Patient education on medication safety

NURSING PRACTICE & SKILL

Author Zeena Engelke, RN, MS

Cinahl Information Systems, Glendale, CA

Reviewers Alysia Gilreath-Osoff, RN, BSN, CEN,

SANE Cinahl Information Systems, Glendale, CA

Sara Richards, MSN, RN Cinahl Information Systems, Glendale, CA

Nursing Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

April 13, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Patient Education: Home Care – Teaching Medication Self-Administration

What Is Teaching Medication Self-Administration in Home Care? › Teaching medication self-administration in home care is the process of teaching patients

to safely and independently take their prescribed medications in the home environment. Medication self-administration involves having the patient follow the five “rights” of medication administration: right patient (i.e., self), right medication, right dose, right time, and right route • What: Teaching medication self-administration in home care typically involves

educating and verifying that the patient understands –the name of the medication, its mechanism of action, and what it is used for –correct dose –correct timing of administration –correct route of administration (e.g., oral or via subcutaneous injection) and the proper

technique for self-administering the drug –potential adverse effects and potential interactions with other medication, food, and

supplements –appropriate storage –the importance of communicating information about medication that is currently being

taken to healthcare clinicians, including both prescription and over-the-counter (OTC) medications

• How: A variety of teaching/learning and motivational activities (e.g., face-to-face instruction, telephone communication, written materials, computer-mediated programs) can be utilized to support patients and family members in learning about medication self-administration –Combined strategies (e.g., face-to-face communication and providing a written

pamphlet) have been shown to be more beneficial than verbal instruction only –For patients with a complex medication regimen, offering information in more than one

session allows the patient to process smaller amounts of information and avoid feeling overloaded with information

• Where: Teaching about medication self-administration in home care occurs in the home environment. In some cases, teaching might begin in an ambulatory care setting (e.g., the treating clinician’s office) or prior to discharge from the hospital or a long-term care facility –Patients should receive consistent educational information in all healthcare settings and

in the home throughout the course of patient care • Who: Patient teaching about medication self-administration in home care is provided by

healthcare professionals (e.g., registered nurses, pharmacists, physicians) and should not be delegated to assistive staff members

What Is the Desired Outcome of Teaching Medication Self- Administration in the Home? › Education about medication self-administration can empower patients and allow them to

• understand the name, dose, route, timing, and purpose of each prescribed medicine

• build confidence and skills necessary for successful medication self-administration (e.g., filling pill organizers, drawing up insulin, using safe injection techniques, properly disposing of syringes, using aerosol delivery systems correctly, using cues to promote proper timing of medications, properly storing medication)

• observe for adverse effects of medication when taken with specific other medications, foods, or supplements and seek medical assistance as needed

• engage in lifestyle changes to decrease risk for complications (e.g., maintaining a consistent intake of vitamin K when taking warfarin, regularly checking EPINEPHrine expiration dates, wearing a medical alert bracelet when taking high-risk medications)

• recognize the importance of communicating information about medications that are currently being taken, including prescription and OTC medications, to healthcare professionals and participate in shared decision making about medication self-administration

• cope with the psychosocial and emotional aspects of having an illness that requires medication and adhering to a prescribed medication regimen

Why Is Teaching Medication Self-Administration Important in Home Care? › Teaching home care patients how to correctly take their own medications helps to promote safe, cost-effective delivery of

medications; self-administrationof medications is an important component of self-care › Errors in medication self-administration can lead to decreased symptom control, increased risk for severe health issues, and a

greater number of emergency department visits, hospitalizations, and nursing home placement, and can significantly increase healthcare costs for preventable complications

› Patient education is required by The Joint Commission (TJC), and medication safety is an integral part of TJC Home Care National Patient Safety Goals. The home care nurse is required to provide patients with written information on medications that are being taken in the home care setting and to educate about their role in providing information about the medications they are taking (e.g., giving a list of current medications to the treating clinician, serially updating the list, carrying medication information in the event of an emergency) (TJC, 2018)

