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Sheets

From 2BlogI

Fig.1 My nemesis: a feather duvet

Abandoning a feather filled duvet in the B&B ‘retreat’ in Devon for health reasons (asthma) I find my feet tucked, contained and strapped into place like it was the 1960s and I’m eight years old and sleeping over at my Granny’s house. (Every effort was made to accommodate my allergy including putting a barrier sheet on the mattress). I ought to have come armed with a few items: a handheld zapper mini-vacuum that draws the pesky house-dust mite into its bag while killing any that may remain).

From 2BlogI

Fig. 2. Raycop

Meanwhile, the efforts to learn how to write a novel are thus far proving highly productive: one 3000 word scene written, substantial plotting, seven further scenes conceived with another two reaching the 1000 word mark, two key characters established with a third making his presence felt.

Unpicking three decades of going about it the wrong way. Its hard when you’ve taught to play the piano with your feet and your dick that you have to use your hands and your brain instead.

Escape

From NSSC 3AUG14 ARK

Fig. 1 Five Lasers, like butterflies

Helming the boat that set the buoys for this race (it’s called ‘Ark’) I got this shot and likened it to butterflies in the back garden. I so wanted to be out there competing in the race and juggling my inabilities to control the dinghy, but got a thrill from this moment all the same with this imbalance of boats. One getting away, the others heading towards the buoy.

My turn next week.

I’ve done 12 hours on a ‘pond’ in various winds on a Laser so feel ready for the sea, and ready for bruises, muscle pain, a dunking: ready too for managed risk: I will have on a wet suit and life jacket. I will have a pouch containing an inhaler (asthmatic) and water.

I like danger. I need the physical and mental thrills I so enjoyed in my ‘youth’. I prefer a challenge. I want to be hit with a stick and offered a carrot. The Open University equivalent of the written exam and recognition of success: Tutor Marked Assignments (TMAs) are too infrequent for essay writing to become a way of life, whilst End of Module Assignments (EMAs) lack the danger and challenge of an examination. At Oxford University essays are weekly, read out and shared in a tutor group of two or three and at the end of the year you sit exams – terrifyingly demanding but both proof that you know your stuff and a way to distinguish the pack.

‘Ark’ is a bit of a tug, a diesel engined quasi-fishing vessel on which the day’s race buoys are kept – hunking great things on a long length of rope with a chain and anchor attached. It has a VHS radio so you call back and forth to your harbour of departure and the Race Officer in the clubhouse and RIBS in the bay.

Seven years since I was last on the thing I had with me a cushion I grabbed from the sofa at home not thinking why I did this … until in the chop I recalled how I had broken my coccyx training to do this when I had bounced off the rubbery side of the RIB and landed on the anchor: twice. Broken coccyx. Imagine how they test for this in A&E? Basically someone prods you up the arse and if you scream there’s a problem. This problem then turns into ‘there’s nothing we can do’. But here’s a rubber-ring you may like to have to sit on for the next six weeks … or don’t sit down????

You live and learn, or rather learn through giving things a go until you can get it right enough.

Can an email-prompted web-based e-learning platform aimed at undergraduates in the UK with moderate to persistent asthma improve compliance to their prescribed preventer drugs to 80%?

Fig. 1 Preventer, Reliever and volumetric. With good adherence the ‘brown one’ is taken as prescribed and the ‘blue one’ rarely needed. With poor adherence there is no brown on and there is dependence on the blue one. In this example a QVAR easibreather and a Venotlin inhaler. Mine. 

By presenting these ideas here I asking for support on how to make this research happen.

The medical profession is replacing the term ‘adherence’ with the term ‘compliance’. This reflects the desire to encourage self-management of prescribed drugs in concordance with health care providers (HCPs). For the purposes of this paper the terms should be considered interchangeable.

Asthma is a chronic and complex condition affecting the lungs that can be managed but not cured. (NHS Choices, 2013) (See Appendix 1 for a definition of ‘moderate to persistent asthma’). The World Health Organisation estimates that 300 million people globally are asthmatic (Web, 2001) while in the UK in 2010 5.4 million people were receiving treatment for asthma and there were 1,143 deaths. (Asthma, UK. 2013) An estimated 75% of hospital admissions for asthma are avoidable and as many as 90% of the deaths are preventable. (Asthma, UK. 2013) 80% compliance is the minimal level required for treatment to be effective (Lasmar et al., 2009).

Research construct

Asthmatics form a heterogeneous group that shows great diversity of triggers, effective medication, management strategies and outcomes. Research clusters asthmatics into four to six groups based on how they present and the drug regime they are on (Webb, 2011). Isolating a participant’s conditions and being confident that their medication is correct will be a challenge. For this reason, thorough in-depth interviews with participants, potentially with an HCP present, will be vital in order to set a benchmark.

A team at Harvard Medical School designed Qstream, the proposed e-learning platform (Kerfoot et al., 2008). Qstream (Fig.1.) takes its approach from an understanding of Ebbinghaus (Ebbinghaus, 1913) and how we forget and remember to provide a spaced-learning response that uses a combination of email alerts and interactive content to build knowledge. Its use has been researched with junior doctors in relation to their formal medical training and assessment (Kerfoot et al., 2008; Kerfoot et al., 2012) and in applied settings with healthcare practitioners to support informed decision-making. (Kerfoot et al., 2010)

Fig.1. Screengrab from Qstream homepage. (www.qstream.com)

On the basis of their research, Dr B Price Kerfoot says that ‘educational games work’ (Kerfoot et al., 2008. Kerfoot suggests that the next step is to use this approach with patients and ‘clinical decisions of greater complexity’ Kerfoot (2010:477). Research using Qstream involving people with chronic illnesses is planned to take place in North America in the Fall of 2013 (Vernon and Kerfoot, 2013).

What is the problem?

Too many people with a chronic illness, such as asthma, fail to take their medication as prescribed (Royal Pharmaceutical Society (RPS) of Great Britain, 1997; Hayes et al., 1979). This can lead to an exacerbation of the disease, risks hospitalization and even death. Non-compliancy rates are between 10-60% (Cochrane, 1992. Rand,1994), 30–50% (Horne, 1999), 50% (Di Matteo, Giordani, Lepper & Croghan, 2001; Kyngas, 2007 in Wales et al., 2011:148).

Reasons for non-compliance include medication side effects, expense of treatment, personal value judgments or religious or cultural beliefs about the proposed treatment, age–related debility, not having an action plan prescribed by an HCP, the patient not following the adequate treatment prescribed (Cerveri et al., (1999:288) or the presence of a mental disorder (e.g., schizophrenia, personality disorder).  American Psychiatric Association [DSM-5], (2013:726).

