Effectiveness of school-based family asthma educational programs in quality of life and asthma exacerbations in asthmatic children aged five to 18: a systematic review

Scoping review: multiple stakeholders and child asthma management interventions

OBJECTIVE

This study reviewed research to identify interventions aimed at improving asthma management among children by educating parents and other professionals.

DATA SOURCES

PubMed, Medline, and Embase databases were utilized.

STUDY SELECTIONS

Three databases were searched for child asthma management interventions published between 2012-2022 in English. Search terms included children, asthma, intervention(s), community pediatrics, coaches, schools, and stakeholders. Inclusion criteria were being an experimental study focused on children with asthma (birth-18 years), including stakeholder involvement, education, and a community focus. The search yielded 153 articles; nine were reviewed.

RESULTS

In general, stakeholders developed programs that resulted in improvements in asthma symptoms, knowledge of asthma management, perceptions of health care, and decreased emergency health care visits. Successful interventions involved education about asthma management, providing medications, and partnerships with school staff, healthcare teams, and community members. Effective coordination and communication contributed to successful program implementation. Using technology for asthma management education was effective in tracking access to care and facilitated the delivery of medications.

CONCLUSION

The findings indicate that interventions were effective in improving child asthma management. Stakeholder partnerships were critical to the effectiveness of interventions. Marketing the intervention and encouraging communication with parents also fostered success. Being able to assess the home environment and staying in contact with parents were barriers to these interventions. Conducting randomized controlled trials using the interventions found effective in these studies to assess change in symptoms and emergency care visits over time would yield important information about their long-term success and cost for implementation.

Evaluation of the effect of an education program using cartoons and comics on disease management in children with asthma: a randomized controlled study

OBJECTIVE

The aim of this study was to determine the effect of an education program, the Health Promotion Program for Children with Asthma (HPPCA), on disease control and quality of life in children aged between 7 and 11 and diagnosed with asthma. The program was developed using cartoons and color-in materials and was based on the health promotion model developed by Nola J. Pender and brain-based learning theories.

MATERIALS AND METHODS

The sample of the study consisted of 74 children between the ages of 7 and 11 who presented to the respiratory diseases' unit of a university hospital in Istanbul. All participants were given basic asthma education by their physicians, and were then randomly assigned to a group that received the HPPCA program or a control group that received no further education. After the HPPCA education was applied to the experimental group alone, both groups were administered two post-tests as a follow-up and retest at the end of the first and fourth month after the intervention. The standardized Sociodemographic Question Form, the Childhood Asthma Control Test (C-ACT) and the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) were used for the follow-up.

RESULTS

The asthma control and quality of life scores of the children included in the experimental group were found to be significantly higher compared to the control group at the first- and fourth-month follow-ups (p<.001). The rate of school absenteeism decreased significantly in children who received HPPCA education at the first follow-up compared to the children who did not receive the education (p<.05).

PRACTICE IMPLICATIONS

The present study found that the HPPCA education, whose design was based on the health promotion model, and which was supported by cartoons in order to attract the attention of the children, was effective. The HPPCA was proven to create a sense of control over asthma and to improve the quality of life in the children. It is recommended that there be an asthma nurse in pediatric allergy and immunology outpatient clinics who can specifically provide an HPPCA. Further studies should be conducted to demonstrate the effectiveness of this program, which was examined in the present study for the first time with a randomized controlled method.HighlightsAsthma control is extremely important for the quality of life in children with asthma.Asthma education provided to school-age children yields the best results when new teaching techniques and multimedia content are used.Asthma education for children must be based on a good theoretical methodology.Children can best manage asthma when they learn about it directly.Asthma education conducted according to the guidelines is of great importance during the COVID-19 pandemic.

Stakeholders' views of supporting asthma management in schools with a school-based asthma programme for primary school children: a qualitative study in Malaysia

OBJECTIVE

The WHO Global School Health Initiative aimed to improve child and community health through health promotion programmes in schools, though most focus on preventing communicable disease. Despite WHO recommendations, no asthma programme is included in the Malaysian national school health service guideline. Therefore, we aimed to explore the views of school staff, healthcare professionals and policy-makers about the challenges of managing asthma in schools and the potential of a school asthma programme for primary school children.

DESIGN

A focus group and individual interview qualitative study using purposive sampling of participants to obtain diverse views. Data collection was guided by piloted semistructured topic guides. The focus groups and interviews were audiorecorded, transcribed verbatim and analysed using inductive thematic analysis. We completed data collection once data saturation was reached.

