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8/18/2019 Educational Interventions for Asthma in Children
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Educational interventions for asthma in children (Review)
Wolf F, Guevara JP, Grum CM, Clark NM, Cates CJ
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 4http://www.thecochranelibrary.com
Educational interventions for asthma in children (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
http://www.thecochranelibrary.com/http://www.thecochranelibrary.com/
8/18/2019 Educational Interventions for Asthma in Children
2/187
T A B L E O F C O N T E N T S
1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
14CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Self-management vs. Usual Care, Outcome 1 Lung Function. . . . . . . . . . . 61
Analysis 1.2. Comparison 1 Self-management vs. Usual Care, Outcome 2 Exacerbations (% Patients). . . . . . 62
Analysis 1.3. Comparison 1 Self-management vs. Usual Care, Outcome 3 Exacerbations (Mean). . . . . . . . 62
Analysis 1.4. Comparison 1 Self-management vs. Usual Care, Outcome 4 School Absences (% Patients). . . . . . 63
Analysis 1.5. Comparison 1 Self-management vs. Usual Care, Outcome 5 School Absences (mean days). . . . . . 63
Analysis 1.6. Comparison 1 Self-management vs. Usual Care, Outcome 6 Restricted Activity (% Patients). . . . . 64
Analysis 1.7. Comparison 1 Self-management vs. Usual Care, Outcome 7 Restricted Activity (Mean Days). . . . . 65
Analysis 1.8. Comparison 1 Self-management vs. Usual Care, Outcome 8 Nights Nocturnal Asthma (% Patients). . 65
Analysis 1.9. Comparison 1 Self-management vs. Usual Care, Outcome 9 Nights Nocturnal Asthma. . . . . . . 66
Analysis 1.10. Comparison 1 Self-management vs. Usual Care, Outcome 10 Self-efficacy Scale. . . . . . . . . 66
Analysis 1.11. Comparison 1 Self-management vs. Usual Care, Outcome 11 Asthma Severity Score. . . . . . . 67
Analysis 1.12. Comparison 1 Self-management vs. Usual Care, Outcome 12 General Practitioner Visits. . . . . . 67 Analysis 1.13. Comparison 1 Self-management vs. Usual Care, Outcome 13 ED Visits (% Patients). . . . . . . 68
Analysis 1.14. Comparison 1 Self-management vs. Usual Care, Outcome 14 ED Visits (mean). . . . . . . . . 69
Analysis 1.15. Comparison 1 Self-management vs. Usual Care, Outcome 15 Hospitalization (% patients). . . . . 70
Analysis 1.16. Comparison 1 Self-management vs. Usual Care, Outcome 16 Hospitalizations (mean). . . . . . . 71
Analysis 2.1. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 1 Lung Function. 72
Analysis 2.2. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Analysis 2.3. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 2.4. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Analysis 2.5. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 5 School Absences
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74 Analysis 2.6. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 6 Restricted Activity
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Analysis 2.7. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Analysis 2.8. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis 2.9. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Analysis 2.10. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 10 Self-Efficacy
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
Analysis 2.11. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79
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Analysis 2.12. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 Analysis 2.13. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 13 ED Visit (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Analysis 2.14. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 14 ED Visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
Analysis 2.15. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
Analysis 2.16. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
Analysis 3.1. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 1 Lung Function. 85
Analysis 3.2. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
Analysis 3.3. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87 Analysis 3.4. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 4 School Absences
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Analysis 3.5. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 5 School Absences
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
Analysis 3.6. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 6 Restricted Activity
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Analysis 3.7. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90
Analysis 3.8. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 3.9. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Analysis 3.10. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 10 Self-Efficacy Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92
Analysis 3.11. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Analysis 3.12. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 12 General
Practitioner visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Analysis 3.13. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 13 ED Visit (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Analysis 3.14. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 14 ED Visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
Analysis 3.15. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 15 Hospitalization
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
Analysis 3.16. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98 Analysis 4.1. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 1 Lung Function. . . 99
Analysis 4.2. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Analysis 4.3. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 3 Exacerbations (Mean). 101
Analysis 4.4. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Analysis 4.5. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 5 School Absences (mean
days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
Analysis 4.6. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103
Analysis 4.7. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 7 Restricted Activity (mean
days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
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Analysis 4.8. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 8 Nights Nocturnal Asthma
(% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105 Analysis 4.9. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 9 Nights Nocturnal Asthma
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
Analysis 4.10. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 10 Self-Efficacy Scale. 106
Analysis 4.11. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Analysis 4.12. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
Analysis 4.13. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 13 ED Visit (% patients). 109
Analysis 4.14. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 14 ED Visits (mean). 110
Analysis 4.15. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
Analysis 4.16. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112 Analysis 5.1. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 1 Lung Function. . 113
Analysis 5.2. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Analysis 5.3. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Analysis 5.4. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Analysis 5.5. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 5 School Absences (mean
days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Analysis 5.6. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Analysis 5.7. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117 Analysis 5.8. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Analysis 5.9. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
Analysis 5.10. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 10 Self-Efficacy
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Analysis 5.11. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119
Analysis 5.12. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
Analysis 5.13. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 13 ED Visit (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Analysis 5.14. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 14 ED Visits (mean). 122 Analysis 5.15. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Analysis 5.16. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
Analysis 6.1. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 1 Lung Function. . . . . . 125
Analysis 6.2. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 2 Exacerbation (% patients). . 126
Analysis 6.3. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 3 Exacerbations (Mean). . . 127
Analysis 6.4. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 4 School Absences (% patients). 127
Analysis 6.5. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 5 School Absences (mean days). 128
Analysis 6.6. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 6 Restricted Activity (% patients). 129
Analysis 6.7. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 7 Restricted Activity (mean days). 130
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Analysis 6.8. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 8 Nights Nocturnal Asthma (%
Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Analysis 6.9. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 9 Nights Nocturnal Asthma
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Analysis 6.10. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 10 Self-Efficacy Scale. . . . 132
Analysis 6.11. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 11 Asthma Severity Scale. . 133
Analysis 6.12. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 12 General Practitioner visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Analysis 6.13. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 13 ED Visit (% patients). . 135
Analysis 6.14. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 14 ED Visits (mean). . . . 136
Analysis 6.15. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 15 Hospitalization (% patients). 137
Analysis 6.16. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 16 Hospitalizations (mean). . 138
Analysis 7.1. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 1 Lung
Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139