What is the opportunity?

According to McGavock et al., (1996) efforts to improve compliance have been unsuccessful; it is hoped that efforts using e-learning will be successful. The healthcare community – manufacturers, prescribers and frontline carers, recognise that education offers a way to reduce hospital admissions and deaths (Cerveri et al.,1999:288). The opportunity exists to increase compliance to 80% and therefore improve the health of millions of people with asthma.

A variety of programmes have tested a potential solution to non-adherence. (Byer & Myers, 2000; Hand, 1998; Tettersell, 1993), while Hacihasanoğlu and Goözuöm (2011) showed that patient education on medication adherence is effective. A variety of studies on e-learning in healthcare have used emails linked to multiple-choice questions and answers to improve patients’ knowledge and behaviours (Volpp et al. 2009; Kato et al. 2008).

The hypothesis

The hypothesis is that as a result of greater compliance through a ‘spaced learning’ e-learning education programme, non-compliant moderately persistent asthmatics will show changes in measurements of their illness and changes in their medication beliefs. (Based on Petrie et al., 2012:76).

Desired outcomes / results

Having completed a programme of e-learning using Qstream people with moderate to persistent asthma who had been noncompliant (under 80% compliant) should show changes in their illness and medication beliefs, improved compliance to their preventer inhaler and measured improvement across a range of physiological measures. (Based on Petrie et al., 2012:76) As a result of what they learn, the research will address patient perceptions, such as beliefs (Horne & Weinman, 2002), worries about long term use of steroids (Apter et al., 2003), fears and other concerns (Kaptein, Klok, Moss-Morrs & Brand, 2010). For example, 28% of asthma patients think that drugs are bad and not necessary while 12% think that drugs may not be not bad but aren’t necessary. Cerveri et al., (1999:292).

Achieving a reasonable level of compliance with treatment regimes has been shown to improve the health outcomes of patients undergoing treatment and reduce demands on health resources (Bender, Milgrom, Wamboldt & Rand, 2000; Dunbar-Jacob, Burke & Puczynski, 1995).

The long-term and broader opportunity exists to reduce hospitalizations, reduce costs, improve and extend lives.

Learning Theories

The learning theories that form the basis of Qstream are behaviourist (Skinner, 1974) and cognitive (Wenger, 1987; Hutchins, 1993; Anderson, 1983; Piaget, 1952) with problem solving, explanations and re-combinations. In line with this behaviourist approach early versions of Qstream worked best in formal learning contexts, for example first year medical students needing to pass an exam on anatomy. (Kerfoot et al., 2008) and practical clinical guidelines (Kerfoot et al., 2009). By complementing traditional medical training, with clear goals and the motivation to pass, the attraction of the platform are clear in this context. This stimulus-response approach, builds on the work of Ebbinghaus (1913) (Fig. 2)

Fig. 2. A typical forgetting curve for newly learned information. After Ebbinghaus (1913)

Through association, the learner takes a number of steps to build a composite skill. (Skinner, 1984; Gagné, 1985) (Fig.3) An accurate reproduction of knowledge can be assessed or demonstrated in drill and practice.

Fig.3. Screengrab from Qstream showing how a participant receives feedback on their response to a multiple-choice question.

Later and current versions of Qstream include components of peer competition, participant interaction and collaboration. This constructivist approach takes the view that learners build their own structures (Piaget, 1954). It also suites task orientated learning (Bruner, 1993) and assimilative learning. This constructed and socio-constructed approach to learning is less suited to assessment simply by looking at exam grades, therefore in-depth interviews or comprehensive self-reporting surveys are required to elicit what took place and the level of knowledge attained especially as evidence of learning by people with asthma won’t be elicited through formal assessment.

Why undergraduates?

The research shows that younger asthma patients in the age 14-25 years are less likely to use their preventer medication than older patients (Diette et al., 1999; Legorreta et al., 1998), which makes ‘young people an important group to target for improving adherence and reducing their underuse of preventer-inhaler corticosteroids’, (Pertie et al., 2012:75). For this reason, and to exploit study parameters of population size and geography, a university undergraduate population is proposed.

METHODOLOGY/METHODS

A mixed-method approach will be adopted with qualitative and quantitative components. In-depth pre and post intervention interviews will form the qualitative element, while the quantitative component will be based on several hundred student participants taking part in a randomized controlled trial and use analytics generated by the Qstream platform. The aim is to interview approximately 30 students in-depth within the parameters of a single university. For example, Adams, Pill & Jones, (1997) favoured in depth interviews with a carefully selected and eligible number of patients before and after intervention. For quantitative analysis the far larger pool of participants will be drawn from a UK wide undergraduate student population using platforms such as The Student Room (www.thestudentroom.com. The Student Room, 2013) and Asthma UK to recruit participants. According to Kerfoot & Baker (2012) an individual randomized control trial is preferable were there is a large sample size. Extending to a sample of four UK universities might increase the potential number of participants to 9000+ (See Appendix 2). Self-reporting screening would be used to ensure that only those in the desired group took part.

Based on UK statistics on asthma in the population, it can be calculated that at, for example, the University of Southampton from a total undergraduate population of 17,000 there are likely to be between 485 and 586 students with moderate to severe asthma. (This intentionally excludes those likely to have a mild form of the disease, and those with a profoundly severe form of the condition). (See Appendix 2 for break down of likely respondents). Asthma UK (2013) suggests that amongst asthmatics 48% consider themselves to be at risk. If this percentage of potential participants volunteered then the starting population for the proposed research is likely to be around 250. It is reasonable to suggest that by working with four different universities of a similar size the total population for a randomized control trial would increase to 1,000.

Identifying those who are moderate to severe asthmatics and agreeing criteria has confounded asthma studies in the past, therefore great care will be required to set parameters, the simplest being that where an asthmatic has been prescribed only two medications, a preventer inhaler (known as the ‘brown one’) and the reliever inhaler (the ‘blue one’) that their condition is considered to be ‘moderate to severe’.

Having a sound basis for giving a person’s baseline, for both compliance and knowledge of asthma and how it is treated, will indicate if an improvement in adherence has been made and whether this e-learning approach has been effective.

To have a physical measure you can audit the prescriptions issued or weigh the inhalers to establish how much has been expelled, however Spector (1985) found cases of both miss-application and trial firing.  A blood test is definitive, but this could only be carried out by an HCP. The alternative is to ask patients how they got on, however patients are thought to overestimate their actual drug use by between 30 and 50% (Spector, 1985; Sacket and Snow, 1979). In the case of people with asthma, Horn (1992:126) found that 11% who claimed to have inhaled salbutamol in the preceding four hours had no detectable drug in their urine.

