Effectiveness of pictorial versus text-based personalised asthma action plans in Malaysian public primary care clinics: a randomised controlled trial

Asthma self-management, supported by a personalised asthma action plan (PAAP), improves clinical outcomes. In Malaysia, only about 14% of adult patients with asthma were counselled on asthma action plan. We developed a pictorial-PAAP to facilitate asthma self-management. This study aimed to compare the effectiveness of the pictorial-PAAP with a text-based PAAP (text-PAAP). We recruited 180 adult asthma patients who were treated with daily inhaled corticosteroids and able to understand Malay or English from four urban public primary care clinics in Klang District, Selangor, Malaysia. Patients enrolled were randomly assigned to receive either a pictorial-PAAP or a text-PAAP with a 1:1 allocation. Those who agreed to participate in the study had their baseline assessment conducted before being handed a sealed envelope with allocated asthma action plan within. Subsequently, the treating doctors or pharmacist opened the sealed envelope and counselled the patients according to the arm they were allocated to. The study outcomes were measured at baseline, 3-, 6- and 12-months using a questionnaire. The primary outcome was asthma control, and the secondary outcomes were reliever medication use, adherence to controller medication, acute exacerbations, asthma-related emergency visits, and asthma-related hospital admissions, workdays lost due to asthma and use of PAAP. Generalized Estimating Equation (GEE) analysis was used to investigate the effectiveness of the intervention. Mean age of participants was 44.93 years (SD 13.59); 63.9% were <50 years, 80.0% were females, 57.8% were Malay, 84.4% had secondary or tertiary education, 72.8% were married, 91.1% were from low-income households, and 27.2% had inadequate health literacy. Baseline sociodemographic and clinical characteristics of the participants were similar between groups. Over time asthma control improved in both groups. At baseline, 3-, 6- and 12 months, the proportion of well controlled asthma in the pictorial-PAAP and the text-PAAP group was 20.0, 28.7, 40.7, 64.3, and 21.1, 28.9, 45.5, 44.6% respectively. Both groups demonstrated significant reductions in the proportion with ≥1 asthma attacks, asthma-related emergency visits, hospital admissions, and leave from work and medical certificate issued at all follow-up points compared with baseline (p < 0.05). In both groups, PAAP usage peaked at 3 months and declined thereafter, but even at 12-month remained significantly greater than at baseline (p < 0.05). Controller medication adherence increased significantly at 3- and 12-month in both groups (baseline, 3- and 12-month: text-PAAP: 34.4, 63.3, 67.9%, pictorial-PAAP: 34.4, 70.1, 65.9%; p < 0.05). Reliever medication use decreased significantly at 6- and 12-month in the pictorial-PAAP group (baseline, 6- and 12-month: 87.8,73.3, 69.0%; p < 0.05), and all follow-up points in the text-PAAP group (baseline, 3-, 6- and 12-month: 87.8, 83.8, 70.5, 74.7%; p < 0.05). Generalized estimating equation analysis showed a higher likelihood of achieving good control in the pictorial-PAAP group than the text-PAAP group at 12-month follow-up (OR = 2.645, 95%CI:1.232–5.679, p = 0.013). Both groups demonstrated improvement in asthma control over the 12-months follow-up. The pictorial-PAAP group had significantly higher odds of achieving well controlled asthma than the text-PAAP group at 12 months. Primary care physicians should consider offering pictorial-PAAP to facilitate patient self-management.