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Chronic Illness
0(0) 1–15
Using projective exercises to ! The Author(s) 2019
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DOI: 10.1177/1742395319872788
of living with comorbid type 2 journals.sagepub.com/home/chi

diabetes and asthma

Michelle L Litchman1 , Nancy A Allen1,

Carrie McAdam-Marx2 and Michael Feehan3

Abstract
Objective: Patient self-management of a single chronic condition can be challenging, but few
studies have examined the emotional impact of living with comorbid conditions and how that
differs from a single chronic condition. This study examined patient perspectives of the emotional
impact of living with asthma or asthma with comorbid type 2 diabetes (asthmaþdiabetes).
Methods: Data were collected from 41 adults (asthma only n ¼ 22, asthmaþdiabetes n ¼ 19)
using semi-structured interviews on two separate online bulletin boards. Respondents engaged in
discussions that leveraged two projective exercises: describing their health condition(s) as an
animal, and selecting one of eight images that best illustrated how they were living with and
managing their health condition(s).
Results: Respondents described physical and emotional challenges related to managing asthma
or asthmaþdiabetes. Animal- and image- projective exercises were categorized by response and
health condition. Thematic analysis across both projective exercises identified four themes:
(1) frustrations with dual diagnosis, (2) juggling the dual diagnosis, (3) anticipating the future,
and (4) unpredictability.
Discussion: Projective exercises are one way to elicit feelings about living with chronic
conditions. Healthcare providers can improve support for patients with more than one health
condition by providing education on how to manage comorbid conditions.

Keywords
Diabetes, asthma, online bulletin board, projective exercise, multimorbidity
Received 1 February 2019; accepted 30 July 2019

