Patient Education and Counseling 54 (2004) 329–336

The development of a helpline for chronicobstructive pulmonary disease (COPD)

Dina Brooksa,∗, Carol A. Fancotta,b,c, Laura-Beth Faltera,Alan McFarlaned, Mika L. Nonoyamaa

a Department of Physical Therapy, Faculty of Medicine, University of Toronto,500 University Avenue, Room 848, Toronto, Ont., Canada M5G 1V7

b Institute for Work and Health, Toronto, Ont., Canadac Toronto Rehabilitation Institute, Toronto, Ont., Canada

d Ontario Lung Association, Toronto, Ont., Canada

Received 29 January 2003; received in revised form 5 May 2003; accepted 30 June 2003

Abstract

Background: The goal of the helpline is to assist individuals with chronic obstructive pulmonary disease (COPD) better manage theirdisease through improved understanding of COPD, its symptoms and treatment.Objectives: The purpose of this project was to develop andvalidate a protocol for a COPD helpline.Methods: Ten key informants with expertise in helpline development or COPD were interviewed.Fifty individuals with COPD participated in content validation of the protocol.Results: An initial protocol for the helpline aimed to provide:(1) information and education regarding COPD and its management via the telephone and with written materials; (2) guidance regardingcourse of management; (3) resource links to other support services and programs locally, provincially, and/or nationally; and (4) caringsupport and reassurance to those with COPD and their families. The majority of the calls from individuals with COPD sought medicalinformation (74%) and required 36.6 ± 14.5 min (range: 15–85) to complete. Many different topics were discussed, with medication andexercise being the most common. The availability of the call center was identified as one means of replacing information sought fromother health care providers, mainly physicians and pulmonary rehabilitation staff.Conclusion: A protocol of a helpline for COPD has beendeveloped based on the literature, theoretical knowledge, and input from key informants and individuals with COPD.© 2003 Elsevier Ireland Ltd. All rights reserved.

Keywords: Helpline; Call center; Telehealth; Chronic obstructive pulmonary disease

1. Introduction

Telehealth has been defined as “the use of telecommuni-cations equipment and communication networks for trans-ferring health care information”[1]. Telehealth has manypotential uses in health care, ranging from patient and prac-titioner education and direct patient care to that as an emer-gency response system[1]. Telephone helplines may play animportant role within the realm of telehealth and have beenused with a number of patient groups to provide medicaladvice (e.g. asthma)[2], to decrease the use of emergencyservices[3], or for behavioral modification (e.g. smokingcessation).

In the field of chronic obstructive pulmonary disease(COPD), only two reports of telehealth were located[4,5].

∗ Corresponding author. Tel.:+1-416-978-1739; fax:+1-416-946-8562.E-mail address: dina.brooks@utoronto.ca (D. Brooks).

Mair and colleagues[4] used videoconferencing to providenursing care at home during an acute COPD exacerbation.Young and colleagues[5] described a telephone-linked carefor COPD designed to emulate patient monitoring by hav-ing patients call in weekly. No report of a COPD helplinewas located.

The goal of a Canadian COPD helpline is to help in-dividuals better manage their disease through improvedunderstanding of COPD, the symptoms, and its treatment.Ultimately, the helpline, in conjunction with reinforcementfrom other support systems, may lead to improvement inhealth-related quality of life, health care utilization, anddecreased hospitalizations of acute exacerbations of COPD.The objectives of the COPD helpline were to provide: (1)information and education regarding COPD and its man-agement via the telephone and with written materials; (2)guidance regarding signs and symptoms and changes inthese; (3) resource links to other support services and pro-grams locally, provincially, and/or nationally; and (4) caring

0738-3991/$ – see front matter © 2003 Elsevier Ireland Ltd. All rights reserved.doi:10.1016/j.pec.2003.06.001

330 D. Brooks et al. / Patient Education and Counseling 54 (2004) 329–336

support and reassurance to those with COPD and theirfamilies.

The purpose of this study was to develop a protocol forthe COPD helpline using key informant interviews and toexamine the content validity of the protocol with individualswith COPD.

2. Methods

This project was approved by the University of TorontoResearch Ethics Board. There were three components to thisproject. First, the literature and theoretical frameworks wereused to inform protocol development. Second, a consultationprocess was used to develop the components of the protocol.Third, the protocol was applied with individuals with COPDto seek their input.

