Children with Asthma
Home
Dust Mite Intervention
Article Citation(s):
Halken S, Host A, Niklassen U, Hansen LG, Nielson F, Pedersen S,
Osterballe O, Veggerby C, Poulsen LK. Effect of mattress and pillow
encasings on children with asthma and house dust mite allergy. Journal
of Allergy and Clinical Immunology. 2003;111:169-76.
Intervention Setting:
Participants’ homes
Target Population:
Children aged 6–15 years with well managed asthma and house dust
mite (HDM) allergy.
Program Description:
This investigation aimed to determine whether use of mattress and
pillow encasings resulted in effective long-term control of HDM allergen
levels, thereby reducing the need for asthma medication in the children.
Children were randomized to either an active treatment group that was
provided mattress and pillow encasings coated with semipermeable
polyurethane or a control group that received specially constructed
cotton placebo mattress and pillow covers that resembled the active
treatment covers. All encasings were delivered directly from the
manufacturer to the patients. During the study, the encasings were to
remain unwashed, and changes in the child’s mattress, bed and bedroom,
as well as structural changes in the residence, were not allowed. Three
children in the active group and four children in the placebo group were
excluded during the study when their families could not comply with
these controls or when the child did not take the medications as
prescribed. A clinical evaluation with lung function measurement,
adjustment of the pharmacologic treatment, and dust sampling from the
child’s mattress occurred at baseline and every 3 months during the
12-month study period. At inclusion and during baseline and treatment
periods, asthma medication was titrated to the lowest effective dose of
inhaled steroids and B2-agonists on the basis of symptoms,
need for B2-agonists, and peak flow recorded in diaries. Lung
function measurements were determined using spirometry. Diaries were
used to record morning and evening peak expiratory flow symptoms
(symptom scores of 0–3 with 0 being no symptoms and 3 being worst case)
during night and day. The number of doses of B2-agonist used
on demand were recorded for 2 weeks before the visits. Forty of the 47
children using inhaled steroids used the same product during the entire
study period. All children used short-acting B2-agonist as
needed during the study period.
Evaluation Design:
A randomized controlled study approach was used.
Sample Size:
The study comprised 60 children with physican-diagnosed asthma, a
positive skin-prick test response to HDM, a positive bronchial
provocation test result with HDM allergen extract, and a measured amount
of dust from the child’s mattress.
Outcome Measures/Results:
Outcome measures included reduction in HDM allergen concentrations
and reductions in use of inhaled steroids. Concentrations of total HDM
allergens on mattresses in the active group significantly decreased but
not in the placebo group after 6 and 12 months. The daily dose of
inhaled steroids (budesonide or fluticasone) was reduced by at least 50%
in significantly more children in the active group than in the placebo
group (73% vs. 24%, p<.01) after 12 months. The approximate 50%
reduction in inhaled steroid use among the children in the active
treatment group occurred without worsening in symptoms or lung function
or need for rescue medication. Encasing mattresses and pillows resulted
in a significant long-term reduction in both HDM allergen concentrations
on mattresses and in the need for inhaled steroids in children with
asthma and HDM allergy.
Materials available:
None
European Multi-Center Mite Allergen Sensitization Program
Article Citation(s):
Tsitoura S, Nestoridou K, Botis P, Karmaus W, Botezan C, Bojarskas J,
Arshad H, Kuehr J, Forster J. Randomized trial to prevent sensitization
to mite allergens in toddlers and preschoolers by allergen reduction and
education. Archives of Pediatric Adolescent Medicine 2002;156:1021-27.
Associated citations:
Arshad SH, Bojarskas J, Tsitoura S, et.al. Prevention of sensitization
to house dust mite by allergen avoidance in school age children: A
randomized controlled study. Clinical and Experimental Allergy
2002;32(6):843-49).
Halmerbauer G, Gartner C, Schirl M, et al. Study on the prevention of allergy in children in Europe [SPACE]: allergic sensitization at 1 year of age in a controlled trial of allergen avoidance from birth. Pediatric Allergy and Immunology 2003;14:10-17.
Intervention Setting:
This multi-site community-based study was conducted in homes in four
countries: England, Germany, Greece, and Lithuania.
Target Population:
Toddlers and preschoolers who initially were not sensitized to mite
allergens and had at least one parent with atopic symptoms and
sensitization were targeted for this study.
Program Description:
The objective of this study was to determine the effects of the
reduction of mite allergen exposure on prevention of sensitization to
house dust mites and development of allergic disease in toddlers and
preschoolers age 1.5–5 years who were at high risk for atopy. All
parents received an educational program. All were given background
information about allergies and the higher risk for their child to
develop an allergy. Booklets on environmental influences on children’s
health and preventive recommendations were provided to the intervention
group, along with additional oral explanations. A similar booklet,
without information about mattress covers, was distributed to parents of
the children in the control group. The intervention included providing a
special dust mite-impermeable encasement for all beds in the room at
home where the children in the intervention slept. Intervention group
parents received extensive advice about measures to reduce dust mite
allergens in the child’s room (carpet removal; hot washing of sheets,
pillow, blankets, and toys; cleaning tips; ventilation; elimination of
pets in the room; and avoidance of cigarette smoking). A healthcare
worker visited participants’ homes at 6 months to ensure the encasements
were in place and to repeat instructions for reducing house dust mite
allergens. Information about the child’s atopic symptoms was obtained at
6 months in health centers. All the families in the control group in all
four locations received the following common recommendations: avoid
exposure to pets in bedrooms, ensure good ventilation of rooms, and
avoid cigarette smoking. Likewise, information about the child’s atopic
symptoms was obtained at the 6-month follow-up. After 12 months, all
parents and their children were invited to participate in a follow-up
examination that included a skin-prick test or immunoglobulin E (IgE)
determination and a questionnaire on symptoms.
Evaluation Design:
A randomized controlled study approach was used.
Sample Size:
The study comprised 636 children with a mean age of 3.1 years.
Inclusion criteria included: 1) local residence; 2) a positive parental
screening questionnaire result (history of asthma, atopic eczema, or hay
fever) and positive parental skin-prick test or IgE; 3) no sensitization
to mite allergens at the beginning of the study; and 4) atopic
manifestations, such as bronchial asthma, hay fever, or atopic eczema.
Because investigators were interested in new cases of sensitization to
mite allergens, they excluded all children whose skin prick tests were
positive for D pteronyssinus or D farinae in
the initial screening.
Outcome Measures/Results:
The primary outcome measure was sensitization to mite allergens as
indicated by skin prick test or specific Ig E. Of the 330 children in
the intervention group, 10 (3%) had sensitization to mite allergens
compared with 20 (6.5%), in the control group, a statistically
significant difference. The finding suggests that a simple program of
prevention measures in childhood may reduce the risk for later
development of asthma. The prevalence of atopic clinical manifestations
was available for the 566 children who participated in the 12-month
follow-up. Children with sensitization had a higher prevalence of
symptoms of asthma and eczema (two to three times more common) and a
higher prevalence of reported physicians’ diagnoses of food allergy and
asthma than non-sensitized children.
Materials available:
Dr. Wilfried Karmaus, Associate Professor, Department of
Epidemiology, Michigan State University, 4660 S Hagadorn Rd., Suite 600,
East Lansing, MI 48823; Telephone (517) 353-8623 ext. 115; fax (517)
432-1130;
www.epi.msu.edu/faculty/directory/karmaus.htm.
[external link]
Health Buddy Asthma Intervention
Article Citation:
Guendelman S, Meade K, Benson M, Chen YQ, Samuels S. Improving asthma
outcomes and self-management behaviors of inner-city children: A
randomized trial of the Health Buddy interactive device and an asthma
diary. Archives of Pediatric and Adolescent Medicine 2002;156(2):114-20.
Intervention Setting:
Participants’ homes and an outpatient clinic at Children’s Hospital
Oakland, Oakland, California
Target Population:
Inner-city children aged 8–16 years with persistent
physician-diagnosed asthma. The child’s caregiver had to speak English,
and the home had to have telephone.
Program Description:
The objective of this study was to assess the effectiveness of an
interactive health communications device programmed for the management
of pediatric asthma. This approach departs from conventionally delivered
asthma education programs or interactive computer-based educational
programs that do not rely on the interaction between the child and a
health professional, educator, social worker, or other instructor.
Health Buddy, programmed for the care of inner-city children with
asthma, monitors asthma symptoms, quality of life, and self-care and
sends information through a secured Web site to the health-care
provider. The hypothesis was that by allowing children an opportunity to
acquire knowledge about asthma and symptom recognition and receive
immediate feedback on their decisions and behaviors, asthma symptoms
among Health Buddy users would decrease. Continued use of the Health
Buddy would help to increase self-care behaviors, which in turn would
reduce symptoms.
All children were prescribed daily prevention medication and a quick-relief medication to use as needed. A nurse conducted a kickoff standardized teaching session. Each child received a peak flow measuring device and instruction on its use to establish personal best. They were instructed to take daily peak flow measurements and to record them in their diary. Children were then randomized and instructed how to use the assigned tracking method to record their peak flow readings and symptoms. The intervention children assigned to Health Buddy were given a demonstration on how to use the device and explained how to install it at home. The control group used an asthma diary. Each day the nurse coordinator queried to the intervention children using a standard Internet browser. The children answered the queries by pressing buttons on the device. The device automatically telephoned a data processing center at night, which processed the responses and published them to a secure website the next day. The nurse coordinator then reviewed the information. Each answer to a question received immediate feedback from the device: praise for a correct answer or encouragement to try again. Additionally, asthma facts and trivia questions that changed daily were included on Health Buddy program to pique children’s curiosity and enhance learning. The dialogs were designed for a third-grade reading level. By protocol, children had to access the device once a day. All children were asked to return for two follow-up visits at 6 and 12 weeks during which the nurse interviewed the child and delivered a standardized teaching session that reinforced peak-flow measurement compliance with meds and tracking symptoms. A physician examined each child during these follow-up visits.
Editor’s Note:
Health Buddy was developed by Health Hero Network, Mountain View,
California. The device, connected to a home telephone, can be programmed
to present questions and information on a screen and to record
responses. Example of exchange between the child and Health Buddy: “Hi!
Thanks for hanging out with your Health Buddy today. Your questions are
now ready for you. Have you had any coughing or wheezing in the last
day?” If the child answers “Yes”: “This could be a sign that your asthma
is acting up. You may need to take your Albuterol as directed by your
doctor when you are coughing and wheezing.” If the answer is “No”:
“That’s great! You must be taking your preventor [sic] medicine. Did you
miss out on any sports, exercise, or play yesterday because of your
asthma?” If child answers “Yes”: “Sorry to hear you missed out on some
fun. If your asthma acts up while doing sports, exercise, or play,
please talk to your doctor about this. It is important to know what
activities might trigger your asthma.” If the answer is “no”: “That is
fantastic! Sports and exercise are fun and healthy.”
Evaluation Design:
A randomized controlled trial design
Sample Size:
Sixty-six participants in the intervention group, and 68 in the
control group
Outcome Measures and Results:
Outcome measures included limitation to activity, peak flow reading
in the red zone (<50% of the personal best) or yellow zone (50%-80% of
the personal best) in the 2 weeks before the interviews, missed school
days, and use of health services because of asthma in the preceding 6
weeks. Children in both arms of the study reported a decrease in asthma
symptoms and decrease in peak flow readings in the yellow or red zone at
6 weeks and 12 weeks compared with baseline. Fewer children in the
intervention group had peak flow readings in the yellow or red zone
during the 2 weeks before the 6-week follow-up visit compared with
control group children. Children in the intervention group were less
likely to report limitation in activities. The odds of an urgent call
for health services with Health Buddy were 0.43 of the odds of an urgent
call with the asthma diary.
Availability of Protocol and Materials:
The principal investigator of the study plans to replicate this
first trial in a different setting using a health-care plan and local
physicians. The protocol and materials are not available for widespread
distribution.
Case Study:
None
Inner-City Pediatric Home Intervention
Article Citation:
Carter MC, Perzanowski MS, Raymond A, Platts-Mills TA. Home intervention
in the treatment of asthma among inner-city children. Journal of Allergy
and Clinical Immunology 2001;108(5):732-7.
Intervention Setting:
Participants’ homes
Target Population:
Low socioeconomic, inner-city, minority children with asthma
Program Description:
This study investigated whether implementing low-cost measures for indoor
allergen avoidance could reduce the number of sick days and unscheduled
visits to health care facilities for asthma, and thus be considered a
treatment for asthma among inner-city children. An intervention in
patients’ homes was hypothesized to affect housekeeping and other aspects
of asthma care. Participants were randomized to one of three groups: an
active intervention group; a placebo group; or a second group. The
children were tested for allergies at the end of the study, ensuring that
neither the families nor the clinic staff knew which patients were
allergic. Avoidance measures for the intervention group included
mite-impermeable mattress and pillow covers, effective roach traps, and
instructions to wash the bedding once a week in hot water. Parents in this
group were also given instructions about cleaning measures to control dust
mites and cockroaches. The placebo group received mite-permeable mattress
and pillow covers, ineffective roach traps, and instructions to continue
their normal practice of washing the bedding. Patients in the intervention
and placebo groups were given a peak flow monitor, peak flow charts, and a
history sheet for symptoms and medication use. They were requested to fill
these in for 2 weeks after each home visit. Children in the control group
continued to have their routine medical care provided at the clinic, but
allergen control measures were not discussed. Only one home visit was
conducted 1 year after enrollment in the study for the control group. The
homes of the active and placebo group children were visited at enrollment
for the initial intervention (described above) and again at 3, 8, and 12
months after enrollment to collect dust samples and inspect the house. The
dust samples were sieved and assayed for dust mite, cockroach, and cat
allergen. During follow-up visits mattress covers were checked, and
replaced as needed, up to six cockroach traps were provided, and advice
was given about their placement and about cleaning the house. The homes of
children in the control group were visited for dust collection after 12
months. No intervention occurred in these homes. All the children received
skin tests at the end of the study for dust mite, cockroach, cat,
alternaria, rat, and mouse sensitivities. Hospital and clinic charts were
examined, and the number of unscheduled visits was recorded for a 2-½ year
period (1 year before enrollment and 18 months after enrollment).
Evaluation Design:
A blinded, randomized, controlled study was used that evaluated three
groups of participants: an active intervention group; a placebo group; and
a control group that received no intervention.
Sample Size:
A total of 104 children aged 5–16 years who had asthma and whose primary
health care was provided by a clinic in Northwest Atlanta or at an urban
Atlanta pediatric hospital. Children were offered enrollment when they
accessed medical care.
Outcome Measures and Results:
Unscheduled clinic visits, emergency department visits, acute visits
for asthma, and changes in mite and cockroach allergen levels were the
measured outcomes. Acute visits for asthma among the active intervention
group decreased 33% from a 15-month period (beginning 18 months before
enrollment) to the end of the 15-month period after enrollment. In the
placebo group, acute visits for asthma decreased 30% during the same
period. By contrast, in the control group, acute visits increased by 6%. A
combination of sensitization and significant exposure to dust mite or
cockroach allergen was present in 59% and 43% of the study participants,
respectively. A decrease in allergen concentration was judged substantial
if the decrease was 70% or greater over the four visits. A substantial
decrease of mite allergen occurred only in 37% of the homes with no
difference between the active and placebo groups. Forty-one percent of
homes in the intervention group with cockroach allergens showed
significant decrease in such allergens compared with 32% of homes among
the placebo group. Analyzing the outcome for children who were
specifically allergic to mite or cockroach demonstrated a significant
effect for decreased mite allergen but not for cockroach allergen.
Children allergic to and exposed to mites who had a significant decrease
in mite allergen concentration showed a statistically significant decrease
in acute visits. Among the 14 children with mite allergy who had a
decrease in visits, the mean change in mite allergen was –22.4% compared
with +30.1% among the 15 children without a decrease in visits. This
statistically significant decrease in acute visits among children with
mite allergy who had a decrease in mite allergen strongly supports the
relevance of allergen avoidance as an objective of treatment in this
population. Although parents reported visible decrease in numbers of
cockroaches, decreases in cockroach allergens were not associated with
change in acute visits.