Whilst therefore there are advantages in conducting interviews, patients are giving a subjective measure of their treatment compliance (Sawyer, Rosier and Phelan, 1995). This method suffers from being the most inaccurate of any available (Horn, 1999:126), however the alternative requires a series of tests that need to be administered by an HCP.

This ethnographic investigation would be open and exploratory  (RPS, 1997). A system of meanings would be taken either from transcripts (Scherman and Löwhagen, 2004:4) or preferably from audio recordings as current best practice in medical market research favours working from the audio as nuances of meaning are more likely to be apparent (Kazmer & Xie, 2008).

Given the complexity of influencing compliance and the desire to use this as a measure of effective learning, structured and semi-structured in depth interviews will take place. In addition physiological improvements to lung functionality need to be measured for a sample of the participants to offer an objective indicator that a change of behaviour has occurred.

Other influences on outcomes that should be revealed in a semi-structured interview include issues of identity in relation to learning (Kirkup, 2001; and Hughes, 2007) and motivation, what Resnik (2008) describes as ‘passion based learning’.

The text from these interviews will be analysed for clusters of meaning, aiming to pick out nuanced responses, potentially from video but at least from audio recording of interviews (Kazmer & Xie, 2008), which according to Webb (2011) is preferable to working from text alone

The aim would be to reveal the experiences of those interviewed and so come to a view of ‘understandings and misunderstandings’ about their condition, the role their prescribed ‘preventer’ medication plays and the value of Qstream.

Qstream offers a variety of ways to monitor and measure activity on the platform (fig. 4) . This is how data and metadata from several hundred participants would be analysed. (Appendix 3 lists the affordances of using a Qstream private site)

Fig. 4. Screengrab showing example of analytics available on a group of 356 learners.

TIME LINE CHART


Fig. 5. Simplified model of research. Punch (2006: KL 487 )

Phase One

  1. Submit Proposal

  2. Seek and secure funding

  3. Purchase UK license for Qstream.

  4. Undertake training on the Qstream platform

  5. Seek approval from appropriate ethics committee

  6. Speak to and engage subject matter experts and HCPs: consultant, GP, practice nurse, welfare office and disability officer.

  7. Consider the merit of ‘reversibility testing’ which involves taking measurements of asthmatics’ breathing before and after the Qstream ‘trial’.

  8. Prepare content for Qstream: text, images, multiple-choice questions. Contents to include: bite-size video, interactive notes and legalese.

  9. Prepare recruitment communications (posters, email campaign, university and student websites, the student rooms, Asthma UK.)

  10. Test platform on university server

  11. Email links to online survey

  12. Screen potential participants to under 1000 and divide for randomized controlled trial. See Kerfoot et al. 2010:332 Flowchart of a randomized controlled trial.

  13. Filter the sample for in-depth interviewing from those enquiring about respiratory symptoms, attacks of asthma, use of asthma allergies, together with questions on how they have or usually gain knowledge on the disease, its treatment and their diagnosis and compliance behaviours. This is likely to be kept to one geographical and healthcare region based on the population of a single university.

  14. Conduct initial interviews from this filter group to establish eligibility.

Eligibility for interviews and physiological testing would be based on patients with the indicated symptoms though excluding patients with serious social problems and severe learning difficulties. (Franklin et al., 2006)

  • Who?

  • How many?

  • Age?

  • Gender?

  • Where referred?

  • How long diagnosed for?

  • Smoking or not?

Aim to recruit 30+ students for in-depth interviews and <1000 for a randomized controlled trial using the Qstream platform.

Confirm participants, ensure that they understand the terms and nature of the research and request that they read and agree to these and that participation is voluntary, information will be confidential and their written consent is required.

Invite all or some to complete either an asthma Journal or, as they have been shown to be effective, an audio log. Patient-reported outcomes would help us understand the impact of drugs on patients’ lives and activities. “Are patients really doing better? Can they sleep through the night rather than waking up with a sense of shortness of breath?” Bohen (2013: 863)

Phase Two

Pre-Qstream Interviews

  • Conduct in-depth interviews to establish baselines for compliance as well as knowledge of asthma as a chronic illness with responses given on a Likert Scale. (Horne, 1999).

  • Video or audio record.

  • Horn’s ‘Offer Self Image Questionnaire’ (1977) will be used as part of the in-depth interview to Horn (199:126) considered this a central part of compliance assessment strategy. The chronic disease compliance instrument (CDCI) (Kyngas, Skaar-Chandler, and Duff, 2000) will be adapted and its use considered.

  • Complete physiological measurements: blood test, skin test and assessment of lung function and spirometry and airway challenge. Cerveri et al., (1999:289)

Run Qstream e-learning programme for 12 weeks

Phase Three

Post-Qstream Interviews

  • Conduct in-depth interviews to re-assess compliance. Aim to gauge how and if this has changed and why amongst the 30 selected for this purpose. Assess verbally for knowledge of asthma. Include questions on the Qstream platform itself. According to Van Dijik, 2005) questions after the intervention should include operational skills, managing the software on different platforms and how they got on with the multiple-choice process skills.

  • Video or audio record.

  • Repeat of physiological measures to understand if there have been improvements in, for example, lung function.

Analyse data and metadata generated by the Qstream platform

  • Listen through interviews and undertake cluster analysis of ideas and issues in order to establish patterns of meaning.

  • Is there a correlation between compliance and reduction in the severity of asthma?

  • Is there a correlation between increased compliance and completing the Qstream e-learning module?

Write up and report findings.

Follow up a year later to see if the impact of the learning is maintained over time through changing behaviours.

Limitations

No study of a therapeutic regime can be considered fully valid without some documentation of whether the patients took their treatment. Horn (1992:127) Establishing valid data on whether people take their medication as prescribed will be a challenge.

No single method of assessment of compliance with (anti-asthma) therapy is ideal nor does any one method give a full picture of the pattern of compliance. Usually the chosen method(s) will require to be validated specifically for the particular circumstances under investigation.

An issue arises with using an Internet and mobile alert system where potentially limited or broken Internet access or paid-for Wi-Fi impinges on the student’s access to the resources. Care will be taken both over how content is scripted and produced, as well as securing a robust platform. Kerfoot and Baker (2012:13) had problems in relation to: ‘server errors’,  ‘attrition’ (Kerfoot & Baker, 2012:4), ‘fatigue’ (Kerfoot et al., 2010) and technical hitches due to spam blockers (Shaw et al., 2011) as well as the challenging nature of the content. (In Vernon, 2013)

It is also reasonable to suggest that those who are noncompliant to regularly taking their prescribed medicine could also be ‘noncompliant’ to the features of Qstream – a twice or thrice weekly prompt to take a few minutes to answer some questions.

