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Qualitative study using indepth interviews, an open ended questionnaire, and participatory action research (PAR) groups.
24 community living adults >60 years of age (67% women, mean age 76 y, age range 60–92 y) who had medically diagnosed asthma and were using, or had been prescribed, daily preventative medications.
Data were collected using individual indepth interviews, an open ended questionnaire, and 2 PAR groups. Indepth interviews lasting about 1 hour each were held in participants’ homes, and guiding questions were used to help participants reflect on their personal asthma self management stories. Interviews were tape recorded, transcribed verbatim, and collaboratively analysed by 3 researchers. 18 patients and 6 invited partners participated in 2 PAR meetings to collaboratively develop a model that would enable self management of asthma for older people. PAR meetings were transcribed and analysed concurrently to ensure prompt feedback of issues to participants. The voices of participants were represented in the text to enhance study rigour. In addition to ongoing feedback, and as part of the PAR cycles, the study report was validated by all participants.
3 models of asthma management emerged: a medical model, a collaborative model, and a self agency model. Most participants described being in a medical model of asthma management. In this model, the key to self management was taking prescribed medications, for which participants mostly took the responsibility of managing themselves. Participants also identified and avoided triggers to prevent asthma attacks. In this model, the doctor managed the disease process, and the participants trusted and followed the doctor’s authority. The doctor’s authority, however, was more likely to be trusted if he/she provided specific disease knowledge and sound medical advice.
Participants described a collaborative model of asthma management in which asthma self management involved other people or was perceived by participants to be their own agency. Collaborative management was most likely a joint effort between participants and healthcare professionals. Participants were offered not only medical advice, but also had input into the decision making process of their care. When participant input was acknowledged and valued, it was conducive to self agency in the asthma management process.
The self agency model of asthma management involved self identification of responses to illness and self planning of daily routines to create order in daily life. Taking control of their own lives was an important part of self management, and taking action with daily life routines facilitated self determination. Participants who described using a self agency model talked about self management only in terms of their own agency. They took control of their own illness and responses to illness and decided when to share their management decisions with their doctors.
In community living older adults with asthma, 3 models of asthma self management were described: the medical, collaborative, and self agency models. Participants described self management as reclaiming the self and regaining self identity, including achieving recognition and support for the self monitoring process.
Research on chronic illness has often identified the intricacies of illness management: the complex issues involved in clients’ understanding of, and behaviour with respect to, symptoms, treatment regimens, and lifestyle modifications. The study by Koch et al adds an important dimension to the notion of self management by identifying 3 models of asthma management arising from their data. Their findings are interesting given their use of both “conventional” and PAR approaches. PAR brings client experiences and insights to the forefront, highlighting self management processes. Although the findings of the study relate to asthma, their potential application to a larger chronic illness context is evident.
The 3 self management models—medical, collaborative, and self agency—are relevant for clinical nursing practice because they articulate foci of care, roles and relationships between clients and healthcare providers, decision making processes, and lifestyle modification. It might be tempting, however, to view these models as either mutually exclusive or hierarchical, with self agency being construed as the most desirable goal. The authors, although arguing for incorporating the “self” in self management, point out that processes of learning and taking control are strategies that evolve over time. Furthermore, they encourage concurrent processes of medical and self management.
As chronic illness care moves increasingly into the primary care domain, it will be important to understand the ways in which clients and nurses can collaboratively address the many issues surrounding both healthcare intervention and lifestyle change. Although this study adds to the body of knowledge about asthma, its themes and implications resonate for other illnesses that are long term in nature. It provides a useful foundation for both practice and future research.
For correspondence: Dr T Koch, University of Newcastle, Newcastle, New South Wales, Australia.
Sources of funding: Commonwealth Department of Health and Ageing (Australia) and Asthma Innovative Management (AIM).
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