2.1. Theoretical framework

Three behavior change models were reviewed: health be-lief model, social learning theory/social cognitive theory,and self-efficacy theory. These theories are briefly reviewedhere, and their links to the development of the helpline arediscussed inSection 3.

The health belief model was originally formulated to ex-plain preventative health behavior, but has also been used toexplain early detection action, illness behavior, sick role be-havior, and chronic illness behavior[6]. The model suggeststhat the likelihood that a person will take action relative to ahealth condition is determined both by the individual’s psy-chological state of readiness and by the perceived benefit ofthe action weighed against the perceived cost or barriers in-volved in the proposed action[6]. The health belief modelconsists of five major constructs: perceived susceptibility,perceived severity, perceived benefits/value, perceived bar-riers, and cues to action[7].

The social learning theory considers both the acquisitionof behavior as well as behavior change[5,8]. Bandura[7]added the concept of self-efficacy, thus developing a morecomprehensive framework in the social cognitive theory.The pivotal concept of social cognitive theory is reciprocaldeterminism, which emphasizes the dynamic interplay be-tween the person and the environment. Behavior is seen toresult from the continual interaction among three compo-nents: the characteristics of a person, the behavior of thatperson, and the environment in which behavior is performed[5]. Social cognitive theory consists of four major constructs:behavioral capability (knowledge to perform the behavior),self-efficacy (belief in one’s capability of performing the be-havior), outcome expectation (belief that behavior will leadto positive outcome), and reinforcement.

In the self-efficacy theory, Bandura[9] postulates twotypes of expectancies that influence behavior. First, there isself-efficacy expectancy, which is the conviction that one cansuccessfully execute the behavior required to produce the

desired outcome. Self-efficacy expectancy may be informedby performance accomplishments (i.e., gaining confidencewhen doing a task, vicarious experiences such as role mod-eling, verbal persuasion, and emotional/physical arousal).Performance accomplishments are the strongest source ofself-efficacy expectancy[10]. The second expectancy is thatof outcome expectancy, or the conviction that certain behav-iors will lead to certain outcomes[9,10].

2.2. Pre-protocol development

A total of 10 key informants were interviewed to gain theirperspectives regarding helplines and about the content for aCOPD helpline. They were selected by the principal inves-tigator (DB) and by the manager of the COPD program atthe Ontario Lung Association (AM) because of their exper-tise in COPD/respiratory conditions, or with helplines. Thissample did not include all stakeholders but represented keyones and consisted of experts in the field. Participants in-cluded three nurses, three physicians, one physical therapist,one pharmacist, and two program coordinators. Five wereCOPD/asthma educators and five were experts in telehealthin the respiratory or related field (i.e., asthma, smoking ces-sation, and alpha-antitrypsin support helplines). Interviewswere conducted either face to face or over the telephone,and ranged from 30 to 90 min in length.

A semi-structured interview guide was used with all ofthe participants (Table 1). The feedback from each interviewwas recorded. These records were coded and grouped un-der categories of analysis by two members of the team (DBand CF). Primary coding categories were developed as therecords were collectively scrutinized, and emergent themesand subthemes became apparent. These themes and sub-themes were used to develop the protocol for the helpline.

2.3. Post-protocol development

Following the development of the initial draft protocol,feedback was solicited from persons with COPD. Individu-

Table 1Interview questions for the key informants

Theme Specific questions

Helplines ingeneral

What are your thoughts on helplines in general?What do you think a helpline should or could beused for?What are the challenges indeveloping/implementing/evaluating such a service?Have you ever used a helpline before? If yes,what makes it work/not work?

About COPDin particular

What types of information do you think should begathered for the COPD population on a helpline?Are you aware of any COPD protocols that havebeen used for telephone triage type situation?What services should be provided through aCOPD helpline?How should a helpline be evaluated?

D. Brooks et al. / Patient Education and Counseling 54 (2004) 329–336 331

als were considered eligible for this study if they had a med-ical diagnosis of COPD, experienced shortness of breath orcough daily that limited their activity, were able to speakand understand English, and were at least 45 years of age.Individuals with COPD were excluded if they had asthmaas a primary diagnosis (i.e. greater than 15% reversibility inFEV1 with bronchodilator).

