asthma education
Educational Interventions to Improve Asthma
Outcomes in Children
Noreen M. Clark, PhD, Christy R. Houle, MPH, and Martyn R. Partridge, MD
Abstract
• Objective: To present an overview of educational
interventions to assist children with managing their
asthma. • Methods: Review of exemplary, well-conducted
studies and meta-analyses.
• Results: Educational interventions for children in
clinical settings have proven effective in achieving
clinical outcomes. Education provided at home and
focused on the indoor environment has reduced
allergen levels, but fewer studies have assessed
health outcomes. School programs have produced
outcomes, including symptom reduction and
im­proved school attendance and performance.
Computer-based education for use at home has
not shown strong results. Asthma coalitions and
community partnerships have had an effect on institutional and public policy. Available data suggest
that cost savings and benefits are associated with
asthma education interventions. Questions remain
about the effect of asthma education on very young
children, women, and older adults. • Conclusion: Asthma educational interventions for
children conducted in schools and clinical settings
have demonstrated strong results. Education at
home focusing on the environment is promising.
Home-based interventions relying on electronic
means of instruction require further study. Coalition
and community partnerships can leverage change
by affecting systems and policies.
A
sthma continues to be one of the costliest long-term
disorders of childhood. Among chronic pediatric
conditions, it accounts for the highest number of
pediatric emergency department (ED) visits and hospitalizations and the highest number of missed school days for
children and missed work for parents. The resulting financial costs are considerable [1,2].
There have been dramatic advances in the therapeutics
of asthma, specifically the availability of anti-inflammatory,
combination, and long-acting drugs, and we know more
about the pathophysiology and treatment of asthma than
554 JCOM October 2007 Vol. 14, No. 10
ever before. However, prevalence and problems associated
with the disease (eg, health care use, family disruption,
costs) have not dramatically decreased in kind. This may in
part be due to patients and families not following the recommendations of their clinicians and effectively managing
their disease. Studies have shown rates of adherence to the
medical regimen to be less than 50% [3].
An increasing amount of attention has been paid to the
roles of the patient and family in the day-to-day management
of asthma. This has, in part, evolved from recognition in the
medical community of the need for partnership with patients
in the effective control of chronic conditions [4,5]. The day-today experiences of the patient coupled with the clinical expertise of the physician are thought to be equally as important in
reducing the effects of the disease. The Figure illustrates the
relevant idea that the person with the chronic condition must
be at the center of efforts to control asthma.
To further control asthma and its effects on individuals,
families, and communities, a range of interventions have
been evaluated. Most national guidelines recommend that
patients should be offered education in self-management
and written asthma action plans that focus on individual
need [4,6]. In this paper, we present an overview of educational interventions to assist children with asthma that focus
on the social, behavioral, and clinical aspects of managing
the condition.
Educational Interventions in the Clinical Setting
Numerous reviews have assessed the efficacy of educational
interventions provided in clinical settings, generally clinics
or physicians’ offices. A review by Guevara et al [7] identified
45 trials of asthma self-management education programs for
children with the disease. Of these, 32 studies involving 3706
patients were included in a Cochrane Database review [8].
The asthma education programs in general focused on effective use of medicines, devices, and treatment plans; management of emergencies; modification of indoor environments;
and communication with family and health care providers.
From the Center for Managing Chronic Disease, University of Michigan, Ann
Arbor, MI (Dr. Clark and Ms. Houle); and the Department of Respiratory
Medicine, Faculty of Medicine, Imperial College London, UK (Dr. Partridge).
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Virtually all were geared to the age and developmental abilities of children, and most directly involved parents; 1 or 2 indirectly involved them through provision of informational or
educational materials. Programs produced improvement in a
range of measures, including reductions in children’s days of
restricted activity from asthma symptoms, airflow, ED visits,
and days absent from school. There were reductions in nighttime symptoms when fixed-effects analysis was used but not
when using a random-effects model. The authors concluded
that asthma self-management education for children improves
a wide range of measures of outcome.
Haby et al [9] conducted a Cochrane analysis of educational interventions focused on children who had visited the
ED for asthma within the previous 12 months. Eight trials
involving 1407 patients were included. Programs were provided to individuals or groups and were offered in the ED,
the clinic, the person’s home, or another setting. Analyses
indicated that these programs had no effect on subsequent
health care use.
