A self-management program for adult asthma: part IV, Analysis of context and patient behaviors.

Patient behaviors performed in the self-management of asthma have been investigated by use of black box theory as a model for examining behavioral change. Consequently, the context within which patients learn and perform processes of self-management has been ignored. The purpose of the present study was to investigate contextual and behavioral elements that comprise the management of asthma attacks by a large number of adult patients. A total of 3442 reports of attack were obtained from 90 subjects, including 76 patients described in the article by Kotses and colleagues, 9 who dropped out of the study, and 5 who served as pilot subjects. The major focus of the analysis, however, was on the 63 subjects who submitted forms during two periods: intake/baseline and training/after training. Data included information about the episode (e.g., severity, duration, etc.), prior actions taken by patients (e.g., adherence to treatment regimens, collection of peak flow data, etc.), and the impact of contextual variables (e.g., setting where attack occurred, time when attack occurred, etc.) on patient behaviors The variables were subjected to a probability analysis to demonstrate changes in the probability of responses as influenced by contextual variables present during any given attack. The results indicated that contextual variables affect behavioral change. Changes occurred in actions taken to manage an attack in the two periods, intake/baseline and during and after training. Three findings are of interest. The first was the emergence of discriminative stimuli that because they were present when self-management skills were initially reinforced, altered the future probability of performance of the skills. Peak flow values and asthma action plans qualified as discriminative stimuli in that their use often prompted patients to perform steps to alleviate and abort episodes. Second, several processes comprise self-management, ranging from goal setting to self-appraisal of one's actions. Self-monitoring is the backbone of self-management. However, what emerged from the current study is the importance of two other processes: 1) information collection and processing and 2) decision making. When subjects were introduced to self-monitoring via use of peak flow meters, an asthma diary, and a report of an attack, they began using these tools, often in a trial-and-error manner, to match the information they obtained to the actions they took. As a result, they became skilled at self-monitoring prior to training. During and after training, however, patients indicated they were skilled at processing and making decisions based on the data they collected. Finally, stimuli present during an attack came to prompt distinctive patterns whereby individual patients considered the reciprocal interaction of environmental, physiological, behavioral, and cognitive variables to control attacks. Action taken by patients reflected data processing and decision making on the part of patients in selecting and performing those self-management skills they anticipated would generate the best outcomes.