Potential participants were recruited by direct advertise-ments to COPD patients affiliated with pulmonary rehabili-tation programs, through Lung Association newsletters andinformation lines. The following was the wording in the ad-vertisement: “Have you been diagnosed with Chronic Bron-chitis or Emphysema (COPD)? Do you experience shortnessof breath or a cough that interferes with your daily activi-ties? Do you often have questions and concerns about theseissues? Would you use a COPD Helpline if one existed tohelp answer your questions? We would like your thoughtsand opinions on a study for a COPD helpline.” Since thisstudy was mostly exploratory and descriptive in nature, nospecific sample-size calculation was performed. However,in order to capture input from individuals with COPD withdifferent levels of disability and backgrounds, phone inter-views were performed with a total of 50 individuals withCOPD. Individuals with COPD were informed about thegoals, objectives, and availability of the helpline, and askedto “simulate” a call that they might make, based on how theyfelt that day.

A respiratory therapist (MN) with extensive experience inCOPD acted as the operator for the calls. Participants wereasked the following: “Assume that the helpline is operationalat this time. What information, guidance or support wouldyou access the helpline for?” If this did not lead to any dis-cussion, she proceeded to the questions about COPD control(Table 2). These questions initiated discussion about differ-ent issues and resulted in them requesting information aboutcertain topics or seeking guidance. Since the helpline wascaller-driven, the respiratory therapist only used the compo-

Table 2Set of questions to be used to determine if COPD is well controlled

Have there been any changes in your symptoms over the last week?(Coughing, breathing difficulties with exercise, sleepquality/disturbed nights, increased phlegm, chest pain)

Has there been any change in phlegm color over the last week?

Please tell me your COPD medications and how often you take them.Do you have any medication side effects that are troubling you?Do you feel your inhalers are losing their effectiveness?Do you have any difficulty remembering to take your medications?

How many times a week do you do your exercise?

Do you ever avoid social activities because of your condition?

Do you ever avoid physical activities because of your symptoms?

Do you smoke? If yes, are you interested in learning about ways ofquitting?

When did you last have a shot for the flu/pneumonia?

nents of the protocol that the participants expressed inter-est in. For example, if they were interested in informationabout exercise, she only discussed that specific module withthem. After the calls, the respiratory therapist debriefed theresearch team.

3. Results

3.1. Links between theoretical frameworks and thedevelopment of the content of the protocol

Behavior change models were used to inform the devel-opment of this protocol and formed its theoretical basis. Dueto the nature of this COPD helpline (i.e., a resource thatmay be used on a one-time basis), none of the models couldbe solely applied to the helpline’s goals and objectives. In-stead, components of each of the models were consideredwhen developing the protocol so as to maximize behavioralchange. Within the Health Belief Model, we focussed onensuring that the helpline include components that reinforceissues of susceptibility and severity and recognize the bene-fits and options for treatment. These factors would increasethe likelihood of individuals with COPD taking action withrespect to their health. For example, for each informationmodule within the helpline protocol (e.g. exercise, nutrition),evidence to support the options and their benefits and riskswere included.

Using the social learning theory model, we focused on theimportance of positive reinforcement by Helpline operatorsto provide encouragement to callers for appropriate behaviorand knowledge. Specifically, within the helpline protocol,we incorporated a component of psychosocial support andreassurance.

With respect to the self-efficacy theory, we recognizedthe importance of verbal persuasion, that is, convincing thecaller that he/she is able to perform the task, and helpingreinforce his/her performance accomplishments by identi-fying the activities that have been completed successfully.The helpline may also assist in convincing the caller thathealth-promoting behavior will lead to improved health andwell-being, thus affecting outcome expectancy. On the ba-sis of this, we recognized the importance of follow-up callsfor some individuals for whom a change in behavior or aspecific action is recommended by the helpline operator.For example, if an individual with COPD calls because of achange in symptoms, such as an increase in sputum produc-tion, the operator may reinforce some self-care strategies butalso recommend a visit to a physician to maximize healthoutcome. A follow-up call by the operator a few days laterwould reinforce the suggestion and provide further support.

3.2. Input from key informants

Several themes emerged and were agreed upon by keyinformants. These were: (1) a strong support for a helpline

332 D. Brooks et al. / Patient Education and Counseling 54 (2004) 329–336

in COPD; (2) ensuring that the helpline provides both in-formation and support to individuals with COPD and theirfamilies; (2) the importance ofnot providing medical adviceover the phone; (3) having the helpline caller-driven; (4) en-suring that the evaluation of the helpline reflects the goalsand objectives; and (5) recognizing the challenges associ-ated with developing a helpline. In addition, key informantsprovided a list of topics that they identified as important toinclude in the helpline protocol. These topics were used todevelop the information module of the helpline protocol.

