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Children with Asthma

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Family Coordinator Asthma Education Program

Article Citation:
Bonner, S, Zimmerman BJ, Evans D, Irigoyen M, Resnick D, Mellins RB. An individualized intervention to improve asthma management among urban Latino and African-American families. Journal of Asthma 2002;39(2):167-79.

Intervention Setting:
Classroom and home

Target Population:
Urban Latino and African-American families with a child with asthma

Program Description:
This study hypothesized that an educational intervention based on a readiness model would lead to improved health outcomes among patients with asthma. This individualized asthma education intervention, based on the asthma self-regulation model, comprised four sequential phases of patient readiness to manage asthma: 1) asthma symptom avoidance, 2) asthma acceptance, 3) asthma treatment compliance, and 4) asthma self-regulation.

Baseline interviews were conducted in participants’ homes and families were randomly assigned to intervention or control groups. Control families received usual medical care. Patient education was delivered by a family coordinator, a college educated, bilingual, social services-oriented individual, who acted as a behavioral change agent. Educational workshops and individualized counseling sessions used an asthma diary as a primary intervention tool. The family coordinator conducted three group educational workshops at 1-month intervals. The workshops followed the learning sequence identified in the asthma self-regulation model. In the first workshop, families were trained to use asthma diaries and peak flow meters. Patients were required to monitor peak flow, triggers, symptoms, medications, and side effects. The family coordinator regularly called families to discuss their diary records. The second workshop used patients’ diary records as illustrations of the relative effectiveness of controller medicines over rescue/quick-relief drugs in preventing asthma symptoms over time. The strategy of using patients’ own diaries as evidence of the efficacy of control medicines helped overcome patients’ preference for rescue/quick-relief drugs. The third workshop described asthma management as a two-pronged effort of medications and trigger control. Again, patients’ own diary records of fluctuations in asthma were shown as cues to step up medications according to their action plans. In addition, the family coordinator visited each family at home to assess the reliability of the diary with a spot check of peak flow accuracy. The family coordinator helped prepare each family for its doctor visit; accompanied the family to the visit; and assisted it in presenting the asthma diary, describing the child’s condition, and acquiring an asthma plan. Allergy testing was performed to help families develop an informed approach to controlling triggers. After the third workshop, the family coordinator conducted a home environment assessment and suggested strategies for reducing asthma triggers, especially in the child’s bedroom. Allergen-impermeable casings for pillows and bedding were provided for children who tested positive for dust mites. Caretakers were again interviewed following the 3-month intervention.

Evaluation Design:
A randomized controlled cohort design

Sample Size:
Each of 119 families with a child ages 4-19 years who had moderate to severe asthma were recruited into one of seven cohorts of 16-18 members each.

Outcome Measures/Results:
Outcome measures included asthma knowledge, self-efficacy for managing asthma, asthma self-regulatory phase, adherence to prescribed medications, prophylactic use of a bronchodilator, asthma symptom persistence, and activity restrictions caused by asthma. The intervention produced improvements on all health outcome measures. Intervention families’ knowledge of asthma rose to a statistically significant 67% correct responses, and asthma knowledge among the control group remained constant at about 40%. The intervention program contributed to a 41% increase in the participants’ self-efficacy for managing asthma, compared with a 9% increase in the control group. At follow-up, 66% of the intervention group had achieved asthma self-regulatory phases 3 (asthma compliance) or 4 (asthma self-regulation). In contrast, 28% of the control families were classified in phase 3, and one reached phase 4. Physicians’ prescription of controller medications increased significantly in the intervention group but decreased in the control group. At follow-up, 82% of the intervention group reported adhering to the prescribed frequency of medication administrations, and 86% adhered to prescribed dosages, compared with only 40% and 42% for the control group, respectively. At follow-up, 26% of intervention families reported cough or wheeze more than twice a week, 14% reported nighttime awakening more than twice a week, and 26% reported keeping their child at home more than twice a month. The comparative frequencies among the control group were 50%, 40%, and 48%, respectively. The intervention group reported a 20% reduction in activity restrictions from baseline to follow-up, compared with a 2% increase for the control group.

Editor’s Notes:
A pre-post design trial of this phase-based asthma education program was implemented in 2002-03 in East Harlem among Head Start families. The New York City Agency for Children’s Services has instituted a mandate requiring written asthma plans for all children in Head Start programs, a requirement that was phased in over the 2002-03 school year and is considered a prerequisite milestone for achieving success with the intervention.

Availability of Protocol/Materials:
With an additional study under way, the protocol and materials are not available for widespread distribution.

Case Study:
None


Living With Asthma

Article Citation:
Creer TL, Backial M, Burns KL, Leung P, Marion RJ, Miklich DR, Morrill C, Taplin PS, Ullman S. Living with asthma. I. Genesis and development of a self-management program for childhood asthma. J Asthma 1988;25(6):335-362.