SETTING

Stakeholders in education and health sectors in Malaysia.

PARTICIPANTS

Fifty-two participants (40 school staff, 9 healthcare professionals and 3 policy-makers) contributed to nine focus groups and eleven individual interviews.

RESULTS

School staff had limited awareness of asthma and what to do in emergencies. There was no guidance on asthma management in government schools, and teachers were unclear about their role in school children's health. These uncertainties led to delays in the treatment of asthma symptoms/attacks, and suggestions that an asthma education programme and a school plan would improve asthma care. Perceived challenges in conducting school health programmes included a busy school schedule and poor parental participation. A tailored asthma programme in partnerships with schools could facilitate the programme's adoption and implementation.

CONCLUSIONS

Identifying and addressing issues and challenges specific to the school and wider community could facilitate the delivery of a school asthma programme in line with the WHO School Health Initiative. Clarity over national policy on the roles and responsibilities of school staff could support implementation and guide appropriate and prompt response to asthma emergencies in schools.

School-based self-management interventions for asthma among primary school children: a systematic review

A Cochrane review of school-based asthma interventions (combining all ages) found improved health outcomes. Self-management skills, however, vary according to age. We assessed effectiveness of primary school-based self-management interventions and identified components associated with successful programmes in children aged 6-12 years. We updated the Cochrane search (March 2020) and included the Global Health database. Two reviewers screened, assessed risk-of-bias and extracted data. We included 23 studies (10,682 participants); four at low risk-of-bias. Twelve studies reported at least one positive result for an outcome of interest. All 12 positive studies reported parental involvement in the intervention, compared to two-thirds of ineffective studies. In 10 of the 12 positive studies, parental involvement was substantial (e.g. attending sessions; phone/video communication) rather than being provided with written information. School-based self-management intervention can improve health outcomes and substantial parental involvement in school-based programmes seemed important for positive outcomes among primary school children.

Aberrant Expression of Immune-related MicroRNAs in Pediatric Patients with Asthma

MicroRNAs (miRNAs) have been implicated as regulatory molecules that could play a considerable role in the pathogenesis of different diseases including asthma. This work aims at exploring the role of miR-146a and miR- 106b in the pathogenesis of asthma and their association with asthma severity, IgE, and inflammatory cytokines in asthmatic children. Thirty asthmatic children and twenty age-matched healthy children aged 4-17 years old were enrolled. Expression of plasma miR-146a and miR-106b was measured using quantitative real-time PCR. Plasma levels of interleukin-5 (IL-5) and interleukin-13 (IL-13) were assessed using ELISA. Lung functions were measured by Spirometry. MiR-146a and miR-106b were significantly over-expressed in asthmatic children compared to healthy children. A significant positive correlation between total IgE and both miR-146a and miR-106b was found while no significant correlation could be detected between these miRNAs and asthma severity in asthmatic children. Plasma levels of IL-5 and IL-13 were non-significantly higher in asthmatic children compared to healthy children, and there was no significant correlation between them and both miR-146a and miR-106b expressions in the asthmatic children. The aberrant expression of immune-related miRNAs (miR-146a and miR-106b) and inflammatory cytokines (IL-5 and IL-13) among asthmatic children suggest their probable role in asthma pathogenesis.

How young children learn independent asthma self-management: a qualitative study in Malaysia

OBJECTIVE

We aimed to explore the views of Malaysian children with asthma and their parents to enhance understanding of early influences on development of self-management skills.

DESIGN

This is a qualitative study conducted among children with asthma and their parents. We used purposive sampling and conducted focus groups and interviews using a semi-structured topic guide in the participants' preferred language. All interviews were audio-recorded, transcribed verbatim, entered into NVivo and analysed using a grounded theory approach.

SETTINGS

We identified children aged 7-12 years with parent-reported, physician-diagnosed asthma from seven suburban primary schools in Malaysia. Focus groups and interviews were conducted either at schools or a health centre.

RESULTS

Ninety-nine participants (46 caregivers, 53 children) contributed to 24 focus groups and 6 individual interviews. Children mirrored their parents' management of asthma but, in parallel, learnt and gained confidence to independently self-manage asthma from their own experiences and self-experimentation. Increasing independence was more apparent in children aged 10 years and above. Cultural norms and beliefs influenced children's independence to self-manage asthma either directly or indirectly through their social network. External influences, for example, support from school and healthcare, also played a role in the transition.

