
asthma medication (beliefs about its necessity and concerns over its use). It also
begins the empirical testing of an extended self-regulatory model, which includes
treatment beliefs as well as illness perceptions. Using a cross-sectional design, 100
community-based patients completed validated questionnaires assessing their
perceptions of asthma, beliefs about preventer inhalers and reported adherence to
them. The findings showed that non-adherent behaviours were associated with doubts
about the necessity of medication and concerns about its potential adverse effects and
with more negative perceived consequences of illness. 59
To assess effectiveness of providing education in setting, Williams et
al (2013) implemented a simple educational intervention for asthmatic patients and
their parents during ED visits and found that the group who received an educational
session had significant improvement in outpatient follow-up rate (50% vs. 20.8%, p <
0.001) as compared with a group of asthmatic children who presented to the ED but
did not receive educational intervention.60
The inter disciplinary approach of asthma education was assessed by
Walders et al (2006). They performed a randomized control trail using written
31
asthma management plan for both study groups. The intervention group received
asthma education sessions, asthma risk profile assessment and problem solving
therapy to patient's family. Both, experimental and control groups, had significant
reduction in asthma symptoms and improved quality of life, but the intervention
group showed decreased utilization of medical resources as indicated by 32%
reduction in ED or inpatients use of resources. This study showed that involving
different health care disciplines in asthma education can be of great benefit to the
program.61
Using a non-traditional approach to teaching during asthma education has
been shown to produce positive results. In a randomized control trial, Watson et
al (2009) compared the effect of small group, interactive asthma education with usual
asthma management care as prescribed by patients' primary care physician. Patients
who received small group interactive asthma education made fewer ED visits, and the
likelihood of requiring emergency care was reduced by 38% (RR 0.62, p < 0.004) as
compared to the routine care group. Asthma symptoms for patients in the study group
and missed work days for their parents were less with comparison to controlgroup. 62
Poureslami et al (2012) conducted a randomized Controlled Trial to explore
the effectiveness of different formats of culturally relevant information and its impact
on asthma patients’ self-management within the Punjabi, Mandarin, and Cantonese
communities. Using a participatory approach, they developed and tested knowledge
and community educational videos (with similar information, but used a different
approach, i.e., scientific vs. colloquial) and a pictorial pamphlet. A total of 92
physician-diagnosed adult asthma patients (47 Chinese and 45 Punjabi) were assigned
32
at random to three experimental groups (watched one or both videos) and one
comparison group (read pictorial pamphlet) and participated in three in-person
interviews and one telephone interview within a 9-month period. Patients received
education on asthma self-management via videos and pamphlet and outcomes,
including their knowledge of asthma triggers (environmental-related and behavioral-
related triggers) and symptoms; inhaler use skills and patient-reported medication
adherence were measured. Knowledge of asthma symptoms, inhaler use, and
understanding of physician’s instructions improved significantly from pretest to 3
months post-intervention follow-up among all participants. Participants performed
significantly better at follow-up than they did at baseline assessment, with the most
notable improvements observed in the group that watched both community and
knowledge videos.63
Barthwal et al (2009) conducted a non-randomized prospective trial study to
assess the impact of optimal asthma education programme on asthma morbidity,
inhalation technique and asthma knowledge. Asthma morbidity, (comprising of
control of symptoms, unscheduled OPD visits and limitation of physical activities),
inhalation technique and asthma knowledge were assessed before and one year after
implementation of optimal asthma education programme. One hundred and seventy
two patients of persistent bronchial asthma aged 12 years or more, taking daily anti-
inflammatory drugs and having not attended any type of asthma education programme
before were included in the study. There was significant improvement in asthma
morbidity with increase in the number of patients with intermittent and mild persistent
asthma and significant decrease in patients with moderate and severe persistent
asthma. Before optimal AEP, 30 (17.4%) patients had visited hospital thrice or more
33
due to asthma sickness, after optimal AEP only 5 (8.6%) patients made unscheduled
visits only once to hospital.64
Manchana and Mahal (2014) conducted a study to assess the impact of
Asthma Education on self care management among Bronchial asthma patients.
Objectives were to assess the knowledge on self care management of Bronchial
asthma; to develop and administer the Asthma educational intervention on self care
management of asthma; and to evaluate the impact of Asthma educational
intervention on patient knowledge levels in comparison of pre and post test scores.
Quasi experimental Pre test-post test design was used on thirty patients. Two
weeks after administering structured asthma education, post-test was conducted. The
Pre-test and Post-test scores were compared to evaluate the effectiveness of the
Asthma education. There was significant enhancement on knowledge levels on four
areas of assessment and education. After asthma education the knowledge levels on
disease process raised from minimum of 10% in the pre test to 77.50% in the post test.
The knowledge scores on asthma triggers and warning signs enhanced 12% to
72%. The area of self monitoring and management records a rise in knowledge levels
from 20% minimum scoring in pre test to 82.5% in the post test. The scores in diet,
breathing exercises and adherence to drugs rose from 12.5% to 72.5% after asthma
education. The findings revealed that educating patients remarkably increased their
knowledge levels, which facilitate their behavioral modification thus enhances their
self-care.65 Effective self care management at home level decreases asthma related
morbidity and frequent visit to hospitals. 65
Osman et al (2002) designed a short (40-60 min) self-management
educational programme for 280 asthmatic patients during hospital admission and
34
found that morbidity after discharge (daytime wheezes, night disturbances and
activity limitation) has significantly reduced after implementation of the programme.
Also, readmission rate has significantly decreased [17% vs. 27%, odds ratio (OR) 0.5,
confidence interval (CI) 0.3 − 1.0] in self-management group when compared to
patients on standard care. Because patients differ in important characteristics that
could interfere with the learning process, tailoring the programme to address patient's
needs, literacy level and culture could produce better outcomes. 66
Based on this premise, Thoones et al (2002) studied the efficacy of tailored
versus traditional AEP ( Asthma educational programme). The tailored programme
was designed based on information needed by asthmatic patients as determined by a
panel of experts. The authors reported better patient satisfaction and better interaction
between patients and health-care providers when tailored programme was used.67
Takemura et al (2010) tested the effect of a structured educational
programme on the use of inhalation devices and reported that implementation of the
programme for asthmatic patients led to proper use of inhaler devices and better
adherence to treatment. In a systematic review of 38 research studies including 7,843
children with asthma, AEP was found to reduce risk for ED visits (RR 0.73) and
hospital admissions (RR 0.79).68
Martínez-Moragón et al (2014) conducted Multicenter, prospective,
observational, cohort study, assessing demographic and clinical factors that have an
impact on the quality of life (QoL) of patients with asthma in 40 Spanish Pneumology
Units during a 12-month period on 536 patients in Spain. Data on sociodemographic,
clinical variables, asthma treatment and QoL were collected in a case report form.
35
QoL was better for patients from Northern and Central Spain as compared with those
from the South and the East (p < 0.001), students and employed patients as compared
with housewives and unemployed (p < 0.01), for those who had received asthma
information (p < 0.01), for those with milder daytime symptoms (p < 0.01) and for
patients with higher level of education (p < 0.05). Thus it indicates quality of life will
be better for who receive asthma information. 69
Kotwani A and Shendge S (2012) carried out a study to assess the Effect of
patient education and standard treatment guidelines on asthma control: an intervention
trial. They evaluated the effect of standard treatment guidelines and asthma education
programme on asthma control among patients enrolled from a referral health facility
of Delhi in India.
Fifty patients who visited the health facility first time for treatment of asthma
were enrolled after confirming the diagnosis of asthma by symptoms and reversible
spirometry. Patients were interviewed at baseline using three researcher-administered
questionnaires - quality of asthma management questionnaire, asthma control
questionnaire (ACQ) and asthma knowledge questionnaire (AKQ).
All patients were given pharmacotherapy according to standard treatment
guidelines. In addition, every alternate patient was also given a face-to-face
educational intervention. Patients were followed up at 2, 4, 8 and 12 weeks. The ACQ
was used at each visit, and AKQ was reassessed at the twelfth week. The paired “t”
test was used to detect significant changes in various domains of asthma control.
The knowledge of asthma among patients and the care provided by previous
health-care providers were found to be poor at baseline assessment. The application of
standard treatment guidelines improved asthma control by the second week and the
36
changes became significant by the fourth week, which persisted till the twelfth week
(p <0.0001). Educational intervention led to improvements in knowledge in several
domains. Improvements in asthma symptoms began earlier among those who had
additional educational intervention.70
Low health literacy has been identified as an independent predictor of poor
asthma control. The Institute of Medicine considers the role of information
technology (IT) as critical in providing "safe, effective, patient centered, timely,
efficient, and equitable" care with the potential to reduce health disparities in
underserved populations.
Peak Flow Self-Management and Quality of Life
Malarvizhi et al (2015) conducted a study on “Effectiveness of Peak Flow
Guided Self Management Plan on Asthma Health Outcomes among Patients with
Bronchial Asthma. Randomized controlled trial design was used. Interventions given
to the group was Self Management plan guided by peak flow measurements that
resulted in less number of visits to Outpatient department and days off work. The
study concluded that Peak flow guided self management plan reduces the episode of
asthma and improves quality of life.71
Kaya et al (2009) conducted a study on Self-management plans for asthma
control and predictors of patient compliance to evaluate the impact of peak flow or
symptom-based self-management plans on asthma control and patients' quality of life
and to determine the main psychosocial factors that affect compliance with these
plans. Of the 63 patients 85% of them had moderately or severely persistent asthma.
Personal asthma plans increased optimal asthma control significantly. Emergency
visits, antibiotic treatments, systemic corticosteroid treatments, and unscheduled visits
37
were fewer than the previous year. Control parameters were better in the PFM group.
After the self-management education, the quality of life dimensions, i.e., vitality, total
mental and general scores of both groups increased. Compliance with the action plans
was better in the PFM group. No statistically significant association was found
between demographic parameters and the compliance. The study concluded
Introduction of self-management plans improved illness control and quality of life in
asthma patients.72
Akiyama (2002) in her literature on Self-Management with Peak Expiratory
Flow Monitoring—Treatment for Bronchial Asthma—explains that Peak expiratory
flow (PEF) monitoring should be considered in patients with moderate to severe
asthma, who are older than 5 years of age, have measurable PEF values, and receive
medication on a daily basis. In the practical treatment and management of asthma, the
PEF monitoring is most effective in cases where step-wise therapy according to
asthma severity is applied in long-term management.
The guidelines recommend to determine asthma severity on the basis of
symptoms and PEF, and subsequently to select a controller medication for each
patient consistent with the severity of the disease. The following two basic strategies
are useful for increasing or decreasing the medication dosage: One is the step-up
therapy in which treatment is moved to the next step if the disease is not controlled by
the current treatment, and the other is the step-down therapy in which the dosage can
be reduced if the target of each treatment is achieved and the disease is controlled and
confirmed to be stable for at least 3 months.
In these strategies, PEF monitoring serves as an important indicator. The
guidelines also recommend the ZONE SYSTEM to detect the earliest possible signs
38
of asthma exacerbation and start the use of a reliever medication as early as
possible.73
Features of asthma severity and control were examined on 500 patients by
Cowie et al (2007) to determine the extent to which objective measurements,
including forced expiratory volume in 1 s and forced expiratory volume in 1 s/forced
vital capacity, correlated with other manifestations of the disease. Patients were a
consecutive sample of patients with asthma attending a university-based asthma
clinic.
All patients underwent routine assessment using a standard questionnaire and
spirometry. Their assessment showed that neither symptoms nor history could predict
or be predicted by their measurements of lung function. Routine measurement of lung
function should be performed on patients with asthma if normal or near-normal lung
function is a desired component of asthma control. 74
Kotwani et al (2012) conducted a study to investigate the quality of asthma
management, knowledge about asthma and quality of life in 50 asthma patients
referred to a public tertiary care chest hospital in Delhi. Patients were interviewed
using three questionnaires on quality of asthma management before visiting referral
hospital, asthma knowledge and asthma quality of life (AQLQ). Correlation amongst
quality of treatment, asthma quality of life, and asthma knowledge was also
determined. Findings revealed that only 60 per cent of patients were informed about
their disease, and 10 per cent had undergone lung function tests previously. Only 44
per cent of patients were prescribed inhalers. None were provided with any
educational material. Patients had poor knowledge of etiology, pathophysiology,
39
medication and how to assess the severity of their asthma. The mean scores in AQLQ
indicated a moderate degree of impairment in quality of life. 75
Kotwani et al (2012) conducted a study to investigate the pattern of self-
management in asthmatic patients enrolled as out-patients in a tertiary care referral
public chest hospital, in Delhi, India. The study population was adult asthma patients
(n=200) visiting the emergency room (December 2008-December 2009) of a chest
hospital for asthma exacerbation.
The data was collected through a questionnaire regarding the self-management
of asthma. Enrolled patients (64.0% female) were registered as asthma out-patients in
the study hospital for a mean of 5.4±4.4 years. Patients visiting the emergency room
(ER) and having an unscheduled visit to doctor at least twice in the previous 12
months were 86.5% and 91.0%. Patients were classified according to the disease
severity as having intermittent (17.0%) or persistent (83.0%) asthma.
Not all patients had metered dose inhalers at home. Only 2.0% of patients
were prescribed peak flow meters and were keeping a diary of their readings. With
one exception, patients did not have written action plans for treatment provided by
doctor or health facility. No statistical difference was found in the pattern of self-
management of patients having persistent or intermittent asthma. Adherence to ICS
therapy is poor and many factors modulate adherence to therapy. These findings lend
preliminary support for an extended self-regulatory model of treatment adherence,
which incorporates beliefs about treatment. 76
McGrath KW (2010) conducted a study on Objective airway monitoring
improves asthma control in the cold and flu season: a cluster randomized trial. The
40
purpose of this study was to improve inhaled corticosteroid (ICS) adherence and
asthma control by cueing therapeutic communication between patients with asthma
and their primary care clinicians.
They conducted a prospective, cluster-randomized, controlled effectiveness
trial to assess the effect of providing visually standardized, interpreted peak flow
graphs (CUE intervention) to patients and their clinicians on ICS adherence and
asthma control. Asthma control outcomes were analyzed by season to account for
seasonal variations in exacerbation frequency.
Intervention patients required fewer courses of oral steroids during winter (9%
vs 23%, p < .001) and spring (3% and 17%, p < .001) compared with control patients.
Intervention patients also had fewer periods of worsening symptoms (65% vs 89%, p
< .001) and fewer urgent care visits (10% vs 23%, p < .001) during winter compared
with control patients.
Post hoc analysis showed significant improvement in the intervention group
with respect to ICS adherence during winter months (p < .05), the likely explanation
for the reduction in prednisone use and symptoms. Day-to-day peak flow variability
in the intervention group fell consistently throughout the study from an average of
32% at baseline to 23% at final measurement (p < .001), indicating less airway
reactivity over time. Their findings provided evidence of the value of peak flow
monitoring for patients with asthma during seasons of greatest vulnerability, the
cold/flu season. The peak flow information apparently led to improvements in ICS
adherence resulting in less need for prednisone rescue and fewer episodes of
worsening symptoms.77
41
McGrath et al (2009) along with the University of California San Francisco
conducted a 24-week randomized, controlled trial to determine if individualized
instruction in asthma self-management adds significantly to the effects of self
monitoring alone on patients’ adherence to inhaled corticosteroids (ICSs),
medications that can help reduce inflammation in the airway and prevent asthma
attacks. In the study, 84 adults with asthma, self-monitored their symptoms and kept a
daily log of their peak expiratory air flow. Of that group, 45 patients were randomly
selected to receive a personal 30-minute session that included asthma information,
personally relevant allergen exposure reduction, a personal action plan, and
instruction in the correct use of their inhalers. During the study period, adherence to
ICSs was consistently higher in the intervention group compared with the control
group.
In addition, participants in the intervention group experienced fewer nighttime
awakenings, a marker of asthma control. Intervention participants also used rescue
inhalers less frequently, experienced an increased sense of control over their asthma,
and had a significant decrease in their levels of tryptase, which is released from cells
in the presence of allergens.78
Slader et al (2007) conducted a study on Measuring peak flow enhances
adherence to monitoring in asthma. Data were obtained from a randomised double
blind study of breathing techniques in 57 adults with poorly controlled asthma.
Patients were non‐smokers aged 19–80 years, using reliever as‐needed ⩾4 times/week
and taking inhaled corticosteroids ⩾200 μg/day. The patients used electronic diary
spirometers (AM2, Erich Jaeger GmbH, Hoechberg, Germany) twice daily to answer
questions about symptom frequency/intensity and treatment.
42
There were three “PEF periods” during which patients also measured
spirometry twice daily. PEF was displayed after each of three maneuvers followed by
the highest PEF. At study visits, data were uploaded and reviewed by the research
assistant. The adherence to monitoring was higher during PEF periods than non‐PEF
periods (79% vs. 65%, p<0.0001). Mixed model analysis showed that weekly
adherence with monitoring increased by 13% with PEF monitoring (p<0.0001) and by
5% with each 10 years of increasing age (p<0.0001). There was no effect of gender
(p = 0.80) or time to next/last visit (p = 0.59).
In contrast with the perception that PEF monitoring is burdensome to patients,
this analysis showed that, with electronic diaries, asking adults to measure PEF
significantly improved their adherence with monitoring. While a randomised study
would be required to formally evaluate the impact of PEF measurement on adherence
with monitoring, this is the first study to assess differences in adherence with
monitoring with and without PEF. They used patients as their own controls as they
crossed over between periods. Good adherence was also achieved with similar
electronic devices, despite the routine nature of the monitoring for assessment of
study outcome variables and the absence of physician feedback to patients. 79
De Asis ML Greene R (2004) conducted a study to analyze the cost-
effectiveness of peak flow-based action plans in reducing costs associated with ER
visits and hospitalizations due to acute asthma exacerbation in a population of high-
risk and high-cost patients, defined as patients with moderate to severe asthma with a
history of recent urgent treatment in the ER or hospitalization due to asthma.
A literature review of randomized clinical trials comparing peak flow-based
(PFB) action plans, symptom-based (SB) action plans, and usual care/no action plan
43
(NAP) was performed. Probability values regarding the effectiveness of each
alternative (as measured by increase/decrease in ER visits and hospitalizations over a
6-month period) were derived. Incremental cost-effectiveness and cost-benefit ratios
were calculated for each alternative. Sensitivity analyses were performed.
For high-risk and high-cost asthma patients, their analysis revealed that the
most cost-effective alternative for reducing ER visits was a peak flow-based self-
management plan. The peak flow-based self-management program had an incremental
cost-effectiveness (C/E) ratio of $ 60.57 per ER visit averted compared to usual
care/NAP and a C/E ratio of $31.46 compared to the SB-AP. The PFB-AP was also
the most cost-effective in reducing asthma hospitalization costs with an incremental
C/E ratio of $300 per hospitalization prevented, compared with usual care and a C/E
ratio of $311, compared to a SB-AP. Cost-effectiveness and cost-benefit analyses
revealed that for high-cost patients, a peak flow-based asthma education and self-
management plan program is the most cost-effective alternative in reducing costs
associated with ER visits and hospitalizations due to asthma exacerbation. 80
Adams RJ et al (2001) conducted a prospective, randomized controlled trial
of 134 adults with moderate-to-severe asthma who did not have evidence of poor
perception of bronchoconstriction on histamine challenge testing, who were recruited
from inpatients and outpatients of a university teaching hospital. Comparison was
made over 12 months of the effectiveness of written action plans using either peak
flow monitoring or symptoms to guide management. Patients were contacted at
monthly intervals by telephone for reinforcement and evaluation of use of the action
plans, and to provide ongoing education. Spirometry and PD20 histamine were
measured at 3-monthly intervals. Measures of health care utilization and morbidity
44
(asthma exacerbations; hospitalizations; emergency department (ED) visits; days
absent from work or school due to asthma; medication use and a self-rating of asthma
severity) were made monthly. A psychosocial questionnaire (attitudes and beliefs,
state-trait anxiety, denial) was given at entry and at 12-months or at withdrawal from
the study.
The results showed there were significant improvements for both groups for
hospitalizations, ED visits, days off from school or work, and PD20 histamine, but no
between-group differences. Appropriate use of action plans was 85% in the symptoms
group and 86% in the PFM group. For all patients, those who subsequently had an ED
visit had significantly higher levels of denial (p=0.04) and lower scores for self-
confidence (p=0.04), compared to those who did not have an ED visit. Use of written
action plans, combined with regular contact to reinforce self-management, improved
airway reactivity and reduced health care utilization. Peak flow meters (PFM)
continued to be recommended as an important part of asthma self-management plans
though it remains unclear if there is an advantage in using PFM in people with
moderate-to severe asthma who are not poor perceivers of bronchoconstriction. 81
Correia de Sousa J et al (2013) conducted a study on Asthma control,
quality of life, and the role of patient enablement: a cross-sectional observational
study assessing asthma severity, medication use, asthma control, and patient
enablement in patients with asthma treated in primary care and to study the
relationship between these variables and quality of life on 180 patients in an urban
clinic in northern Portugal. Data were collected from both clinical records and
questionnaires from a random sample of asthma patients. The modified Patient
Enablement Instrument, the Asthma Quality of Life Questionnaire, and the Asthma
45
Control Questionnaire were used. Peak expiratory flow and forced expiratory volume
in one second (FEV1) were measured. Receiver operating characteristic curve
analysis was performed to establish cut-off values for the quality of life
measurements. The associations between enablement, asthma control, and quality of
life were tested using logistic regression models.
There was a strong correlation between asthma control and quality of life
(r=0.81, p<0.001). A weak association between patient enablement and asthma
control and quality of life was found in the logistic regression models. Poor control of
asthma was associated with female gender, concomitant co-morbidities, reduced
FEV1, and increased severity of asthma.The weak correlation between enablement
and asthma control requires further study to determine if improved enablement can
improve asthma outcomes independent of gender, severity, and concomitant co-
morbidities. This study confirms the strong correlation between asthma control and
quality of life.82
Online Asthma Information
Basyouni et al (2014) conducted a study on Online Health Information Needs
for Patients with Asthma in Saudi Arabia. A self-administered questionnaire was
administered to 83 asthma patients attending the outpatient pulmonary clinic.
Approximately two-thirds of participants who use the Internet have searched for
asthma information online. Thirteen percent of the participants reported that the
Internet was their main source of information about asthma, and 33.7% reported that
the Internet was their favorite additional source of information about asthma.
Seventy-eight percent of the participants were interested in an asthma
information Web site in the Arabic language. Employment and higher income were
46
associated with participants who chose the Internet as the favorite source of additional
information about asthma (OR 4.5, 95% CI 1.6–12.7) and (OR 4.2, 95%CI 1.4–12.5),
respectively, and an education level higher than high school was associated with
participants who previously had looked for online information about asthma (OR
11.2, 95%CI 3.8.6–33.5)83
In the era of computer and mobile technology, some health-care providers
and researchers have utilized available technology as means of delivering asthma
education. Burns et al (2013) pilot-tested web-based asthma self-management
programme in 51 adult asthmatic patients and found that this form of delivery
increased patients' asthma knowledge, improved asthma control and enhanced quality
of life.84
Also, interactive smart phone applications have been used to improve
communication between asthmatic patients and health care providers. Preliminary
studies on using smart phone applications to support asthma action plan showed
promising results. It has been reported that patients who used asthma action smart
phone applications had better compliance with self-management advice, fewer asthma
symptoms and better interaction with health-care providers.85,86
Asthma online treatment In the UK one in 12 adults are affected by asthma.
Asthma Inhaler Consultation is available online. The Online Clinic prescribe inhalers
to patients where they have been instructed on how to use an inhaler by a doctor in a
face to face environment. Start Free Consultation page as well as A-Z list of triggers,
please follow the link to Asthma UK page are also available.
47
Vargas PA et al (2010) conducted a study to evaluate an interactive
computer-based questionnaire to assess asthma symptoms in children of parents with
limited health literacy and/or limited English proficiency. A total of 48 parents
participated in the study, 26 completed the electronic ASQ and 21 the paper-and-
pencil form. Thirty-five percent of the children had well-controlled asthma (n = 17).
Most participants were Spanish speaking (67%) Hispanic (n = 44) mothers (n = 43)
with a median age of 32 years. More than half had ≤8 years of education (n = 25) and
earned <$20,000 per year (n = 27). The median health literacy score was 32 (range 0-
36). The correlation between health literacy scores and years of education was
significant (ρ = .47, p < .01). Concordance between the electronic ASQ and the nurse
interview was significantly higher than concordance between the paper ASQ and the
nurse interview (68% versus 54%; p < .01).
All parents who completed the electronic questionnaire reported being
satisfied; 96% felt comfortable using it, and found it simple to use. Thus facilitating
the assessment of asthma symptoms at manageable cost, interactive information
technology tools may help reduce barriers to access due to inadequate levels of
English proficiency and health literacy. 87
Asthma symptoms and lung function
Dorinsky et al (2001) conducted a retrospective study to determine whether
there is a correlation between changes in asthma symptoms during treatment and
changes in lung function, as measured by peak expiratory flow on 2890 male and
female adolescent and adult patients with persistent asthma. A secondary goal was to
compare the relative efficacy (in terms of improvement in asthma symptoms and lung
48
function) of 3 commonly used asthma treatments: inhaled fluticasone propionate,
inhaled salmeterol xinafoate, and oral zafirlukast.
Patients were enrolled in 8 randomized, double-blind, double-dummy,
parallel-group studies. Data on patients' self-rated symptoms, PEF, supplemental
albuterol use, nighttime awakenings, and frequency of asthma exacerbations were
used to ascertain whether there was a correlation between changes in asthma
symptoms and changes in pulmonary function, and to compare treatment effects. The
study showed that there is a strong correlation between lung function as expressed as
peak respiratory flow and symptom management. 88
Aburuz S et al (2005) examined the relationship between measures of asthma
control and lung function in patients with asthma in a cohort of difficult to control
asthmatics attending a hospital outpatient clinic. FEV1 % and asthma control scores
were measured at first clinic visit and at a follow-up visit. A total of 59 patients took
part in the study. At the initial visit, FEV1 % correlated with limitation of activity (p =
0.002), shortness of breath (p = 0.02), wheezing (p = 0.029), and ACS (p = 0.014).
However, at follow-up, there was no correlation between FEV1 % and any measured
index of asthma control. When patients with severe fixed airflow obstruction were
excluded from the analysis (n = 16), FEV1 % at follow-up became significantly
correlated with night waking (p = 0.02), wheezing (p = 0.05), and ACS (p = 0.036).
The improvement in asthma control score at follow-up was significantly and
strongly associated (r = 0.51 for total asthma control, p < 0.001) with the
improvement in lung function in patients without severe fixed airflow obstruction.
Lung function was not associated with any measure of asthma control in patients with
severe fixed airflow obstruction. FEV1 % correlates well with asthma symptoms in
49
difficult asthma patients with poor control but not when control improves. This loss of
relationship is due to patients with severe fixed airflow obstruction where good
subjective control does not exclude the presence of significant obstruction. 89
Hancox et al (2006) explored the associations between respiratory symptoms,
lung function, and gastro-esophageal reflux symptoms in a birth cohort of
approximately 1000 individuals. They obtained information on respiratory symptoms,
asthma, atopy, lung function and airway responsiveness at multiple assessments from
childhood to adulthood in an unselected birth cohort of 1037 individuals followed to
age 26. Symptoms of gastro-esophageal reflux and were recorded at age 26.
Heartburn and acid regurgitation symptoms that were at least "moderately
bothersome" at age 26 were significantly associated with asthma (odds ratio = 3.2;
95% confidence interval = 1.6–6.4), wheeze (OR = 3.5; 95% CI = 1.7–7.2), and
nocturnal cough (OR = 4.3; 95% CI = 2.1–8.7) independently of body mass index. In
women reflux symptoms were also associated with airflow obstruction and a
bronchodilator response to salbutamol. Persistent wheezing since childhood,
persistence of asthma since teenage years, and airway hyper responsiveness since age
11 were associated with a significantly increased risk of heartburn and acid
regurgitation at age 26.90
Drs Michael Wechsler and Ted Kaptchuk (2011) led a research team
assembling a group of 46 chronic asthma sufferers. On each visit, the patients
received 1 of 4 different interventions: an inhaler with albuterol (the standard
treatment for relieving sudden asthma symptoms), a placebo inhaler, sham
acupuncture or no treatment. The patients received each of these 4 interventions in
50
random order on different visits. The cycle was then repeated 2 more times for a total
of 12 visits.
The researchers assessed how well the treatments worked both objectively and
subjectively. The objective test measured how much air the patients could expel from
their lungs in 1 second. The subjective test asked the patients to rate their symptom
improvement on a scale of 0 to 10. As expected, patients reported symptom relief with
the albuterol treatment.
However, they also felt similar improvement when using the placebo inhaler
or the sham acupuncture. When the team looked at the maximum air volume that
patients could exhale, they found improvement in lung function only when the
patients received albuterol. There was no improvement in objective measurements
with the other treatments.91
Development of Nursing Evidence-Based Practice Protocol
For the development of evidence based practice guideline, an extensive
systematic review was carried out by the researcher. The electronic data bases and
various hand search strategies were adopted for the systematic review. The search
engines included were Pubmed Central, Med line, Google Scholar, Science Direct,
Cochraine Library and Proquest. All the studies identified through this search were
subjected to quality check by using Johns Hopkins evidence Practice Model. The
researcher obtained permission from Johns Hopkins University (https://www.ijhn-
education.org) to use the Johns Hopkins Nursing Evidence Based Practice (JHN EBP)
model and tools. (Annexure I)
51
The Protocol includes the following aspects in this study:
1. Nursing Evidence Based Practice Question Development
2. PRISMA Flow Diagram
3. Individual Evidence Summary
1. Nursing Evidence Based Practice Question Development
What is the problem and why is it important?
This research focuses on introducing peak flow self management plan as asthma
patients are suffering from wheezing due to bronchospasm and chest tightness
affecting their routine life activities. This research work was undertaken by the
investigator to seek evidence as the asthmatics have poor quality of life and decreased
productivity due to their prolonged hospitalization and emergency visits.
What is the current practice?
At present, asthma patients across the world widely use pharmacological
measures such as corticosteroids and bronchodilators by means of inhalational
methods or oral that may cause serious side effects. Some asthmatics may not be
aware of correct inhaler techniques and are also steroid resistant that calls for the
home management and self monitoring of symptoms.
What is the focus of the problem?
The focus of the problem is both of clinical and educational concern. Reduce
the severity of asthma and number of asthma episodes. Patients will be taught on how
to identify or recognize the symptoms early by monitoring their lung status so that
emergency visits are avoided, reduce hospitalization keeping asthma under control. So
they are instructed to practice peak flow self-management of asthma about when to
take rescue medications, how to identify and avoid triggers. Thus majority ought to
focus through asthma educational / non pharmacological interventions.
52
How was the problem identified?
The problem was identified by the researcher observed when asthma patients
had frequent admissions to hospital and patients visiting to OPD with wheezing and
other chest symptoms requiring bronchodilators, corticosteroids with nebulization.
What is the scope of the problem?
In this research work the researcher initially looks at the individual’s asthma
exacerbations later overcome fatigue, reduce physical and emotional effects such as
wheezing, and improve breathing ability having less absenteeism to work or school
and better quality of life and well being so that he can lead an active and healthy life.
What are the PICO Components?
P - Population / Patient. Here it is the asthma patients experiencing breathing
difficulty and distress related to bronhospasm
I – Intervention. Here peak flow self management plan is the intervention planned.
C – Comparison. A comparison group is also identified who follows regular practices
/ routines without the given intervention.
O – Outcome – The expected outcome is reduction of chest symptoms and asthma
severity and reduced hospitalization related to bronchospasm and is based on peak
flow self management plan as an intervention measured by using Asthma Quality of
Life Questionnaire (AQLQ) and Well being index (WBI) and level of satisfaction .
2. PRISMA Flow Diagram
PRISMA (Preferred Reporting Items for Systematic Reviews and Meta –
Analyses) is an evidence based minimum set of items aimed at helping authors to
report a wide array of systematic reviews and meta-analyses that assess the benefits
and harms of a health care intervention. PRISMA focuses on ways in which authors
can ensure a transparent and complete reporting of this type of research.
53
The two important components of PRISMA are the PRSMA checklist and the
PRISMA flow diagram. In this research work, the researcher used the PRISMA flow
diagram to depict the flow of information through the different phases of systematic
review. In this research work, PRISMA helped the author mainly focus and improve
the reporting of systematic review of randomised controlled trials.
It is further used as a basis for reporting reviews of other types of researches
like cross sectional, cohort, case-control studies. Total records collected for the
systematic review include 87, out of which 65 were identified through database search
and 12 were identified through other searches. Duplicate records were excluded at this
stage were 33. The remaining records after undergoing screening for abstract and
methodology were 54. Among these 54, 41 were excluded based on the exclusion
criteria. The remaining 13 full text articles were assessed for eligibility, out of which
8 full text articles were excluded with reasons. Hence there were 5 studies included
for qualitative synthesis / metasynthesis.
54
PRISMA Flow Diagram depicting the different phases of Systematic Review
Identification
Records identified Additional records

