PEDIATRICS Vol. 105 No. 3 March 2000, pp. 469-477

VIDEO RESEARCH:
Asthma in Life Context: Video Intervention/Prevention Assessment (VIA)

Michael Rich, MD, MPH^*, Steven Lamola, MS^*, Colum Amory, MPH^*, and Lynda Schneider, MD

From the ^* Divisions of Adolescent/Young Adult Medicine and  Immunology, Children's Hospital/Harvard Medical School, Boston, Massachusetts.

	ABSTRACT

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Objective.  Video Intervention/Prevention Assessment (VIA) was developed to determine whether medical information gathering might be augmented by video diaries created by patients to show clinicians the realities of managing chronic disease in the contexts of their lives.

Design.  Children and adolescents who met National Heart, Lung, and Blood Institute criteria for moderate or severe asthma were enrolled from an urban pediatric hospital and an inner-city health center. Comprehensive, asthma-specific medical histories were obtained from study participants in standard clinical interviews. Participants were trained to use video camcorders and recorded visual narratives of how they lived with and managed their asthma over a 4- to 8-week period. These visual narratives were screened by a trained observer, who completed the initial comprehensive medical history based solely on viewing the video. Information from participants' medical history interviews was compared with observations of their visual narratives.

Results.  Twenty young people 8 to 25 years old completed the VIA Asthma study. Important variations were found between participants' medical history interviews and their visual narratives. All 20 participants reported specific environmental triggers for their asthma; 19 had 1 or more of these triggers documented on video in their daily living environments (video illustrations online, available at: www.pediatrics.org). Exposures to known triggers ranged from 25% (noxious fumes) to 91% (mold). Exposure to tobacco smoke that was denied in the interview was revealed on video in 63%. The 18 participants who revealed medication use in their visual narratives were assessed for adherence: 33% exceeded prescribed doses, 28% discontinued medications without consulting a clinician, and 72% used ineffective inhaler technique.

Conclusions.  VIA visual narratives extended a comprehensive, standard of care medical history, yielding a more complete and accurate understanding of exacerbating environmental exposures and inappropriate medication usage of children and adolescents with asthma. VIA is an effective tool for revealing the physical and psychosocial environments in which young people live with disease. Patient-created video can enrich our understanding of the illness experiences of children and adolescents. VIA has the potential to enhance clinical data gathering, guide the development of more effective and sensitive management strategies, and educate clinicians about the realities of the young person living with illness.  Key words:  asthma, adherence, environment, medical history, video, qualitative research.

Successful management of a chronic disease in children and adolescents depends on accurate, comprehensive information about patients and their lives. Patients' lifestyles, their disease-related knowledge and behaviors, environmental exposures, and self-management practices all contribute to their health-related quality of life and medical outcomes. The problem-oriented medical history interview is time-efficient but may miss information that is critical to the long-term management of disease. Patients' misunderstanding of questions, selective recall, and desire to please the clinician can all contribute to incomplete or inaccurate medical histories.

The medical history has been regarded by physicians as having higher diagnostic value than the physical examination or laboratory analysis.¹ Effective clinician-patient communication correlates positively with improved patient outcomes² and poor verbal communication has been associated with patient dissatisfaction and medical nonadherence.³ One study found that, in attempting to focus the clinical problem, clinicians directed medical histories away from potentially relevant information in 69% of their patient interviews.⁴ Another showed significant variation in the medical history interviews of asthma patients, depending on the specialty of the clinician.⁵ Patients may not reveal complete or accurate information, which may be attributable to lack of knowledge about the disease⁶ or the necessity of repeating their medical history several times in a visit, often to clerical or other nonclinical personnel.⁷ They may deliberately suppress pertinent information because of denial, fear, repression, or active concealment.^8,9 The result has been that information from the medical history has shown fair to poor reliability compared with documented treatment history¹⁰ and medication use.¹¹ In 1 controlled study, medical history interviews yielded an average of ~50% (range: 9%-85%) of the information considered important to patient management by clinician consensus.¹² Suboptimal outcomes in chronic disease may often be attributable to incomplete or inaccurate clinical assessments guiding management choices.