Analysis 7.2. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 2Exacerbation (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
Analysis 7.3. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 3
Exacerbations (Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141
Analysis 7.4. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 4 School
Absences (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Analysis 7.5. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 5 School
Absences (mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Analysis 7.6. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 6
Restricted Activity (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . 143
Analysis 7.7. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 7
Restricted Activity (mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . 144
Analysis 7.8. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 8 Nights
Nocturnal Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Analysis 7.9. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 9 Nights
Nocturnal Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Analysis 7.10. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 10 Self-
Efficacy Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Analysis 7.11. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 11
Asthma Severity Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Analysis 7.12. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 12
General Practitioner visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . 148
Analysis 7.13. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 13 ED
Visit (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Analysis 7.14. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 14 ED
Visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 150
Analysis 7.15. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 15Hospitalization (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
Analysis 7.16. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 16
Hospitalizations (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152
Analysis 8.1. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 1 Lung Function. 153
Analysis 8.2. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154
Analysis 8.3. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Analysis 8.4. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Analysis 8.5. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 5 School Absences
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
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Analysis 8.6. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Analysis 8.7. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
Analysis 8.8. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 158
Analysis 8.9. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Analysis 8.10. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 10 Self-Efficacy
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Analysis 8.11. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 160
Analysis 8.12. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Analysis 8.13. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 13 ED Visit (%patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 162
Analysis 8.14. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 14 ED Visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
Analysis 8.15. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
Analysis 8.16. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Analysis 9.1. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 1 Lung Function. . . . 166
Analysis 9.2. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 2 Exacerbation (% patients). 167
Analysis 9.3. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 3 Exacerbations (Mean). 168
Analysis 9.4. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Analysis 9.5. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 5 School Absences (meandays). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Analysis 9.6. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 170
Analysis 9.7. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 7 Restricted Activity (mean
days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
Analysis 9.8. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 8 Nights Nocturnal Asthma (%
Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Analysis 9.9. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 9 Nights Nocturnal Asthma
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Analysis 9.10. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 10 Self-Efficacy Scale. . 173
Analysis 9.11. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 11 Asthma Severity Scale. 174
Analysis 9.12. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 12 General Practitioner visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Analysis 9.13. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 13 ED Visit (% patients). 176
Analysis 9.14. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 14 ED Visits (mean). . 177
Analysis 9.15. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
Analysis 9.16. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
179 WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
179HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
180INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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[Intervention Review]
Educational interventions for asthma in children
Fredric Wolf 1, James P Guevara 2, Cyril M Grum3, Noreen M Clark 4, Christopher J Cates5
1Department of Medical Education & Biomedical Informatics, University of Washington School of Medicine, Seattle, WA, USA.2Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. 3University of Michigan, Ann
Arbor, MI 48109-0368, USA. 4 School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA. 5 Community
Health Sciences, St George’s, University of London, London, UK
Contact address: Fredric Wolf, Department of Medical Education & Biomedical Informatics, University of Washington School of
Medicine, E-312 Health Sciences, Box 357240, Seattle, WA, 98195-7240, USA. [email protected].
Editorial group: Cochrane Airways Group.Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.
Review content assessed as up-to-date: 31 July 2002.
Citation: Wolf F, Guevara JP, Grum CM, Clark NM, Cates CJ. Educational interventions for asthma in children. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD000326. DOI: 10.1002/14651858.CD000326.
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
A B S T R A C T
Background
Self-management education programs have been developed for children with asthma, but it is unclear whether such programs improveoutcomes.
Objectives
To determine the efficacy of asthma self-management education on health outcomes in children.
Search strategy
Systematic search of the Cochrane Airways Group’s Special Register of Controlled Trials and PSYCHLIT, and hand searches of the
reference lists of relevant review articles.
Selection criteria
Randomized and controlled clinical trials of asthma self-management education programs in children and adolescents aged 2 to 18
years.
Data collection and analysis
All studies were assessed independently by two reviewers. Disagreements were settled by consensus. Study authors were contacted for
missing data or to verify methods. Subgroup analyses examined the impact of type and intensity of educational intervention, self-
management strategy, trial type, asthma severity, adequacy of follow-up, and study quality.
Main results
Of 45 trials identified, 32 studies involving 3706 patients were eligible. Asthma education programs were associated with moderate
improvement in measures of airflow (standardized mean difference [SMD] 0.50, 95% confidence interval [CI] 0.25 to 0.75) and self-
efficacy scales (SMD 0.36, 95% CI 0.15 to 0.57). Education programs were associated with modest reductions in days of school absence
(SMD -0.14, 95% CI -0.23 to -0.04), days of restricted activity (SMD -0.29, 95% CI -0.49 to -0.08), and emergency room visits
(SMD -0.21, 95% CI -0.33 to -0.09). There was a reduction in nights disturbed by asthma when pooled using a fixed-effects but
not a random-effects model. Effects of education were greater for most outcomes in moderate-severe, compared with mild-moderate
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asthma, and among studies employing peak flow versus symptom-based strategies. Effects were evident within the first six months, but
for measures of morbidity and health care utilization, were more evident by 12 months.
Authors’ conclusions
Asthma self-management education programs in children improve a wide range of measures of outcome. Self-management education
directed to prevention and management of attacks should be incorporated into routine asthma care. Conclusions about the relative
effectiveness of the various components are limited by the lack of direct comparisons. Future trials of asthma education programs should
focus on morbidity and functional status outcomes, including quality of life, and involve direct comparisons of the various components
of interventions.
P L A I N L A N G U A G E S U M M A R Y
Educational interventions for asthma in children
Learning self-management strategies related to asthma prevention or attack management can help improve children’s lung function
and feelings of self-control, as well as reduce school absences and days of restricted activity and decrease emergency room utilization.
There were no differences in the risk or frequency of hospitalizations between usual care and care supplemented with self-management
education. These types of more rare andseriousevents maybe beyondthe ability of educationto influence. While more research is needed
to make direct comparisons between different types of interventions, the limited evidence currently available suggests that in general,
self-management education works well for persons with moderate-to-severe asthma as well as for those with mild-to-moderate asthma.
Peak flow-based educational strategies generally show greater effects than symptom-based strategies. Beneficial effects on measures of
physiological function were apparent within six months, but benefits did not become fully apparent on measures of morbidity or health
care utilization until 7 to 12 months following enrolment in an educational program.
B A C K G R O U N D
Asthma is the most prevalent chronic pulmonary disorder afflict-
ing children (Shamssain 1999; Habbick 1999; McFadden 1992).