3
Kantar LLC, San Francisco, CA, USA
1
University of Utah College of Nursing, Salt Lake City, Corresponding author:
UT, USA Michelle L Litchman, University of Utah College of
2
University of Utah College of Pharmacy, 30 S 2000 E, Salt Nursing, 10 S 2000 E, Salt Lake City, UT 84112, USA.
Lake City, UT, USA Email: michelle.litchman@nurs.utah.edu
2 Chronic Illness 0(0)
Introduction
Approximately 30.3 million Americans are
living with diabetes,1 and 25 million have
asthma.2 These conditions are linked phys-
iologically. When controlling for potential
confounders, individuals diagnosed with
diabetes have an 8% higher risk for
asthma than patients without diabetes,3
and patients with asthma have a 25%
higher odds of having diabetes.4 The mech-
anism(s) for this relationship are not
completely understood, though multiple
pathological pathways have been hypothe-
sized. Higher rates of reduce lung function
and asthma in patients with diabetes
may be due to diabetes-driven alterations
to the connective tissue in the lung
and hyperglycemia-induced microangiop-
athy.3 The development of diabetes in
individuals with asthma may be due to
asthma medications, such as corticoste-
roids.5 Additionally, patients with asthma
have been found to have a higher risk of
developing pro-inflammatory conditions
including diabetes.6 Furthermore, reduced
lung function can limit physical activity,
resulting in weight gain that can trigger
insulin resistance which may progress
to diabetes.7
Diabetes and asthma self-management
Diabetes and asthma both require a great
deal of self-management, i.e. tasks that indi-
viduals must undertake to live with one or
more chronic conditions.8 These tasks
require the “confidence to deal with medical
management, role management and emo-
tional management of their conditions”
(p. 57).8 Individuals with diabetes must per-
form several daily activities to manage their
diabetes, e.g. monitor glucose levels, take
medications, follow a recommended diet
and exercise plan, problem solve issues
such as hyperglycemia, and learn coping
skills.1 Asthma self-management tasks
include measuring daily peak air flow
through the lungs, managing maintenance
medications such as inhaled corticosteroids,
recognizing when to use a rescue
inhaler, recognizing deterioration in symp-
toms, recognizing and avoiding triggers,
and knowing when to seek professional
help or emergency treatment. In patients
with both diabetes and asthma, disease
self-management is more complicated.
Managing multiple conditions often
requires complex medication regimens that
may lead to drug–drug or drug–condition
interactions, competing behavioral and life-
style modifications, and engagement with
multiple healthcare providers.9
Asthma, diabetes, and emotional distress
The stressors related specifically to diabetes
or asthma have been well studied. Stressors
associated with asthma include fear of having
an asthma attack or having an asthma attack
in public.10 Asthma symptoms can worsen
quickly during exacerbations, which can
often be frightening. Such a scare can lead
to health-related anxiety and hypervigilance,
which can further trigger asthma.11 Diabetes-
related research has shown that perceived
control, self-efficacy and diabetes-related dis-
tress are related to glycosylated hemoglobin
A1c and several self-management behaviors
such as medication adherence.12
However, few studies have examined the
emotional impact of specifically having
both asthma and diabetes. While it is
known that the pressures of living with mul-
tiple conditions are associated with reduced
quality of life, lower self-efficacy, and
higher rates of depression,13 patient percep-
tions and the stress that they face in simul-
taneously managing these two common,
chronic conditions are not known. As a
first step to filling this gap in knowledge,
this study examines patient perspectives of
the emotional impact of living with asthma
with or without comorbid type 2 diabetes.
Litchman et al.
To elicit patients’ emotional response to
managing these conditions, we used projec-
tive exercises in an online focus group set-
ting. Projective techniques have a history of
use in mental health research and have been
more recently used in market research and
to describe patient experiences with chronic
conditions.14–16 In recent applications,
projective exercises facilitate an inhibited
discussion, which may generate more com-
plete responses than through direct
questioning.17
Methods
This qualitative study was conducted in
2016 by a contract market-research compa-
ny using an online bulletin board (OBB)
with investigator oversight for sampling
and data collection. The study protocol
and consent forms were reviewed by the
University of Utah Institutional Review
Board and considered exempt based on
applicable guidelines involving the ethical
treatment of human subjects. The market-
research organization recruited patients,
hosted and moderated the OBB discussions
with investigator oversight.
Sample and setting
Adults (>18 years old) were recruited by the
contract market-research company using
these criteria: (1) diagnosed with either
asthma or both asthma and type 2 diabetes
(asthma þ diabetes) and (2) had filled at
least one prescription for an asthma and/
or diabetes medication by a community
pharmacy within the past year. Eligible
adults were screened before inclusion to
obtain a geographically diverse sample
with mixed gender, age, race, ethnicity,
employment status, annual household
income and type of asthma and/or diabetes
medication. Respondents were allocated to
one of two mutually exclusive OBBs:
asthma only and asthma þ diabetes.
3
OBBs are a useful platform that allows
moderators to probe in-depth individual
respondents’ health experiences and to
convey the aggregate responses to all
respondents for group discussion to solicit
wide variation in opinions over an extended
period.18 OBBs have also been used as a
platform for peer-to-peer support patient
care settings.19 Given the ability of OBBs
to elicit information and the narrow study
aim, recruitment efforts targeted 20 partic-
ipants per arm to ensure saturation.20
Measures
Each OBB was moderated by a researcher
team who led respondents through two pro-
jective exercises to facilitate discussions
about managing asthma or asthmaþdiabe-
tes. Projective exercises, whose responses
are categorized as association, completion,
construction, expressive and choice order-
ing, are used in qualitative research to
elicit participants’ deeper, more visceral
and often unconscious beliefs, attitudes
and motivations.16 This technique has
been used in patients with chronic health
conditions including idiopathic lung dis-
ease, cystic fibrosis, and diabetes15,21 and
as well as other public health issues.22
In the first projective exercise, respond-
ents were asked to describe their asthma or
asthma þ diabetes as an animal and explain
why they choose that animal. Respondents
with asthma þ diabetes were asked to
choose two animals, one for asthma and
one for diabetes. When making their selec-
tion, respondents were asked to consider
how the animal behaves, its personality
and how it makes them feel.
In the second projective exercise,
respondents were asked to select an abstract
image (Figure 1) that best illustrated their
experience living with and managing
asthma or asthma þ diabetes and why they
chose that image. In each projective exer-
cise, the moderator probed respondents to
4 Chronic Illness 0(0)

