Effect of Family Education on Clinical Outcomes in Children with Asthma: A Review

Abstract

Childhood asthma still imposes an enormous burden on children and their families. To the best of our knowledge, no study reviewed the literature on the effect of family asthma education on major asthma outcomes. This study aimed to explore the effect of family education programs on major asthma outcomes in children. Quasi-experimental studies and randomized controlled trials were conducted among children with asthma aged 6–18 years and their parents were included. Pub Med, Science Direct, and Trip databases were used to extract data published in English from 2010 to 2021. Twenty-two studies were reported in this review. It was demonstrated that family empowerment interventions were effective in improving the quality of life of children and their parents, asthma symptom control, and pulmonary function. Family education that was specific to medication improved medication adherence, inhalation technique, and asthma control. Family asthma education enhanced asthma management and family functioning. This approach should be a cornerstone of pediatric asthma therapy. It helps health care professionals to build a strong connection and trustful relationship with children with asthma and their families.

1. Introduction

Asthma is a serious childhood issue that still imposes an enormous burden on children, their families, and health care systems [1]. Currently, 339 million people worldwide suffer from asthma, and approximately 14% of children are affected [2]. In 2019, asthma caused 2.29% of total disability adjusted life years and 3.76% of years lived with disability in children with asthma aged 5–14 years worldwide [3]. Besides, pediatric asthma affects the parents through the loss of productivity at the workplace and family disruption [1, 4].

The Global Atlas of Asthma stated that asthma is one of the main causes of hospitalization in children [5]. Additionally, a recent study noted that children and adolescents with asthma had a higher number of outpatient and emergency department (ED) visits in comparison with non-asthmatic children [6]. The lack of asthma control can place severe limits on the daily life of children and is sometimes fatal. Treatment and effective management of asthma can save lives [7]. Patient education and self-management plans have been convincingly shown to reduce exacerbations requiring hospitalization [5]. Besides, a growing emphasis has been on involving families in health care and assessing their needs. Family education consists of the active involvement of the child and his or her parent in the process of chronic disease management and treatment [8, 9].

A recent systematic review examined the effectiveness of school- and community-based nurse-led educational interventions on asthma management for school-age children and their parents [10]. This literature review included eight studies published from 2014 to 2016, which is a limited sample. It reported that school- and community-based interventions led by nurses improved knowledge and skills related to asthma self-management in school-age children with asthma and their parents. Furthermore, Walter and colleagues systematically reviewed the effect of school-based family asthma education programs on QOL and asthma exacerbations in children with asthma aged 5–18 years. This review reported a limited number of randomized control trials (n = 6) published from 2004 to 2010. It revealed that school-based family asthma educational programs for children and their caregivers can have a positive effect on QOL and asthma management of children with asthma [11].

Numerous studies assessed the impact of family education on asthma major outcomes. The findings of these interventions were controversial. This study aimed to report results from recent studies on the effectiveness of family education on clinical outcomes in children with asthma.

2. Methods

2.1 Study design

This was a literature review of randomized and non-randomized controlled studies, which assessed the effectiveness of family asthma educational interventions on asthma outcomes. A regional Institutional Review Board approved the study under the approval number DEFMS 01/2018.

2.2 Sources of information

The data search was carried out using three electronic databases: PubMed, ScienceDirect, and Trip database. Data collection was conducted from January to December 2021. Studies identified in the references of the selected articles, and that met the inclusion criteria were included in this review (Figure 1).

Figure 1.

The studies’ selection procedure. ^aRCT: Randomized controlled trials.

2.3 Search strategies

The keywords used were: asthma, child, adolescent, caregivers, quality of life, education, and disease management.

These terms were combined via the Boolean switch statement “AND” and “OR”, as following: (("Asthma”[Mesh]) AND “Child”[Mesh]) AND “Quality of Life”[Mesh]; ((("Asthma”[Mesh]) AND “Disease Management”[Mesh]) AND “Child”[Mesh]) AND “Caregivers”[Mesh]; ((((“Asthma”[Mesh]) AND “Child”[Mesh]) AND “Adolescent”[Mesh]) AND “Education” [Subheading]; (((("Asthma/nursing”[Majr] OR “Asthma/rehabilitation”[Majr] OR “Asthma/therapy”[Majr])) AND ("Patient Education as Topic/education”[Majr] OR “Patient Education as Topic/methods”[Majr] OR “Patient Education as Topic/organization and administration”[Majr])) AND “Family”[Mesh] AND “Child”[Mesh].

Randomized controlled trials and quasi-experimental studies published in English from 2010 to December 2021 were considered.

