Agrawal et al.85
| To evaluate the effects of adding a
individualized written asthma home-management plan to
standard asthma care. | 60 children aged 5–12 years with moderate
persistent asthma in India. | RCT | 32 children completed the self-management
program that included an individualized home-management
plan (trained to perform PF measurement, use a PF and
symptom diary, and given specific instructions for home
medication management based on symptoms and PF
measurement). 28 children completed the usual care arm.
All subjects were followed weekly for 4 weeks then
monthly for 3 additional months (7 visits). | 4 months after the intervention, children
in the intervention group had fewer acute asthma events
(p=0.02), fewer days missed from school (p=0.015), fewer
nocturnal awakenings (p=0.001), and fewer symptoms
(p=0.0006).85
|
Bartholomew et al.53
| To evaluate whether a computer-based asthma
self-management tool would increase process and clinical
outcomes of care for inner-city children with moderate
to several asthma in Houston. | 133 children aged 6–17 with asthma. | RCT | 70 children used the Watch,
Discover, Think, and Act multimedia CD-ROM
program for variable amounts of time after their
scheduled office visits. The program presents an
“adventure game” in which the player makes choices to
manage the game character's asthma (the game's character
is matched with the subject on gender and ethnicity).
Within the game, children can learn new skills, identify
symptoms, reduce environmental triggers, and take
preventative actions. 63 children received usual care
with telephone reminders before their scheduled office
visits. | 7.9 months after enrollment in the
intervention, there were no differences between groups
in the number of ED visits, hospitalizations, or
symptoms.53
|
Burkhart et al.71
| To determine the effects of interventions
that combine education and behavioral techniques in
managing asthma at home. | 42 English-speaking children aged 7–11
years with persistent asthma in Kentucky;
Nint=21; Ncon=21. | RCT | Patients received asthma education and
instructions on how to use an electronic PF meter twice
daily and record data in an asthma diary. Patients
received three 1-hour individual sessions with a nurse,
a contingency management intervention, which consisted
of a contingency contract, reinforcement, tailoring, and
reminders. The contract outlined requested behaviors (PF
monitoring, diary self-reporting) and associated
rewards. (We describe the rewards used in the section on
financial incentives.) A nurse educator also contacted
patients weekly to reinforce teachings. The control
group received the teaching sessions but no contingency
contract and no follow up calls from nurses. | At 5 weeks, they found no difference in
adherence with PF monitoring between the intervention
and the usual-care (control group) children.71
|
Cicutto et al.77
| To evaluate whether an interactive
childhood asthma education program improved
asthma-related morbidity among elementary school
children in Toronto, Canada. | 256 children with asthma in grades 2 to 5
(aged 6–11 years) and their parents.
Nint=132, Ncon=124. | RCT | The “Roaring Adventures of Puff (RAP)”
consists of 6 sessions of 50–60minutes held once a week
for 6 consecutive weeks. Sessions cover use of PF
meters, diary monitoring, trigger identification and
control, use of inhalers and medications, symptom
recognition and action plan use, and managing asthma
exacerbations. Parents are invited to the last session
in which children showcase their learning and new
skills. The strategies utilized included games,
puppetry, and model building to teach about trigger
identification, medication use, symptom recognition,
sharing information with teachers and parents. | 12 months after the intervention, RAP
attendees had 32% fewer urgent health visits
(p<0.01), less asthma-related school absenteeism
(p<0.05), and less activity limitation due to
asthma (p<0.01) than control children.77
|
Dahl et al.86
| To evaluate the effects of a behavioral
treatment program when superimposed on medical
treatment. | 19 children in Sweden with severe asthma
using continual β-agonist therapy. Ncon=10,
Nint=9. | RCT | All patients underwent a 4-week baseline
period during which a behavioral analysis was made for
each child and daily asthma charts were kept. Patients
in the intervention group underwent a 4-week
intervention period, during which they received four
1-hour individualized behavior therapy treatment
sessions in their home or school focusing on
discrimination training of asthma signals,
self-management techniques for breathlessness,
counter-conditioning any learned fear response,
contingency management of asthma-related behavior, and
compliance training. The control group received usual
care. | All data were presented as comparisons of
change from baseline. After 4 weeks of follow up,
patients in the intervention group had a significantly
larger reduction in “as needed” spray doses of β-agonist
and a significantly larger reduction in days of school
absenteeism compared to patients in the control group.
