Asthma Management Handbook

Managing asthma in Aboriginal and Torres Strait Islander people

Recommendations

Consider whether the person has any comorbid conditions that may affect asthma management or be affected by asthma medicines.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Consider using and providing asthma self-management resources that have been designed specifically for Aboriginal and Torres Strait Islander people, where appropriate.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Keep influenza and pneumococcal vaccination up to date, following immunisation guidelines for Aboriginal and Torres Strait Islander children and adults.

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • Australian Technical Advisory Group on Immunisation of the Australian Government Department of Health and Ageing, 20131

Provide a written asthma action plan that is culturally appropriate for each patient.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Where possible, involve Aboriginal health workers or Aboriginal and Torres Strait Islander health practitioners in Team Care Arrangements and Multidisciplinary Care Plans.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Culturally secure asthma care for Aboriginal and Torres Strait Islander people

Primary care services can aim to deliver healthcare that is culturally secure. However, only the Aboriginal or Torres Strait Islander person themselves can determine whether their care is culturally safe or respectful.2

Making the healthcare system a secure environment for Aboriginal and Torres Strait Islander peoples involves cultural respect, which involves not only respecting cultural difference but recognition, protection and continued advancement of the inherent rights, cultures and traditions of Aboriginal and Torres Strait Islander peoples.3

Cultural awareness (or ‘cultural sensitivity’) among individual health professionals involves sensitivity to the similarities and differences between different cultures to enable effective communication with members of another cultural group.4

Training in cultural awareness and  ‘cultural safety’ is available for non-Indigenous health professionals who provide healthcare for Aboriginal and Torres Strait Islander people.

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Involvement of Aboriginal and/or Torres Strait Islander health workers and health practitioners in asthma care

Aboriginal and Torres Strait Islander health workers and Aboriginal and Torres Strait Islander health practitioners can provide self-management education for people with asthma and parents of children with asthma. Culture-specific programs may be more appropriate than mainstream programs for Aboriginal and Torres Strait Islander people.5

An education program (three sessions) conducted by Aboriginal and Torres Strait Islander health workers in primary health care in  the Torres Strait region reduced the number of school days missed due to wheezing among school-aged children, and increased carers’ knowledge of asthma, the contents of the child’s written asthma action plan, and where the written asthma action plan was kept.6 However, it did not reduce the rate of asthma flare-ups, compared with children whose families did not participate.6

Aboriginal and Torres Strait Islander health workers and practitioners can provide health care services that are reimbursable through Medicare.78

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Risk factors for asthma in Aboriginal and Torres Strait Islander people

Compared with the whole Australian population, Aboriginal and Torres Strait Islander people have higher rates of some risk factors for developing asthma or for poor asthma control.

Smoking and smoke

Rates of tobacco smoking are high among Aboriginal and Torres Strait Islander people:9101112

  • Approximately 45% of Aboriginal and Torres Strait Islander people aged 15 years and over smoke daily (more than twice the rate among non-Indigenous Australians).
  • Approximately half of Aboriginal and Torres Strait Islander mothers smoked during pregnancy (3.7 times the rate among non-Indigenous mothers).
  • Approximately 65% of Aboriginal and Torres Strait Islander children live households with someone who smokes daily (approximately twice the rate among non-Indigenous children).

Many Aboriginal people are also frequently exposed to smoke from outdoor vegetation fires and cooking fires, particularly in remote regions.

Allergies

Limited available data suggest that sensitisation to house dust mite is increasing among rural and remote Aboriginal communities, correlating with adoption of urban lifestyles.13

Factors contributing to an increase in allergic disease may include dietary changes and reductions in parasitic infestation and exposure to some bacteria.13

Dietary factors

Low fruit and vegetables intakes are more common among Aboriginal and Torres Strait Islander people than non-Indigenous Australians.9

Increasing intake of pro-inflammatory fats and low intake of antioxidant-rich fruits and vegetables may be contributing to an increase in allergic asthma among Aboriginal and Torres Strait Islander people.13

Obesity

The rate of obesity among Aboriginal and Torres Strait Islander adults (approximately 34%) is almost twice the rate in non-Indigenous adults (approximately 18%).9

Among Aboriginal and Torres Strait Islander people aged 18 years and over living in non-remote areas, rates of overweight and obesity increased between 1995 (51%) and 2004–05 (60%).9

