The Internet is fast becoming the go-to place for asthma self-management information and strategies.

 Asthma is a chronic, potentially fatal disease affecting more than 20 million people in the United States and 150 million people worldwide.1,2 The direct and indirect costs of asthma are substantial. In 2000, the US Centers for Disease Control and Prevention (CDC) estimated that the disease was responsible for 12 million asthma attacks, 465,000 hospitalizations, and 1.8 million emergency-department visits. Poor, minority, and inner-city populations are disproportionately affected, with African Americans three times more likely than white US residents to make emergency-department visits, be hospitalized, or die from asthma.1

Benefits of Asthma Education
Given these statistics and current trends, asthma education and control should be key concerns for health care providers and their clients. In the international arena, activities to raise asthma awareness and improve control have been spearheaded by the World Health Organization through its Global Initiative for Asthma. The National Asthma Education and Prevention Program (NAEPP) at the National Heart, Lung and Blood Institute, and the CDC’s National Asthma Control Program, have taken the lead in controlling the disease in the United States. NAEPP guidelines3 suggest that asthma education raises patients’ knowledge about the disease, increases compliance with physician-directed regimens and avoidance of environmental triggers, and decreases the severity of asthma-related symptoms. It can also reduce hospital admissions, decrease limited-activity days, and improve quality of life.4

Despite these clear advantages, such programs are not as common as they should be. For example, Peterson et al5 studied how often teaching hospitals with training programs in pulmonary and critical care medicine offered asthma education programs. They found that, of the 117 hospitals surveyed, 64% (75) had formal asthma education programs with nurses providing the patient instructions. A broad majority (96%) of respondents with a formal asthma education program considered the program effective in improving asthma self-management skills for their patients. The reasons most often cited for not having a program were expense and time requirements. Personnel costs were the primary expense in patient education. Although a Current Procedural Terminology code exists for patient education, many payors do not reimburse for it. In the Peterson et al5 study, two thirds of respondents viewed computer-based asthma education as a cost-effective means of supplementing their patient-education programs. This suggests the significant potential of computer-based education to bridge the gap between limited clinical resources and the need for patient education.

Benefits of Internet Use
The availability of computers and related technologies has grown dramatically over the past decade.6-8 In fact, using computers and accessing the Internet have become routine for many US residents. By the end of 2004, on a typical day, 70 million US adults logged onto the Internet,9 and 55% to 74% of this population has used the Internet to obtain health and medical information.10-12

The introduction of Internet-based education into clinical practice has created numerous opportunities for creative interventions that benefit both patients and providers.13,14 This phenomenon, e-health, is the intersection of medical informatics, public health, and business; and the term refers to health services and information delivered or enhanced through the Internet.8 Interactive health communication (IHC), part of e-health, is the interaction of an individual with or through an electronic device or communication technology to access or transmit health information, or to receive or provide guidance and support on health-related issues.7 Interactive health communication has several advantages over traditional media and methods of patient instruction (see Table 1). Interactivity may create and maintain interest in a Web site, which, in turn, may reduce attrition and contribute to positive behavioral change.15 Therefore, IHC has the potential to play a pivotal role in creating a healthier society by altering the way people prevent disease, maintain their health, and recover from illness. Nguyen et al12 add that incorporating regular feedback and reinforcement by health professionals into online interventions targeting health behavior could further increase their impact.

Table 1. Internet use in asthma patient education.

Benefits
• The Internet is a cost-effective adjunct to traditional patient education; closes patient-provider gap.
• Continuously updated information is available.
• Information reaches a large, diverse, geographically spread audience.
• Access is available in many settings (homes, workplaces, schools, and libraries), 24 hours/day.
• The Internet is already used by many patients for health
information.
• Varied, often innovative, cutting-edge perspectives from patients, providers, and others are offered.
• Self-paced instruction is tailored to patient’s needs and
encourages self-management.
• Users can access supportive, interactive online support groups, chat rooms, and provider feedback.
• The Internet can be used to obtain a second opinion.16
• Information can be accessed anonymously.
• Users can track disease progression, prevention, and management activities.
• The Internet provides age-appropriate, entertaining, interactive learning tools for self-management that children can access.

Barriers
• Access varies by age, race/ethnicity, gender, income, and
education.
• Overall literacy and health literacy limit ability to interpret and apply information.
• Web site design and information are unregulated and of highly variable quality.
• Commercial sponsorship of sites is common.
• Patients can bypass interactions with health care providers, following medical advice without provider input.
• Provider comfort levels vary in recommending Internet sites and resources.
• Inadequate research has been conducted on characteristics of patients most likely to benefit from use, impact on health, sustainability of changes, and other factors.

Belda,6 Wantland et al,13 and others12 suggest that computer applications can assist patients in synthesizing knowledge into information that they can then use to help them manage their chronic diseases, and should be considered an effective adjunct to traditional methods of patient education. Indeed, the Internet may become a low-cost vehicle for asthma self-management programs. The Internet offers certain advantages over traditional paper-based, unidirectional methods of patient instruction that are resource intensive and rigid.4,12-14 As patients’ awareness of their disease increases, compliance with treatment goals improves.6 Internet health resources serve to enhance access and decrease barriers to health care.