There was no difference between the groups in PF
values.86
|
Evans et al.68
| To evaluate whether a school-based
self-management program would increase children's asthma
management skills and other process and clinical
outcomes for low income 3rd–5th
graders in public schools in New York. | 204 low income
3rd–5th graders in public schools
in New York, aged 8 to 11 with asthma. | CBA | 93 children attended the Open Airways
program's six 1-hour small group sessions (over a 3 week
period) in which children learned basic information
about asthma, recognizing and responding to symptoms,
using medications and when to seek help, keeping
physically active, identifying and controlling triggers,
and handling problems related to school. 87 control
children received no additional self-management
training. | 1 year after the program, experimental
children reduced the annual frequency (p=0.024) and
duration (p=0.007) of asthma episodes, and annual days
with symptoms (p=0.004), and they increased their
self-management index score compared to controls
(p=0.05). There were no differences between the groups
in terms of school attendance and number of episodes
requiring a physician visit. 68
|
Fireman et al.81
| To determine whether a nurse teaching
self-management skills to children and their caregivers
would improve their disease outcomes. | 26 children aged 2–14 with asthma in
Pittsburgh | Sequentially assigned (not randomly)
controlled trial | 13 children and their caregivers received 4
individualized sessions with a trained nurse on the use
of symptom and medication diaries, two 2-hour group
sessions for discussion of asthma management, and phone
follow up every 3 months by the nurse. 13 children
received usual care. | 13 months after enrollment, the
intervention group had fewer asthma attacks (1.5 vs. 6
per child) (p<0.01) and less school absenteeism
(0.5 vs. 4.6 days per child) (p<0.05). The
authors reported fewer hospitalizations and ED visits
for the intervention group but no statistical test for
the difference between the groups. There was no
difference in wheezing days per month.81
|
Homer et al.54
| To assess the effectiveness of multimedia
educational software program about asthma for inner-city
children. | Children aged 3 to 12 with asthma living in
inner-city Boston. Nint=57;
Ncon=49. | RCT | “Asthma Control” is an interactive
educational computer game designed to teach children
about asthma and its management. The object of the game
is to help the main character, Spacer, a superhero with
asthma complete all 6 game levels (3 home and 3 outdoor
levels). The player uses his or her knowledge of asthma
to help Spacer eliminate common indoor allergens and to
avoid outdoor allergens. If Spacer's condition worsens,
the program producing coughing and wheezing sounds and
he may not be about to jump or run. If the player does
not eliminate allergens or use preventive medications,
Spacer's mother blocks his/her exit from home. Study
patients were asked to return to the study site 3 times
to use the educational computer program. | During the one year study period, there
were no differences between intervention and control
children in terms of ED visits, acute office visits,
asthma severity, exposure to environmental triggers, use
of PF meters, or asthma management behaviors. |
| | | | | Note: 40% of children enrolled in the study
had exposure to a least one smoker at home.54
|
LaRoche et al.78
| To evaluate a multifamily asthma group self
management program designed to be culturally relevant
and encouraged group cohesiveness among the attending
families. | 24 African American and Hispanic families
living in Boston with children aged 7–13 with asthma. | RCT | The 24 experimental families were
randomized to receive three 1-hour sessions that
emphasized collaborative asthma management among
patients, parents, and physicians and provided training
on asthma symptoms and skills for self management. Half
of the experimental families received encouragement to
work as a group to share experiences and learn from each
other. The 11 control families received no intervention. | During the year after the intervention, the
experimental children from families that shared group
experiences had fewer ED visits (0.7±0.9) than either
the experimental children with standard self-management
teaching (1.2±1.7) or controls (1.4±2.4) (p=0.04). There
were no differences in self-management scores. The
intervention program costs were approximately $2,295
(per 11 patients) and the savings from reduced ED visits
was $4,675 (per 11 patients).78
|
Maslennikova et al.82
| To assess the effects of a adapting a U.S.
self-management educational intervention on asthma
outcomes for children in Moscow. | 122 children with asthma and their families
living in Moscow. Nint=60;
Ncon=62. | RCT | The authors adapted “Open Airways”
(developed for low literacy children aged 4–7 years) and
“Air Power” (developed for average literacy children
aged 8–14 years) for similar populations in Moscow.