Two recent trials examined asthma education following
ED discharge. Brown et al [10] found that children seen
in the ED and provided with asthma education benefited
somewhat more from the intervention (hazard ratio, 0.62
[95% CI, 0.33–1.19]) than adults, but effect sizes for either
group were not great. Over one third of study patients
did not comply with the suggested post–emergency visit
activities recommended in the intervention. Khan et al [11]
assessed an intervention to provide telephone education and
reinforcement to children seen in the ED. The program had
no effect on asthma symptoms, but more program children
had a written action plan postintervention (p = 0.002).
Individualized, written asthma action plans have proven
in meta-analyses to be an important aspect of asthma
control. For example, Bhogal et al [12] showed that both
symptom-based and peak flow meter–based action plans
for children used within asthma education programs were
associated with significant outcomes. Their review analyzed
data from 4 trials involving 335 children. They found that
children using symptom-based written action plans had
lower risk of exacerbations requiring an acute care visit
(relative risk, 0.73 [95% CI, 0.55–0.99]), and children using
peak flow–based action plans had a half-day reduction in
the number of symptomatic days per week (mean difference,
0.45 days/week [95% CI, 0.04–0.26]). Children preferred
using symptom-based plans, while parents expressed no
preference. Evidence suggests that symptom-based plans are
somewhat superior to peak flow plans; however, the differences may be associated with other factors, such as greater
compliance with the preferred plan.
A review by Kamps and Brand [13] questioned the value
of peak flow meters within an educational program for
children with asthma. They note that most evaluations of
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PATIENT
MANAGING
ASTHMA
Fam
ily involvement
Clinic
al expertise
Co
Wor
m
Co
k/school support
ion
mu
s
act
nity
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&
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Conduciv olicies
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Figure. Circles of influence in the management of asthma.
(Reprinted with permission from Clark NM, Gong M, Kaciroti
N. A model of self-regulation for control of chronic disease. Health Educ Behav 2001;28:769–82.)
asthma education interventions have not separated out the
individual components of the program (eg, information,
skills training, problem solving, action plans, symptom and
peak flow monitoring), and there is a dearth of information
regarding which element is most important in producing
results. They posit that because questions remain regarding
how well peak flow meters assess changes in asthma severity and how accurate patients are in recording information,
the educational components alone may account for the
outcomes observed. Ronchetti et al [14] have in fact shown
that asthma education alone (without home monitoring
with a peak flow meter) reduced asthma exacerbations. The
observations of these researchers underscore the need for a
better understanding of the relative effects of the elements of
effective asthma education interventions.
Cost-effectiveness of asthma education has not been widely
assessed, as Sullivan and Weiss [15] noted in their review of the
economic impact of asthma-related educational interventions.
They affirmed that while few true cost-effective studies have
been conducted in this area, existing economic evaluations are
encouraging, especially for programs targeting high-risk or
high-utilizing subgroups. Supporting this conclusion, Sullivan
et al [16] assessed the cost-effectiveness of a comprehensive social worker–based asthma education and environmental control program involving 1033 children in 8 urban areas. Overall,
the intervention improved outcomes at an average additional
cost of $9.20 per symptom-free day gained (95% CI, $–12.56 to
$55.20). For 3 subgroups of children with more severe disease,
however, the intervention decreased costs. In a 1-year randomized controlled trial involving adults with asthma, Gallefoss
and Bakke [17] were able to show significant benefits for
Vol. 14, No. 10 October 2007 JCOM 555
asthma education
self-management education in terms of reduced health care
costs and improved quality of life.
Education in Nonclinical Settings
A number of interventions for children related to asthma
education provided in the home and in schools have been
evaluated.
Home
Asthma education provided in the home can generally be
divided into 3 types: self-management education, environmental control education (often with a self-management
component and sometimes with provision of materials
needed for allergen reduction), and computer education.
Self-management. Butz et al [18], for example, assessed
home-based nebulizer education in a trial to determine if it
could increase nebulizer use and reduce health care utilization. They studied 221 children over 12 months and found
no effect on the use of nebulizers or on severity of the child’s
asthma or level of health care use. (One could argue this was
actually a positive result: European and Australian clinical
views and guidelines are now very much against the use of
nebulizers in children.)
