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(Chest. 1999;116:229S-234S.)
© 1999 American College of Chest Physicians

A Pilot Study Describing Local Residents' Perceptions of Asthma and Knowledge of Asthma Care in Selected Chicago Communities*

Terrence Conway, MD; Tzyy-Chyn Hu, RN, MSPH; Susan Bennett, RN, MSN and Maria Niedos, MPH

* From The Chicago/Cook County Ambulatory Care Council Asthma Taskforce (Dr. Conway, and Mss. Hu, Bennett, and Niedos), Chicago, IL; and the Ambulatory and Community Health Network, Cook County Bureau of Health Services (Dr. Conway), Chicago, IL.

Correspondence to: Terrence Conway, MD, Ambulatory and Community Health Network, Cook County Bureau of Health Services, 1835 W Harrison St, Chicago, IL 60612; e-mail: tconway{at}uic.edu


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: To understand inner-city Chicago residents' perception of the prevalence and severity of asthma as well as their knowledge of asthma control and management.

Design: Cross-sectional survey using a random digital telephone dialing method.

Settings: Five inner-city Chicago communities where a high prevalence and mortality of asthma have been recognized.

Participants: All the residents in the selected communities with a residential telephone had an equal opportunity to be surveyed.

Measurements and results: The unit of measurement was the household. Only one adult member (age 18 or older) in any randomly selected household was interviewed. The survey included questions modified from the Chicago Asthma Surveillance Initiative study. A total of 2,322 phone calls with 527 successful contacts were made over 1,938 distinct phone lines, resulting in a response rate of 175 of 527 calls (33.2%). Seventy-nine of the participants (45.1%) reported that at least one of their family members (including themselves) has asthma. Eight persons (4.6%) reported asthma as one of the top three health concerns in their community. Of the top three health reasons mentioned for children's being absent from school, only seven persons (4%) mentioned asthma. Participants were unlikely to perceive that the problems with access to asthma care and environmental triggers for asthma in their communities were any worse compared with other communities. Participants having family members with diagnosed asthma scored no better when asked general-knowledge questions about asthma or its signs and triggers than those without a family member having asthma.

Conclusions: The participants' knowledge and beliefs about the seriousness of asthma revealed in this study appeared unlikely to enhance or support compliance with the challenging requirements of the National Asthma Education and Prevention Panel guidelines. The study was conducted with a small sample, and the results should be carefullyinterpreted. (CHEST 1999; 116:229S–234S)


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
There has been a startling increase in the prevalence of and mortality from asthma in the United States and worldwide.1 2 Persons living within the inner city of Chicago suffer disproportionately from this increase, as do those living in other poor urban neighborhoods.3 4 5 6 To reverse the trend, the 1997 National Institutes of Health National Asthma Education and Prevention Program (NAEPP) guidelines emphasize the importance of building a partnership between health-care providers and patients in the management and control of asthma.7

The goal of the NAEPP guidelines is to manage asthma to a degree that a normal life can be maintained. To achieve this, other family and community members, in addition to the patients themselves, must play critical roles. For example, the parents of an asthmatic child need to be aware of the early signs and symptoms of an asthma attack. Relatives and visitors must not smoke in the house of the person with asthma, a beloved pet may have to be given away, the school teacher must allow and even supervise the administration of medications, and an employer may have to accommodate the need of a person with asthma to avoid occupational triggers even if no one else is affected. Local residents' perceptions and awareness of the impact of asthma and their understanding of asthma care have a real influence on the overall level of asthma care in that community.

We conducted a telephone survey to understand the residents' perceptions of the importance and impact of asthma, as well as their knowledge of asthma care, in five community areas where high prevalence and mortality of asthma have been recognized.8 9 The following specific questions were answered through this study: (1) Do the local residents believe that asthma is a prevalent and important health issue in their community? (2) Do they understand the implications of asthma on attendance of children in their neighborhood schools? (3) Do they feel that access to and quality of asthma care are adequate in their community? (4) Do they know the common signs and environmental triggers for asthma? and (5) Do they know the basic elements of asthma control and management consistent with the NAEPP guidelines?

This study was sponsored by the Chicago/Cook County Community Health Council—a coalition of community organizations, individuals, government agencies, and health-care organizations. The Community Health Council seeks to improve the health status of community residents by changing health-care providers' practice behavior, by encouraging patient involvement in their own health care, and by empowering local residents to ensure that all the health care delivered within their local communities is of good quality.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
From June 1, 1998, to August 7, 1998, we conducted a telephone interview in five Chicago inner-city communities (ie, Englewood, Greater Roseland, Northeast, District Five, and West) using random digital dialing.10 All the residents in the selected community with a residential telephone had an equal opportunity to be a participant. The unit of measurement was the household; therefore, only one adult member (>= 18 years of age) in any randomly selected household was interviewed.