through data base identified through other
searching (n=65) sources (n=12)
Total records collected

Duplicate records
(n=87)
excluded (n = 33)
Screening
Records screened (54) Records excluded

(Title/Abstract + Method according to exclusion
ology screening) criteria (n=41)
Eligibility
Full-text articles assessed Full-text articles

for eligibility (n=13) excluded with reasons
(n=8)
Studies included in
Included
qualitative synthesis (n=5)
Fig. 2 PRISMA Flow Diagram
55
EBP Question: Is Peak flow Self management Plan Effective as an Intervention in improving
quality of life for Asthma patients
Table.1 Individual Evidence Summary of RCT’s based on effectiveness of Peak flow Self management plan upon Quality of life
Article Author & Title / Objective Evidence Sample, Sample Study findings that help Evidence
No Date Type Size, Setting and answer the EBP question Level &
tool used Quality
Malarvizhi et Title: “Effectiveness of Randomized Sample: Patients with The mean number of visits Level 1
al, (2015) Peak Flow Guided Self controlled mild to moderate type to OPD, days off work were
Management Plan on trial design of asthma lower. There were no
Asthma Health Outcomes admissions during the data

Sample size: 60
among Patients with collection period. Peak flow
Setting Dept of Chest
Bronchial Asthma. guided self -management
and TB,OPD
plan reduces the episode of
Objective: to determine
Tool used: Diary asthma and improves quality
the effect of peak flow
56
Guided Self Management card,pocket size peak of life
Plan on Asthma Health flow metre,
Outcomes among Patients questionnaire, written
with Bronchial Asthma instructions on how to
monitor PEFR values.
McGrath KW Title: Objective airway Prospective, Sample: Adults with Intervention patients had Level 1
(2010) monitoring improves cluster- persistent asthma. fewer periods of worsening
asthma control in the cold randomized, symptoms (65% vs 89%, p <

Sample size: 139
2
and flu season: a cluster controlled .001) and fewer urgent care
Study setting: Clinical
randomized trial. effectiveness visits (10% vs 23%, p <
laboratory
trial .001) during winter
Objective: to assess the
Tool used: Asthma- compared with control
effect of providing
status questionnaire subjects.
visually standardized,
57
interpreted peak flow The peak flow information
graphs (CUE apparently led to
intervention) to patients improvements in ICS
and their clinicians on adherence resulting in less
ICS adherence and need for prednisone rescue
asthma control. and fewer episodes of
worsening symptoms
3. McGrath et.al Title: Individualized 24 week Sample: adults with Intervention group had Level 1
(2009) asthma self-management prospective, moderate- severe higher adherence to ICSs
improves medication RCT asthma. than control group. They
adherence and markers of experienced fewer nighttime

Sample size: 84
asthma control. awakenings, a marker of
Setting: Metropolitan
asthma control and also
Objective: to study the
community
used rescue inhalers less
effect of self-management
58
education on long term Tool: Daily log diary frequently.
adherence to ICS and of their peak
markers of asthma expiratory air flow, a
control. personal action plan,
asthma information.
Adams RJ et al Title: A randomized trial Prospective, Sample: moderate-to- There were significant
(2001) of peak-flow and randomized severe asthma. improvements for both

4 Level 1
symptom-based action controlled groups for hospitalizations,
Sample size:134
plans in adults with trial (RCT) ED visits, days off from
adults
moderate-to-severe school or work, and PD20
Setting: inpatients and
asthma histamine, but no between-
outpatients of a
group differences.
Objective: Comparison on
university teaching
Appropriate use of action
effectiveness of written
59
action plans using either hospital. plans was 85% in the
peak flow monitoring or symptoms group and 86% in

Tool: Psycho social
symptoms to guide the PFM group. For all
questionnaire, Action
management. subjects, those who
plans, Measures of
subsequently had an ED visit
self-rating scale of
had significantly higher
asthma severity
levels of denial (p=0.04) and
lower scores for self-
confidence (p=0.04),
compared to those who did
not have an ED visit.
5. Poureslami. et Title: Impact of optimal Randomized Sample: Physician- Knowledge of asthma Level 1
al, (2012) asthma education Controlled diagnosed adult symptoms, inhaler use, and
programme on asthma Trial asthma patients. understanding of physician’s
60
morbidity, inhalation Sample size: 92 instructions improved
technique and asthma significantly from pretest to

Setting: Punjabi,
knowledge 3 months post-intervention
Mandarin, and
follow-up among all
Objective: To explore the Cantonese
participants. Participants
effectiveness of different communities.
performed significantly
formats of culturally
Tool: videos and
better at follow-up than they
relevant information and
pamphlet, read
did at baseline assessment,
its impact on asthma
pictorial pamphlet,
with the most notable
patients’ self-management
improvements observed in
the group that watched both
community and knowledge
videos.
61
Summary
This chapter has dealt with the review of research literature related to the
problem stated. It had helped the researcher to understand the importance of education
and self management plan for asthma patients. It had helped enabling the investigator
to design the study, develop the tool, plan for data collection and to analyze the data.
Among 54 sources of literature review collected, 50 were primary sources and 4
were secondary sources of literature data.
62
Chapter – III
Research Methodology
63
CHAPTER - III
RESEARCH METHODOLOGY
Methodology indicates the general pattern for organising the procedures for
the development of the tool, pilot study, procedures for data collection and plan for
92
data analysis. Research methodology is the conceptual structure within which the
research is conducted.93
The present study was conducted to assess the Effectiveness of Peak flow Self
Management Plan on Quality of life for Asthma Patients in Selected Community at
Coimbatore.
This chapter describes the aspects like Research approach, Research design,
Research variables, Research setting, Population, Samples, Sampling technique,
Criteria for sample selection, Development of description of Study instruments,
Description of intervention tool, Psychometric properties of study instruments,
Intervention protocol, Pilot study, Data collection procedure, Ethical considerations,
and Data analysis plan.
Research Approach
The selection of research approach is the basic procedure for the conduct of
research inquiry.94 A quantitative experimental research approach was used for the
present study as it is aimed at assessing the effectiveness of peak flow self
management plan among asthma patients on quality of life.
64
Research Design
A quasi-experimental time series two group pre-test post-test design was
adopted for the study. Here both groups were observed before and after introducing
the independent variable (intervention).
Groups Pretest Interven Post test
tion Quality of life
2 months 4 months 6 months
Control 01 - 02 03 04
(n=100)
Experimental 01 X 02 03 04
(n=100)
01 Observation of quality of life and well being using AQLQ and well being
Index at the time of interview before intervention in control and experimental
group of asthma patients.
X – Intervention was peak flow self management (information on asthma)
02 - Observation of quality of life and well being using AQLQ and well being
Index at the end of 2 months in control and experimental group of asthma
patients.
03 - Observation of quality of life and well being using AQLQ and well being
Index at the end of 4 months in control and experimental group of asthma
patients.
04 - Observation of quality of life and well being using AQLQ and WB Index
at the end of 6 months in control and experimental group of asthma patients.
65
In order to assess the effectiveness of nursing intervention on peak
flow self management, quality of life and well being were observed using
AQLQ and general well being Index at the time of interview before
intervention in control and experimental group of asthma patients.
Then after giving intervention only for experimental group, quality of
life and general well being was observed using AQLQ and general well being
Index at the interval of two months interval for over a period of six months
for both control and experimental group of asthma patients.
66
Quasi Experimental Research design
Accessible population: Asthma Patients with asthma symptoms from Primary health centre
of Somanur & Kangeyampalayam
Study population: Asthma patients who had at least one exacerbation during last 6 months
Purposive Sampling Purposive Sampling based on Inclusion

based on Inclusion Criteria Criteria
Sample 100 Sample 100
Control Group Experimental group
Pretest assessment of clinical variables, Pretest assessment of clinical variables,