Availability of Protocol and Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Pediatric Asthma Center Program
Article Citation:
Harish ZH, Bregante AC, Morgan C, Fann CSJ, Callaghan CM, Witt MA,
Levinson KA, Caspe WB. A comprehensive inner-city asthma program reduces
hospital and emergency room utilization. Annals of Allergy and Asthma
Immunology 2001;86:185-189.
Intervention Setting:
Pediatric asthma center in New York City
Target Population:
This research targets inner-city, pediatric asthma patients ages
2–17 and their parents/caregivers recruited from the pediatric emergency
department (ED) of the Bronx Lebanon Hospital in South Bronx. The
hospital serves a predominantly Hispanic (58%) and African-American
(37%) population.
Program Description:
The study objective was to evaluate the efficacy of a comprehensive
asthma program on ED visits and hospital admission rates in an
inner-city pediatric population. The intervention consisted of three
1-hour visits conducted 2 weeks apart. The activities in the first visit
included review of patient history, asthma regimen with adjustment to
the National Asthma Education and Prevention Program (NAEPP) guidelines
as needed, proper use of a metered dose inhaler and spacer, and a review
of clinical signs of asthma. A computerized asthma education program was
used to present information on asthma pathogenesis and medications. The
second visit included teaching the use of a peak flow meter for patients
over age 5 and instructing the children and caregivers on use of an
asthma emergency plan. Visit three included skin testing for common
perennial and seasonal aeroallergens. Atopic patients received detailed
training in environmental control measures. Mattress and pillow
encasements were provided to patients allergic to dust mites. Caregivers
were encouraged to call program staff any time if symptoms did not
respond to one treatment of inhaled bronchodilators. Patients were given
inhaled and oral corticosteroids to be used only when instructed by the
provider on call.
Evaluation Design:
The evaluation consisted of a prospective randomized controlled
trial. A visiting nurse reviewed medication use and environmental
allergens at home. Questionnaires were sent to each patient’s home each
month asking a) “Has your child visited the ED for asthma in the last
month?” – if ‘yes’ the number of times, b) “Was your child admitted to
the hospital for asthma in the last month?” – if ‘yes’ the number of
days, c) “Did your child miss any school days because of asthma?”
Participants were awarded a lottery ticket for each completed
questionnaire.
Sample Size:
Sixty children were in the treatment group, and 69 were in the
control group.
Outcome Measures/Results:
Outcome measures include ED attendance and hospitalizations. In the
first study year, 32 patients in the treatment group visited the ED 73
times; 46 patients in the control group visited the ED 269 times. The
mean number of ED visits per patient per month was 0.1 in the treatment
group and 0.326 for the control group. The decrease in ED use by
treatment patients was statistically significant for 6 months of the
year including the last 4 months. There were fewer admissions in the
treatment group (22) than in the control group (29). In the second year
of the study, the mean number of ED visits per patient per year was
0.396 for treatment group and 1.0 for the control group, a statistically
significant difference. Also, in the second year, 14 (26%) of the 53
patients in the treatment group visited the ED at least once, compared
with 32 (53%) of the 60 patients in the first year. In first year, 53%
of the treatment group visited the ED compared with 26% in the second
year, and 27% of the treatment group was admitted to the hospital in the
first year compared with 11% in year 2.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Sentara’s Asthma Disease Management Program
Article Citation(s):
Axelrod RC, Zimbro KS, Chetney RR, Sabol J, Ainsworth VJ. A disease
management program utilizing "life coaches" for children with asthma.
Journal of Clinical Outcomes Management 2001;8:38-42.
Intervention Setting:
Patients’ homes
Target Population:
Children with asthma insured by Sentara Health Management referred to
the program by health plan case managers or primary care physicians.
Participants had diagnosed asthma and one or more of the following: 1) one
or more hospital admissions; 2) more than two emergency department visits
in a 6-month period; 3) used beta-agonist reliever medications and little
or no anti-inflammatory controller medications.
Program Description:
The program objective was to help children achieve and maintain
control of asthma-related symptoms and to reduce resource use and
associated costs. Sentara’s Asthma Disease Management Program used "life
coaches" and home-based strategies to assess, teach, and monitor asthma
self-management (defined as successful use of the treatment plan,
successful behavior and/or lifestyle changes, and decreased use of
intensive, higher-cost services) by children and their caregivers. Life
coaches were registered nurses who were certified in asthma disease
management and knowledgeable about community and family resources. The
program provided education and support that promotes optimal independent
functioning to reduce the need for more intensive and higher-cost
services. Once a child was enrolled in the program, the life coach
scheduled a 2–3 hour home-care visit, reviewed the child’s history,
performed a physical and psychosocial assessment, evaluated past resource
use, and assessed knowledge about asthma management. The life coach
determined the child’s asthma severity level and set a return visit
pattern with the caregiver depending on the child’s severity level and the
family needs. The child was provided a peak flow meter and instructed in
its use at the initial meeting in the home. After the first in-home
meeting, the life coach and the primary care physician initiated the
Asthma Program Treatment Plan, an asthma action plan, based on the
individual needs of the child and caregiver. In later in-home meetings,
the life coach taught the child and caregiver asthma self-management. Both
the child and the caregiver were trained to use the Asthma Program
Treatment Plan, including when to call the life coach when symptoms
intensified or current treatment did not work. Frequently, the life coach
could provide effective telephone intervention, preventing exacerbation of
symptoms. Life coaches were available 24 hours a day, 7 days a week, to
intervene and assist the child. The goal of asthma education was to
increase compliance with use of appropriate asthma medications and to
encourage children and their caregivers to make comprehensive behavior and
lifestyle changes. After the initial visit, life coaches made routine
telephone calls to monitor the children and to provide early intervention
as needed to prevent complications. During the monthly follow-up calls,
life coaches spoke with both the child (those aged > 6 years and
older) and the caregiver to assess medication use, treatment plan results,
number of days missed from school and work, and success at making home and
life-style changes. Children were followed for 1 year or until
self-management was achieved.
Evaluation Design:
Pre-post design
Sample Size:
A total of 294 children participated in the study
Outcome Measures/Results:
Outcome measures included medication use, hospitalizations, emergency
visits, primary and specialty care visits, and costs. After enrollment,
children were significantly less likely to be admitted to the hospital, a
decline of 45%. Emergency department visits decreased 17% after
enrollment, and primary care visits declined by 19%. No change was seen in
visits to allergy or pulmonary specialists. The
beta-agonists–to–anti-inflammatory medication ratio declined 20%. The
average health care costs per child per month – including costs of
hospital admissions, emergency visits, primary care and specialist visits,
home health visits and asthma medications – declined by 25%.
Materials available:
None
The Canadian Asthma Primary Prevention Study
Article Citation(s):
Becker A, Watson W, Ferguson A, Dimich-Ward H, Chan-Yeung M. The
Canadian Asthma Primary Prevention Study: outcomes at 2 years of age. J
Allergy Clin Immunol 2004;113(4):651–6.
Intervention Setting:
Homes of study participants
Target Population:
This study focused on a cohort of infants at high-risk for
development of asthma on the basis of an immediate family history of
asthma. High-risk infants were defined as those with at least one
first-degree relative with asthma or two first-degree relatives with
other classic IgE-mediated allergic diseases as identified during the
mother’s third trimester of pregnancy.
Program Description:
This study sought to determine the effectiveness of a multifaceted
intervention program in the primary prevention of asthma in high-risk
infants. The hypothesis was that there existed a potential for long-term
modification of the infant’s risk for asthma during this small window of
opportunity. After baseline assessment, a sealed envelope was opened
that determined the family’s allocation to the intervention or control
group. The control group did not receive specific information about
intervention measures but followed the usual care recommended by their
primary care physicians. Home visits were carried out during the third
trimester of pregnancy, at 2 weeks, and at 4, 8, 12, 18, and 24 months
after the birth of the child. Demographic and health characteristics
were gathered through use of a standardized questionnaire. Home
characteristics were assessed using a questionnaire and a walk-through
survey.
The intervention program included the following:
- The infant’s mattress and all mattresses and box springs in the parent’s bedroom were encased to limit exposure to house dust mites. Families were instructed to wash all bedding weekly using the hot cycle of their washing machines. Benzyl benzoate powder was applied to carpets in the infant’s bedroom, the parent’s bedroom, and the most commonly used room. Benzyl benzoate foam was applied to upholstered furniture in the most commonly used room before birth and at 4 and 8 months after birth.
- Families were counseled to remove cats, dogs, or both from the home, or to keep pets outside the home, or at least outside the infant’s bedroom.
- For environmental tobacco smoke (ETS), parents were counseled on smoking cessation and families were instructed to keep homes smoke free.
- Families were encouraged to avoid daycare until after the first year of life. Nurses reinforced various avoidance measures at each home visit.
- Mothers were encouraged to breast feed their infant for at least 4 months and for the first year if possible. Where breast-feeding was not possible, partially hydrolyzed whey formula was supplied until 12 months of age.
During each home visit dust samples were collected from the infant’s and parent’s bedroom floors and mattress and the floor and upholstered furniture in the most commonly used room. Samples were analyzed in duplicate for house dust mite and cat allergens. Allergens from these sites at each time were averaged. Each child was seen by a pediatric asthma specialist blinded to the study group and to compliance with intervention and who did not provide health care to the families. They examined the child and conducted a structured interview to record symptoms and physical findings. Allergy skin tests were conducted using house dust mite (HDM), cat, dog, cockroach, Alternaria species (fungi), cow’s milk, egg white, wheat, soy, and peanut allergens.
The intervention successfully decreased HDM exposure in the first and second year. There was significantly less cat allergen exposure in intervention homes at 2 weeks and 4 months. Mothers in the intervention group breast-fed longer and delayed introduction of solid food longer than mothers in the control group. Significantly fewer intervention group children were in daycare by 1 year of age. Finally, there was less ETS exposure in intervention homes.
Evaluation Design:
This was a prospective, prenatal, randomized, controlled clinical
trial. Mothers of infants were randomized to an intervention group or a
control group. The study included infants born between October 1994 and
August 1996.
Sample Size:
Participants included 545 mothers of 549 high-risk infants for
asthma
Outcome Measures:
Prevalence of asthma* and atopy at age 2 years
in high-risk infants
Results:
At age 2 years, 19.5% of children in this high-risk cohort satisfied the
criteria of having asthma, and 14.5% had positive skin test responses to
at least one common allergen. At age 2 years, 16.3% of intervention
group children and 23.0% of control children had asthma; 15.6% of
children in the intervention group and 13.7% of control children were
atopic. The intervention had a significant effect on the prevalence of
asthma at age 2 years, decreasing the number of children given a
diagnosis of possible and probable asthma in the intervention group
(16.3%) compared with the control group (23.0%).
The main difference between the control and intervention groups was in the substantial reduction of persistent asthma, defined as asthma present at both year 1 and 2, in the intervention group (4.9%) vs. 11.3% for the control group, a 60% decrease in the intervention group. Recurrent wheeze was defined as three or more episodes of wheezing, each lasting 1 week or more. At 2 years of age, significantly fewer children had recurrent wheeze in the intervention group (1.0%) compared with control group (3.5%). The intervention had its greatest effect on recurrent wheeze with a 90% reduction in the intervention group compared with that seen in the control group at 2 years.
*Asthma was defined as the sum of children with a diagnosis of both possible asthma and probable asthma. Possible asthma was defined as at least two distinct episodes of cough each lasting for 2 or more weeks; at least two distinct episodes of wheeze, each lasting 2 or more weeks; or in the absence of a cold, at least one of the following: nocturnal cough (at least once a week) and hyperpnea-induced cough or wheeze. Probable asthma was defined as at least two distinct episodes of cough, each lasting 2 or more weeks, or at least two distinct episodes of wheeze, each lasting 1 or more weeks and one of the following: nocturnal cough lasting a week in the absence of cold, hyperpnea-induced cough or wheeze, response to treatment with B-agonist, anti-inflammatory drugs, or both.
The Inner-City Asthma Study-Environmental Intervention
Article Citation(s):
Morgan WJ, Crain EF, Gruchalla RS, O’Connor GT, Kattan M, Evans III
R, et al. Results of a home-based environmental intervention among urban
children with asthma. N Engl J Med 2004;351:1068–80.
Intervention Setting:
Study participants’ homes
Target Population:
Inner-city children with atopic asthma
Program Description:
The objective of this study was to determine whether an
environmental intervention tailored to each child’s allergic
sensitization and environmental risk factors could improve
asthma-related outcomes. Previous studies of environmental interventions
for patients with asthma have focused on a single allergen, such as dust
mites or environmental tobacco smoke, rather than on the multiple
exposures encountered by many urban children with asthma.
Eligibility was limited to residents of census tracts in which at least 20% of households had incomes below the federal poverty level. Eligibility criteria included at least one asthma-related hospitalization or two unscheduled, asthma-related visits to the clinic or emergency department during the previous 6 months and a positive skin test in response to at least 1 of 11 indoor allergens. A baseline clinical evaluation included questionnaires on complications related to asthma and the home environment, and skin testing was performed. A baseline home evaluation involved direct visual inspection and dust collection from the child’s bedroom. The home evaluation team collected separate, vacuumed dust samples from the child’s bedroom floor and bed. Samples were tested for dust mite, cockroach, cat, and dog allergens.
Children were randomly assigned to the control group or the intervention group by blocked randomization within a site. Families in the control group received visits only for evaluation at 6-month intervals throughout the study. The goal of the intervention was to provide the child’s caretaker with the knowledge, skills, motivation, equipment, and supplies to perform comprehensive environmental remediation. Researchers educated the family regarding the importance of the mitigation behavior and its effectiveness and modeled the targeted behavior. Caretakers performed the mitigation behavior while the environmental counselors provided feedback and encouragement.
The intervention was organized into six modules that focused on remediation of exposure to dust mites, passive smoking, cockroaches, pets, rodents, and mold. Intervention activities were tailored to each child’s skin-test-sensitization profile and environmental exposures on the basis of the caretaker’s report and the study staff’s observations during the baseline home evaluation. During the 12-month intervention, two research assistants conducted five mandatory and two optional home visits. All visits were followed by a telephone call to address any barriers to implementing the remediation plan.
During the first visit, the intervention teams taught the caretaker about the role of allergens and irritants in the child’s asthma. They also introduced the environmental intervention plan, which included the creation of an environmentally safe sleeping zone. Allergen-impermeable covers were placed on the mattress, box spring, and pillows of the child’s bed at the first visit. The teams gave families a vacuum cleaner equipped with a high-efficiency particulate air (HEPA) filter and instructed them on its use. A HEPA air purifier was set up in the child’s bedroom if the child was exposed to passive smoking, sensitized and exposed to cat or dog allergens, or sensitized to mold. Professional pest control was provided for children sensitized and exposed to cockroach allergen. Follow-up surveys of the home environment and collection of dust allergens were repeated at 6, 12, 18, and 24 months to assess changes in the home environment.
Evaluation Design:
This randomized controlled trial lasted 1 year. It included
education and remediation of exposure to both allergens and
environmental tobacco smoke. Home environmental exposures were assessed
every 6 months and asthma-related complications were assessed every 2
months during the intervention and for 1 year after the intervention.
Interviewers conducted standardized telephone interviews with each
child’s primary caretaker every 2 months during the year of the
intervention and the year after the intervention. They collected data on
asthma symptoms, medication use, and health care use.
Sample Size:
The sample included 937 children, ages 5–11 years (mean age 7.7
years), in six major U.S. cities (Boston, Chicago, Dallas, New York
City, Seattle-Tacoma, and Tucson), whose asthma had been diagnosed by a
physician at research centers in those cities. Most of the children were
black or of Hispanic descent, as reported by each child’s caretaker.