The interview took about 10 to 15 min to complete and was conducted by two trained interviewers. Twenty percent of the randomly selected interviews were recorded and monitored for cross-validation. An informed consent was obtained for each of the participants. A list of computer-generated random digital dialing telephone numbers was used (Survey Sampling; Fairfield, CT). A minimal sample size of 30 was required for parametric analysis; therefore, 35 completed interviews in each of the five communities were determined to be sufficient to provide meaningful descriptive parameters.11

The survey questionnaire was developed from the 1997 NAEPP guidelines and included questions taken from the Chicago Asthma Surveillance Initiative survey12 that were modified and validated for content. The questionnaire consisted of five different sections: (1) perceived impact of asthma, (2) knowledge about asthma care, (3) specific knowledge relevant to the 1997 NAEPP guidelines, (4) simple demographics, and (5) history of selected health screenings received during the past 12 months.

Descriptive analysis was performed to answer all the above-mentioned research questions. A {chi}2 test was applied to compare the group of participants who had a family member with asthma or who themselves had asthma with those who did not have a family member with asthma or did not themselves have asthma. A p value of 0.05 was defined as statistically significant.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
A total of 2,322 phone calls were made to satisfy the predetermined 35 completed interviews for each of the five selected communities. The number of calls for Englewood, Greater Roseland, Northeast, District Five, and West were 560, 419, 435, 482, and 426, respectively. The 2,322 phone calls represent 1,938 distinct telephone lines. Of the 1,938 phone lines, 486 (25.1%) were disconnected, 277 (14.3%) were fax or answer machines, 449 (23.2%) had no answer, and 199 (10.3%) were commercial lines. Of 527 successful contacts, 289 (54.8%) refused to participate, 44 did not speak English, and 19 had no adult at home. Therefore, the response rate of successful contacts was 175 of 527 (33.2%).

Seventy-six percent (n = 134) of participants have been living in the zip code area for > 3 years. Sixteen of the participants (9.1%) had asthma diagnosed, and 79 (45.1%) reported at least one of their family members (any members including themselves) had asthma diagnosed. Table 1 outlines the characteristics of community residents who completed the survey. The majority of residents who completed the survey were women (70.7%), individuals with a high school (44%) or college (43.4%) level of education, and individuals 30 to 45 years old (41.7%) or < 30 years old (22.3%).


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  		Table 1. Characteristics of Community Residents Who Participated in Study (n = 175)*

 
Table 2 displays participants' perceptions of the top three health concerns in their communities. Eight persons (4.6%) reported asthma as one of the top three health concerns in their communities. Heart disease, cancer, and HIV were the most frequently reported concerns. Only seven persons (4%) mentioned asthma within the top three perceived health reasons for a child's absence from school (Table 3 ).


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  		Table 2. Ten Most Frequently Reported Top Three Health Concerns (n = 175)

 

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  		Table 3. Ten Most Frequently Reported Top Three Perceived Health Reasons Why Children Are Absent From the Schools of Their Communities (n = 175)*

 
More than half of the participants perceived that the problems with access to asthma care and environmental triggers for asthma in their communities were about the same compared to other communities (Fig 1 ). When asked to think of all the health conditions in their communities today and to compare how much of a problem they considered asthma to be using a 10-point scale (where 1 was "not a problem" and 10 was a "very large problem"), a central tendency distribution to the answer was noticed (Fig 2 ).



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  		Figure 1. Perceived problems with access to asthma care and environmental triggers for asthma.

 


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  		Figure 2. Representation of answers to the question, "Thinking of all the health conditions in your community today, how much of a problem do you think asthma is?"

 
Table 4 displays a post hoc comparison of the knowledge of asthma between those who had a family member with diagnosed asthma and those who did not, in a true/false format (the correct answer is in italics). In most of the listed knowledge attributes (Table 4) , the group of participants that did not have a family member with diagnosed asthma had a higher percentage of correct answers than the participants who had at least one family member with asthma.


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  		Table 4. Comparison of Asthma Knowledge Between Those Who Have a Family Member Diagnosed With Asthma and Those Who Do Not*

 
Table 5 compares knowledge about signs and triggers of asthma (the correct answer is in italics) between those who had a family member with diagnosed asthma and those who did not. More than half of the participants answered correctly on most of the items.


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  		Table 5. Comparison of Knowledge About Signs and Triggers of Asthma Between Those Who Have a Family Member Diagnosed With Asthma and Those Who Do Not*

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Asthma is an important health condition in the communities we surveyed. Mortality from asthma in these communities is among the highest in the nation for persons 5 to 34 years old.13 The estimated prevalence of asthma may be as high as 16%.3 Asthma is believed to have a significant impact on quality of life, lost wages, and high medical care costs.14 15 However, our study revealed that local residents were not aware that asthma is more prevalent or severe in their communities than in other Chicago communities.

