Asthma Program

• Asthma Home
• About the Program
• Data & Surveillance
• General Information
• Interventions
• Legislation & Policy
• Resources

The pediatric asthma education program known today as Wee Wheezers: An Asthma Education Program for Parents of Young Children has been in existence since 1995. The program grew out of original asthma research, and it has been fully developed into a complete educational package. The program targets parents of children under the age of seven years who have asthma. It is designed for delivery in connection with a community-based asthma initiative. Departments of Health, research studies, hospitals, medical centers, and primary care providers also may use the program.

Investigators seeking to better understand the behaviors of parents whose infants and young children have asthma received a grant from the National Heart, Lung and Blood Institute of the National Institutes of Health. The grant proposal outlined tasks supporting the study of parents’ asthma management practices and whether behaviors could be changed. This work was published by S.R. Wilson, J.H. Mitchell, S. Rolnick and L. Fish in a manuscript titled "The Effective and Ineffective Management Behaviors of Parents of Infants and Young Children With Asthma" in 1993 in volume 18 of the Journal of Pediatric Psychology. The proposal also included development of an asthma education program to be tested in a clinical trial to determine the effectiveness of education in changing parents’ management behaviors. Investigators carried out this study in the early 1990s. The trial was described in detail by S.R. Wilson, D. Latini, N.J. Starr and others in "Education of Parents of Infants and Very Young Children with Asthma: A Developmental Evaluation of the Wee Wheezers Program" that was published in 1996 in volume 33 of the Journal of Asthma.

Wee Wheezers is based on the premise that many families of very young children experience significant stress related to the child’s asthma. This premise suggests that families need help in coping with the asthma when the disease first becomes apparent. Furthermore, because ineffective asthma management practices of parents of very young children can result in life-threatening and even fatal consequences, parents need sound education about asthma directed at improving the manner in which they manage this disease at home. Changing the way parents manage their children’s asthma requires addressing various underlying attitudinal and situational factors that often present barriers to more effective practices. Such factors may include denial of the child’s illness by one or both parents, fears about routine use of medications, tobacco use, and issues related to family pets.

In 1995, Dr. Sandra Wilson and colleagues conducted a randomized control trial of the Wee Wheezers asthma education prototype for parents with children aged less than 7 years who had asthma. This program comprised two brief educational sessions for children aged 5 and 6 years. The behavior change strategies used in Wee Wheezers were derived from psychological principles embodied in Bandura’s social cognitive theory, which includes the construct of self-efficacy as a determinant of behavior. (Self-efficacy refers to one’s belief in his/her ability to perform a task effectively as a prerequisite to undertaking that task.) The in-class practice, behavioral contracts, and at-home activities were structured to ensure successful completion by all class members, thus enhancing self-efficacy and promoting the willingness to try other new behaviors. The small group format also facilitated vicarious mastery experience, modeling, social comparison, and information sharing.

The clinical trial demonstrated the asthma education to be effective in helping parents to manage their children’s asthma better. Subsequently, the researchers fully documented the education program (including a complete asthma curriculum with instructor guide, scripted lesson plans, visual aids, and handouts) so that it could be implemented in other settings.

The following sections present the goals of this intervention, educational content, evaluation design, important characteristics of the study population, and results of the intervention.

Wee Wheezers addresses a void in asthma self-management education programs, namely the lack of appropriate education for parents with infants and young children with asthma. Despite the unique medical and developmental needs of young asthma patients and their parents, no educational program existed in the early to mid-1990s that was especially designed for parents of children under age 4. Thus, Wee Wheezers was developed specifically to meet the educational needs of parents with children under age 7. Specifically, program goals aimed to give parents the knowledge, skills, and motivation to:

• Prevent asthma symptoms
• Appropriately manage symptoms
• Use medical, educational, and interpersonal resources appropriately for asthma care
• Communicate effectively with all adults responsible for the child’s care
• Promote the psychosocial well-being of the family unit

Educational Content of the Intervention
The educational package is composed of four small-group sessions of approximately 2 hours each, conducted at 1-week intervals by nurses experienced in the management of pediatric asthma. The parents of children aged less than four years and 4-6 years met in separate groups.