Socioeconomic risk factors

Traditional markers of socioeconomic status (e.g. education, income and employment status) are not strongly associated with asthma risk among Aboriginal and Torres Strait Islander peoples,14 unlike the associations between socioeconomic status and asthma risk in non-Indigenous Australians, and the risk of other chronic diseases such as diabetes and kidney disease in Aboriginal and Torres Strait Islander people.14

In the 2000–2002 Western Australian Aboriginal Child Health Survey, Aboriginal children aged 0–17 years living in areas with highest socioeconomic status were more than nine times more likely to have ever had asthma than those living in the lowest socioeconomic status areas.15 However, when socioeconomic status was measured by parental, family and household indicators rather than by area, it was less strongly association with asthma.15

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Asthma morbidity and mortality in Aboriginal and Torres Strait Islander people

Among Australians aged 5 years and over, the rate of hospitalisation due to asthma is higher for Aboriginal and Torres Strait Islander people than non-Indigenous people.16 Among Aboriginal and Torres Strait Islander people, asthma is the reason for approximately 11% of all hospitalisations.9

The rate of deaths due to asthma is approximately 2.5 times higher among Aboriginal and Torres Strait Islander people than non-Indigenous Australians.16

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Respiratory disease in Aboriginal and Torres Strait Islander peoples

Morbidity and mortality from respiratory diseases among Aboriginal and Torres Strait Islander people is higher than among non-Indigenous Australians across all age groups and regions.17 Among Aboriginal and Torres Strait Islander people living in remote areas, the rate of hospitalisation for respiratory disease is approximately three times the rate among Aboriginal and Torres Strait Islander people living in major cities.18 However, from 1997 to 2010 there was a 39% reduction in deaths due to respiratory disease among Aboriginal and Torres Strait Islander people.9

Detection, diagnosis and management of asthma may be complicated by increased rate of respiratory infections and chronic lung disease in rural remote Aboriginal and Torres Strait Islander communities.

  • Approximately 30% of Aboriginal and Torres Strait Islander people report respiratory problems.19
  • Chronic cough in Aboriginal and Torres Strait Islander children may be under-reported because it is so common that is considered normal by parents and caregivers.20
  • Pneumonia and COPD are the most common causes of hospitalisation for respiratory disease among Aboriginal and Torres Strait Islander people.18 The prevalence of COPD among Aboriginal and Torres Strait Islander people cannot be accurately estimated.21 The rate of death due to COPD among Aboriginal and Torres Strait Islander people is five times the rate among non-Indigenous Australians.22
  • The prevalence of bronchiectasis is disproportionately high in remote Aboriginal communities, particularly in Central Australia, but is underdiagnosed.1923 High-resolution computed tomography of the chest is necessary to diagnose bronchiectasis in adults.19 In Aboriginal and Torres Strait Islander adults, it may be difficult to distinguish between asthma, COPD and bronchiectasis.21 Bronchiectasis is associated with relatively rapid decline in lung function.19 
  • Chronic suppurative lung disease is highly prevalent among Aboriginal and Torres Strait Islander children in remote communities.19 The diagnosis of chronic suppurative lung disease is made in children who have symptoms and signs of bronchiectasis without radiographic features of bronchiectasis.19 In Aboriginal and Torres Strait Islander children, it may be difficult to distinguish between asthma and bronchiectasis or chronic suppurative lung disease.21 
  • Protracted bacterial bronchitis is often misdiagnosed as asthma,24, 25 but can also co-occur with asthma.25 Protracted bacterial bronchitis might precede chronic suppurative lung disease, but this is not yet well understood.25 Inadequate treatment of protracted bacterial bronchitis might put Aboriginal and Torres Strait Islander children at risk for chronic suppurative lung disease.25 Recurrent episodes of protracted bacterial bronchitis that does not resolve after treatment (e.g. a 14-day course of antibiotics) require investigation for chronic suppurative lung disease, bronchiectasis and aspiration.25

Notes

† Chronic suppurative lung disease is defined as a clinical syndrome of respiratory symptoms and signs due to chronic endobronchial suppuration, including continuous, wet or productive cough > 8 weeks, with or without other features (e.g. exertional dyspnoea, symptoms of reactive airway disease, recurrent chest infections, growth failure, clubbing, hyperinflation or chest wall deformity).26

‡ Bronchiectasis is diagnosed in patients with both chronic suppurative lung disease and the presence of radiological features on a chest high-resolution computed tomography scan.26

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Non-respiratory comorbidity among Aboriginal and Torres Strait Islander peoples

Aboriginal and Torres Strait Islander peoples have a high burden of chronic diseases that may affect asthma control and management, including:9

  • diabetes
  • cardiovascular disease
  • kidney disease
  • ear disease
  • mental health problems.
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Written asthma action plans for adults

Every person with asthma should have their own written asthma action plan.