Madge et al [19] conducted a trial of nurse-led asthma
home management training for children who had been
admitted to the hospital for acute asthma. The nurse used
problem-solving, planning, and telephone follow-up with
201 children and their families. From 2 to 14 months
postprogram, readmissions to the hospital were reduced
(p = 0.002), with no concomitant increase in ED use or need
for urgent treatment in a physician’s office. Similarly, Brown
et al [20] assessed the Wee Wheezer program [21], a wellknown intervention for use with young children in a clinical
setting provided in the home. In a trial with 95 children, they
found that treatment was associated with less bother from
asthma symptoms (P < 0.01) and more symptom-free days
(from 37 days at baseline to 154 at 12 months; P < 0.01). They
also found enhanced quality of life for caregivers (P < 0.01).
However, it was among the younger children (aged 1–
3 years) that these findings were significant. Jones et al [22]
studied 204 underserved Latino families, half of whom were
provided at- home asthma self-management education by a
bilingual, bicultural educator in the participant’s preferred
language. They found a subsequent increase in the use of
controller medicines in the treatment group (P < 0.001).
Environmental control. The majority of home-based programs for asthma have emphasized the indoor environment
and reduction of allergens. For example, Kreieger et al [23]
conducted a trial of an intervention provided by community
health workers to reduce exposure to indoor asthma triggers,
556 JCOM October 2007 Vol. 14, No. 10
which included assessment of exposures, action planning, and
provision of allergen reduction equipment. Children (n = 274)
were randomized to either a high-intensity program (7 visits
and household cleaning equipment provided) or low-intensity
program (1 visit and limited resources provided). Reductions
in the presence of allergens were observed in both groups
but were significant only in the high-intensity group. The
high-intensity group also demonstrated greater reductions
in asthma-related urgent health care use (P = 0.03) and better
caregiver quality of life scores (P = 0.005).
Eggleston et al [24] assessed an intervention to reduce
environmental pollutant and allergen exposure in homes of
children with asthma living in the inner city. One hundred
children were involved. Those randomized to the treatment
group received education, cockroach and rodent extermination, mattress and pillow encasings, and a high-efficiency particulate air cleaner. In the treatment group, particulate matter
decreased significantly in the home after 12 months (P < 0.001).
Cockroach allergen levels decreased by 51%, and daytime
asthma symptoms decreased (P = 0.04). No differences were
seen in other measures of morbidity (eg, nighttime symptoms,
ED use). Further examination of the data [25] showed that
decreases in allergen levels in the homes were associated with
decreases in complications of asthma (P < 0.001). Williams
et al [26] conducted a trial involving 402 children to evaluate a
similar intervention with the addition of a professional house
cleaning. After 14 months, overall asthma severity scores
for the children did not differ between groups, although the
median functional severity score of the scale utilized was
significantly better (P < 0.01). Differences in other outcomes,
including health care use, were not significant.
Kercsmar et al [27] assessed a home-based asthma environmental education program focusing on mold and damp
indoor spaces. All 62 children received education, but those in
the treatment group also received help in remediation of the
home (home repair and remodeling). The remediation group
subsequently had a significant decrease in asthma symptom
days (P = 0.003) and a lower rate of exacerbations (P = 0.11). In a
very small study with other methodologic flaws, Nishioka et al
[28] compared the effect of home visit counseling for environmental control of house dust mites with that of usual guidance
provided in clinics. They enrolled 36 families with an asthmatic child aged 7 years or younger. Families in the treatment
group received monthly counseling visits over a 1-year period.
Compared with control children with atopic asthma, treatment
group children with atopic asthma appeared to experience a
reduction in the frequency of asthma attacks (P < 0.001) and
levels of house dust mites allergen exposure.
Computer education. Computer games and exercises
have been developed to teach asthma self-management to
children and adolescents in their homes. Although these
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applications have also been developed for use as part of a
more comprehensive educational program, we will focus
here on computer programs that were designed to be freestanding and for the child and parent to use at home on their
own time. Homer et al [29], for example, evaluated the effectiveness of an interactive educational computer program for
children aged 3 to 12 years in a trial involving 137 subjects.