A UK license for up to 1,000 participants to use the Qstream platform is $15,000 per annum.

In research carried out by ZoRA et al. (1989). Only 1 in 17 diary sheets completed by asthmatic children (under age 14) were accurate to within 10% of the number of puffs used. Whilst the participants in this research are older, any completion of a dairy sheet will include errors and inaccuracies.

Overestimation in self-reporting is well known and probably due to a desire to please. (Cochrane, 1995. Cochrane 1998)

Failure of a therapeutic regime can only be ascribed to poor compliance if appropriate drugs are being prescribed in adequate dosage that historically has tended not to be the situation in the management of asthma. (Horn, 1992:127)

The population using the Internet is diverse. This impacts on research in relation to access and having a representative group of participants. (Eynon, 2009). The use of Qstream in a student population favours use of a mobile device for ease of response to email prompts. It is suggested that 53.7% of people in the UK will be using smartphones by 2014 with those aged 18-25 by far the largest group followed by teenagers (New Media Trend Watch, 2013) whilst it is estimated that nearly 38% will have tablets by this time. (eMarketer, 2013).

Ethics

For ethical reasons an institutional review board would be approached for approval to perform this study. (Kerfoot & Baker, 2012:2)  (In Vernon, 2013)

  • A standardized form will be used to obtain informed consent from participants.

  • Well Being, confidentiality and anonymity will be stressed.

  • Rights will be clearly explained

  • The personal safety of those conducting the research will be considered.

  • Conflicts of Interest will be declared, for example, Dr Kerfoot is on the board of Qstream.

  • Unintended consequences will be considered.

  • People have to have the freedom to make mistakes in relation how they elect to adhere, or not, to the prescription drugs they are prescribed. Mental Healthcare Act.

Validity and reliability

If one hope is to correlate a physiological change with improved knowledge an array of factors need to be isolated and measured. Data from both a qualitative and a quantitative approach, the clusters of issues and ideas from analysing what is said in pre and post interviews and the activity on the Qstream platform will offer some indication of what is taking place and why.

Implications for future policies, practice and further research

1) Socio-constructed learning and connectivism

It is further hypothesized that effective compliance is most likely to be achieved where in addition to the patient, the related HCPs engage in the proposed e-learning programme. Social interaction has an important role to play in learning. (Vygotsky, 1978) Donath (2002) shows how through exchanging information a person gains recognition and that social learning of this kind provides affiliation. This suggests value in having HCPs, even family, especially parents and guardians, of younger people with asthma taking part in a Qstream learning programme and exploiting how we connect in networks (Kit Yee et al., 2011) Wang (2008:05) considers the importance in learning of both the student and instructor. HCPs would play the role of ‘intermediaries’ (Laurillard, 1993).

This not only invokes ideas of values relating to communities of practice (Lave and Wenger, 1991) but also, in our digital age, to ‘connectivism’ (Siemens, 2006; Calvani, 2009: de Waard, 2011) – where ‘nodes of readily available information’ are linked to and shared between learners. (Edudemic, 2013) The asthmatic as a learner can question their own knowledge and understanding by connecting with others, as part of a ‘community of practice’ (Lave and Wenger, 1991), from the periphery (Brown, 2002; Brown, 2007) and vicariously (Cox, 2006). Connecting with other people with asthmatics online is supported by the Asthma UK website (Asthma UK, 2013)

2) Use of narrative and creative content

Fig. 5 Screengrab introducing a series of animated videos on design. Open Learn (2013)

The quality and style of scriptwriting using the Qstream platform will impact on effectiveness. (Laurillard, 2000 and Jewell and Hooper, 2011) understand the role of narrative in learning. Resnik and Chang (2008) talk about the need for e-learning to be self-revealing, pleasurable and fun, with a ‘low threshold and high ceiling, supporting collaboration, plugins and making it iterative’ and ‘tinkerable’. The Open University, through Open Learn, often use rich video content to engage audiences, for example with a series of short video in ‘Design in a nutshell’. (Open Learn, 2013)

3) Further personalisation of e-learning

Intelligent Web pages that can adapt themselves to a person’s linguistic and other competence are examples of more ambitious applications that we might look forward to in coming decades. (Hara et al., 2006:352)

4) Extend duration of study period

This study would initially be restricted to a single term or academic year, though it could be extended, for example, to include first year undergraduates through the 3 to 4 year duration of their undergraduate studies. Ostojic et al.,  (2005) carried out a 4-month trial, whilst trials run by Kerfoot (2008-2012) have run for as long as 45 weeks.

5) Include other chronic illnesses:

Allergic rhinitis is comorbid with asthma (Bousquet at al., 2013) warranting its inclusion in future research alongside studies on asthma. Other chronic illnesses that may benefit from Qstream’s use by patients includes diabetes, epilepsy, Parkinson’s and Alzheimer’s.

6) Consider ‘Big Data’, Web 2.0, Pedagogy 2.0

There is the potential of automatic real-time data gathering relating to inhaler use with a microchip and the use of wearable technology even an ingestible smart pill (Engineer Online 2012; Arnold, 2013) in medicine. Supported by enhanced patient knowledge of their illness. Armed with this data, analysed automatically, and read by the patient or an HCP, the drug regimen and response to it is closely monitored. Such patient analytics are akin to student performance analytics (Koller, 2012) providing HCPS and educators with the potential for gathering and analysing data and metadata from hundreds of thousands of participants.

Conclusion

The opportunity exists to develop an e-learning programme that change lives – that improves the health of those with moderate to persistent asthma. Research suggests that greater knowledge and understanding of a chronic medical condition and personal medical and lifestyle responses and self-management improves compliance. However, the way the illness presents are complex, the triggers and symptoms vary greatly. The approach suggested here also offers the chance to establish if learning brings about a change in behaviour that can be measured in a physiological response – improved lung function and the role an e-learning platform can play. In due course, if a reasonable percentage of the 300+ million asthmatics who are online engage with an e-learning programme such as this significant insights and improvements to health can be made.

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Kerfoot, B.P., Armstrong E.G., O’Sullivan P.N. (2008) Interactive spaced education to teach the physical examination: a randomized controlled trial. J Gen Intern Med 2008;23:973–978.

Kerfoot, B.P. (2009) Learning benefits of on-line spaced education persist for 2 years. J Urol 2009;181:2671–2673.

Kerfoot, B.P, Kearney MC, Connelly D, Ritchey ML. (2009) Interactive spaced education to assess and improve knowledge of clinical practice guidelines: a randomized controlled trial. Ann Surg 2009;249:744–749.

