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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

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]

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

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

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:

1. 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.
2. 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.
3. For environmental tobacco smoke (ETS), parents were counseled on smoking cessation and families were instructed to keep homes smoke free.
4. Families were encouraged to avoid daycare until after the first year of life. Nurses reinforced various avoidance measures at each home visit.
5. 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.

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:

1. number of days with wheezing, tightness in the chest, or cough;
2. number of nights with disturbed sleep as a result of asthma; and
3. 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.

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.

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

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

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

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 20^th St. NW
Washington, DC 20036
phone: 1-800-7-ASTHMA

Case Study:
None

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 20^th St.  NW
Washington, DC 20036
phone: 1-800-7-ASTHMA

Case Study:
Asthma Care Training (ACT), Providence Alaska Medical Center, Anchorage, Alaska

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

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

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:

1. in-service instruction to the clinic staff on new asthma guidelines;
2. health education for the clinic population that focused on improving living conditions, cleanliness, and hygiene;
3. instruction on the proper use of medications;
4. ongoing instruction to asthma patients;
5. provision of free spacers for those eligible; and
6. 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:

1. 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;
2. a decrease in hospitalizations for asthma from 6 in the preintervention period to none in the postintervention period;
3. a decrease in referrals for emergency treatment from 61 in the preintervention period to 6 in the postintervention period; and
4. 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.

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

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

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

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

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

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

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

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

1. 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),
2. 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
3. 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.

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.

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

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 20^th St.  NW
Washington, DC 20036
phone: 1-800-7-ASTHMA

Case Study:
Wee Wheezers Asthma Education Program,
Darnell Army Community Hospital, Fort Hood, Texas

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.

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

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

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

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

1. getting to know each other, goal setting, use of a peak flow meter, diary monitoring;
2. trigger identification, control and avoidance, basic pathophysiology;
3. medications and proper use of inhalers;
4. symptom recognition and action plan;
5. lifestyle, exercise, managing an asthma episode; and
6. 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.

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

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