The prevalence of diagnosed asthma has been growing over the
past 20 years (Magnus 1997; Senthilselvan 1998). Of greater con-
cern is that both asthma morbidity and mortality appear to be
increasing (Ng 1999). This increase is seen particularly in lower
socioeconomic groups and in minority populations (Cunningham
1996). Children with asthma suffer a high number of school ab-
sences (Doull 1996), endure a high and increasing rate of disabil-ity (Perrin 1999; Newacheck 2000), and incur substantial health
care costs (Lozano 1997).
Self-management educational programs for children with asthma
have been developed in recent years in recognition of the need to
improve health care practices, reduce morbidity, and lower costs of
care(Hurd 1992; Clark 1989). To be successful, programs must be
basedon a soundtheoretical understandingof behavior change and
employ self-management strategies designed to improve knowl-
edge, skills, and feelings of self-control (Clark 1994). A number
of educational programs have been the subject of rigorous eval-
uations (Lewis 1984; Wilson-Pessano 1985; Clark 1986a ; Clark
1986b; Evans 1987; Creer 1976; Hindi-Alexander 1984; Parcel
1980). These programs incorporate a variety of educational strate-
gies, are designed for different clinical settings, and are targeted to
different patient groups.
While it has become increasingly clear that limited asthma edu-
cation involving only information transfer is ineffective (Gibson
1999), the effectiveness of self-management education programs
in children with asthma is unclear. In adults with asthma, the use
of a self-management education program that includes self-mon-
itoring, regular medical review, and an asthma action plan doesappear to improve measures of morbidity and reduce health care
utilization (Gibson 1998). Inchildren,however, a publishedmeta-
analysis of 11 self-management teaching programs concluded that
asthma self-management programs do not reduce morbidity or
decrease health care utilization (Bernard-Bonnin 1995). This re-
searchsynthesiswas limited to trialspublished prior to 1992, and a
large number of studies have been published subsequently. There-
fore, a new review that incorporates more recent studies may help
to clarify the uncertainty regarding the effectiveness of asthma ed-
ucation in children.
The purpose of this study was to systematically review the research
literature on the efficacy of self-management educational inter-
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ventions in modifying health outcomes for children with asthma.
We hypothesized that self-management programs would be asso-ciated with improvements in measures of lung function, decreases
in measures of morbidity, and lead to reductions in health care
utilization.
O B J E C T I V E S
The specific study objectives were two-fold:
(1) To determine the effectiveness of self-management education
programs on measures of physiological function, morbidity and
functional status, self-perception, and health care utilization in
children and adolescents with asthma.
(2) To determine the characteristics of self-management educa-
tion programs and trials that are associated with improvements in
health outcomes in children and adolescents with asthma.
M E T H O D S
Criteria for considering studies for this review
Types of studiesRandomized controlled trials (RCTs) and controlled clinical trials
(CCTs) were considered in this systematic review.
Types of participants
Studies of children and adolescents with asthma from two to 18
years of age were included.
Types of interventions
Any educational intervention targeted to children or adolescents
(and/or their parents) designed to teach one or more self-manage-
ment strategies related to prevention, attack management, or socialskills using any instructional strategy or combination of strategies
(problem solving, role-playing, videotapes, computer assisted in-
struction, booklets, etc.) presented either individually or in group
sessions was included in the review.
Types of outcome measures
Categories of outcomes examined for this review are based on a
consensus of clinically relevant outcomes from the Asthma Out-
comes Conference and adapted from Clark and Starr-Schneid-
kraut’s model of patient management (Clark 1994). These out-
come categories are (1) physiological function, (2) morbidity and
functional status, (3) self-perception measures, and (4) health care
utilization. Two additional outcome categories from the confer-ence, adverse effects of medications and quality of life, are not in-
cluded here because they were not reported in any eligible trial. A
full listing of more specific outcomes within each category is pro-
vided below. We have selected one outcome from each category as
primary outcomes. These decisions were typically made because
the most data were available for these outcomes, both in terms of
the number of studies and sample sizes for the individual studies
and because these outcomes were considered the most salient in
each category. The primary outcomes are a combined measure of
lung function (1c), days of school absence (2b), self-efficacy (3b),
and emergency department visits (4b).
(1) Physiological function
(a) forced expiratory volume in 1 second (FEV1): exact numberor percent of predicted
(b) peak expiratory flow rate (PEF): exact number or percent of
predicted
(c) a combined measure of lung function: defined as either FEV1
or PEF
(2) Morbidity and functional status
(a) exacerbations: defined as asthma attacks or episodes of asthma
(b) days of school absence: defined as days of school non-atten-
dance due to asthma or other causes
(c) days of restricted activity: defined as days of asthma symptoms
or days of activity restriction
(d) nights disturbed by asthma: defined as nights of sleep inter-
ruption due to asthma or nights with asthma symptoms(3) Self-perception measures
(a)asthma severity: defined as subjective measures of asthmasever-
ity and includes asthma symptom or severity scores
(b) self-efficacy: “Self-efficacy is the belief in one’s capabilities to
organize and execute the sources of action required to manage
prospective situations” (Bandura 1996). A strong sense of personal
efficacy has been shown to be related to a variety of outcomes,
including better health, higher achievement, and more social inte-
gration (Schwarzer 1995). For purposes of this systematic review,
we have included measures of coping scores and health locus of
control scales.
(4) Health care utilization
(a) general practitioner visits: defined as routine and urgent am-bulatory clinic visits to a general practitioner, family physician,
pediatrician, or other related health care provider
(b) emergency department visits: defined as urgent visits to a hos-
pital emergency department
(c) hospitalizations: defined as any inpatient hospital stay
If outcomes were reported separately by time, the outcome cor-
responding to six months or later post-enrollment was selected.
Regarding measures of lung function, if outcomes were reported
at multiple times during the day, the morning measurement was
selected.
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Search methods for identification of studies
Electronic searches
We identified studies from the Cochrane Airways Group’s tri-
als register comprised of references from MEDLINE, EMBASE,
CINAHL, and hand searched airways-related journals. This
database was searched using the following terms:
asthma OR wheez* AND education* OR self management OR
self-management.