The four educational sessions for adults covered the following topics:

• Basic concepts of asthma: epidemiology and physiology
• Coping in a crisis: fears of having a child with asthma and fear of taking the child to the emergency department
• Action plan for asthma management: recognition of early warning signs, use of the peak flow meter, asthma medications
• Symptoms of an acute episode: treatment of early symptoms, and appropriate time to seek medical help
• Feelings about having a child with a chronic health problem
• Prevention of symptoms: trigger identification and control, use of preventive medications
• Communication about asthma with teachers, child-care workers, physicians, family

The parents and children ages 4-6 years together attended the first 45 minutes of the adult sessions 3 and 4. These sessions covered the following topics:

• Asthma physiology
• Early warning signs and symptoms
• Asthma medications
• Belly breathing
• Asthma self management and triggers
• Use of the metered-dose inhaler

The children were then cared for in a separate room while their parents completed the adult sessions, lasting about 90 minutes.

Evaluation Design
Data collection instruments (questionnaires, 2-week symptom-medication diaries, physical examination forms, and medical record abstraction forms) were used to collect information from parents about each child at enrollment in the program and at a 3-month follow-up visit. The primary clinical endpoints were selected to reflect asthma status in a population primarily of children too young for reliable standard pulmonary function testing. The following outcome measures were used to detect changes in the children’s asthma condition and to assess disease management practices.

• Number of days in which the child was free of asthma symptoms in the preceding 2 weeks and in the preceding month
• Number of nights in which the parents’ sleep was interrupted because of the child’s asthma during a typical week
• Degree to which the child was bothered by symptoms of asthma in the preceding month
• Number of days the child was sick at home because of asthma during the preceding month
• Frequency with which parents performed each of 17 asthma symptom management and prevention practices using a 5-point scale ranging from 1 (almost always) to 3 (sometimes) to 5 (rarely)
• Frequency with which parents rated how much of the time they had each of 16 feelings about their child’s asthma and its effect on the child and the family using a 5-point scale ranging from 1 (almost never) to 3 (about half the time), to 5 (most of the time)

Recruitment and Characteristics of the Study Population
To recruit participants for the study, researchers identified and screened children and their families from the medical records of members of the Aspen Medical Group, Minneapolis, Minnesota and patients of St. Paul Children’s Hospital in St. Paul, Minnesota. Eligibility criteria for children included 1) age 1-6.5 years, 2) patient of the medical group for at least the preceding year and had been hospitalized, 3) documented history of airways obstruction that was reversible with bronchodilator treatment, and 4) mention of any anti-asthma medications.

A computer search of potential participants meeting the age and medical diagnosis requirements identified 129 eligible families, of which 76 agreed to participate and were enrolled in the program. Families were randomly assigned to the education group (41) or the control group (35). The children were predominantly white (minorities accounted for less than 11%) and from middle class families of educated parents (52% of mothers were college educated). Sixty-four percent were boys, and the average age of the children was 3.8 years. The children’s asthma severity was determined on the basis of a medication regimen: 31% with mild asthma, 54% with moderate asthma, and 18% with moderately severe or severe asthma. Eighty-one percent of the children were in generally excellent health, and 19% were in good health.

The intervention improved three measures of asthma symptoms. Morbidity among children in the intervention group increased less between baseline and follow-up (and in some cases, actually showed a decrease) than did that of controls. The mean number of symptom-free days in the preceding 2 weeks increased in the intervention group from 8.5 to 10.2 and decreased in the control group from 11.9 to 9.3. Likewise, the number of symptom-free days in the preceding month increased from 20.2 to 22.2 in the intervention group and decreased from 24.6 to 20.8 in the control group.

The impact of the education intervention also was evident in parental sleep interruption. The increase in the number of nights of parental sleep interruption at follow-up was significantly greater in the control group than in the intervention group, although both groups showed significant increases between enrollment and follow-up. At enrollment, intervention and control group parents averaged, respectively, 0.6 and 0.8 nights of sleep interruption in a typical week. Sleep interruption more than tripled at the follow-up: to 2.6 nights per week for the control group compared with an increase to only 1.3 nights per week for the intervention group – less than twice their baseline (summer) rate.

Parents rated how much their children had been bothered by asthma in the preceding 3 months and the mean number of reported days the children were sick because of asthma during the preceding month. Pre- and post-intervention changes did not differ significantly between the two groups.

The development and evaluation of Wee Wheezers was supported by Grant #R01 HL41819 from the Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health. Upon validation of the Wee Wheezers program, the principal investigator, Dr. Sandra R. Wilson, of the Palo Alto Medical Foundation Research Institute (PAMFRI), Palo Alto, California, acquired copyright for the educational package. In 1997, the copyright was transferred to PAMFRI.