Facts and Figures › Children are at increased risk for having problems with managing medication. In a study of children receiving medications

for asthma,the following were the most common areas of risk (Wilson et al., 2015): • Responsibility in medication administration (i.e., the degree to which the patient takes his/her medication); researchers

reported that about 39% of children take their medication “all of the time,” 7% take their medication “quite a bit of the time,” and 46% are at high risk for not taking responsibility for taking their medication

• Wellbeing of the child’s caregiver, particularly related to coping and stress management • The child’s well-being, including his/her behaviors and emotions • Medication adherence

› A multidisciplinary work group at Johns Hopkins Health System developed and implemented a post discharge home-based, pharmacist-provided medication management service. This service not only enhanced continuity from hospital to home, it ensured that pharmacists identified and resolved medication discrepancies, educated patients about their medications, and provided primary clinicians and community pharmacists with a complete and reconciled medication list. While prevention of readmissions was not a targeted outcome of the project, only 8% of patients who received the service were readmitted within 30 days. On average, the readmission rate for similar patients in the same hospital was 16–17% (Pherson et al., 2014)

› Improper use of dry powder inhalers can result in an insufficient amount of the drug being deposited in the lungs. In a study of patients with chronic obstructive pulmonary disease, educational handouts were given to help patients who were already using inhalers. Researchers found that the handouts alone were effective in improving inhaler technique; vision and health literacy did not impact on the patients’ inabilities to learn proper technique (Alsomali et al., 2017)

› Prescription opioid abuse is epidemic. Opioid diversion to family members and friends is a major source of abused prescription opioids. Nurses play a key role in reversing this opioid abuse by providing essential anticipatory guidance each time a patient receives a medication prescription (Manworren et al., 2015)

› In Spain, researchers studied 45 patients with infective endocarditis (IE) who self-administered parenteral antibiotics in a “hospital-in-home” (HIH) environment. During each self-administration session, a nurse or treating clinician briefly visited the patient. The rate of inpatient readmission was 12.5% and no patients died while in the HIH program (Pajarón et al., 2015)

› In a study of 23,614 patient records, researchers concluded that when patients with a high risk for adverse reactions and a slow immunotherapy buildup phase were excluded, systemic reaction (SR) rates during home immunotherapy were significantly lower than SR rates during office-basedimmunotherapy (Schaffer et al., 2015)

› When prescribing oral cancer agents, clinicians must be aware of factors that affect adherence; these include side effects, forgetfulness, beliefs about medication necessity, established routines for medication self-administration, social support, ability to fit medications in lifestyle, cost, and medication knowledge. Depression and negative expectations can also negatively influence adherence (Irwin et al., 2015)

› In a qualitative study of mental healthcare professionals, researchers found that although health professionals recognize that treatment adherence is a major issue, they frequently do not use evidence-based interventions to address the problem. The researchers concluded that it is necessary for clinicians to challenge their own pre-existing beliefs about treatment adherence to more effectively help patients manage medications (Brown et al., 2015)

What You Need to Know Before Teaching a Patient about Medication Self- Administration in the Home Care Setting › Prior to initiating medication self-administration, the nurse must carefully assess the patient’s ability to safely self-administer

medication. This is often determined using subjective judgment, including subjectively judging the patient’s knowledge of each medication, cognitive ability to follow instructions, ability to read medication labels and package inserts, manual dexterity needed to administer the prescribed medications, ability to administer each medication, and ability to recognize adverse effects and report them to the treating clinician • The Self-Administration of Medication (SAM) tool used to assess a patient’s ability to self-administer medications offers

consistency in evaluation, can be completed in a short time, and is more objective than the perceptions of healthcare clinicians. Other similar tools are available

• Assessing medication self-administration abilities in stroke patients is particularly important. Stroke patients might not be aware of their cognitive deficits and can overestimate their competence related to medication self-administration

› TJC’s focus on medication safety requires that home care nurses accurately and completely reconcile medications in the home environment. This process includes comparing current and newly ordered medicines, communicating about medications with the next clinician who will provide patient care, giving a written list of the patient’s medicines to the patient and family,and educating the patient and family about the list (TJC, 2018). To improve medication safety, TJC suggests that patients should adopt the following: • Properly discarding old or outdated medications (for information about safe disposal of medicines, refer to the

U.S. Food and Drug Administration (FDA) Web site at http://www.fda.gov/Drugs/ResourcesForYou/Consumers/ BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/default.htm)