During the 12-month follow-up period, no differences in
health care use, symptoms, or functional status were observed
beyond some increase in asthma knowledge in treatmentgroup children. Huss et al [30] also found in a trial with
101 children from the inner city that a computer game did
not improve asthma outcomes. In a trial with 438 children
divided into traditional asthma education and computerassisted asthma education, Runge et al [31] found no differences in efficacy between the interventions. Shegog et al [32]
assessed a computer program with 76 children and found
that children in the treatment group had higher scores on
questions about steps of asthma self-regulation postprogram
(P < 0.01) and demonstrated greater self-efficacy (P < 0.05).
No behavioral outcomes were noted. A version of the game
was assessed in clinics and physicians’ offices with a larger
sample of 171 children and was found to be correlated with
positive outcomes, including fewer hospitalizations, better
symptom scores, and improved functioning [33].
Schools
Two types of school-based asthma education programs
have been evaluated. One type is nurse-, physician-, or
school clinic–dependent. The other is provision of asthma
education not dependent on clinical personnel. Assessment
of school-based programs have been relatively numerous
and many have focused on the particular problems for lowincome minority students.
School-based programs independent of school clinics. A
study conducted some years ago was the first to illustrate
outcomes for children from an asthma self-management program (Open Airways) provided in the school. Evans et al [34]
showed in a trial with 12 schools and 239 children aged 8 to
11 years that group sessions for children with asthma during
regular school hours provided by a health educator resulted
in greater self-efficacy with respect to asthma management
skills (P < 0.05), more influence on parents’ asthma management decisions (P < 0.05), better grades in school (P = 0.05),
and fewer episodes of asthma (P < 0.01) with shorter average
duration (P < 0.01). No differences were observed for changes
in number of school absences. Results were subsequently
confirmed in a trial involving 102 children in inner-city
schools [35]. An additional study by Clark et al [36] illustrated that a self-management program broadened to provide
educational activities for classmates of children with asthma,
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principals, counselors, as well as building environment personnel (Open Airways Plus) produced even better outcomes
than the original version. They showed in a trial with 835 elementary school students that 2 years after the intervention,
children in the intervention group with persistent disease
had significant declines in daytime (P < 0.001) and nighttime
(P < 0.001) symptoms. Treatment-group children had higher
grades for science subjects (P < 0.02) and fewer absences for
asthma (P < 0.05). Parents of treatment group children who
had been indirectly involved through program assignments
and exercises taken home by the child had higher scores on
an asthma self-management index (P = 0.02).
Bartholomew et al [37] assessed a program involving
946 urban youth in Texas that included development of an
asthma action plan, a computer-assisted educational program tailored to children’s asthma symptoms, and a school
environmental assessment–based intervention. At follow-up,
children in the treatment group had higher reported levels
of self-efficacy (P = 0.0368), trigger management (P < 0.001),
exercise pretreatment self-management (P = 0.0049) and
self-management of asthma episodes at home (P = 0.0087).
No differences were noted in health status, school performance or attendance, or levels of environmental allergens.
Cicutto et al [38] assessed a program for children in grades
2 to 5 in 26 schools in a suburb of Toronto. They found that
children in the treatment group had fewer days of activity interrupted by asthma (P = 0.01) and no differences for
scheduled asthma visits or parental work absenteeism. Shah
et al [39] assessed the effectiveness of a peer-led educational
program for adolescents with asthma in a trial of 272 students in grades 7 and 10 from 6 high schools in New South
Wales, Australia. Positive effects on adolescents in the treatment group versus controls were noted in quality of life
(P = 0.01), and for 10th-grade students, days absent from
school (P < 0.05). Students in the control group experienced
an increase in the number of asthma attacks at school.
McGhan et al [40] conducted an assessment of an asthma
management education program for children aged 7 to
12 years that involved 162 students in 18 elementary schools.
Compared with children in the control group, they found
treatment children missed less days of school (P = 0.07), experienced less limited play (P < 0.01), and had improvements
in key aspects of asthma management, including the appropriate use of preventive medication (P < 0.001). No differences were noted in health care use or asthma symptoms.
Joseph et al [41] conducted a trial of a Web-based, tailored
asthma management program with 412 adolescents reporting asthma symptoms in 6 urban high schools. The 4 computerized sessions were focused on 3 primary behaviors:
controller medication adherence, rescue inhaler availability,
and smoking cessation or reduction. At 1-year follow-up,
students in the treatment group reported fewer symptomatic
Vol. 14, No. 10 October 2007 JCOM 557
asthma education
days (P < 0.001), nighttime symptoms (P = 0.009), school days
missed (P = 0.006), restricted activity days (P = 0.02), and
hospitalizations for asthma (P = 0.01).