Outcome Measures/Results:
Children in both groups had a high prevalence of allergic
sensitization to cockroach and dust-mite allergens. Exposure to tobacco
smoke and airborne allergens was common. Detectable levels of cockroach
allergens were found in 68.4% of bedrooms. Dust-mite allergens were
found in 84.1% of bedrooms. Additionally, 76.8% of children sensitive to
cockroach and 86.7% of those sensitive to dust-mite allergen had
detectable levels of these allergens in their bedrooms. Home
environmental interventions resulted in significantly fewer dust-mite
allergens in the bed and cockroach and dust-mite allergens on the
child’s bedroom floor. Those improvements remained significantly higher
for the intervention group in the second year.
The primary health outcome was the maximal number of days with asthma symptoms in the 2 weeks before the telephone interview (conducted every 2 months for 2 years). Symptom days were defined as the largest value among the following three variables:
- number of days with wheezing, tightness in the chest, or cough;
- number of nights with disturbed sleep as a result of asthma; and
- number of days on which the child had to slow down or discontinue play activities because of asthma.
The intervention group reported significantly fewer symptoms of asthma during the intervention year and the follow-up year. The maximal number of days with symptoms was lower in the intervention group by 0.82 day per 2-week period in the first year and 0.60 day per 2-week period in the second year. This observed reduction in symptoms translates into 34 fewer days with reported wheeze during the 2 years of the study among children in the intervention group compared with those in the control group. The interventions also helped significantly reduce disruptions of caretakers’ plans, caretakers’ and children’s lost sleep, and school days missed by the children in the intervention group. The intervention resulted in 13.6% fewer unscheduled visits for asthma per year, 19.3 fewer days with symptoms per year, and 20.7% fewer missed school days per year.
United Healthcare Asthma Management Program
Article Citation(s):
Georgiou A, Buchner D, Ershoff DH, Blasko KM, Goodman LV, Feigin J.
The impact of a large-scale population-based asthma management program
on pediatric asthma patients and their caregivers. Annals of Allergy,
Asthma, and Immunology. 2003;90:308-15.
Intervention Setting:
Participants’ homes
Target Population:
Children aged 5–3 years with asthma in the United States whose
families were covered by the United Health Plans were eligible for this
study.
Program Description:
The objective of this study was to determine the impact of an asthma
management program on pediatric patients with asthma and their
caregivers over a 12-month period. In this longitudinal study, 401
randomly selected households with children with asthma completed a
survey questionnaire before and after 12 months of participation in the
Asthma Management Program. Information collected included daytime and
nighttime asthma symptoms, functional impact of the disease,
interference attributable to treatment, and impact on family activities.
In addition to seeking information from caregivers on process measures
(such as the use of written action plans, knowledge about asthma
triggers, attack management, use of a peak flow meter), caregivers were
questioned about lost work and lost school days related to their child’s
asthma. Additional information about participants was supplemented by
asthma-related medical care use obtained from the computerized claims
database.
The Asthma Management Program interventions were tailored to each child’s asthma health risk and need as determined from medical records, filled prescriptions, and the self-reported survey. The interventions for all participants consisted of an educational booklet, asthma treatment guides and seasonal and quarterly mailings about asthma-related issues (called "educational touches"), and an asthma control kit that included a peak flow meter and an educational video. All "high-needs" asthma patients were offered one-on-one asthma education and intensive "telephonic care management" conducted by registered nurses and respiratory therapists. Telephonic care managers provided feedback to patients’ physicians when appropriate. Additionally, all high-risk members received an asthma control kit that included a peak flow meter and an educational video. All physicians were given a list of their identified asthma patients, including a medication and utilization history, and were provided copies of the NAEPP guidelines. Physicians of high-risk members were sent a letter regarding their patients’ involvement in the program and were encouraged to provide these patients with asthma action plans.
Evaluation Design:
A one-group pretest-posttest design was used with a comparison of
responses to questionnaire items before and after exposure to the asthma
health management program.
Sample Size:
A total of 1,003 patients were randomly sampled from a group of
3,585 patients in 17 regional health-care districts. Only 401 patients’
families completed the study.
Outcome Measures/Results:
Outcome measures related to the child’s health included daytime
symptoms, nighttime symptoms, functional limitation, life interruptions
resulting from treatment, impact on family activity, emergency or
inpatient care for asthma, and missed school days. Caregiver measures
included missed workdays because of the child’s asthma. Data indicated
higher post intervention scores on all of the child’s quality of life
parameters. The largest improvement was detected for nighttime symptoms
(a gain of 5.8 points), the smallest change was detected for daytime
symptoms (2.4 points). The proportion of children classified as having
mild symptoms based on frequency of reported symptoms increased from
66.9% at baseline to 75.3% at follow-up. The percentage of patients
requiring inpatient admission or emergency care decreased significantly,
(9.7% vs. 5.5%) according to claims data from the baseline year and the
12-month period of intervention preceding the follow-up. The percentage
of children who missed one or more school days because of asthma
decreased significantly from 36% to 23%. Forty-eight (17.1%) working
caregivers reported having missed 1 or more days from work during the
previous 4-week period because of the child’s asthma in the
preintervention period; this figure decreased to 27 (9.6%) at follow-up.
Of the 48 respondents reporting 1 or more missed workdays at baseline,
38 reported no missed days at follow-up. The mean annualized number of
caregiver workdays missed because of asthma care fell from 3.8 days at
baseline to 1.8 days at follow-up. This computed to a baseline annual
mean of 30.5 missed hours per employed primary caregiver of an child
with asthma, compared with 14.4 hours per year at follow-up. The
estimated indirect costs related to lost caregiver work time suggested a
savings of $327.00 per employed caregiver resulting from the reduction
in lost work hours.
In 2003, this program was implemented in over 30 United Healthcare Plans.
Materials available:
Materials are not available for widespread distribution.
Wee Wheezers at Home
Article Citation:
Brown JV, Bakeman R, Celano MP, Demi AS, Kobrynski L, Wilson SR.
Home-based asthma education of young low-income children and their
families. Journal of Pediatric Psychology 2002;27(8):677-88.
Intervention Setting:
The home of the patient’s caregiver
Target Population:
Inner-city African-American children aged less than 7 years from
low-income families in metro Atlanta, Georgia, who made a health care
visit for asthma in the preceding year, who had been prescribed medication
for asthma for daily use, and whose primary caregiver spoke English.
Program Description:
Families were recruited for the study during clinic visits or by
invitation letters and telephone calls. Participants were paid $75 for
three study-related visits by a social worker including induction and two
follow-up data collection visits. Researchers had previously adapted and
piloted the Wee Wheezers education program (Wilson et. al. 1993/94) before
its use with the study’s intervention group. The Wee Wheezers teaching
script was modified for use with individual families, handouts were
tailored to low-literacy and child audience, and the instructors delivered
the content over eight sessions rather than the four used in Wee Wheezers.
The revised program emphasized specific content areas, such as the
developmentally appropriate level of participation of young children in
asthma management.
Wee Wheezers at Home (WWH) consists of eight 90-minute education sessions provided at weekly intervals. Registered nurses conducted the course in the participants’ homes. Each session consisted of the completion of a checklist of the child’s asthma symptoms for the previous week, a discussion of the previous week’s homework assignment, an overview of the day’s session, the session topics (about 1 hour total), a review of concepts learned that day, and assignment of homework.
Session topics were:
- Basic concepts of asthma;
- Developmentally appropriate involvement of the child in asthma self-management, asthma cues;
- Asthma medication and nonmedication techniques for managing asthma symptoms, working with the child to administer medicines;
- Symptoms of acute asthma episodes, review of the action plan, children with chronic health problems;
- Symptom prevention (trigger identification, environmental control of triggers, use of preventive medication);
- Communication about asthma to teachers, physicians, and family members;
- Review of asthma management concepts; and
- Review of communication about asthma.
Caregiver and child activities included tracing the airflow on a picture of a child with the lungs drawn, identifying and coloring asthma cues and environmental triggers in a coloring book, practicing belly breathing, keeping an asthma diary, watching videos about asthma management, and practicing the use of a peak flow meter. At each session, the home visitor used a set of prepared questions based on the educational objectives to assess caregivers’ and children’s understanding of the material. Caregiver responses were used to guide the instruction in subsequent sessions. Families received printed materials and homework at each session and videotapes at some sessions. The same nurse conducted all eight sessions with a given family. The usual-care group was offered asthma training after the study was completed.
Evaluation Design:
A randomized controlled study approach was used.
Sample Size:
A total of 95 children were recruited primarily from three asthma
specialty clinics.
Outcome Measures/Results:
Outcome measures included asthma symptoms, symptom-free days, acute
asthma visits, and caregiver quality of life (QoL). The intervention was
effective for younger children in the areas of morbidity and caregiver
QoL. Researchers used the Pediatric Asthma Quality of Life Questionnaire
(Juniper, 1996a) to assess QoL with three measures: a rating of how much
children were bothered by asthma symptoms, the number of symptom-free
days, and the number of medical visits for acute asthma exacerbations.
Intervention children ages 1–3 were bothered less than usual-care children
by asthma symptoms at 3- and 12-month follow-up visits. Older intervention
children and the usual-care children were basically unchanged.
Symptom-free days increased significantly for younger intervention
children (from 37 days at baseline to 154 at 12 months) but not for older
intervention children. No intervention effects were noted in the number of
medical visits for acute asthma care for the 12 months preceding baseline
and the period between baseline and the 12-month visit. Researchers also
used the Caregiver Quality of Life (adapted from Juniper 1996b).
Caregivers of younger intervention children were bothered significantly
less than caregivers of usual-care children and older intervention
children because of the child’s condition following the intervention.
Measures of caretakers being bothered by the child’s asthma were 1=never
bothered and 2=bothered 1–2 days per week or very little. The mean for
caretakers of younger intervention children over time was 1.90, 1.37, and
1.17. No significant treatment effect existed in the older intervention
children or usual-care children. Asthma management practices were assessed
by parameters such as 1) adherence to the prescribed medical regimen for
asthma on a previous day, 2) administration of asthma medication promptly
with the signs of an upper respiratory infection, 3) identification of
coughing or stuffy or runny nose among the earliest signs of asthma, 4)
caretaker report of the frequency of 16 symptom management and prevention
practices, 5) caretaker report of the level of child participation in each
of the tasks required in asthma self-management. The intervention did not
produce statistically significant improvement in asthma management
behaviors.
Availability of Protocol/Materials:
The Wee Wheezers at Home materials are available in a program kit
distributed by the Asthma and Allergy
Foundation of America. [external link]
Case Study:
None
Hospital emergency departments
Asthma Education Program
Article Citation:
Jones PK, Jones SL, Katz J. Improving compliance for asthmatic patients
visiting the emergency department using a health belief model
intervention. J Asthma 1987; 24(4):199-206.
Intervention Setting:
The emergency department or discussion via telephone
Target Population:
Children and adults with asthma presenting to an emergency department
with an acute attack
Program Description:
An asthma education program, based on the Health Belief Model,
designed to increase the likelihood participants will make and keep
follow-up appointments after a visit to the emergency room.
An initial assessment of the role of demographic and situational factors on patients’ compliance rates with appointment referrals was conducted. In response, an asthma education program was developed to increase how patients perceived their susceptibility to acute asthma episodes, the seriousness of an episode, the risks associated with an episode and the benefits of preventing an episode by making and keeping referral appointments. The program was tailored for participants based on individual assessments of perceived risk and benefits. A shorter version of the education program was also conducted via telephone 1-2 days after discharge from the emergency room.
Evaluation Design:
A randomized control study
Patients were randomly assigned to three treatment groups and one control group. The extent of compliance was assessed by calling the agency to which patients were referred to find out if appointments were made and kept. All patients were subsequently contacted via phone by a nurse. Data were also collected on individual demographic and situational factors that might influence compliance.
Sample Size:
74 asthmatic patients randomly assigned to four groups: (1) routine
nursing care, (2) routine care in the ER with a follow up phone
intervention, (3) education during ER visit with no follow up
intervention, and (4) education during the ER visit and a follow up
phone intervention.
Outcome Measures/Results:
The primary outcome measures were the number of follow-up referral
appointments made and kept. Patients receiving any of the interventions
were more likely to make (91% vs. 43%) and keep appointments (75% vs.
10%) than the control group. Other findings suggest that females were
more likely to make appointments, and people over age 30 were more
likely to make and keep appointments. In addition, patients whose
primary health problem was rated as serious were more likely to make and
keep appointments, as were those patients with low need for childcare.
The telephone intervention was almost as effective as the education
program in the ER; consequently, it may be the more effective approach
in terms of cost-benefit.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Hospital inpatients
Hospital Discharge Program
Article Citation:
Wesseldine LJ, McCarthy P, Silverman M. Structured discharge
procedure for children admitted to hospital with acute asthma. Archives
of Disabled Children 1999;80:110-4.
*Editor’s note: This program is very similar to the study by Madge, McColl, and Paton carried out in Glasgow, United Kingdom (UK) and described in Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: A randomized controlled study. Thorax 1997;52:223-8.
Intervention Setting:
A pediatric hospital in the UK
Target Population:
Children with acute asthma admitted to the hospital in Leicester, UK
during 1996
Program Description:
The study objective was to examine the impact of a structured,
nurse-led discharge intervention for children admitted to the hospital
with acute asthma upon readmission to the hospital, re-attendance at the
emergency department (ED), and general practitioner consultation for
asthma. The intervention consisted of a 20-minute patient education
program and self-management plan. A knowledgeable pediatric nurse
provided Instruction. The intervention included provision of information
on the nature of asthma, risk factors and their avoidance, and
appropriate use of medications and devices. The educational component
emphasized guided disease self-management. An individualized written
management plan was provided for each child. The booklet At Home with
Asthma was provided to reinforce verbal information. Contact numbers
for help-lines were also provided.
Evaluation Design:
The study was a randomized controlled trial with follow-up after 6
months of being discharged from the hospital for asthma treatment.
Baseline data were collected via questionnaire on the day of discharge
from the hospital. Data were collected regarding medications used,
admissions to the hospital, emergency-care received, and physician
visits. The pattern and severity of asthma symptoms, atopy and allergy,
and causal factors also were recorded.
Sample Size:
A total of 160 children aged 2–16 years of age participated (80 in
each of the intervention and control groups) who previously had been
admitted to the hospital for asthma and were readmitted to the hospital,
re-visited an ED, or had a general practitioner consultation for asthma
during a 12-month period.
Outcome Measures/Results:
Outcome measures included re-admission (with overnight stay) to the
hospital within 6 months after discharge. Secondary outcome measures
included re-attendance without admission either in the ED or the
children’s admission unit. The proportion of children re-admitted to
hospital was substantially lower in the intervention group (15%) than in
the control group (37%), a statistically significant difference. The
total number of re-admissions in the intervention group was 18 compared
with 69 in the control group (in which multiple re-admissions occurred).
Emergency department attendance was substantially lower for the
intervention group, at 8% compared with 38% for the control group. Of
the children in the intervention group, 39% visited physicians compared
with 90% of children in the control group.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Inpatient Asthma Service Program
Article Citation(s):
Ebbinghaus S, Bahrainwala AH. Asthma management by an inpatient asthma
care team. Pediatric Nursing 2003; 29:177-83.
Intervention Setting:
Children’s Hospital of Michigan in Detroit
Target Population:
Children admitted to the hospital with an asthma exacerbation
Program Description:
Administrators at Detroit’s Children’s Hospital of Michigan
initiated an Inpatient Asthma Service program to address glaring
discrepancies in treatment plans for the care of patients not admitted
by private primary care physicians but, instead, through channels such
as the emergency department. Treatment plan discrepancies applied to
asthma exacerbations, asthma education, and length of stay in the
hospital. Objectives of the new Inpatient Asthma Service included 1)
standardized asthma care by a specialist team in accordance with
National Asthma Education and Prevention Program (NAEPP) guidelines, 2)
comprehensive asthma education to patients and their families; and 3)
referral to the outpatient asthma clinic for further follow-up,
management, and reinforcement of asthma education. The Inpatient Asthma
Service consists of physicians specializing in asthma and allergy and
pediatric asthma nurse specialists trained in inpatient asthma
management and education. The nurse specialist independently assessed
and monitored asthma patients, conducted asthma education (customizing
instruction according to learner needs), developed new educational
materials as standards of asthma management change, and facilitated
coordination of resources for inner-city families. The nurse
specialist’s activities included:
- Obtaining a detailed family history, a detailed asthma history, and clinical assessment of the exacerbation;
- Helping families with social needs (language barrier, insurance coverage, access to a nebulizer and medications, transportation);
- Informing the asthma specialist of changes in clinical status of the patient that required modifications in management; and
- Providing asthma education to inpatients and families during the
hospital stay.