Kerfoot, B.P, Lawler EV, Sokolovskaya G, et al. (2010) Durable improvements in prostate cancer screening from online spaced education a randomized controlled trial. Am J Prev Med 2010;39:472– 478.

Kerfoot, B.P., Baker, H., (2012) An Online Spaced-Education Game for Global Continuing Medical Education: A Randomized Trial. Annals of Surgery  Volume 256, Number 1, July 2012. pp.1227-1232  www.annalsofsurgery.com

Kerfoot, B.P., Baker, H., Pangaro, L., Agarwal, K., Taffet,G.,  Mechaber, A.J., Armstrong, E.G. (2012)  An Online Spaced-Education Game to Teach and Assess Medical Students: A Multi-Institutional Prospective Trial. Technology and Learning. Academic Medicine, Vol. 87, No. 10 / October 2012 pp. 1443 – 1449

Kirkup, G. (2001) Getting our hands on IT. Gendered inequality in access to ICTs. Conference paper at Gender and Virtual Learning, Hagen, Germany.

Kit Yee, A, Moon, G, Robertson, T, DiCarlo, L, Epstein, M, Weis, S, Reves, R, & Engel, G (2011), ‘Early Clinical Experience With Networked System for Promoting Patient Self-Management’, American Journal Of Managed Care, 17, 7, pp. e277-e287, Academic Search Complete, EBSCOhost, (viewed 19 June 2013).

Koller, D (2012) What we’re learning from online education http://www.youtube.com/watch?feature=player_embedded&v=U6FvJ6jMGHU (Accessed 24 June 2013)

Laurillard, D. (1993). Rethinking university teaching: A framework for the effective use of educational technology.

Lave, J, and Wenger, E. (1991) Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.

New Media Trend Watch (2013) http://www.newmediatrendwatch.com/markets-by-country/18-uk/154-mobile-devices  (Accessed 23 June 2013)

NHS Choices. Health A-Z. Asthma. http://www.nhs.uk/conditions/asthma/Pages/Introduction.aspx  (Accessed 23rd June 2013)

Offer, D, Ostrov, E., Howard, K.I. (1977) The Offer Self-Image Questionnaire for Adolescents. A manual, revised. University of Chicago, Illinois.

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Picard, R, Papert, S, Bender, W, Blumberg, B, Breazeal, C, Cavallo, D, Machover, T, Resnick, M, Roy, D, & Strohecker, C (2004) ‘Affective learning – a manifesto’, Bt Technology Journal, 22, 4, pp. 253-269, Science Citation Index, EBSCOhost, (viewed 24 June 2013).

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APPENDIX ONE

How to define asthma

MODERATE PERSISTENT – IN THE RESEARCH GROUP (aboutasthma.com)

Your asthma severity is classified as moderate persistent asthma when:

  • You have asthma symptoms daily.

  • You wake up from your asthma more than one night per week, but not every night.

  • You use your rescue inhaler daily.

  • Your asthma moderately interferes with your daily activities.

With moderate persistent asthma, you will need daily asthma medication with anti-inflammatory properties, as well as a second medication.

You are able to gain control of your asthma with two medications, what we call the ‘blue one’ and the ‘brown one’.

The brown one, the inhaled steroid, you take a couple of puffs in the morning and a couple at night.

The blue one, the reliever, or what in North America they call the ‘rescue’ inhaler, you take as required

Source:

National Heart, Lung, and Blood Institute. Accessed: May 20, 2010. Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma

APPENDIX 2

% =/-5% too ill to attend ‘profound’

SOTON 17000 undergraduates

First years 5,000 – 5,500

Total Soton

9.5%

Total

Soton 11.5%

First Years

9.5%

First

Years

11.5%

Across4 UK

universities

Approx: students with asthma in the undergraduate population

1,615

1,955

475

575

64,500

Describing themselves as:

41% very mild

662

801

195

234

26,445

27% mild

436

528

128

155

17,415

19% moderate

307

371

90

109

12,255

11% severe (Wales et al., 2011)

178

215

52

63

7,095

Moderate to severe likely to be:

485

586

142

172

19,350

48% think they are at risk (Asthma UK)

232

263

68

82

3,405

53.7% smartphones by 2014

125

141

37

44

1,829

less 4% self exclude from digital devices

120

135

36

42

1,756

University of Southampton

Of an undergraduate population at the university of Southampton of 17,000 UK asthma statistics (Asthma UK, 2013) would suggest that between 1 in 10 and 1 in 12 are asthmatic (in a school population 1 in 12 has asthma, while there are 1 in 10 in the general population). Of these 5% have severe asthma and are unlikely to be attending university. This would suggest that between 9.5% and 11.5% as asthmatic. So between 1,615 and 1,955 asthmatic, of whom 662 to 801 likely to say that they are very mild and from 436 to 528 mild so have no medication, or a reliever at most (if they’re right). Between 307 and 371 moderate and 178 to 215 severe – so likely to be on a reliever at least at one end of the spectrum and a preventer too towards the more persistent or severe levels. i.e from 485 to 586. Of these 232 to 263 are likely to think they are ‘at risk’ (Asthma UK). Horn (1992) suggests that patients who admit to poor compliance may be more amenable to compliance modifying strategies; EU funded research into asthma has shown a significant willingness of those with this troublesome disease to take part in research (Cerveri et al., 2013) Whilst use of a smartphone does not define a person as digitally literate a self-reporting interview will isolate those who are … which might be, given use of e-learning in higher education, most of this group. A further reduction is given to exclude some who will not use these devices.

Potentially conducted across four universities:

  • University of Southampton. 17,000 students.
  • City University, Finsbury, London. 17,000 students. Urban
  • University of Cumbria in Lancaster and Newton Rigg, Penrith. 10,500 students. Rural
  • University of Oxford. 20,000 students.

APPENDIX THREE

Benefits of a private site using Qstream

User admin

Batch invite

Batch enroll

History – invite, enroll

Delete

Email issue mgmt

User registration report

Access to learner email addresses

Reporting & analytics

User tagging

Management roles & reporting

Management summary engagement emails (weekly)

Engagement summary

Engagement detail & export

Learner performance summary

Learner performance detail & export

Snapshot analytics

Trend analytics

Question performance report

Question performance answer matrix

Question performance analytics

Site admin

Monitor site activity

Monitor comment activity for site

Site branding (logo, tagline, home page, Dashboard, URL)

Site localization (site branding translations)

Email branding (sender name, organization logo)

Private site publishing privileges

Course admin

Manage comment activity for course

Shut down courses

Basic course branding (course logo, course title)

Adv course branding (sender name, organization logo)

Private course catalog

Public course catalog listing

Private, closed courses

Open enrollment courses

Control course ‘operations’ (spacing, locked/unlocked)

Completion management (%, certificate, messaging)

Assign authors, co-authors

Assign moderators

Learner experience

Customized leaderboard gaming (email display, online display, invid, team, monthly, rollilng)

Localization

Mobile

Native app with notifications

Mobile interface

Course authoring

Course catalog description/listing

4 question types (MC, MCA, T/F, FIB)

Preview/validation of questions

Security

Auto login

Data security

Social & collaboration

Assign course moderator

Learners can post private or public comments

Comment management tools

Asthma

20130731-084802.jpg

Asthma

It’s so rare that I feel wheezy or am woken with a crackle in my lungs that these last few days remind me, unkindly, that I do afterall have the condition.