Participants were in strong agreement that helplinescan act as a resource, to provide verbal information andfollow-up with written materials, and to act as a link to com-munity resources (e.g. respiratory rehabilitation or smokingcessation programs), especially for those living in isolatedareas. However, several informants felt that the COPD pop-ulation represents a complex and diverse group and, subse-quently, may be difficult to generalize under one protocol.

In addition to information, some participants also felt thatthis helpline could provide psychological support and reas-surance to callers. Some key informants anticipated that thehelpline would be used primarily when callers felt unwell.In this case, the helpline may act as a screen and provide ad-vice as to what action should be taken (e.g. return to familyphysician, go to emergency, etc.).

There was strong caution that this helpline should notprovide medical advice. Aside from legal issues, providing

Fig. 1. Overview of COPD protocol.

medical advice may be difficult to do over the phone, particu-larly when the caller is unknown to the helpline operator andwithout a full medical history of the caller. In addition, therewould be the risk of the caller not fully understanding advicegiven verbally over the phone. Key informants emphasizedthe importance of having the purpose of the helpline clearlyarticulated to the public and other health care professionals.

All informants agreed that the protocol should becaller-driven (i.e., information or guidance provided isbased on the needs of the caller at that time) and based onthe best available scientific evidence for the care of COPD.Helpline providers need to be experts in COPD (e.g. COPDeducators) and well trained in the provision of helpline care.

Evaluation of the helpline should reflect the purpose andhave direct links to the goals and objectives of the helpline.Key informants felt that the helpline could not be evaluatedin relation to health services utilizations, hospital admis-sions, behavior change, or quality of life, as they were skep-tical about the impact that one telephone call could make inthese domains. They recommended that evaluation includeboth process and outcome components, such as patient sat-isfaction (e.g. hours of operation, professionalism of opera-tors, and usefulness/appropriateness of information given),patient education (e.g. changes in knowledge/attitudes), anda sense of mastery or control. Demographic information toidentify who accesses the helpline would also be gathered.An evaluation may also serve as a needs assessment, to track

D. Brooks et al. / Patient Education and Counseling 54 (2004) 329–336 333

Fig. 2. Overview of information module.

the primary concerns of callers, and when materials need tobe updated.

Several challenges in the design and implementation ofhelplines were identified. These challenges included the

Fig. 3. Overview of change in medical condition module.

following: difficulty advertising the helpline, legal issuesaround confidentiality, accountability and liability for guid-ance given over the telephone, possible misinterpretation ofinformation provided, and potential abuse by repeat callers.

334 D. Brooks et al. / Patient Education and Counseling 54 (2004) 329–336

Fig. 4. Overview of psychological support and reassurance module.

Follow-up calls and evaluation were potential solutions tohandle issues of misinterpretation. Collaboration with otherorganizations/associations was suggested as the best way toadvertise and promote the COPD helpline.

3.3. Protocol

Based on this key informant information, a draft proto-col was developed. The framework for the COPD helplineprotocol has three sections (seeFig. 1): (1) a brief initialscreen; (2) four modules based on anticipated types of calls,which include (i) information gathering, (ii) change in med-ical condition, (iii) psychological support/validation and re-assurance, (iv) follow-up calls; and (3) demographic infor-mation (to be collected at the end of the call). An overviewof these modules is provided inFigs. 2–4. As well, a ques-tionnaire on “How well is your COPD controlled” was in-corporated to ensure that relevant information about carewas discussed and to provide an icebreaker at the start ofthe call (seeTable 2).

3.4. Input from individuals with COPD

Fifty individuals with a medical diagnosis of COPD foran average of 7.8 ± 4.7 (S.D.) years (range: 0.3–20) anda mean age of 68.2 ± 9.1 years (range: 47–86) providedinput on the helpline. Four participants had bronchiectasis,one had alpha-one-antitrypsin deficiency, while the remain-ing participants had chronic bronchitis and/or emphysema,with or without asthma. Thirty-one (62%) participants weremale. The majority of subjects (n = 46, or 92%) had previ-ously smoked, although only two were still smoking at thetime of the study. The mean number of years of smoking andthe number of packs per day were 35.3± 15.5 years (range:0–56) and 1.2 ± 0.6 packs per day (range: 0–2.5), respec-tively. Thirteen individuals (22%) lived with a smoker. Addi-tional demographic characteristics are presented inTable 3.