When provided with appropriate self-management education, self-monitoring and medical review, individualised written action plans consistently improve asthma health outcomes if they include two to four action points, and provide instructions for use of both inhaled corticosteroid and oral corticosteroids for treatment of flare-ups.27 Written asthma action plans are effective if based on symptoms28 or personal best peak expiratory flow (not on percentage predicted).27

How to develop and review a written asthma action plan

A written asthma action plan should include all the following:

  • a list of the person’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on how to change medication (including when and how to start a course of oral corticosteroids) in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • when peak flow falls below an agreed rate (for those monitoring peak flow each day)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name of the person writing the action plan, and the date it was issued.

Table. Options for adjusting medicines in a written asthma action plan for adults Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/42

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

Asset ID: 43

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate).

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans2930 is available online.

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Asthma self-management resources for Aboriginal and Torres Strait Islander people

Templates for written asthma action plans have been specifically designed for Aboriginal and Torres Strait Islander people. These include:

  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Aboriginal Australians who do not use written English).

Short wind resources (booklets and flip chart) developed by Asthma Foundation Northern Territory explain:

  • how asthma medicines are used
  • how to take asthma medicine
  • how to use puffers and spacers.

An online library of health promotion resources designed for Aboriginal and Torres Strait Islander people is available through LungInfoNet. LungInfoNet is the respiratory health stream of the Australian Indigenous HealthInfoNet from Edith Cowan University.

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Australian government health initiatives for Aboriginal and Torres Strait Islander people

Asthma Spacer Ordering System

The Asthma Spacer Ordering System provides Aboriginal and Torres Strait Islander health services with access to low cost asthma spacers for their clients.

Health Assessment Medicare items

The MBS Health Assessment for Aboriginal and Torres Strait Islander People (MBS Item 715) reimburses health professionals for health assessments for (any of):8

  • Aboriginal and Torres Strait Islander children (<15 years)
  • Aboriginal and Torres Strait Islander adults (≥15 years and < 55 years)
  • Aboriginal and Torres Strait Islander older people (≥ 55 years).

This item is linked to follow-on item numbers to support follow-up care by allied health professionals and Aboriginal/Torres Strait health workers and practitioners to manage asthma and comorbid conditions.

The Indigenous Chronic Disease Package

The Indigenous Chronic Disease Package provides a range of supports to Aboriginal and Torres Strait Islander people with chronic disease or at risk of chronic disease. The package includes:31

  • subsidy of PBS medicines (reduced copayments for Aboriginal and Torres Strait Islander people with chronic disease)
  • orientation and training for Aboriginal and Torres Strait Islander Outreach Workers in Aboriginal community-controlled general practices
  • professional development scholarships and clinical placement scholarships for nurses working in Community Controlled Aboriginal/Torres Strait Island Health Services
  • general practitioner registrar training posts for Aboriginal Medical Services
  • Practice Incentives Program Indigenous Health Incentive to support general practices and Indigenous health services to provide care for people with chronic disease
  • increased access to specialist medical and allied health care
  • GPs can access these services to overcome barriers to health care for Aboriginal and Torres Strait Islander people. 

National immunisation program

Additional vaccinations are recommended and reimbursed for Aboriginal and Torres Strait Islander people.  Refer to national guidelines.

Other resources

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Health system initiatives that support asthma care

Chronic Disease Management Medicare items

Patients with asthma are eligible for Chronic Disease Management Medicare items.7 These include:

  • Preparation of a GP Management Plan (Item 721)
  • Review of a GP Management Plan (Item 732)
  • Coordination of Team Care Arrangements (Item 723) for patients who need ongoing care from a multidisciplinary team of at least three health or care providers
  • Coordination of a Review of Team Care Arrangements (Item 732)
  • Contribution to a multidisciplinary care plan being prepared by another health or care provider (Item 729)
  • Contribution to a multidisciplinary care plan being prepared for a resident of an aged care facility (Item 731).