Asthma Patient Education
Although chronic diseases are responsible for about 70% of US deaths and 75% of US health care costs annually,17 the current health care system is oriented toward illness and does not provide adequate incentives to prevent or manage chronic conditions.6 Given this perspective, much of the burden is shifted to the individual health practitioner and patient. A necessary response is to focus greater attention on self-care and self-management and to encourage individuals with chronic diseases like asthma to learn more about their conditions, take more active roles in decision making, and make behavioral changes. When individuals receive personalized information about their chronic disease through Internet education, they can ultimately become invested in the success of the intervention, which may lead to self-management skills. Acquisition of these skills has been demonstrated to increase adherence to treatment regimens and to improve health outcomes.12,13

Specifically for asthma, Web-based education and interventions have been shown to improve knowledge, behavioral outcomes, health outcomes, and health care utilization.4,12-14 Individualized computer-generated materials have contributed to improved patient morbidity and compliance, promoted self-management, increased knowledge of asthma treatment, slowed health decline, increased participation in health care, and improved quality of life.4,6,13,15 This is the case not only for adults but also for children. For example, a study18 examining the impact of an interactive multimedia asthma program on 228 children and their caregivers reported improvements in asthma knowledge and a decrease in symptom days, emergency-department visits, and daily doses of inhaled cortico-steroids. Other studies12 have shown similar success: participants who used professionally developed and facilitated Internet-based programs had significant improvements in physical function, resource utilization, and self-management. In comparison with traditional asthma patient education (which can be expensive, time-consuming, and poorly compensated), Internet-based education offers a low-cost, effective alternative that can help overcome obstacles to delivering effective patient education.4-6,14,18

Both practitioner-directed and Internet patient education face barriers, however. Such barriers can result in the failure of the health care system to provide the tools necessary for disease management.18 Factors that may limit the effectiveness of practitioner-directed education include time constraints, lack of skill, cultural and emotional issues, and the unidirectional nature of the relationship.15 Internet barriers (see Table 1) include the fact that most sites are in English only and that reading levels may be inappropriate, among others.14,19 The most commonly raised concern is about the quality of Web sites, including that many sites are not created by health professionals and many authors of health information on the Internet lack adequate expertise in health and communication sciences, which can result in the availability of inaccurate and even dangerous information.6,7,14,15 Moreover, too few tools are available to assist patients in finding useful information.15,19

Helping Patients Use Information
RTs may find it helpful, in selecting asthma Internet sites and evaluating the reliability of patient education materials, to rely on one of the rating or vetting systems developed for this purpose.6,14 The Health on the Net Foundation’s code of conduct (HONcode) for medical and health Web sites20 is one of the best known and most respected rating tools in the field. Only Internet sites that agree to comply with its eight principles receive the HONcode seal. Displaying the seal, however, is not always proof of content accuracy. For example, Meric et al21 found that 12 of 184 popular breast-cancer sites contained inaccurate statements, including three of the 19 commercial sites featuring the HONcode seal. A second, frequently referenced rating system uses the JAMA Benchmarks or guidelines,21-23 which employ four criteria: authorship, references, currency, and disclosure. In the Meric et al21 study, none of the Web sites that met the JAMA Benchmarks standards contained inaccurate information.

There are other criteria that RTs can employ in vetting Internet-based asthma patient education. For example, Croft and Peterson,14 in their assessment of 145 Web sites on asthma education, used the criteria of accessibility (measured as readability, language, and download time); information quality; compliance with HONcode principles; and use of innovative technology. They also used coverage of six core educational principles: basic asthma pathophysiology, triggers and avoidance of asthma attacks, mechanisms of action of asthma medications, importance of anti-inflammatory medications, self-assessment of respiratory status, and necessity of an action plan dependent on respiratory status.14

To increase the likelihood of capturing relevant asthma patient education materials, RTs and their patients can also follow links provided by recognized professional associations, government agencies, and nonprofit organizations for more information (see Table 2); check information against evidence-based guidelines for asthma control; and contact the authors and Webmasters of sites that fall short of these standards.

Table 2. Asthma Web sites.

Allergy and Asthma Network/Mothers of Asthmatics, Inc www.aanma.org

American Academy of Allergy, Asthma and Immunologywww.aaaai.org  

American Academy of Pediatrics www.aap.org

American Association for Respiratory Care www.aarc.org

American College of Emergency Physicians www.acep.org

American Lung Association www.lungusa.org

Association of Asthma Educators www.asthmaeducators.org

Asthma Action America www.AsthmaActionAmerica.org

Asthma and Allergy Foundation of America www.aafa.org

National Asthma Education and Prevention Program www.nhlbi.nih.gov/about/naepp

National Medical Association www.nmanet.org

US Centers for Disease Control and Prevention www.cdc.gov/asthma  

World Health Organization www.who.int/noncommunicable_diseases/about/respiratory

Conclusion
As access to health information on the Internet increases, health care professionals will need to take a more proactive role to give patients guidance and prevent them from acting on misinformation.6 Moreover, patients have demonstrated that they want this assistance and information. As a recent survey of inner-city emergency-department patients showed, more than half of respondents were interested in being given quality medical links as part of their discharge instructions. Younger patients and those with higher income or education levels responded that they were more likely to be interested (or very interested) in being provided with links to high-quality Web sites related to their health problems; 13% of respondents did not have Internet access, but still wanted the links.15 Using the Internet for asthma patient education is not always an easy task. Given the wealth of Internet-based information and its potential benefits for patients, it is an essential one.

Roberta B. Hollander, PhD, MPH, is professor of health education, and Donna Oliver-Freeman, RRT, is adjunct professor of health education at Howard University, Washington, DC.

References
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