Detailed knowledge about the nature of disease in an individual patient is particularly important to long-term care of chronic conditions. Asthma, the most common chronic disease of childhood and adolescence, affects 4.8 million Americans under 18 years old.¹³ The prevalence of asthma in the United States increased by 75% from 1980 to 1994,¹⁴ to as high as 14.3% among children and adolescents in the inner-city.¹⁵ Normal independence-seeking behaviors may place adolescents at increased risk for inadequate asthma control.^16-18 Adverse outcomes from asthma have been found to be highest in teens,¹⁹ with near-fatal asthma exacerbations most prevalent in 12- to 15- year-old children.²⁰ Paradoxically, asthma morbidity and mortality have increased as the disease has become better understood and medically managed. Asthma care has evolved rapidly since 1992 when the National Heart, Lung, and Blood Institute (NHLBI) issued consensus guidelines²¹ that recommend patient-clinician management partnerships to recognize and avoid asthma-exacerbating factors and to control airway inflammation and symptoms with medications.

Airborne allergens are symptom triggers for over 80% of children with asthma.²² Contemporary American lifestyles may increase the incidence of allergic symptoms²³ through increased exposure to indoor allergens, such as dust-mites, cockroaches, dog and cat dander, and molds.²⁴ Sensitization to allergens and severity of asthma symptoms are associated with the level of allergen exposure²⁵ and avoidance of allergens has been found to reduce airway inflammation.²⁶ Exposures to environmental tobacco smoke²⁷ and irritating fumes²⁸ increase the frequency and severity of asthma exacerbations. Standard of care asthma management includes identifying environmental exposures and educating patients about their risks so they can modify their environments accordingly.²⁹

In addition to environmental controls, aggressive prevention with medications, particularly inhaled antiinflammatory agents, is a key component of long-term management.³⁰ Inadequate adherence to medications has long been suspected as a major factor in poor asthma control.^31-33 One research study showed that neither patient report nor clinician assessment was predictive of long-term adherence,³⁴ and another found that asthma patients lied about their medication use in their medical histories.³⁵ Poor adherence may reflect an inability to obtain needed medications³⁶ or to adequately deliver medications because of poor inhaler technique.³⁷ It may result from lack of knowledge about appropriate medication use, inability to recall medical plans,³⁸ or not believing that medical treatment will improve symptoms or lead to better outcomes.³⁹ Interventions on risk factors and adherence to medical plans are the cornerstone of asthma control. As a result, clinician awareness of patients' real-life environmental exposures and self-care issues is critical to long-term co-management. Video Intervention/Prevention Assessment (VIA)^40-42 was developed to augment and validate the medical history interview by asking young patients to make visual illness narratives, video diaries of how they live with and manage disease in the contexts of their lives.

	METHODS

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Young people diagnosed with moderate or severe asthma by NHLBI severity classifications²¹ were recruited from primary care and allergy programs at an urban tertiary care pediatric hospital (Children's Hospital, Boston, MA) and an inner-city health center (Martha Eliot Health Center, Jamaica Plain, MA). Informed consent was obtained from each participant and from a parent if the participant was under 18 years old. Because the VIA study data were video of the participants' lives, the informed consent for this study had several unique features. It contained a paragraph extending the clinician/researcher's role as a mandated reporter of child neglect or abuse to what was revealed in the study videos. The informed consent obtained on enrollment gave only the research and clinical teams permission to view and analyze the study videos. On completion of data collection, participants were provided copies of their visual narratives. After being allowed to view and edit out any unwanted material, participants were asked for a written release of their image and voice recordings for dissemination in any medium, allowing their visual data to be used for multimedia publication, research presentations, and educational purposes. This study protocol was approved by the Children's Hospital Committee on Clinical Investigation.