Figure 1. Abstract art image for projective exercise.

elicit the emotional impact of their condi-
tion (e.g. can you tell me more about why
you chose that image?).
Data collection
Data were collected through OBB inter-
views following a semi-structured discus-
sion guide programmed for online textual
administration. Respondents engaged in
OBB discussions for approximately
2 hours spread over the course of a day, as
convenient. They could log on to answer
initial questions posted to the board and
respond to moderator follow-up questions.
Each board ran from 4 a.m. to 3 a.m. EST
the following day (1 am to 12 am PST) to
allow for maximum participation across
time zones and employment considerations.
Respondents received an honorarium for
their participation.
Data analysis
OBB transcripts were analyzed using prin-
ciples of qualitative description.23,24
Transcripts of each projective exercise
were read and coded separately by two
independent researchers to avoid bias due
to an individual researchers subjectivity.
Using matrices categorized by health condi-
tion(s), animal projective-exercise data were
categorized by animal type and/or rationale
for animal selection; and abstract image
projective-exercise data were categorized
by image selection and rationale for image
selection and the number of participants
choosing each image. Saturation was
reached25 and through a group interpretive
process, overarching themes about respon-
dent experiences living with asthma and
asthma þ diabetes were identified.26
Results
Of 41 respondents, 24 participated in the
asthma only OBB. Of these, 22 completed
the discussion on the day of the research.
Another 23 respondents took part in the
asthma þ diabetes discussion, of which 19
completed the OBB discussion on the day
Litchman et al. 5

Table 1. Respondent demographics.

Asthma only (n¼22) Asthmaþ diabetes (n¼19)

n (%) Mean  SD n (%) Mean  SD

Female 12 (54) 12 (63.2)

Age (years) 43  11.2 51 11.4
Residence
Urban 11 (50) 7 (36.8)
Suburban 8 (36.4) 10 (52.6)
Rural 3 (13.6) 2 (10.5)
White 14 (63.6) 9 (47.3)
BMI 329.7 356.5
BMI > 30 10 (45.5) 14 (73.7)
College graduate 11 (50) 7 (36.8)
Employment status
Full-time 16 (72.7) 11 (57.8)
Part-time 1 (5) 4 (21.1)
Retired 2 (9) 2 (10.5)
Student 1 (5) 0 (0)
Unable to work 1 (5) 2 (10.5)
Unemployed, looking 0 (0) 1 (5.3)
Prefer not to answer 1 (5) 0 (0)
Household income
$10,000–$19,999 1 (5) 2 (10.5)
$20,000–$29,999 0 (0) 3 (15.8)
$30,000–$49,999 6 (27.3) 3 (15.8)
$50,000–$69,999 3 (13.6) 3 (15.8)
$70,000–$99,999 8 (36.4) 2 (10.5)
>$100,000 3 (13.6) 6 (31.6)
Prefer not to answer 1 (5) 0 (0)
Insurance (not mutually exclusive)
Private – through employer 13 (59.1) 11 (57.9)
Private–personal 3 (13.6) 2 (10.5)
Medicaid 4 (18.2) 3 (15.8)
Medicare 3 (13.6) 6 (31.6)
Uninsured 1 (5) 1 (5.3)

of the research. Detailed demographics of examples and representative quotes for

respondents are in Table 1. asthma and diabetes are in Table 2.

Animal projective exercise Image projective exercise

Animals projected to depict asthma and
diabetes were categorized into five catego-
ries: (1) sneaky or unpredictable, (2) heavy,
constricting and slow (3) trainable, (4)
annoying, and (5) masquerading. Animal
Respondents with asthma and asthmaþdia-
betes were asked to select an image that
represented their disease(s). Overall, more
respondents with asthma than with diabetes
chose images, with the majority selecting
6 Chronic Illness 0(0)

Table 2. Animal projections.