Pre- test AQLQ scores, well being Pre- test AQLQ scores, well being index
index scores scores
Intervention
Peak flow self management, asthma
information on asthma control
Post test assessment of clinical variables, AQLQ scores, WBI at end of 2 nd,4th 6th
months, Level of Acceptability after 6 months
Ananlysis and Interpretation
Fig.3 Schematic Representation of Research Design
67
Research Variables
Variables are phenomena or characteristics that are measured, manipulated
and controlled in a research.
Independent Variable
An independent variable is the variable that is changed or controlled in a
scientific experiment to test the effects on the dependent variable. In this study, the
independent variables includes peak flow self monitoring taught to the patients in
addition to the education on asthma for the patients who are clinically diagnosed as
asthma.
Dependent Variables
A dependent variable is what the researcher is able to measure in the
experiment and what is affected during the experiment or research study. In this
study, the dependent variables are the quality of life, well-being and symptoms of
asthma patients.
Attribute Variables
It includes the demographic variables such as age in years, gender, education,
occupation, marital status, income, residence, type of family and presence of industry
near home and the clinical variables such as smoking habit, duration of asthma,
family history of asthma, presence of co-morbid illness, severity of asthma, type of
cooking fuel used, number of days absent from work or college, medications used,
frequency of experiencing asthma symptoms, whether used peak flow meter and
68
products of allergies which has influence on asthma symptoms of patients diagnosed
with asthma.
Research Setting
The study was conducted at the Somanur Primary health centre (PHC) and
kangeyampalayam subcentre situated at Coimbatore District. These rural healthcare
centres are maintained by the State Government. Somanur PHC has a population of
1,30,000 covering 14 villages such as Annur, Sulur 9-km, Karumathampatty-3km,
Thekkalur and Kangeyampalayam 6 km. it is equipped with 180 bedded inpatient
health care facilities and 7000 out patients regularly visits the physician. The average
number of asthma out-patients range from 250-300 and 50-75 respectively in each
centre in a month.
Population
Population is the entire aggregation of patients with similar characteristics and
on whom the researcher would generalize the study findings.
Target Population
It is the entire group of all the elements, individuals or objects that meet
certain criteria for inclusion in order to make generalization. The target population for
the present study was 200 patients who had symptoms of Asthma during last 6 months
and were clinically diagnosed.
Accessible Population
It refers to the aggregate of patient with whom the designated criteria are
confirmed and accessible population was all adults who were asthmatic residing in
69
somanur and asthmatics who were available at Somanur PHC during the study were
selected for the study.
Sample
Sample is a subset of population selected to participate in a research study. In
this study, Sample consisted of asthma patients with asthma symptoms who fulfil the
inclusion criteria and are permanent residents of the selected community areas and
primary health centers of Somanur at Coimbatore district.
Estimating Sample Size
Determination of the optimal sample size for the study assures an adequate
power for detection of statistical significance. The sample sizes, which were required
for this main study was calculated through online calculators on the basis of pilot
study data.
The following statistics were fed in to the online calculator. The sample size
was estimated based on the two scales namely Asthma Quality of Life Questionnaire
and Well-Being Index. The type I error was α=0.05 and type II error β=0.20. The
standard deviation of them were 2.3 and 2.7 respectively. The power of the study was
80% of clinically diagnosed cases of 200 asthma patients. The number of patients
required for Asthma Quality of Life Questionnaire =85 and Well-Being Index=117.
By taking the average of the two scales, the required sample size is 101. Thus the
sample size was arrived at 100 per group. The study will be Type I error α=0.05 and
Type II error β= 0.20. The power of the study will be 0.80 (1-0.20=0.80) or 80% and
the effect size will be 0.7.
70
Sample Size
With the estimation of 202 asthma patients, 200 were selected for the study
who fulfilled the inclusive criteria and were present during the study. Though the
study planned to include 202 samples, at the time of data collection, some asthma
patients were acutely ill or with co morbidity who could not be included to produce
the data.
Sampling Technique
Purposive sampling technique was used in this study. Researcher identified the
samples with the help of OPD nurse and patients’ records. Patients who met the
inclusion criteria were included in the study. Selected samples were assigned to either
control or experimental group alternatively using odd and even number.
Sampling Criteria
Inclusion Criteria
 Only respondents with current asthma who can follow the instructions were
included in the study.
 Patients with a history of clinically diagnosed asthma were studied.
 Patients of 20 - 70 years of age with at least one documented exacerbation of
their asthma in the previous 6 months which required contact with a
doctor/nurse.
 Patients who were willing to use peak flow metre.
71
Exclusion Criteria
 Patients with co-existing cardiac or other respiratory ailments.
 Patients who were not willing to participate in the study.
Development of the Study Instruments
The following instruments were used for data collection.
 Demographic Variable Proforma
 Clinical Variable Proforma
 Asthma Quality of Life Questionnaire (AQLQ)
 WHO Well being Index (1998 version)
 Observation schedules: Peak flow graph, peak flow diary
 Level of Acceptability for Peak flow Self management
 Asthma education booklet
Demographic Variable Proforma
It was developed by the researcher to assess the following demographic
characteristics: Age in years, gender, education, occupation, marital status, Income,
residence, type of family and presence of industry near home.
Clinical Variable Proforma
It includes smoking habit, duration of asthma, family history of asthma,
presence of co morbid illness, severity of asthma, date of consulting physician,
72
medical diagnosis, type of cooking fuel used, number of days absent from work or
college, medications used, frequency of experiencing asthma symptoms, whether used
peak flow metre and products of allergies.
Asthma Quality of Life Questionnaire (AQLQ)
It is a standardized, widely used instrument to assess the quality of life in
asthma patients. The AQLQ was developed to measure the functional problems
(physical, emotional, social and occupational) that are most troublesome to adults (17-
70) years with asthma.95 The Tamil and English version were used. There are 32 items
in AQLQ and are divided into the following four domains– symptoms (12 items),
activity limitations (11 items), emotional function (5 items) and environmental stimuli
(4 items). Patients responded to each item on a seven-point scale by recollecting their
experiences during the previous two weeks.
The overall AQLQ score is the mean of all 32 responses and the individual
domain scores are the means of the items in those domains. Each domain score ranges
from 1 to 7 representing the greatest impairment possible or most of the time and 7
represents the least or none of the time. 96,97 Total obtainable score is 32-224.
WHO’s General Well being Index (1998 version)
The WHO-5 is a short questionnaire consisting of 5 simple and non-invasive
questions, which tap into the subjective well-being of the respondents. The scale has
adequate validity both as a screening tool for depression and as an outcome measure
in clinical trials and has been applied successfully across a wide range of study fields.
This is also a standardized tool developed by World Health Organization and
is mainly concerned for emotional aspects of patients. It has 5 statements on a 6 point
73
scale (5=All of the time, 0= At no time). It measures the well being of the individual.
The higher the scores, the better the well-being.98
Scoring of WHO Well being Index: The raw score is calculated by totaling
the figures of the five answers. The raw score ranges from 0 to 25, 0 representing
worst possible and 25 representing best possible quality of life.
To obtain a percentage score ranging from 0 to 100, the raw score is
multiplied by 4. A percentage score of 0 represents worst possible, whereas a score of
100 represents best possible quality of life.
Translation of the WHO Well being Index Tool. Translated version of the
Tool from English to Tamil was used from the study conducted by Dr. Latha
Venkatesan, Principal, Apollo College of Nursing, Chennai with her Permission. 99
Observation schedules
Peak flow graph, peak flow diary: This Peak flow tool is made to be used by
the asthma patients where by they can mark the readings of peak flow meter every day
morning and evening then plotted in the peak flow graph.
Level of Acceptability for Peak flow Self Management: This is a four-point
likert scale developed and used by the investigator to evaluate and measure the
acceptability for the experimental group. The scale consisted of 10 items regarding the
asthma information and intervention provided to asthma patients. The respondents
indicated their level of agreement or disagreement scoring the items on the scale.
Scoring: The scale consists of responses marked as Highly Acceptable, Acceptable,
un acceptable, and Highly Unacceptable. The responses were quantamized as 4,3,2,1,
scores respectively. The raw score is calculated by totaling the figures of the ten
74
answers. The raw score ranges from 1 to 40. The level of acceptability was interpreted
after the scores were converted into percentage and classified as follows:
Highly Acceptable – 76-100%
Acceptable – 51-75%
Unacceptable – 26-50%
Highly unacceptable – 0-25%
Asthma Information booklet The booklet consists of the information
regarding what is asthma, Anatomy and function of Lungs, Symptoms of
inflammation in chronic and moderate, and severe asthma, Controlling Triggers of
Irritants such as smoke, smog, allergens, dust mites, molds, pets, pollen, cockroaches,
weather, colds, flu, and sinus infections, food additives, medications, Emotion,
Exercise and Asthma medications.100,101 (Annexure - P)
Psychometric Properties of the Instruments
Content Validity
Validity refers to how well an instrument measures what it is intended to
measure. In general, validity is an indication of how sound one’s research is. So
content validity of instruments were obtained.
Tools were constructed by the researcher to assess the demographic variables,
clinical variables and level of acceptability of the asthma patients. Standardized tools
like Asthma Quality of Life Questionnaire (AQLQ) and Well being index were used
in this study. The constructed tools were given to experts for content validity.
75
Opinions and suggestions were obtained from the experts in the field of chest
medicine, adult health and geriatric nursing, medical and surgical nursing,
physiotherapist and biostatistics.
The AQLQ is very responsive to within-patient change over time. This is the
property that is needed both in clinical practice and in clinical trials. Extensive
construct validity studies (both cross-sectional and longitudinal) have shown that the
AQLQ correlates appropriately with other measures of clinical asthma status and
generic health status. Studies have built up very strong evidence that the AQLQ
really does measure the health-related quality of life of adults with asthma. 102,103
WHO well being index 1998 version’s validity: The scale was sufficiently
homogeneous (Loevinger’s coefficient: version 1=0.38, version 2=0.47; Mokken
coefficient τ; 0.3 in nearly all items).104
Reliability
Reliability is concerned with how consistently and accurately the
measurement technique measured the concept of interest. In this study, the reliability
of the tools used are as follow.
S.No. Tool Method R

1. AQLQ(Over all & Domain wise) Intra class correlation 0.95, 0.71
2. WHO Well being Index (Tamil version) Cronbach-alpha 0.92

Cronbach-alpha 0.90
WHO Well being Index (English version)
3. Satisfaction scale on Level of acceptability Test Re test 0.74
of peak flow monitoring
76
Ethical Considerations
 The study was conducted after obtaining the ethical approval from
Institutional Ethics Committee, Apollo Hospitals, Chennai.
 Formal written Permission was obtained from the Office of Directorate of
Public Health and Deputy Director of Health Services, Coimbatore and the
copy of the letters were submitted to the Medical Officers of the concerned
PHCs.
 Adequate explanation was given regarding intervention and purpose of the
study for the experimental group of asthma patients.
 The informed verbal and written consent was obtained from the asthma
patients for acceptance of the peak flow self management and their
willingness. Confidentiality was maintained throughout the study.
Intervention Protocol
The peak flow self monitoring intervention was designed by the investigator to
evaluate the lung status or function of asthma patients. Peak Expiratory Flow Rate
(PEFR) is a simple indicator of ventilatory function. Peak flow metre was used to
measure how fast one can push air out of his lungs. As per National Asthma
Education and Prevention Program (2007), periodic assessment of pulmonary
function by peak flow rate monitoring was intervened for asthma patients. Peak flow
rate monitoring and a written asthma action plan as well as information booklet was
used. The instructions for peak flow usage were as follow:
77
Step 1.
 Move the marker in the peak flow metre to 0 or to the lowest number on the
scale.
• Stand up. If you can't stand, sit up straight in a chair. Be sure you're in the
same position each time.
Step 2. Take a deep breath. Fill your lungs all the way.
• While holding your breath, put the mouthpiece of the meter between your
teeth. Close your lips tightly around it, making a tight seal around the
mouthpiece. Be sure your tongue does not block the hole.
• Blow into the mouthpiece once, as hard and fast as you can. Your peak flow
meter will measure how fast you can blow air out.
• Take the meter out of your mouth.
• Check where the marker has moved to on the numbered scale. Write this
number down.
Step 3: Move the marker back to 0. Repeat the above steps 2 more times.
• Write down the highest of the three numbers. This is your peak flow number.
78
Color zones of Peak flow metre.
Zone Reading Description

Green 80 to 100 A peak flow reading in the green zone indicates that
Zone percent of the the asthma is under good control. Peak flow reading is
usual or normal above 460-600 EU
peak flow
readings are
clear.
Yellow 50 to 79 percent Indicates caution. It may mean respiratory airways are
Zone of the usual or narrowing and additional medication may be required.
normal peak Peak flow reading is between 287-460 EU
flow readings
Red Less than 50 Indicates a medical emergency.Severe airway narrowing
Zone percent of the may be occurring and immediate action needs to be
usual or normal taken. This would usually involve contacting a doctor or
peak flow hospital. Peak flow reading is only upto 2 EU
readings
An asthma action plan (also called a management plan) is a written plan that
was developed to help control patients’ asthma. 15 The asthma action plan showed
daily treatment, such as what kind of medicines to take and when to take them. This
plan describes how to control asthma long term and how to handle worsening asthma,
or attacks. The plan explained when to call the doctor or go to the emergency room.
The asthma booklet consisted of the information regarding what is asthma, Anatomy
and function of Lungs, Symptoms of inflammation in chronic and moderate, and
severe asthma, Controlling Triggers of Irritants such as smoke, smog, allergens, dust
79
mites, molds, pets, pollen, cockroaches, weather, colds, flu, and sinus infections, food
additives, medications, Emotion, Exercise and Asthma medications and peak flow
instructions.99,100
Pilot Study
A pilot study was conducted during the month of September 2015 to
November 2015 to find the feasibility of the study and appropriateness of the
research tools among 20 asthma patients. It was noted that some patients needed help
in explaining the questionnaire. Thus the investigator made a point to help them in
answering the questions and discussing with group regarding asthma information
booklet as well as training them on using peak flow meter. Overall study was feasible
and there was no confusion or ambiguity about the tools.
Data Collection Procedure
With the support of multi-purpose health care workers, staff nurses of PHC,
the researcher proceeded with the data collection. The data were collected in four
phases.
 Phase I: Purpose of the study was explained and informed oral consent were
obtained from the study participants. Pre test was conducted using the tools
such as the baseline data of demographic variables, clinical variables, and the
questions related to Symptoms, Activity limitation, Emotional function and
Environmental stimuli using Asthma quality of life questionnaire (AQLQ)
were assessed for both Control and Experimental group through interview
method.
80
Selected samples were randomized using odd and even method
(alternate samples). Control group patients were given routine treatment.
Experimental group patients were made to gather in a separate room and the
investigator explained about asthma home care and peak flow instructions.
 Phase II: Peak flow Self management Plan along with written Asthma Action
Plan was implemented for experimental of asthma patients. Information
booklet was also provided by the researcher followed by which the patients
were instructed to perform the peak flow monitoring and to note down the
readings of peak flow in peak flow diary for 6 months. The investigator has
obtained the list of mobile numbers and their address of all the samples for
follow up.
 Phase III: Each day the investigator reminded the patients through phone to
enter the readings two times and every two weeks supervision was done. At
the end of every two months quality of life and well being (Post test I, II, III)
were assessed for six months at their home.
 Phase IV: The level of acceptability was assessed only for experimental group
of asthma patients using level of acceptability scale and the study was
concluded.
Plan for Data Analysis
The plan for data analysis is as follows:
Data analysis is the evaluation of information and its pertinence to the study
variables. The data obtained was analysed using both descriptive and inferential
81
statistics based on the objectives and hypotheses of study. The computed data was
entered and analysed in SPSS-20.
 Baseline proforma containing sample characteristics was analysed using
frequency and percentage.
 The quality of life and well being before and after administration of peak flow
self management was calculated using descriptive statistics like mean and
standard deviation.
 The effectiveness of peak flow self management was analysed by independent
and paired “t” test and ANOVA for finding the significant difference in
quality of life between and within control and experimental group of asthma
patients.
 The domain wise relationships of experimental and control groups were
computed by Karl Pearson product moment correlation methods.
 Association between quality of life and selected variables was analysed by
Chi-square test
Summary
Research Methodology is the blue print or overall plan of the entire process of
tackling the research problem in a systematic and scientific manner. This chapter has
dealt with description about Research approach, research design, Research variables,
Research setting, Population, Sample, Sampling technique, Development of Study
82
instruments, Psychometric properties of study instruments, Intervention protocol,
Pilot study, Data collection procedure, Ethical considerations, and Data analysis plan.
83
Chapter – IV
Analysis and Interpretation
CHAPTER - IV
DATA ANALYSIS AND INTERPRETATION
Data were coded and analyzed using IBM SPSS-20 statistical package. The
variables namely Asthma Quality of Life Questionnaire (AQL) and Well Being Index
(WBI) of the study patients were analyzed and interpreted. Appropriate statistical
methods were used based on the objectives and hypotheses of the study.
Descriptive Statistics used were Frequency, Percentage, Mean and Standard
deviation. The discreet variables like demographic and clinical were analyzed and
interpreted by χ2 (Chi-square) test for their homogeneity. The continuous variables
(AQLQ and WBI) were interpreted by appropriate parametric tests and the discrete
variables were interpreted by appropriate non parametric tests. In this study the
parametric tests such as Student “t” test viz. Paired and Unpaired and ANOVA were
applied.
The domain wise relationships between the experimental and control groups
were computed by Karl Pearson product moment correlation methods. The non-
parametric χ2 (Chi- squared) tests were utilized to analyze the association between
selected demographic variables and clinical variables with the pre-test scores of
AQLQ and Well being index. The p-values less than or equal to 0.05 (p≤0.05) were
fixed as level of statistical significance.
83
Organization of Study Findings
The substantive summary of the data analysis is organized under the following
sections.
Section I: Description of Demographic and Clinical Variables of
Control and Experimental group of Asthma patients.
Section II: Mean, Standard Deviation and “t” values of AQLQ and
Well being Index showing the Effectiveness of peak flow self
management plan in improving the Quality of Life within and between
groups among control and experimental group of asthma patients.
Section III: Pre and Post test Assessment of Domain Wise Asthma
Quality of Life Questionnaire (AQLQ) and category wise AQLQ and
Well being Index in Control and Experimental group of Asthma
patients.
Section IV: Test of ANOVA in Control and Experimental readings
from Pre test to Post test I to III
Section V: Assessment of Level of Acceptability of Peak flow
Intervention among Experimental group of Asthma patients.
Section VI: Assessment of Correlation between Quality of life and its
Domains in Control and Experimental group.
Section VII: Association between quality of life of Asthma patients
with their Selected Demographic Variables and Clinical Variables.
84
Section I: Description of Demographic and Clinical variables of Control and
Experimental group of Asthma patients with regard to Homogeneity.
Table-2: Frequency and Percentage Distribution and Homogeneity of
Demographic variables in Control and Experimental group of Asthma Patients.
Control
Experimental
group p value
Demographic Categories group (n=100) χ2
(n=100)
variables
f % f %
20-39 21 21.0 18 18.0
χ2 =0.35
Age (Years) 40-59 37 37.0 40 40.0 p=0.84
df=2
≥60 42 42.0 42 42.0
Male 54 54.0 72 72.0 χ2 =6.95 p=0.01
Gender
Female 46 46.0 28 28.0 df=1
No formal 14 14.0 13 13.0
Primary 23 23.0 21 21.0
Educational χ2 =1.77 p=0.78
High School 24 24.0 21 21.0
status df=4
Hr.Sec 19 19.0 17 17.0
Degree 20 20.0 28 28.0
Cooly 26 26.0 28 28.0
Occupational Unskilled 42 42.0 37 37.0 χ2 =0.79 p=0.77
status Skilled 21 21.0 25 25.0 df=3
Professional 11 11.0 10 10.0
Married 57 57.0 66 66.0
Un married 27 27.0 13 13.0 χ2 =6.25 p=0.1.00
Marital status
Widowed 11 11.0 14 14.0 df=3
Divorced 5 5.0 7 7.0
<5 11 11.0 9 9.0
Monthly family 5-10 44 44.0 41 41.0
χ2 =6.25 p=0.78
income 10-15 29 29.0 32 32.0
df=4
(000) 15-20 11 11.0 15 15.0
≥ 20 5 5.0 3 3.0
Rural 69 69.0 74 74.0 χ2 =0.61 p=0.43
Residence
Urban 31 31.0 26 26.0 df=1
85
Joint 84 84.0 79 79.0 χ2 =0.83 p=0.36
Type of family
Nuclear 16 16 21 21 df=1
Table 2 reveals that majority of the asthma patients were males (54%,72%),
married (57%,66%), from rural back ground (69,74), from joint family (84%,79%) in
control group and experimental group respectively. Considerable percentage of them
were above 60 age years (42%,42%), were unskilled workers (42%,37%) with
monthly family income of Rs.5001 - 10,000 (44%,41%) and had degree education
(20%,28%), in control group and experimental group respectively.
The above table-2 also describes the homogeneity of control and experimental
groups according to their demographic profiles. Except gender all other demographic
variables such as age, education, occupation, marital status, monthly income,
residence and type of family were not statistically significantly differed (p>0.05). The
two groups were homogeneous groups and they were comparable groups in respect of
their demographic characteristics.
86
Table-3: Frequency and Percentage Distribution and Homogeneity of Clinical
variables in Control and Experimental groups of Asthma Patients.
Control
Experimental χ2 & p
Clinical group
Components group (n=100) value
variables (n=100) df
f % f %
1st day 16 16.0 18 18.0
Last 2-7 days back 9 9.0 19 19.0 χ2 =5.00 p=0.61
consultation 8-15 days back 17 17.0 12 12.0 df=3
1 month back 58 58.0 51 51.0
Industries Yes 81 81.0 77 77.0 χ2 =0.49 p=0.49
around No 19 19.0 23 23.0 df=1
Wood 23 23.0 16 16.0
χ2 =4.05 p=0.07
Cooking fuel Cow dung 6 6.0 2 2.0
df=2
LPG 71 71.0 82 82.0
Lost no 43 43.0 38 38.0
1-2 weeks 20 20.0 18 18.0
Abstain from χ2 =1.18 p=0.76
2-4 weeks 21 21.0 23 23.0
work df=4
>5 weeks 9 9.0 12 12.0
Unable 7 7.0 9 9.0
Budamate 3 3.0 5 5.0
Salbutamol 41 41.0 42 42.0 χ2 =0.68 p=0.88
Medication
Deriphyline 27 27.0 27 27.0 df=3
Any other 29 29.0 26 26.0
No 61 61.0 48 48.0 χ2=3.41 p=0.07
Smoking
Yes 39 39.0 52 52.0 df=1
1st degree 67 67.0 72 72.0
χ2 =0.59 p=0.44
Family history No 1st degree
33 33. 28 28.0 df=1
relative
< 6 months 14 14.0 8 8.0
Duration of χ2 =5.72 p=0.34
6-12 months 21 21.0 32 32.0
Asthma df=3
1-5 years 35 35.0 39 39.0
87
>5 years 30 30.0 21 21.0
Mild 34 34.0 27 27.0
Asthma χ2 =5.26 p=0.28
Moderate 49 49.0 64 64.0
severity df=2
Severe 17 17.0 9 9.0
Diabetes 19 19.0 14 14.0
Hypertension 16 16.0 16 16.0
Co- morbidity χ2 =3.06 p=0.38
Bone 3 3.0 2 2.0
present df=4
Gastric 16 16.0 11 11.0
Nil 46 46.0 57 57.0
Pets 8 8.0 12 12.0
Dust 13 13.0 5 5.0
Pollen 19 19.0 11 11.0 χ2 =7.63 p=0.30
Allergy
Smokes 14 14.0 17 17.0 df=5
Fumes 6 6.0 8 8.0
Cold air 40 40.0 47 47.0
Use of Peak Yes 23 23.0 6 6.0 χ2=11.66 p=0.00
flow metre No 77 77.0 94 94.0 df=1
Table 3 depicts that majority of the asthma patients had industry around home
(81%, 77%), used LPG Gas for cooking (71%,82%), used no peak flow metre (77%,
94%), had family history of first degree relative with asthma (67%,72%), had no habit
of smoking (61%, 48%), with moderate asthma (49%,64%), had consultation with
physician one month back (58%,51%) and had no presence of co-morbid illness
(46%,57%). Considerable percentage of them had no absenteeism in work or school
(43%, 38%), used Salbutamol medication (41%, 42%), with history of asthma for 1-5
years (35%,39%) and allergy to cold air (40%,47%) in control group and
experimental group respectively.
88
The above table -3 also describes the homogeneity between the groups in
respect of their clinical variables. All other clinical variables namely Last
consultancy, Industries around the house, Cooking fuel, Abstain from work,
Medication, Smoking habits, Family history, Duration of Asthma, Asthma severity,
Co-morbidity present and Allergy were not statistically differed between the groups
(p>0.05).
89
Section II: Mean, Standard Deviation and “t” values of AQLQ and Well being
Index showing the Effectiveness of Peak flow Self management plan in
improving the Quality of Life within and between groups among Control and
Table. 4 Comparison of Mean, Standard Deviation and Mean Difference between

Tests of AQLQ in Control Group of Asthma Patients
(N =100)
Assessment Mean SD Mean SD “t” value p’ Value
Diff (paired)
Pre Test & 95.90 7.84 1.94 p=0.55
2.47 12.5
Post Test I 98.29 8.40 NS
Post Test I 98.29 8.40 1.93 p=0.055
2.40 10.4
&Post Test II 100.77 11.72 NS
Post Test II 100.77 11.72 1.43 p=0.150
2.32 7.6
&Post Test III 103.09 13.28 NS
NS - Not significant
Table. 4 depicts the mean, standard deviation, and mean difference of AQLQ
scores from pretest to post test III of control group. The mean scores of AQLQ in
control group during pretest was M=95.90, SD=7.84, though there was slight increase
during Post test I (98.29, SD=8.4), Post test II (100.77, SD=11.72), and Post test III
(103.09, SD=13.28), there was no improvement between the means of first and
subsequent observation which indicates that it is not significant (p>0.05) having the “t”
value for pre test with post test I (“t” 1.94.3), post test I with post test II (“t” 1.76)
and post test II with post test III (“t” 1.43) respectively as it is below table value 2.36.
(p<0.05). Hence, the H02: There will be no significant difference in the mean AQLQ
90
score and well being index score between first and subsequent observations in control
group is accepted.