A standardized 84-question medical history interview, based on assessment guidelines established by the NHLBI,²¹ was designed by a pediatrician specialized in adolescent medicine (M.R.) and an allergist (L.S.) to elicit the maximum possible asthma-specific clinical information. The interview included the question, "Do you know what sets off your asthma?" and asked specifically whether allergic responses precipitated asthma. The question continued by listing 21 specific asthma triggers including colds, dust, mold, furry pets, cosmetics, noxious fumes, and secondhand smoke. It asked whether the participant had specific environmental exposures to dust ("Is your home dusty?"), mold-producing conditions, secondhand smoke, furry pets, mice, and cockroaches. The interview asked participants to list their asthma medications, dosages, schedules, and whether they believed that they knew what they needed to know to take care of their asthma.

After completing the medical history, we trained participants to use a video camcorder with indirect teaching techniques modified from those developed by visual anthropologists to generate participant-created visual data.^43,44 Participants were taught only the mechanics of operating the camcorder: turning it on and off, changing tapes and batteries, and aiming the camcorder so that it would capture what they wanted to document. We helped participants become competent at shooting video, while not influencing their visual style, so that they could accurately document their own perspectives of their lives and worlds.

Participants were asked to "teach their clinicians about asthma" by using video to reveal their experiences living with and managing asthma for a period of 4 to 8 weeks. They were given a list of video assignments, specific life situations that they were to document at least once during their visual narrative period. These included tours of their home and neighborhood environments, activities of daily living, such as meals, school, and play, interactions with health care providers, and management of their asthma. VIA participants interviewed family members, friends, and teachers about those persons' perceptions of and experience with the participant's asthma. Participants were asked to set up the camcorder each evening and speak to it directly in a personal monologue about the events of the day and their observations, thoughts, and feelings. The research coordinator (S.L.) met with participants weekly to replace microphone batteries, exchange blank for recorded videotapes, and discuss any problems or issues that may have arisen in the visual narrative process.

The completed visual narratives were copied to VHS tape with running visual readouts designating the participant number, tape number, and time code in hours:minutes:seconds:frames, so that researchers could locate and note the tape locations of specific observations. The visual narratives were viewed in their entirety and their video and audio content were logged in detail on a standardized observation framework. Using the master logs as a guide, a trained observer (C.A.) viewed all scenes in which participants' physical environments and medication use were either shown or discussed. Solely from viewing the visual narratives, the observer completed the same medical history with which participants were interviewed. Frequencies of the environmental risk factors identified by participants in their medical history interviews and observed in their visual narratives were determined. Medication use observed or heard about in the visual narratives was evaluated for number of puffs per administration and frequency of use (referenced on the running time codes). Inhaler technique was evaluated using a previously established objective observation scale⁴⁵ that assessed 5 features: shaking metered dose inhaler, emptying lungs, coordination of activation with inspiration, deep inspiration, and breath-holding. Frequencies of inappropriate or ineffective medication use were calculated using SPSS 9.0 statistical software (Chicago, IL).⁴⁶

	RESULTS

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Twenty-three children and adolescents were enrolled in the VIA Asthma study, but 3 did not complete their visual narratives because of time constraints. The 20 young people who completed the VIA Asthma study were between 8 and 25 years old, with a median age of 15 years. Ten of the participants were male and 10 were female. Ten participants were black, 7 white, and 3 of mixed race. Six were of Latino ethnicity. By NHLBI staging, 11 of the participants had moderate and 9 had severe persistent asthma. The participants' visual narratives ranged in length from 4 to 78 hours, with a median length of 22 hours.