Intervention subjects also received asthma care from
clinicians who had been trained “according to the U.S.
guidelines for the diagnosis and management of asthma
and use of modern asthma medications.” Intervention
subjects participated in 4 weekly 1hr sessions. Control
subjects received usual care from clinicians who
received no additional training. | 1 year after the intervention, the % of
children in the education group who were on inhaled
anti-inflammatory medications increased by 46% compared
to only 8% for the control group (p<0.05).
Intervention children's PF measures also improved more
than for control children (p<0.05). There was no
difference in terms of the change in the percent of
children using theophylline or β-agonists or days missed
from school. |
McGhan et al.76
| To determine whether the asthma education
program “Roaring Adventures of Puff (RAP),” improved
asthma management behaviors and health status in
elementary school children in Edmonton, Canada. | 136 children with asthma aged 7–12 years.
Nint=65; Ncon=71. | RCT | Parent and teacher asthma awareness events
were held within the school setting. The intervention
provided recommendations for school asthma guidelines
and six educational group sessions for children with
asthma described above.77
| 9 months post-intervention, experimental
children had “more appropriate use of preventive
medication” (p<0.001), improvement in
asthma-related limitations in play, (p<0.001) but
there were no differences between groups in medication
use, possession of an action plan, ED visits,
unscheduled doctor visits, asthma symptoms, or days lost
from school. 26% of the children had regular smoking in
the home.76
|
McNabb et al.80
| To evaluate whether children with asthma
who had not been compliant with standard medical
management would benefit from self-management education
that could be tailored to their educational and
behavioral needs. | 14 children aged 9 to 13 with asthma in
northern California. | RCT | Experimental subjects (N=7) received a 30
minute diagnostic interview followed by four 45-minute
individually tailored weekly sessions with a nurse
educator on asthma self-management. Control subjects
(N=7) received usual care. | In the 12 months after the intervention,
the experimental group averaged 1.9 emergency treatments
compared to 7.4 for the control group (no p value
provided). There were no differences in non-emergency
visits or drug use between groups. They estimated a
program related $507 per child savings on the basis of
the reduced emergency visits.80
|
Morgan et al.,73 Evans et al.,74, and Sullivan et al.75
| To evaluate whether a home-based
intervention for inner-city children designed to teach
caregivers to reduce environmental asthma triggers
specific to that child would result in improvements in
asthma-related outcomes. (The National Cooperative
Inner-City Asthma Study.) | 1,023 families of children aged 5 to 11
with asthma from 8 major U.S. cities.
Nint=515, Ncon=518. | RCT | During the 12 month intervention, 2
research assistants visited each home 5 to 7 times. Each
visit was followed by a phone call to address any
barriers to implement the plan. Caregivers were taught
about the role of allergens in asthma, mattress covers
were installed, families were given a vacuum cleaner
with HEPA filter and a HEPA air purifier was set up in
the child's bedroom. Professional pest control was
provided. | Two years after enrollment, intervention
children had more symptom free days (565.1 vs. 538.5),
fewer asthma symptoms (p<0.001), days lost from
school (p<0.009), and allergen levels.73 There were no differences in spirometry or PF
measurements or unscheduled visits to the ED, clinic or
hospital between the two groups.73–75 The cost of the intervention was $337 per child
for 2 years resulting in an estimate incremental
cost-effectiveness ration of $9.20 per symptom-free day
gained (95% CI: -$12.56 to $55.29 per symptom free day
gained).75
|
Pérez et al.66
| To evaluate the effectiveness of a
self-management program based on social learning models
and self management programs with demonstrated
effectiveness on asthma morbidity. | 29 children with asthma aged 6–14 years in
Venezuela. | RCT | 17 children and their parents were
randomized to receive asthma education. Parents received
two 90 minute sessions on asthma pathophysiology,
treatment and psychological factors associated with the
disease. Children received six 60-minute self-management
training sessions that included modeling, positive
reinforcement, group dynamics, behavioral practice,
role-playing, and feedback. | 6 months after the intervention, children
reported fewer asthma crises, and their physicians
reported less severe asthma than control patients
(p<0.05).66
|
Persaud et al.87
| To evaluate the effects of a school-nurse
based self management program for school children in
Texas. | 36 children aged 8 – 12 years with moderate
to severe asthma. | RCT | All children had a visit with a primary
care provider at the time of enrollment during which
time they were all given written guidelines for