2.4 Selection criteria of the studies

Studies were primarily selected based on the titles and abstracts. After the exclusion of duplicates, studies were assessed according to the established inclusion criteria. Included studies were quasi-experimental studies or randomized controlled trials conducted in children with asthma aged between 6 and 18 years and their parents, and published (or accepted for publication) in English from January 2010 to December 2021. Abstracts and research protocols were excluded.

2.5 Data extraction

For each study included in this literature review, the following variables were identified: country and year of publication, study design, study groups, follow-up assessment, intervention approach, intervention duration, number of sessions, duration of each session, theoretical framework (if applicable), and clinical outcomes and their measurement tools.

3. Results

3.1 Selection of the studies

After removing duplicates, 81 articles were screened. Forty-two articles were removed since they were published before 2010. After the analysis of the full-text articles, 17 articles were excluded since they did not meet the inclusion criteria. Finally, 22 articles were included in this literature review.

3.2 Characteristics of the included studies

Table 1 shows that 9 studies were randomized controlled trials (RCT). The sample sizes of the reviewed studies ranged from 14 to 167 children with asthma, with a total of 1087 participants. The major target group of the educational interventions was asthmatic school-aged children and their families [13, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25]. Some studies included teachers [13], and asthma physicians [20]. Most of the educational sessions were conducted in groups. The duration of sessions varied between 30 and 120 minutes. The assessment time ranged from 2 weeks to 12 months.

The first author, year, country	Study design	Target population	Study groups	Follow-up assessment	Intervention approach	Intervention duration	Number of sessions	Duration of each session	Theory
Clark et al., 2010 [12], USA	RCT	Preteen students (5th to 8th grade)	Open airways at school (n = 468); open airways at school + peer asthma action (n = 416); control n = 408)	12 months; 24 months	School-based, group	6 weeks	6	60 min	NA
McGhan et al., 2010 [13], Canada	RCT	Children aged 6–13 years (2nd to 5th grade), their parents, and teachers	The roaring adventures of puff (n = 104); usual care (n = 162)	6 months; 12 months	School-based, group	NA	6 (children); 1 (parent/teacher)	45–60 min (children); 2 h (parent/teacher)	The social cognitive theory
Mosnaim et al., 2011 [14], USA	RCT	Youth (8–12 years); Teenagers (13–18 years)	FAN youth curriculum (n = 275), control (n = 69); FAN teen curriculum (n = 141), control (n = 51)	Posttest	School-based, group	4 consecutive school days	4	45 min	NA
USA	RCT	Adolescents aged 14–16 years (9th to 10th grade), their medical providers	Asthma self-management for adolescents (n = 175); control (n = 170)	6 months; 12 months	School-based, group, and tailored individual	8 weeks (group); 5 weeks (individual)	3 (group); At least 1/week (individual)	45–60 min	The social cognitive theory
Celano et al., 2012 [15], USA	RCT	Children aged 8–13 years	Home-based family intervention (n = 23); enhanced treatment as usual (n = 20)	Posttest; 6 months	Home-based, Individual	4 months	4–6	NA	NA