All 20 of the VIA participants recorded tours of their homes as part of their visual narratives. Sixteen (80%) documented complete environmental surveys of each room of their home, while 4 (20%) recorded partial surveys of their bedrooms and common rooms in the home. In their medical history interviews, only 15 participants responded yes to the question of whether allergic responses set off their asthma. However, in responding to the detailed list of possible asthma triggers, all 20 reported that specific allergens triggered their asthma. The participants' visual narratives revealed substantial environmental risks not reported in their medical history interviews (Table 1). Despite knowledge of specific factors that exacerbated their asthma, 1 or more of these known triggers were observed by visual narrative in the living environments of 19 participants (95%). Although no triggers were observed in the remaining participant's home environment, 2 (dust and tobacco smoke) were observed in the homes of friends and family where she regularly spent time. Fifteen (75%) were observed to have dust exposures, ranging from a dust-covered television in a cluttered bedroom (Fig 1) to a construction site extending to the front door of the home (Fig 2). Ten of 11 (91%) mold-allergic participants had mold producers, such as large household plants or visible dampness, in their environments (Fig 3). Six of 14 (43%) lived with animals to which they were sensitive. In her medical history interview, 1 participant acknowledged that her mother had a number of pet cats, but asserted that the cats were never allowed in her room. In her visual narrative, she showed a kitten sleeping in her bed (Fig 4).

View larger version (142K): [in this window] [in a new window]   Fig. 1.   Patient's cluttered bedroom with dust-covered television.

View larger version (140K): [in this window] [in a new window]   Fig. 2.   Dusty construction site outside patient's apartment building.

View larger version (134K): [in this window] [in a new window]   Fig. 3.   Damp, plant-filled entrance to patient's home.

View larger version (150K): [in this window] [in a new window]   Fig. 4.   Cat-allergic patient with kitten hidden in her bed.

Among participants for whom inhaled irritants exacerbated asthma, 7 of 15 (47%) cosmetics-sensitive participants revealed exposures (Fig 5). Three of 12 (25%) were exposed to noxious fumes, including 1 who used bleach, which she knew to be an asthma trigger (Fig 6). Nineteen participants identified secondhand smoke as a trigger and asserted in their medical history interview that they had eliminated tobacco smoke from their environments. Nevertheless, 12 (63%) of their visual narratives revealed others smoking around them. One young woman did not smoke, nor did anyone in her home, but she was repeatedly exposed to passive smoke at parties (Fig 7). One participant's mother, who repeatedly stated that she never smoked in the house, was observed switching the camcorder off with a lit cigarette in her hand (Fig 8).

View larger version (130K): [in this window] [in a new window]   Fig. 5.   Patient uses hairspray, precipitating reactive cough.

View larger version (152K): [in this window] [in a new window]   Fig. 6.   Patient needs treatment after using bleach, a known asthma trigger.

View larger version (154K): [in this window] [in a new window]   Fig. 7.   Nonsmoking patient is exposed to passive smoke at parties.

View larger version (136K): [in this window] [in a new window]   Fig. 8.   Holding a lit cigarette, patient's mother switches off camcorder.

All the VIA Asthma study participants had repeatedly received comprehensive asthma education from a nurse specialist or physician, including training and practice in the appropriate use of their asthma medications. All stated in their medical history interviews that they felt knowledgeable and confident in medication use as part of their disease self-management. However, of the 18 participants for whom medication use was observed or heard about in the visual narrative, 1 or more inappropriate uses of asthma medications were observed in 16 (89%; Table 2). Six (33%) were observed exceeding prescribed dosages of their quick relief medications. In 1 visual narrative (Fig 9), the time code revealed that the participant used albuterol twice in 8 minutes. Five (28%) were seen or verbally admitted to discontinuing 1 or more asthma medications without obtaining medical advice. One participant said to the camcorder, "I ran out of my puffer, don't tell my doctor!" Due to unpleasant side effects, 1 participant unilaterally discontinued her systemic steroids after an exacerbation and her condition deteriorated, necessitating a return to the intensive care unit (Fig 10). Thirteen (72%) used ineffective technique with their metered dose inhalers (Fig 11). One participant, who has had severe, life-threatening asthma all her life, instructed her newly diagnosed father to fill his lungs with air before inhaling from his metered dose inhaler (Fig 12). Eight (44%) of the participants demonstrated more than 1 type of inappropriate medication adherence.

View larger version (138K): [in this window] [in a new window]   Fig. 9.   Patient exceeds recommended dosage, using albuterol twice in 8 minutes. (Note minutes in time code, top row, second from left.)

View larger version (150K): [in this window] [in a new window]   Fig. 10.   Patient describes unpleasant side effects before self-discontinuation of steroids.