I know too well what the causes could be:

Creoset on a neighbour’s fence and shed. This was applied a week ago. The vapour is noxious and heavier than air – both it and my feeling stressed about it in the hot weather would trigger a response.

A change in medication. Whilst I have always managed with the inhaled preventer Qvar and a spacer (two puffs twice a day), for the last ten weeks or so, by mistake rather than design, I have been using an ‘Autoinhaler’ that puts a powder into the lungs with a pumpmevhanism rather than an aerosol. This also elliminated the chance of getting thrush in the mouth.

Having the builders in: this has meant three things: dust in the house from building, fumes from some paints/vanishes though where possible low emmition paints are used and pilling things into our bedroom and a fourth … letting the dog sleep in our room as the building works and rearrangement of furniture has unsettled her.

Being rundown: a mild cold can go to the chest.

ACTION

20130731-084844.jpg

ACTION

I will:

change my prescription back to the autoinhaler – I have an appointment to see my GP;
sort out the bedroom and vacuum the bed, duvet and pillows with a device that removes dust mite – it works;
get some fresh air!

Though I will, mask in place, presson with sanding and painting various surfaces in the bathroom, putting up mirrors and towels rails.

Time to write

Fig.1 H809 EMA Mindmap (for fellow H809 / MA ODErs I’ve added a PDF version in the TMA Forum) Created using Simpleminds.

  • H809 – Practice-based research in e-learning
  • MA ODE – Masters in Open and Distance Education
  • TMA – Tutor Marked Assignment
  • PDF – PDF

Yonks ago I realised for me the best time to study was v.early in the morning. 4.00 am to breakfast isn’t unusual, 5.00 am is more typical. All it costs is an early night. This is easy too – no television. Its move from the shed to the dump is imminent.

A week ahead of schedule I find I have an EMA to complete – this’ll give me a three hour, exam like run of it. Even the dog knows not to bother me.

For those on the same path the mindmap of my H809 EMA is above.

Ask if you’re interested in a legible PDF version.

This gorse bush off density has patterns within it that I can decipher. The net result ought to come out somewhere around the 4,000 word mark too. This approach could not be more different to my earliest TMAs and EMAs three years ago – they were too often the product of what I call ‘jazz writing’ (this kind of thing), just tapping away to see where it takes you. This process used to start on scrolls of backing wallpaper taped to my bedroom wall. Now it goes onto a whiteboard first.

As always this blog is an e-portfolio: most notes, moments in student forums and references are in here.

I recommend using a blog platform in this way. You can default to ‘private’, or share with the OU community … or ‘anyone in the world’. One simple addition to this would be a ‘share with your module cohort’.

By now I have clicked through some 165 posts taggeed H809 and can refer to H809ema for those picked out for it.

One split occured – I very much wanted to explore the use of augmented reality in museum visits, but found instead a combination of necessity and logic taking me back to the H809 TMA 01 and a substantial reversioning of it. Quite coincidentally this proposed research on adherence to preventer drugs amongst moderate to severe asthmatics had me taking a very close interest on a rare visit to a hospital outpatient’s. Nasal endoscopy must look like a circus trick to the casual observer as the consultant carefully ‘lances’ my skull through the nose with a slender and flexible rod on which there is a tiny camera and light. ‘Yes, I can see the damage from surgery’ he declares (this was 33 years ago), ‘but no signs of cancer’.

There’s a relief.

An unexplained nose bleed lasting the best part of 10 weeks was put down to my good-boy adherence to a steroid nasal spray that had damaged the soft tissue. And the medical profession wonder why drug adherence can be so low? 20% to 60% 33 years on and courtesy of the OU Library I found a wholly convincing diagnosis – allergic rhinitis. The ‘paper’ runs to over 80 pages excluding references and has some 20 contributors (Bousquet, 2008). I’ll so miss access to the online library as most papers appear to cost around the £9 to download. This desire to remain attached by a digital umbilical chord to such a resource is one reason I wish to pursue yet more postgraduate studying and potentially even an academic career. I get extraordinary satisfaction browsing ‘stuff’ to feed my curiosity.

When I stop diddling around here I’ll pick off this mindmap in a strick clockwise direction from around 1 O’Clock.

Simpleminds is great as a free App. It’s taken me a couple of years to get round to paying £6 for a version that can be exported into a word file though I rather enjoy the slower, more considered ‘cut and paste’ which adds another opportunity to reflect, expand or ditch an idea.

REFERENCE

Bousquet, J, Khaltaev, N, Cruz, A, Denburg, J, Fokkens, W, Togias, A, Zuberbier, T, Baena-Cagnani, C, Canonica, G, Van Weel, C, Agache, I, Aït-Khaled, N, Bachert, C, Blaiss, M, Bonini, S, Boulet, L, Bousquet, P, Camargos, P, Carlsen, K, & Chen, Y (2008) ‘Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 Update (in collaboration with the World Health Organization, GA2LEN’, Allergy, 63, pp. 8-160, Academic Search Complete, EBSCOhost, viewed 19 June 2013.

What will the impact be of the Web on education? How is knowledge sharing and learning changing?

Fig. 1. Father and daughter

From four or five months after conception with the formation of the brain, to the moment of brain death we have the capacity to learn, subconsciously as well as consciously.

Whether through interlopers before birth, in infancy and early childhood, or through family and carers in our last moment, days, weeks, months or years. At both ends of life the Web through a myriad of ways can advise, suggest and inform, and so educate, like never before. While for all the time in between as sponges, participants and students we can access, interact, interpose and interject in an environment where everything that is known and has been understood is presented to us. The interface between person and this Web of knowledge is a fascinating one that deserves close study for its potentially profound impact on what we as humans can do as people and collectively:  Individually through, by, with and surfing the established and privileged formal and formal conveyor belt of education through nursery, primary, secondary and tertiary centres of learning. Individually, also through expanding opportunities globally to learn unfettered by such formal education where such established opportunities don’t exist unless hindered through poverty and politics or a lack of communications infrastructure (a robust broadband connection to the Web). And individually and collectively alongside or beyond whatever formal education is provided or exploited by finger tapping into close and expanded networks of people, materials, ideas and activities

Open learning comes of age.