Asthma education discussion topics included- asthma as a chronic disease with airway changes
- symptom recognition
- asthma action plan
- differentiation between rescue and controller medication and their use and effects
- environmental control measures
- importance of regular physician monitoring and follow-up after hospital discharge
- demonstrating proper inhaler technique and medication use with placebo inhalers, spacers, masks, nebulizer tubing, and peak flow meters
- reviewing written home instructions before discharge about medication use, time, and dosing with the family; verifying correct inhaler use; scheduling follow-up appointments with the allergy-asthma clinic; arranging for a visiting nurse agency referral to assist with ongoing asthma education and environmental assessments; and reinforcing appropriate medication use.
A number of teaching tools have been developed to support the inpatient asthma education that are culturally sensitive and reflect patients’ needs. An animated metered dose inhaler named Peter Puffer® is depicted in an animated live action video, comic book, and educational handouts with African-American children living in the Detroit community who attend school and take asthma medication. Commercially available pocket-sized flipcharts and pamphlets depicting asthma airway changes and common asthma medications complemented information discussed in the patient handouts.
Evaluation Design:
A pre-post design was used.
Sample Size:
An average of 4,500 children are treated each year in the Children’s
Hospital of Michigan emergency department for asthma exacerbation.
Roughly 1,500 of these children are hospitalized each year. The actual
number of children included in this evaluation was not provided.
Outcome Measures/Results:
Outcome measures included the length of stay in the hospital and
cost savings. Before 1996, the average length of stay in the hospital
was 2.2 days. Since 1996, an average of 55% of pediatric patients with
asthma have been admitted to the Inpatient Asthma Service program, and
the length of stay for this group of patients decreased to an average of
1.7 days. The length of stay for patients admitted under the care of
hospital staff or private primary care physicians since 1996 continued
to average 2.2 days. This 0.5 day (or 12 hours) average shorter stay per
patient reduced costs for the hospital and costs incurred by the family
related to meals, parking, transportation, sibling child care, and
missed days from work and school. Since 1996, the cost of patient
admission to the inpatient asthma service averaged $420 less than the
cost of an admission to hospital staff or private physicians. The annual
difference in care costs per patient multiplied by the number of
patients admitted to the Inpatient Asthma Service program each year
yielded an average annual cost savings of $300,000 per year.
Materials available:
None
You Can Control Asthma
Article Citation:
Taggart VS, Zuckerman AE, Lucas S, Acty-Lindsey A, Bellanti JA. Adapting
a self-management education program for asthma use in an outpatient
clinic. Ann Allergy March 1987;58(3):173-178.
Taggert VS, Zuckerman AE, Sly RM. You can control asthma: Evaluation of an asthma education program for hospitalized inner-city children. Patient Education and Counseling 1991;17:35-47.
Intervention Setting:
Inner city hospital
Target Population:
Hospitalized asthmatic children between the ages of 4 and 12
Program Description:
A nurse-administered pediatric asthma program for hospitalized children.
Several theories were used to guide the development of the program: self-learning, self-regulation, and health locus of control. An environmental assessment of the hospital setting in which the program was to be delivered was conducted using the PRECEDE model. The program consists of five lessons and was developed to demonstrate the feasibility of teaching children about asthma and self-management techniques as part of their standard medical care. The program was adapted from a successful earlier version, set in the emergency room, which taught parents and children how to successfully manage acute attacks. The program used a combination of written materials, games, videotape and one-on-one discussions with the nurse.
Evaluation Design:
Pre- and post questionnaires were given to children and, whenever
possible, parents to test knowledge and their health locus of control.
Nurses were also asked to keep logs to determine how many eligible
patients actually received the program. Nurses were also asked to
complete a questionnaire on the perceived feasibility of the program.
Medical records were reviewed for fifteen months prior to and after
enrollment into the program.
Sample Size:
40 children
Pre-test data were collected on all 40; however, post-test data were available for only 30 children
Outcome Measures/Results:
The goal of the program was to improve children’s management of
asthma, decrease emergency room visits and hospitalizations and increase
follow through on routine asthma clinic appointments. Results indicate
that nurses felt the program was feasible. Despite the large percentage
of parents who did not participate in any of the sessions, it appears
that children were able to transfer the knowledge and skills they
learned. Hospitalization and parent’s report of frequency of symptoms
did not decrease; however, rate of emergency room use decreased. The
program’s impact on health locus of control and self-efficacy was
unclear.
Evolution of the Program:
In 1991, the educational materials from this intervention were
published as You Can Control Asthma: A Book for the Family and
You Can Control Asthma: A Book for Kids. These materials have served
as the core of multiple interventions in varied settings over time. Over
the following decade, the books have been periodically updated and are
distributed by the Allergy and Asthma Foundation of America (AAFA).
Availability of Materials:
You Can Control Asthma: A Book for the Family and You Can
Control Asthma: A Book for Kids are available by mail or phone, or
can be ordered on line from:
Asthma and Allergy
Foundation of America [external link]
1233 20th St. NW
Washington, DC 20036
phone: 1-800-7-ASTHMA
Case Study:
None
Medical clinics/physicians’ offices
Asthma Care Training (ACT) for Kids
Article Citation:
Lewis CE, Rachelefsky G, Lewis MA, de la Sota A, Kaplan M. A randomized
trial of A.C.T. (Asthma Care Training) for Kids. Pediatrics October
1984;74(4):478-486.
Rachelefsky GS, Lewis CE, de la Sota, A, Lewis MA. ACT (Asthma Care Training) for Kids. A childhood asthma self-management program. Chest January 1985;(suppl to no.1):98S-100S.
Intervention Setting:
Kaiser-Permanente facilities
Target Population:
Children identified with severe asthma between the ages of 7 and 12 and
their parents
Severe asthma was defined as requiring medication at least 24% of the days of a month. All participants were members of the Kaiser Permanente health care system.
Program Description:
An asthma education and self-management program designed to give
children and their parents the knowledge, confidence, and skills to
reduce the frequency and severity of asthma attacks.
The program was developed as a supplement to existing medical care. Children and parents are taught to recognize symptoms, triggers and how to decide when to use medication and when to get additional help. The five, 1-hour educational sessions are held separately for parents and children; however, they come together for the last 15 minutes of each session to practice what they have learned. The program utilizes principles of social learning theory to reinforce the message that children are in control of their asthma. To convince children they have the ability to manage their asthma, a driving analogy (“You are in the driver’s seat”) is used throughout the interactive group educational sessions.
Evaluation Design:
Children and their parents were randomly assigned to either the
intervention or the control group. The control group received 3-½
hours of lecture presentations whereas the intervention group received 5
hours of interactive activities in a smaller group setting. Data
were collected via a structured telephone interview at baseline, 3, 6,
and 12 months after the study. Medical records were also reviewed
to ascertain if there were any changes in emergency room visits and
hospitalizations. ANOVA and non-parametric contingent analyses were used
to analyze the data.
Sample Size:
76 children and their parents including 48 in the intervention group
and 28 in the control group.
Outcome Measures/Results:
Outcome measures included the number of emergency room visits and
hospitalizations, knowledge of asthma symptoms, triggers and treatments;
parental and child’s perceptions of child’s health status and ability to
control attacks; and steps taken during an attack. Although the
intervention and control groups had equivalent increases in knowledge
and changes in beliefs, the intervention groups increased their use of
compliance behaviors and reduced emergency room visits and days of
hospitalizations. Qualitative data indicated there were improvement in
father/child relationships and less smoking around children in the home.
Availability of Protocol/Materials:
The ACT for Kids Program kit is available by mail or phone, or it
can be ordered on line.
Asthma and Allergy
Foundation of America [external link]
1233 20th St. NW
Washington, DC 20036
phone: 1-800-7-ASTHMA
Case Study:
Asthma Care Training (ACT), Providence Alaska
Medical Center, Anchorage, Alaska
Asthma Education Program for Pediatric Medicaid Patients
Article Citation:
Kelly CS, Morrow AL, Shults J, Nakas N, Strope GL, Adelman RD.
Outcome evaluation of a comprehensive intervention program for asthmatic
children enrolled in Medicaid. Pediatrics 2000;105(5):1029-35.
Intervention Setting:
The intervention took place at a pediatric allergy clinic in a
Norfolk, Virginia tertiary-care children’s hospital.
Target Population:
Low-income minority children enrolled in Medicaid who had two or
more emergency department (ED) visits or a hospitalization in the
previous year were targeted for the intervention.
Program Description:
The study objective was to evaluate the use of ED and
hospitalization outcomes for Medicaid-insured asthmatic children after
the comprehensive asthma intervention program. Children in the
intervention group received asthma education and medical treatment at
the child’s pediatric allergy clinic. Education was tailored to the
needs of each family by providing one-on-one contact between child and
family and a physician and asthma nurse. Education included recognition
of asthma triggers, environmental controls, symptoms and warning signs,
medication use and side effects, use of spacers and peak flow meters,
and management of exacerbations. Written action plans were provided. An
asthma outreach nurse maintained monthly contact with the intervention
group families to review the health status of the child, medicine
administration, to refill prescriptions, and to reinforce liaison
between patient and provider.
Evaluation Design:
Children were alternately assigned in this controlled clinical
trial, resulting in similar intervention and control groups. Children
were identified for the study by computerized medical records. No
incentive was offered for participation. Skin testing was used where
indoor allergen sensitivity was apparent and avoidance techniques based
on results were possible. Immunotherapy was not started. ED and hospital
records were used to assess medical services use for the study year.
Sample Size:
A total of 80 children aged 2–16 years were included in the study.
Outcome Measures/Results:
Outcome measures included ED visits and hospitalizations. The mean
number of ED visits at baseline and 1 year for the intervention group
was 3.6 and 1.7 per child. Hospital visits decreased from 0.6 to 0.2 per
child and hospital days decreased from an average of 2.4 to 0.9 per
child. In the control group, ED visits decreased from 3.5 to 2.3 visits
per child whereas hospitalizations decreased from 0.53 to 0.48 and
average hospital days decreased from 1.8 to 1.7 per child. Logistic
regression analysis was used to control for individual history of asthma
outcomes in the prior year. Children in the control group compared with
those in the intervention group were 1.4 times more likely to have an ED
visit and 2.4 times more likely to be hospitalized, a statistically
significant difference.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Asthma Outreach Program (AOP)
Article Citation:
Greineder, DK, Loane KC, Parks P. A randomized controlled
pediatric asthma outreach program. J Allergy Clin Immunol March
1999;103(pt 1):436-440.
Intervention Setting:
The Health Centers Division of Harvard Pilgrim Health Care, a large
HMO in New England
Target Population:
Children with asthma ages 1-15 and their families
Program Description:
An asthma education program developed in accordance with the NHLBI
Guidelines for diagnosis and management for pediatric asthma. The
program is a team-based intervention using an allergy nurse, nurse
practitioner, and allergist to help patients gain knowledge about
controlling their asthma. The program components include a
doctor’s visit to assess a family’s knowledge base, and education in the
following seven areas: 1) asthma definition/ pathogenesis, 2) triggers
and warning signs, 3) asthma medications, 4) inhaler, spacer, and
nebulizer training, 5) peak flow meter and zoning instruction, 6)
environmental control and adherence to medication schedules, and 7)
importance of doctor visits. The patient and family receive 1 one-on-one
education session led by the AOP nurse.
Evaluation Design:
Patients continuously enrolled in a HMO for at least 2 consecutive
years were randomized into two groups. The control group received
a single-intensive asthma education intervention and the intervention
group received the same initial education but followed by asthma case
management through the intervention. The Wilcoxon matched pair
signed rank and Chi-square tests were used to analyze the data.
Sample Size:
A total of 57 patients participated, of whom 9 were recruited during
hospitalization and randomized into the “control group” and another 9
into the intervention group. Thirty-nine other patients recruited
by referral were randomized independently into the control and
intervention groups.
Outcome Measures/Results:
Data were collected on three key outcome variables: (1) ER visits,
(2) hospitalizations, and (3) health plan expenditures. Control patients
had significant reductions in ER visits (39%), hospitalizations (43%)
and health plan costs (28%), likely resulting from baseline educational
intervention for all enrolled patients. Intervention patients had
significant reductions in ER visits (73%), hospitalizations (84%) and
health plan costs (82%). Compared to the control group,
intervention patients demonstrated additional reductions in ER visits,
hospitalizations, and outside of health plan use.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Bedouin Primary Care Clinic Asthma Program
Article Citation(s):
Peleg R, Gehtman P, Blancovich I, Aburabia R, Allush R, Hazut S,
Shvartzman P. Outcomes of an intervention programme for treatment of
asthma in a primary care clinic for Bedouins in Southern Israel. Family
Practice 2002;19:448-51
Intervention Setting:
A rural primary care clinic for Muslim Bedouins in southern Israel
Target Population:
Bedouin children aged <14 years with asthma attending a health
clinic.
Program Description:
Many Bedouin children with asthma in southern Israel exhibited
severe symptoms even following medical treatment. A new Arabic clinical
intervention was developed that included numerous elements designed to
optimize the treatment of asthma at the clinic to improve children’s
health. The program included:
- in-service instruction to the clinic staff on new asthma guidelines;
- health education for the clinic population that focused on improving living conditions, cleanliness, and hygiene;
- instruction on the proper use of medications;
- ongoing instruction to asthma patients;
- provision of free spacers for those eligible; and
- an invitation to an asthma health fair at which participants heard general information about asthma, viewed a 20-minute videotape on allergens and asthma, saw a demonstration and practiced using nebulizers and space chambers, and had an individual review of their medications.
Evaluation Design:
A pre-post study design was utilized.
Sample Size:
The study comprised 267 children (preintervention) and 276 children
(postintervention) who had been diagnosed with asthma.
Outcome Measures/Results:
Outcome measures included nebulizer treatments received by asthma
patients in the clinic, referrals to the emergency department,
hospitalizations, and availability of electric nebulizer equipment or
space chambers in the homes of children with asthma. Data on these
parameters were collected over the course of 3 months (November –
January) before the intervention. These data were again collected a year
later (following the intervention) during the same three-month period.
Results included:
- a 30.2% reduction in nebulizer treatments from 9.89 per 100 children per month in the preintervention period to 6.9 in the postintervention period;
- a decrease in hospitalizations for asthma from 6 in the preintervention period to none in the postintervention period;
- a decrease in referrals for emergency treatment from 61 in the preintervention period to 6 in the postintervention period; and
- an increase in the number of homes with inhalation equipment from 73 in the preintervention period to 150 in the postintervention timeframe.
Materials available:
The educational material used in this study included simulators and
air spacers donated by TEVA, an Israeli pharmaceutical company. CHS
health promotion and marketing unit provided posters and videos on
asthma management used in patient education. Materials are not available
for widespread distribution.
Children’s Hospital Asthma Management Program
Article Citation(s):
Miller K, Ward-Smith P, Cox K, Jones EM, Portnoy JM. Development of
an asthma disease management program in a children’s hospital. Current
Allergy and Asthma Reports 2003;3:491-500.
Intervention Setting:
Children’s Mercy Hospital (CMH) in Kansas City, Kansas. CMH serves a
large metropolitan area and surrounding region. It is a regional
Medicaid health facility.