The Airways Group databases combine EMBASE, CINAHL and
MEDLINE records. We identified the EMBASE records through
keyword or text word (in title or abstract fields) searches on
asthma* or on the term wheez*. In Medline and CINAHL, the
text word searches (in title or abstract fields) were made on
terms asthma* or wheez*. The MeSH searches in MEDLINE and
CINAHL were made on the following two MeSH terms: respira-
tory sounds and asthma. The MEDLINE records cover the period
1966 to 1998, EMBASE records span 1980 to 1998, and the ear-
liest CINAHL records date from 1982. The main Airways Group
databases include the records downloaded from the three elec-
tronic systems. We searched the main Airways Group databases
using the following terms: placebo* OR trial* OR random* OR
double-blind OR double blind OR single-blind OR single blind
OR controlled study OR comparative study) and we exported
those records to a separate RCT register.
In addition, we identified asthma-related studies from PSYCH-
LIT using the Cochrane Schizophrenia Group’s search strategy to
identify trials in that behavioral sciences database. We searched
this database using the following terms: “asthma* OR asthma- in
DE OR wheez* OR [(bronchial*) near (hyper-reactiv* or hyper-
reactiv*)] AND randomi* OR [(singl* OR doubl* OR trebl* OR
tripl*) near (blind* OR mask*)] OR crossover”.
Searching other resources
Finally, we hand searched the reference lists from relevant re-
views that had been identified (Clark 1993; Clark 1994; Bernard-
Bonnin 1995).
Data collection and analysis
Selection of studies
One reviewer screened the title and abstract of each citation that
we identified through the search strategy to determine possible
eligibility for inclusion. We then obtained the complete article
of each citation identified as eligible or possibly eligible. At least
two investigators (FW, CG, JG, MR) independently assessed each
article to determine study eligibility. Disagreement was settled by
consensus.
Studies were included if (a) they were published randomized con-
trolled trials (RCTs) or controlled clinical trials (CCTs); (b) they includedchildren or adolescents ages 2 to 18 years old; (c)they had
an educational intervention designed to teach one or more self-
management strategies related to prevention, attack management,
or social skills; (d) they included outcomes on pulmonary func-
tion tests, morbidity, functional status, or health care utilization.
We excluded studies if they included participants with pulmonary
diagnoses other than asthma, lacked suitable control populations
for comparison, used non-standard educational interventions, or
did not report on any outcomes of interest.
Data extraction and management
We abstracted all eligible studies onto preprinted data collection
forms. Information on randomization methods, participants, fol-
low-up procedures, nature of educational interventions, and out-
comes was collected. We also contacted, by mail, authors of all
eligible studies to verifythe accuracy of published data or to obtain
missing data. Twenty authors (63%) provided additional informa-
tion on allocation concealment procedures or missing information
that was then incorporated into this review.
Assessment of risk of bias in included studies
We based the methodological quality of included trials primarily
on an assessment of allocation concealment. Allocation conceal-ment refers to whether trials sufficiently concealed group alloca-
tion prior to randomization andwas measured using theCochrane
approach (Clarke 1999):
• Category A: Adequate concealment using formal
randomization procedures (e.g. sealed envelopes or random
numbers).
• Category B: Uncertain or unclear concealment.
• Category C: Clearly inadequate concealment using non-
random procedures (e.g. alternation).
Methodological quality of included trials was also based on assess-
ments of studies indicating whether performance bias, exclusion
bias, or detection bias were present. Performance bias refers to
whether differences in care may have existed between treatment
and control groups apart from the intervention and was measured
as present or absent. Exclusion bias refers to whether significant
differences in withdrawal existed between treatment and control
groups (generally at least 10%) or whether withdrawal rates in the
combined group were large (generally greater than 20%) and was
measured as present or absent. Detection bias refers to whether
differences in outcome assessment may have existed between treat-
ment and control groups and was measured as present or absent.
Dealing with missing data
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In addition, if continuous outcomes were reported without stan-
dard deviations, we imputed pooled standard deviations from thefollowing generalized formula for the t-statistic (Rosenthal 1991):
t = [M1 - M2 / S] X [ 1/ sq root (1/n1 + 1/n2 ) ]
Where t refers to the t-statistic, M refers to the mean of the treat-
ment and control groups, S refers to the pooled standard devia-
tion, and n refers to the sample size of the treatment and control
groups. If the t-statistic was not reported in a given paper, the t-
statistic corresponding to the exact p-value with the appropriate
degrees of freedom was used. If the t-statistic and exact p-value
were not reported in a given paper, the t-statistic corresponding
to p = 0.05 (for a reported p 0.05) with the appropriate degrees of freedom was used.
Data synthesis
For continuous outcomes, we used the standardized weighted
mean difference (SMD) to estimate a pooled effectsize, since in all
cases, outcomes were reported in different units or scales. We re-
ported the pooled effect sizes with 95% confidence intervals (CI).
We used both a fixed-effects model (Hasselblad 1995) and a ran-
dom-effects model (DerSimonian 1986) to pool the data, since
there does not appear to be general consensus as to which method
is superior. In general, the random-effects method is a more con-
servative approach than the fixed-effects method and results in
larger CIs.
For consistency and simplicity, We reported the SMDs based on
the fixed-effects model in the text of the review and in the table of
comparisons. Where effect sizes differed statistically, we reported
the pooled effect size from the random-effects model in footnotes
to the tables and in the text of the review. For dichotomous out-
comes, we used the odds ratio (OR) with 95% CIs to estimate
a pooled effect size (Greenland 1985). We also used both fixed-
effects and random-effects models to pool data on dichotomous
outcomes. We calculated the number needed to treat (NNT) to
prevent an adverse event for all statistically significant dichoto-
mous outcomes ( Altman 1998).
Where necessary, we computed standard deviations from standard
errorsof the mean or confidence intervals using standard statistical
formulas (Hedges 1985; Wolf 1986).
Subgroup analysis and investigation of heterogeneity
We performed subgroup analyses by stratifying studies on key pa-
tient-level, study quality, and program variables in order to esti-
mate the magnitude of these effects.
(1) Patient characteristics: Subgroup analysis was performed on
the effect of educational interventions by asthma severity. Asthma
severity (mild-moderate vs. moderate-severe) was determined by
study self-report, examination of mean FEV1 or PEFR baseline
measurements, or chronicity of asthmasymptomsat baseline ( ATS
1991; NAEP 1997). Patients were determined to have severe
asthma if they had mean FEV1 < 0.50 of predicted, mean PEFR
< 0.60 of predicted, or reported daily asthma symptoms. We cat-egorized studies as moderate to severe if asthmatics with severe
asthma were enrolled in the study population and mild-moderate
otherwise.