USA	RCT	Children aged 8–12 years	Modified open airways at school (n = 15); control (n = 17)	3 weeks; 6 weeks	School-based, Group	3 weeks	3	90 min	NA
Canada	RCT	1316 Children aged 6–9 years and their families	The roaring adventures of puff; control	2 months; 12 months	School-based, group	NA	6	45–60	The social cognitive theory
USA	RCT	Children of 9th to 12th grade (mean age of 15.6)	Tailored web-based program (n = 204); generic asthma websites (n = 218)	6 months; 12 months	School-based, group	6 months	4	15–30	Behavioral theories
Payrovee et al., 2014 [16], Iran	Quasi-experimental	Children aged 7–11 years and their parents	Family empowerment intervention (n = 14); usual treatment (n = 16)	2 weeks	Family-based, group	4 weeks	4	2 h	NA
Fouda et al., 2015 [17], Egypt	Quasi-experimental	Children age 6–12 years and their parents	Family empowerment intervention (n = 23); usual care (n = 24)	2 weeks	Family-based, group	2 weeks	2	NA	NA
Grover et al. [18], India	RCT	Children aged 7–12 years and their parents	Healthy breathing program (n = 24); usual care (n = 16)	1 month; 6 months	Individual parent-child pair	NA	1	1 h	Pedagogical principles
Arikan-Ayyildiz et al., 2016 [19], Turkey	RCT	Children age 6–12 years and their parents	Asthma education program (n = 26); usual care (n = 21)	1 month; 3 months	Group	NA	1	1 h	NA
Canino et al., 2016 [20], Puerto Rico	RCT	Children with a mean age of 8.3, their families, and asthma physician	CALMA-plus (child, parent, physician) (n = 167); CALMA (child, parent) (n = 164)	6, 12, and 18 months	Home-based, individual	NA	2	NA	The social cognitive theory
Yeh et al., 2016 [21], Taiwan	RCT	Children aged 6–12 years and their families	Asthma family empowerment program + self-management intervention (n = 34); self-management intervention (n = 31)	3 months; 1 year	Family-based	16 weeks	4	50 min	Freire’s empowerment theory
Australia	RCT	Children aged 6–16 years	Electronic monitoring devices with reminder alarms (n = 47); electronic monitoring devices without reminder alarms (n = 42)	3, 6, 9, and 12 months	Individual	NA	1	NA	NA
Kashaninia et al., 2018 [22], Iran	Quasi-experimental	Children aged 6–12 years and their parents	Family empowerment intervention (n = 14); usual treatment (n = 16)	2 weeks	Family-based, group	4 weeks	4	2 h	NA
Mosenzadeh et al., 2018 [23], Iran	Quasi-experimental	Children aged 8–11 years and their parents	Self-care education (n = 35); usual treatment (n = 35)	8 weeks	Family-based, group	NA	4	45 min	NA
USA	RCT	Children aged 8–14 years, their caregivers, and school nurses	Telemedicine asthma education intervention (n = 180); usual care (n = 183)	3, and 6 months	School-based Individual (children); Group (caregivers and nurses)	5–9 weeks	5 (children); 2 (caregivers); 1 (nurses)	30–45 min (children); 60–90 min (caregivers and nurses)	NA
Netherlands	RCT	Adolescents aged 12–18 years	Interactive mobile health intervention (n = 87); usual care (n = 147)	6 months	Mobile phone application; Individual	6 months	All-time during 6 months	All-time during 6 months	NA
Montalbano et al., 2019 [24], Italy	RCT	Children aged 6–11 years and their families	Mobile phone application and multidisciplinary education (n = 25); mobile application (n = 25)	1 month, 2, and 3 months	m-health program; Group	3 months	3	30–60 min	NA
Dardouri et al., 2020, 2021 [25, 26], Tunisia	RCT	Children aged 7–17 years and their parents	Family empowerment program (n = 34); Usual care education (n = 34)	12 months	Family-centered care; Group	2 months	4	60 min	Family empowerment model