Target Population:
Children who had an emergency visit or hospitalization for asthma
Program Description:
In 1996, a small audit on the quality of CMH care for asthma
patients revealed that asthma care was deficient. The emergency
department served as a primary source for the children’s asthma care. A
more extensive audit showed that, in 1995, 2,738 children had emergency
visits, and 472 were hospitalized for asthma. These numbers represented
about 6% of all emergency visits and hospital admissions – a
considerable impact on the hospital’s health care system. This discovery
prompted development of a comprehensive asthma disease management
program at CMH with the goal of providing high-quality interventions for
children in whom asthma was diagnosed. Specific program aims were to 1)
reduce the frequency of admissions, 2) provide more cost-effective care
to patients who were admitted to the hospital, and 3) develop clinical
practice guidelines that encourage providers to use the best-known
treatments and thus improve the quality of care. The hospital developed
a database to merge clinical information from different hospital-based
sources into a central registry. The database was expanded to include
encounter information from a health plan mainframe, thereby creating a
comprehensive registry of all members with asthma in the health plan.
This information, along with prescription fill data, permitted the
identification of all health plan members who had asthma, regardless of
whether they were seen at CMH, and to fully track them through patterns
of prescription use.
Stratification of patients by clinical severity and hospital use was carried out to provide the most cost-effective asthma care and assign hospital resources where they would produce the greatest benefit. Asthma severity also was used to establish performance outcomes; e.g., providers prescribing practices for patients with persistent asthma. Interventions included education and use of clinical practice guidelines. An asthma educator was hired to work in the primary care clinic 2 days a week to deliver standardized asthma education, to foster awareness of proper asthma management and inspire desirable changes in provider behavior. The hospital asthma educator taught asthma self-management skills. Providers were encouraged to prepare asthma action plans for the patients. Easy-to-read and color-coded Asthma Action Cards were developed for use in teaching self-management.
The staff developed an Asthma Clinical Practice Guide (CPG) to standardize management of asthma. An algorithm was developed that described an entire hospital-based asthma encounter from presentation in the emergency setting through an inpatient stay and, finally, to discharge planning. The CPG was available to all hospital providers on an internal website linked to an electronic order entry system to help minimize errors. Outcomes were imbedded directly into the CPG so clinical outcomes and performance of providers could be monitored.
Evaluation Design:
Cohort study comparing outcomes between two groups of asthma
patients treated at the hospital: managed patients (Family Health
Partners)(FHP) and unmanaged Medicaid patients (non-FHP).
Sample Size:
The sample size varied depending on the measure (emergency use or
hospitalization). The exact number is not clear.
Outcome Measures/Results:
Outcome measures included hospital admissions, costs, and quality of
life (QoL). Most hospital admissions for asthma occurred during
the fall, with a baseline admission rate throughout all seasons. During
1997 and 1998, asthma admissions peaked in the fall both for the FHP
group patients and the non-FHP group patients. In 1999 and subsequent
years, the peak was present only for non-FHP patients. The main effect
of the hospital intervention was that it reduced peak use for
FHP-insured patients. Costs per patient per admission for inpatient
asthma care in 1997–98 averaged $6,422.00 for FHP members and $6,402.00
for non-FHP members. Per admission inpatient asthma care for FHP members
fell in 1998–1999 to an average of $4,266.00, while asthma care for
non-FHP members stayed nearly the same at $6,398.00 per admission. Data
on QoL were obtained from a randomly selected group of unmanaged and
managed patients. Data were collected at the initial visit, when the
participants in the managed group received asthma education and an
asthma action plan, and at the new two subsequent visits. The baseline
QoL score for both patients and caregivers in both groups was 4.5. In
the managed population, caregiver QoL scores rose to 5.2 by visit two (a
0.5 point change is considered clinically significant). The patient’s
QoL remaining unchanged. By the subsequent visits, the patients also
reported an improved QoL. The QoL of unmanaged patients did not improve.
The CMH Asthma Disease Management Program led to fewer hospitalizations,
improved QoL for children and their caretakers, and a 37.5% decrease in
care costs.
Materials available:
None
Decreasing Smoke Exposure for Children with Asthma
Article Citation:
Hovell MF, Meltzer SB, Zakarian JM, Wahlgren DR, Emerson JA, Hofstetter
CR, Leaderer BP, Meltzer EO, Zeiger RS, OConnor RD, et al. Reduction of
environmental tobacco smoke exposure among asthmatic children: a
controlled trial. Chest Aug 1994;106(2):440-446.
Wahlgren DR, Hovell MF, Meltzer SB, Hofstetter R, Zakarian JM. Reduction of environmental tobacco smoke exposure in asthmatic children. Chest Jan 1997; 111(1):81-88.
Intervention Setting:
Pediatric medical clinic
Target Population:
Children aged 6-17 years with asthma and at least one parent who smoked
cigarettes
Program Description:
A behavioral medicine program designed to reduce asthmatic children’s
exposure to environmental tobacco smoke (ETS) at home.
The program consisted of (1) a six-month series of counseling sessions designed to decrease ETS exposure attended by target parents and children, (2) regular clinic visits, (3) two-week monitoring intervals preceding clinic visits (with session diaries), and (4) standard medical care. Between counseling sessions patients used diaries to record peak flow meter readings and symptoms. Behavior modification techniques such as stimulus control, shaping, and personal feedback were incorporated into programs tailored for each families.
Evaluation Design:
A randomized clinical trial using a three-group repeated measures
design.
The design assigned families to (1) an experimental group that received counseling, monitored patients’ exposure to smoke and monitored patients’ asthma symptoms, (2) a group that did not receive counseling but engaged in the same monitoring activities, or (3) a control group that received the usual care. Families were measured six times in twelve months. ANOVA was employed to identify differences among groups.
Sample Size:
91 families recruited from four large pediatric allergy clinics in San
Diego.
Data were collected and final analyses conducted with 79 families.
Outcome Measures/Results:
Data were collected on children’s exposure to ETS, and an
environmental monitor was used to validate parents' reported exposure
and smoking rates. Exposure to parents’ cigarettes at home
decreased for all groups. The experimental group attained a 79%
decrease in children’s ETS exposure, the monitoring group had a 42%
decrease, and the control group had a 34% decrease. ANOVA revealed
a significant (p<.05) effect of the program over time. After 1
year, only the experimental group had a decrease in ETS exposure at home
for all smokers. The monitoring group increased exposure 14% and
the usual treatment group increased 22% over time.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Family-to-Family Network
Article Citation:
Ireys HT, Chernoff R, DeVet KA, Dim Y. Maternal outcomes of a
randomized controlled trial of a community-based support program for
families of children with chronic illnesses. Archives of Pediatric and
Adolescent Medicine 2001;155(7):771-7.
Chernoff RG, Ireys HT, DeVet KA, Kim YJ. A randomized controlled trial of a community-based support program for families of children with chronic illness. Pediatric outcomes. Archives of Pediatric and Adolescent Medicine 2002;156(6):533-9.
Intervention Setting:
A community-based family support intervention and the referring
sub-specialty and general pediatric clinics and practices in the
metropolitan Baltimore, Maryland area.
Target Population:
The study targeted mothers of children aged 7–11 years who had been
diagnosed as having diabetes, sickle cell anemia, cystic fibrosis, or
asthma. Each child had been treated at a clinic or a pediatrician’s
office. Eligible participants lived within a 50-mile radius of
Baltimore, their household had a telephone, and the primary care giver
was a woman and English-speaking. To be included in the study as an
asthma patient, the child had to have moderate to severe disease,
receive daily medication, and wheeze 2-3 times a week or had at least
one hospital or emergency department visit in the previous 6 months.
Program Description:
Parents of children with chronic illnesses are at high risk for
secondary mental health problems (e.g., anxiety and depression). The
objective of this study was to evaluate potential changes in maternal
mental health, anxiety, and depression following participation in an
intervention for families of children with selected chronic illnesses,
including asthma. Participants were recruited through clinic directors
or pediatricians. Network Mothers (mothers of older children with
similar conditions as the intervention mother’s child) were assigned one
to seven of the intervention mothers. The Network Mothers made bi-weekly
phone contacts, seven face-to-face visits (usually at the subject’s
home), and three special family events.
Evaluation Design:
The study design was a randomized controlled clinical trial with
repeated measures one year apart. A 45-90 minute interview was conducted
at baseline and at 12 months post-baseline. Interim interviews of 15-20
minutes were conducted by phone at 4, 8, and 16 months post-baseline for
each participant. Mothers were compensated for their time and effort.
Control children received standard clinical care, and the mother
received contact information for an experienced parent whom they could
call if they chose to do so.
Outcome Measures/Results:
Participants in the experimental group reported lower levels of
anxiety post-intervention compared with their baseline scores. By
contrast, participants in the control group reported higher levels of
anxiety 1 year after baseline. Analyses suggested that the
intervention’s effect was especially pronounced for mothers who were
highly anxious at baseline. The mean anxiety score for experimental
group mothers who reported that they were in good, fair, or poor health
at baseline decreased from 26.4 to 23.9 during the intervention period.
By contrast, the mean anxiety score for the control group mothers who
reported being in good, fair, or poor health at baseline increased from
24.8 at baseline to 26.5 twelve months later. The intervention had no
demonstrable effect on symptoms of depression, perhaps because baseline
levels were low. However, after controlling for baseline anxiety, there
was a substantial decrease in anxiety among the experimental group. The
study demonstrated that a family support intervention can have positive
effects on maternal anxiety.
Using a cut-off score that indicated a measure of adjustment and maladjustment, 19% in the experimental group and 15% of the control group fell below this cutoff point, i.e., were in the maladjustment category, at baseline. At follow-up, 10% of the experimental group children and 21% of the control group scored below this cut-off point. The study demonstrated that the family-support intervention had modest, positive effects on the adjustment of children with selected chronic illnesses. Investigators found no effect of the intervention on measures of children’s anxiety, depression, or self-esteem.
Sample Size:
A total of 161 families participated in the study. Of these, 73 in
the experimental group and 66 in the control group completed the trial.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution. However, an intervention implementation manual can be
requested from Dr. Henry Ireys, the principal investigator for this
study, at
hireys@mathematica-mpr.com.
Case Study:
None
Interactive Multimedia Program for Asthma Control and Tracking (IMPACT)
Article Citation(s):
Krishna S, Francisco BD, Balas EA, Konig P, Graff GR, Madsen RW.
Internet-enabled interactive multimedia asthma education program: A
randomized trial. Pediatrics 2003;111:503-511.
Intervention Setting:
Asthma clinic
Target Population:
Children under 18 years of age with confirmed diagnosis of asthma at
all severity levels
Program Description:
The program was designed to determine 1) whether the addition of an
interactive multimedia asthma education program would significantly
increase asthma knowledge of children and caregivers and 2) whether this
increase in asthma knowledge would be significantly related to disease
outcomes and healthcare resource use among the children with asthma when
compared with a control group. At enrollment, participants completed the
Asthma Summary since Last Visit, Pediatric Asthma Care Knowledge Survey,
and Pediatric Asthma Caregiver’s Quality of Life Questionnaire. Data
were collected at two subsequent visits scheduled about 3 months and 12
months after enrollment. The intervention and control groups both
received instruction from a nurse practitioner using printed and verbal
approaches to education. This instruction followed the Caring for Kids
with Asthma series, using 26 instructional sheets that focused on
understanding asthma, selected devices, medication and environmental
factors. During the clinic visits, each child or caregiver took part in
one-on-one training to ensure correct use of devices and medications.
All families received an individualized, computer-generated asthma
action plan with detailed instructions for daily self-management and
guidelines for handling exacerbations and emergencies.
In addition to receiving conventional patient education, intervention group children and families used the Interactive Multimedia Program for Asthma Control and Tracking (IMPACT) during routine office visits. The IMPACT Kids CD consists of vignettes covering basic pathophysiology of asthma, environmental triggers, quick-relief and control medications, and strategies to control and manage asthma. The program incorporates self-management principles in an interactive format comprising animated lessons, each averaging a minute in length. Ten of the lessons present real-life scenarios and require decisions about alternative behaviors that would be likely to affect asthma. Other lessons involve activities in which children learn to more accurately describe their symptoms and medication use. IMPACT used the Internet and a Web-based server to respond to individual learning needs (based on how participants responded to questions posed in the lessons). The program was made available to children and families only during clinic visits. The program tracked educational progress of individual children and generated standardized reports to help children, families, and schools record current symptom level and medication use. The program was completed in about 1.3 hours, although actual time varied by individual reading level and comprehension. The program was used during waiting times within the flow of clinic activities between recording patient vital signs, spirometry, physical exam, discussions of therapeutic options and discharge teaching. It used participants’ time effectively while not incurring additional staffing overhead.
If the child was under 7 years of age, the parent used the program, and his/her knowledge was assessed. Children aged 7–17 used the program while their parents observed. At each tutorial session, IMPACT first presented review lessons previously viewed from which incorrect answers were entered, followed by new content. Users progressed in linear manner through the 44 lessons. IMPACT interspersed several types of lessons, including traditional instructional vignettes, decision-making scenarios, and exercises to improve the child’s ability to report symptoms and medication use.
Evaluation Design:
A randomized controlled study approach was used.
Sample Size:
The study comprised 238 children with asthma visiting the Pediatric
Pulmonary and Allergy Clinic of the University of Missouri — Columbia
Health Care referred by their primary care physicians for asthma.
Outcome Measures/Results:
Outcome measures included changes in asthma knowledge, use of quick
rescue relief medicine, asthma symptoms, lost school days and emergency
visits. Asthma knowledge improved significantly in the intervention
subgroups: caregivers of children aged 0–6 years, caregivers of children
aged 7–17 years, and children aged 7–17 years. At 12 months asthma
symptom days decreased from 81 days to 51 days per year. The rate of
school absences, decreased significantly: 5.4 days per child per school
year for the intervention children compared with just a 1.6-day
reduction for control children. The number of emergency visits among the
intervention group participants also decreased significantly from 1.93
per year to 0.62. The intervention group children used a significantly
lower average daily dose of inhaled corticosteroids following the third
visit.
Materials available:
Dr. Santosh Krishna, School of Public Health, St. Louis University,
3545 Lafayette Ave., Suite 300, St. Louis, M0 63104; phone (314)
977-8280; krishnas@slu.edu
Managing Asthma
Article Citation:
Clark NM, Feldman CH, Evans D, Duzey O, Levison MJ, Wasilewski Y,
Kaplan DL, Rips JL, Mellins RB. Managing better: Children, parents and
asthma. Patient Education and Counseling 1986;8:27-38.
Intervention Setting:
Pediatric allergy clinics in Harlem, St. Luke’s-Roosevelt and
Presbyterian Hospitals in New York, NY
Target Population:
Predominantly African American and Hispanic children, 4-17 years old,
diagnosed with asthma by a physician, and their caregivers
The children had at least one clinic visit and one wheezing episode in the past year.
Program Description:
A health education program based on the idea of family management of
asthma.
This concept explicitly recognizes that pediatric self-management of asthma often involves the participation and guidance of parents and other family members. Based on previous interviews with asthmatic children, their parents and physicians, the program was designed to give families a better understanding of the medical aspects of asthma and what they can do as a unit to help the child better manage his/her asthma. The program is grounded in self-efficacy theory and Friere’s idea that shared dialogue can lead to more effective problem-solving skills among adults. The program, which was taught in six weekly sessions, was also designed to be developmentally appropriate for the children who participated. It was delivered in both Spanish and English.
Evaluation Design:
Children were randomly assigned to the control and experimental
groups. All sibling groups were kept together. Children and
parents were interviewed prior to the start of the study and one year
following completion. From the interview data, pre- and
post-asthma management indices were constructed for each child. Medical
and school records were also reviewed. ANOVA and chi-squared statistics
were used to analyze the data.
Sample Size:
600 participants
310 children with asthma and 290 parents were assigned to either the intervention or control group. 207 children were in the intervention group, and 103 were in the control group.