(2) Educational program characteristics: Subgroup analyses were
performed on the effect of educational interventions by (a) inter-
vention type (individual vs. group); (b) intensity of intervention
(single vs. multiple sessions); (c) time since enrolment (one to six
months vs. seven to twelve months vs. > twelve months); and (d)
self-management strategy (peakflow-based vs. symptom-based) to
estimate the effect of various intervention characteristics.
(3) Study quality characteristics: Subgroup analyses were per-
formed on the effect of educational interventions by (1) trial type(RCT vs. CCT); (2) allocation concealment (adequate vs. unclear
vs. inadequate); and (3) adequacy of follow-up (adequate vs. in-
adequate) to estimate the effects of study characteristics.
R E S U L T S
Description of studies
See: Characteristicsof included studies; Characteristicsof excluded
studies.
Results of the search
The search identified 318 titles and abstracts of potentially eligi-
ble studies. After preliminary review, a total of 45 randomized or
controlled clinical trials were identified from the literature search
and review of bibliographies as possibly eligible for inclusion. Af-
ter review of the full text of these studies, 13 were excluded for
the following reasons: absence of a suitable control population (N
= 2), inclusion of children less than two years old (N = 2), use of
non-standard or information only educational interventions (N =
4), inclusion of children with conditions other than asthma (N =
1), and no outcomes of interest (N = 4).
Included studies
A total of 32 trials involving 3706 children and adolescents with
asthma were selected for inclusion (see Characteristics of included
studies). Twenty-six (81%) of these trials were RCTs, and the re-
mainder were non-randomized CCTs. The trials varied in size
(mean 116, range 20 to 451 participants), severity of asthma
among participants (15 with moderate-to-severe asthma, four with
mild-to-moderate asthma, and 13 with unclear severity), and the
proportion of participants with complete follow-up (range 43
to 100%). Fifteen of the trials reported inclusion of adolescents
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(age 13 years old and above), while twelve reported inclusion of
preschool age children (ages two to five years old). The self-man-agement educational programs employed by the trials differed by
type of educational session (15 employing group sessions, 14 em-
ploying individual sessions, three employing both), intensity (five
employing only a single session, two employing two sessions, 25
employing three or more sessions), self-management strategy (13
employing peak flow-based strategies, 19 employing symptom-
based strategies), and length of the intervention (mean 3.8, range
one to twelve months). While thirteen trials incorporated social
skills development into their educational strategy, all trials focused
on asthma prevention measures (e.g. identification and avoidance
of asthma triggers) and/or attack management plans (e.g. use of
an asthma action plan).
Outcomes assessed
(1) Measures of physiological function:
Forced expiratory volume in 1 second (FEV1) (N = 2)
Peak expiratory flow rate (PEF) (N = 4)
Combined measure of lung function (N = 7)
(2) Measures of morbidity and functional status:
Proportion with exacerbations (N = 2)
Exacerbations (N = 5)
Proportion with School Absences (N = 1)
Days of School absence (N = 17)
Proportion with restricted activity (N = 1)
Days of restricted activity (N = 6)Proportion with Nights disturbed by asthma (N = 1)
Nights disturbed by asthma (N = 3)
(3) Measures of self-perception:
Self-efficacy scales (N = 10)
Asthma severity scores (N = 5)
(4) Measures of health care utilization:
Physician visits (N = 10)
Proportion with ED visits (N = 6)
ED visits (N = 14)
Proportion with hospitalization (N = 4)
Hospitalizations (N = 9)
Risk of bias in included studies
The methodological quality of the studies varied. Twelve trials
were felt to have adequate concealment of allocation of patients
to intervention or control groups, while six trials had clearly in-
adequate or no concealment methods (eg allocation based on al-
ternating sites or sequential assignment). In fourteen trials, it was
not possible to determine the method of allocation concealment
based on published methods. Six studies had differences in the
care provided to treatment and control groups apart from the in-
tervention. Eight studies had systematic differences in withdrawal
between treatment and control groups. There did not appear to
be systematic differences in the assessment of outcomes between
treatment and control groups in any of the studies.
Effects of interventions
AUTHOR VERIFICATION
An attempt was made to contact corresponding authors of all
studies in order to verify allocation concealment procedures and
to obtain missing data. A total of twentyauthors (63%) responded
to requests for additional information.
OUTCOMES: SELF-MANAGEMENT VERSUS
USUAL CARE (N = 32 trials)
(1) PHYSIOLOGICAL FUNCTION
Four trials involving 258 patients reported complete data on the
effect of self-management education programs on measures of
physiological function. There was a significant improvement on
a combined measure of lung function (SMD 0.50, 95% CI 0.25
to 0.75) as well as on individual measures of FEV1 (SMD 0.46,
95% CI 0.08 to 0.84) and PEF (SMD 0.53, 95% CI 0.19 to
0.86) associated with self-management education programs when
the trials were pooled. Three additional trials involving 192 pa-tients, which could not be pooled due to missing data, reported
no significant effect of education on measures of lung function
(Hughes 1991; Dahl 1990; Szczepanski 1996). The pooled esti-
mates obtained by the random-effects model were consistent with
those from the fixed-effects analyses. There was no significant het-
erogeneity among the trials reporting on the combined measure of
lung function (Chi-square = 2.44; p = 0.49) and PEF (Chi-square
= 2.38; p = 0.3).
(2) MORBIDITY AND FUNCTIONAL STATUS
Eighteen trials involving 1649 patients reported complete data on
the effect of self-management education programs on measures of morbidity and functional status. There was a small but significant
reduction in the days of school absence (SMD -0.14, 95% CI -
0.23 to -0.04) and days of restricted activity (SMD -0.29, 95% CI
-0.49 to -0.08) when the 16 and six trials respectively reporting on
these outcomes were pooled by either the fixed effect or random-
effects model. One additional trial involving 84 patients which
could not be pooled, due to missing data, reported statistically sig-
nificantly less school absenteeism (p < 0.05) among the education
group than the control group (Szczepanski 1996). There was a
significant reduction in the nights disturbed by asthma when the
three trials reporting on this outcome were pooled by the fixed-
effect model (SMD -0.34, 95% CI -0.62 to -0.05) but not by
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the random-effects model (SMD -0.39, 95% CI -1.07 to 0.28).