• Bringing all prescription and OTC medicines and supplements to physician office visits or to a local pharmacy for review • Carrying a list of the names and numbers of healthcare providers and pharmacies used • Carrying a list of all prescription medications and OTC medications and supplements that are currently being taken with

dosages, special instructions, and known allergies › Patients should be taught basic information about drug safety in the home such as the importance of

• keeping drugs in their original, labeled containers • finishing a prescribed medication (e.g., an antibiotic) unless instructed otherwise • not saving drugs for future use and not giving them to another person • keeping drugs out of reach of children • storing medicines at proper temperatures (e.g., refrigerate as needed, store in a clean and dry area, keep away from extreme

temperatures) • reading medication labels carefully and following all instructions • being aware of look-alike, sound-alike drugs

› Home care patients with a complex medication regimen should be taught strategies for organizing their medications and establishing a system of cues for taking them at specific times (e.g., posting a schedule on the refrigerator; creating a medication calendar with pictures of the pills; having someone send text reminders to take medicines; using a self-administration medication documentation sheet to keep track of administration; using pill boxes, egg cartons, or cupcake tins to organize medications; using color-coded sections to designate specific days and times)

› Common concerns about oral medication self-administration include adhering to the routine of taking multiple pills several times a day, coping with having severe or constant adverse effects, and coping with medication-relatedfinancial difficulty

› Older adults often self-administer medications despite being at increased risk for having problems managing their medication. A common mistake is often omission of a prescribed medication

› Medication administration routes that are used in the outpatient setting or in the home care setting each have their own risks and benefits; for example:

• Outpatient parenteral antibiotic therapy (OPAT)was introduced in the U.S. in the 1970s. OPAT is currently practiced worldwide and is a safe and effective option for carefully selected patients

• Home self-administered allergen immunotherapy, which was previously considered controversial, is now thought to be a safe option for carefully preselected patients

› Although oral medication administration is the easiest, most common method, it is contraindicated in patients who have gastrointestinal (GI) abnormalities, including patients with a nasogastric tube (NGT), gastrostomy tube, or poor gag reflux and patients who are unable to swallow or are unresponsive • Home care patients taking oral medicines need to be cautioned about drugs that cause gastrointestinal distress • Patients taking sublingual medicines should be reminded not to swallow them, and patients taking buccal medications

should be taught to allow the medicine to dissolve against the mucous membrane of the cheek and then swallow the saliva › It is common for patients with asthma to use up to three metered-doseinhalers (MDIs) daily, and each meter requires

performing multiple steps for safe and accurate use. Most patients do not use their MDIs correctly and many healthcare professionals lack knowledge about proper technique. Spacer devices can be used with certain MDIs to improve technique and allow the patient to inhale for a longer period. Dry-powder inhalers are recommended as an effective alternative. Although variations exist among types of MDIs, patients should be educated to generally perform the following steps: • Remove the cap and hold inhaler upright • Shake the inhaler • Breathe out slowly and completely • Place the inhaler 1–2 inches away from the mouth or in the mouth • Start to breathe in slowly and press the lever as indicated on the inhaler • Inhale slowly over a period of 3–5 seconds • Hold breath at full inhalation for 10 seconds • Exhale • Repeat if indicated after 1 minute • Rinse mouth with water if using an inhaled steroid

› During the past decade, self-administration and safe handling and disposal of oral chemotherapy agents by patients with cancer have been areas of concern, yet not all clinics, hospitals, and healthcare agencies have implemented standard protocols for teaching patients and family members about these medications • To help patients more effectively manage self-administration of prescribed oral chemotherapy agents, refer to the Oncology

Nursing Society oral adherence toolkit at https://www.ons.org/practice-resources/toolkits/oral-adherence • Education alone is not enough to promote adherence to oral medication regimens for cancer. Adherence tools, technologies,

and reminder aids can be used to assist patients in adhering to an oral regimen › According to the American Association of Poison Control Centers (www.aapcc.org),the most common poisons are found

in medications (e.g., pain medicine, including OTC agents, prescribed pain relievers, and illicit drugs; sedatives, hypnotics, and antipsychotics; antidepressants; and cardiovascular drugs). Recent online alerts caution readers to beware of potentially dangerous health effects after using synthetic marijuana and liquid nicotine. Lack of patient concern about the appropriate use of medication (e.g., saving medication for future personal use to avoid having to see a healthcare clinician,giving prescribed medication to others, and taking more medication than prescribed in the hope that it will be curative) can result in adverse reactions, organ failure, and death