Animal
Theme examples Asthma quotes Diabetes quotes

Animals that are Snake Asthma would be a bear. Diabetes is a piranha fish that
sneaky or Tiger Generally, it hibernates but eats you little pieces at a time.
unpredictable Lion during certain times of the Diabetes is a rat that can repro-
Bear year can be ferocious.If my duce at an enormous rate, full
Cheetah asthma were an animal it of ugly poison that is hard to
Goat would be a cheetah because get rid of. A vicious unforgiv-
Rabbit asthma attacks happen sud- ing disease. More like a silent
Mouse denly and need to be acted killer. You don’t realize just
Chameleon upon fast. Also, cheetahs can’t how bad it was kicking your
Cat be tamed and neither can my ass until it’s too late.
Piranha asthma.Cats are gentle, playful It doesn’t bother me, [gorillas
Sloth and tame at times, but also are] laid back and peaceful, but
Gorilla wild and uncontrollable as when it flares up it has an
Wolf well. It makes me feel that explosive side for a few sec-
Whale having Asthma can be unpre- onds and then it is calm again.
dictable and predictable at [Lions] can be mild mannered
times, because you don’t but raging when out of control
know when an attack will can devour everything in sight.
start, and at the same time [It] can affect all areas
you can also mange living with of health.
asthma by controlling how
much you do to prepare for an
attack and take the necessary
steps to prevent a
major attack.
Animals that are Snake “Even if I’m not having an attack N/A
heavy, constrict- Fish out of it still feels like it has a grip on
ing and slow water me. Especially if I attempt to
Octopus do anything too physical it
Fire breathing reminds me that it is ready to
dragon squeeze the life out of me.”
Panting dog
Elephant
Bear
Sloth
Animals that Dogs Cats’ can be intimidating at first My diabetes is a very large dog. If
are trainable Cats but them [sic] once you get to you train it well and are disci-
Elephants know them you know how to plined, it’s controllable. If you
handle them correctly. This is don’t, you’re in trouble.
the way I felt at first, I was Elephant. . .because they are
intimidated. But once I figured large and heavy and that is
out my triggers and how to how I feel about having diabe-
manage them, it was a whole tes. . .like something is weigh-
lot easier. ing on me all the time.
(continued)
Litchman et al. 7

Table 2. Continued
Animal
Theme examples Asthma quotes Diabetes quotes

I think an elephant. My asthma is

a big thing, it can tower over
your life and interactions but it
can also be controlled. It can
be managed. You just have to
be trained on how to manage
it properly. Having asthma to
me is just another thing. I do
not let it dictate my life or my
decisions. I still live every day
and enjoy life to its fullest. I
refuse to let it cripple me.
Animals that are Pesky My asthma is a mosquito – it’s Diabetes is like a mosquito there
annoying or mosquito annoying, but avoidable. Use a all the time and annoying. It
never go away Leech bug spray! makes me feel useless and
Ant concerned, and at time debili-
Rat tated.
Monkey A Rat. Rats can reproduce at an
enormous rate. Their [sic]
ugly full of poison, can be hard
to get rid of. Should they bite
you, you’ll need a series [of]
shots to fight [them] off.
My diabetes is like an ant. When
ants are in a colony they are a
nuisance and getting rid of
them is a pain. Diabetes is a
nuisance and pain when not
controlled.
Diabetes would be a monkey,
because it takes over your life.
Like having another child.
Animals that are Flamingo Asthma would be flamingo, N/A
masquerading because you can’t tell they
don’t fly. . .so pretty on the
outside you wouldn’t know
they really struggle.

Image B (n ¼ 7 for the asthma-only group)
or Image F (n ¼ 12 for asthma-only group)
(Table 3).
Image B was described in three ways:
tunnel with light at the end, long and chal-
lenging hallway, and narrowing airway. For
nine respondents, the image represented a
tunnel. The tunnel sometimes had a light
at the end. For example, one respondent
said, “As long as a I take care of myself,
things will be ok and I can keep on moving
forward.” In other instances, the tunnel was
referred to as a long and challenging hall-
way with a heavy burden. The image was
8 Chronic Illness 0(0)

Table 3. Projective image selections by group.