Tieffenberg et al [42] conducted a trial with 355 Spanishspeaking school children with asthma and epilepsy in
Buenos Aires. The program consisted of games, problemsolving, and role playing. They found that treatment children
with both conditions had fewer crises than control children
(P = 0.04 and P = 0.026). Physician visits declined for the children with asthma (P = 0.05) and ED visits for children with
epilepsy (P = 0.05). Absenteeism also decreased (asthma,
P = 0.006; epilepsy, P = 0.03).
School-based clinics and case management. In a trial involving 6 New York City elementary schools and 599 children,
Webber et al [43] assessed whether school-based clinics
versus no clinics enhanced asthma outcomes. They found
that in the follow-up period, children in schools with clinics
were less likely to have visited a community health provider
for asthma care (relative rate ratio, 0.52 [95% CI, 0.30–0.88]).
No changes in hospitalization were noted. Levy et al [44] conducted a trial in 14 elementary schools involving 245 students
with asthma. Schools were divided into either a nurse-led
intervention or control group. Nurses provided asthma selfmanagement education (Open Airways) and followed up on
students’ school absences and coordinated asthma care with
families, school personnel, and medical care providers. The
control group received the routine nursing services provided
in the schools. They found children in the schools with the
nurse-led program had fewer ED visits (P < 0.001) and fewer
hospitalizations (P < 0.05) postprogram.
Bruzzese et al [45] conducted a trial in which nurses were
trained to foster relationships between school children with
asthma, their families, primary care physicians, and school
personnel. Many difficulties were faced in conducting the
intervention. At 1-year follow-up, children in the intervention schools had a reduction in activity limitations due to
asthma (P < 0.05) and days with symptoms (P = 0.06), but
no differences were observed on any other health-related
outcomes and initial differences were no longer evident at
the 24-month follow-up. Millard et al [46] conducted a trial
to assess in 8 elementary schools with 50 students whether a
clinician administering asthma medications at school could
achieve enhanced outcomes. During the administration period, improvements were observed in treatment children’s
peak flows (P = 0.05) and nocturnal awakening with symptoms (P = 0.02), visits to the primary care provider (P = 0.02).
However, no postprogram outcome data were reported.
Coalitions and Community Partnerships
In recent years, coalitions and community partnerships have
been viewed as a means to effect change in health systems
558 JCOM October 2007 Vol. 14, No. 10
and public policy such that people with asthma are able to
manage their disease better. In the United States alone, there
are over 200 community-based asthma coalitions, and there
are many more around the world. There is an extensive
literature [47,48] on the processes of collaboration and action
undertaken by these partnerships and what best enables
them to function as a collective versus a group of separate
organizations. However, actual outcomes data for asthma
coalitions are scant, likely because employing controlled
research designs and collecting population-wide data are
difficult in community settings. Nonetheless, the studies
that have been undertaken suggest that asthma coalitions
can make significant change in their locales.
Fisher et al [49] assessed an asthma coalition focused on the
health of children in a predominantly low-income, AfricanAmerican community. It sponsored educational programs
for neighborhood parents and children, asthma awareness
activities, and trained neighborhood residents to provide supportive care and information to individual households where
a child had asthma. More than 3 years of data were collected
in the 4 coalition locales and in 4 comparison neighborhoods
involving 249 children. They found that participation in coalition activities affected outcome. Families that were high-level
coalition participants had lower rates of ED and hospital use
postprogram (P = 0.02) compared with low-level participants
and the comparison group. The program was especially effective in reaching socially isolated families.
Thyne et al [50] assessed the impact of the Yes We Can
urban partnership for asthma control. The coalition involves a
wide range of community organizations and health care provider institutions. They deployed community health workers
to provide education and social support to children with asthma that included 3 components: medical evaluations, social
intervention by the community health worker, and integrated
efforts to reach families and provide patient self-management
education. The evaluation compared outcomes for the 88
coalition-assisted families, with a total of 102 children receiving service in the community asthma clinic. Improvements in
the treatment-group children were observed with regard to
use of controller medicines (P = 0.05), action plans (P = 0.001),
mattress covers (P = 0.001), and asthma symptoms (P < 0.01).