› Although certain educational interventions (e.g., providing reading materials, engaging the patient in self-care training) are used most commonly in clinical practice to teach patients about medications and self-administration, counseling and behavioral interventions have been found to be more effective in enhancing medication adherence

› Evidence of the effectiveness of specific medication adherence-enhancinginterventions is limited. Researchers warn that findings should be interpreted with caution • The strongest evidence-based support for improving medication adherence involves policy-level interventions that promote

reduced out-of-pocket expenses, case management, and educational interventions • Among patients with different clinical conditions, medication adherence is highly variable. In a comparative study of the

effectiveness of interventions, the greatest opportunities for medication adherence improvement were seen in patients with asthma, depression, or hypertension

› The most successful strategies for teaching patients about medication self-administration are individualized educational interventions • Patient education and teaching tools (e.g., handouts, books, videos) should be tailored to the patient’s specific needs and

priorities

• Visually oriented informational handouts (i.e., those with diagrams and limited wording) should be patient-friendly and easy to read

• All teaching should be patient-centered and evidence-based –Home care patients should be given detailed and accurate medication information; they should be instructed to avoid the

use of advertised medications and products unless they have been reviewed by healthcare professionals • Educational information should be delivered in a culturally sensitive manner and in a language and at a level that is easily

understood by the patient and family • Professional certified medical interpreters, either in person or via phone, should be used when there are language barriers • Simple, nonmedical language should be used for all patients and families, but especially when low literacy levels are

assessed › Preliminary steps that should be performed prior to teaching a patient about medication self-administration in the home care

setting include the following: • Become knowledgeable about the requirements of TJC related to patient education • Review facility/agency protocols specific to patient education, particularly about medication self-administration practices

in the home care setting • Become familiar with facility/agency practices for teaching a patient about medication self-administration • Identify acceptable patient teaching resources that are available onsite and via the Internet

› Verify availability of supplies prior to initiating the educational session (noting that supplies will vary based on patient assessment, below). Supplies can include • a teaching guideline or documentation form outlining key content areas • printed and audiovisual materials about medication self-administration procedures • medication administration equipment (e.g., medications in their original containers, a pill organizer, syringes, alcohol

wipes, MDIs) • information about Internet and community resources that are available to assist patients with self-administration of

medication and with proper storage and disposal of medications • information on how to contact members of the healthcare team with questions or concerns

How to Teach a Patient about Medication Self-Administration in the Home Care Setting › Perform hand hygiene › Don personal protective equipment (PPE), if indicated › Identify the patient per facility protocol › Establish privacy › Introduce self and explain planned education › Assess the patient for

• readiness to learn –Patients can be at different stages of readiness; it is important to individualize your approach based on each individual

learner’s readiness • preferred learning style

–Individuals are auditory, visual, or tactile learners, and learn by hearing (e.g., listening to other patients talk about the challenges of managing the side effects of medications), by seeing (e.g., observing the home care nurse draw up insulin), and by doing (e.g., filling a pill organizer)

–To quickly identify one’s preferred learning style, have the learner think back to the last time he or she learned something, and ask, “How did you go about it?”

• patient-identified learning priorities –When there is incongruence between the patient’s priorities and the healthcare provider’s goals, all will need to explore

why the incongruence exists (e.g., when the patient being treated with an antibiotic decides not to continue to take it because he/she is feeling much better)

• learning barriers –Barriers can include impaired memory or cognitive difficulties; learning disabilities; physical limitations; language; low

literacy; impaired hearing, sight, and/or speech; financial issues; and cultural, psychosocial, and/or emotional concerns

- Patients with a low literacy level can have difficulty calculating dosages and measuring liquids. In the home care setting, the nurse has an ideal opportunity to observe what a patient uses to measure a medication dose and how he/she determines how much to take