View larger version (123K): [in this window] [in a new window]   Fig. 11.   Patient demonstrates ineffective inhaler techniques.

View larger version (147K): [in this window] [in a new window]   Fig. 12.   Patient teaches her father, newly diagnosed with asthma, to fill his lungs before inhaling asthma medication.

	DISCUSSION

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VIA visual narratives augmented the medical history by extending the clinician's observation to the patient's day-to-day life with asthma, revealing exposures to environmental risk factors and medication adherence issues greater than those shown by previous investigative techniques. These findings have implications both for asthma management strategies and for clinical information gathering.

The medical history is subject to the effects of understanding and recall. No previous studies have compared the environmental review reported in the medical history to a patient-generated environmental survey. Clinicians often suspect that an asthma patient has more environmental risk factors than have been related in the medical history interview, an assumption supported by the VIA findings. A previous study, which used telephone interviews of parents while they were in the environment being evaluated, found that children with symptomatic asthma were exposed to dust (34%), pets (21%), and environmental tobacco smoke (56%).⁴⁷ Previous questionnaire-based studies of children with asthma have found exposures as high as 59% to mold⁴⁸ and 40% to environmental tobacco smoke.⁴⁹ Other research suggests that there are still-unidentified environmental risks for many children, particularly those who live in poverty,⁵⁰ which a descriptive research method such as VIA can help characterize.

Given the level of asthma education to which the VIA participants had been exposed, it is of interest that only 15 understood that their asthma was exacerbated by allergic responses, even though all 20 identified specific allergens as asthma triggers. Despite substantial asthma education, 25% of the participants did not connect their allergic process with their asthma. It is particularly concerning that in their medical histories, clinicians' major source of information, 19 of the 20 participants did not reveal known asthma triggers to which they were regularly exposed. Although patients may modify medical histories to please their clinicians, this is unlikely to explain such a large discrepancy. It is more likely that patients do not make a direct connection between features of the environments in which they have always lived and the asthma from which they have always suffered. Because asthma exacerbations are intermittent and often multifactorial, young people may not believe that specific factors have direct effects on their conditions. Coupled with the sense that there is little that they can do to change their environments, that they must accept the realities of deteriorating housing, unsanitary neighborhoods, and adult behaviors, young patients may not report these exposures in the detail necessary for appropriate management decision-making. Patients who have been asked similar medical history questions many times may become habituated to the interview, answering out of expediency rather than considering the question. They may have limited recall or report of environmental features beyond their bedroom or immediate living area. Self-esteem, wanting to fit in with peers, and not wishing to be restricted by their asthma may lead some, such as the young woman who used bleach, to consciously place themselves at risk for asthma exacerbations rather than limit their lifestyles. The participant reported this exposure on video at the time of the resulting asthma exacerbation. By the time of her next medical interview, this exposure might have been forgotten. Because the patient controlled the flow of clinically relevant information, she may have felt safe relating an exposure that might have been suppressed in the more judgmental setting of the clinical interview. Augmenting the medical history interview with the patient-controlled camcorder, VIA was able to show, without interpretation or explanation, what the patient's mind and memory may have filtered out.

The VIA method may be clinically useful as an environmental screening tool. Although resource-intensive as a broadly applied research method, VIA can be cost-effective as a focused survey that yields a more accurate and complete picture of the patient's environment than the patient's memory. The gold standard, direct inspection of the living environment by a visiting nurse or environmental specialist,⁵¹ may require 2 or more home visits and is often limited by the family to areas of the home that may have been cleaned especially for the visit. Although nurse visits can be implemented as posthospitalization follow-up when the patient is acutely ill, the nurse is focused on patient care and the thoroughness of the environmental survey may suffer. Environmental inspection by a trained specialist is more focused and complete, but this may cost 500 dollars or more and is not covered by medical insurance, rendering it prohibitive to all but a few patients. In contrast, videotape costs only a few dollars and a camcorder that can be reused many times may be obtained for ~300 dollars. A patient-generated video survey of his or her living environments takes less than an hour. Because there is no visitor entering the home, they may be more likely to show all of the house in its natural state. This video survey can be screened by the patient with a health educator or nurse at their next asthma maintenance visit, allowing the patient to discover and discuss with an expert the risks to which they are regularly exposed but may be oblivious. In this way, patient-controlled video surveys can serve not only to guide environmental modifications but may be implemented as potent asthma education. This application of a modified VIA technique as a therapeutic intervention requires additional study.