medication use, asthma control and prevention, PF
meters, and asthma diaries. Intervention children (N=18)
also received 8 individualized, weekly, 20 minute
sessions with a school nurse to review asthma symptoms
and medication and PF meter use. Control children (N=18)
visited the school nurse sporadically, on their own
initiation. | 20 weeks after enrollment, the percentage
of children visiting the ED for asthma was higher in the
control group (50%) than in the intervention group (22%,
p<0.05); however, there were no differences in
number of ED visits per child or days lost from school
between groups.87
|
Rakos et al.83
| To evaluate the effectiveness of a
self-administered self-management program for pediatric
asthma. | 43 children aged 7–12 years with moderate
to severe asthma in Cleveland. | RCT | 20 children and their caregivers received a
“Superstuff” kit in the mail. This program, developed by
the American Lung Association, includes a Parent's
Magazine containing 29 articles on asthma
pathophysiology, triggers, relaxation techniques, and
personal control and decision making. The Children's Kit
includes riddles about asthma facts, “breathe easy”
board game, puzzles and dolls with self-care messages,
comic strip about relaxation exercises, mystery house to
discover allergens, phone book to advise when to call
the doctor and record emergency numbers, and
asthma-related door signs, posters, stickers, records,
and paper cutouts. 23 children received usual care. | 12 months after receiving the intervention,
parental reports suggest a significant decrease in
“interruptions due to asthma” (p<0.04). No
difference in school absenteeism between groups. The
cost of the kits was $7.83
|
Ronchetti et al.72
| To compare the Open Airways program to
Living With Asthma program among Italian children with
asthma. | 209 children with asthma from 12 centers
across Italy. | CBA | 58 children received either the original
version of Open Airways or a 4 session abbreviated
version, 56 children received either the original
version of Living with Asthma or a 4 session abbreviated
version (see text for intervention description). 95
children received usual care. | One year after participation, patients in
the Open Airways but not the Living With Asthma groups
has fewer emergency treatments for asthma than controls
(p<0.03).72
|
Runge et al52
| To evaluate whether an internet-based
education program as an add-on to a standard patient
education program improved health outcomes and reduced
costs of children with asthma in Germany. | 178 children with asthma aged 8–16. | CBA | 48 children in the control group received
no education until after the trial. 86 children received
the self-management program of five 2hr sessions in
which they used role-playing and small group sessions to
teach inhaler use, trigger avoidance, medication
management, PF monitoring, and decision making. 44
children received this self-management program plus
self-selected to also use the interactive internet
adventure game incorporating virtual asthma-related
situations in need of management and also provides
access to online chats with asthma experts, an online PF
protocol that can be maintained by the patient, and chat
rooms for other users and healthcare providers. | 6 months after enrollment, the
self-management plus internet (SMI) education group had
a mean of 0 emergency visits compared to 0.2 for the
control group (CG) and 0.3 for the self-management (SM)
alone group (p=0.03). The SM group had significantly
(p<0.05) fewer physician visits (-44%) and
emergency treatments (-67%) than CG. PF improved in all
groups, no difference among groups. Significant
improvements were seen in 3 of 8 QOL domains in both
intervention groups but not in the CG. It cost 585€ to
deliver the SMI intervention which reduced asthma costs
by 461€. Adjusting for benefits in the CG, 0.79€ were
saved for every 1€ spent on the SMI intervention during
the 1st year. (1 year follow up data
available for the two intervention groups but not the
CG.)52
|
Tieffenberg et al.67
| To evaluate a chronic disease self
management program based on behavioral change and
learning theory directed at increasing autonomy on the
part of children. | 188 children with moderate to severe asthma
aged 6 to 15 in Argentina. | RCT | 65 children were randomized to receive 5
weekly 2-hour meetings with a reinforcement meeting 2–6
months later. The curriculum included identifying early
warning signs and symptoms of an attack, identifying
triggers, understanding therapies, and decision making
skills through games, drawings, stories, videos, and
role-playing. 52 children received usual care. | 12 months after the intervention,
experimental subjects had fewer regular visits for
asthma (p=0.048), asthma crises (p=0.36), and less
school absenteeism (p=0.006 for fall/winter and p=0.029
for spring semesters) but no difference in emergency
visits compared to controls.67
|
Toelle et al.88
| To evaluate whether a community-based
asthma management program could reduce asthma symptoms