Clark et al [51] reported on policy- and system-related
changes achieved by 7 asthma coalitions in communities
around the United States. They focused on advocacy, education, and related activities to make health care more consistent across community institutions and to create or modify
public policy to enhance conditions for children with asthma.
Qualitative evaluation indicated 8 areas of accomplishment:
environmental control, care coordination across community
facilities, community-wide patient registries, integration
of community health workers and clinical care, standardized asthma action plans across institutions, links between
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health facilities and schools, community-wide education for
clinicians, and intra-institutional coordination.
Summary
This overview of asthma educational interventions is not
meant to be exhaustive but exemplary. We have tried to include a reasonable sample of the largest and most rigorously
conducted studies in each area under consideration. From
this, it is possible to get a sense of the direction in which the
data are leaning for the types of asthma education programs
we have examined. The Table presents our tentative assessment of the state of the art. These estimations represent the
view of the authors and are not a statistical assessment of
data beyond that provided in individual studies or metaanalyses that we have included here.
As the Table suggests, the data are adequate to support
self-management education provided in clinical settings as a
means to achieve desired asthma outcomes related to symptom reduction and health care use. This area of work is the
one of longest-standing in the field. Indeed, in most national
guidelines, clinic-based asthma self-management education
is a recommended practice if not a requirement.
Similarly, education provided at home that focuses on the
indoor environment has adequately been shown to be associated with outcomes. For this type of education, however, it
is necessary to accept reduction of allergens as the achievable result. While not a bad outcome, the direct relationship
between reductions in allergens and improvements in the
health status and reduction in health care use in children
has not been well documented [52]. In addition, the cost of
remediation of indoor conditions (bed covers, dehumidifiers, elimination of dampness, pest and allergen control) can
be high if desired outcomes are not reliably achieved.
Considerable work evaluating school-based interventions
has been undertaken, and the data suggest that they produce
important results for children, families, and the schools
themselves. However, as noted, it is frequently difficult to
work in schools because of competing priorities and because
the costs associated with programs are not reimbursed or
otherwise covered. We may be losing our best opportunity to
reach and educate children by not capitalizing on the models
for asthma education in schools. The data are not as clear for
school-based programs that depend on nurses or physicians
for implementation. The costs of these programs would be
high unless nursing and medical personnel were part of the
everyday routine of a school, an uncommon situation.
Home-based electronic applications of asthma education
have not fared well in evaluation. However, it may be that
computers used in combination with a broader program may
produce results. One issue in the available assessments is the
research designs that have been employed. In the main, the assessments have not included collection of behavioral or health
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Table. Evidence Supporting Education in Pediatric
Asthma for Achieving Behavioral and/or Health
Outcomes: A Tentative Assessment
Findings*
Study Type/Target
(Outcome)
Self-management education in clinics/physicians
offices (sx, hcu)
Positive Questionable
X
Education targeting ED
users
Education using action
plans (sx, hcu)
X
X
Education using peak
flow monitoring
X
Psychological interventions
X
Home-based nebulizer
education
Home-based self management education (sx,
qol, meds, hcu)
X
X
Home-based computer
education
School-based interventions (sx, grades,
absenteeism)
X
X
School-based clinics and
case management
Coalitions (policies, hcu)
Negative
X
X
hcu = health care use; meds = medicine use; policies = system and
policy change; qol = quality of life; sx = symptoms.
*Positive = consistent findings regarding behavioral or health out­
comes in more than 1 study; questionable = inadequate numbers
or inconclusive results; negative = available studies show no significant differences.
outcome data nor have they gone much beyond the immediate postprogram phase. In schools, Web-based programming
that provides individualized messages to promote asthma
management may be promising. One reason computerized
programs designed for home use may be less effective than
those used in clinics or schools is because access and level of
exposure to the programs cannot be guaranteed.
No definitive assessment of the cost-benefit or costeffectiveness of asthma education has been undertaken.
Nonetheless, the available data do suggest that cost savings
can be realized. Studies that account for the significant indirect costs of asthma (eg, absenteeism, pharmaceutical costs,
out-of-pocket expenses) would need to be conducted to better understand the value of such interventions.