The overarching goals for DACH-AIR’s Wee Wheezers program are to improve the participants’ ability to prevent asthma symptoms and to manage those symptoms that occur by using all their known resources appropriately for asthma care, especially adherence to their personal asthma management plan. The following asthma treatment goals are addressed in the introduction to DACH-Air’s Wee-Wheezers course and are reinforced in the sessions.

• No chronic symptoms
• Normal or near normal lung function
• Normal activity level, including exercise
• Optimal control on minimal amount of medication
• No or few medication side effects
• Confidence and satisfaction with care

At the level older children can understand, the replicated program goals are stated simply as:

• Sleep (no nocturnal symptoms)
• Play (no down time in activity)
• Learn (no missed school or daycare)

Education referrals are included in the clinical pathway for all asthma patients. People are referred electronically through the "consults" program on an integrated computer database that links all the providers to the hospital and pharmacies, including the pulmonary clinic, where asthma education is administered. Wee Wheezers is available for all Ft. Hood military families who have a child diagnosed with asthma. Doctors inform the parents of a child with asthma that they can attend education classes and that a "consult" has been established with DACH-AIR to enroll them in the program. Ft. Hood physicians are required to place a consult for the classes, providing families the opportunity to attend. Attendance at the class is voluntary.

DACH-Air and physicians have collaborated to automatically schedule anyone whose child they diagnose as having asthma for an education class and provide the message that education is an essential part of asthma care. This link between the diagnoses and treatment of patients and systematic referral and follow-up of patient and parent education should be a primary strategy associated with implementing the education program within a community.

The DACH-AIR coordinator schedules the families for education with a notice in the mail of the session date and time. The coordinator also telephones the parent the day before class to remind him/her of the appointment. A walk-in policy also exists for asthma education, which works well because classes are routinely taught at the hospital on Thursday afternoons. Families with providers outside of DACH are encouraged to attend in this manner.

Although both parents are encouraged to attend Wee Wheezers, the nature of military life often makes this impossible. Parents frequently are soldiers who spend weeks or months at a time away from home. DACH-Air targets the primary caregiver for education regardless of that person’s relationship to the child. As with many communities, a grandmother or a friend of the family may provide primary care and attend the course.

Wee Wheezers is offered in two formats: one for the primary caretakers of children aged less than 5 years, and one for the caretakers and children age 5-12 (an older upper age limit than that for which the program was designed). Attendance is deliberately kept small to allow for ample participant interaction and application of the learning activities for the children. The children’s sessions are always team-taught. The facilitator for the children’s session is a certified elementary school teacher and counselor. An on-staff registered nurse, a respiratory therapist, and a pharmacist each conduct relevant segments of the children’s sessions. A well-experienced registered nurse conducts the caretaker’s sessions.

No formal instructor training is provided specifically to teach Wee Wheezers. The DACH-Air instructors are all experienced health professionals. New instructors observe the class in session, instruct a portion of a next class under the direction of a more senior instructor, and are phased in to become one of the team teachers.

Initial funding to support Wee Wheezers was secured from the facility commander when the Asthma Process Action Team projected a 30% cost avoidance created by reductions in emergency department visits and admissions. Today, Wee Wheezers is funded as an operating cost of the hospital’s pulmonary clinic. The only full-time employee associated with the asthma education program is the DACH-Air coordinator. DACH supplied asthma instructors are full-time employees of the hospital who participate in the asthma program as part of their duties. The instructors supplied by Health Net Federal Services are part-time asthma instructors.

The instructors evaluate Wee Wheezers by a pre-test administered just prior to the education session and a post-test administered immediately after the program. The evaluation instrument includes 20 multiple choice and true/false questions that address asthma physiology, symptoms, triggers, medications, and delivery and measurement devices. Results of the tests show an average of about 30% increase in knowledge following completion of the class.

A Pediatric Quality of Life Assessment (Juniper) questionnaire gauges how much children are bothered by asthma when doing certain activities and how well they manage their asthma before receiving this education. The questionnaire is mailed to class participants 6 months after attendance with the assumption that, with appropriate therapy and the self-management skills learned in the education sessions, quality of life will have improved. The results of the Juniper questionnaire indicate an average 22% improvement in quality of life. (Although this level of improvement appears to be impressive, it is important to remember that there was no control group against which these results can be compared).