Table 1.

Description of the characteristics of family asthma educational interventions.

RCT: Randomized Controlled Trial; NA: not available.

The topics discussed in almost 90% of the educational sessions were asthma pathophysiology, triggers identification, symptoms recognition, effective response during exacerbations, asthma action plan, types of asthma medications and their correct use, and communication with care providers [16, 17, 18, 19, 20, 21, 22, 23, 24, 25].

Five interventions were conducted by the research team of the trial [16, 17, 18, 22, 25]. Other interventions were carried out by a multidisciplinary team [24], and certified educators of asthma [15, 20].

Table 2 shows the outcomes assessed in each study and their assessment tools. The Pediatric Asthma Quality of Life Questionnaire and the Pediatric Asthma Caregiver Quality of Life Questionnaire were used to assess the QOL of children and their parents in all studies respectively. Different tools were used for symptoms control assessment. The Asthma Control Test (ACT) was commonly used.

First author, year, country	Child’s QOL	Parent’s QOL	Asthma symptom control	Lung function	ED visit/hospitalization	Adherence to treatment	Inhalation technique
Clark et al., 2010 [12], USA	Pediatric Asthma Quality of Life Questionnaire (PAQLQ)		Series of questions about the frequency of specific asthma symptoms in the past year during the day and at night
McGhan et al., 2010 [13], Canada	PAQLQ				Number of ED visits in past year
Mosnaim et al., 2011 [14], USA							The 8-item FAN Spacer Checklist
USA	PAQLQ		Number of symptom days and nights awoken in the last 2 weeks		Number of acute medical and ED visits, hospitalization
Celano et al. 2012 [15], USA			Number of symptom days in last 2 weeks		Number of ED visits and hospitalizations in the past year		Metered dose inhaler checklist
USA	PAQLQ		Child Asthma Control Test	SpiroUSB portable spirometry machine
Canada	PAQLQ				Number of urgent visits		Checklist
USA			Number of symptom days and nights		Number of ED visits
Payrovee et al., 2014 [16], Iran	PAQLQ
Fouda et al., 2015 [17], Egypt	PAQLQ	PACQLQ
Grover et al., 2015 [18], India		PACQL	Asthma Control Questionaire			Self-reported adherence	MD, Lupihaler and Rotahaler checklists
Arikan-Ayyildiz et al., 2016 [19], Turkey			Asthma Control Test		Number of ED visits and hospitalizations
Canino et al., 2016 [20], Puerto Rico			Symptom days and nights		Number of ED visits and hospitalizations
Yeh et al., 2016 [21], Taiwan			Self-reported asthma symptoms	Portable Spirometer
Australia	Mini PAQLQ		Asthma Control Questionnaire	Spirometry test	Number of ED visits	Number of daily doses taken
Kashaninia et al., 2018 [22], Iran			Asthma Control Test
Mosenzadeh et al., 2018 [23], Iran	PAQLQ
USA	PedsQL 3.0 PAQLQ		Symptom free days in past 2 weeks	Spirometry test
Netherlands	PAQLQ					Medication Adherence Report Scale
Montalbano et al., 2019 [24], Italy	PAQLQ		Asthma Control Test	Portable spirometer		Medication Adherence Report Scale
Dardouri et al., 2020 [25], Tunisia	PAQLQ	PACQLQ		Spirometry test using ZAN 100 machine
Dardouri et al., 2021 [26], Tunisia			GINA guidelines		Number of ED visits and hospitalizations	Number of doses used weekly	Inhaler checklist

Table 2.

Asthma outcomes and measurement tools used by the studies included in the systematic review.

ED: emergency department; PAQLQ: Pediatric Asthma Quality of Life Questionnaire.

3.3 Impact of educational interventions on asthma-related health outcomes

3.3.1 Quality of life

As shown in Table 2, five studies assessed the QOL of children with asthma, and three studies assessed the QOL of parents. One RCT [25] and two quasi-experimental studies [16, 17] referred to family empowerment in school-age children with asthma and their parents. Improved QOL scores were observed after implementing family empowerment interventions in Tunisia, Egypt, and Iran. Furthermore, the “Healthy Breathing Program” implemented by Grover and colleagues in children with asthma aged 7–12 years and their parents in India led to a significant improvement in the QOL scores of parents at six-month follow-up in the intervention group (p < .001) [18]. Similarly, the self-care education program contributed to improved QOL scores of children in Iran [23]. Montalbano et al. conducted a therapeutic asthma education that combines a multidisciplinary education with a smartphone application in school-age children with asthma and their parents in Italy. The program contributed to higher scores of QOL in the intervention and the control group at the three-month follow-up (Intervention group, p = .014; Control group, p = .046) [24].

3.3.2 Asthma symptom control

It was demonstrated that family education contributed to a significant decrease in asthma symptoms days and nights [15, 18, 20]. Indeed, family empowerment interventions were significantly effective in reducing asthma symptoms, such as coughing, wheezing, and dyspnea (p < .0001) [21], and improving asthma symptom control in school-age children (p < .001) [22, 26, 27]. Besides, the m-Health program of Montalbano et al. was effective in improving the Child-Asthma Control Test scores (p = .0089) in the intervention group [24].

3.3.3 Pulmonary function

Two family empowerment interventions led to a significant improvement in pulmonary function parameters, including forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) (p < .05) [21, 25]. Moreover, Montalbano et al. revealed that the m-health program combined with multidisciplinary education contributed to a better performance of forced expiratory maneuvers [24].

3.3.4 Acute health care utilization

The “Roaring Adventures of Puff” program incorporated a multitude of childhood educational approaches based on theory and evidence of factors that influence a child’s motivation and self-efficacy [13]. This school-based program targeted the children and their support community (parents, peers, and teachers). After a 12-month follow-up, the number of unscheduled doctors and ED visits due to asthma was reduced in the experimental and the control group. However, three child-parent education programs did not show a significant difference in ED visits and hospitalizations between the intervention and the control group at follow-up [19, 20, 26].

3.3.5 Medication use: Inhaler technique and adherence.

A medication education program for children and their parents contributed to an improvement in inhaler technique and self-reported adherence to the prescribed medication [18]. Besides, Celano et al. showed that, at follow-up, a greater proportion of children who received a home-based family intervention demonstrated adequate technique as compared to children in the usual care group (84%; 44%; p = .019 respectively) [15]. A recent RCT showed that a six-month family empowerment intervention improved inhalation techniques in children with asthma [26]. However, the same intervention was not effective in enhancing medication adherence.