Outcome Measures/Results:
Data was collected to determine how well the program met its goals
of teaching families how to set realistic guidelines for children’s
activities; how to prevent, monitor and treat attacks; how to administer
medication; how to get useful information from physicians; and how to
improve the child’s performance is school. Parents in the
experimental group improved significantly in their ability to prevent
and manage children’s attacks as well as set more reasonable limits on
physical activity. Children demonstrated improvement in their use of
several asthma self-management techniques. It also appeared that
parents were more confident in their child’s ability to manage his/her
asthma.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
National Cooperative Inner-City Asthma Study (NCICAS)
Article Citation:
Evans R, Gergen P, Mitchell H, Kattan M, Kercsmar C, Crain E, Anderson
J, Eggleston P, Malveaux FJ, Wedner HJ. A randomized
clinical trial to reduce asthma morbidity among inner-city children:
Results of the National Cooperative Inner-City Asthma Study.
Journal of Pediatrics 1999;135(3): 332-338.
Intervention Setting:
Clinics
Target Population:
Children diagnosed by physicians with moderate to severe asthma, 5-
to 11-years old, English or Spanish-speaking, and living in selected
inner-city census tracts of one of eight metro areas served by the study
Program Description:
A comprehensive community-based initiative designed to reduce asthma
symptoms and improving the quality of life for inner-city children
The initiative focused on asthma education, self-management techniques and improving physician interaction with patients. The program utilized Asthma Counselors (ACs) to educate and support families in their efforts to manage the child’s asthma. ACs were responsible for developing asthma management plans based on oral instructions from physicians, helping families improve their communication with physicians, encouraging caretakers to attend adult group asthma education sessions, and referring families to community resources for assistance with psychological/social issues and smoking cessation. The initiative also provided families with pillow and mattress covers and instructed families on way to minimize children’s exposure to tobacco smoke and pets.
Evaluation Design:
A randomized, multi-site, controlled trial
Participants completed a comprehensive baseline assessment on hospitalizations, doctor visits, symptoms, home environment and medical care. After the group sessions were completed, data were collected during bimonthly, in-person caretaker interviews and telephone conversations during the alternate months. Parents were asked to recall how well their child was doing in the previous two weeks. Baseline and outcome data were compared using ANOVA or the Mantel-Haenszel chi-square tests.
Sample Size:
1033 children with asthma - 515 in the intervention group, and 518 in
the control group
Outcome Measures/Results:
Outcomes included self-reported maximum number of symptom days,
hospitalizations, and unscheduled visits. For the first year,
participants in the intervention group reported fewer symptom days than
did the control group. The reduction among children with severe
asthma was 3 times greater for the intervention group. More
control group children were hospitalized than intervention group
children. These results were similar in the second year of the
follow-up during which time they did not have access to the AC.
The results indicate that a community-based approach is an effective
method for inner city children and may be transportable to other
settings.
Availability of Protocol/Materials:
The Guide for Helping Children with Asthma, one of the
primary intervention materials, is available from the National Institute
of Allergy and Infectious Diseases by calling 301-496-7353. Other
materials are not available at this time.
Case Study:
The Inner-city Asthma Intervention,
El Rio Santa Cruz Community Health Center, Tucson, Arizona
Outpatient Clinic Asthma Management Program
Article Citation:
Hui SHL, Jeung TF, Ha G, Wong E, Li AM, Fok TF. Evaluation of an asthma
management program for Chinese children with mild-to-moderate asthma in
Hong Kong. Pediatric Pulmonology 2002;33:22-9.
Intervention Setting:
Outpatient clinic of a university teaching hospital in Hong Kong
Target Population:
Children with mild to moderate asthma
Program Description:
This intervention is based on the hypothesis that an asthma
management program conducted by a pediatric nurse specialist and focused
on key symptoms could improve outcome measures of asthma in children
living in Hong Kong. The intervention consisted of an interactive 2-hour
group session with follow-up visits at 3-month intervals with the nurse
specialist. The asthma management program addressed asthma symptoms and
pathophysiology; trigger factors, potential allergens, and importance of
environmental control; principles and techniques of using asthma
medications; and use of an asthma diary. All patients and their parents
attended an interactive program session that consisted of a video
display summarizing the major issues related to asthma pathogenesis and
management. This session included a presentation on appropriate
contingency plans in case of acute asthma attacks. A final 30-minute
group discussion allowed patients and parents to ask questions, and the
nurse specialist evaluated each patient’s inhaler use technique.
Educational pamphlets that reinforced the program session were
distributed to each family, and patients were asked to keep an asthma
diary on asthma symptoms and the use of anti-asthma drugs. Children were
then followed up in the clinic at 3-month intervals during which patient
knowledge and emergency action plans for acute asthma attacks were
reviewed and a check on drug compliance was checked. The frequency of
nocturnal cough and wheezing attacks, as well as subjective evaluation
of asthma severity, asthma-related quality of life, and asthma knowledge
scores were obtained from each patient at baseline and 6 and 12 months
after the educational session. Information also was collected about the
number and duration of hospitalizations, unscheduled outpatient visits
to any medical practitioners, unscheduled emergency department visits,
and number of school or daycare days missed for the year before and
after the asthma management program.
Evaluation Design:
A prospective cohort study design
Sample Size:
A total of 106 children aged 0–18 years with asthma who had no
previous formal education on contingency plans to help during acute
asthma attacks
Outcome Measures and Results:
Outcome measures included asthma symptoms, unscheduled outpatient
attendance, emergency department visits, school absenteeism, number and
duration of hospitalizations, and use of inhaled corticosteroids.
Nocturnal cough, wheezing attacks, and asthma severity decreased
significantly while asthma-related quality of life, and knowledge scores
regarding asthma increased at 6 and 12 months after the asthma
management program from those at baseline. Additionally, acute asthma
attacks, unscheduled outpatient visits, emergency department visits,
school absenteeism, total number of hospitalizations, and duration of
stay in hospitals because of asthma were significantly reduced during
the same period. Approximately 53% of patients used inhaled
corticosteroids (ICS) at baseline, which increased to 74% over the study
period. This increased use of appropriate medication accounted for much
of the beneficial effect associated with the asthma management program.
Nonetheless, some additional improvement in asthma symptoms attributable
to this program could be detected after adjustment for steroid use.
At baseline 7% of families reported having taken avoidance measures against house dust mites. Six months after the asthma management program, 92% of families reported avoidance measures, and 12 months after the program, 93% reported taking avoidance measures. This behavioral modification may have resulted in reduced exposure of patients to this important aeroallergen and probably contributed to improvement in asthma outcomes.
Availability of Protocol and Materials:
The educational materials used in this study were based on an asthma
course from the New Zealand Asthma Foundation. The nurse specialist used
an education plan in conjunction with the asthma management program that
is not copyrighted and can be requested from the authors (see the
published article referenced above).
Case Study:
None
Pediatric Asthma Care Patient Outcomes Research Team II Study
Article Citation(s):
Lozano P, Finkelstein JA, Carey VJ, Wagner EH, Inui TS, Fuhlbrigge
AL, et al. A multisite randomized trial of the effects of physician
education and organizational change in chronic asthma care. Arch Pediatr
Adolesc Med 2004;158:875–83.
Intervention Setting:
This study involved 42 primary care pediatric practices affiliated
with four managed care organizations. These included 15 practices in
Seattle, Washington; 11 Chicago, Illinois, area practices; and 16
practices in eastern Massachusetts.
Target Population:
Children aged 3–17 years with mild-to-moderate persistent asthma
enrolled in primary care practices affiliated with managed care
organizations (MCO)
Program Description:
Researchers incorporated—a “peer leader” physician education program
and a physician education program with a nurse-run intervention (to
better organize chronic asthma care in the primary care practice). They
hypothesized that the two interventions would reduce asthma symptom days
as compared with usual care.
Subjects for the study were identified from automated claims and pharmacy data from MCOs for children with any asthma-related use in 1 year. That included hospitalizations, emergency department visits, or ambulatory care treatment that required two or more asthma medications during the same period.
The peer leader education intervention consisted of training one physician in each practice site to serve as an asthma “champion” who would share asthma care guidelines and other information with colleagues and encourage their use. Peer leaders received training in asthma pharmacotherapy and physician behavior change strategies. They also received ongoing support in their role as change agents.
The interventions included two workshops, central support by an educational coordinator, and an ongoing learning network for peer leaders via national and local teleconferences. Each peer leader received a physician tool kit. The kit included the National Asthma Education and Prevention Program/Expert Panel Report 2 (NAEPP/EPR2) guidelines and laminated pocket cards summarizing the EPR2 approach to diagnosis and treatment, among other resources. Each practice also received a tool kit of patient education materials.
The educational coordinator contacted each peer leader every 1–2 months to provide ideas, materials, and support; identify and resolve barriers to change; and encourage less active peer leaders to become more involved. All practices randomized to the second intervention, called Planned Asthma Care (PAC), also received the peer leader education intervention. In addition, PAC set up visits with a trained asthma nurse.
Asthma nurses were trained in EPR2 and in self-management support techniques. Nurses attended a full day of training to learn motivational enhancement and problem-solving techniques. They also met weekly or every other week for 10 weeks for 1-hour conference calls to review written materials with one of the investigators. The asthma nurse scheduled four or five PAC visits during the 2 years of the study in conjunction with visits to the primary care physician. At each visit the asthma nurse aimed to
- conduct a standardized assessment of asthma symptoms, medication use, environmental control, and self-management skills (and share a computer-generated report of findings with the child’s physician),
- support and participate in care planning (including medication and environmental measures) in conjunction with the primary care physician, using the EPR2, with emphasis on the use of controllers for persistent disease, and
- provide self-management support to families (regarding medication adherence, technical skills, and environmental triggers) using problem-solving and motivational techniques.
In between PAC visits, asthma nurses made standardized telephone follow-up calls and worked with patients and parents who were reluctant to attend PAC visits. Other asthma nurse activities included reviewing quarterly registry-based asthma panel reports on medication use and emergency department visits with physicians. They also arranged for allergists to visit the primary care site for case discussions. The peer leader education coordinator documented peer leader reports of asthma-related activities through telephone contacts attempted every 1 to 2 months. Asthma nurses tracked PAC visits and telephone calls and used a laptop database to record the data. Peer leaders performed an average of 9.5 group sessions in their practices in 2 years. Planned care intervention subjects had on average three PAC visits and 4.7 telephone follow-up calls by the asthma nurse during the 2 years. PAC visits averaged 65 minutes (including the physician visit) and telephone sessions averaged 20 minutes.
Evaluation Design:
This randomized controlled clinical trial compared two National
Asthma Education and Prevention Program guideline-based strategies to
improve asthma care for children in the primary care setting against
usual care. Practices were randomized within each geographic site to two
intervention arms and usual care.
Sample Size:
638 children with an average age of 9.4 years. Of those, 60% were
boys. According to parent reports, the sample included 421 white
subjects, 108 African American subjects, and 108 subjects of other
races. [Ed Note: 421 + 108 + 108 = 637, but these are
the numbers reported in the journal article]
Outcome Measures:
Annualized asthma symptom days and frequency of brief oral steroid
courses (bursts)
Results:
Researchers followed asthma symptom days across a 2-week period
every 8 weeks. This allowed them to assess 25% of the actual time on
study and to measure the effect of the intervention on long-term health
status. Evaluation of oral steroid bursts allowed researchers to detect
exacerbations that might not result in an emergency department visit or
health care encounter.
Details:
The pre-intervention mean (+/– standard deviation) annualized asthma
symptom days was 107.4 (+/– 122) days. Children in the planned care
group had 13.3 fewer symptom days annually (–12% from baseline; P=0.02)
than the usual care children. Children in the peer leader group had 6.5
fewer symptom days per year than the usual care children, a
nonsignificant difference. The planned care children had a 39% lower
oral steroid burst rate per year relative to usual care children.
Children in the peer leader group had a 35% lower oral steroid burst
rate per year compared with children in the usual care group.
Pediatric Asthma Episodes of Care Disease Management Program
Article Citation:
Marosi A, Stiesmeyer J. Improving pediatric asthma patient outcomes by
incorporation of effective interventions. Journal of Asthma
2001;38(8):681-90.
Intervention Setting:
Health clinic office
Target Population:
Children who had uncontrolled asthma or those who did not adhere to
prescribed medication therapy
Program Description:
This study tested the use of objective home pulmonary function
monitoring in conjunction with the use of long-term control medications
and comprehensive patient education to improve treatment adherence and
asthma control and decrease asthma severity. At the initial clinic
appointment, a pediatric allergist completed a comprehensive patient
evaluation comprising an extensive medical history, physical exam, allergy
testing, pulmonary function studies, radiographs (if indicated), and
disease severity assessment. An asthma management plan was then designed
and explained to the patient and caregiver. At the initial visit, the
nurse specialist provided an individualized educational plan and
one-on-one instructions to each patient and family. Major topics included
introduction to asthma, trigger identification and control, asthma
medications, asthma equipment skills and asthma self-management. During
follow-up visits the nurse specialist evaluated the patient’s
asthma-related knowledge and skills and provided additional information.
Adherence to prescribed therapy, response to medications, and symptom
control also were evaluated at follow-up visits. Adherence strategies were
designed with patients to promote regular use of long-term control
medications and routine monitoring of pulmonary function. Between clinic
visits, the nurse specialist contacted patients by phone to answer
questions and resolve adherence difficulties. Each patient was given an
AirWatch monitor and taught how to use it. The AirWatch electronic airway
monitoring system (ENACT Health Management Systems, Mountain View,
California) comprises a hand-held, pager-sized electronic device that
measures peak expiratory flow (PEF) and forced expiratory volume in 1
second (FEV1). Once a week, the patient connected the AirWatch
monitor to a phone line and sent lung function data to AirWatch Central.
AirWatch Central then faxed the patient status report, consisting of
graphs of the patient’s PEF and FEV1 values for the previous 30
days and 6 months, to the allergist for evaluation. Patients received a
monthly report card summarizing pulmonary function values and compliance
information for the previous 30 days. During follow-up visits at 1, 3, and
6 months, the allergist assessed changes in the patient’s health status
and asthma severity.
Evaluation Design:
An observational cohort design
Sample Size:
A total of 80 children with uncontrolled asthma enrolled with the
Lovelace Health Systems in Albuquerque, New Mexico. Patients were enrolled
in the study if they chose to use the AirWatch computerized peak flow
meter instead of the conventional peak flow model.
Outcome Measures and Results:
Outcome measures included adherence to medications, adherence to
AirWatch, asthma control, and asthma severity. Prestudy adherence to
medication was 40% of their combined prescribed medication therapy, and
after 6 months of intervention, the patients increased their combined
adherence to 75% of their total prescribed doses. Collective adherence to
AirWatch decreased from 56% of their prescribed readings at 1 month
following initial visit to 40% at 3 months and to 23% at 6 months. The
number of patients with optimal control increased by more than threefold
from 12 to 42 (15% to 52%), and patients with only occasional symptoms
almost doubled from 17 to 33 (21% to 41%). The number of patients with
frequent symptoms decreased from 32 to 3 (40% to 4%), and patients with
daily symptoms decreased from 19 to 2 (24% to 33%). Asthma severity
improvements also resulted from the intervention. At baseline, only 10
patients had mild persistent asthma; at follow-up this number rose to 21
patients. At baseline 70 patients presented with moderate and severe
persistent asthma. At follow-up this number had decreased to 58. Initially
59 had moderate persistent asthma; this number decreased to 50 following
the intervention, and the 11 diagnosed with severe persistent disease
decreased to eight at follow-up.
Availability of Protocol and Materials:
The Pediatric Asthma Episodes of Care Disease Management Program is
copyrighted by Lovelace Health Innovations, an organization supported by
Greenstone Healthcare Solutions, a subsidiary of Pharmacia and Johnson &
Johnson. Lovelace was dissolved in 1999. The protocol and materials are
not available for widespread distribution.
Case Study:
None
Physician Asthma Education Program
Article Citation(s):
Brown R, Bratton SL, Cabana MD, Kaciroti N, Clark NM. Physician
asthma education program improves outcomes for children of low-income
families. Chest 2004;126(2):369–74.
This study is a subset of a larger intervention described in two earlier reports:
- Clark NM, Gong M, Schork MA, Evans D, Roloff D, Hurwitz M, et al. Impact of education for physicians on patient outcomes. Pediatrics 1998;101(5):831–6.