Asthmaþdiabetes N¼19

Image Asthma only N¼22a Asthma responses Diabetes responses

A 0 1 3
Swollen airway; trying, but not able to Spiral out of control or a whirlwind
catch a breath
B 7 5 6
þ Tunnel with a light at the end þ Tunnel with a light at the end
A long, challenging hallway with heavy burden. A long journey or road ahead, or a
Narrowing airway þ A steady path long hallway
C 0 1 2
þ Straight and narrow path to treating asthma.
D 0 1 0
þ/– The straight lines of the star represent
good days of living with asthma; points on
the lines represent when asthma had been
triggered and required multiple treatments.
E 0 1 1
White area represents the lack of air; the þ Stability, stable and currently
small purple circle represents the small comfortable with their condition
amount of air getting into their
lungs during an asthma attack
F 12 10 4
A long and winding, never ending road, and an Twists and turns that come with
uphill battle having diabetes
Never knowing what is going to be around An uphill battle requiring focus
the turns and attention
The ups and downs of living with asthma
G 1 0 0
Hills and valleys, always having to climb a hill in
order to breathe better
H 0 0 3
þ Positive – jump for joy, for having
“diabetes under control”
þ Sunshine, things would be okay
a
Two are missing image selections for asthma-only group.

also described as a narrowing airway. Two
respondents described the airway as “trying
to take a breath out of a tiny straw” or
“claustrophobia and panic that I feel
when I can’t breathe.” To one respondent,
the image indicated asthma was on a
“steady path”.
Image F was described in two ways: a
long, winding, and never ending road; and
the ups and downs of living with asthma;
Respondents reported that sometimes they
would be fine, and other times they would
experience a trigger that would lead to an
asthma exacerbation. Triggers included
mold, pollen, perfume, and animals. The
winding road was also described as an
“uphill battle” or “never knowing what is
going to be around the turns.” For one
Litchman et al.
respondent, the winding road described the
activities experienced prior to asthma diag-
nosis, such as shortness of breath, respira-
tory infections, and emergency department
visits. Respondents raised concerns about a
maintenance-only approach without cure.
They described the “highs and lows” of
asthma. The high points included being
able to maintain a balance between the
right amount of medication to exercise
and to breathe freely. The low points
included being inactive, stopping taking
medications, or experiencing unpredictable
asthma exacerbations.
Image responses for respondents with
diabetes were more diverse, but they also
commonly chose images B (n ¼ 6) and F
(n ¼ 4) to represent diabetes. Image B was
described by the diabetes group, similar to
the asthma group, as a light at the end of a
tunnel, a long journey or road ahead, or a
long hallway. Respondents noted that that
they had to be mindful along this path,
checking glucose levels, watching their
diet, exercising, and being in tune with
their body. For some, the path seemed so
long that it was discouraging.
Image F was also used to describe the
twists and turns that come with having dia-
betes. In contrast to the asthma group,
however, the diabetes group described this
image as representing an uphill battle that
requires focus and attention. One respon-
dent noted, “My eating habits, mood, just
my whole being can be disrupted if my glu-
cose levels are off.”
While less commonly selected, Image H
was used by two respondents to provide
positive sentiments about diabetes. One
described legs jumping in the air with joy
for having “diabetes under control,” while
another respondent reported that her regi-
men was working and the image repre-
sented sunshine, indicating things would
be okay. For more detailed descriptions of
images, see Table 3.
9
Thematic analysis
Two researchers reviewed transcripts to
identify themes. During the process, four
themes clearly emerged from the data with
no disagreement between investigators in
terms of identified themes: (1) frustrations
with dual diagnosis, (2) juggling the dual
diagnosis, (3) anticipating the future, and
(4) unpredictability.
Frustrations with dual diagnosis
Individuals with asthmaþdiabetes reported
more frequent physical and emotional
effects of having two chronic conditions.
One respondent noted, “I feel unhealthy
having asthma and diabetes; it makes me
sad and angry.” Another respondent
stated, “It makes me feel useless and con-
cerned, and at times, debilitated.” While
one may feel healthy for a period of time,