Tests of AQLQ in Experimental group of Asthma patients
(N=100)
Diff (paired)
Pre Test & 96.96 9.1 30.8 12.1 25.39 p=0.000
Post Test I 127.73 7.9
Post Test I 127.73 7.9 16.4 13.5 12.18 p=0.000
&Post Test II 144.14 10.4
Post Test II 144.14 10.4 17.1 12.2 13.95 p=0.000
&Post Test III 161.17 7.3
Table. 5 shows the effectiveness of peak flow self management plan from
pretest to post test III of AQLQ in Experimental group. The mean scores of AQLQ in
experimental group during pretest was only M=96.96, SD=9.1 but there was gradual
increase during Post test I (M=127.7, SD=7.9), Post test II (M=144.1, SD-10.4), and
Post test III (M=161.17 SD=7.3) which determined the effectiveness of peak flow
monitoring for asthma patients. The improvement was statistically significant
(p<0.001) having the “t” value for pre test with post test I (“t” 25.3), post test I with
post test II (“t” 12.18) and post test II with post test III (“t” 13.95) respectively. (p
<0.001).
91
Fig. 4 Mean scores of AQLQ of Experimental group from Pre test to Post test
III.
Fig. 4 depicts the mean scores of AQLQ in experimental group that gradually
increased from pretest (M=96.96, SD=9.1), Post test I (M=127.7, SD=7.9), Post test II
(M=144.1, SD-10.4), and Post test III (M=161.17 SD=7.3), which determined the
effectiveness of peak flow monitoring for asthma patients.
92
Tests of AQLQ Scores between Control group and Experimental group of
Asthma patients
Control Group Experimental Differ

Assess ence “t” value
(n=100) Group (n=100) p’ Value
ment b/w (unpaired)
Mean SD Mean SD
means
p=0.378
Pre-test 95.90 7.84 96.96 9.05 1.06 0.88
p=0.000
Post I 98.31 8.88 127.73 7.88 29.36 24.4
p=0.000
Post II 100.77 11.72 144.14 10.36 43.37 27.72
p=0.000
Post III 103.09 13.28 161.17 7.23 58.08 38.26
Table 6 reveals mean scores of AQLQ of control group and experimental group
(95.9, 96.9/224) that were almost same during pretest having the “t” value 0.88 which
shows there is no significant difference in mean pretest scores (p>0.05). But the post
test scores of experimental group were significantly higher after 2 months (127.7), 4
months (144.1) and 6 months (161.1) than the post test scores of control group at 2
months (98.3) 4 months (100.7) and 6 months (103.09) respectively p<0.001. Hence
there is significant difference between control group and experimental group in post
test I, II, III. This indicates the effectiveness of peak flow self management plan for
asthma patients.
93
Fig. 5 Mean scores of AQLQ of Control group and Experimental group from Pre
test to Post test III
Fig. 5 indicates the post test scores of experimental group that were
significantly higher after 2 months (127.7), 4 months (144.1) and 6 months(161.1)
than the post test scores of control group at 2 months (98.3) 4 months (100.7) and 6
months (103.09) respectively.
94
Table. 7 Comparison of Mean and Standard Deviation between Tests of Well
Being Index Scores in Control Group of Asthma patients.
(N =100)
Diff (paired)
Pre Test & 30.36 2.51 p=0.000
Post Test I 35.52 2.44 5.16 2.9 4.43
Post Test I 35.52 2.44 p=0.000
&Post Test II 40.96 1.89 5.44 3.2 4.30
Post Test II 40.96 1.89 p=0.002
&Post Test III 45.20 2.75 4.24 3.4 3.12
Table. 7 depicts the mean, standard deviation and mean difference of well
being scores of control group. The mean scores of control group during pretest was
only 30.36 and there was no statistically significant improvement during post test I,
though there was only a slight increase during post test II and III for asthma patients.
Thus the H02: there will be no significant difference between the mean well being
score of first and subsequent observations in control group is partially rejected.
95
Table. 8 Comparison of Mean and Standard Deviation between Tests of Well
being Index scores in Experimental group of Asthma patients.
(N =100)
Diff (paired)
Pre Test & 29.32 2.55 20.16 3.8 13.35 p=0.000
Post Test I 49.48 2.75
Post Test I 49.48 2.75 11.80 3.5 8.44 p=0.000
&Post Test II 61.28 1.86
Post Test II 61.28 1.86 19.52 2.4 20.54 p=0.000
&Post Test III 80.80 1.58
Table. 8 depicts the effectiveness of peak flow self management plan from pre
to post test III of well being Index in Experimental group. The mean scores of well
being index scores in experimental group during pretest was only M=29.32 but there
was gradual increase during Post test I (M=49.48, SD=2.7 ), Post test II (M=61.28,
SD=1.86), and Post test III (M=80.80, SD=1.5), which can be attributed to the
effectiveness of peak flow monitoring for asthma patients. The improvement was
statistically significant (p<0.001) having the t’value for pre test with post test I
(t”13.3), post test I with post test II (t” 8.4) and post test II with post test III (t”20.5)
respectively.
96
Table. 9 Comparison of Mean, and Standard Deviation of Well being Index
Scores between Control group and Experimental group of Asthma patients.
Control Group Experimental Differ

Assess (n=100) Group (n=100) ence “t” value
p’ value
ment b/w (unpaired)
Mean SD Mean SD
means
Pre-test 30.36 2.51 29.32 2.51 1.04 0.72 NS p=0.469
Post I 35.52 2.44 49.48 2.75 13.96 9.46 p=0.000
Post II 40.96 1.89 61.28 1.86 20.32 19.10 p=0.000
Post III 45.20 2.75 80.80 1.58 35.60 28.01 p=0.000
NS Not significant
The effect of peak flow monitoring within experimental and control groups are
showed in the above Table 9. The mean Well being index scores before peak flow
monitoring in experimental group was M=29.32, SD=2.5 and after peak flow
monitoring was M=49.4, SD=2.7, M=61.2, SD=1.8, M=80.8, SD=1.5 during post test
I,II,III respectively. The mean Well being index scores during pre test in control
group was M=30.36, SD=2.5 and in post test M=35.52, SD=2.4, M=40.96, SD=1.8,
M=45.20, SD=2.7 during post test I,II,III respectively. The same was statistically
highly significant (p<0.001) during post test I (t’9.46), post test II (t’19.10), post test
III (“t” 28.01) and not during pretest (t’0.72). Hence Ho1 (no significant difference in
well being index score between control and experimental group before intervention) is
accepted.
97
Fig. 6 Mean scores of Well being Index from Pre test to Post Test III between
Control and Experimental Group.
Fig. 6 depicts the improvement in well being index scores during the post
tests of experimental group comparing with control group that determines the
effectiveness of peak flow self management plan for asthma patients.
98
Section III Comparison of Pre and Post test Assessment of Domain Wise Asthma
Quality of Life Questionnaire (AQLQ) and Category wise AQLQ and Well being
Index in Control and Experimental group of asthma patients.
Table. 10 Comparison of Domain Wise AQLQ Scores between Control and

Experimental group in Pretest of Asthma Patients
Sl: Domains Control Experimental “t” test

(Unpaired)
p’ Value
No: (n=100) (n=100)
Mean SD Mean SD
1 Symptoms (12) 35.19 4.90 36.33 5.38 1.56 NS p=0.119
2 Activity limitation (11) 33.48 4.84 33.51 4.49 0.45 NS p=0.964
3 Emotional function (5) 15.26 3.03 14.74 3.66 1.09 NS p=0.276
4 Environmental stimuli (4) 11.97 3.00 12.38 2.81 0.99 NS p=0.321
NS: Not significant

Table. 10 depicts the domain wise AQLQ scores of pre-test in control and
experimental group. There was no significant difference in mean scores of control and
experimental group during pretest and the “t” values (1.56, 0.45, 1.09 & 0.99)
respectively for each domain was not statistically significant showing no significant
difference between the mean AQLQ scores of control and experimental group before
intervention. Therefore the hypothesis H01: there will be no significant difference
between the mean AQLQ scores of control and experimental group before
intervention is accepted. (p>0.05).
99
Fig.7 Mean Scores of Domain wise AQLQ in Control and Experimental group in
Pre Test
The data in Fig.7 depicts that there was no change Domain wise AQLQ scores
in Control and Experimental group in Pre Test.
100
Table. 11 Comparison of Domain wise AQLQ Scores between Control and
Experimental Group in Post test I of Asthma Patients
Sl: Control Experimental “t”

No: Domains (n=100) (n=100) test p’ value
Mean SD Mean SD (Unpair
ed)
1 36.62 5.70 47.43 5.32 13.71 p=0.000

Symptoms (12)
2 33.38 4.56 43.89 4.60 16.79 p=0.000

Activity limitation (11)
3 15.56 3.09 20.25 3.37 10.34 p=0.000

Emotional function (5)
4 12.81 2.81 16.16 2.96 8.28 p=0.000

Environmental stimuli (4)
The effect of peak flow monitoring on Asthma quality of life questionnaire
among control and experimental during post test I are showed in the above table 11.
The mean AQLQ scores of experimental group (M=47.43, SD=5.32, M=43.89,
SD=4.60, M=20.25, SD=3.37, M=16.16, SD= 2.96) for all the domains such as
symptoms, Activity limitation, Emotional function and Environmental stimuli were
higher when compared with control group (M=36.62, SD=5.7, M=33.38, SD=4.5,
M=15.56, SD=3.0, M=12.8, SD=2.81) and the unpaired “t” test (14.09, 16.22, 10.22
&8.19) for each domain respectively showed significant difference p<0.001 for all
the domains which can be attributed to the effectiveness of peak flow monitoring for
asthma patients.
101
Post test I
The data in figure 8 shows that there was increase in domain wise AQLQ
scores in Experimental group in Post test I that determines the effectiveness of peak
flow self management plan for asthma patients.
102
Table. 12 Comparison of Domain wise AQLQ between Control And
Experimental Group in Post test II of Asthma Patients
Sl: Control Experimental “t” test

No: Domains (n=100) (n=100) (Unpair p’ Value
Mean SD Mean SD ed)
1 37.99 5.80 54.09 5.92 19.40 p=0.000

Symptoms (12)
2 34.20 5.19 49.18 5.60 19.59 p=0.000

3 15.82 3.77 22.53 3.48 13.05 p=0.000

4 12.76 2.97 18.34 3.48 12.17 p=0.000

The effect of peak flow monitoring on Asthma quality of life questionnaire
among control and experimental in post test II are showed in the above table 12. The
mean AQLQ scores of experimental group (M=54.09, SD=5.9, M=49.18, SD=5.6,
M=22.53, SD=3.4, M=18, SD=3.4) for all the domains such as Symptoms, Activity
limitation, Emotional function and Environmental stimuli were higher when
compared with control group (M=37.99,SD=5.8, M=34.20, SD=5.1, M=15.82,
SD=3.7, M=12.76, SD=2.97) and the unpaired “t” test p<0.001 (19.40,19.59,13.05
&12.17) respectively showed significant difference for all the domains which can be
attributed to the effectiveness of peak flow monitoring for asthma patients.
103
Post Test II
The data in figure 9 presents the improvement in Domain wise AQLQ in
Control and Experimental group in Post test II that determines the effectiveness of
peak flow self management plan for asthma patients.
104
Table 13 Comparison of Domain wise AQLQ scores between Control and
Experimental Group in Post test III of Asthma Patients
Sl: Control Experimental “t” test p’ value

No: Domains (n=100) (n=100) (Unpair
Mean SD Mean SD ed)
1 38.32 6.56 60.28 4.42 27.75 p=0.000

Symptoms (12)
2 35.64 5.25 55.63 4.89 27.85 p=0.000

3 16.30 3.11 25.46 3.09 20.87 p=0.000

4 12.83 2.97 19.80 2.88 16.80 p=0.000

Table. 13 depicts the domain wise AQLQ scores of control and experimental
group during post-test-III. The mean AQLQ scores of experimental group (M=60.28,
SD=4.4, M=55.63, SD=4.8, M=25.46, SD=3.0, M=19.80, SD=2.8) for all the domains
such as Symptoms, Activity limitation, Emotional function and Environmental stimuli
were higher when compared with control group (M=38.32,SD=6.5, M=35.64,
SD=5.2, M=16.30, SD=3.1, M=12.83, SD=2.97) and the unpaired “t” test p<0.001
(27.75, 27.75, 20.87 &16.80) respectively showed significant difference for all the
domains which can be attributed to the effectiveness of peak flow monitoring for
asthma patients.
105
Fig. 10 Mean Scores of Domain wise AQLQ in Control and Experimental group
in Post Test III
The data in figure 10 presents the improvement in Domain wise AQLQ in
Control and Experimental group in Post test III that determines the effectiveness of
peak flow self management plan for asthma patients.
106
Table 14 Assessment of Quality of life of Control and Experimental group from
Pre -test to Post-test III
Pre test Post-1 Post-2 Post-3

Groups Score QOL
f % f % f % f %
32-96 Poor 53 53.0 37 37.0 39 39.0 34 34.0

Avera
Control 97-160 47 47.0 63 63.0 61 61.0 66 66.0
ge
(n=100)
161-224 Good 0 0.0 0 0.0 0 0.0 0 0.0
Total 100 100 100 100 100 100 100 100
32-96 Poor 49 49.0 0 0.0 0 0.0 0 0.0
Experi- Avera
97-160 51 51.0 100 100.0 93 93.0 48 48.0
mental ge
(n=100) 161-224 Good 0 0.0 0 0.0 7 7.0 52 52.0
Total 100 100 100 100 100 100 100 100
The table-14 assesses the quality of life of both groups from pretest to post test
III. In control group, 53% and 47% of the patients had poor and average quality of life
in pre-test and no one had good quality of life in post-test. Similarly in experimental
group 49% and 51% had poor and average quality of life respectively in pre-test but
after intervention majority of patients (52%) had good quality of life and the
remaining 48% asthma patients’ quality of life was average and no one had poor
quality of life. This attributes to the effectiveness of peak flow self management plan
for asthma patients.
107
Table 15 Assessment of Well being of Control and Experimental group from
Pre-test to Post-test III
Pre test Post-1 Post-2 Post-3

Well
Groups Score
being f % f % f % f %
0-40 Poor 87 87.0 75 75.0 51 51.0 38 38.0

Avera
Control 41-80 13 13.0 25 25.0 49 49.0 62 62.0
ge
(n=100)
81-100 Good 0 0.0 0 0.0 0 0.0 0 0.0
Total 100 100 100 100 100 100 100 100
0-40 Poor 87 87.0 25 25.0 0 0.0 0 0.0
Experi- Avera
41-80 13 13.0 75 75.0 100 100 59 59.0
mental ge
(n=100) 81-100 Good 0 0.0 0 0.0 0 0.0 41 41.0
Total 100 100 100 100 100 100 100 100
The table-15 states the assessment of well being of the control and
experimental group of patients from pre test to post test III. Both groups had 87% and
13% of poor and average well being respectively at pre test. Control group had poor
well being (75%, 51% and 38%) and average well being (25%, 49%, 62%) during
post-test I, II, III respectively and no one had good well being. Experimental group
had poor well being (25%), average well being (75%, 100%, 59%) during post-test I,
II, III respectively and good well being (41%) at post III, and though a minimal 25%
had poor well being at post test I, no one had poor well being at post test II & III.
This attributed to the effectiveness of peak flow self management plan for asthma
patients.
108
Section IV Test of ANOVA between the Experimental and Control readings
from Pre test to Post test I to III.
Table 16 Comparison of AQLQ Scores between Pre-test and Post-tests in

Control and Experimental group of Asthma patients using ANOVA.
Assessment Control group (n=100) Experimental group (n=100)

Mean SD F Sig Mean SD F value Sig
value
Pre test 95.90 7.84 96.96 9.05
Post test I 98.37 8.88 461.28 0.000 127.73 7.88 2078.39 0.000
Post test II 100.77 11.72 144.14 10.36
Post test III 103.09 13.28 161.17 7.23
Table 16 infers that there is significant difference in AQLQ scores in pre-test
and post test I,II,III scores within the groups.( p=0.000).
Asthma patients in control group had F=461.28, but F=2078.39 in
experimental group showing significant difference in repeated observations which
showed improvement in quality of life.
109
Fig 11. Trends of AQLQ improvements from Pre-test to Post-test III between the
Control and Experimental groups of Asthma patients.
Fig 11 depicts Confirmation of AQLQ score by repeated measures of ANOVA
from pretest to post-test III. The plots clearly shows that the trends have a significant
difference between the two groups. The experimental group had an improvement in
AQLQ score that was statistically significant (p<0.001). Thus, it determines the
effectiveness of peak flow self-management plan for asthma patients.
110
Fig 12. Trends of Well being improvements from Pre-test to Post-test III between
the Control and Experimental groups of Asthma patients.
Fig 12 depicts Confirmation of Well being index score by repeated measures
of ANOVA from pretest to post-test III. The plots clearly shows that the trends have
a significant difference between the two groups. The experimental group had an
improvement in Well being index score that was statistically significant (p<0.001).
Thus, it determines the effectiveness of peak flow self-management plan for asthma
patients.
111
Section V: Assessment of Level of Acceptability of Peak flow Intervention among
Table. 17 Level of Acceptability of Peak flow Self Management Plan in

Experimental Group of Asthma Patients
(N=100)
Peak flow self
Score Satisfaction category management patients
Frequency %
0-10 Highly Unacceptable - -
11-20 Unacceptable - -
21-30 Acceptable 37 37%
31-40 Highly Acceptable 63 63%
Total 100 100.0
Table 17 reveals that majority (63%) of asthma patients have highly accepted
and 37% of the patients accepted the peak flow self management plan intervention.
112
Section VI: Assessment of Correlation between Quality of life and Symptoms in
control and experimental group
Table 18 Correlation between the Domains of AQLQ in Control group of

