Development and assessment of a low literacy, pictographic asthma action plan with clinical automation to enhance guideline-concordant care for children with asthma

Abstract

Objective

Asthma is characterized by reversible pulmonary symptoms, frequent hospitalizations, poor quality of life, and varied treatment. Parents with low health literacy (HL) is linked to poor asthma outcomes in children. Recent practice updates recommended inhaled corticosteroids for the management of persistent asthma, but guideline-concordant care is suboptimal. Our aim was to develop and assess an Asthma Action Plan (AAP) that could serve as an individualized plan for low HL families and facilitate guideline-concordant care for clinicians.

Methods

We followed the National Institute of Health 5-step “Clear & Simple” approach to develop the Uniformed Services AAP. Our AAP included symptom pictographs (dyspnea, cough, sleep, activity) and guideline-concordant clinical automation tools. Caregivers assessed the pictograms for validity (transparency of ≥ 85%; translucency score ≥ 5; and ≥ 85% recall). Readability was assessed using 7 formulas. (<6th Grade was acceptable). Comprehensibility, design quality, and usefulness was assessed by caregivers using the Consumer Information Rating Form (CIRF) (>80% was acceptable). Understandability and actionability was assessed by medical librarians using the Patient Education Materials Assessment Tool-Printable (>80% was acceptable). Suitability was assessed by clinicians using the modified Suitability Assessment of Materials (SAM) instrument (>70% was superior).

Results

All 12 pictograms were validated (N = 118 respondents). Readability demonstrated a 4th grade level. Overall CIRF percentile score = 80.4%. Understandability and Actionability = 100%. Suitability score = 75%.

Conclusions

Our AAP was formally endorsed by the Allergy & Asthma Network. The Uniformed Services AAP is a novel tool with embedded clinical automation that can address low HL and enhance guideline-concordant care.

Keywords:

• Discharge planning
• patient care planning
• patient education handout
• emergency/acute management

Acknowledgements

Thank you to the medical librarian experts outside of our research team who made the assessment of the USAAP possible. Your contributions made this an enduring, invaluable tool for our patients: Michele Mason-Coles, MLS, CHIS, [email protected]; Sarah Clarke, MSLS, AHIP, [email protected]; Thank you to the Allergy & Asthma Network team for your creative input, help and support during the development process of this project. Specifically, we would like to acknowledge: De De Gardner, DrPH, RRT, RRT-NPS, FCCP, FAARC; Leandra Tonweber PA-C, AE-C; Sally Schoessler, MSEd, BSN, RN, AE-C. Thank you to Nancy Reeves for your constant support, creativity and teamwork. Thank you to Dr. Daniel Hsu for your mentorship.

Article summary

Our study describes the development and assessment of a novel, pictographic clinical symptom action tool for the out-patient management of asthma.

Disclaimer

This work was prepared as part of the official duties of Drs. Reeves, Kenny, Mulreany, McCown, Rogers, Welsh, Jacknewitz-Woolard and Ms. Echelymer who are employed by the United States Army, and Department of Defense. The identification of specific products or scientific instrumentation is considered an integral part of the scientific endeavor and does not constitute endorsement or implied endorsement on the part of the author(s),DoD, or any component agency. The views expressed in this manuscript are those of the authors and do not necessarily reflect the official policy of the Department of Defense or the U.S. Government.

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Disclosure statement

The authors have no financial relationships relevant to this article to disclose. There are no prior presentations of the study data as an abstract or poster.

Funding

There was no funding support beyond the salary disclaimers, as above, for the completion of this project. Salary support was provided for to all authors by the United States Department of Defense.

What’s known on this subject

Asthma is characterized by chronic and acute lower airway inflammation and pulmonary symptoms. Clinical practice guidelines and recent evidence have highlighted the importance of early symptom recognition and intervention.

What this study adds

Our study introduces the first evidenced-based, electronic patient-friendly Asthma Action Plan with validated pictograms that provides clinician enhancements to support guideline-concordant care.