a crisis or disease progression from either
disease could result in major issues for the
other condition. For example, one respon-
dent described not being able to exercise as
she wanted to due to asthma, which impact-
ed her diabetes. Respondents realized they
are responsible for managing both condi-
tions. While some were angry, worried
and tired, others tried to remain optimistic
because they realized the alternative (i.e.
death) if they did not manage
both conditions.
Juggling the dual diagnosis
In general, asthma and diabetes were both
identified as important health concerns.
However, respondents differed in how
they viewed their asthmaþdiabetes.
Perceived effective management of one con-
dition did not always reflect the perceived
management of the other condition.
Severity of asthma (i.e. number of medica-
tions and triggers) and diabetes (i.e. ability
to make lifestyle changes, number of medi-
cations, and diabetes complications)
10
impacted asthmaþdiabetes management.
Some respondents found that diabetes is
more manageable than asthma, in part
because of the inability to control environ-
mental factors that may trigger asthma,
whereas the environment specific to diabe-
tes was perceived to be controllable. Some
respondents with seasonal asthma symp-
toms or mild asthma requiring only a
rescue inhaler found asthma easier to
manage than diabetes. However, many
respondents found asthmaþdiabetes to be
equally challenging, with only two partici-
pants indicating that they felt their asthma
and diabetes were well managed.
Anticipating the future
Most respondents indicated that they
expected their asthma to remain more or
less the same in the future, but saw an
opportunity for further improvement par-
ticularly through exercise or healthier
behaviors (healthier diet to lose weight).
Exercise was commonly mentioned as
having major limitations, which kept them
from fully committing to a more active life-
style. The outlook for diabetes in patients
with both conditions was slightly less opti-
mistic. Many respondents were unsure
about their ability to commit to the dietary
constraints and healthier lifestyle to
adequately manage diabetes. A few
respondents (n ¼ 3) were more attuned to
the connection between the two conditions,
recognizing the possibility for improvement
in both conditions by making healthier life-
style choices.
Unpredictability
Asthma exacerbations were a real and
unpredictable threat often lurking in the
background of respondents’ daily routine.
Many felt that their asthma could be
docile and manageable one moment and
aggressive and threatening the next. This
Chronic Illness 0(0)
constant threat and lack of predictability
created stress and worry for many. Several
(n ¼ 13) noted that they attempted to gain a
sense of control by avoiding social situa-
tions with triggers (e.g. going to the home
of a friend with pets). However, all
respondents mentioned times when they
were caught unaware by a trigger that led
to an attack (e.g. being stuck in an elevator
with someone wearing a lot of perfume).
The unpredictability of asthma can be
scary, but many had learned to avoid trig-
gers and prepare for the worst (i.e. always
carrying their rescue inhaler).
Exacerbations were scary and stressful for
many, as they fought for air. Memories of
attacks motivated individuals to carry their
rescue inhaler and may have increased
stress levels when they were exposed to a
trigger and wondered if an exacerbation
would occur again.
Discussion and conclusion
Discussion
In this study, we identified the emotional
impact of living with asthma or asth-
ma þ diabetes, using projective exercises.
Among those with asthma, with or without
diabetes, respondents described their health
condition as an animal who was unpredict-
able, a burden, and annoying. In the image
exercise, many respondents selected images
that portrayed their asthma as a long
tunnel with a heavy burden or a long, wind-
ing road with ups and downs. These image
descriptions were aligned with animal meta-
phors depicting disease burden and unpre-
dictability. Most projections related to
asthma were negative, although a few were
more optimistic, depicting a light at the end
the tunnel or optimism in the ability to make
progress with asthma management.
Respondents with asthma þ diabetes
projected their experience of living with dia-
betes in an overlapping, but broader
Litchman et al.
manner than that of respondents with
asthma only. Diabetes was similarly associ-
ated with unpredictability and disease
burden in the projective animal exercise.
However, these respondents also projected
their diabetes as silent and sneaky as well as