There was no significant reduction in the number of exacerbations(SMD -0.21, 95% CI -0.43 to 0.01) when the five trials reporting
on this outcome were pooled. In addition, there was no significant
reduction in the proportion of patients experiencing an exacer-
bation (OR 1.43, 95% CI 0.94 to 2.18), day of school absence
(OR 0.78, 95% CI 0.36 to 1.66), day of restricted activity (OR
2.51, 95% CI 0.61 to 10.29), or night disturbed by asthma (OR
0.65, 95% CI 0.29 to 1.44). However, few studies reported on
dichotomous morbidity outcomes. There was significant hetero-
geneity among the trials pooled for nights disturbed by asthma
(Chi-square = 11.19, p = 0.004), but not among trials pooled for
exacerbations, days of school absence, or days of restricted activity.
(3) SELF PERCEPTION
Nine trials involving 522 patients reported complete data on the
effect of self-management educationprogramson measures of self-
perception. There was improvement on measures of self-efficacy
(SMD 0.36, 95% CI 0.15 to 0.57) when the six trials reporting
this outcome were pooled using the fixed effect or random effects
model. Four additional trials that could not be pooled, due to
missing data, reported that education was beneficial on scales of
self-efficacy in three studies involving 313 patients (Evans 1987;
Kubly 1984; Szczepanski 1996) but not in one study involving
43 patients (Rakos 1985). There was no significant reduction by
education on asthma severity scores (SMD -0.15, 95% CI -0.43
to 0.12) when the four trials were pooled. One additional trial
involving 84 patients which could not be pooled due to missing
data reported a decrease in asthma severity scores in the education
plus follow-up group (p < 0.05) but not in the education only
or control groups (Szczepanski 1996). There was no significant
heterogeneity among the trials pooled for self-efficacy scales but
there was heterogeneity among trials pooled for asthma severity
scores (Chi-square = 6.72, p = 0.08).
(4) HEALTH CARE UTILIZATION
Eighteen trials involving 1899 patients reported complete data on
the effect of self-management education programs on measures of health care utilization. There was a significant reduction in the
number of emergency department (ED) visits (SMD -0.21, 95%
CI -0.33 to -0.09) associated with education when the 12 tri-
als reporting complete data on this outcome were pooled using
both fixed effect and random effects models. Two additional tri-
als which could not be pooled due to missing data reported no
benefit of education in one study involving 43 patients (Rakos
1985) but a benefit of education in one study involving 84 pa-
tients (Szczepanski 1996). There was no significant reduction in
the number of general practitioner visits (SMD -0.15, 95% CI -
0.31 to 0.01) when the six trials reporting complete data on this
outcome were pooled. Four additional trials that could not be
pooled due to missing data reported a significant benefit of ed-
ucation on general practitioner visits in one study involving 78patients (Colland 1993) but not in three studies involving 141
patients (McNabb 1985; Rakos 1985; Szczepanski 1996). There
was no significant reduction in the number of hospitalizations
associated with education (SMD -0.08, 95% CI -0.21 to 0.05)
when the eight trials reporting complete data on this outcome were
pooled. One additional trial involving 84 patients which could not
be pooled due to missing data reported no significant reduction
in hospitalizations associated with education (Szczepanski 1996).
Moreover, there was no significant reduction in the proportion of
patients who experienced an ED visit (OR 1.30, 95% CI 0.93
to 1.84) or a hospitalization (OR 1.00, 95% CI 0.70 to 1.42)
when the six trials and four trials respectively reporting data on
these outcomes were pooled. There was significant heterogeneity among the trials pooled for hospitalizations (Chi-square = 13.03,
p = 0.07) and ED visits (Chi-square = 19.68, p = 0.05) but not
for general practitioner visits.
SUBGROUP ANALYSES
OUTCOMES: SELF-MANAGEMENT VERSUS USUAL
CARE BY TIME SINCE ENROLLMENT (N = 32 TRIALS)
When self-management education programs were examined by
time since enrollment, effects of education versus usual care on
measures of physiological function were evident within the firstsix months of enrollment ((SMD 0.50, 95% CI 0.25 to 0.75).
However, effects on measures of morbidity [exacerbations (SMD
-0.28, 95% CI -0.53 to -0.03), days of school absence (SMD -
0.16, 95% CI -0.29 to -0.04), days of restricted activity (SMD
-0.26, 95% CI -0.48 to -0.04), and nights disturbed by asthma
(SMD -0.86, 95% CI -1.38 to -0.35)], self-perception [self-effi-
cacy scales (SMD 0.54, 95% CI 0.28 to 0.80)], and health care
utilization [ED visits (SMD -0.19, 95% CI -0.32 to -0.05), and
hospitalizations (SMD -0.26, 95% CI -0.44 to -0.08)] became
more evident at seven to twelvemonths post-enrollment.Evidence
for effectiveness from longer term follow-up was sparse.
OUTCOMES: SELF-MANAGEMENT VERSUS USUAL
CARE BY SELF-MANAGEMENT STRATEGY (N = 32
TRIALS)
When comparing the effectiveness of self-management strategies,
studies that employed peak flow-based strategies and studies that
employed symptom-based strategies were similar with respect to
improvements in self efficacy scales and reductions in ED visits.
However, studies that employed peak flow based strategies demon-
strated greater improvement in a measure of physiological func-
tion [combined lung function (SMD 0.50, 95% CI 0.25 to 0.75)]
and greater reductions in measures of morbidity [days of school
absence (SMD -0.22, 95% CI -0.40 to -0.04), days of restricted
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activity (SMD -0.68,95% CI -1.13 to -0.23), and nightsdisturbed
by asthma (SMD -0.72, 95% CI -1.09 to -0.36)], and health careutilization [general practitioner visits (SMD -0.24, 95% CI -0.55
to 0.06) and risk of hospitalization (OR 0.41, 95% CI 0.21 to
0.81; NNT 9.0, 95% CI 6.4 to 30.5)] than studies that employed
symptom basedstrategiesafter stratification and pooling. No stud-
ies reported on direct comparisons of symptom based versus peak
flow based strategies.
OUTCOMES: SELF-MANAGEMENT VERSUS USUAL
CARE BY INTERVENTION TYPE (N = 32 TRIALS)
When comparing studies by the type of intervention, both indi-
vidual and group interventions demonstrated similar beneficial ef-
fects on a combined measure of lung function, self-efficacy scales,
and ED visits when compared to usual care. The reductions in
morbidity measures [days of school absence (SMD -0.20, 95% CI
-0.35 to -0.04), days of restricted activity (SMD -0.68, 95% CI -
1.13 to -0.23), nights disturbed by asthma (SMD -0.86, 95% CI
-1.38 to -0.35)] and a measure of health care utilization [general
practitioner visits (SMD -0.29, 95% CI -0.56 to -0.03)] were gen-
erally stronger among trials pooled for individual interventions
as opposed to group interventions. There was a reduction in a
measure of health care utilization [hospitalizations (SMD -0.22,
95% CI -0.44 to -0.01)] that was stronger among trials pooled for
group interventions as opposed to individual interventions. How-
ever, there were no trials reporting on direct comparisons of indi-
vidual versus group interventions. Two studies employed a com-
bination of individual and group interventions (Fireman 1981;
Shields 1990), and the results from these two studies were con-
sistent with those obtained from the other studies. Overall, the
number of trials available for individual and group comparisons
of most outcomes were relatively sparse (eg between one and three
trials).