DACH-Air experienced difficulty retaining high attendance for multiple asthma education sessions that went beyond two class periods. The program was altered to eliminate nonessential information and multiple start up and shut down activities to keep Wee Wheezers to two somewhat longer sessions and retain participants who otherwise would not return.

Because of anxieties related to group sharing of reactions and feelings about how their child’s asthma affects the parents in the class, video segment 2 was eliminated from Session 1. DACH-Air eliminated the discussion of participant’s feelings about their children’s chronic health problem from Session 3.

Within civilian populations, discussions of parents’ feelings about dealing with an asthma crisis or having a child with a chronic disease are routinely used to bring those feelings to mind, acknowledge how frightening and confusing such a crisis can be, and use the possibility of preventing such episodes as a means of motivating parents to make the requisite change. Although useful in this setting, it should not be concluded that segments of the Wee Wheezers program addressing feelings ought to be eliminated or scaled back just because this replicated program has done so.

Because of two factors, DACH-Air decided to eliminate two group discussions about parents’ feelings. First, the rank structure within the military may result in reluctance to express feelings, and the asthma classes comprised parents in a wide range of ranks. Second, stoicism exists among the military as demonstrated by failure to report broken bones suffered during long marches or the inability to talk about events witnessed in war zones. As a compensatory measure, parents are given a copy of the videotape to view at home and receive the handouts on feelings about having children with asthma. Feelings about asthma are fully addressed in the sessions for the children, for whom these barriers are not generally an issue.

DACH-Air reduced the amount of time spent on learning to communicate about asthma with teachers, child-care workers, physicians, and family (addressed in Session 4) and on the review and discussion of the asthma action plan.

This content change is practical for the following reasons. 1) The DACH physicians are required to develop an asthma action plan for new patients, at which time they go over the entire form, or review or update the plan, with the patient at each subsequent office visit. The Medical Record-Supplemental Medical Data form, DA-4700, used to record this action, also requires the physician to teach or correct peak flow meter and spacer use. 2) Each DACH clinic has designated nurses trained to provide instruction on the use of the asthma action plan. Patients are encouraged to call their clinic asthma nurse or the DACH-Air coordinator (a registered nurse) if they have a question about the use of the plan. 3) Printed materials for parents and children explain the use of the plan. In addition, the action plan is included with the documented discharge instructions for asthma admissions and emergency department visits.

In many situations in which Wee Wheezers will be implemented, asthma educators will have to educate the parents about the asthma action plan, then encourage them to take the action plan form to their doctor and ask him/her to write out a plan. Wee Wheezers was developed on the assumption that most patients would receive asthma care that is not as well organized as DACH’s is in this respect. Users of the Wee Wheezers program should include the asthma action plan instruction in the curriculum as designed unless justification is identified for not doing so.

The two children’s sessions were designed initially for 45 minutes each to be delivered at the beginning of adult sessions 3 and 4 with the parents hearing the same information as their children. DACH-Air offers two 90-minute sessions for children conducted separately but delivered at the same time as the two adult sessions. The intended audience for this education is children ages 5-6 years. At Ft. Hood, Wee Wheezers is not confined to younger children, but is open to all children aged 5-12 years. Because the children’s sessions are team taught, age appropriate instruction and activities can be tailored for the younger and older children.

Data collection capabilities that support asthma education intervention.
Wee Wheezers operates within a health-care system that supports the entire military base population and all its dependents. The medical records system can track emergency visits and inpatient dispositions, among a host of other medical parameters. Pre-tests and post-tests at the asthma education classes and the quality-of-life survey at class and at 6 months, along with the medical records, demonstrate that the educational program is increasing participant knowledge and that this asthma health-care system is improving the lives of children with asthma. This capability has been essential to acquiring continued senior management support and DACH-Air funding for asthma care. DACH recently received a commendation from the medical command for its leadership in implementing the military’s asthma management guidelines and presented the asthma program at the MEDCOM annual conference in San Antonio, Texas, in May 2002.

Outstanding people who promote the program.
DACH-Air staff are highly motivated; they believe in what they are doing, are committed to success and sell the program not only to the asthma patient population but also to the hospital and clinic staff in the form of provider education and resources. The DACH-Air director conducts provider asthma education classes for the Darnell medical staff based on the military guidelines for asthma diagnosis and treatment. Members of the DACH-Air staff often educate in their offices asthma patients who need more immediate help or who have not attended the scheduled class. They also respond to requests for help from providers throughout the network.

