title: A Low-Literacy Asthma Action Plan to Improve Provider Asthma Counseling: A Randomized Study.
abstract: OBJECTIVE
  The use of written asthma action plans (WAAPs) has been associated with reduced asthma-related morbidity, but there are concerns about their complexity. We developed a health literacy-informed, pictogram- and photograph-based WAAP and examined whether providers who used it, with no training, would have better asthma counseling quality compared with those who used a standard plan.
  
  
  METHODS
  Physicians at 2 academic centers randomized to use a low-literacy or standard action plan (American Academy of Allergy, Asthma and Immunology) to counsel the hypothetical parent of child with moderate persistent asthma (regimen: Flovent 110 μg 2 puffs twice daily, Singulair 5 mg daily, Albuterol 2 puffs every 4 hours as needed). Two blinded raters independently reviewed counseling transcriptions.
  
  
  METHODS
  medication instructions presented with times of day (eg, morning and night vs number of times per day) and inhaler color; spacer use recommended; need for everyday medications, even when sick, addressed; and explicit symptoms used.
  
  
  RESULTS
  119 providers were randomly assigned (61 low literacy, 58 standard). Providers who used the low-literacy plan were more likely to use times of day (eg, Flovent morning and night, 96.7% vs 51.7%, P < .001; odds ratio [OR] = 27.5; 95% confidence interval [CI], 6.1-123.4), recommend spacer use (eg, Albuterol, 83.6% vs 43.1%, P < .001; OR = 6.7; 95% CI, 2.9-15.8), address need for daily medications when sick (93.4% vs 34.5%, P < .001; OR = 27.1; 95% CI, 8.6-85.4), use explicit symptoms (eg, "ribs show when breathing," 54.1% vs 3.4%, P < .001; OR = 33.0; 95% CI, 7.4-147.5). Few mentioned inhaler color. Mean (SD) counseling time was similar (3.9 [2.5] vs 3.8 [2.6] minutes, P = .8).
  
  
  CONCLUSIONS
  Use of a low-literacy WAAP improves the quality of asthma counseling by helping providers target key issues by using recommended clear communication principles.
authors.affiliation: Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York; Department of Population Health, New York University School of Medicine, New York, New York; yinh02@med.nyu.edu.
authors.forename: H Shonna
authors.initials: HS
authors.lastname: Yin
authors.affiliation: Center for Community Health, and Smith Child Health Research Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; and.
authors.forename: Ruchi S
authors.initials: RS
authors.lastname: Gupta
authors.affiliation: Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York;
authors.forename: Suzy
authors.initials: S
authors.lastname: Tomopoulos
authors.affiliation: Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York; Department of Population Health, New York University School of Medicine, New York, New York;
authors.forename: Alan L
authors.initials: AL
authors.lastname: Mendelsohn
authors.affiliation: Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Maureen
authors.initials: M
authors.lastname: Egan
authors.affiliation: Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York;
authors.forename: Linda
authors.initials: L
authors.lastname: van Schaick
authors.affiliation: Health Literacy and Learning Program, Center for Communication in Healthcare, Division of General Internal Medicine, and Institute for Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois;
authors.forename: Michael S
authors.initials: MS
authors.lastname: Wolf
authors.affiliation: Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York;
authors.forename: Dayana C
authors.initials: DC
authors.lastname: Sanchez
authors.affiliation: Center for Community Health, and.
authors.forename: Christopher
authors.initials: C
authors.lastname: Warren
authors.affiliation: Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York;
authors.forename: Karen
authors.initials: K
authors.lastname: Encalada
authors.affiliation: Department of Pediatrics, New York University School of Medicine and Bellevue Hospital Center, New York, New York;
authors.forename: Benard P
authors.initials: BP
authors.lastname: Dreyer
mesh_terms: D000328:Adult; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use*; D001249:Asthma / Q000188:drug therapy* / Q000628:therapy; D002648:Child; D003376:Counseling / Q000379:methods*; D005260:Female; D057220:Health Literacy / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010290:Parents; D010820:Physicians
chemical_list: D018927:Anti-Asthmatic Agents