- Clark NM, Gong M, Schork A, Kaciroti N, Evans D, Roloff D, et al. Long-term effects of asthma education for physicians on patient satisfaction and use of health services. Eur Respir J 2000;16(1):15–21.
Intervention Setting:
Physicians in the New York, New York, and Ann Arbor, Michigan, areas
were enrolled to receive two asthma seminars lasting 2–3 hours and
spaced over a 2–3 week period.
Target Population:
Children with asthma from low-income families (income < $20,000) who
were treated by physicians taking part in the study. (Note: The
objective of this arm of the larger study was to determine if low-income
child patients of physicians who participated in the intervention also
benefited in health outcomes.)
Program Description:
The study hypothesis was that physicians participating in the
seminars regarding asthma care would improve their patient health
outcomes. Primary care pediatricians were randomized to the interactive
seminars or to a control group. A random sample of patients (children)
from each of the participating physicians was selected to assess the
effectiveness of the program. Children qualified for the study if they
had an asthma diagnosis by a physician, had no other chronic conditions,
and had received emergency care at least once for asthma in the prior
year. Children in the study had frequent asthma symptoms. Parents
reported that 96.1% of all children had persistent symptoms and that
88.2% had moderate-to-severe persistent asthma during at least one
season of the year.
The interactive seminar was based on a previously reported theory of physician self-regulation to enhance their therapeutic skills in treating childhood asthma and to develop their ability to educate and counsel families about asthma self-management. The two main components of the program included optimal clinical practice following National Asthma Education and prevention (NAEPP) guidelines and patient teaching and communication. The program included several activities and materials:
- brief lectures from a local asthma expert,
- a video showing effective clinician teaching and communication behavior,
- case studies that presented clinical problems,
- a protocol by which physicians could assess their oral communication behavior, and
- a review of messages to communicate and materials to distribute to patients and their families.
The first visit that the patient made to the physician within 22 months after the intervention was followed by an interview with the parent. The parent interview consisted of questions related to the children’s asthma symptoms, prescribed medications, use of health care services, and parental observations regarding physicians’ teaching and communication behaviors. The patient then was tracked and evaluated at 12 months and 24 months after the initial visit.
Evaluation Design:
Randomized controlled trial
Sample Size:
The sample included 23 pediatricians and 36 of their patients:
children with asthma from low-income families, ages 1–12 years. This
study is a subset of a larger study involving 74 pediatricians and 637
of their patients.
Outcome Measures:
Health care use for asthma: presenting at emergency departments and
admission to the hospital
Results:
Low-income children in the treatment group were significantly less
likely to be admitted to an emergency department (annual rate, 0.208 vs.
1.44, respectively) or to the hospital (annual rate, 0 vs. 0.029,
respectively) for asthma care compared to low-income children in the
control group during the 2-year assessment period. Low-income children
in the treatment group tended to have higher levels of use of controller
medications, to receive a written asthma action plan, and to miss fewer
days of school. These differences were not statistically significant
compared to low-income children in the control group. This study shows
that the effectiveness of the physicians’ education program is not
reserved merely to those patients with more resources. The greatest
decline in emergency department use was in children from low-income
families, when compared with children of middle- and upper-income
families in the larger study.
Tobacco Smoke Reduction Program
Article Citation:
Wilson SR, Yamada EG, Sudhakar R, Roberto L, Mannino D, Mejia C,
Huss N. A controlled trial of an environmental tobacco smoke reduction
intervention in low-income children with asthma. Chest 2001;20:1709-22.
Intervention Setting:
The pediatric pulmonary service of a regional pediatric hospital in
central California
Target Population:
Low-income minority children with asthma exposed to environmental
tobacco smoke (ETS) who were Medicaid/Medi-Cal-eligible and were at risk
of having been seen for acute asthma in an urgent-care setting, hospital
emergency department, or impatient hospital setting in the previous year
Program Description:
The study objective was to determine the effectiveness of a
cotinine-feedback, behaviorally-based education intervention in reducing
ETS exposure and health-care utilization of children with asthma. The
intervention consisted of three one-on-one, behaviorally-based
counseling sessions provided by a nurse-educator spaced over 5 weeks.
The protocol included instruction about asthma and its treatment,
environmental controls, the inflammatory nature of asthma, and the role
of ETS in exacerbating and sustaining inflammation. Behavior-changing
strategies were used to gain cooperation. ETS exposure recall was
reported at each session for the 3 days preceding the session. A key
feature of the intervention was repeated feedback to parents over a
5-week period regarding the results of four successive urine cotinine
measures to inform them of the level of exposure to the child and the
success of their efforts to reduce this exposure.
Evaluation Design:
The study was a randomized controlled trial of an educational
intervention compared with usual care. Assays for urine cotinine and
creatinine were completed for intervention and control children at
enrollment and at 6 and 12 months after enrollment. Intervention
children provided urine samples at each intervention session. All
children’s asthma drugs were adjusted as needed following enrollment.
Medical records were reviewed at the end of the follow-up year.
Sample Size:
A total of 87 children aged 3–12 years, 44 in the intervention group
and 43 in the control group, participated in the study.
Outcome Measures/Results:
The primary outcome measures investigated were emergency and urgent
health utilization for asthma and ETS exposure as indexed by the child’s
urine cotinine/creatinine ratio (CCR). The proportion of children with
more than one asthma-related medical visit decreased substantially in
the intervention group from 50% in baseline year to 29.6% in follow-up
year, contrasted by a substantial increase of 37.2 % to 46.5% in the
control group. The odds of having more than one medical visit were
reduced by about two thirds in the intervention group compared with the
control group. Cotinine-level differences correspond to a 46% greater
reduction in the CCR in the intervention group than in the control
group, a difference that is not statistically significant. A trend
toward relatively low odds of hospitalization in the intervention group
was observed, but the differences were not statistically significant.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Wee Wheezers
Article Citation:
Wilson SR, Latini D, Starr NJ, Fish L, Loes LM, Page A, Kubic P.
Education of parents of infants and very young children with asthma: a
developmental evaluation of the Wee Wheezer’s program. J Asthma
1996;33(4):239-254.
Intervention Setting:
Outpatient clinic
Target Population:
Children with asthma and less than seven years of age and their
families
Program Description:
An asthma education program in English and Spanish, based on social
learning theory, designed specifically for parents of young children
under the age of seven
The program helps parents gain the knowledge, skills and motivation necessary to recognize, prevent, and/or appropriately manage asthma symptoms; to use medical, educational, and interpersonal resources for information and support; communicate effectively with other adult caretakers and physicians; and promote general well-being of the family unit. The program consists of four small group sessions that last approximately 2 hours each. Nurses familiar with asthma management facilitate the sessions.
Evaluation Design:
Unavailable
Sample Size:
76 families, 41 in the intervention and 35 controls
The control families received the program after the intervention was completed.
Outcome Measures/Results:
Outcome measures included symptom-free asthma days as reported by
parents, parental sleep interruption, degree to which child was bothered
by asthma symptoms, and the number of days the child was sick due to
asthma. ANOVA was used to analyze the data. Children in the treatment
group experienced improvement on all five outcomes and statistically
significant improvement in two outcomes: symptom-free days and sleep
interruption. There were also significant gains in parental knowledge
about asthma and asthma management.
Availability of Protocol/Materials:
The Wee Wheezers Program kits available from:
Asthma and Allergy
Foundation of America [external link]
1233 20th St. NW
Washington, DC 20036
phone: 1-800-7-ASTHMA
Case Study:
Wee Wheezers Asthma Education Program,
Darnell Army Community Hospital, Fort Hood, Texas
Schools
Bronx NY School-Based Health Centers
Article Citation(s):
Webber MP, Carpiniello KE, Oruwariye T, Lo Y, Burton WB, Appel DK.
Burden of asthma in inner-city elementary schoolchildren: Do
school-based health centers make a difference? Archives of Pediatric and
Adolescent Medicine 2003;157:125-9.
Intervention Setting:
Six elementary schools: four with a school-based health center
(SBHC) and two without a SBHC (comparison schools)
Target Population:
Children in kindergarten through fifth grade attending inner-city
schools in the Bronx that were participating in the study
Program Description:
About 1,400 SBHCs provide care to 1.1 million children in the United
States. Whether access to on-site health services is associated with
better health outcomes, is unknown. The objective of this study was to
evaluate whether the availability of SBHCs measurably affected the
health and school performance of children with asthma. The study
examined differences in emergency visits, hospitalizations, medication
use, and school absenteeism. Bilingual Spanish and English surveys were
sent home with children during the 1999–2000 school year. The survey
asked about demographics, whether the child has asthma, and the presence
of specific asthmatic symptoms in the last year. Of the 6,433 families
surveyed, 74.2% returned completed questionnaires (72.6% from SBHC
schools and 78.7% from comparison schools). Eighty-seven percent of the
children at these schools whose parents or caretakers responded to the
survey had health insurance coverage. The prevalence of probable asthma
was 18.9% at SBHC schools and 22.4% at comparison schools. Criteria for
probable asthma included responding "yes" to the question inquiring
whether the child had ever had asthma and reporting that one or more of
the following was true during the past 12 months: 1) taken asthma
medication; 2) experienced sleep disturbance because of wheezing,
coughing, or tightness in the chest; 3) coughed after or during exercise
when the child did not have a cold; 4) had weather-related breathing
problems; or 5) wheezed in the presence of pets, mold, strong odors or
cigarette smoke. During the study period, 13.5% of all visits to SBHCs
were for asthma care, with a mean annual frequency of 4.9 visits per
child. About half of the children with asthma used the SBHCs for asthma
care during this 1-year period.
Evaluation Design:
A cohort study design was used.
Sample Size:
The study comprised 949 children with asthma (645 from the four
schools with SBHCs and 304 from the two comparison schools).
Outcome Measures/Results:
Outcome measures included activity limitation, hospitalization,
emergency visits, and school absenteeism. A total of 234 (27.1%) of the
865 respondents to this question from all schools reported at least a
moderate amount of activity limitation; 293 (33.9%) of the same
respondents reported their child did not experience any activity
limitation. No statistically significant differences were noted in
activity limitation by sex, race or ethnicity, health insurance
coverage, or availability of an SBHC. Of the 949 children, 120 (12.6%)
from all schools had been hospitalized for asthma at least once in the
previous year. Children attending the comparison schools were more
likely to have been hospitalized for asthma (17.l%) than those in
schools with SBHCs (10.5%). No statistically significant differences
were noted between hospitalization and sex, race or ethnicity, and
health insurance coverage. A total of 438 (46.2%) of the 949 parents
from all schools responded that the child had emergency treatment at
least once for asthma in the past year. No statistically significant
differences were noted in emergency visits by sex, race or ethnicity,
health insurance coverage, or availability of an SBHC. Overall, students
in the comparison school missed about 2 more days of school than those
in schools with an SBHC (16.4 and 14.5 days, respectively). Among
children with asthma, those attending the comparison school missed an
average of 3 more school days (21.3) than those attending schools with
an SBHC (18.2).
Materials available:
Contact Dr. Mayris Webber at
mwebber@montefiore.org. Materials can be transmitted electronically.
Community-Based Asthma Management Program
Article Citation:
Toelle BG, Peat JK, Salome CM, Mellis CM, Bauman AE, Woolock AJ.
Evaluation of a community-based asthma management program in a
population sample of schoolchildren. Med J Australia June
1993;158(11):742-746.
Intervention Setting:
Parent and child educational sessions were held at the child’s
school.
Target Population:
Children with asthma aged 8–11 attending randomly selected schools
Program Description:
A community-based management program designed to improve outcomes for
children with asthma in Sydney, Australia
The program targeted children and those responsible for the participating children: parents, pharmacists, doctors, community clinic nurses, and school teachers. Children and parents attended two 2-hour educational sessions. The first session explained asthma as a disease to help parents and children identify symptoms and triggers and use medication more effectively. The second session emphasized the importance of monitoring airway function and the use of a written asthma management plan. Doctors and pharmacists attended an evening workshop explaining the development and use of written asthma management plans. School teachers and community nurses received an in-service session about asthma symptoms and triggers.
Evaluation Design:
Children with asthma from randomly selected schools participated in
the intervention group. Children with asthma from schools in a
selected geographic area served as controls. Baseline data were
collected on both groups of children. Knowledge of asthma and morbidity
were asked of parents via questionnaire. Follow-up
data were collected three months and six months after educational
sessions were completed. The data were analyzed using ANOVA and paired
t-tests.
Sample Size:
120 children (65 in the intervention group and 55 in the control group)
147 teachers and community nurses, 53 families, 15 pharmacists and 11 doctors attended the educational sessions.
Outcome Measures/Results:
Although morbidity varied, most of the participating children had
mild asthma. The outcome measures in this study were lung function
as measured by forced expiratory volume in one-second (FEV1)
bronchial responsiveness to histamine and airflow variability. The
prevalence of symptoms such as wheezing or night coughs, the number of
doctor and emergency room visits, and days absent from school due to
asthma were also measured. At six months, bronchial
hyper-responsiveness and night cough were significantly reduced and FEV1
was improved compared to both baseline measurements and the control
group. Unscheduled (emergency) visits were reduced in both the
intervention and control groups. Days absent from school did not
change in either group.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Inner-city School-based Health Center Program
Article Citation:
Lurie N, Bauer EJ, Brady C. Asthma outcomes at an inner-city
school-based health center. Journal of School Health 2001;71(1):9-16.
Intervention Setting:
A health clinic in a large, inner-city elementary school
Target Population:
Minority children aged 6–14 years with asthma attending an
inner-city elementary school
Program Description:
An initial sample survey of 400 students indicated that
approximately 17% of children in the school had asthma. School-wide
screening then identified all the students with asthma. Families of
these children were interviewed to assess asthma symptoms and morbidity.
Children were then grouped into three categories based on severity.
Those classified with severe or moderate asthma were prioritized for
immediate intervention at the school health center. The initial visit
consisted of confirming the asthma diagnosis by history, physical exam,
and spirometry. Individualized information about asthma management,
medications, and environmental control (based on parental knowledge) was
provided in individual sessions to parents and children by a health
educator. Asthma education group sessions were also held at the school
for students and parents. An asthma symptom-control plan was developed
for each child without a plan, and each child received a written asthma
plan that included the use of rescue medications. Health center staff
attempted to identify a primary-care provider (PCP) for each child and
encouraged each family to obtain regular asthma checkups with that
provider. Health center staff communicated their findings regarding the
asthma diagnosis and the care plan to the PCP. All children with severe
and moderate asthma were prescribed anti-inflammatory medications.
Inhaler technique was emphasized, and spacers and peak flow meters were
provided. Children experiencing asthma symptoms during the school day
could go to the health center on a walk-in basis or by referral from the
school nurse. Asthma care in the health center was tailored to
individual need. Many high-risk students with compliance issues began
taking their daily anti-inflammatory medication at school.
Evaluation Design:
This study used a pre- and post-intervention comparison with
longitudinal and cross-sectional cohort of children. A baseline survey
completed by parents addressed self-rated health, asthma-related
symptoms the prior 3 months, asthma morbidity, asthma management
practices, home environment, demographic characteristics, health
insurance, and health care use in the prior 3 months. Baseline data were
collected at the beginning of the school year and again about 9 months
later.
Sample Size:
This intervention comprised 156 children with asthma who attended
the same school, had physician-diagnosed asthma, had asthma symptoms
such as wheezing and nocturnal coughs within the past 12 months, and
were taking asthma medication. The sample included all children in the
baseline who remained in school through the study period as well as
children who entered school during the year after the baseline screening
and the beginning of the intervention and were enrolled in school for at
least 6 months of the study year.
Outcome Measures and Results:
Outcome measures included school absenteeism, hospitalization rates
for asthma, outpatient visits for asthma in the absence of asthma
symptoms, percentage of students seeing a specialist for asthma, use of
peak flow meters, use of asthma-care plans, use of inhalers, and school
absenteeism. The percentage of students who were patients overnight in a
hospital because of asthma during the prior 12 months decreased from 15%
to 3% for the longitudinal population and from 10% to 2% for the
cross-sectional sample, a reduction of 75%-80%. School absenteeism
associated with asthma did not change. Parents reported substantially
fewer nights that the child awakened because of asthma and substantially
fewer days the family had to change plans because of the child’s asthma.