Full-time asthma education coordinator.
With the addition of the asthma coordinator in 2000, one-on-one communications with families scheduled for Wee Wheezers is now possible. Appointment slips are now mailed to all families referred for education along with a letter of explanation about the course and its value to the family. The coordinator makes a follow-up reminder phone call the day before the session. When a parent misses a scheduled session, she/he is routinely placed on another schedule and receives written notices and phone calls about attendance. Since hiring the coordinator, attendance at Wee Wheezers has improved by more than 40%.

Use of peak flow-based asthma management plans.
Before implementation of DACH-Air and the Wee Wheezers program, only 30% of asthma patients used an asthma action plan. The education classes emphasize the importance of following the asthma action plan. Currently, 68% of children old enough to perform peak flow have an approved asthma action plan from their physicians based on peak flow performance. Use of the asthma management plans and recognition of asthma triggers and the symptoms of asthma as taught in the classes have improved parents’ confidence that they can manage their child’s asthma. In February 2002, DACH-Air was awarded the GlaxoSmithKline 2001 Circle of Excellence Award for Total Patient Management. Parents interviewed for this case study commented on how their asthma action plans had helped them manage their children’s asthma.

Sibling attendance at asthma education classes.
All siblings of children with asthma who are themselves at least 6 years old are encouraged to attend the Wee Wheezer sessions. Experience has shown that older siblings – probable caregivers and role models – can be instrumental with compliance issues.

Child-care for parents while in the education session.
Ft. Hood hospital accommodates parents bringing children to the hospital who are not there for health care. Some parents bring babies and younger children to their asthma education sessions at the hospital. Although the hospital has a quiet room for caring for these children, DACH-Air is not staffed to provide formal child-care during the 2-plus hours the parents or guardians are in class. Failure to provide child-care leads to some distractions and disruptions in class from these children.

Medical staff turnover.
Success improving asthma management depends on provider education in concert with patient education. The turnover of military medical staff is high. Providing asthma education for the large number of incoming medical staff requires constant leadership and ongoing delivery of instruction. The biggest single challenge is educating medical staff at the hospital and satellite clinics on the proper use of controller medications and application of the clinical guidelines for asthma diagnosis and management.

No formal follow-up of education for parents of young children.
Because parents of children aged less than 5 years only attend one Wee Wheezer session, no routine mechanism exists to receive feedback on how well these parents practice what they learned at the class. Parents are provided with the coordinator’s phone number and are encouraged to call with any questions or problems. The 6-month follow-up using Juniper’s quality-of-life questionnaire provides a window into the family’s success and prompts the coordinator to contact the primary-care providers of patients with any significant decreases.

The APAT was a performance improvement initiative undertaken in 1998 involving management and staff from numerous hospital units. These people met regularly to work through issues and develop actions to launch the asthma information and resources program. The performance improvement approach, founded on a commitment to excellence, facilitated the needed buy-in from the leadership, including pediatrics, family practice, emergency medicine, pharmacy, pulmonary medicine, and resource management. This effort was an essential prerequisite to making the sweeping changes needed to establish an asthma care program that would provide consistent, comprehensive care system-wide at the base. The APAT, with senior military staff support, acquired a partnership with Health Net, secured initial funding, created and implemented pathway forms and processes, and selected an asthma education program in order to place the asthma-care program on a solid foundation. In 2001, DACH-Air was selected to present its innovative performance improvement program to the Joint Commission for Accreditation of Hospital Organizations survey team.

A genuine enthusiasm exists for the work with a characteristic feature of "One Team!" Staff members learned that input from everyone involved is important and that every task associated with asthma care and education is valuable. Support from the numerous hospital chiefs and their staffs are essential to the success of the asthma education program.

Getting children into a social framework in which they can best learn new information and skills requires a special understanding of child learning psychology and the willingness to work with children at their level. The introduction of a master children’s course facilitator and use of the multi-station, round robin format with three or four children per group created a learning environment in which children flourish, have fun, and learn at a recognizably more rapid pace.

Wee Wheezers instructors and staff attempt to keep children’s classes to fewer than 20 students. Even with team-teaching, more individualized attention ensures that each child understands the information. The parent classes are comparably limited, which supports the small-group dynamics that promotes discussion and sharing of information.

The DACH-Air coordinator took the asthma program to the school children by involving the local elementary schools in a contest to provide a name for the asthma program logo. This activity got the children and the teachers talking about asthma and made them aware of the program. The activity also involved the school nurses resulting in several calls about asthma action plans, symptoms, and triggers.