and lung function among school children in Sydney,
Australia. | 132 school children aged 8 to 11 with
asthma and all the adults who influence their care
including parents, doctors, pharmacists, community
nurses and school teachers. | CBA | Children in the intervention group and
their parents (Nint=72) were invited to
attend 2 education session each 2 hours, 1 week apart
with a curriculum on asthma triggers, medication use,
inhalation technique, use of written self-management
plan. These children's physicians and pharmacists were
invited to attend evening workshops during which asthma
management guidelines were reviewed. Community nurses
and school teachers in the intervention community
received an in-service education session at their
workplace. All families, children, physicians, and
pharmacists who did not attend the intervention sessions
were mailed the materials. 60 children received usual
care. | 147 teachers and community nurses, 53
families (74%), 15 pharmacists (21%), and 11 physicians
(20%) attended intervention sessions. 6 months after the
intervention, both FEV1 and dose-response
ratios improved in the intervention group but not the
control group (p<0.001). The number of children
with wheeze and symptoms that limit activity did not
change but night cough decreased significantly in the
intervention group (p<0.001). There was no
significant difference in physician or ED visits or days
absent from school.88
|
Vazquez and Buceta79,
89
| To evaluate the effects of adding
relaxation training to asthma self-management education
to improve the care of children with asthma in Spain. | 27 children with “light or moderate” asthma
aged 8 to 13 years. | CBA | 9 children in the control group received
usual care; 9 children received six 1-hr weekly sessions
with their parents on asthma pathophysiology, use of
medication, identification of triggers, and breathing
exercises; and 9 children received the self-management
instruction plus additional training on relaxation
techniques at the end of each self-management session. | At 12 months after the intervention, both
intervention groups had better scores on the adherence
with self-management behaviors scale used by this study
compared to the control group but there were no
differences among groups in terms of attack frequency or
duration, PF, emergency medical consultations or school
absenteeism. 79,
89
|
Velsor-Friedrich et al.69
| To examine the effects of a school-based
intervention program on self care abilities, practices
and health outcomes of children with asthma. | 102 African American 8–13 year old children
with asthma recruited from 8 inner-city public schools
in Chicago. | QRCT* | The Open Airways educational program
utilized an interactive teaching approach applying group
discussions, stories, games and role-playing to promote
children's active involvement in the learning process.
In six 45-minute sessions offered once a week, small
groups of children learned new asthma management skills.
Nint=40, Ncon=62. | 5 months after completion of the program,
the treatment group had significantly more improvement
in PF measurements (7.5% vs. 2.9% improvement, p=0.046),
reduction in number of days with symptoms (p=0.047), and
number of urgent medical visits (p=0.01). No differences
in terms of reported medication use or school
absences.69
|
Webber et al.70
| To evaluated whether the Open Airways
program would reduce asthma morbidity and health
services utilization among inner-city children with
asthma in the Bronx. | 599 3rd to 5th graders in the Bronx with
asthma. | CBA | 599 children in schools with school-based
health centers were scheduled to attend the Open Airways
program (as described in the two prior studies). They
were compared with students in schools with school-based
health centers that did not offer the Open Airways
program (N not specified) and children in control
schools without school-based health centers (N not
specified). | Approximately 15 months after enrollment,
there were declines in office visits for children
attending schools with school-based health centers (with
and without the Open Airways program) but not for
control school children (for whom there was a (9%
increase in office visits) (p=0.01). ED use and
hospitalizations declined for all children (no
difference among groups). 70
|
Whitman et al.84
| To evaluate the effects of a
self-management curriculum on asthma knowledge, skills,
and “asthma experiences.” | 38 children aged 6 to 14 in Utah. | RCT | 19 children received eight 90-minute
classes for children and caregivers given twice a week
for a month included education on breathing control
skills, body relaxations skills, bronchial hygiene
silks, and physical conditioning. Additionally,
intervention subjects received the “Superstuff” kit
described in Rakos.83 19 children received no training. | Three months after the intervention, there
was no difference in number of asthma episodes or days
without asthma between groups. Participants' knowledge
(p=0.02) and asthma skills (p<0.01) improved
compared to controls.84
|