The mean number of scheduled well-child physician visits significantly
decreased. The percentage of students who ever visited a specialist for
asthma markedly increased, and children were more likely to use a peak
flow meter and take appropriate medications.
Availability of Protocol and Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Open Airways
Article Citation:
Clark NM, Feldman CH, Evans D, Levinson MJ, Wasilewski Y, Mellins
RB. The impact of health education on frequency and cost of health care
use by low income children with asthma. J Allergy & Clin Immunol
1986;78:108-115.
Evans D, Clark NM, Feldman CH, Rips J, Kaplan D, Levison MJ, Wasilewski Y, Levin B, Mellins RB. A school health education program for children with asthma aged 8-11 years. Health Educ Q Fall 1987; 14(3):267-279.
Intervention Setting:
Elementary schools
Target Population:
Predominantly low-income African American and Latino children between
the ages of 8 and 11 years old
Program Description:
The Open Airways program, originally designed for delivery in health
care settings with predominantly African American and Latino children
from underserved communities, was adapted for delivery in the New York
City school system. The program, which is grounded in social learning
theory, consisted of six group sessions where children learned basic
information about asthma, how to recognize symptoms and triggers, how to
use medicine effectively and how to handle problems at school. Parents
were also mailed educational materials.
Evaluation Design:
Twelve schools were chosen. Schools were matched in pairs as closely
as possible on demographic characteristics. Of the 6 pairs, one
school was randomly assigned to the control group and one to the
intervention group. Multivariate and univariate analyses of covariance
were used to analyze the data.
Sample Size:
A total of 239 children, of which 135 were in the intervention group
and 105 were in the control group.
Outcome Measures/Results:
Outcome measures included changes in behavior, changes in feelings
expressed by children, school attendance, school performance, frequency
of asthma episodes, and the number of attacks requiring a doctor visit
or treatment at home. Participants showed significant improvement in
school performance, self-management behaviors and decreased number of
episodes.
Availability of Protocol/Materials:
Open Airways for Schools is disseminated through local American Lung
Association (ALA) affiliates. Individuals and organizations
interested in implementing the program or serving as instructors in the
schools should contact ALA at 1-800-LUNG-USA. Collaborating
organizations and instructors receive training in the curriculum and are
expected to stay in contact with the Lung Association for technical
assistance and results reporting.
Case Study:
Open Airways for Schools; Office of School
Health,
Department of Health; Anne Arundel County, Maryland
The Alberta School-Based Asthma Education Program: The Roaring Adventures of Puff
Article Citation(s):
McGhan SL, Wong E, Jhangri GS, Wells HM, Michaelchuk DR, Boechler
VL, et al. Evaluation of an education program for elementary school
children with asthma. J Asthma 2003; 40(5):523–33.
Intervention Setting:
Elementary schools in Edmonton, Alberta, Canada
Target Population:
School children ages 7–12 years with physician-diagnosed asthma
Program Description:
The purpose of the study was to determine whether The Roaring
Adventures of Puff (RAP), an interactive childhood asthma education
program, improved asthma management behaviors and health status, and
quality of life in elementary school children. The RAP intervention
schools received parent and teacher asthma awareness events,
recommendations for school asthma guidelines, and six educational
sessions for the children with asthma. Children in the control schools
received regular medical care. Using the 300-page manual, the
instructors taught six 60-minute asthma educational sessions. Topics by
session number included
- getting to know each other, goal setting, use of a peak flow meter, diary monitoring;
- trigger identification, control and avoidance, basic pathophysiology;
- medications and proper use of inhalers;
- symptom recognition and action plan;
- lifestyle, exercise, managing an asthma episode; and
- sharing this information with teachers and parents.
Sessions were held during the students’ lunch hour. Teaching strategies included puppetry, games, role play, model building, discussions, and asthma diary recording. The puppet is a dinosaur named Puff who has asthma. Puff interacts with the children, instructing them on what to do to better control their own asthma. Puff is featured in the workbook that children complete during the week between sessions, share with their parents at home, and use in class. Over the course of the instructional period, the instructor worked with teachers and parents as needed for individual child asthma concerns and with teachers and principals to develop practical school guidelines for asthma.
Evaluation Design:
This study was a cohort, pre-post intervention design. The study
compared children with asthma in randomly assigned intervention schools
with those in control schools. The unit of randomization was the school.
All participating students in each school were assigned to the same
group. Children, however, were the primary unit of analysis. All
children with asthma in the intervention and control schools and their
parents completed questionnaires at the beginning of the project and
following the intervention. Questionnaires included the pediatric asthma
quality of life questionnaire, parent’s RAP questionnaire, and the
childhood asthma self-efficacy scale. The RAP questionnaire assessed
demographic information, perception of their child’s symptom severity,
medication use, health care utilization, school absenteeism, and
attitudes toward asthma. The primary analysis compared pre-intervention
and post-intervention outcomes for the children with asthma receiving
the education program and those not receiving the program.
Sample Size:
This study involved 76 children in the intervention group and 86 in
the control group. The two groups, including those who dropped out, were
comparable for demographic and disease related variables.
Outcome Measures:
Unscheduled doctor visits in the last year, emergency department
visits in the last year, missed school days, asthma symptoms, limited
type and amount of play.
Results:
For most indicators of asthma control, the intervention group improved
after the RAP intervention. Statistically significant improvements for
the intervention group included over-all parent-rated severity,
unscheduled physician visits in the last year, moderate-to-severe
shortness of breath, limitations in the kind of play, and any missed
school days in the last year.
Details:
In the year before RAP, 76.2% of the intervention children had
unscheduled doctor visits. Followup after RAP showed that 33.8% of RAP
participants had unscheduled doctor visits. Before RAP, 87.7% of
intervention children missed some school because of asthma. Post
intervention followup showed that 38.5% of children missed some school
because of asthma. Some characteristics of asthma improved at followup
among the controls, whereas others remained the same or got worse.
Unscheduled physician visits and any missed school days were the only
statistically significant improvements also seen in the control group.
However, the improvement in the control group was just over half that of
the RAP group for both variables. Although not significant, the
reduction in the number of emergency visits in the RAP group was more
than twice that of the control group. The intervention group
demonstrated a significant improvement in use of appropriate medication
for relief of symptoms (20.6% improvement) and preventing symptoms
(31.4% improvement) at followup, in contrast to the control group of
(17.4% and 3.7%, respectively).
Materials Available:
The Roaring Adventures of Puff asthma education program is
available from the Alberta Asthma Centre, Box 4033, 11402 University
Avenue, Edmonton, AB T6E 6K2, Canada.
Other
Family Coordinator Asthma Education Program
Article Citation:
Bonner, S, Zimmerman BJ, Evans D, Irigoyen M, Resnick D, Mellins RB.
An individualized intervention to improve asthma management among urban
Latino and African-American families. Journal of Asthma 2002;39(2):167-79.
Intervention Setting:
Classroom and home
Target Population:
Urban Latino and African-American families with a child with asthma
Program Description:
This study hypothesized that an educational intervention based on a
readiness model would lead to improved health outcomes among patients with
asthma. This individualized asthma education intervention, based on the
asthma self-regulation model, comprised four sequential phases of patient
readiness to manage asthma: 1) asthma symptom avoidance, 2) asthma
acceptance, 3) asthma treatment compliance, and 4) asthma self-regulation.
Baseline interviews were conducted in participants’ homes and families were randomly assigned to intervention or control groups. Control families received usual medical care. Patient education was delivered by a family coordinator, a college educated, bilingual, social services-oriented individual, who acted as a behavioral change agent. Educational workshops and individualized counseling sessions used an asthma diary as a primary intervention tool. The family coordinator conducted three group educational workshops at 1-month intervals. The workshops followed the learning sequence identified in the asthma self-regulation model. In the first workshop, families were trained to use asthma diaries and peak flow meters. Patients were required to monitor peak flow, triggers, symptoms, medications, and side effects. The family coordinator regularly called families to discuss their diary records. The second workshop used patients’ diary records as illustrations of the relative effectiveness of controller medicines over rescue/quick-relief drugs in preventing asthma symptoms over time. The strategy of using patients’ own diaries as evidence of the efficacy of control medicines helped overcome patients’ preference for rescue/quick-relief drugs. The third workshop described asthma management as a two-pronged effort of medications and trigger control. Again, patients’ own diary records of fluctuations in asthma were shown as cues to step up medications according to their action plans. In addition, the family coordinator visited each family at home to assess the reliability of the diary with a spot check of peak flow accuracy. The family coordinator helped prepare each family for its doctor visit; accompanied the family to the visit; and assisted it in presenting the asthma diary, describing the child’s condition, and acquiring an asthma plan. Allergy testing was performed to help families develop an informed approach to controlling triggers. After the third workshop, the family coordinator conducted a home environment assessment and suggested strategies for reducing asthma triggers, especially in the child’s bedroom. Allergen-impermeable casings for pillows and bedding were provided for children who tested positive for dust mites. Caretakers were again interviewed following the 3-month intervention.
Evaluation Design:
A randomized controlled cohort design
Sample Size:
Each of 119 families with a child ages 4-19 years who had moderate to
severe asthma were recruited into one of seven cohorts of 16-18 members
each.
Outcome Measures/Results:
Outcome measures included asthma knowledge, self-efficacy for managing
asthma, asthma self-regulatory phase, adherence to prescribed medications,
prophylactic use of a bronchodilator, asthma symptom persistence, and
activity restrictions caused by asthma. The intervention produced
improvements on all health outcome measures. Intervention families’
knowledge of asthma rose to a statistically significant 67% correct
responses, and asthma knowledge among the control group remained constant
at about 40%. The intervention program contributed to a 41% increase in
the participants’ self-efficacy for managing asthma, compared with a 9%
increase in the control group. At follow-up, 66% of the intervention group
had achieved asthma self-regulatory phases 3 (asthma compliance) or 4
(asthma self-regulation). In contrast, 28% of the control families were
classified in phase 3, and one reached phase 4. Physicians’ prescription
of controller medications increased significantly in the intervention
group but decreased in the control group. At follow-up, 82% of the
intervention group reported adhering to the prescribed frequency of
medication administrations, and 86% adhered to prescribed dosages,
compared with only 40% and 42% for the control group, respectively. At
follow-up, 26% of intervention families reported cough or wheeze more than
twice a week, 14% reported nighttime awakening more than twice a week, and
26% reported keeping their child at home more than twice a month. The
comparative frequencies among the control group were 50%, 40%, and 48%,
respectively. The intervention group reported a 20% reduction in activity
restrictions from baseline to follow-up, compared with a 2% increase for
the control group.
Editor’s Notes:
A pre-post design trial of this phase-based asthma education program was
implemented in 2002-03 in East Harlem among Head Start families. The New
York City Agency for Children’s Services has instituted a mandate
requiring written asthma plans for all children in Head Start programs, a
requirement that was phased in over the 2002-03 school year and is
considered a prerequisite milestone for achieving success with the
intervention.
Availability of Protocol/Materials:
With an additional study under way, the protocol and materials are not
available for widespread distribution.
Case Study:
None
Living With Asthma
Article Citation:
Creer TL, Backial M, Burns KL, Leung P, Marion RJ, Miklich DR,
Morrill C, Taplin PS, Ullman S. Living with asthma. I. Genesis and
development of a self-management program for childhood asthma. J Asthma
1988;25(6):335-362.
Intervention Setting:
Residential treatment facility for resident children with asthma
Target Population:
Children and their families
Program Description:
A pediatric asthma program based on social learning theory.
The program is designed to teach children how to manage their asthma by
providing education and opportunities to use their newly acquired skills
to recognize symptoms and triggers and to determine the appropriate
course of action. The program consists of eight sessions. The first four
provide basic asthma education and an understanding of how to medically
manage asthma. The last four occurred during the “performance phases”
and focused primarily on utilizing and refining the knowledge and skills
learned earlier.
Evaluation Design:
Families were assigned randomly to the intervention group and a
wait-listed control group. Once 10 families were assigned to each group,
the intervention began. The wait-listed control received the
intervention approximately three months later; therefore, participants
served as their own controls during the performance segment of the
study. The data was analyzed using ANOVA.
Sample Size:
399 participated over a three-year period of time. The data
reported in the study were based on 278 individuals including 123
children between the ages of 5 and 17.
Outcome Measures/Results:
Several pen and paper instruments were used to measure changes in
knowledge and attitudes about asthma on the parts of children and their
parents. Pulmonary physiology measures (a complete work-up and peak flow
meter readings); self-report measures on compliance and on the number
and severity of attacks (in the form of an asthma diary); and the
financial cost of asthma were also collected. Patients improved
significantly in their ability to prevent and manage attacks. School
absenteeism and financial costs associated with asthma were reduced as
well. There were also improvements in parental and child attitudes about
asthma.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None
Pediatric Asthma Program
Article Citation:
Tieffenberg JA, Wood EI, Alonso A, Tossutti MS, Vincente MF. A
randomized field trial of ACINDESs*: A child centered training model for
children with chronic illnesses (asthma and epilepsy). Journal of Urban
Health 2000;77(2):280-96.
*ACINDESs is the Association for Health Research and Development, Buenos Aires, Argentina.
Intervention Setting:
The intervention was conducted in a classroom in Buenos Aires,
Argentina that was not associated with a hospital or clinic. Families
were recruited from several health facilities (including asthma clinics)
within the City of Buenos Aires and its environs. This program
reportedly represents the first Hispanic child-centered group training
program in Latin America focused on asthma self-management.
Target Population:
Spanish-speaking school-aged children aged 6–15 years who had been
diagnosed with moderate to severe asthma
Program Description:
The study’s objective was to assess the effectiveness of an asthma
education program founded on the basis of a child’s autonomy. This
approach places the children in the center in the management of their
own health; parents become facilitators and physicians are counselors.
The program was designed to help the children change their beliefs and
attitudes about their ability to care for themselves. By learning about
the alternatives from which they can choose, children acquire tools to
modify their health behaviors. The participants attended five weekly
2-hour group meetings (parents and children in separate sessions
conducted at the same time) followed by a reinforcement meeting 2 and 6
months later. Instruction was provided by professional teachers who
employed games, drawings, stories, videos, and role play. Children and
parents learned a) the child’s condition, body signals, and warning
signs, b) triggers, c) treatment alternatives, d) risks and
actions-emergency home treatment, and e) decision-making based on
expected values.
Evaluation Design:
This study utilized a randomized controlled design. The experimental
group was invited to participate in training and receive home interviews
and follow-ups at 6 and 12 months. The control group received home
interviews at same time. Surveys included a socio-cultural
questionnaire, and school absenteeism was also recorded. Number of
crises, routine and emergency department visits, and hospitalizations
registered from medical records 6 months prior and up to 1 year after
the program were recorded.
Sample Size:
The study consisted of 188 children; 127 were randomly placed in the
experimental group and 61 in the control group. A total of 64 children
in the experimental group and 43 in the control group completed the
study.
Outcome Measures/Results:
Outcome measures included general knowledge of asthma, beliefs,
attitudes, and behaviors, clinical outcomes, and school absenteeism.
Parents in the experimental group showed increased asthma knowledge
whereas knowledge for parents serving as controls waned. Fear of the
child’s death decreased from 39% to 4% in the experimental group whereas
parents in the control group showed no decrease in levels of fear.
Children’s confidence in self-care skills showed marked improvement
after the intervention. The experimental group had fewer asthma crises:
an average 2.02 compared with 1.09 in the control group in a 12-month
period, a statistically significant difference. Medical-care visits
decreased from an average 3.29 to 1.65. School absenteeism fell in the
experimental group from 10 to 5.91 during March through July (fall and
winter in Argentina). School attendance was above that of a sample of
345 Buenos Aires children without chronic illness for the same time
period.
Availability of Protocol/Materials:
The protocol and materials are not available for widespread
distribution.
Case Study:
None