Asthma patients in Pre-test
(N=100)
Domains Percentage of
p’ domain (1)
r r2
1 2 Value determined
domain (2)
Symptoms Activity -0.077 p=0.45 0.006 0.6
Symptoms Emotional 0.026 p=0.80 0.0007 0.07
Symptoms Environmental 0.017 p=0.87 0.003 0.3
Activity Emotional 0.070 p=0.49 0.005 0.5
Activity Environmental -0.106 p=0.29 0.011 1.1
Emotional Environmental -0.048 p=0.64 0.002 0.2
The table 18 states the relationships between domains of AQLQ among
control group in pre test. The results revealed that there was no statistically significant
correlation between the domains (p>0.05).
113
Asthma patients in Post-test I
(N=100)
domain (1)
r p’value r2
1 2 determined
domain (2)
Symptoms Environmental 0.017 p=0.87 0.000 0
Activity Environmental 0.070 p=0.49 0.005 0.5
The table 19 shows the relationships between each domains of AQLQ among
control group of asthma patients in post-test I. The results revealed that there was no
statistically significant correlation between the AQLQ domains (p>0.05).
114
Asthma patients in Post-test II
(N=100)
domain (1)
r p’Value r2
1 2 determined
domain (2)
Symptoms Activity 0.261 p=0.01 0.068 6.8
Emotional Environmental 0.208 p=0.04 0.043 4.3
The table 20 states the correlation between each domains of AQLQ among
control group patients in post- test II. The domain symptom was statistically
significantly correlated with the domains namely activity, emotional and
environmental domains (p<0.05). The domain activity was statistically significantly
correlated with emotional domain (p<0.01). The activity domain did not correlated
with environmental domain (p>0.05). The domain emotional was statistically
significantly correlated with environmental domain (p<0.05). The domain symptom
determined activity domain, emotional and environmental domain as 6.8%, 4.4% and
5.1% of variance respectively. The activity domain determined 6.7% of emotional
domain. The emotional domain determined 4.3% variance of environmental domain.
115
Asthma Patients in Post-test III
(N=100)
domain (1)
r p’value r2
1 2 determined
domain (2)
Symptoms Environmental 0.469 p=0.00 0.220 22
The table 21 shows the correlations between each domains of AQLQ among
control group in post-test III. The symptom was statistically highly significantly
correlated with activity, emotional and environmental domains (p<0.001). The
activity was statistically significantly correlated with emotional and environmental
domain (p<0.05). The symptom domain determined activity, emotional and
environmental domain as 31.9%, 9.4% and 21.9% variance respectively. The activity
domain determined the emotional and environmental domains as 7.7% and 4.5%
variance respectively.
116
Table 22 Correlation between the Domains of AQLQ in Experimental group of
Asthma patients in Pre-test
(N=100)
domain (1)
R p’Value r2
1 2 determined
domain (2)
The table 22 states the relationships between domains of AQLQ among
experimental groups in pre-test. The results revealed that there was no statistically
significant correlation between the domains (p>0.05).
117
Asthma patients in Post-test I
(N=100)
domain (1)
R p’Value r2
1 2 determined
domain (2)
Symptoms Emotional -0.113 p=0.26 0.013 1.3
Symptoms Environmental -0.011 p=0.91 0.0001 0.01
Activity Emotional -0.252 p=0.01 0.063 6.34
experimental group patients in post-test I. There was no statistically significant
relationship established except activity limitation domain with emotional domain. The
correlation between activity with emotional domain was statistically significant
(p<0.05) and it determined 6.3% of variance.
118
Asthma patients in Post-test II
(N=100)
domain (1)
R p’Value r2
1 2 determined
domain (2)
experimental group patients in post-test II. None of the domains were established
correlations between them (p>0.05).
119
Asthma patients in Post-test III (N=100)
domain (1)
R p’ value r2
1 2 determined
domain (2)
Activity Environmental -0.044 p=0.66 0.002 0.2
The table 25 shows the correlation between each domains of AQLQ among
experimental group patients in post-test III. The domains did not show statistically
significant correlation except symptom with emotional domain of AQLQ (p>0.05).
The symptom was statistically significantly negatively correlated with emotional
domain (p<0.05). The symptom determined 7.3% variance with emotional domain of
AQLQ in asthma patients.
120
Section VII: Association between quality of life of Asthma patients with their
Selected Demographic Variables and Clinical Variables.
Table 26 Association between Pre Test Mean Scores of AQLQ (Asthma
quality of life questionnaire) and Selected Demographic Variables among
Asthma Patients in Control group. (N=100)
Demographic Total
Categories Poor Average χ2 and df p’ Value
variables
20-39 12 9 21
χ2=3.126 p=0.209
40-59 23 14 37
Age (Years)
≥60 18 24 42 df=2
Total 53 47 100
Male 33 21 54 χ2=3.100 p=0.078
Gender Female 20 26 46
df=1
Total 53 47 100
No formal 10 4 14
Primary 11 12 23
χ2=6.461 p=0.167
Educational High School 16 8 24
status Hr.Sec 7 12 19 df=4
Degree 9 11 20
Total 53 47 100
Cooly 11 15 26
χ2=0.697 p=0.697
Occupational Unskilled 26 16 42
status Skilled & Prof 16 16 32 df=2
Total 53 47 100
Married 29 28 57
χ2=2.646 p=0.266
Un married 14 13 27
Marital status
Widow & Div 10 6 16 df=2
Total 53 47 100
Monthly family <10 27 28 55 χ2=1.353 p=0.508
income 10-15 18 11 29
df=2
(000) >15 8 8 16
121
Total 53 47 100
Rural 37 32 69 χ2=0.035 p=0.852
Residence Urban 16 15 31
df=1
Total 53 47 100
Joint 46 38 84 χ2=0.654 p=0.419
Type of family Nuclear 7 9 16
df=1
Total 53 47 100
The above table 26 shows the association between selected demographic
variables and AQLQ of patients of the control group at the time of the pre-test. None
of the demographic variables of the patients had any statistically significant
association (p>0.05) with their quality of life.
122
Table 27 Association between Pre Test Mean Scores of AQLQ (Asthma quality
of life questionnaire) and Selected Clinical Variables among Asthma Patients in
Control group.
(N=100)
Clinical
Components Poor Average Total χ2 and df p’ Value
variables
1st day 5 11 16
χ2=5.911 p=0.052
Last After day 3 6 9
consultation After week 45 30 75 df=2
Total 53 47 100
Yes 48 33 81 χ2=6.705
Industries p=0.010
No 5 14 19
around df=1
Total 53 47 100
Wood &Dung 17 12 29 χ2=0.518 p=0.472
Cooking fuel Gas 36 35 71
df=1
Total 53 47 100
Lost no 23 20 43
1-2 weeks 12 8 20 χ2=2.085
Abstain from p=0.555
2-4 weeks 12 9 21
work df=3
>5 & Unable 6 10 16
Total 53 47 100
Drug 1&2 23 21 44
χ2=0.079 p=0.961
Deriphyline 14 13 27
Medication
Others 16 13 29 df=2
Total 53 47 100
Yes 25 14 39 χ2=11.709 p=0.001
Smoking No 28 33 61
df=1
Total 53 47 100
1st degree 35 32 67 χ2=0.047 p=0.828
Family history No 18 15 33
df=1
Total 53 47 100
123
<1 year 21 14 35
χ2=1.072 p=0.585
Duration of 1-5 years 17 18 35
Asthma >5years 15 15 30 df=2
Total 53 47 100
Mild 12 22 34
χ2=13.287 p=0.001
Moderate 29 20 49
Asthma severity
Severe 15 2 17 df=2
Total 53 47 100
DM 11 8 19
HT 9 7 16 χ2=0.418
Co- morbidity p=0.937
Gastro& Bone 10 9 19
present df=3
Others 23 23 46
Total 53 47 100
Pets 4 4 8
Dust 7 6 13
Pollen 9 10 19 χ2=1.99 p=0.851
Allergy Smokes 9 5 14
df=5
Fumes 2 4 6
Cold air 22 18 40
Total 53 47 100
Yes 44 34 78 χ2=1.655
Use of Peak p=0.198
No 9 13 22
flow metre df=1
Total 53 47 100
The above table 27 shows the association between selected clinical variables
and AQLQ of the patients of the control group at the time of the pre-test. The
patients’ asthma severity, habit of smoking and whether or not they had industries
around their homes had statistically highly significant (p<0.01) associations with their
quality of life. The rest of the variables such as when they had lastly met a physician,
whether or not they had used a peak flow meter at any time, and what kind of cooking
124
fuel they used at that time did not have any kind of statistically significant association
with their quality of life (p>0.05).
Table 28 Association between Pre Test Mean Scores of AQLQ (Asthma quality
of life questionnaire) and Selected Demographic Variables among Asthma
Patients in Experimental group. (N=100)
Demographic Total
Categories Poor Average χ2 and df p’value
variables
20-39 6 12 18
χ2=2.156 p=0.340
40-59 21 19 40
Age (Years)
≥60 22 20 42 df=2
Total 49 51 100
Male 35 37 72 χ2=0.016 p=0.900
df=1
Total 49 51 100
No formal 6 7 13
Primary 10 11 21
χ2=6.566 p=0.161
Educational High School 9 12 21
Degree 11 17 28
Total 49 51 100
Cooly 13 15 28
χ2=0.327 p=0.849
Occupational Unskilled 15 22 37
Total 49 51 100
Married 31 35 66
χ2=2.828 p=0.243
Un married 7 6 13
Marital status
Total 49 51 100
Monthly family <10 19 31 50
χ2=5.064 p=0.079
income 10-15 20 12 32
125
(000) >15 10 8 18 df=2
Total 49 51 100
Rural 34 40 74 χ2=1.062 p=0.303
Residence Urban 15 11 26
df=1
Total 49 51 100
Joint 42 37 79 χ2=2.611 p=0.106
Type of family Nuclear 7 14 21
df=1
Total 49 51 100
variables and AQLQ of the patients of the experimental group at the time of the pre-
test. None of the demographic variables of the patients had any statistically significant
association (p>0.05) with their quality of life.
126
Table 29 Association between Pre Test Mean Scores of AQLQ (Asthma
quality of life questionnaire) and Selected Clinical Variables among Asthma
Patients in Experimental group.
(N=100)
Clinical
Components Poor Average Total χ2 and df p’ Value
variables
1st day 13 5 18
χ2=5.491 p=0.064
Last After day 10 9 19
Total 49 51 100
Yes 36 41 77 χ2=0.676
Industries p=0.411
No 13 10 23
around df=1
Total 49 51 100
Wood&Dung 6 12 18 χ2=2.156 p=0.142
Cooking fuel Gas 43 39 82
df=1
Total 49 51 100
Lost no 21 17 38
1-2 weeks 7 11 18
χ2=1.362 p=0.715
Abstain from 2-4 weeks 11 12 23
work >5 weeks & 21 df=3
10 11
Unable
Total 49 51 100
Drug 1&2 17 30 47
χ2=7.442 p=0.024
Deriphyline 14 13 27
Medication
Others 18 8 26 df=2
Total 49 51 100
Yes 27 21 48 χ2=1.942 p=0.164
Smoking No 22 30 52
df=1
Total 49 51 100
127
1st degree 34 38 72 χ2=0.325 p=0.568
Family history No 15 13 28
df=1
Total 49 51 100
<1 year 18 22 40
χ2=1.782 p=0.410
Duration of 1-5 years 18 21 39
Asthma 5+ years 13 8 21 df=2
Total 49 51 100
Mild 10 17 27
χ2=7.285 p=0.026
Moderate 30 34 64
Asthma severity
Severe 8 1 9 df=2
Total 49 51 100
DM 9 5 14
HT 7 9 16 χ2=3.295
Co- morbidity p=0.348
Gastro& Bone 4 9 13
present df=3
Others 29 28 57
Total 49 51 100
Pets 4 8 12
Dust 3 2 5
Pollen 4 7 11 χ2=7.42 p=0.191
Allergy Smokes 5 12 17
df=5
Fumes 5 3 8
Cold air 28 19 47
Total 49 51 100
Yes 1 5 6 χ2=2.670
Use of Peak p=0.102
No 48 46 94
flow metre df=1
Total 49 51 100
128
and AQLQ of the patients of the experimental group at the time of the pre-test. The
patients’ asthma severity, and the medications they used had statistically significant
associations with their quality of life (p<0.05). The rest of the variables such as when
they had lastly met a physician, whether or not they had used a peak meter at any
time, and what kind of cooking fuel they used at that time had no statistically
significant association with their quality of life (p>0.05).
129
Table 30 Association between Post-test II Mean Scores of AQLQ (Asthma
Asthma Patients in Control group. (N=100)
Demographic Test
Categories Poor Average Total χ2 and df
variables statistics
20-39 15 6 21
40-59 10 27 37 χ2=12.079 p=0.002
Age (Years)
≥60 14 28 42 df=
Total 39 61 100
Male 20 34 54
χ2=0.190 p=0.662
df=1
Total 39 61 100
No formal 6 8 14
Primary 10 13 23
Educational High School 8 16 24 χ2=1.348
p=0.853
Degree 9 11 20
Total 39 61 100
Cooly 14 12 26
Occupational Unskilled 10 32 42 χ2=7.317
p=0.026
Total 39 61 100
Married 20 37 57
Un married 11 16 27 χ2=1.215
Marital status p=0.545
Total 39 61 100
<10 22 33 55
Monthly family
10-15 11 18 29 χ2=0.052
income p=0.974
>15 6 10 16 df=2
(000)
Total 39 61 100
130
Rural 28 41 69
χ2=0.234
Residence Urban 11 20 31 p=0.629
df=1
Total 39 61 100
Joint 30 54 84
χ2=2.383
Type of family Nuclear 9 7 16 p=0.123
df=1
Total 39 61 100
variables and AQLQ of the patients of the control group at the time of the post-test II.
The asthma patients’ age had a statistically highly significant association with their
quality of life and the patients’ occupations had a statistically significant association
with their quality of life (p<0.01). The rest of the variables such as the type of their
families, their education, marital statuses, and how much their households earned at
that time had no statistically significant association with their quality of life (p>0.05).
131
Patients in Control group.
(N=100)
Total χ2 & df Test

Clinical Components Poor Average
statistics
variables
1st day 6 8 14
Last After day 6 7 13 χ2=0.492
p=0.782
Total 39 61 100
Yes 30 51 81
Industries χ2=0.691
No 9 10 19 p=0.406
around df=1
Total 39 61 100
Wood & 29
13 16
Dung χ2=0.583
Cooking fuel p=0.445
Gas 26 45 71 df=1
Total 39 61 100
Lost no 20 23 43
1-2 weeks 9 11 20
Abstain from χ2=4.852
2-4 weeks 4 17 21 p=0.183
work df=3
5+ & Unable 6 10 16
Total 39 61 100
Drug 1&2 22 22 44
Deriphyline 11 16 27 χ2=6.356
Medication p=0.042
Others 6 23 29 df=2
Total 39 61 100
Yes 19 6 25
χ2=19.182
Smoking No 20 55 75 p=0.000
df=1
Total 39 61 100
1st degree 25 42 67 χ2=0.243
Family history p=0.622
No 14 19 33 df=1
132
Total 39 61 100
<1 year 17 18 35
Duration of 1-5 years 14 21 35 χ2=3.281
p=0.194
Total 39 61 100
Mild 10 24 34
Moderate 15 34 49 χ2=16.194
Asthma severity p=0.000
Severe 14 3 17 df=2
Total 39 61 100
DM 10 9 19
HT 8 8 16
Co- morbidity Gastro & 19 χ2=3.754
7 12 p=0.290
present Bone df=3
Others 14 32 46
Total 39 61 100
Pets 4 4 8
Dust 7 6 13
Pollen 8 11 19
χ2=8.908
Allergy Smokes 7 7 14 p=0.113
df=5
Fumes 4 2 6
Cold air 9 31 40
Total 39 61 100
Yes 13 15 28
Use of Peak χ2=0.902
No 26 46 72 p=0.342
flow metre df=1
Total 39 61 100
133
and AQLQ of the patients of the control group at the time post-test II. The patients’
habit of smoking and asthma severity had statistically very highly significant
associations with their quality of life and the patients’ medications had a statistically
significant association with their quality of life (p<0.01). The rest of the variables
such as when they had lastly consulted with a physician, whether or not they had
industries around their home at that time, what kind of cooking fuel they used at that
time, and how long they had been absent from their works in the last six months had
no statistically significant association with their quality of life. (p>0.05).
134
Asthma Patients in Experimental group. (N=100)
Demographic Test
Categories Average Good Total χ2 and df
20-39 13 5 18
40-59 39 1 40 χ2=14.558 p=0.001
Age (Years)
≥60 41 1 42 df=2
Total 93 7 100
Male 68 4 72
χ2=0.824
Gender Female 25 3 28 p=0.364
df=1
Total 93 7 100
No formal 12 1 13
Primary 19 2 21
Educational High School 20 1 21 χ2=1.475
p=0.831
Degree 27 1 28
Total 93 7 100
Cooly 24 4 28
Occupational Unskilled 36 1 37 χ2=2.220
p=0.330
Total 93 7 100
Married 63 3 66
Un married 11 2 13 χ2=3.422
Marital status p=0.181
Total 93 7 100
<10 48 2 50
Monthly family
10-15 30 2 32 χ2=3.303
income p=0.192
>15 15 3 18 df=2
(000)
Total 93 7 100
135
Rural 70 4 74
χ2=1.112
Residence Urban 23 3 26 p=0.292
df=1
Total 93 7 100
Joint 75 4 79
χ2=2.168
Type of family Nuclear 18 3 21 p=0.141
df=1
Total 93 7 100
variables and AQLQ of the patients of the experimental group in post-test II. The
patients’ age had a statistically highly significant association with their quality of life
(p<0.01). The rest of the variables such as their education, occupations, marital
statuses, and how much their households earned at that time had no statistically
significant association with their quality of life (p>0.05).
136
Patients in Experimental group. (N=100)
Clinical χ2 & df Test