Table 3Demographic characteristics of participants

Characteristic Number ofparticipants

Percentage(%)

Residential settingUrban 39 78Rural 11 22

Marital statusMarried 31 62Widowed 12 24Divorced/separated 6 12Never married 1 2

Living circumstancesLiving with spouse 31 62Living alone 16 32Living with children, parent, or other 3 6

Oxygen useNo 39 78Yes 11 22

Highest schoolingCompleted elementary school 5 10Some high school 10 20Completed high school 14 28Some community college or

undergraduate university10 20

Completed community college orundergraduate university

9 18

Some post-graduate education 1 2Completed post-graduate education 1 2

Current employmentEmployed full-time 2 4Employed part-time 1 2Long-term disability 6 12Unemployed 1 2Retired 37 74Homemaker 2 4Self-employed 1 2

Change in employment due to conditionNo 38 76Yes 12 24

D. Brooks et al. / Patient Education and Counseling 54 (2004) 329–336 335

Table 4Topics for which participants requested information

Topic Number ofparticipants

Medications and side effects 31Exercise 29About COPD (the disease, sign, and symptoms, test) 12Coughing and sputum 12Oxygen therapy 11Breathing techniques 9Anxiety and relaxation 6Travelling 6Environmental concerns and triggers 4Nutrition 3Surgery 3Energy-saving techniques 2Recent development in COPD 2Social activities 2Vaccines 2Alpha-one-antitrypsin 1Alternative therapies 1Sexuality 1Sleep 1Smoking 1

On average, the calls required 36.6 ± 14.5 min (range:15–85) to complete. The majority of the calls (n = 37, or74%) were for information gathering only. One call wasexclusively for consultation on a change in medical condi-tion and one was purely for psychological support. Sevencalls were a combination of change in medical conditionand information gathering and four were for a combinationof psychological support and information gathering. Whenseeking psychological support, the majority of callers (83%)were anxious regarding their chronic illness. When seekingadvice related to changes in their medical condition (n =7), the main concerns were increased difficulty breathing(n = 3), change in cough/sputum production (n = 3), andother medical conditions requiring attention (n = 1). Infor-mation gathering included many different topics as outlinedin Table 4. For 10 participants, material was mailed out aftercompletion of the call.

Table 5Alternative help sources cited by helpline callers

Source of information or help Number ofparticipants

Percentage(%)

Contacted physician 17 34Contacted pulmonary rehabilitation

staff14 28

Contacted Lung Association 8 16Found information on internet or at

a library4 8

Emergency department 2 4Contacted family or friends 1 2Contacted pharmacist 1 2Contacted oxygen company 1 2Accessed telehealth 1 2Do not know 1 2

When asked about the hours of service that they wouldfind most helpful, 82% preferred service outside the regu-lar daytime hours. Sixteen participants (32%) preferred 24 hservice. All respondents found the provided information tobe useful and appropriate and reported that the service mettheir needs. When asked where they would seek informa-tion or help if they had not called the helpline, participantsidentified many different sources as outlined inTable 5.

Although the feedback from individuals with COPD re-sulted in changes in the flow of the questions, it did not re-sult in any change in content. While some educational topicswere not accessed during this phase, these were left in theprotocol for further evaluation.

4. Discussion

A protocol for a COPD helpline has been developed us-ing the literature, theoretical frameworks, and a consulta-tive process with key experts. The helpline aims to provideinformation and education, guidance regarding signs andsymptoms, and caring support and reassurance to those withCOPD and their families. The findings from this study showthat the majority of the calls were for information gather-ing. Many different topics were discussed, medication andexercise being the most common. The availability of thehelpline may replace seeking information from other healthcare providers, mainly physicians and pulmonary rehabili-tation staff. A large percentage of participants preferred ex-tended hours of service beyond daytime hours.

This study is the first report of the development of ahelpline for persons with COPD, with specific aims to helpindividuals better manage their disease through improvedunderstanding of COPD, its symptoms and management.Only two other studies have been found related to the use oftelehealth and COPD. Young and colleagues[5] developedan automated telephone-linked communication system, withthe main objective to function as “a home monitor, educatorand counselor” for the patients and to provide surveillancebetween office visits. Using computer-controlled speech,the system inquires about the patient’s status and providesappropriate feedback. The second study by Mair and col-leagues[4] used real-time interactive video to allow patientsin their own home to obtain nursing support from a remotenurse during an acute exacerbation. However, there wereseveral technical problems encountered during this study,thereby limiting its utility.