slowly taking over their health, consistent
with the progression of type 2 diabetes.1
These respondents offered a greater diversi-
ty of responses to the projective image exer-
cise for diabetes, which is perhaps related to
varying treatment options or time since
their diabetes diagnosis. Like the
projective-image responses for asthma,
those elicited for diabetes included a long
tunnel or winding road with twists and
turns, but diabetes was also sometimes pro-
jected to be “out of control” or a whirlwind
impacting all aspects of life. On the other
hand, more positive responses were elicited
for diabetes than for asthma, indicating
positive feelings about managing diabetes
well and the ability to live with diabetes.
Overall, however, these finding are aligned
with a study by Slightam et al.,27 which
found that in patients with multiple comor-
bid conditions, diabetes and lung condi-
tions were among the most bothersome.
When asked about co-managing these
diseases, asthmaþdiabetes respondents
noted the physical and emotional demands,
challenges and frustrations of simulta-
neously managing these conditions.
Despite more optimistic responses overall
for diabetes versus asthma, when asked
about their future experiences, asthmaþdia-
betes respondents were less optimistic with
diabetes than with their asthma. These
themes may reflect concerns and stress
over day-to-day asthma control versus the
long-term implications of suboptimal dia-
betes control.
Clinical implications
Understanding patient’s emotional response
to chronic conditions is an important aspect
11
of patient care,28,29 and can help providers
acknowledge and address patient concerns,
help establish appropriate expectations
about treatment and outcomes, and ideally
help patients develop healthy coping skills.30
Further, the Institute of Medicine (IOM)
cautioned against treating conditions sepa-
rately in Crossing the Quality Chasm: A
New Health System for the 21st Century.31
Rather, the report suggested that day-to-day
problem-solving skills overall may be more
important than disease-specific education.
Such skills may help patients overcome
self-care challenges such as medication use,
adherence to diet and exercise recommenda-
tions, and effective communication with
their health-care provider, as well as in man-
aging emotions.31
Knowledge of patients’ emotional
response to asthma and diabetes could be
incorporated into patient care and allow
providers to tailor conversations and mes-
sages that reflect patient hopes, expecta-
tions, and concerns.32,33 For instance,
knowing that a patient is optimistic about
diabetes but frustrated with the unpredict-
ability of asthma control help providers and
patients understand that optimism about
diabetes may facilitate medication compli-
ance, while frustration and fear of asthma
attacks may cause the same patient to avoid
exercise. This turn could lead to discussion
that taps into patient optimism (e.g. the
positive effects of exercise on diabetes and
asthma) and coping skills (e.g. avoiding
asthma triggers and use of a rescue inhaler
during exercise). This approach is poised to
create patient–provider relationships that
facilitate patient engagement and participa-
tion in treatment decisions.
However, in busy practice settings, pro-
viders may find it challenging to engage
patients at this level to identify and address
the emotional aspects of living with and
self-managing chronic diseases. Projective
exercises may help balance time and
resource constraints with the value of
12
information by quickly eliciting emotional
responses from patients. This technique
may also be useful in children, who have
been responsive to projective exercises and
may have a more limited ability to effective-
ly communicate emotions.34
Yet, there is a dearth of literature explor-
ing the use of projective-exercise interven-
tions. While our study provides insights
into patient emotional experience with dia-
betes and asthma, more research is needed
to develop and test projective-exercise inter-
ventions in clinical care for patients with
these conditions. Tools must be developed
and projective responses mapped to specific
emotional states, followed by research to
establish relationships between emotional
states and disease distress, self-
management behaviors, and outcomes. In
developing and testing projective exercises
in asthma and/or diabetes, researchers can
look to pain research, which also has a
strong emotional component. Abstract ani-
mations called “Painimations” have been
developed and tested for adults to commu-
nicate their pain and for providers to assess