Medications are often the mainstay of asthma management, but patients' attitudes toward their medications can be ambivalent and their usage variable.⁵² Clinicians assume that if patients understand the rationale behind the management plan, they will use medications appropriately. VIA observed that 89% of the study participants had 1 or more clinically significant adherence problems in the setting of everyday self-care. Previous studies evaluating adherence to asthma medications used a variety of investigative methods. Evaluated by prescription records, primary nonadherence to asthma medications has been reported at 30% in the general population.⁵³ This method of comparing prescriptions written to those filled does not assess actual use of the medications obtained. Patient self-report of inhaler use is highly variable,⁵⁴ limited by the patient's memory and modified by their desire to satisfy the clinician. Attempting to quantify inhaler use with electronic timer/counters and by weighing inhaler canisters, researchers have found underuse in 55% and overuse in 2%,⁵⁵ but results from this method have been confounded by excess inhaler actuation just before seeing clinicians.⁵⁶ Assessment of inhaler use by direct observation found poor technique in 38% of patients⁴⁵ and postinhaler pulmonary function tests revealed inadequate technique in 54%.³⁷ VIA permitted physicians to witness patients using medications in their day-to-day lives. Although patients were aware of the camcorder, they were not being judged in a clinical setting and may have demonstrated inhaler technique and management practices closer to their usual routine, rather than giving their best performances. Because patients controlled the observation process, the research dynamic changed from "What are you (the patient) doing wrong?" to "This is what I (the patient) am having difficulty with." They openly shared their dislike of medication side effects with the camcorder, revealing misuse or discontinuation of their medications. As a clinical intervention, VIA may allow patients who are struggling with medication adherence to reveal the obstacles that make appropriate self-care difficult or impossible, permitting the clinician to problem-solve in partnership with the patient.

Limitations of the VIA method include the cost of video camcorders and the time required for researchers to train participants with camcorders and view the visual narratives. As a research method, it is revealing but resource-intensive. There were initial concerns that camcorders would be stolen or damaged, but all camcorders were returned after participants' visual narratives were completed and damage was limited to easily repaired wear and tear. The small numbers of participants that can be studied in depth with the VIA method may make statistical significance difficult to achieve. However, VIA findings can be generalized to the larger population with asthma because we investigated the experiences of exemplar patients.⁵⁷ Epidemiology has characterized the population of American children and adolescents who suffer from asthma.^14,58 By enrolling young people who represent the health-related characteristics and the diversity of gender, race, ethnicity, culture, and socioeconomic status of the broader population affected by asthma, VIA revealed the types of needs and issues that exist for asthma patients, generating new questions for study. Finally, the fact that the patient controls the video recording introduces selection bias. Control of the information stream yielded unexpectedly candid and unselfconscious portrayals of the participants and their lives, but because patients chose what to show and not show of their disease management, underreporting of environmental asthma triggers and adherence problems were to be expected. VIA shifts control of the flow of clinical information from the clinician asking questions to the patient sharing his or her experience. The patient's perspective on his or her medical condition is selective, but complementary to the medically focused information obtained by the clinician in the medical history interview.

The findings of the VIA Asthma study raise concern about the effectiveness of current asthma management with children and adolescents. However, they also point toward possible solutions. As assessment, VIA augments the medical history interview and indicates areas where it might be redesigned to improve its sensitivity to the realities of patients' lives. Reducing the judgmental quality of the assessment may allow patients to recall risk factors and management problems in partnership with their clinicians. Explicit and honest discussions about medications, how they work and what side effects to expect, may allow clinicians and patients to develop more effective medication plans. Patients, and clinicians for that matter, do not inherently know how to use a metered dose inhaler, and once they know, they do not consistently do it right. As clinicians, we must know and be able to demonstrate proper inhaler technique, remember to ask our patients to demonstrate their technique, and review it with them on a regular basis.