By seeking to peg answers to the role the Web is starting to play, at one end to the very first opportunity, at the micro-biological level to form a thought and at the other end to those micro-seconds at the end of life once the brain ceases to function – and everything else in between, requires an understandings neuroscience and an answer to the question ‘what is going on in there?’ How do we learn?

From an anthropological perspective why and how do we learn?

Where can we identify the origins of knowledge sharing and its role in the survival and domination of homo sapiens? And from our migration from the savannas of Eastern Africa to every nook and cranny of Earth, on land and sea, what recognised societal behaviours are playing out online? And are these behaviours mimicked or to a lesser extent transmogrified, warped or elevated by the scope, scale and speed of being connected to so much in such variety?

A history of learning is required.

From our innate conscious and subconscious capacity to learn from our immediate family and community how has formal education formed right the way through adding reading, writing and numeracy as a foundation to subject choices and specialisms, so momentarily expanded in secondary education into the single subjects studied at undergraduate level and the niche within a niche at Masters and doctoral levels. And what role has and will formal and informal learning continue to have, at work and play if increasing numbers of people globally have a school or university in their pockets, courtesy of a smartphone or tablet and a connection to the Web?

The global village Marshall McLuhan described is now, for the person connected to the Web, the global digital fireplace.

It has that ability to gather people around. Where though are its limits? With how many people can we develop and maintain a relationship? Once again, how can an understanding of social networks on the ground inform us about those that form on the Web? Multiplicity reins for some, flitting between a variety of groups while others have their niche interests indulged, celebrated and reinforced. Is there an identifiable geography of such hubs small and large and if visualised what does this tell us? Are the ways we can now learn new or old?

In relation to one aspect of education – medicine – how are we informed and how do we respond as patients and clinicians?

The journey starts at conception with the mixing of DNA and ends once the last electrochemical spark has fired. How, in relation to medicine does the quality (or lack of), scale and variety of information available on the Web inform and impact upon our ideas and actions the length of this lifetime’s journey At one end, parents making decisions regarding having children, then knowledge of pregnancy and foetal development. While at the other end, a child takes part in the decision-making process with clinicians and potentially the patient – to ‘call it a day’. Both the patient or person, as participant and the clinicians as interlocutors have, potentially, the same level of information at their fingertips courtesy of the Web.

How is this relationship and the outcomes altered where the patient will know more about their own health and a good deal about a clinician’s specialism?

The relationship between the doctor and patient, like others, courtesy of the connectivity and capacity of the Web, has changed – transmogrified, melted and flipped all at the same time. It is no longer them and us, though it can be – rather, as in education and other fields, it can be highly personalized and close.

Can clinicians be many things to many people?

Can any or only some of us cope with such multiplicity? A psychologist may say some will and some won’t, some have the nature for it, others not. Ditto in education. Trained to lead a classroom in a domain of their own, can a teacher take on multiple roles aimed at responding to the unique as well as the common traits of each of their students? While in tertiary education should and can academics continue to be, or expected to be undertake research as well as teach? Where teaching might be more akin to broadcasting, and the classroom or tutorial takes place asynchronously and online as well as live and face-to-face.

Disaggregation equals change.

In relation to one aspect of education in medicine and one kind of problem, what role might the Web play to support patients so that they can make an informed decision regarding the taking of potentially life saving, if not simply life improving, medications? Having understood the complexity of reasons why having been prescribed a preventer medication, for example, to reduce or even eliminate the risk of a serious asthma attack, what is going on where a patient elects, sometimes belligerently, not to take the medication. Others are forgetful, some misinformed, for others it is the cost, or the palaver of ordering, collecting and paying for repeat prescriptions. Information alone isn’t enough, but given the capacity of the web to brief a person on an individual basis, where they are online, what can be done to improve adherence, save lives and enhance the quality of life?

My hypothesis is that a patient can be assisted by an artificial companion of some kind, that is responsive to the person’s vicissitudes while metaphorically sitting on that person’s shoulder i.e. in the ‘Cloud’ and on their smartphone, tablet, headset, laptop or whatever other assistive interface will exist between us and the Web.

 

Fig. 2. Where it ends … more or less

At a parent’s side when they die is a profound experience. The breathing stopped and a trillion memories drained away. To what degree will this no longer be the case when a life logged digitally becomes a life in part preserved?

 

We’re no longer trying to sell magic potions out the back of a tub-trap

Photo

Fig.1. We’re no longer trying to sell magic potions out the back of a tub-trap. 

Still playing catch-up after the Tutor Marked Assignment (TMA)

Through week six writing and most activities (a few hours left to wrap)

I’m on my seventh Open University Postgraduate module – six on e-learning, one from the MBA programme.

I’m familiar with week 7 as we begin week 8.

I’ll catch up over the weekend.

Perhaps.

If it rains a good deal and my son’s football is off (again). This will come back to haunt me – with all the bad weather they are moving to two matches a week. The Daddy Taxi might be busy.

For H809 conjured up the ‘Perfect Storm of Online Research’

  • Young people, including minors
  • Online – gamified if not virtual worlds, with social aspects (whether wanted or not)
  • Medical – not a medical market research but ostensibly an ‘intervention’ of sorts that would require expertise, training and sign off for everyone involved.
  • Global – what isn’t if it is accessible online?

The good news?

  • They haven’t found life on Mars yet so I can keep it contained to Earth.

My plan

  • Set further parameters.

I’m looking at use of e-learning to improve uptake of preventer medication by young people with severe moderate asthma (i.e. they are supposed to take a daily preventer inhaler, like me, I do – they don’t).

I may ‘contain’ the research to a group where in some cases a step has already been taken to ameliorate the situation – swimming. I’ll talk to the ASA (hypothetical) and have participants as UK swimmers with asthma

This on ethics and permissions relating to research will be of value. 

University of Oxford Research Integrity

By entering medical research I have entered a minefield!

There are pages of protocols and procedures, training and checks with personnel and so on from the universities, the NHS and UK Government legislation.

Photo

Fig.2 A foothill just turned into climbing Olympus Mons, the 21000m largest mountain on Mars.

A picnic just turned into a medieval banquet for Henry VIII and all his six wives … (I’m off to walk the dog).

If I’m burying my head in sand then it is the red sand of Mars.  In any case, why climb Olympus Mons when I can land on it in a Twitter / PayPal sponsored Mars Rocket.

In truth I am reassured by the scope and comprehensive nature of the guidelines, protocols and legislation.

