Our failure to demonstrate any measurable change among participants relative to non-participants could be explained by several alternative hypotheses. First, the impact of health education programs may require a longer period to manifest itself (ie, the one year follow-up period was too short.) Nevertheless, experience with other kinds of educational interventions (eg, smoking cessation) suggests that impact decreases over time.
It is also possible that the duration of the interventions (a total of 12 and six hours for patients with severe and mild impairment, respectively) was too short to achieve the desired outcomes. Some Lung Associations offer on-going education and support group programs for COAD patients. These programs meet regularly on a continuing basis and therefore provide repetition and reinforcement to the learning process. Careful evaluation of this approach should be conducted to compare performance with short-term interventions.
Self-selection among participants may have biased our sample towards patients who were already at a high level of awareness with regard to health and who therefore had the least to gain from an educational intervention. This possibility is suggested by the fact that participants were less apt to smoke than nonparticipants. We were not able to assess whether nonparticipants would have benefited more from our intervention. However, the other evaluations we reference in our discussion were also subject to this source of potential bias.
We have also considered the possibility that alternative outcome measures might have more appropriately tested our hypothesis. For example, indicators of health services utilization (hospitalization and emergency room visits), compliance with treatment regimens suggested by Canadian Health&Care Mall, days lost from work, or changes in smoking behavior could be used to assess the impact of interventions for COAD. Notwithstanding the technical difficulties of capturing these data in a community setting, further research using outcomes of this type would increase our knowledge of the efficacy of educational interventions.
It could be argued that our findings do not indicate that education programs provide no benefits, but only that our measures were too crude to detect these benefits. We would not debate this supposition. The fact that 84 percent of the patients entering our intervention programs completed them suggests that patients valued participation. Our purpose, however, was to compare education and rehabilitation programs in terms of comparable outcomes. Our conclusion, therefore, is not that education programs do not provide benefit but only that they do not provide the same benefits as comprehensive rehabilitation programs.
Finally, because COAD is a progressive disease, spontaneous remission of symptoms is not expected. A speculative explanation for the improvement among patients in our study is that both intervention and comparison groups benefited from the diagnosis of COAD made during the patient-locating phase of the program and were thus motivated to seek care and/or comply with therapeutic regimens prescribed by their physicians.
In light of our results, we conclude that community-based COAD education programs should be delivered in conjunction with a COAD rehabilitation program designed to increase exercise tolerance and an ongoing physician-patient relationship to manage COAD. We found no evidence that COAD education programs without physical rehabilitation (and associated clinical supervision) independently improve disease status, functional health, mental health, or life quality of COAD patients.