CONCLUSION

Children learnt the skills to self-manage asthma as early as 7 years old with growing independence from the age of 10 years. Healthcare professionals should use child-centred approach and involve schools to facilitate asthma self-management and support a smooth transition to independent self-management.

TRIAL REGISTRATION NUMBER

Malaysian National Medical Research Register (NMRR-15-1242-26898).

How nurses and other health professionals use learning principles in parent education practice: A scoping review of the literature

Background

Health Professionals (HPs) play an important role in supporting parents to care for their children, by facilitating parents' knowledge and skills development through parent education. This is achieved through teaching, whereby planned strategies, based on principles of how people learn, enable learning. Despite Learning Principles being the fundamental tenets of the learning process, how HPs perceive and use Learning Principles in their practice is neglected in the healthcare literature.

Objective

To identify, describe and map the existing literature on nurses' and HPs' perceptions and use of Learning Principles in parent education practice.

Method

A scoping review was performed using the Joanna Briggs Institute approach. A comprehensive search of 10 databases and the grey literature was undertaken between March and June 2017 to identify pertinent English-language publications. The search was limited to literature published between 1998 and 2017. Following a screening and inclusion criteria eligibility check, 89 articles were selected for inclusion.

Results

HPs' perceptions of Learning Principles were diverse, somewhat disorganised, divergent in meaning and implicit. This was until the Dimensions of Learning construct was applied to guide the analyses and mapping. This revealed that HPs, of whom 60.7% were nurses, used Learning Principles in parent education, but only referred to them in the context of Adult Learning. Enablers to HPs using Learning Principles included shared partnerships between parents and HPs, while barriers included parents' health beliefs, psychological issues and organisational assumptions about learning. Evaluation of parents' learning also represented implicit use of Learning Principles by HPs.

Conclusion

This scoping review is the first to examine HPs' perceptions and use of Learning Principles within parent education practice. The findings reveal a significant gap in this body of knowledge. The paucity of studies containing any explicit descriptions of Learning Principles strongly supports the need for further exploration and codification of Learning Principles, through qualitative methods, whereby a deeper understanding of what is happening in healthcare practice can be established.

A randomized controlled trial of a nurse-led education pathway for asthmatic children from outpatient to home

BACKGROUND

Education for asthmatic children in the outpatient department is insufficient.

AIM

To evaluate the efficacy of a nurse-led education pathway, a standard education programme, on children with asthma.

METHODS

One hundred and eighty participants enrolled and were randomly assigned to either the control group or the intervention group. The intervention group received predetermined step-by-step education sessions based on the self-designed education pathway, while the control group received usual care. Asthma control, health-related quality of life, and health-care utilization measures were taken at baseline and at follow-up visits between February 2016 and May 2018.

RESULTS

Significantly higher scores for health-related quality of life and inhaler technique at the third-month visit and asthma control test at the sixth-month visit were seen in the intervention group. The numbers of unscheduled physician visits and school absences were lower in the intervention group than in the control group within 6 months. However, no significant differences were observed in emergency department visits and hospitalizations.

CONCLUSION

The nurse-led education pathway could be considered effective for children with asthma visiting the outpatient department.

School-Based Telemedicine Interventions for Asthma: A Systematic Review

BACKGROUND

School health systems are increasingly investing in telemedicine platforms to address acute and chronic illnesses. Asthma, the most common chronic illness in childhood, is of particular interest given its high burden on school absenteeism.

OBJECTIVE

Conduct a systematic review evaluating impact of school-based telemedicine programs on improving asthma-related outcomes.

DATA SOURCES

PubMed, Cochrane CENTRAL, CINAHL, ERIC, PsycINFO, Embase, and Google Scholar.

STUDY ELIGIBILITY CRITERIA

Original research, including quasi-experimental studies, without restriction on the type of telemedicine.

PARTICIPANTS

School-aged pediatric patients with asthma and their families.

INTERVENTIONS

School-based telemedicine.

STUDY APPRAISAL AND SYNTHESIS METHODS

Two authors independently screened each abstract, conducted full-text review, assessed study quality, and extracted information. A third author resolved disagreements.

RESULTS

Of 371 articles identified, 7 were included for the review. Outcomes of interest were asthma symptom-free days, asthma symptom frequency, quality of life, health care utilization, school absences, and spirometry. Four of 7 studies reported significant increases in symptom-free days and/or decrease in symptom frequency. Five of 6 reported increases in at least one quality-of-life metric, 2 of 7 reported a decrease in at least 1 health care utilization metric, 1 of 3 showed reductions in school absences, and 1 of 2 reported improvements in spirometry measures.