Community partnership and coalition actions have included improving and coordinating services for children
Vol. 14, No. 10 October 2007 JCOM 559
asthma education
with asthma and their families, providing families the skills
and resources necessary to manage asthma, and training
health care providers in the community to both practice at
the standard of care and support family self-management
efforts. Although methodologic obstacles can present challenges for evaluators, more studies are needed to illuminate
the connection between the processes of partnerships or
coalitions and changes in asthma-related outcomes for
children.
An important issue to keep in mind is that selfmanagement education cannot be viewed in isolation from
routine health care. Indeed, the literature emphasizes the
importance of clinical follow-up. However, clinical followup needs to be easy to access and available at convenient
times and by convenient routes [53]. Patients with asthma
are more likely to attend for follow-up if they are seen
promptly in the clinic and prefer to see the same health care
professional on each occasion [54,55]. Keeping appointments
may be enhanced by reminder phone calls to patients [56].
Telephone consultations have been shown to be an effective
alternative to face-to-face visits [57], and telephone outreach
has been shown to reduce health care resource use among
children and adolescents [58].
Considerations for Future Research
The understanding of the social, behavioral, and environ­
mental aspects of asthma as they affect behavior and health
outcomes has increased greatly in the recent past. Although
some types of education have adequately proved their
worth, some require further study or replacement with
more efficacious approaches. In addition, there continues
to be a number of important questions that deserve careful
study and issues that deserve consideration.
For example, it is clear from our review that different
programs produce different outcomes. One could argue that
beyond purposes having to do with researchers’ interests,
some assessment measures are no longer useful. If increased
knowledge or self-efficacy is not accompanied by changes
in behavior and health outcome, are they good measures of
asthma education? Extant data suggest that there is a kind of
gold standard for asthma education: the reduction of symptoms and the reduction of health care use. Many large trials
have shown these results to be forthcoming. If programs fail
to demonstrate these achievements, are they good models
for further use? Yet for many families, feelings of confidence
and quality of life and other subjective assessments are
personally important. Likely, models can be developed that
could achieve these ends, as well as the more objective ones
related to health status and need for health care. A related
but different issue is the fact that most asthma education
studies continue to be “black box” evaluations. We need to
see more studies employ multifactorial designs to determine
560 JCOM October 2007 Vol. 14, No. 10
which elements of a program are central to its success. Other
questions also need to be answered: are longer or shorter
versions of a program more effective? Are some program
providers (eg, nurses, physicians, school teachers, peers)
more effective than others? What venues for reaching providers are the best (practice settings, residency programs,
basic training)? Answers to these questions will help make
interventions more efficient as well as effective.
Although we have considerable data on interventions for
children from age 6 to adolescence, we have a dearth of information for other groups. Little is understood about effective
interventions for very young children, with a few exceptions
(eg, Wee Wheezers). We know that in adolescence asthma
shifts from a disease predominantly affecting boys to a female disease. We know little about how to assist adolescent
girls as their asthma becomes more problematic or how to
help them manage the onset of the condition at this time.
As prevalence of asthma and its effects continue to be most
evident in low-income minority populations, we continue to
need innovative means to reach and assist these children.
The work by Tieffenberg et al [42] raises an interesting question deserving attention. Could interventions that combine
diseases and reach children at school with a range of conditions be a model for chronic disease control? At least 1 group
[59] has found that a program for patients with different
chronic diseases resulted in positive outcomes for adults.
A number of studies have shown positive outcomes of
asthma interventions for children with more severe disease.
This has generally been defined as more frequent occurrence of more serious symptoms. However, there is increasing awareness (although not a lot of data) that children
with intermittent disease can have a “slammer” attack of
sufficient force to require hospitalization and that in some
instances can be life-threatening. We need to understand
more about these children and how to help them manage
the serious episode that (seemingly) comes out of the blue.
Finally, given that we have good models for assisting
children with asthma in clinics, in their homes, and at
school, should we not concentrate much of our effort on the
dissemination and widespread use of these interventions?
The major stumbling block to such action is the fact that
the costs of these programs are not underwritten in most
locales, health systems, and insurance plans. If we are serious about intervening to help children manage their asthma
and as a result reduce morbidity and health care use, we
must also be serious about providing the funds for program
implementation.
Corresponding author: Noreen M. Clark, PhD, Myron E. Wegman
Distinguished University Professor, Director, Center for Managing
Chronic Disease, Univ. of Michigan, 109 S. Observatory, Ann Arbor,
MI 48109, [email protected].
www.turner-white.com
Clinical review
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