- Cultural beliefs and practices should be carefully examined because they can influence ideas about medication use • learning needs and desires

–Many home care patients are preoccupied with the complexity of their care and might need to be encouraged to learn more about medication self-administration

› Plan for timely delivery of relevant information • The plan for medication instruction should be comprehensive, but tailored to meet the patient’s specific learning needs; it

should be divided into information segments that are scheduled at intervals to avoid overwhelming the patient –There should be clear delineation in the healthcare team of who provides what information and at what time throughout

the course of patient care; for example, - an acute care nurse provides the hospitalized patient with written information about drugs, discusses the risks and

benefits of taking the drugs, helps him or her learn how to self-administer the drugs, and emphasizes the importance of timely and consistent use of the drugs

- at discharge to home, a pharmacist who fills prescriptions in the community reinforces the medication instructions, emphasizing the medication name, purpose, dose, route, frequency, and potential adverse effects

- during a follow-up appointment, the home health nurse reconciles the patient’s medications, assesses the patient’s use of the medications, listens to the patient’s concerns about the drugs, and educates about the need to alter patient behavior (e.g., eliminate alcohol consumption to avoid liver damage) and change habits of self-administration as appropriate

• High-quality teaching tools (e.g., clear, concise drug information sheet written at a 5th grade reading level; a DVD about the safe use of digoxin; a Website about the national Drug Take-Back program for safe medication disposal) should be identified in advance to support teaching and learning –The assessment of the patient’s learning characteristics, along with his/her clinical needs, should guide the selection of

appropriate teaching tools • When appropriate, patient education should be scheduled when family members or caregivers are available to support the

patient in learning › Implement the patient education plan

• Discuss and set mutually achievable goals for learning about medication self-administration with the patient –Anticipate a planned approach to teaching and learning, but be prepared to be flexible and individualize information based

on the patient’s changing needs and desires • Emphasize the name, dose, route, timing, purpose, and adverse effects of each medication, and educate about safety

concerns related to medication self-administration –Make the education situation as realistic as possible; if feasible, schedule home visits to coincide with the patient’s

medication self-administration times –Allow sufficient time for the patient to practice skills and talk about any concerns –If the patient is not able to safely administer his/her medication regimen, arrange for family members or other caregivers

to support the patient as needed • Promote collaborative partnerships between the patient and members of the healthcare team to achieve the highest levels of

medication adherence –Use open-ended requests that allow the patient to explain or demonstrate and that enable the healthcare provider to verify

the patient’s understanding (e.g., “Tell me [or show me] how you take your medication”) –Ask specific questions about the patient’s medication regimen (e.g., “What time do you take the medicine?”, “How many

pills do you take?”, “What is the name of this green pill?”) –Observe facial expressions and other cues that indicate that the patient does not understand the prescribed medication

regimen • Use a variety of teaching and learning strategies for best results

–Direct communications (e.g., face-to-face conversation, telephone calls) are fundamental in helping patients learn about medication self-administration

–Written materials (e.g., a booklet, fact sheets) have received mixed reviews - The effectiveness of print materials varies based on comprehensibility, visual appeal, legibility, text style, size, and

layout –Some computer-mediated medication programs have been customized for older adults (e.g., with enlarged text size,

high color contrast between the text and the background, slower animations to allow for processing information, extra

wide scroll bars). These programs allow the nurse to enter patient-specific information (e.g., medication regimen, blood pressure readings) so that the information can be tailored to meet the patient’s specific learning needs; such programs can be effective in reducing medication errors and increasing adherence in older adults

–Internet resources are readily available to most patients, although healthcare professionals disagree as to the value of Internet information - One strategy to enhance Internet use by patients is to provide a list of relevant Websites that are thought to be accurate,

current, and understandable › Evaluate the patient’s response to education

• Continually assess learning throughout the continuum of care • Use a teach-back method to evaluate learner understanding

–Have the patient repeat medication information and/or demonstrate medication self-administration while allowing the educator to listen, observe, and clarify the information or skill demonstration, as needed

