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QUESTION: Do self management educational interventions improve lung function and decrease morbidity and healthcare use in children and adolescents with asthma?
Studies were identified by searching the Cochrane Airways Group’s and Cochrane Schizophrenia Group’s Special Registers of Controlled Trials and reviewing bibliographies of relevant articles.
Studies were selected if they were randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing an educational intervention designed to teach ≥1 self management strategy related to prevention, attack management, or social skills with usual care; measured objective outcomes; and patients were children or adolescents (2–18 y).
Data were extracted on sample size, patient demographic characteristics, details of the intervention, setting, study quality, and outcomes (lung function, morbidity and functional status, self perception, and healthcare use).
26 RCTs and 6 CCTs met the selection criteria (3706 children and adolescents). The self management educational programmes evaluated in individual trials differed by type of session (group, individual, or both), intensity (single session, 2 sessions, or ≥3 sessions), self management strategy (peak flow or symptom based strategy), and length of the intervention (mean 3.8 mo, range 1–12). Whereas all trials focused on asthma prevention measures (eg, identification and avoidance of asthma triggers) and/or attack management plans (eg, use of an asthma action plan), 13 trials incorporated social skills development into the educational strategy.
Meta-analyses of RCTs were done using a fixed effects model. Improvements in lung function and measures of self efficacy were greater in the self management group than in the usual care group (table). The mean number of days absent from school and mean number of visits to the emergency department were lower in the self management group than in the usual care group (table). The groups did not differ for days of restricted activity, nights disturbed by asthma, asthma severity scores, number of exacerbations, or visits to a general practitioner (table).
Self management educational interventions improve lung function and decrease some measures of morbidity and healthcare use in children and adolescents with asthma.
Evidence suggests that the global prevalence of asthma is increasing by as much as 50% every 10–15 years.1 Usually, asthma can be controlled so that an individual experiences minimal symptoms (cough, wheeze, shortness of breath) and few disruptions in usual daily activities. As a result, the goal of asthma care guidelines internationally is to achieve minimal experience of symptoms and disruption because of asthma while using the least amount of medication.1–4 Typically, core elements of asthma practice guidelines include confirming the diagnosis, providing appropriate medications, using environmental control strategies to minimise or avoid exposure to triggers, and providing asthma education and support for self management.1–4
Previous work by Gibson et al established that adults with asthma who receive self management education, RMR, and a written action plan show important improvements in asthma outcomes, such as use of healthcare services (emergency department visits and unscheduled doctor visits), days lost from work, nocturnal asthma, indirect costs, and quality of life.5 Furthermore, Gibson et al’s work highlighted the fact that less intensive education programmes are not as beneficial,5–6 specifically programmes that provide only patient information. The reviews by Wolf et al and Powell and Gibson extend our current understanding of key aspects of asthma care, education, and self management.
The review by Powell and Gibson suggests that optimal asthma control in adults, through the adjustment of medications, can be achieved equally well using either a written action plan or RMR. Furthermore, the action plan can be based on symptom experience alone or peak flow measurements plus symptoms. This finding is important because it shows that patients have the ability to self adjust medications according to a written plan developed in conjunction with asthma care providers. Thus, individuals who prefer to be more actively involved in their own care can adjust medications as a stepped course of action without seeking medical assistance.
An action plan is a written set of instructions that helps patients to self monitor the level of asthma control through symptom experience and/or peak flow measurements and outlines steps to maintain or regain asthma control. The action plan sets individual parameters for monitoring asthma control and steps to respond to the level of asthma control, such as increasing the dose of inhaled corticosteroid, starting an oral glucocorticoid, or seeking medical attention. The importance of action plans or self management plans for achieving optimal control is acknowledged in asthma care guidelines.1–4
The review by Wolf et al shows that the benefits of asthma self management programmes also apply to children and adolescents. All of the studies included in this review provided action plans and education on asthma prevention and management of worsening asthma.
In summary, these reviews establish the importance of the recommendations of asthma care guidelines. Patients with asthma should receive self management education and a written action plan, based on symptoms or peak expiratory flow, which is tailored to individual needs. After determining a patient’s ability to follow an action plan and readiness to learn, nurses need to ensure that each patient has an action plan that is understood and used appropriately, and that the recommended medications are used with appropriate techniques. Asthma education should be regarded as a process, rather than a single event, with ongoing reassessment and reinforcement at each encounter.
Sources of funding: National Institutes of Health Fogarty International Center; National Heart, Lung and Blood Institute; Garfield Weston Foundation UK.
For correspondence: Professor F M Wolf, Department of Medical Education and Biomedical Informatics, University of Washington School of Medicine, Seattle, WA, USA.
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