Reflection on Block 1 – towards compliance for those with moderate severe asthma

The most straight forward of assignments has proved anything but … not for how to write this 2000 word piece, that is straight forward, but rather committing to a subject, then narrowing down the theme, possible research question and then dig up some papers … and not simply offer the lot, but give the five ‘that say it all’. To pick five how many must you read, at least as abstracts. I made three false starts, even read a PhD thesis on blogging before deciding it is a minefield. I may like to blog but I no more want to research it for an OU assignment than sort out pebbles on Brighton Beach. Lifelogging, memory and neuroscience all interest me … but are too big to get my head around in a few months – a few years perhaps. Looking at my notes I see I have papers also on augmented learning for field trips and museum visits. Then I returned to a platform that caught my eye three yesrs ago on H807 when I interviewed Dr. B. Price Kerfoot of Harvard Medical School on ‘Spaced Education’. So far this system has been usef with doctors, to support their learning and decission making … the next step will be patients. One of the humdingers here is ‘compliance’ – taking the medication you are prescribed if you have a chronic condition. What dawned on me this afternoon is that as a asthmatic I am the perfect patient – compliant to the nth degree. What surprised me is that such a large percentage of asthmatics are not. But with alleregies – a double-whammy of irritations, I ignore the nasal steroids and antehistemines almost completely. Compliant, and defiant in one go so just about canceeling the two out. But why? This is what fasciantes. You know you need to take something to avoid a return of the symptoms, but as there are no symptoms you stop taking the medication. Anyway, I am sifting through papers to set me straight and to offer some answers. If you have a moderately severe chronic condition and wish to share your medication regime or attitude please speak up – asthma, allergies, diabetes, epilepsy, other mental illnesses – chat on Skype? Meanwhile I checked my preventer inhaler – it was empty. I at least had a spare and will get a repeat prescription in tomorrow.

The wonders of the OU Library

I will never tire from serving my curiosity when I entre the OU Online Library. I am often lost for weeks at a time, dipping into everything that catches my eye, reading some of if all the way through, following up further leads, then further leads until I find I’ve either circumnavigated the globe, dropped back a century or more or am spinning circles in a slow, spiraling descent through a single authors previous thinking.

I don’t need a ball of thread to help me find my way out and there’s no Minotaur to slay at the centre.

All I hate is a underpowered laptop and a rubbish internet connection.

Currently my interest is reseach on compliance, noncompliance, adherence and coherence in use of asthma drugs. I should know, I am one. My compliance is excellent. One asthma attack in my teens and I do everything to the letter. I fail to understand how and why 30% of people with my condition end up hospitalised or dead. The reading is extraordinarily diverse, bringing it down to the person, their identity with the condition and unwillingness to take a couple of puffs on an inhaler morning and night – when surely they are in and out of the bathroom anyway?

If you know any asthmatics like this please put them in touch or send them to my blog where I will add notes.

 

How to improve asthma patient outcomes using spaced education

Cover of "Living with Asthma"

Cover of Living with Asthma

There had been no plans to make this content public, but I thought I’d share it because of my interesting realisation that the Zemanta search tool may be  a reasonably valid way to winkle out papers relevant to a topic of interest. Out of habit it now I offer link to further content that on first appearances seems to  offer similar or contrasting views. Before I look at the selection that was offered to me, and the 7 from the 16 or so I was offered I am going to go through conventional route using the Open University Online Library and see what I may find that to any large extent differs.

I am not a physician or Medical Docotor, though I am asthmatic and have been in, on and off a variety of inhalers and sometimes oral steroids for some thirty years.

Preventer – Inhaled Steroid – two puffs twice a day. Used with a spacer to reduce chances of thrush.

Reliever – as needed, which is generally never, with rare need if I develop a chest infection, in which case I may end up on antibiotics anyway.

Oral Steroids – Very rarely, usually related to a chest infection. Once every five years?

Nebulizer – Never. Unlike my late father and one (or two) relations who take the view that they only need the preventer when they are wheezy … and end up hospitalised when they have an asthma attack and in the case of my father on steroids for so long that he became diabetic.

Preventative measures – know your triggers, avoid them, keep fit and attend an annual Asthma Clinic. I have to be cautious with house dust allergy and its partner in crime – damp. The odd list of triggers includes, at times, bleach, cumin seeds, one of the Lucozade sports drinks (odd that, coming from GSK who also produce asthma drugs). Possibly white flour. Yeast causes other problems too. We have a dog, but I’m not comfortable for long in a house with soft furnishings where there are cats. Get the bedroom windows open as often as possible. Use a specialist vacuum cleaner on the mattress, pillows and duvet. No carpets. No curtain. Leather sofa preferred.

Fig. 1. Twenty years ago I found myself producing, directing and writing a two information videos for a major pharmaceutical company – ‘Living with Asthma’ and ‘the Cost of Asthma’.

These had a shelf life of some ten to fifteen years, eventually to be replaced by DVD and online interactive equivalents. We did a combination of narrative drama reconstruction – a thread from a TV soap  in which a protagonist has an asthma attack, interviews with patients and experts (doctors and pharma) and narration with 3D animations and charts.

The purpose of this exercise is to:

  • Justify and explain the question for a piece of empirical research.
  • Offer FIVE pieces that  support then set you research on its way.
Though an academic exercise I’m going to treat this as something that could find funding, and that I could carry out.
What is the proposed research about? Asthma patient ignorance of best practice in relation to taking their prescribe drugs – why they are taking the drugs, how they work, when they should take them, how and how often …
What is it trying to find out or achieve? Improve patient care i.e. compliance (UK) – so taking their medicine correctly. This is important where the condition is chronic and the symptoms aren’t continuous. People tend to lapse taking the preventative drugs … it takes several days on onset of symptoms for these to kick in.
How will it go about doing that? A randomised controlled trial in which all asthmatics are invited to sign up to receive information over a period of x months, reminders about asthma and their drug taking regime.
What will we learn from it and why was it worth learning? That a significant percentage of asthmatics who have been prescribed an inhaled steroid (preventer medicine) to take twice daily are failing to do so, simply because they don’t see the need to do so unless they are feeling wheezy (a misconception, it should be taken regardless) or they allow their inhalers to run on empty for some time before being aware of this.That a significant percentage of asthmatics, probably largely the same group as above, misuse their reliever inhaler a) taking it too often b) not correctly inhaling so that drug ends up lining their mouth rather than entering their lungs.Taking the right dosage of inhaled steroid, as prescribed, in the correct manner, is likely to reduce need for the reliever inhaler to nil and will result in less long term damage being done to the lining of the lungs.It will improve patient outcomes, reduce the use of inhibitors and reduce hospital visits or overnights where a person has suffered an avoidable asthma attack.

 

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