Intervention Setting:
Residential treatment facility for resident children with asthma

Target Population:
Children and their families

Program Description:
A pediatric asthma program based on social learning theory. The program is designed to teach children how to manage their asthma by providing education and opportunities to use their newly acquired skills to recognize symptoms and triggers and to determine the appropriate course of action. The program consists of eight sessions. The first four provide basic asthma education and an understanding of how to medically manage asthma. The last four occurred during the “performance phases” and focused primarily on utilizing and refining the knowledge and skills learned earlier.

Evaluation Design:
Families were assigned randomly to the intervention group and a wait-listed control group. Once 10 families were assigned to each group, the intervention began. The wait-listed control received the intervention approximately three months later; therefore, participants served as their own controls during the performance segment of the study. The data was analyzed using ANOVA.

Sample Size:
399 participated over a three-year period of time. The data reported in the study were based on 278 individuals including 123 children between the ages of 5 and 17.

Outcome Measures/Results:
Several pen and paper instruments were used to measure changes in knowledge and attitudes about asthma on the parts of children and their parents. Pulmonary physiology measures (a complete work-up and peak flow meter readings); self-report measures on compliance and on the number and severity of attacks (in the form of an asthma diary); and the financial cost of asthma were also collected. Patients improved significantly in their ability to prevent and manage attacks. School absenteeism and financial costs associated with asthma were reduced as well. There were also improvements in parental and child attitudes about asthma.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None


Pediatric Asthma Program

Article Citation:
Tieffenberg JA, Wood EI, Alonso A, Tossutti MS, Vincente MF. A randomized field trial of ACINDESs*: A child centered training model for children with chronic illnesses (asthma and epilepsy). Journal of Urban Health 2000;77(2):280-96.

*ACINDESs is the Association for Health Research and Development, Buenos Aires, Argentina.

Intervention Setting:
The intervention was conducted in a classroom in Buenos Aires, Argentina that was not associated with a hospital or clinic. Families were recruited from several health facilities (including asthma clinics) within the City of Buenos Aires and its environs. This program reportedly represents the first Hispanic child-centered group training program in Latin America focused on asthma self-management.

Target Population:
Spanish-speaking school-aged children aged 6–15 years who had been diagnosed with moderate to severe asthma

Program Description:
The study’s objective was to assess the effectiveness of an asthma education program founded on the basis of a child’s autonomy. This approach places the children in the center in the management of their own health; parents become facilitators and physicians are counselors. The program was designed to help the children change their beliefs and attitudes about their ability to care for themselves. By learning about the alternatives from which they can choose, children acquire tools to modify their health behaviors. The participants attended five weekly 2-hour group meetings (parents and children in separate sessions conducted at the same time) followed by a reinforcement meeting 2 and 6 months later. Instruction was provided by professional teachers who employed games, drawings, stories, videos, and role play. Children and parents learned a) the child’s condition, body signals, and warning signs, b) triggers, c) treatment alternatives, d) risks and actions-emergency home treatment, and e) decision-making based on expected values.

Evaluation Design:
This study utilized a randomized controlled design. The experimental group was invited to participate in training and receive home interviews and follow-ups at 6 and 12 months. The control group received home interviews at same time. Surveys included a socio-cultural questionnaire, and school absenteeism was also recorded. Number of crises, routine and emergency department visits, and hospitalizations registered from medical records 6 months prior and up to 1 year after the program were recorded.

Sample Size:
The study consisted of 188 children; 127 were randomly placed in the experimental group and 61 in the control group. A total of 64 children in the experimental group and 43 in the control group completed the study.

Outcome Measures/Results:
Outcome measures included general knowledge of asthma, beliefs, attitudes, and behaviors, clinical outcomes, and school absenteeism. Parents in the experimental group showed increased asthma knowledge whereas knowledge for parents serving as controls waned. Fear of the child’s death decreased from 39% to 4% in the experimental group whereas parents in the control group showed no decrease in levels of fear. Children’s confidence in self-care skills showed marked improvement after the intervention. The experimental group had fewer asthma crises: an average 2.02 compared with 1.09 in the control group in a 12-month period, a statistically significant difference. Medical-care visits decreased from an average 3.29 to 1.65. School absenteeism fell in the experimental group from 10 to 5.91 during March through July (fall and winter in Argentina). School attendance was above that of a sample of 345 Buenos Aires children without chronic illness for the same time period.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

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Data & Surveillance

Percents by Age, Sex, and Race, United States, 2012. Age: Child = 9.3%, Adult =  8.0%, Sex: Male = 7.0%, Female =  9.5%, Race/Ethnicity: White =  8.1%, Black =  11.9%, Hispanic =  7%. Source: National Health Interview Survey, National Center for Health Statistics, Centers for Disease Control and Prevention.

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