However, effective education alone is not the answer. Participants in VIA Asthma demonstrated high levels of knowledge about their asthma triggers and medical management that did not correlate with appropriate asthma care, findings that are consistent with those previously found in a study of inner-city children and their adult caregivers.⁵⁹ In several studies, systematic education of patients about appropriate medication use has demonstrated increased knowledge, but little significant improvement in asthma morbidity.^60-62 Knowledge does not necessarily translate into behavior change. Ultimately, it is patient beliefs, attitudes, and actions that determine medical outcomes. As clinicians, we must respect the wisdom and experience that the patient brings to their self-management. The medical plan is most effectively designed and implemented when it is based on clear communication and the partnership of patient with clinician. Frank discussions between clinicians and patients allow open acknowledgment of areas of concern and collaborative problem-solving in response.

VIA is an effective means of expanding our knowledge of disease beyond the medical history and the physical examination into the day-to-day worlds of children and adolescents living with illness. The VIA method has great potential for revealing new understandings of other environmentally and socially mediated chronic conditions, such as obesity, function-limiting disabilities, human immunodeficiency virus infection, and others. A camera in the patient's environment presents a remarkable opportunity for studying disease in vivo. The eye that VIA provides clinicians can guide medical management that is sensitive to and effective for patients in the contexts of their lives. The voice that VIA gives patients can reveal their experience of illness, their understanding of disease, and their motivations for behaviors that, ultimately, play the most powerful role in their medical outcomes. When we ask patients to teach us of their illness experiences, they have much of value to share. The illness narratives that these young people who live with asthma have produced is a body of important information about this disease that could not have been obtained in any other way. VIA visual narratives, in combination with the medical history interview and physical examination, reveal a more multidimensional and complete understanding of the experience of living with and managing asthma in the context of young people's lives.

	ACKNOWLEDGMENTS

The development and implementation of the VIA research methodology was funded by the John W. Alden Trust, the Arthur Vining Davis Foundations, the Gerondelis Foundation, the Agnes M. Lindsay Trust, the Mary A. and John M. McCarthy Foundation, the Deborah Munroe Noonan Memorial Fund, and by Project MCJ-MA 259195 from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Services Administration, Department of Health and Human Services. Equipment and supplies were donated by BASF, Cambridge Soundworks, Duracell, Eastpak, JVC, Sennheiser, 3 M, TDK, and Tocad.

We thank the clinicians and staff of the Children's Hospital Pediatric Allergy Center and Adolescent/Young Adult Clinic for their assistance in identifying and recruiting VIA study participants; Richard Chalfen, PhD, for his mentorship in developing the VIA method; Jason Gordon for coordinating the data analysis; and Mariah Almond, Huguette Arza, Jackie Chandler, Jessica Heimbaugh, Michael Melone, Allison Nagy, Dharani Reddy, Adrienne Lyons Ruth, Lauriann Serra, Amanda Stein, Stacy Taylor, Krishna Upadhya, Mahlet Woldemariam, and Sheldon Zink for logging the video data. We are grateful to Elizabeth R. Woods, MD, MPH, and S. Jean Emans, MD, for their guidance and support. Finally, and most importantly, we thank the young people who had the grace and courage to share their lives with illness through VIA.

	FOOTNOTES

Dr Rich received the Society for Adolescent Medicine New Investigator Award for this research.

Received for publication Aug 19, 1999; accepted Nov 15, 1999.

This paper was presented, in part, at the Society for Adolescent Medicine annual meeting; March 5, 1998; Atlanta, GA.

Reprint requests to (M.R.) Division of Adolescent/Young Adult Medicine, Children's Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: michael.rich{at}tch.harvard.edu

	ABBREVIATIONS

NHLBI, National Heart, Lung, and Blood Institute; VIA, Video Intervention/Prevention Assessment.

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