GPs can be assisted by practice nurses, Aboriginal and Torres Strait Islander health practitioners, Aboriginal health workers and other health professionals.7

Asthma cycle of care

The Asthma cycle of care is an Australian Government initiative to support primary care health professionals (GPs, other medical practitioners and trainees) to provide asthma care. It is implemented through the Practice Incentives Program (PIP) Asthma Incentive and applies to the clinical care of people with moderate-to-severe asthma, generally defined as people with (any of):32

  • symptoms on most days
  • use of preventative medication
  • bronchodilator use at least three times per week
  • hospital attendance or admission following an acute asthma flare-up.

The Asthma cycle of care involves at least two asthma-related consultations within 12 months for a patient with moderate-to-severe asthma, of which at least one visit is a planned asthma review. Each consultation includes:

  • documenting the diagnosis, assessing asthma severity and assessing level of recent asthma symptom control
  • reviewing the patient’s use of and access to asthma medicines and inhaler devices
  • providing a written asthma action plan (or documented alternative, if the patient is unable to use a written action plan)
  • providing asthma self-management education
  • reviewing the written or documented asthma action plan.

The Personally Controlled eHealth Record System

The eHealth record is an electronic record for a patient that contains a summary of their health information. Patients can choose to register for an eHealth record. Authorised healthcare professionals can access a patient’s record and upload information to the record if their healthcare organisation has registered for the eHealth record system.

Health system initiatives for Aboriginal and Torres Strait Islander people

Health system initiatives to support the care of Aboriginal and Torres Strait Islander people include:

  • Health Assessment Medicare items
  • The Indigenous Chronic Disease Package
  • The Asthma Spacer Ordering System.
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References