that pain.35 This approach was well
received by patients, with 82% of respond-
ents agreeing or strongly agreeing that they
would use painimation to communicate
pain to their providers.35
In addition to having a role in clinical
practice, projective exercises could play an
important role in research. In the current
study, respondents could quickly identify
animals or abstract images that represented
their feelings about their asthma, diabetes or
asthmaþdiabetes using OBBs, a form of
social media. This technique has application
potential in research using other social
media platforms such as Facebook, Twitter
(such as tweet chats) or Instagram. This
approach may also be useful as an ice break-
er in focus groups, for example, to facilitate
participants’ willingness to openly discuss
health-related topics. Using projective exer-
cises as metaphors may elicit emotional
Chronic Illness 0(0)
responses in those who experience difficulties
with linguistics or expression.36
Limitations
The interpretation of our study findings has
limitations. First, respondents were middle-
aged, all had asthma, and those with diabe-
tes had type 2 diabetes, had Internet access,
and were familiar with OBB use (able to type
in English). Our findings cannot be general-
ized to adults with type 2 diabetes without
asthma, those with asthma and type 1 dia-
betes, or children. Second, this study used
OBBs, which did not capture emotional
nuances, such as body language or tone of
voice, that would have been captured using
in-person interviews. Third, respondents
were sampled by convenience from individ-
uals with computer access and time to par-
ticipate in the OBB, thus introducing a self-
selection bias whose impact on responses
is unknown.
Finally, while projective techniques have
a long history in health care, particularly
mental health and psychology, use in
chronic conditions and for developing inter-
ventions and guiding care is limited. While
useful for quickly exploring emotional
response to chronic conditions, the validity
and reliability projective exercises for this
purpose have not been established. We
took steps to reduce researcher bias in inter-
preting responses and identifying themes,
but caution should be used in interpret-
ing results.
Conclusion
In this study, respondents identified their
feelings about their asthma or asthmaþdia-
betes through animal-projective or abstract
image-projective exercises. Most respond-
ents with asthma had negative projections
related to asthma. Overall, their health con-
dition was associated with unpredictability,
burden, and annoyance. In contrast,
Litchman et al.
respondents with asthmaþdiabetes had a
greater diversity of responses to the
image-projective exercise for diabetes and
overall responses to the exercises were
more positive. Respondents found these
exercises easy to complete and several clin-
ical applications could be developed to elicit
the emotional impact of living with chronic
conditions. Projective exercises are useful in
helping patients express their emotional
state regarding chronic disease manage-
ment. Healthcare providers must familiarize
themselves with projective exercise techni-
ques and consider them a resource when
assessing patients.
Acknowledgements
N/A.
Contributorship
MLL, NAA, CMM and MF researched litera-
ture and conceived the study. MF was involved
in protocol development, gaining ethical approv-
al, and patient recruitment. MLL, NAA and MF
were involved in data analysis. MLL, NAA,
CMM and MF contributed to the writing sec-
tions of the manuscript. All authors reviewed
and edited the manuscript and approved the
final version of the manuscript.
Declaration of conflicting interests
The authors declared no potential conflicts of
interest with respect to the research, authorship,
and/or publication of this article.
Ethical approval
University of Utah Institutional Review Board,
approved (#00094395).
Funding
This research was supported by grant funds from
the Community Pharmacy Foundation
(#71324). Funding sources had no involvement
in the study design; collection, analysis or inter-
pretation of the data; writing of the report; or
decision to submit the article for publication.
13
Guarantor
ML.
Informed consent
Informed consent was obtained from the patient
(s) for their anonymized information to be pub-
lished in this article. Specifically, participants
were phone screened and gave verbal consent,
then directed to the Online Portal where they
completed electronic consent.
Trial registration
N/A.
ORCID iD
Michelle L Litchman https://orcid.org/0000-
0002-8928-5748
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