4. Discussion

The family, as the core of society, is responsible for providing adequate care for children. Besides, it should have correct information and perception of the child’s disease [28]. According to Piaget’s theory, school-aged children (7 to less than 12) gain the ability to solve concrete problems [25]. For that, they can manage and control asthma by themselves and with their parents’ supervision through education and support. The fact of being responsible for asthma management as a school-age child is a huge development, which provides strength and command over the disease. The National Heart, Lung and Blood Institute (NHLBI), and the Global Initiative for Asthma (GINA) strictly emphasize educating asthmatic children, their parents, and health care professionals [1, 29]. Family education has a crucial role in empowering children and their families to effectively control and manage asthma. Evidence supported pediatric nurses to educate children with asthma and their families [8, 9]. The British guideline on asthma management suggested that family therapy may be a useful adjunct to medication use in children with asthma [30].

In this study, we reviewed the characteristics and the impact of family education on asthma outcomes. The reported asthma clinical outcomes were QOL, asthma symptom control, pulmonary function, ED use/hospitalization, medication adherence, and inhalation technique. This literature review revealed that home- and clinic-based family education was significantly effective in enhancing the QOL of children with asthma and their parents and asthma symptom control. Five family interventions improved pulmonary function, medication adherence, and inhalation technique [15, 18, 21, 24, 26]. One family education program reduced ED use [13].

Indeed, family interventions are needed to develop empowerment skills in families to take care of asthmatic children [21, 25]. The literature revealed that family empowerment education based on empowerment theories enhanced the QOL of children and parents, asthma symptom control, and pulmonary function in asthmatic children, as well as reduced parental stress [16, 17, 21, 22, 25]. Moreover, the use of predetermined open-ended communication, meaningful learning, art therapy, problem-solving, and goal setting principles was advantageous for better medication use, parent’s QOL, and asthma symptom control [18]. Besides, the multidisciplinary intervention that included a pediatrician, a pediatric pulmonologist, a pediatric psychologist, and two experts in the field of Information and Communication Technologies-based tools had a crucial role in improving the QOL of children, forced expiratory maneuvers, and asthma symptom control [24].

The synthesis of the literature demonstrated that it is beneficial to educate children and their parents about the different asthma aspects in group sessions at home, school, or in clinical settings. Asthma aspects can include asthma pathophysiology, triggers identification, symptoms recognition, effective response during exacerbations, asthma action plan, types of asthma medications and their correct use, and communication with care providers. The interventions must be age-appropriate, culture-tailored, and well-designed to satisfy the unmet health care needs of families of children with asthma. These data suggested that family interventions can promote the health of asthmatic children in diverse settings. Furthermore, this study revealed that family asthma educational interventions were widely and successfully implemented in lower- and upper-middle income countries, including Tunisia, India, Egypt, Iran, and Turkey [31].

This literature review presented several limitations. First, articles published in languages other than English were not considered. Second, only three databases were used for data search. Due to these facts, some of the relevant articles may not be included in this literature review. Besides, half of the studies included (11 of 22 studies) had small samples, which can limit the generalizability of the results. However, this literature review reported recent interventions in detail. The practice implication for pediatric nurses was noticeable and fitted the guidelines of the National Heart, Lung and Blood Institute, and the Global Initiative for Asthma.

5. Application to practice

Pediatric nurses have a crucial role in promoting family asthma interventions. They are well-positioned to empower families of children with asthma to achieve optimal asthma control. Through family interventions, pediatric nurses can build a strong connection and trusting relationship with children with asthma and their families. Such strategies can improve asthma control and reduce ED use [13, 21, 22]. In family interventions, pediatric nurses should provide families of asthmatic children with unmet health care needs, supportive communication, correct use of medication, and effective ways of exacerbation prevention. Family interventions supported the active involvement and collaboration of families in the asthma therapeutic regimen of their affected children.

6. Conclusions

Asthma education is a key component of asthma management. Well-established family interventions can promote the health of children and improve the QOL of parents, when conducted at home, school, or in a clinic. The current review added to existent literature that family asthma education was effective in improving major asthma outcomes, including QOL, asthma symptom control, pulmonary function, and inhalation technique. This type of intervention was highly recommended to be applied by pediatric nurses. Scant family interventions reduced ED use and enhanced medication adherence. Family intervention associated with innovative technologies such as artificial intelligence may help children and families to better adhere to their medication and manage asthma crises to reduce ED visits. New asthma research should assess the effectiveness of family education associated with artificial intelligence on medication adherence and ED visits.

Conflict of interest

The authors declare no conflict of interest.