OUTCOMES: SELF-MANAGEMENT VERSUS USUAL
CARE BY INTERVENTION INTENSITY (N = 32 TRIALS)
When the intensity of the programs were compared, both single
and multiple session interventions were associated with similarimprovements in measures of combined lung function, exacerba-
tions, and days of school absence. However, studies employing
single sessions were associated with greater reductions in certain
morbidity measures [days of restricted activity (SMD -0.61, 95%
CI -1.12 to -0.11) and nights disturbed by asthma (SMD -0.86,
95% CI -1.38 to -0.35)] than studies employing multiple sessions.
On the other hand, studies employing multiple sessions were as-
sociated with improvement in a measure of self-perception [self-
efficacy scales (SMD 0.36, 95% CI 0.15 to 0.57)] and reductions
in measures of health care utilization [general practitioner visits
(SMD -0.17, 95% CI -0.35 to 0.00) and ED visits (SMD -0.21,
95% CI -0.33 to -0.09)] that were not seen in studies employing
single sessions. There were no direct comparisons of single ses-
sions versus multiple sessions for any reported outcome, and mostoutcomes were sparse after stratification by session number.
OUTCOMES: SELF-MANAGEMENT VS. USUAL CARE BY
TRIAL TYPE (N = 32 TRIALS)
When comparing studies by trial type, both RCTs and CCTs were
similar with regard to improvements in combined lung function
and self-efficacy scales and reductions in days of school absence.
CCTs were generally associated with greater reductions in certain
morbidity measures [exacerbations (SMD -0.47, 95% CI -0.90 to
-0.04), days of restricted activity (SMD -0.58, 95% CI -1.00 to -
0.15), and nightsdisturbed by asthma (SMD -0.86, 95% CI -1.38
to -0.35)] anda measure of healthcare utilization [hospitalizations(SMD -0.41, 95% CI -0.90 to 0.09)] than RCTs when studies
were stratified by trial type and pooled. Only for a single measure
of health care utilization [EDvisits (SMD -0.23,95% CI -0.36 to -
0.09)] were RCTs generally stronger than CCTs after stratification
and pooling of trials.
OUTCOMES: SELF-MANAGEMENT VS. USUAL CARE BY
ADEQUACY OF ALLOCATION CONCEALMENT (N = 32
TRIALS)
When studies were compared by the adequacy of allocation con-
cealment, studies judged to have both adequate and inadequate
concealment demonstrated similar improvements in combinedlung function and self-efficacy scales, and reductions in days of
school absence and ED visits. However, studies with inadequate
concealment generally had greater reductions in certain measures
of morbidity [exacerbations (SMD -0.47, 95% CI -0.90 to -0.04),
days of restricted activity (SMD -0.58,95% CI -1.00 to -0.15)and
nights disturbed by asthma (SMD -0.86, 95% CI -1.38 to -0.35)]
and a measure of health care utilization [hospitalization (SMD -
0.41, 95% CI -0.90 to 0.09)] than studies with adequate conceal-
ment when studies were stratified by the adequacy of allocation
concealment and pooled. Studies judged to have unclear conceal-
ment performedbetterthan studies in either of the other two cate-
gories for some outcome measures [combine lung function (SMD
1.24, 95% CI 0.26 to 2.22), general practitioner visits (SMD -0.72, 95% CI -1.45 to 0.01), and ED visits (SMD -0.29, 95%
CI -0.47 to -0.11)] and worse than studies in either of the other
two categories for other measures [days of school absence (SMD
-0.09, 95% CI -0.22 to 0.04), days of restricted activity (SMD -
0.12, 95% CI -0.47 to 0.24), nights disturbed by asthma (SMD
0.24, 95% CI -0.21 to 0.68), self-efficacy scales (SMD 0.23, 95%
CI -0.09 to 0.54), and hospitalizations (SMD -0.01, 95% CI -
0.16 to 0.15)]. Studies judged to have adequate concealment had
a greater decrease in a single measure of health care utilization [the
risk of hospitalization (OR 0.41, 95% CI 0.21 to 0.81; NNT 9.0,
95% CI 6.4 to 30.5)]. Generally, most outcomes were sparse after
stratification by the adequacy of allocation concealment.
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OUTCOMES: SELF-MANAGEMENT VERSUS USUAL
CARE BY ADEQUACY OF FOLLOW-UP (N = 32 TRIALS)
When studies were compared by the adequacy of follow-up of
participants, studies judged to have adequate and inadequate fol-
low-up of participants had similar reductions in days of school
absence, days of restricted activity, self-efficacy scales, and ED vis-
its. However, studies judged to have adequate follow-up were as-
sociated with improvements in a measure of physiological func-
tioning [combined lung function (SMD 0.50, 95% CI 0.25 to
0.75)] and a measure of morbidity [nights disturbed by asthma
(SMD -0.34, 95% CI -0.62 to -0.05)] and had greater reductions
in two measures of health care utilization [risk of hospitalization
(OR 0.38, 95% CI 0.20 to 0.73; NNT 7.8, 95% CI 5.8 to 19.6)
and hospitalizations (SMD -0.25, 95% CI -0.42 to -0.07)] than
studies judged to have inadequate follow-up after stratification by
adequacy of follow-up and pooling of trials. Studies judged to
have inadequate follow-up of participants had greater reduction
in a measure of health care utilization [general practitioner visits
(SMD -0.55, 95% CI -0.99 to -0.11)] than studies judged to have
adequate follow-up after stratification and pooling. Overall, few
studies were judged to have inadequate follow-up and this created
outcomes with sparse numbers.