The National Institutes of Health NAEPP has developed and published guidelines that initiate a new approach to asthma care and control. The guidelines encourage a partnership between provider and patient for asthma self-monitoring, patient-initiated treatment decisions, and recognition and removal of the environmental triggers. Asthma patients as well as their guardians and families must understand and cooperate in this approach and be willing to change behaviors.

The success of the NAEPP guidelines rests on improved patient and health-care provider education.16 However, discrepancies between asthma self-management knowledge and the actual self-management behavior of patients with acute severe asthma have been reported.17 This is not surprising. Patient education alone has long been recognized as insufficient to change health behavior.18 19 One approach to explain health behavior that has a substantial empirical basis is the health belief model.20 The foundation of the health belief model is that individuals will take action if they perceive themselves as susceptible to an ill-health condition, and if they believe the condition will lead to serious consequences and that a beneficial course of action is available to them.21 Community-wide perceptions and norms also influence whether individuals will access and use health services.22 The perception of the individual and the community that asthma is prevalent, serious, and can be controlled will determine how likely it is that the NAEPP recommendations will actually be followed.

Although asthma prevalence, severity, and mortality are excessive in the communities we surveyed and almost half (n = 79; 45.1%) of our participants reported that at least one of their family members or themselves were asthmatic, only a fraction of the participants (n = 5; 2.9%) perceived asthma as one of the top three health concerns in their communities. Nationwide in the United States, children with asthma averaged 7.6 days absent from school per year compared with 2.5 days for the well group.23 Other studies also report asthma as the major cause of school absences.24 25 26 Nonetheless, only 4% of participants (n = 7) listed asthma as one of the top three health reasons for the absences of children from school. Other conditions (eg, chicken pox) were much more likely to be perceived as causing school absences.

The local residents we surveyed believed that the impact of asthma on their communities was no worse than on other communities. Previous studies have identified poor access to asthma care and high levels of potential environmental triggers as coexisting in the communities we surveyed.3 27 28 A great majority of the respondents in this survey ranked both access to asthma care and environmental triggers as "about the same" compared with other Chicago communities (Fig 1) .

Residents' knowledge about proper treatment of asthma was low overall (Table 4) . They provided the correct answer to true/false questions less than half the time. Those who had at least one family member with asthma did not express better knowledge of asthma and asthma care than those who had no family members with asthma.

This telephone survey may have certain selection bias. Residents with a residential telephone are likely to be of higher socioeconomic status than those who do not have a telephone, but this is unlikely to have seriously affected results.29 The demographic profile of respondents does reflect higher educational achievement than the overall community.8 Women are also overrepresented in our sample. The percentages of persons with asthma we surveyed directly (9.1%) and of those who reported asthma in the family (45.1%) are not prevalence figures and may be an overrepresentation in the sample. The definition of "family" was self-determined by the respondents, perhaps making a comparison with other families imprecise.

The results of our study represent an initial effort to describe local residents' understanding of asthma in inner-city neighborhoods of Chicago. Knowledge and attitudes about asthma have often been studied in patients with asthma, but the overall knowledge and beliefs of the community members who reside in inner-city neighborhoods have not been described. What emerges from this survey is a picture of communities with perceptions, levels of concern, and knowledge about asthma that do not match the findings of epidemiologic studies of poor urban areas or recommendations to control the impact of asthma.

Community-wide health knowledge and attitudes are acquired through education as part of personal health care, from the media, in schools, through mass public education, and over time from other community residents. The failure of our study to demonstrate an increase in knowledge in persons having family members with asthma may represent the inadequacy of educational initiatives from area health-care providers. Within the NAEPP guidelines, the local health-care providers play a key role as asthma educators and should greatly influence local residents' perceptions of asthma self-management. However, in our study, a higher level of knowledge about asthma did not exist in families that had a member afflicted with asthma. Programs to enhance the skills and change the practice behaviors of community-based providers are needed.

The results of our study indicate the need for interventions at the community level for persons with asthma, health-care providers, and the larger community. Since 1980, asthma rates have increased 75%, with cases among very young children up 160%.30 Our data suggest that knowledge and beliefs of the serious impact from asthma have not been widely recognized in inner-city Chicago communities where a high prevalence of and mortality from asthma exist. The 1997 NAEPP guidelines include a component of "education for a partnership in asthma care," which focuses on the individual patient and encourages family involvement. We recommend that the partnership be further expanded to change the attitude and beliefs about asthma at the community level if excellent asthma control and outcomes are to be achieved.


   Footnotes
 
Abbreviations: NAEPP = National Asthma Education and Prevention Program


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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