We studied determinants of the intention to participate in an asthma self-management program using the ASE model. Overall, the results of our analysis showed that the ASE model is useful to understand determinants of participation. Including ASE on top of educational status and clinical variables raised the percentage of explained variance in participation behavior from 23 to 72%.
Our results showed that higher-educated asthmatic patients were twice more likely to participate in the program than patients with fewer years of education. This has repeatedly been found in previous research, although the exact reasons for this effect remain unclear. Most likely, differences in knowledge about asthma rather than attitudinal variables account for this effect, because the odds ratio (OR) of education level as predictor in the first logistic regression analysis did not alter by adding the ASE variables in the second logistic regression analysis. We further on hypothesize that higher educated people can express themselves more easily than lower-educated people and therefore would be more confident in participating in talking sessions.
Interestingly, neither previous hospitalizations nor PEF scores seemed to have predictive value for the intention to participate in an education program, meaning that the clinical status did not seem to convince patients to participate. This finding may parallel Yoon and colleagues observation of a very low participation rate in a group of asthmatic inpatients recovering from a severe asthma exacerbation. The fear, often experienced after an exacerbation, apparently may not last long enough to keep on motivating the patient for an educational program. Some might be surprised to notice that PEF scores had no predictive value for the intention to participate. Indeed, asthma specialists are often tempted to convince patients with more severe asthma to participate in an education program by referring to their poor PEF values. However, objective pulmonary function severity results did not determine participation behavior. The one clinical characteristic with some predictive value was the asthma symptom score: patients having had more intense subjective asthma symptoms 2 weeks before recruitment had more chance to participate in our education program. However, the predictive value of this symptom score seemed to be mediated by social cognitive variables because the initial significant OR in the first regression analysis dropped below conventional significance levels in the second regression analy-sis. This suggests that more symptomatic patients perceive more personal benefits of the program, have higher self-efficacy expectations or experience more social pressure for better self-care and, as a consequence, are more likely to participate.
Patients beliefs about the program appeared of paramount importance. Patients having less structural barriers to participate (such as no time, living too far away, financial barriers or program characteristic barriers—in this case the group format) were 12 times more likely to participate in the program. Perceived personal benefits increased the chance that patients intended to participate by seven to eight times, whereas believing in the general benefits of the program had no predictive value. Finally, our results showed that patients experiencing higher social pressure to take better care of their asthma had approximately three times more chance to intent to participate.
A few limitations may be mentioned here. First, the participation rate in our study might have been influenced by the fact that our study was also an evaluation study. Having to perform effectiveness measures may have dissuaded patients to participate. Second, employment status and flexibility issues in this respect were not included as a measure in this study as we did not realize its importance a priori. Patients’ reactions to the invitation to participate suggested that current employment and the difficulty to leave the job for medical reasons may be an important structural variable. A more in-depth analysis of the social context of the patient may be important in future studies. Finally, the factor analysis of the interview questions resulted in a selfefficacy scale including mostly external barriers. These barriers seemed of predictive importance for the intention to participate in the program. From a theoretical point of view, it might be worth it to explore the role of more intrinsic barriers and the confidence patients have to overcome them.
In order to get more patients involved in asthma education programs, it is essential to develop better recruitment strategies. The present results show that motivation induction to participate in a program should rather focus on patients beliefs and attitudes toward the program than on patients clinical status. Future studies are needed to investigate the relative importance of the different patients’ beliefs. We conclude that recruitment of patients with asthma for an educational program should emphasize personal benefits of the program, should include patients’ social network, and should consider the impact of structural barriers on participation behavior.
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