–Remember that specific information is better recalled than general information • Use a self-efficacy (i.e., the extent to which a person believes he or she can achieve a desired outcome) rating to evaluate a

learner’s confidence in understanding information or performing a skill (e.g., ask “On a scale of 1–10, how certain are you that you will be able to check your blood glucose level and draw up and give yourself the correct amount of insulin?”) –If the patient’s response is < 7, the plan will need to be readjusted (e.g., reteach until the patient’s response is ≥ 7, involve

family members or other caregivers more extensively in teaching and assisting with medication administration) › Update the patient’s plan of care, as appropriate; document the following in the patient’s medical record, and communicate

any concerns with the multidisciplinary healthcare team so that information can be reinforced, and the learning plan can be continued or modified accordingly: • All patient education provided about medication self-administration,including specific teaching and learning strategies

implemented • Assessment findings regarding readiness to learn, preferred learning style, learning needs and desires, and learning

priorities of the patient • Any identified barriers to learning and methods used to help overcome these barriers • Patient’s response to learning, including demonstrated level of understanding and/or ability to perform necessary skills • Plan for continuation of patient education, including whether specific information should be reinforced or taught again

using a different teaching method

What to Expect After Teaching a Patient about Medication Self-Administration in the Home Care Setting? › Patients who receive education about medication self-administration will

• understand the name, dose, route, timing, and purpose of each prescribed medicine • build confidence and skills necessary for successful medication self-administration • observe for potential medication side effects and adverse reactions, and seek medical assistance as needed • initiate and maintain appropriate lifestyle changes to decrease risk for complications • recognize the importance of communicating information about prescription and OTC medications to healthcare

professionals, and participate in shared decision making about medication self-administration • experience the delivery of consistent and ongoing educational information across the healthcare system • perceive that they have received education about medication self-administration in a culturally sensitive manner and in a

language and at a level that is understandable to them

Red Flags › Many cases of hospital and nursing home admissions, malpractice suits, treatment failures, and medical emergencies are the

result of inaccurate medication use by patients › Unless supported by the patient, use of family members, friends, and nonprofessional staff as interpreters is a violation of the

patient’s right to confidentiality › Scientific studies do not support the use of tall man letters when presenting drug names to patients (ISMP, 2016)

What Do I Need to Tell the Patient/Patient’s Family? › Educate patients and their family members about the need for accurate and timely medication self-administration and the

importance of adopting home routines that promote medication safety

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3. Institute for Safe Medication Practices (ISMP). (2016). FDA and ISMP lists of look-alike drug names with recommended tall man letters. Retrieved February 23, 2018, from www.ismp.org/Tools/tallmanletters.pdf (PP)

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5. The Joint Commission. (2018). Home care: 2016 National Patient Safety Goals. Retrieved February 23, 2018, from https://www.jointcommission.org/assets/1/6/ NPSG_Chapter_OME_Jan2018.pdf (PP)

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7. Pajarón, M., Fernández-Miera, M. F., Allende, I., Arnaiz, A. M., Gutiérrez-Cuadra, M., Cobo-Baustegui, M., ... Sanroma, P. (2015). Self-administered outpatient parenteral antimicrobial therapy (S-OPAT) for infective endocarditis: A safe and effective model. European Journal of Internal Medicine, 26(2), 131-136. doi:10.1016/j.ejim.2015.01.001 (R)

8. Pherson, E. C., Shermock, K. M., Efird, L. E., Gilmore, V. T., Nesbit, T., LeBlanc, Y., & Swarthout, M. D. (2014). Development and implementation of a postdischarge home-based medication management service. American Journal of Health-System Pharmacy, 71(18), 1576-1583. doi:10.2146/ajhp130764 (QI)

9. Schaffer, F. M., Naples, A. R., Ebeling, M., Hulsey, T. C., & Garner, L. M. (2015). The safety of self-administered allergen immunotherapy during the buildup and maintenance phases. International Forum of Allergy & Rhinology, 5(2), 149-156. doi:10.1002/alr.21443 (R)

10. Wilson, C., Rapp, K. I., Jack, L., Hayes, S., Post, R., & Malveaux, F. (2015). Asthma risk profiles of children participating in an asthma education and management program. American Journal of Health Education, 46(1), 13-23. doi:10.1080/19325037.2014.977412 (R)