Components Average Good Total
1st day 1 1 2
Last After day 2 1 3 χ2=9.316
p=0.009
Total 93 7 100
Yes 75 2 77
Industries χ2=9.968
No 18 5 23 p=0.002
around df=1
Total 93 7 100
Wood&Dung 14 4 18
χ2=7.813
Cooking fuel Gas 79 3 82 p=0.005
df=1
Total 93 7 100
Lost no days 35 3 38
1-2 weeks 17 1 18
Abstain from χ2=0.558
2-4 weeks 22 1 23 p=0.906
work df=3
>5 & Unable 19 2 21
Total 93 7 100
Drug 1&2 45 2 47
Deriphyline 25 2 27 χ2=1.373
Medication p=0.503
Others 23 3 26 df=2
Total 93 7 100
Yes 24 1 25
χ2=0.461
Smoking No 69 6 75 p=0.497
df=1
Total 93 7 100
1st degree 68 4 72
χ2=0.824
Family history No 25 3 28 p=0.364
df=1
Total 93 7 100
137
<1 year 37 2 39
Duration of 1-5 years 37 3 40 χ2=0.431
p=0.806
Total 93 7 100
Mild 85 6 91
Moderate 7 1 8 χ2=0.470
Asthma severity p=0.791
Severe 1 0 1 df=2
Total 93 7 100
DM 12 2 14
HT 15 1 16
Co- morbidity χ2=8.726
Gastro&Bone 10 3 13 p=0.033
present df=3
Others 56 1 57
Total 93 7 100
Pets 10 2 12
Dust 5 0 5
Pollen 10 1 11
χ2=3.120
Allergy Smokes 16 1 17 p=0.681
df=5
Fumes 7 1 8
Cold air 45 2 47
Total 93 7 100
Yes 93 7 100
Use of Peak χ2=0
No 0 0 0 p=1.000
flow metre df=1
Total 93 7 100
The above table table 33 shows the association between selected clinical
variables and AQLQ of the patients of the experimental group in post-test II. The
patients’ time of last consultancy with a physician, whether or not they had industries
around their homes at that time, what kind of cooking fuel they used at that time had
statistically highly significant associations with their quality of life, and the patients’
co-morbid illnesses had a statistically significant association with their quality of life
138
(p<0.01). The rest of the clinical variables had no statistically significant association
with their quality of life (p>0.05).
Summary
This chapter dealt with the analysis and the interpretation of data obtained by
the researcher. The analysis showed improvement in the quality of life in regard to
Symptoms, Activity Limitation, Emotional Function and Environmental Stimuli
among asthma patients after the intervention on peak flow self management plan. This
indicates that the peak flow self management plan was effective in enhancing the
quality of life for asthma patients
139
140
Chapter – V
Discussion
CHAPTER - V
DISCUSSION
This chapter deals with the discussion of the results of the data analyzed based
on the objectives of the study and the hypotheses. This chapter also presents the major
findings and discusses them in relation to similar studies conducted by other
researchers. The aim of this study was to find out the effectiveness of peak flow self
management plan for asthma patients on quality of life in selected community.
The research design used for the study was quasi experimental time series
design. The study was conducted among 200 asthma patients. The conceptual frame
work based on Bandura’s self regulatory model was applied for the present study. The
findings of the study had proved that there was a significant difference in
experimental group and improved quality of life after intervention.
Major findings of the study
Description of sample characteristics
The present study revealed that majority of the asthma patients were males
(54%, 72%), married (57%, 66%), from rural back ground (69, 74), from joint family
(84%, 79%) in control group and experimental group respectively. Considerable
percentage of them were aged >60 years (42%, 42%), had degree education (20%,
28%), were unskilled workers (42%, 37%) with monthly family income of Rs.5001 -
10,000 (44%, 41%) in control group and experimental group respectively.
In regard to clinical variables, majority of the asthma patients had industry
around home (81%, 77%), used LPG for cooking (71%,82%), used no peak flow
metre (77%,94%), had family history of first degree relative with asthma (67%,72%),
had no habit of smoking (61%, 48%), with moderate asthma (49%,64%) had
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consultation with physician one month back (58%,51%) and had no presence of co-
morbid illness (46%, 57%). Considerable percentage of them had no absenteeism in
work or school (43%, 38%), used Salbutamol medication (41%, 42%), with history
of asthma for 1-5 years (35%,39%) and allergy to cold air (40%, 47%) in control
group and experimental group respectively.
The first objective of the study was to assess the quality of life and general
well being before and after peak flow self management plan in control and
experimental group of asthma patients.
The present study findings indicate that the mean AQLQ scores of control
group and experimental group were almost same (95.90, 96.6/224) during pretest
having the “t” value 0.88 which showed there is no significant difference in mean
pretest scores (p>0.05), but the post test scores of experimental group were
significantly higher after 2 months (127.7), 4 months (144.1) and 6 months(161.1)
than the post test scores of control group respectively 2 months (98.3) 4 months
(100.7) and 6 months(103.09).
The present study also found that the mean Well being index scores before
peak flow monitoring in experimental group was M=29.32, SD=2.5 and after peak
flow monitoring was M=49.4, SD=2.7, M=61.2, SD=1.8, M=80.8, SD=1.5 during
post test I,II,III respectively. The mean Well being index scores during pre test in
control group was M=30.36, SD=2.5 and in post test M=35.52, SD=2.4, M=40.96,
SD=1.8, M=45.20, SD=2.7 during post test I, II, III respectively.
The findings are consistent with the findings of Kaya et al. (2009) who
conducted a study on Self-management plans for asthma control and predictors of
patient compliance to evaluate the impact of peak flow or symptom-based self-
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management plans on asthma control and patients' quality of life and to determine the
main psychosocial factors that affect compliance with these plans. Of the 63 patients
85% of them had moderately or severely persistent asthma. Personal asthma plans
increased optimal asthma control significantly. Emergency visits, antibiotic
treatments, systemic corticosteroid treatments, and unscheduled visits were fewer than
the previous year. Control parameters were better in the PFM group. After the self-
management education, the quality of life dimensions, i.e., vitality, total mental and
general scores of both groups increased. Compliance with the action plans was better
in the PFM group.63So here it indicates the importance of personal asthma plans &
PFM I s required for asthma control and improved quality of life in terms of reduced
emergency visits, antibiotic treatments, systemic or ICS.
The second objective of the study was to assess the effectiveness of peak
flow self management plan among asthma patients by comparing the quality of
life and general well being between control and experimental group of asthma
patients.
H02: There will be no significant difference in the mean AQLQ score and well
being index score between first and subsequent observations in control and
experimental group.
The present study findings showed that the mean scores of AQLQ in control
group during pretest was M=95.90, SD=7.84, though there was slight increase during
Post test I (98.37, SD=8.8), Post test II (100.77, SD=11.72), and Post test III (103.09,
SD=13.2). There was no significant difference between the means of first and
subsequent observation having the “t” value for pre test with post test I (“t” 1.94.3),
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post test I with post test II (“t” 1.76) and post test II with post test III (“t” 1.43)
respectively as it is below table value 2.36 ( p>0.05).
And the post test scores of AQLQ in experimental group were 127.73, 144.14,
161.17 that was significantly higher than in control group (95.90, 100.77, 103.09) at
the end of 2 months 4 months and 6 months respectively. And the unpaired “t” value
(24.42, 27.72, 38.26) showed significant difference between experimental and control
group after the intervention (p<0.001). This showed that peak flow self management
plan among asthma patients was effective on quality of life. Hence H02: There will be
no significant difference in the mean AQLQ score and well being index score
between first and subsequent observations in control group and experimental group of
asthma patients is rejected.
The findings are consistent with the findings of McGrath, et.al (2009) along
with the University of California San Francisco. They conducted a 24-week
randomized, controlled trial to determine if individualized instruction in asthma self-
management adds significantly to the effects of self monitoring alone on patients’
adherence to inhaled corticosteroids (ICSs), medications that can help reduce
inflammation in the airway and prevent asthma attacks.
In the study, 84 adults with asthma self-monitored their symptoms and kept a
daily log of their peak expiratory air flow. Of that group, 45 patients were randomly
selected to also receive a personal 30-minute session that included asthma
information, personally relevant allergen exposure reduction, a personal action plan,
and instruction in the correct use of their inhalers. During the study period, adherence
to ICSs was consistently higher in the intervention group compared with the control
group. In addition, participants in the intervention group experienced fewer nighttime
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awakenings, a marker of asthma control. Intervention participants also used rescue
inhalers less frequently, experienced an increased sense of control over their asthma,
and had a significant decrease in their levels of tryptase, which is released from cells
in the presence of allergens.78 So here is observed that PFM and individualized
instructions helped in adherence to ICS, less night time awakenings, and fewer asthma
episodes leading to good asthma control.
These findings are also consistent with the findings of Malarvizhi et al (2015)
on “Effectiveness of Peak Flow Guided Self Management Plan on Asthma Health
Outcomes among Patients with Bronchial Asthma at Chest OPD, Sri Ramachandra
Hospital, Chennai-116” which showed that the overall improvement in the mean
scores of post-test for experimental group when compared with control group, which
was highly significant. Hence it indicates that peak flow self management plan was
effective in improving quality of life among asthma patients.71
The present study findings are also consistent with the findings of Akiyama
(2002) in her literature on Self-Management with Peak Expiratory Flow Monitoring—
Treatment for Bronchial Asthma—explains that Peak expiratory flow (PEF)
monitoring should be considered in patients with moderate to severe asthma, who are
older than 5 years of age, have measurable PEF values, and receive medication on a
daily basis. In the practical treatment and management of asthma, the PEF monitoring
is most effective in cases where step-wise therapy according to asthma severity is
applied in long-term management.73 Thus PEF monitoring on daily basis is more
useful for chronic asthma patients than for acutely ill asthmatics.
The mean scores of well being index scores in experimental group during
pretest was only M=29.32 but there was gradual increase during Post test I
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(M=49.48,SD=2.7), Post test II (M=61.28, SD=1.86), and Post test III (M=80.80,
SD=1.5), which can be attributed to the effectiveness of peak flow monitoring for
asthma patients. The improvement was statistically significant (p<0.01) having the “t”
value for Pre test with post test I (“t” 13.3), post test I with post test II (“t” 8.4) and
post test II with post test III (“t” 20.5) respectively.
The present study findings are also consistent with the findings of Slader et al
(2007) who conducted a study on Measuring peak flow enhances adherence to
monitoring in asthma. There were three “PEF periods” during which patients also
measured spirometry twice daily. PEF was displayed after each of three maneuvers
followed by the highest PEF. At study visits, data were uploaded and reviewed by the
research assistant. The adherence to monitoring was higher during PEF periods than
non‐PEF periods (79% vs. 65%, p<0.0001). Mixed model analysis showed that
weekly adherence with monitoring increased by 13% with PEF monitoring
(p<0.0001) and by 5% with each 10 years of increasing age (p<0.0001). There was no
effect of gender (p = 0.80) or time to next/last visit (p = 0.59). 79 This study attributed
also stresses the importance of PEF monitoring for good adherence to treatment.
The third objective of the study was to assess the acceptability of asthma
patients regarding peak flow self management.
The present study revealed that majority of asthma patients (63%) have highly
accepted with peak flow self monitoring intervention, 37% just accepted the peak
flow self management plan intervention, no one was under unacceptable or highly
unacceptable categories. It indicates the interest, willingness and possibility of
adherence with monitoring of asthma patients towards asthma treatment and control.
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The present study findings are consistent with the findings of Slader et al
(2007) where he explained that in contrast with the perception that PEF monitoring is
burdensome to patients, this analysis on Measuring peak flow enhances adherence to
monitoring in asthma showed that, with electronic diaries, asking adults to measure
PEF significantly improved their adherence with monitoring. While a randomised
study would be required to formally evaluate the impact of PEF measurement on
adherence with monitoring, this is the first study to assess differences in adherence
with monitoring with and without PEF. They used patients as their own controls as
they crossed over between periods. Good adherence was also achieved with similar
electronic devices, despite the routine nature of the monitoring for assessment of
study outcome variables and the absence of physician feedback to patients. 79 Here it is
observed that instead of manual peak flow, electronic measurement is preferred for
good adherence to treatment and monitoring.
The fourth objective of the study was:
To find out the correlation between quality of life and its domains among
The present study revealed that there is no significant correlation between its
domains of AQLQ during pretest and post test I. But there was significant correlation
among the domains in post test II and III in control group. Same way there was no
significant correlation between quality of life (AQLQ) and its domains during pretest,
post test I (except activity with emotional), post-test II, as well as post-test III among
the domains in in experimental group.
The present study findings are also consistent with the findings of Schatz M
et al where in Questionnaires were completed at home by a random sample of 542
adult asthmatic patients. The correlations of the two asthma control tools (Asthma
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Control Test and Asthma Therapy Assessment Questionnaire) with the quality of life
tool (mini-Asthma Quality of Life Questionnaire) were strongest with the symptoms
and activity domains (r = 0.63–0.77); lower with the emotions domain (r = 0.57–
0.64); and lowest with the environment domain (r = 0.38–0.43). Asthma control tools
reflect the symptoms and activity themes of asthma quality of life well, but reflect the
environmental domain less well.102 Therefore asthma tools may be used to study the
domains in AQLQ and the relationship between quality of life and its domains.
The fifth objective of the study was:
To find the association between demographic and clinical variables with pre-
test quality of life in control and experimental group.
The present study in table 1 showed that majority (63%) of the participants
were males. The findings are supported by the findings of a study conducted by
Chhabra et al, to estimate prevalence of bronchial asthma in different regions of
India and to define risk factors influencing disease prevalence in Chandigarh, Delhi,
Kanpur and Bangalore where in among 73605 respondents, 37682 were men and
35923 were women that showed asthma being found in men than women. 30 This
showed asthma affects women more than men.
Among participants most (39.5%) of the patients were unskilled workers
earning Rs.5001 to 15000/-. The findings are supported by the findings of a study
conducted on ‘Socioeconomic Status and Asthma Prevalence in Young Adults in
which Asthma prevalence was higher in lower socioeconomic groups, and patients of
low educational levels had a higher risk of asthma’. The authors concluded that
community influences of living in a low-educational area are associated with asthma,
independently of patients’ own educational level and social class.31 Similar findings
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are also reported by Apter et al. (2013)48 who studied the association of health
literacy to asthma self-management in 284 adult patients and found that higher health
literacy was linked to better asthma control and adherence to therapy.
Also highest percentages (71.5%) of asthma patients were living in rural area.
The findings are supported by the findings of a study conducted on Prevalence and
risk factors for self-reported asthma in an adult Indian population: a cross-sectional
survey. The prevalence of self-reported asthma was 1.8% (95% CI 1.6–2.0) among
men and 1.9% (95% CI 1.8–2.0) among women, with higher rates in rural than in
urban areas and marked geographic differences. 32 Thus living in rural area may be a
predisposing factor for developing asthma.
Among the participants majority (79%) of patients have industry around their
home. The findings are supported by the findings of a study conducted on ‘Prevalence
of asthma by industry in the US population: A study of 2001 NHIS data’ where in, In
whites, the prevalence and ORs were significantly elevated for printing, publishing,
and allied industries (OR = 2.4, 95% CI 1.2–5.0) and health care (OR = 1.3, 95% CI
1.0–1.7).36 so inhaling or exposure to cotton dust or other industries may be another
predisposing factor for developing asthma.
In respect to smoking habits in this study most of the participants (54.5%) had
smoking habit. The study findings are consistent with the findings of Aggarwal. et al,
in which current tobacco smoking (OR 1.30, 95% CI 1.12–1.50) and ever use of
alcohol (OR 1.21, 95% CI 1.05–1.39) were associated with an increased asthma
risk.32
The same study findings are also consistent with the findings of Cerveri et al
in which Smokers had the highest proportion of patients with chronic cough/phlegm
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(p<0.01). One out of 4 patients with asthma continues smoking and reports
significantly more chronic cough/phlegm than never smokers and ex-smokers. This
stresses the importance of smoking cessation in all patients with asthma, even in those
with less severe asthma.37
Again Rabe et al in their study on Worldwide severity and control of asthma
in children and adults has mentioned that the proportion of adult asthmatic patients
who were current smokers was high. 51 So, having first degree relative has more
chance of developing asthma as a heredity factor.
In regard to family history (first degree) of asthma, majority (69.5%) of the
participants have family history (first degree) of asthma. The findings are supported
by the findings of a study conducted on ‘Family history as a predictor of asthma risk
where in family history of asthma in one or more first-degree relatives was
consistently identified as a risk factor for asthma’. 34
Among the participants a significant percent (51.5%) of the patients had no
co-morbid illness. The findings are supported by the findings of a study conducted on
‘Asthma and comorbidities’ where it says evidence-based medicine is lacking as most
asthma studies exclude comorbidities; and that additional studies are needed. 35
The present study showed majority (37%) of patients had allergy to cold air.
The findings are supported by the findings of a study conducted on Mild Cool Air - A
Risk Factor for Asthma Exacerbations: Results of a Retrospective Study where in the
Maximum attack rate (>90%) was found in October, November (early winter) and
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February and March (spring) during all the four years (2006-2009) studied except in
October 2009 and the common precipitant identified during these months was mild
cool air (environmental temperature of 23-27°c).38
Finally the present study showed majority (85.5%) of the patients had not used
peak flow metre for asthma. Only 14.5% had ever used but that also were not on
regular basis. This highlights the need for Asthma self-management education
program on home monitoring of peak expiratory flow. This is supported by the
findings of another study which was conducted on Asthma Self-Management: A
Study in an Emergency Room of a Chest Hospital in Delhi, India, in which it
explained that not all patients had metered dose inhalers at home. Only 2.0% of
patients were prescribed peak flow meters and were keeping a diary of their readings.
With one exception, patients did not have written action plans for treatment provided
by doctor or health facility. These findings lend preliminary support for an extended
self-regulatory model of treatment adherence, which incorporates beliefs about
treatment.76 This draws the attention to development of new nursing strategies and
evidence based models related to peak flow monitoring and home management in
asthma care.
Association between Pre-test AQLQ Score and Selected Demographic Variables
Findings of the present study showed that there was no significant association
between pre test score and selected demographic variables such as age (χ2 =3.12,
χ2=2.156 p>0.05), Gender (χ2 =3.10, χ2=0.01 p>0.05), Education (χ2=6.46, χ2=6.56
p>0.05), occupation (χ2 =0.69, χ2=0.32 p>0.05), family income (χ2 =1.35, χ2=5.06
p>0.05), Area of residence (χ2 =0.03, χ2=1.06 p>0.05), and type of family (χ2 =0.65,
χ2=2.61 p>0.05) in control and experimental group respectively. From this it is
150
evident that pretest scores of AQLQ were not affected by any of the variables. This is
supported by the findings of a study by Kaya et al which was conducted to evaluate
the impact of peak flow or symptom-based self-management plans on asthma control
and patients' quality of life which showed no statistical significant association
between demographic parameters and the compliance. 72 Hence Ho4: There will not be
significant association between AQLQ scores and selected demographic variables is
accepted.
Association between Pre-test AQLQ Score and Selected Clinical Variables
between pre test scores and quality of life and selected clinical variables of asthma
patients of control and experimental group such as last consultation with physician (χ2
=5.91, p>0.05; χ2=5.491, p>0.05), industries around home (χ2=0.67, p>0.05 only in
experimental group), cooking fuel used (χ2 =0.51, χ2=2.15 p>0.05), absence from
work (χ2 =2.08, χ2=1.36 p>0.05), medication used (χ2 =0.07, p>0.05 only in control),
smoking habit (χ2=1.94 p>0.05 only in experimental), family history of asthma (χ2
=0.04, χ2=0.32 p>0.05), duration of asthma (χ2 =1.07, p>0.05 in control group),
presence of co-morbidity (χ2 =0.41, χ2=3.29 p>0.05), and allergies (χ2 =0.41,
χ2=3.29 p>0.05) in. Hence H04 and H05 : There will not be significant association
between AQLQ scores and selected demographic variables and selected clinical
variables is accepted.
Medications used by the patients and Asthma severity (χ2 =7.44, χ2=7.28,
p<0.05), showed association in experimental group and industry around house (χ2
=6.70), smoking habit (χ2=11.70) and asthma severity (χ2=13.28) in control group
was statistically strongly significantly associated with quality of life (p<0.01). Hence
Ho4 and Ho5: There will not be significant association between AQLQ scores and
151
selected demographic variables and selected clinical variables may be partially
rejected.
Association between Post-Test II AQLQ Score and Selected Demographic
Variables
between post test II score and selected demographic variables such as gender
(χ2=0.190, χ2=0.824, p>0.05), education (χ2=1.348, χ2=1.475, p<0.01), occupation
(χ2=2.220, p>0.05 in experimental group only), family income (χ2=0.05 χ2=3.303,
p>0.05), Area of residence (χ2=0.234, χ2=1.112, p>0.05), and type of family
(χ2=2.38, χ2=2.168, p>0.05) except with age (χ2=12.079, χ2=14.558, p>0.05) in
control and experimental group respectively, thus post test II scores of AQLQ were
not affected by any of the above variables.
But the variable age (χ2=12.07, p<0.01) was statistically strongly significant
association with the quality of life; and occupation status (χ2=7.317, p<0.05), was
statistically significant only in control group.
Association between Post-test II AQLQ Score and Selected Clinical Variables
between post test II scores and quality of life and selected clinical variables of asthma
patients such as last consultation with physician (χ2 =0.492, p>0.05 only in control
group), industries around home (χ2=0.691, p>0.05 only in control group), cooking
fuel used (χ2=0.583, p>0.05 only in control group), absence from work (χ2=4.852,
χ2=0.558, p>0.05), family history of asthma (χ2=0.243, χ2=0.824, p>0.05), duration
of asthma (χ2=3.281, χ2=0.431, p>0.05), presence of co-morbidity (χ2=3.754, χ2=
p>0.05), and allergies (χ2=8.908, χ2= p>0.05), whereas the habit of smoking of the
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patients (χ2 =19.182, p<0.01) and the severity of asthma of the patients (χ2 =16.194,
p<0.01) showed a statistically strong association (p<0.01) and the medications used
(χ2 =6.356, p<0.05) by the patients in control group showed a statistically significant
association with the quality of life.
There was statistically strong significant association with quality of life and
the last time the patients met a physician (χ2 =9.316, p<0.01), industries around the
homes (χ2 =9.968, p<0.01) and cooking fuel used by the patients (χ2 =7.813, p<0.01)
was statistically highly significantly associated with quality of life (p<0.01). And the
co-morbid illnesses of the patients (χ2 =8.726, p<0.05) also had a statistically
significant association with their quality of life in experimental group. These findings
are supported by the findings conducted by Aggarwal et al where in information on
smoking habits, domestic cooking fuel used, atopic symptoms, and family history
suggestive of asthma was collected. Asthma was diagnosed in 2.28%, 1.69%, 2.05
and 3.47% respondents respectively at Chandigarh, Delhi, Kanpur and Bangalore,
with overall prevalence of 2.38%. Female sex, advancing age, usual residence in
urban area, lower socio-economic status, history suggestive of atopy, history of
asthma in a first degree relative, and all forms of tobacco smoking were associated
with significantly higher odds of having asthma. 31 From this it is evident that
advancing age or old age, usual residence in urban area presently due to urbanization
and industrialization, lower socio-economic status ultimately leading to poor nutrition
and decreased immunity, and smoking are all factors that may cause asthmatic
symptoms.
The conceptual frame work for the study was based on the Bandura’s self
regulatory theory which enabled the researcher to appreciate the overall research
153
process. The model designated on individual’s perception of his own capabilities,
attain strong commitment to follow the instructions and achieve the goals on
behaviour change and modification in regard to peak flow self management.
Summary
The above discussion clearly represented that there has been a statistically
significant improvement in experimental group in post test scores than in control
group denoting the effectiveness of peak flow self management plan on quality of life
for asthma patients in a selected community. This emphasizes the importance of
education related to peak flow monitoring on asthma control and home management.
The nurses in community plays a pivotal role in building up the health status of
asthmatics living in community thus enhancing the quality of life and reduce
hospitalization for asthma patients.
This chapter dealt with discussion based on objectives of the study,
hypotheses, relevant consistent literature to support the study findings and utility of
conceptual framework.
Next chapter will focus on summary, conclusion, implications,
recommendations and limitation.
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Chapter – VI
Summary, Conclusion,
Implications, Recommendations
CHAPTER - VI
SUMMARY, CONCLUSION, IMPLICATIONS, RECOMMENDATIONS
AND LIMITATIONS
This chapter presents the summary of the study, major findings, conclusions
drawn and implications of the study, limitations encountered and recommendations
for future research.
The main purpose of this study was to assess the effectiveness of peak flow
self management plan upon quality of life among asthma patients. The research
design used for the study was a quasi experimental two group pre test-post test time
series design. The study was conducted among 200 adults with asthma in a
community at Coimbatore.
Summary
Asthma is a serious health condition. It is established that the prevalence rate
of bronchial asthma and allergic rhinitis is about 10 to 15% irrespective of the area in
which people live whether it is industrial, urban, or rural. Increased life-expectancy in
the face of increased morbidity and health-care utilization makes this an expensive
public health problem that begs attention. In addition, recent evidence of increasing
incidence of steroid resistance in asthmatics has aggravated the situation further.
Therefore identifying and modifying the specific factors that predispose individuals
towards asthma is important. Peak flow self management plan helps to monitor one’s
lung condition detecting early changes in asthma that may require therapy preventing
asthma exacerbations. In this context, the problem selected for the present study was
“A study to assess the effectiveness of peak flow self management plan on quality of
life for asthma patients in selected community at Coimbatore.”
155
The objectives of the study were
1. To assess the quality of life and general well being before and after peak flow
self management plan in control and experimental group of asthma patients.
2. To assess the effectiveness of peak flow self management plan among asthma
patients by comparing the quality of life and general well being between
control and experimental group of asthma patients.
management plan in experimental group.
5. To find the association between demographic and clinical variables with
quality of life in control and experimental group.
The research hypothesis formulated for the present study were
o H01: There will be no significant difference between the mean AQLQ score
and well being index score between control and experimental group of asthma
patients before and after intervention.
o H02: There will be no significant difference in the mean AQLQ score and well
being index score between first and subsequent observations in control and
experimental group of asthma patients.
o H03: There will not be any correlation between quality of life and its domains
among control and experimental group of asthma patients in pre test and post
test.
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o H04: There will not be significant association between AQLQ scores and
selected demographic and clinical variables in control and experimental group
of asthma patients.
o H05: There will not be significant association between AQLQ scores and
selected clinical variables in control and experimental group of asthma
patients.
The major findings of the study were
 In relation to demographic variables, majority of the asthma patients
were males (54%, 72%), married (57%, 66%), from rural back ground
(69,74), from joint family (84%,79%) in control group and
experimental group respectively. In regard to clinical variables,
majority of the asthma patients had industry around home (81%, 77%),
used LPG Gas for cooking (71%,82%), used no peak flow metre (77%,
94%), had family history of first degree relative with asthma
(67%,72%), had no habit of smoking (61%, 48%), with moderate
asthma (49%,64%) %), had consultation with physician one month
back (58%,51%) and had no presence of co morbid illness (46%,57%).
 In pre-test, the mean AQLQ scores of control group and experimental
group were almost same (95.90, 96.6/224) with “t” value 0.88 showed
that there is no significant difference at (p>0.05), however in post test
I, II, III, with the interval of 2 months, there was marked increase in
AQLQ score only in experimental group (127.73, 144.14, 161.17) and
it was statistically significant at (p<0.001). There was also significant
difference between control and experimental group.
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 With regard to general well being index scores also, in pretest
experimental group had M=29.32/100 that gradually increased to 49.4,
61.2, 80.8 during post test I,II,III respectively and it was statistically
significant at (p<0.01).
 On comparison of AQLQ score of pretest, post test 1, post test II and
post test III, repeated measures of ANOVA showed significant
difference between the two groups. The experimental group had an
improvement in AQLQ score that was statistically significant
(p<0.000).
 With regard to association with selected demographic variables and
quality of life, there was no significant association between pre test
score and selected demographic variables such as age (χ2 =3.12,
χ2=2.156 p>0.05), Gender (χ2 =3.10, χ2=0.01 p>0.05), Education
(χ2=6.46, χ2=6.56 p>0.05), occupation (χ2 =0.69, χ2=0.32 p>0.05),
family income (χ2 =1.35, χ2=5.06 p>0.05), Area of residence (χ2
=0.03, χ2=1.06 p>0.05), and type of family (χ2 =0.65, χ2=2.61 p>0.05)
in control and experimental group respectively. And among clinical
variables only asthma severity and medications had statistically
significant association in experimental group (p<0.05). And asthma
severity, habit of smoking and whether or not they had industries
around their homes had statistically highly significant associations with
their quality of life (p<0.01).
 There was no significant association between post test II scores and
quality of life and selected clinical variables of asthma patients such as
last consultation with physician (χ2 =0.492, p>0.05 only in control
158
group), industries around home (χ2=0.691, p>0.05 only in control
group), cooking fuel used (χ2=0.583, p>0.05 only in control group),
absence from work (χ2=4.852, χ2=0.558, p>0.05), family history of
asthma (χ2=0.243, χ2=0.824, p>0.05), duration of asthma (χ2=3.281,
χ2=0.431, p>0.05), presence of co-morbidity (χ2=3.754, χ2= p>0.05),
and allergies (χ2=8.908, χ2= p>0.05), whereas the habit of smoking of
the patients (χ2 =19.182, p<0.01) and the severity of asthma of the
patients (χ2 =16.194, p<0.01) showed a statistically strong association
(p<0.01) and the medications used (χ2 =6.356, p<0.05) by the patients
in control group showed a statistically significant association with the
quality of life.
 There was statistically strong significant association with quality of
life and the last time the patients met a physician (χ2 =9.316, p<0.01),
industries around the homes (χ2 =9.968, p<0.01) and cooking fuel used
by the patients (χ2 =7.813, p<0.01) was statistically highly
significantly associated with quality of life (p<0.01). And the co-
morbid illnesses of the patients (χ2 =8.726, p<0.05) had a statistically
significant association with their quality of life in experimental group.
159
Conclusion
The following conclusion was drawn on the basis of findings of the study:
1. The patients in experimental group developed self-care management skills and
could avoid emergency consultations. It helped in reducing prolonged
hospitalization reducing the severity of asthma, having less days of
absenteeism from work suggesting the effectiveness of peak flow self
management plan on quality of life for asthma patients. It was well-
appreciated and accepted by the patients though it was little difficult at the
beginning of practice.
2. The introduction of peak flow self management plan and peak flow diary
among the patients helped them to gain the importance of awareness on
monitoring the lung status thus preventing asthma episodes which was evident
in the post- test AQLQ score. They could live a normal and active life.
3. The information booklet on asthma identification allergies and avoidance of
triggers as well as monitoring the lung status using peak flow metre as My
asthma action plan with Normal zone, Caution zone, Danger zone proved to
be an effective teaching module in early recognition of symptoms and
managing the same at home.
Thus the overall results of the study indicates that peak flow self management
plan was effective in improving the quality of life for asthma patients.
160
NURSING IMPLICATIONS
The findings of the present study have implications in the field of nursing
education, nursing practice, nursing administration and nursing research. The
investigator has devised the following implications that may be vital for the adult
health nurse working either at hospital or community setting.
 Adult health nurse in medical or respiratory wards can teach asthma patients
regarding asthma care such as identifying or recognize the triggers and avoid
such triggers to minimize the asthma attacks.
 Nurse can implement the written action plan and peak flow monitoring to
determine the lung status and decide the treatment as required (quick relievers
or long term drugs) depending on the condition or symptoms for all patients
diagnosed with asthma.
 Nurse can use the asthma information booklet framed by the investigator
educating the patients in hospital or community.
 Nurse can involve in assessing the patients at OPD regarding adherence to
treatment and correct usage of inhaler techniques while consulting physician.
Nursing Education
The health care delivery system at present is giving more emphasis on
preventive rather than curative aspect. A well planned health education on recognition
of the symptoms of asthma for patients, families, and the public would decrease
asthma-related morbidity and mortality.
Self management education incorporates behavioural strategies and can
improve adherence to treatment in asthma control. Nurses have a vital role in teaching
patients on self monitoring of symptoms and/peak flow. By heightening the patient’s
awareness of symptoms and airflow obstruction, monitoring alone may be sufficient
161
to enhance adherence by showing the patient that asthma control deteriorates when
treatment is ignored and improved when it is taken regularly.
The study also gives priority for the asthma patients’ quality of life in which
self management education was reinforced by a written personalized asthma action
plan and upholds and maintains the health status of patients enabling them to
confidently self manage their care. The effectiveness of the peak flow self
management plan and asthma information booklet can be used as an educational mode
to patients in hospital and community by student nurses. The nurse should be well
equipped with sufficient practical knowledge and skills and assist in asthma control
thus reducing the asthma exacerbations.
The holistic health care approach should be emphasized during the training of
nursing students. This is indeed an eye opener to all those who work in hospitals and
community to provide education to nurses by different teaching strategies. Hence the
nursing students could be empowered to update the knowledge on peak flow usage
and implement the same for better asthma care and improved quality of life for
asthma patients.
Nursing Practice
The nurse has to play a key role in the health delivery system, mainly
emphasizing on primary prevention. Primary prevention includes health promotion.
One of the methods of health promotion is health education. It is known fact that
asthma is treatable. The nurse can diagnose and manage asthma. They have a unique
opportunity as frontline care givers and patients to recognize, assess and effectively
treat the wide spread of uncontrolled asthma. She involves in direct patient care
during emergencies removing the airway obstruction caused by allergens or and
162
promote normal breathing pattern. Therefore the nursing personnel in the hospitals
can be helpful in controlling the complications such as respiratory failure increasing
the productivity of care and thereby reduce the asthma mortality and morbidity and
help patients to be responsible for their care through expert nursing practice and
teaching.
Nursing Administration
Nursing administrators should take initiatives in creating plans and policies in
hospital and community or primary health centres for educating the nurses. In service
education regarding asthma care using peak flow monitoring should be planned for
nurses periodically by nursing administrators. They can display pamphlets in hospital
premises on asthma control or provide educational sessions on inhaler use, controlling
triggers, food additives, medications to avoid, Emotion, Exercise and Asthma
medications for nurses in medical out patient department.
Nursing administrators can prepare protocols on standardized care for
emergency purpose and display the same in emergency wards/ICU. They can train
nurses to become specialized and expert in asthma care. In each session they should
assess their level of knowledge before and after continuing education programme.
They should plan for manpower, money, material, methods and time to conduct
successful educational programmes. Health administrators should appraise the
education department about the prevailing health problems and assist in prevention of
complications of asthma patients.
Nursing Research
An emphasis on nursing research and clinical studies is needed to improve the
quality of nursing care. The present study focused on improving the quality of life for
asthma patients providing peak flow self management plan. This type of individual
163
study would help generate not only a comprehensive model of asthma care, but also
standardized methods for testing common research hypotheses.
Nurse researcher should be aware of the health care system and status of
nursing profession. By conducting research and formulating new theories, research
can improve the practice, skill, attitude of asthma patients and ultimately can improve
the standards of asthma care and asthma control.
The combination of clinical skills and expertise in teaching and counseling
enhances the delivery of care in a manner that is cost-effective. Inherent in the role of
nurse researcher, nurses have the shared responsibility for health care outcomes. This
partnering of nurse with patient not only improves care but strengthens the patient’s
role as self-manager.
Limitations of the study
The investigator could not have close observation on peak flow self
management. Hence there are chances of recall biases.
The investigator had constraints in training the patients till they developed
confidence in using peak flow monitoring.
164
Recommendations
 Similar study can be conducted with personal use of an objective measure of
lung function in association with a medication self management plan in order
to improve patient's condition.
 A prospective, randomized trial can be conducted comparing two asthma self-
management plans for longer duration.
 Comparative study could be conducted incorporating peak expiratory flow and
symptom self-management plans with periodic assessment of pulmonary
function by spirometry.
 Similar study may be conducted by providing relaxation as an intervention for
asthma patients.
 A correlative study between changes in asthma symptoms and lung function
during treatment as measured by peak expiratory flow may be done.
 Comparative study may be done assessing the effectiveness of different
interventions and adherence to treatment in community settings.
 The study may be replicated in different settings covering various
geographical areas in larger population and longer duration as well as for
children.
165
Summary
Asthma is a chronic disease characterized by recurrent attacks of
breathlessness and wheezing. In an individual, they may occur from hour to hour and
day to day. Mortality due to asthma is not comparable in size to the day-to-day effects
of the disease. Although largely avoidable, asthma tends to occur in epidemics and
affects young people.
Experts are struggling to understand why rates world-wide are, on average,
rising by 50% every decade. Therefore self managing of asthma is very important to
lead an active and healthy life. During an asthma attack, the muscles in the airways
tighten and cause the airways to narrow. The peak flow self monitoring with asthma
action plan alerts patient to the tightening of the airways often hours or even days
before he has any symptoms and in managing such symptoms and preventing an
asthma attack by taking rescue asthma medicine and avoid a severe asthma
emergency thus improving the quality of life.
166
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96. Juniper EF, Guyatt GH, Epstein RS, Ferrie PJ, Jaeschke R, Hiller
TK: Evaluation of impairment of health-related quality of life in asthma:
development of a questionnaire for use in clinical trials. Thorax 1992, 47:76–
83.
97. Juniper EF, Guyatt GH, Willan A, Griffith LE. Determining a minimal
important change in a disease-specific quality of life instrument. Journal of
Clinical Epidemiology 1994; 47: 81-87.
98. WHO. (1998). Well being Measures in Primary Health Care/The Depcare
Project. WHO Regional Office for Europe: Copenhagen.
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99. Dr. Venkatesan. L. Dissertation on Impact of Positive Therapy Upon Stress
Levels in Infertility Women, Chennai, 2008
100. Asthma New Zealand-The Lung Association. Asthma triggers, what to do in
an emergency (internet) New Zealand 2015 Available from
www.asthma.org.nz
101. Smeltzer & Bare, Brunner’s Text book of medical surgical Nursing, 12 th
Edition 2010
102. Schatz M, Mosen DM, Kosinski M, Vollmer W.M, Magid DJ, O’Cooner. The
relationship between Asthma Quality of life and Asthma Control, Journal of
Asthma, Vol 44 2007. Issue 5
103. Chhabra S.K and Kaushik. S, Validation of the Asthma Quality of Life
Questionnaire (AQLQ–UK English Version) in Indian Asthmatic Patients
Department of Cardiorespiratory Physiology, Clinical Research Centre,
Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India [Indian J
Chest Disease Allied Science 2005; 47: 167-173].
104. Heun R., Bonsignore M, Barkow K. et al. Validity of the five-item Well
Being Index (WHO-5) in an elderly population European Archives
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179
Annexures
ANNEXURE – A
PROVISIONAL REGISTRATION CERTIFICATE – Ph.D DEGREE
ANNEXURE – B
CONFIRMATION OF PROVISIONAL REGISTRATION
ANNEXURE – C
CONSTITUTION OF DOCTORAL ADVISORY COMMITTEE
ANNEXURE – D
INSTITUTIONAL ETHICS COMMITTEE APPROVAL CERTIFICATE
ANNEXURE – E
CERTIFICATE OF PLAGIARISM CHECK
This is to certify that this thesis work titled “A study to assess the Effectiveness
of Peak Flow Self management Plan for Asthma Patients on Quality of Life in
Selected community at Coimbatore” of the candidate Mrs. Neethi Selvam.T with
Registration Number: 141420014 for the award of Ph.D in Nursing in the branch of
Medical Surgical Nursing personally verified the urkund.com website for the purpose of
plagiarism check. I found that the uploaded thesis file contains from Introduction to
Conclusion pages and result shows 10% percentage of plagiarism in the thesis.
Dr. JANANI SANKAR, MBBS.,DNB.,Ph.D.,M.A.M.S,
Senior Consultant,
Kanchi Kamakoti CHILDS Trust Hospital,
Nungambakkam, Chennai - 600034