LIMITATIONS

Variability in intervention designs and outcome measures make comparisons and quantitative analyses across studies difficult. Only 2 of 7 studies were randomized controlled trials.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

High-quality evidence supporting the use of school-based telemedicine programs to improve patient outcomes is limited. While available evidence suggests benefit, only 2 comparative trials were identified, and the contribution of telemedicine to these studies' results is unclear.

Using machine learning to examine the relationship between asthma and absenteeism

In this study, we found that machine learning was able to effectively estimate student learning outcomes geo-spatially across all the campuses in a large, urban, independent school district. The machine learning showed that key factors in estimating the student learning outcomes included the number of days students were absent from school. In turn, one of the most important factors in estimating the number of days a student was absent was whether or not the student had asthma. This highlights the importance of environmental public health for student learning outcomes.

Investigating the effectiveness of school health services delivered by a health provider: A systematic review of systematic reviews

Schools are the only institution regularly reaching the majority of school-age children and adolescents across the globe. Although at least 102 countries have school health services, there is no rigorous, evidence-based guidance on which school health services are effective and should be implemented in schools. To investigate the effectiveness of school health services for improving the health of school-age children and adolescents, a systematic review of systematic reviews (overview) was conducted. Five databases were searched through June 2018. Systematic reviews of intervention studies that evaluated school-based or school-linked health services delivered by a health provider were included. Review quality was assessed using a modified Ballard and Montgomery four-item checklist. 1654 references were screened and 20 systematic reviews containing 270 primary studies were assessed narratively. Interventions with evidence for effectiveness addressed autism, depression, anxiety, obesity, dental caries, visual acuity, asthma, and sleep. No review evaluated the effectiveness of a multi-component school health services intervention addressing multiple health areas. From the limited amount of information available in existing systematic reviews, the strongest evidence supports implementation of anxiety prevention programs, indicated asthma education, and vision screening with provision of free spectacles. Additional systematic reviews are needed that analyze the effectiveness of comprehensive school health services, and specific services for under-researched health areas relevant for this population.

Targeting quality of life in asthmatic children: The MyTEP pilot randomized trial

BACKGROUND

Quality of life (QoL) is an important outcome in the management of children with asthma. Mobile Health (m-Health) and Therapeutic Education Programs (TEPs) are increasingly recognized as essential components of pediatric asthma management to improve disease outcomes.

OBJECTIVE

To evaluate the effect of an education program (MyTherapeutic Education Program, MyTEP) that couples multidisciplinary TEP intervention with an m-Health Program (mHP) in improving QoL in asthmatic children.

METHODS

This single-center study employed a nonblinded randomized clinical trial design. Italian-speaking children (6-11 years) with mild-moderate asthma were eligible for participation. Participants were randomly paired 1:1 with a control group that received mHP (smartphone app) or an intervention group that received MyTEP (TEP plus a smartphone app). Patients were followed up for 3 months. Descriptive statistics, Least Square (LS) mean change and Generalized Linear Mixed model were used for analysis.

RESULTS

Fifty patients were enrolled. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) score improved in both MyTEP (p = 0.014) and mHP (p = 0.046) with the minimally clinically significant difference of ⩾0.5 points reached in 23% of MyTEP and in 16% of mHP. Changes in PAQLQ scores were significantly greater in MyTEP than in mHP (LS mean difference: 0.269 p = 0.05). PAQLQ score was: positively associated with MyTEP (p = 0.023) and study time (p = 0.002); and inversely associated with current passive smoke exposure (p = 0.003).

CONCLUSION

Despite the small sample size and short observation period, this study demonstrated that implementing a multidisciplinary TEP with an m-Health program results in gains in QoL of children with asthma.

Characteristics of Future Models of Integrated Outpatient Care

Replacement of fee-for-service with capitation arrangements, forces physicians and institutions to minimize health care costs, while maintaining high-quality care. In this report we described how patients and their families (or caregivers) can work with members of the medical care team to achieve these twin goals of maintaining-and perhaps improving-high-quality care and minimizing costs. We described how increased self-management enables patients and their families/caregivers to provide electronic patient-reported outcomes (i.e., symptoms, events) (ePROs), as frequently as the patient or the medical care team consider appropriate. These capabilities also allow ongoing assessments of physiological measurements/phenomena (mHealth). Remote surveillance of these communications allows longer intervals between (fewer) patient visits to the medical-care team, when this is appropriate, or earlier interventions, when it is appropriate. Systems are now available that alert medical care providers to situations when interventions might be needed.

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.