Although the literature in telehealth in the respiratoryfield is scarce, several helplines are operational in relatedareas such as helplines for asthma, smoking cessation, andalpha-antitrypsin deficiency. However, although key infor-mants within these services were consulted, the protocol forCOPD helpline was considerably different because of thefeatures and issues specific to each of the conditions. Forexample, the episodic nature of asthma is different fromthe chronic progressive course of COPD. Individuals with

336 D. Brooks et al. / Patient Education and Counseling 54 (2004) 329–336

alpha-antitrypsin deficiency tend to be younger than thosewith COPD from other causes, mainly smoking.

Key informants unanimously agreed that the helplineshould not provide medical advice such as providing a diag-nosis or recommending a change in medication. The mainreason was the fact that the callers were unknown to thehelpline operator, a full medical history was unavailable,and a proper assessment could not be completed. However,if the caller experienced a change in medical conditions(e.g. increase in sputum and cough), the helpline wouldprovide advice on course of action, but this would be lim-ited to recommending that he/she goes to the emergencydepartment or to the physician or specialist.

Several issues related to process arose during the study.The operator began by asking the question “ assume thehelpline is functional—what information would you want?”If this did not lead to any discussion, she proceeded to thequestions about COPD control. In the actual operation ofthe helpline, the sequence would be the same. Since thediscussion should be caller-driven, the callers’ concerns orquestions would be managed first. However, the questionsabout COPD control would also be used with callers (if theyare willing) to maximize education and influence behavior.

A follow-up call may be needed to reinforce self-carestrategy or a recommended visit to a physician. As part ofthe helpline protocol, if the operator identifies the need fora follow-up call, he/she must obtain verbal consent beforeacquiring identifying information (i.e. contact information).Therefore, this information and a follow-up call are onlycompleted with consent from the caller. The purpose of thesecalls is simply to encourage and support the caller in a rec-ommended behavior or action.

All key informants agreed that evaluation is an importantpart of development and implementation of a helpline. How-ever, there was no clear outcome that was considered “goldstandard” for measuring the effectiveness of the helpline. Itis unreasonable to assume or suggest that one phone callwould result in a change in quality of life. Given the fact thatthe operator may recommend that the caller visit their physi-cian, the helpline may actually result in increased health careutilization. However, if these visits prevent death or seriousmorbidity, then the calls were considered vital, although thiseffect would be difficult to measure. Given the fact that manyof the calls would focus on education, the helpline is likelyto result in more knowledge about the disease, more infor-mation about local resources and thus better control over thedisease. For asthma, for example, based on the input fromthe key informant, the asthma helpline resulted in less use ofrescue medication, indicating better control of disease. Useof rescue medication is not an appropriate measure in COPDand there are presently no validated measures of knowledgeor control over the disease for the COPD population. Weare presently developing a questionnaire to measure thesevariables.

Different sources of opinions (e.g. various health careproviders, individuals with COPD, and telehealth experts)

were used to develop this protocol for a COPD helpline.We selected 10 key informants to interview before the de-velopment of the protocol. This sample did not reflect allstakeholders. With respect to patients, the sample was biasedtowards those who had an established diagnosis of COPD,received pulmonary rehabilitation, and lived in an urbansetting. Present smokers were also underrepresented in thesample. We did not measure disease severity and thereforecannot be sure that we captured patients with a range of dis-abilities. Since this study required informed consent, an arti-ficial environment may have been created between helplineprovider and caller participant, possibly underrepresentingthose who may be seeking medical advice for change incondition. Furthermore, evaluation of satisfaction was per-formed by the same person who conducted the call; the highlevel of satisfaction may reflect social acceptability bias inanswering.

In summary, this paper describes the first helpline protocolfor COPD. The protocol is based on theoretical frameworksand extensive consultation with experts in COPD and tele-health, and individuals with COPD. Since the developmentof the protocol, it has now been computerized, and individ-uals with COPD can access the helpline in Canada. Furtherongoing evaluation is in progress to assess the usefulness ofthis helpline from the patients’ perspective and the effects,if any, on health care utilization.

Acknowledgements

Financial support was received from Ontario Lung Asso-ciation in the form of an unrestricted educational grant.

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