  1. Australian Technical Advisory Group on Immunisation (ATAGI), Department of Health and Ageing. The Australian Immunisation Handbook. 10th Edition. Department of Health and Ageing, Canberra, 2013. Available from: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
  2. National Aboriginal Community Controlled Health Organisation. Creating the NACCHO Cultural Safety Training Standards and Assessment process. A background paper. National Aboriginal Community Controlled Health Organisation, Canberra, 2011. Available from: http://www.naccho.org.au/promote-health/cultural-safety/
  3. Australian Health Ministers' Advisory Council Standing Committee for Aboriginal and Torres Strait Islander Health Working Party. Cultural respect framework for Aboriginal and Torres Strait Islander health, 2004 -2009. Department of Health South Australia, Adelaide, 2004. Available from: http://www.sapo.org.au/pub/pub2142.html
  4. Thomson N. Cultural respect and related concepts: a brief summary of the literature. Australian Indigenous Health Bulletin. 2005; 5: 1-11. Available from: http://archive.healthinfonet.ecu.edu.au/html/htmlbulletin/bull54/reviews/bulletinreviewsthomson.htm
  5. Bailey EJ, Cates CJ, Kruske SG, et al. Culture-specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev. 2009; Issue 2: CD006580. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006580.pub4/full
  6. Valery PC, Masters IB, Taylor B, et al. An education intervention for childhood asthma by Aboriginal and Torres Strait Islander health workers: a randomised controlled trial. Med J Aust. 2010; 192: 574-9. Available from: https://www.mja.com.au/journal/2010/192/10/education-intervention-childhood-asthma-aboriginal-and-torres-strait-islander
  7. Australian Government Department of Health. Chronic Disease Management (CDM) Medicare Items. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement
  8. Australian Government Department of Health and Ageing. Medicare Health Assessment for Aboriginal and Torres Strait Islander People. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycareATSIMBSitem715
  9. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework 2012: detail analysis. Australian Institute of Health and Welfare, Canberra, 2013. Available from: http://www.aihw.gov.au/publication-detail/?id=60129543821&tab=2
  10. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Social Survey, 2008. Cat. no. 4714.0. Australian Bureau of Statistics, Canberra, 2009. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4714.0/
  11. Australian Bureau of Statistics. National Aboriginal and Torres Strait Islander Health Survey 2004-05. Cat. no. 4715.0. Australian Bureau of Statistics, Canberra, 2006. Available from: http://www.abs.gov.au/ausstats/abs@.nsf/mf/4715.0
  12. Australian Bureau of Statistics (ABS), Australian Institute of Health and Welfare (AIHW). The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples 2008. ABS and AIHW, Canberra, 2008. Available from: http://www.aihw.gov.au/publication-detail/?id=6442468085
  13. Walton SF, Weir C. The interplay between diet and emerging allergy: what can we learn from Indigenous Australians?. Int Rev Immunol. 2012; 31: 184-201. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22587020
  14. Cunningham J. Socioeconomic status and self-reported asthma in Indigenous and non-Indigenous Australian adults aged 18-64 years: analysis of national survey data. Int J Equity Health. 2010; 9: 1 - 11. Available from: http://www.equityhealthj.com/content/9/1/18
  15. Shepherd CC, Li J, Zubrick SR. Socioeconomic disparities in physical health among Aboriginal and Torres Strait Islander children in Western Australia. Ethn Health. 2012; 17: 439-61. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22292856
  16. Australian Centre for Asthma Monitoring. Asthma in Australia 2011: with a focus chapter on chronic obstructive pulmonary disease. Asthma series no. 4. Cat. no ACM 22. Australian Institute of Health and Welfare, Canberra, 2011. Available from: http://www.aihw.gov.au/publication-detail/?id=10737420159
  17. O'Grady KA, Revell A, Maguire GP, et al. Lung health care for Aboriginal and Torres Strait Islander Queenslanders: breathing easy is not so easy. Aust Health Rev. 2011; 35: 512-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22126958
  18. MacRae A, Thomson N, Anomie, et al. Overview of Australian Indigenous health status. Perth, 2012. Available from: http://www.healthinfonet.ecu.edu.au/health-facts/overviews
  19. Chang AB, Grimwood K, Maguire G, et al. Management of bronchiectasis and chronic suppurative lung disease in indigenous children and adults from rural and remote Australian communities. Med J Aust. 2008; 189: 386-93. Available from: https://www.mja.com.au/journal/2008/189/7/management-bronchiectasis-and-chronic-suppurative-lung-disease-indigenous
  20. Morey MJ, Cheng AC, McCallum GB, Chang AB. Accuracy of cough reporting by carers of Indigenous children. J Paediatr Child Health. 2013; 49: E199-203. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23438209
  21. O’Grady KF, Revell A, Maguire G, et al. Lung Health Services for Aboriginal and Torres Strait Islander Peoples in Queensland. Queensland Health, Brisbane, 2010. Available from: http://www.lungfoundation.com.au/professional-resources/publications/
  22. Abramson MJ, Crockett AJ, Dabscheck E, et al. The COPD-X Plan: Australian and New Zealand guidelines for the management of chronic obstructive pulmonary disease. Version 2.34. The Australian Lung Foundation and The Thoracic Society of Australia and New Zealand, 2012. Available from: http://www.copdx.org.au/
  23. Chang AB, Masel JP, Boyce NC, et al. Non-CF bronchiectasis: clinical and HRCT evaluation. Pediatr Pulmonol. 2003; 35: 477-83. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12746947
  24. Craven V, Everard ML. Protracted bacterial bronchitis: reinventing an old disease. Arch Dis Child. 2013; 98: 72-76. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23175647
  25. Chang AB, Redding GJ, Everard ML. Chronic wet cough: Protracted bronchitis, chronic suppurative lung disease and bronchiectasis. Pediatr Pulmonol. 2008; 43: 519-31. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18435475
  26. Chang AB, Bell SC, Byrnes CA, et al. Chronic suppurative lung disease and bronchiectasis in children and adults in Australia and New Zealand. Med J Aust. 2010; 193: 356-65. Available from: https://www.mja.com.au/journal/2010/193/6/chronic-suppurative-lung-disease-and-bronchiectasis-children-and-adults-australia
  27. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax. 2004; 59: 94-99. Available from: http://thorax.bmj.com/content/59/2/94.full
  28. Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2002; Issue 3: CD004107. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004107/full
  29. Roberts NJ, Mohamed Z, Wong PS, et al. The development and comprehensibility of a pictorial asthma action plan. Patient Educ Couns. 2009; 74: 12-18. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18789626
  30. Roberts NJ, Evans G, Blenkhorn P, Partridge M. Development of an electronic pictorial asthma action plan and its use in primary care. Patient Educ Couns. 2010; 80: 141-146. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19879092
  31. Australian Government Department of Health. Closing the Gap: Tackling Indigenous Chronic Disease Package. Australian Government, Canberra, 2012. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/work-ab-gap
  32. Australian Government Medicare Australia. Practice Incentives Program Asthma Incentives Guidelines – August 2011. Medicare Australia, Canberra, 2011. Available from: http://www.medicareaustralia.gov.au/provider/incentives/pip/forms-guides.jsp#N10068