ANNEXURE – F
CERTIFICATE FOR ENGLISH EDITING
ANNEXURE – G
CERTIFICATE FOR TAMIL EDITING
ANNEXURE - H
LETTER GRANTING PERMISSION TO CONDUCT THE STUDY FROM
DEPUTY DIRECTOR OF HEALTH SERVICES
ANNEXURE - I
GRANT OF PERMISSION TO USE THE JOHNS HOPKINS NURSING

EVIDENCE BASED PRACTICE MODELS AND TOOLS
ANNEXURE - J
EVIDENCE OF PERMISSION TO USE STANDARDIZED AQLQ
QUESTIONNAIRE
ANNEXURE – K
ANNEXURE - L
EVIDENCE OF PERMISSION TO USE STANDARDIZED WHO WELL BEING
INDEX (TAMIL TRANSLATION)
ANNEXURE - M
LIST OF EXPERTS
1. Dr. Latha Venkatesan, PhD (N)

Principal
Apollo college of Nursing,
Ayanambakkam,
Chennai- 95.
2. Dr. Janani sankar, M.B.B.S.,DNB, PhD, MA,MS.

Pedia Senior Consultant,
Kancha kamakoti CHILDS Trust Hospital,
Nungambakkam, Chennai-18
3. Dr. Lizy Sony, Ph.D (N),

Vice Principal,
Ayanambakkam,
Chennai- 95.
4. Dr. Vijaya Lakshmi, Ph.D (N),

HOD (MHN),
Ayanambakkam,
Chennai- 95.
5. Dr. Surendra Kumar,M.D.,
Chest consultant,
G.K.N.M. Hospital,
Pappanaicken palayam,
Coimbatore.
6. Dr. Anand Kumar, M.D,

Chest Physician,
R.V.S.Hospital,
Trichy Road, Sulur,
Coimbatore
7. Dr. Madhavi, PhD (N)

Principal
KMCH College of Nursing,
Avinasi road,
Coimbatore.
8. Dr. Shanthi Appavu, PhD (N)

Principal
CSI College of Nursing,
Neyyur, Nagerkoil
9. Dr. Jean Abraham, PhD (N)

Principal,
P.S.G.College of Nursing,
Peelamedu
Coimbatore.
10. Dr. Malarvizhi, PhD (N)

Vice Principal,
P.S.G.College of Nursing,
Peelamedu
Coimbatore.
11. Dr. Annamma Prabhakar, PhD (N)

Visiting Professor,
R.V.S. College of Nursing,
Trichy Road, Sulur,
Coimbatore.
12. Dr. Bala subramaniam, PhD (N)

Professor
KMCH College of Nursing,
Avinasi road,
Coimbatore.
13. Dr. Ruby, PhD

(Psychology & Sociology),
Professor,
Koshys College of Nursing,
Bangalore.
14. Dr. Janavi Mungala, MBA,

PhD Statistics,
Professor,
Koshys Management Studies
Bangalore.
15. Prof. Suja Santhosh, MSc Statistics,

Trichy Road, Sulur,
Coimbatore.
16. Prof. Jennifer, M.Phil in Statistics,

R.V.S. College of Engineering,
Kumaran Kottam, Trichy Road,
Kannampalayam,
Coimbatore.
17. Prof. Valarmathi, MSc Statistics

Research Officer,
The Tamil Nadu Dr. M.G.R. Medical University,
Chennai.
18. Prof. P. Arumugam,

Professor Biostatistics (Retd)
Tirunelveli.
19. Prof. Franklin, MPT,

Professor,
R.V.S. College of Physiotherapy,
Trichy Road, Sulur,
Coimbatore.
ANNEXURE - N
LETTER SEEKING PERMISSION TO CONDUCT THE STUDY
From,
Mrs. Neethi Selvam, MSc (N),
Asst. professor,
Trichy Road, Sulur,
Coimbatore.
To,
The Principal,
Trichy Road, Sulur,
Coimbatore.
Respected Madam,
Subject: Request for permission to conduct data collection
This is to kindly inform you that, I would like to conduct data collection in Ph.D research
study which is to be submitted to the Tamil Nadu Dr.M.G.R. Medical University,
Chennai. ‘A study to assess the effectiveness of peak flow self management plan on
quality of life for asthma patients in selected community at Coimbatore’ I need your
esteemed help and co-operation as I am interested in conducting the study in the
community at Somanur. In this regard I request you to extent possible guidance and
support for successful completion of data collection.
Thanking You
Date Yours sincerely
Place Neethi selvam.T
ANNEXURE - O
REQUEST FOR OPINIONS AND SUGGESTIONS OF EXPERTS FOR
ESTABLISHING CONTENT VALIDITY OF RESEARCH
From
Mrs.Neethi Selvam, Msc,(N)
To
Dr. Janani sankar, M.B.B.S., DNB, PhD, MA,MS. Pedia Senior Consultant,
Kancha kamakoti CHILDS Trust Hospital, Nungambakkam, Chennai-18
Respected sir/madam,
Sub: Requisition to expert opinion and suggestion for the content validity of the
research tools.
I, Mrs.Neethi Selvam.T. Msc (N), PhD candidate Apollo College of Nursing,
Chennai has selected the topic mentioned below for the research project to be submitted
to The Tamil Nadu Dr. M.G.R. Medical University, Chennai.
Topic: ‘A study to assess the effectiveness of peak flow self management
plan on quality of life for asthma patients in selected community at Coimbatore’
“With regards may I kindly request you to validate my tool for its appropriateness and
relevancy and content of demographic &clinical proforma, Level of acceptability on
satisfaction Scale, and Observation schedules, AQLQ and WBI give your expert opinion
for necessary modification. I would highly obliged and remain thankful for your great
help if you could validate and sent it as soon as possible.
Thanking you,
Place: Coimbatore Yours sincerely,

Date: Neethi Selvam. T
Encl :
(1) Background, Need for the study, Statement of problem, Objectives of Study.
(2) Criteria Check list of evaluation of tool and content
(3) Tool for collection of data
(4) Peak flow self management plan
(5) Certificate of Validation
Criteria Checklist for Evaluation of Tool Requesting Suggestion and Opinion from the Experts
Dear Madam / Sir,
I kindly request you to go through the tool and place a tick mark () in the columns given against each
question and give your comments on the items you disagree/ partially agree / to be deleted which will help in
modification of tool.
Demographic variable Proforma
Contents Relevant Organized Measurable Remarks

variables Agree Partially Disagree Agree Partially Disagree Agree Partially Disagree
Agree Agree Agree
Age
Gender
Educational
status
Occupational
status
Marital
status
Monthly
family
income
Residence
Type of
family
Clinical Variable Proforma
Contents Relevant Organized Measurable Remarks
variables Agree Partially Disagree Agree Partially Disagree Agree Partially Disagree
Agree Agree Agree
Last
consultation
Industries
around
Cooking fuel
Abstain work
Medications
Smoking
habit
Family
history
Asthma
duration
Asthma
severity
Comorbidity
Allergy
Use of peak
flow
CONTENT VALIDITY INDEX OF TOOL
Dear Sir / Madam,
I request you to kindly examine the research tool and give your valuable opinion and
suggestions on the developed tools. Please enter the items of each tool in the
appropriate column on the basis of relevance. Your valuable opinion and kind
suggestion will be highly appreciated.
Completely Meets the Does not

S.No Tool meets the Criteria to meet the Remarks
Criteria- some extent / Criteria –
Relevant Requires Not
Modification Relevant
I Demographic
variable Proforma
II Clinical Variable
performa
Asthma Quality of Life

Questionnaire (AQLQ)
III
WHO Well being Index
(1998 version)
IV
Observation schedules:
Peak flow graph, peak
flow diary
V
Level of Satisfaction on
acceptability
Rating Scale
VI
Asthma education
booklet
VII
EVALUATION CRITERIA CHECKLIST FOR VALIDATION
Instruction:
The expert is requested to go through the following criteria for evaluation. Three
columns are given for responses and a column for remarks. Kindly please tick mark ( ) in
the appropriate columns and give remarks.
Column I – meets the criteria.
Column II- partially meets the criteria.
Column III- does not meets the criteria.
S.NO CRITERIA I II III REMARKS

1 Content
Logical
Sequence
Adequacy
Relevance
2 Language
Appropriate
Clarity
Simplicity
3 Practicability
Easy to score
Precise
Utility
4 Scoring
Adequacy
Clarity
Simplicity
Any other suggestion:

Signature:
Address:
Name:
Designation:
CERTIFICATE OF VALIDATION / CONTENT VALIDITY
This is to certify that the research tool and intervention protocol constructed by
Mrs. Neethi Selvam. T currently pursuing her part – time Ph.D programe at Apollo
College of Nursing, Chennai under The Tamil Nadu Dr. M.G.R. Medical University,
Guindy,Chennai for the research study to “A study to assess the effectiveness of
peak flow self management plan on quality of life for asthma patients in
selected community at Coimbatore” are found to be valid to the best of my
knowledge.
Date Signature
Place
Name: & Designation:

ANNEXURE - P
RESEARCH PARTICIPANT CONSENT FORM
Dear participant,
I am a Ph.D (N) student Apollo college of Nursing, Chennai. As a part of my

study a research on ‘A study to assess the effectiveness of peak flow self management
plan on quality of life for asthma patients in selected community at Coimbatore’ is
selected to be conducted. The findings of study will be helpful for asthma patients to
maintain quality of life.
Hence I hereby seek your consent and cooperation to participate in study. Please
be frank and honest in your responses. The information collected will be kept confidential
and anonymity will be obtained.
Sign of the investigator
I …………. hereby consent to participate in the study.
Sign of the investigator
Place:
Date:
ANNEXURE – Q
TOOL IN ENGLISH
DEMOGRAPHIC VARIABLES PROFORMA FOR ASTHMA PATIENTS
Purpose:
This proforma is used to measure the demographic variable such as age, gender,
education, occupation, family monthly income, type of family, area of residence.
Instructions
Kindly read the following questions. Tick mark the appropriate answer. Please describe
your responses freely and frankly. The details will be kept confidential and used for
research purpose only.
1. Sample No:
2. Age (in yrs)
a) 20-39
b) 40-59
c) ≥60
3. Gender
a) Male
b) Female
4. Educational status
a) No formal education
b) Primary school
c) High school
d) Higher secondary
e) Degree
5. Occupation
a) Coolie
b) unskilled
c) Skilled
d) Professional
6.Marital status
a) Married
b) Unmarried
c) Divorced
d) Widow
7. Income ( in Rs.) per month
a) ≤ 5000
b) 5001- 10,000
c) 10,001-15,000
d) 15,001-20,000
e) > 20,001
8. Residence
a) Rural
b) Urban
9. Type of family
a) Joint
b) Nuclear
CLINICAL VARIABLE PROFORMA FOR ASTHMA PATIENTS
Purpose
This proforma is used to measure the clinical variables such as last consultation, area of
living, cooking fuel, abstain from work, medications used, smoking habit.
Instructions
Kindly read the following questions. Tick mark the appropriate answer. Please describe
your responses freely and frankly. The details will be kept confidential and used for
research purpose only.
1. Day of consulting physician
a) 1st day (same day of interview)
b) 2-7 days back
c) 2 weeks back
d) 1 month back
2. Area of living (Environment)
Is there any industry around your home
a) Yes
b) No
3. Type of cooking fuel used
a) Wood
b) cowdung
c) L.P.G.gas
4. How often has your asthma prevented you from working or caused you to take off
from work place/school or college? (Total in the past 6 months)
a) Lost no time off work or college
b) Lost 1-2 weeks off work or college
c) Lost 2-4 weeks off work or college
d) Lost more than 5 weeks off work or college
e) Lost worked because of asthma
5. Medications used
a) Budamate
b) Salbutamol
c) Deriphylline
d) Other
6. Smoking habit
a) Non smoker
b) Cigarette smoker
7. Family history of asthma
a) First degree relative
b) No First degree relative
8. Duration of asthma (yrs)
a)<6 months
b) 7-12 months
c) 1-5 years
d) >5 years
9. Severity of asthma
a) Mild
b) Moderate
c) Severe
10. Presence of co-morbid medical illness
a) Diabetes mellitus
b) Hypertension
c) Bone disease
d) Gastro-intestinal disease
e) Nil
11. Are you allergic to any products? If yes, mention the products of allergies.
a) Pets
b) Dust mites
c) Pollen (Flowers)
d) Smoke
e) Fumes and strong odour
f) Cold air
12. Have you used peak flow metre at any time?
a) Yes
b) No
13. Medical Diagnosis

Scoring: The overall AQLQ score is the mean of all 32 responses and the
individual domain scores are the means of the items in those domains. Each domain score
ranges from 1 to 7 representing the greatest impairment possible or most of the time and
7 represents the least or none of the time. Total obtainable score is 32-224.
WHO (Five) Well-Being Index (1998 version)
Please indicate for each of the five statements which is closest to how you have
been feeling over the last two weeks. Notice that higher numbers mean better well-being.
Example: If you have felt cheerful and in good spirits more than half of the time during
the last two weeks, put a tick inthe box with the number 3 in the upper right corner.
S.No Over the last two All of Most of the More than Less than Some of At no
weeks the time time half of the half of the time time
time the
time
1. I have felt 5 4 3 2 1 0
cheerful and in
good spirits
2. I have felt calm 5 4 3 2 1 0
andrelaxed
3. I have felt active 5 4 3 2 1 0

and vigorous
4. I woke up feeling 5 4 3 2 1 0
fresh and rested
5. My daily life has 5 4 3 2 1 0

been filled with
things that
interest me
Scoring: The raw score is calculated by totaling the figures of the five answers. The raw
score ranges from 0 to 25, 0 representing worst possible and 25 representing best possible
quality of life. To obtain a percentage score ranging from 0 to 100, the raw score is
multiplied by 4. A percentage score of 0 represents worst possible, whereas a score of
100 represents best possible quality of life.
OBSERVATION SCHEDULE
PEAK FLOW DIARY (2 week period)
Date Am Pm Comments
PEAK FLOW GRAPH (2 WEEK PERIOD)

Date
650
600
550
500
450
400
350
300
250
200
150
100
50
How many times did I wake last time because of asthma?

How many puffs of reliever did I take today?
Were my activities affected by asthma?
LEVEL OF SATISFACTION SCALE ON ACCEPTABILITY
S.No ITEM Highly Accept Unacce Highly
Accep able ptable unacce
table 2 p
4 3 table
1
1. I am happy about the information
provided to me regarding description
of asthma.
provided to me regarding structure
and function of lungs
provided to me regarding symptoms
of chronic, moderate and severe
asthma.
provided to me regarding controlling
triggers of irritants such as smoke,
smog, allergens, dust mites,
molds,etc
provided to me regarding conditions
that increase the severity of asthma.
provided to me regarding asthma
action plan for self management of
asthma.
7. I am happy about the method of
teaching regarding asthma control
8. I am satisfied with the methods used
for monitoring early symptoms using
peak flow graph and peak flow
monitoring.
9. I am happy with the diet advice
given in controlling asthma
symptoms.
10. I am satisfied with the information
provided to me regarding asthma
medications.
Scoring Key:
Highly acceptable – 4
Acceptable – 3
Unacceptable – 2
Highly Unacceptable – 1
Score Interpretation:
Highly Unacceptable – 0-10
Unacceptable – 11-20
Acceptable – 21-30
Highly Acceptable – 31-40

ANNEXURE – R
TOOL IN TAMIL
மக்கள் த ொகக விகி ம் மற்றும் பின்னணி பரவலொனபடிவம்.
பின்வரும் கேள்விேளை தயவுசெய்து படித்துப் பாருங்ேள். வழங்ேப்பட்ட இடத்தில்
பதில் எதிராே ஒரு டிக் குறி ளவத்து உங்ேள் பதில்ேளை இலவெமாேவும்
சவைிப்பளடயாேவும் விைக்ேவும். விவரங்ேள் இரேெியமாே ளவக்ேப்பட்டு ஆராய்ச்ெி
க ாக்ேத்திற்ோே மட்டுகம பயன்படுத்தப்படும்.
1.ந ொயொளிஎண்:
2.வயது (ஆண்டுகளில்)
அ). 20-39
ஆ) 40-59
இ)>60
3.பொலினம்
அ) ஆண்
ஆ) சபண்
4.கல்வித் கு ி
அ) ொதாரணேல்விஇல்ளல
ஆ) முதன்ளமபள்ைி
இ) உயர் ிளலபள்ைி
ஈ)கமல் ிளல
உ) பட்டம்
5.த ொழில்
அ)கூலி
ஆ)திறளமயற்ற
இ)திறளமயாே
ஈ)சதாழிலறிஞர்
6. ிருமண ிகல
அ)திருமணமானவர்
ஆ)திருமணமாோதவர்
இ)விவாேரத்து
ஈ)விதளவ
7.மொ த் ிற்குவருமொனம் (ரூ.)
அ) ≤ 5000
ஆ) 5001- 10,000
இ) 10,001-15,000
ஈ) 15,001-20,000
உ)> 20,001
8.குடியிருப்பு
அ)ேிராமப்புறம்
ஆ) ேர்ப்புறம்
9.குடும்பவகக
அ)கூட்டுக்குடும்பம்
ஆ)தனிக்குடும்பம்
மருத்துவ பின்னணி பரவலொன படிவம்
வழங்ேப்பட்ட இடத்தில் பதில் எதிராே ஒரு டிக் குறி ளவத்து உங்ேள் பதில்ேளை
இலவெமாேவும் சவைிப்பளடயாேவும் விைக்ேவும். விவரங்ேள்
இரேெியமாேளவக்ேப்பட்டுஆராய்ச்ெிக ாக்ேத்திற்ோேமட்டுகமபயன்படுத்தப்படும்.
1. மருத்துவர் ஆநலொசகன ந ி
அ) க ர்ோணலின் அகத ாைில்
ஆ) 2-7 ாட்ேளுக்கு முன்
இ) 2 வாரங்ேளுக்கு முன்பு
ஈ) ஒரு மாதம் முன்பு
2. வொழும் பகு ி (சுற்றுச்சூழல்)
உங்ேள் வட்ளடச்
ீ சுற்றியுள்ை பகுதியில்ஏகதனும் சதாழிற்துளற இருக்ேிறதா?
அ) ஆம்
ஆ) இல்ளல
3.சகமயல் எரிதபொருள் வகக
அ)விறகு
ஆ)மாடு ொணம்
இ)எரிவாயு
4. ஆஸ்துமொ கொரணமொக நவகலக்கு அல்லது கல்லூரிக்கு நபொக முடியொ ொட்கள்
(கடந் 6 மொ ங்களில்)
அ) ஒரு ாள் கூட இல்ளல
ஆ) 1-2 வாரங்ேள் செல்ல முடியவில்ளல (இழந்தது)
இ) 3-4 வாரங்ேள் இழந்தது
ஈ) 5 வாரங்ேளுக்கு கமல் இழந்தது

உ) ஆஸ்துமா ோரணமாே கவளல செய்யவில்ளல
5. பயன்படுத் ப்படும் மருந்துகள்
அ) ப்யூடாமாட்
ஆ) ொல்ப்யுடாமால்
இ) சடரிபில்ளலன்
ஈ) மற்ற ஏகதனும் மருந்துேள்
6.மயமொ ல் பழக்கம்
அ) புளே பிடிக்ோதவர்
ஆ) ெிேசரட் புளேப்பவர்
7.ஆஸ்துமொவின் குடும்ப வரலொறு
அ) முதல் ிளல உறவினர்
ஆ) முதல் ிளல உறவினர் இல்லாதாவர்
8.ஆஸ்துமொவின் கொல ந ரம்
அ) <6 மாதங்ேள்
ஆ) ≤ 7-12 மாதங்ேள்
இ) 1-5ஆண்டுேள்
ஈ) >5 ஆண்டுேள்
9.ஆஸ்துமொவின் வ
ீ ிரம்
அ) கலொன
ஆ) மிதமான
இ) ேடுளமயான
10.இகண-ஆநரொக்கியமற்ற மருத்துவ ந ொய்களின் இருத் ல்
அ) ீரிழிவுக ாய்
ஆ)உயர் இரத்தஅழுத்தம்
இ) எலும்புக ாய்
ஈ) செரிமான-குடல்க ாய்
உ) எதுவுமில்ளல
11. எந் தவொரு யொரிப்புக்கும் ீங்கள்ஒவ்வொ ர்

ீ களொ? ஆம் என்றொல், ஒவ்வொகம
தபொருட்களின் விவரங்ககளக் குறிப்பிடுங்கள்.
அ) செல்லப்பிராணிேள்
ஆ) தூெி பூச்ெிேள்
இ) மேரந்தம் (மலர்ேள்)
ஈ) புளே
உ) இராெயனப் புளே மற்றும் ேடுளமயான வாெளனேள்
ஊ) குைிர் ோற்று
12. ீங்கள் எப்தபொழு ொவது உச்ச ஓட்டம் மீ ட்டர் பயன்படுத் ினர்களொ?

ீ
அ) ஆம்
ஆ. இல்ளல
13.மருத்துவ ந ொய் கண்டறி ல்

உலக சுகொ ொர ிறுவனத் ின் தபொது ல் வொழ்வு அட்டவகன (1998) ஆம்
ஆண்டின் தபயர்ப்பு
ேீ கழ சோடுக்ேப்பட்ட 5 வாக்ேியங்ேைில் ேடந்த இரண்டு வாரங்ேைில் உங்ேைின் உணர்வுேளை
பிரதிபலிக்ேின்ற வாக்ேியங்ளேை தயவுசெய்து சுட்டிக்ோட்டுங்ேள். அதிே மதிப்சபண் அதிேமான
ல்வாழ்ளவ குறிப்பிடுேிறது.உதாரணமாே ேடந்த இரண்டு வாரங்ேைில் பாதிளயவிட கமலான
க ரங்ேைில், இன்பமாே மற்றும் ல்ல மன ிளலளய உணர்ந்து இருந்தால், மூன்றாவது ேட்டத்தின்
கமல் வலது மூளலயில் √ குறியிடகவண்டும்.
ேடந்த இரண்டு எப்சபா மிே அதிே பாதிளயவிட பாதிளய ெில க ரங் ஒரு
வாரங்ேைில் ழுதும் க ரங்ேைில் கமலான விட குளறந்த ேைில் சபாழுதும்
உங்ேைின் 5 க ரங்ேைில் க ரங்ேைில் இல்ளல
4 1
மன ிளல
3 2 0
ான் இன்பமாேவும் 5 4 3 2 1 0
ல்ல
மன ிளலயில்
இருப்பதாே
உணர்ந்கதன்
ான் 5 4 3 2 1 0
அளமதியாேவும்
ொந்தமாேவும்
ான் 5 4 3 2 1 0
சுறுசுறுப்புடனும்ெக்
தியுடனும்
ான் உறங்ேி 5 4 3 2 1 0
எழும்சபாழுது ன்கு
ஒய்சவடுத்து
புத்துணர்ச்ெியுடன்
எனது அன்றாட 5 4 3 2 1 0
வாழ்க்ளே ான்
விரும்பும்
செயல்ேைால்
ிளறந்திருந்த்து
ம ிப்பீ டு: கமகல சோடுக்ேப்பட்டுள்ை ஒவ்சவாரு வாக்ேியத்தின் மதிப்சபண்ேளை
கூட்டுவதின் மூலம் சபாது ல் வாழ்வின் தரம் ேணக்ேிடப்படுேிறது. 0 மதிப்சபண் ஆனது
மிேவும் தாழ்ந்த ிளலளயயும் 25 மதிப்சபண் ஆனது உயர்ந்த வாழ்க்ளேத் தரத்ளதயும்
குறிப்பிடுேிறது.
கண்கொணிப்புஅட்டவகண
உச்சஓட்டவ ீ ம் ொட்குறிப்பு (2 வார ோலம்)
கததி ோளல மாளல ேருத்துேள்
4.2 உச்ச ஓட்ட வ ீ ம் வகர படம் (2 வொர கொலம்)

கததி
650
600
550
500
450
400
350
300
250
200
150
100
50
 ஆஸ்துமாவின் ோரணமாே ான் எத்தளன முளற எழுந்கதன்?

 விகரவு ிவொரணஉள்ைிழுக்ேப்படும மருந்துகள் இன்று ான் எத்தளன முளற
எடுத்கதன்?
 ஆஸ்துமாவால் என் டவடிக்ளேேள் பாதிக்ேப்பட்டுள்ைனவா?
ிருப் ி அளவிடு லுக்கொன ஏற்பு அளவுநகொல்
S.No ப ொருள் மிேவும் ஏற்ேத் ஏற்றுக் மிேவும்

ஏற்றுக் தக்ேது சோள்ை ஏற்றுக்
சோள் த்தோது சோள்ை
3
ைத்தக் 2 த்தோது
ேது 4 1
1. ஆஸ்துமாளவப் பற்றியவிவரங்ேளைப்
பற்றி எனக்கு திருப்தி யாே இருக்ேிறது.
2. நுளரயீரலின் ேட்டளமப்பு மற்றும்

செயல்பாடு குறித்து எனக்கு வழங்ேப்பட்ட
தேவல்ேள் பற்றி மேிழ்ச்ெியளடேிகறன்.
3. ாள்பட்ட, மிதமானமற்றும் ேடுளமயான
ஆஸ்துமாவின் அறிகுறிேளைப் பற்றி
எனக்கு ேிளடத்ததேவல் குறித்து திருப்தி
யளடேிகறன்.
4. புளே, பனிப்புளே, ஒவ்வாளம,
தூெிப்பூச்ெிேள், அச்சுேள் கபான்றளவ
கபான்ற எரிச்ெல்ேைின் தூண்டுதல்ேளைக்
ேட்டுப்படுத்துவதில்எனக்குேிளடத்திருக்கும்
தேவளலப்பற்றி மேிழ்ச்ெியளடேிகறன்.
5. ஆஸ்துமாவின் தீவிரத்ளத அதிேரிக்கும்

மற்ற ிளலளமேள் குறித்து எனக்கு
வழங்ேப்பட்ட தேவல்ேள் பற்றி ான்
திருப்தியளடேிகறன்.
6. ஆஸ்துமாவின்சுய ிர்வேிப்பிற்ோனஆஸ்து
மாசெயல்திட்டம்சதாடர்பாேஎனக்குவழங்ேப்
பட்டதேவல்ேள்பற்றிமேிழ்ச்ெியளடேிகறன்.
7. ான் ஆஸ்துமா ேட்டுப்பாட்டு சதாடர்பான

கபாதளன முளற பற்றி மேிழ்ச்ெியாே
இருக்ேிகறன்.
8. உச்ெ ஓட்டம் வளரபடம் மற்றும் உச்ெ
ஓட்டம் ேண்ோணிப்பு ஆேியவற்ளறப்
பயன்படுத்தி ஆரம்ப அறிகுறிேளை
ேண்ோணிப்பதற்ோன முளறேைில் ான்
திருப்தி அளடேிகறன்.
9. ஆஸ்துமா அறிகுறிேளைக் ேட்டுப்படுத்தும்
உணவு ஆகலாெளனயுடன் ான்
மேிழ்ச்ெியளடேிகறன்.
10. ஆஸ்துமா மருந்துேள் பற்றி எனக்கு

வழங்ேப்பட்ட தேவல்ேள் குறித்து மேிழ்ச்ெி
அளடயளடேிகறன்.

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“EFFECTIVENESS OF PEAKFLOW SELF MANAGEMENT PLAN

ON QUALITY OF LIFE FOR ASTHMA PATIENTS IN

SELECTED COMMUNITY, COIMBATORE”

Mrs. NEETHI SELVAM. T, M.Sc (N)

THE TAMIL NADU DR.M.G.R MEDICAL UNIVERSITY, CHENNAI

In fulfillment of the requirement for award of the degree of

DOCTOR OF PHILOSOPHY IN NURSING

ON QUALITY OF LIFE FOR ASTHMA PATIENTS IN

SELECTED COMMUNITY, COIMBATORE”

THE TAMIL NADU DR.M.G.R MEDICAL UNIVERSITY,

In fulfillment of the requirement for the award of the degree of

DOCTOR OF PHILOSOPHY IN NURSING

Under the guidance of

Dr. JANANI SANKAR

Kanchi Kamakoti CHILDS Trust Hospital, Chennai

This is to certify that the thesis entitled “EFFECTIVENESS OF PEAKFLOW

SELF MANAGEMENT PLAN ON QUALITY OF LIFE FOR ASTHMA PATIENTS

IN SELECTED COMMUNITY, COIMBATORE” submitted by Mrs. NEETHI

SELVAM. T for the award of the degree of Doctor of Philosophy in Nursing, is a

This is to certify that the thesis entitled “EFFECTIVENESS OF PEAKFLOW

SELF MANAGEMENT PLAN ON QUALITY OF LIFE FOR ASTHMA

PATIENTS IN SELECTED COMMUNITY, COIMBATORE” is a bonafide

the Degree of Doctor of Philosophy in Nursing to THE TAMILNADU

DR.M.G.R MEDICAL UNIVERSITY, CHENNAI under my guidance and

I hereby declare that this thesis entitled ““EFFECTIVENESS OF PEAKFLOW

SELF MANAGEMENT PLAN ON QUALITY OF LIFE FOR ASTHMA PATIENTS

IN SELECTED COMMUNITY, COIMBATORE” is my own work carried out

M.G.R Medical University, Guindy, Chennai.

this University or in any other University / Deemed University without proper

Mrs. Neethi Selvam.T

My sincere and heartfelt thanks to the Management, Apollo College of Nursing,

University, Guindy, Chennai for creating copious opportunities to learn.

throughout the period of study.

I whole heartedly express my sincere gratitude to Dr. Latha Venkatesan, Principal,

were of immense help throughout my thesis work.

time in content validity.

I am extremely thankful to Prof. P. Arumugam, biostatistician for rendering support in

validating the tool.

I am grateful to Mrs. Fancy S, English editing a n d M r . R a v i C for editing this

Most importantly, I express my profound gratitude to Mrs. Saramma Samuel, Principal,

R.V.S. College of Nursing in obtaining permission for the study to be conducted in

taught me a great deal about both scientific research.

My thanks and appreciations also go to my friends and colleague in developing the

Date : Signature of the Candidate

Place : Chennai Mrs. Neethi Selvam.T

Management plan on Quality of life for Asthma Patients in a Selected Community at

The objectives of the study were:

flow self management plan in control and experimental group of asthma

2. To assess the effectiveness of peak flow self management plan among

3. To assess the acceptability of asthma patients regarding peak flow self

flow self management plan)

clinical variable proforma, standardized Asthma Quality of Life Questionnaire to

assess symptoms, activity limitation, emotional function and environmental stimuli

assess level of acceptability of asthma patients and observation schedules of peak

flow diary and peak flow graph for experimental group.

Descriptive statistics (frequency, percentage, mean, standard deviation) and inferential

Major findings of the study

(69,74), from joint family (84%,79%) in control group and

experimental group respectively. Among clinical variables, majority of