OUTCOMES: SELF-MANAGEMENT VERSUS USUAL
CARE BY ASTHMA SEVERITY (N = 32 TRIALS)
When studies were compared by the degree of asthma severity
of participants, trials that enrolled subjects with mild to moder-ate and moderate to severe asthma had similar improvements in
a measure of combined lung function and similar reductions in
exacerbations. However, studies with participants who had mod-
erate to severe asthma were associated with greater reductions in
measures of morbidity [days of school absence (SMD -0.24, 95%
CI -0.37 to -0.10), days of restricted activity (SMD-0.64, 95% CI
-1.02 to -0.25), nights disturbed by asthma (SMD -0.72, 95% CI
-1.09 to -0.36)] and health care utilization [general practitioner
visits (SMD -0.48, 95% CI -0.82 to -0.15), ED visits (SMD -
0.34, 95% CI -0.52 to -0.16), and hospitalizations (SMD -0.35,
95% CI -0.60 to -0.09)] than studies with participants with mild
to moderate asthma. However, trials stratified by asthma severity
were sparse for most outcomes, and no trials reported on direct
comparisons of asthma severity for any outcome. For a number
of studies, it was not possible to determine the asthma severity of
the participants, and the results of outcomes for these studies were
similar to those obtained for studies with participants who had
mild to moderate asthma.
D I S C U S S I O N
In this systematic review of 32 trials involving 3706 pediatric pa-
tients, asthma education programs compared to usual care were
found to improve measures of physiological function and self-effi-
cacy; reduce days of school absence and days of restricted activity,decrease emergency department utilization, and perhaps reduce
nights disturbed by asthma. However, the effects of asthma educa-
tion on the average number of nights disturbed by asthma symp-
toms was only apparent when results were pooled using a fixed-
effects model but not when a more conservative random-effects
model was employed. In addition, it was almost inevitable that
there was significant statistical heterogeneity of results for some
outcome measures (eg, nights disturbed by asthma was reported
as nights with asthma symptoms or nights of sleep interruption),
given the diversity of ways the same outcome is operationally de-
fined and measured.
Subgroup analyses were conducted to examine the impact of pa-tient or educational factors that may be important in the design
of interventions and good quality research. These results are best
viewed as tentative given the small number of pooled trials for
each subgroup post-stratification. In addition, since no studies
included direct comparisons of the different components of pa-
tient or educational factors, subgroup analyses were conducted to
compare the magnitude of effects for each subgroup. In general,
self-management education worked well for persons with moder-
ate-to-severe asthma as well as for those with mild-to-moderate
asthma, although several outcomes were stronger for those with
greater asthma severity. In looking at the characteristics of the in-
terventions, both individual and group interventions, and single
and multiple educational sessions were effective, but not neces-sarily for the same outcomes. Peak flow-based strategies generally
showed greater effect sizesthan symptom-based strategies.In look-
ing at the effects of the interventions by time, beneficial effects
on measures of physiological function were apparent within the
first six months following enrolment, but benefits did not become
fully apparent on measures of morbidity or health care utilization
until 7 to 12 months following enrolment.
Subgroup analyses were also conducted to look at the effects of
study design and methodological quality on outcomes. Both RCTs
and CCTs showed beneficial results but not necessarily for the
same outcomes. CCTs appeared to be associated with greater re-
ductions in manymeasuresof morbidityand healthcare utilizationthan RCTs. The adequacy of allocation concealment was unclear
for a large number of studies (43%), however studies judged to
have inadequate concealment performed better on many morbid-
ityand healthcare utilization measures than studies judged to have
adequate or unclear concealment. Studies with adequate follow-
up generally showed greater effects than studies with inadequate
follow-up, however studies with inadequate follow-up were few
(23%). For four outcome measures (combined lung function, days
of school absence, self-efficacy scales, and ED visits), the effects
of self-management education were consistently as beneficial or
better among pooled studies of higher quality (eg. RCTs, adequate
concealment, adequate follow-up) than among pooled studies of
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lower quality.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
(1) Evidence from this systematic review of existing clinical tri-
als supports the conclusion that self-management educational in-
terventions for children and adolescents with asthma compared
to usual care result in improved physiological function, decreased
asthma morbidity, improved self-perception, and reduced health
care utilization. The educational programs included in this review
all incorporate prevention and attack management components as
part of their interventions. A small subset of the studies included a social skills component. The results suggest the desirability of in-
corporating self-management education consisting of prevention
and attack management components into routine asthma care for
children and adolescents.
(2) Evidence from this systematic review suggests that on aver-
age patients who receive self-management education would incur
moderate improvements in their physiological function over those
who receive usual care.
(3) Evidence from this systematic review suggests that on aver-
age patients who receive self-management education would have
modest reductions in school absences and days with restricted ac-
tivity, andmay reduce thenightsin which asthmasymptomsoccur
compared to those who receive usual care.
(4) Evidence from this systematic review suggests that on aver-
age patients who receive self-management education would have
moderate improvements in their feelings of self-control compared
to those who receive usual care.
(5) Evidence from this systematic review suggests that on aver-
age patients who receive self-management education would incur
modest decreases in their utilization of the emergency department
compared to those who receive usual care.
(6) This systematic review found no reliable differences in the
risk or frequency of hospitalizations between usual care and caresupplemented with self-management education. These types of
more rare andseriousevents maybe beyondthe ability of education
to influence.
(7) There is not enough evidence to reliably discern differences
in the effectiveness of self-management education as a function of
differences in asthma severity or the components of educational
programs. There were no direct comparisons evaluating these dif-
ferences head-to-head. However, tentative results from this review
suggest that patients with more severe asthma may derive greater
benefits from education than those with milder forms of asthma.
In addition, tentative results from this review suggest that peak
flow-based interventions may outperform symptom-based inter-
ventions. In general, benefits of education on physiological out-comes became apparent within the first six months following en-
rolment, but benefits of education on morbidity and health care
utilization measures didnot become apparent until seven to twelve
months following enrolment.
Implications for research
(1)More than half of the intervention studies identifiedwere either
poorlyreported or of less than desired quality, or both. Much more
attentionneedsto be paid to good reporting andhigh quality study
design in the future. Tentative results from this review suggest that
studies judged to be of poorer quality generally reported results
that were stronger than studies judged to be of higher quality.
(2) Many studies contained missing information on outcomes of
interest that either precluded the incorporation of their data into
pooled estimates of effect or resulted in the use of a conservative
method of imputation to obtain pooled measures of variance. Fu-
ture research efforts should assess the reliability of various methods
of imputation and encourage more complete reporting of study
results.
(3) Given that evidence supports the conclusion that education is
moreeffective thanno education, future studies shoulddirectlytest
alternative interventions against one another rather than against
no education controls.
(4) Evidence was insufficient to adequately and reliably estimateeffects for many of the important subgroups for wh