Results

Information on publications describing identified interventions that generally met the inclusion criteria is provided (https://www.cdc.gov/asthma/interventions/). Many of the intervention research activities represented in these publications were funded by outside sources. In addition, many had a high level of support within their organizations (e.g., dedicated staff). Several factors that could have contributed to positive health outcomes in these studies were beyond the written protocols and may have been important in the success of the intervention. These factors may be difficult to identify or duplicate. Although 42 interventions are presented in this report as having positive health outcomes in the research setting, implementing these interventions solely on the basis of the information in the published report is not feasible. The availability of the protocol and materials needed for implementation is noted for each of the interventions.

Literature Review

The following conclusions can be drawn on the basis of the literature review.

• Asthma intervention studies are being carried out in many parts of the world.
  Investigators in many countries have published asthma intervention studies, including (but not limited to) Argentina, Australia, Brazil, Canada, England, Finland, Germany, Hong Kong, New Zealand, Norway, Scotland, the United States, and Venezuela.
  
• Intervention settings are varied.
  Hospitals and outpatient clinics are the most common settings for identified interventions. Schools are used in some pediatric asthma intervention studies; community centers (e.g., such as the YMCA, churches, or day care centers) are less frequently being used. Two asthma education programs (one in Canada and one in Germany) have been conducted in pharmacies. Home visits are also used, particularly when the impact of individualized interventions is being determined on the basis of the patient’s history and living conditions. The most common example of home-based interventions found in the literature was personalized instruction and recommendations for reduction of asthma triggers in homes based on walk-through observations and the results of the child’s allergy skin tests.
• Some studies could not be identified as potentially effective interventions for various reasons. The three deficiencies that appeared most often were as follows: a) the sample size was too small, b) the study yielded negative results, and c) the adaptation of the intervention to the United States market was unlikely (generally because of differences in the healthcare systems). Other limitations to the studies included too short a study period, no concrete health outcomes, and unconventional statistical approaches.
  
  Several active, community-based asthma programs also were identified during this investigation. Some of these programs appeared to have sound, established foundations; community support; demonstrated ongoing need; and the appropriate protocols and procedures were in place. However, they did not have published results of positive health outcomes. Because of this shortcoming, they were not included in formal review and analysis. Hopefully, some of these interventions will demonstrate positive health outcomes that can be documented in the literature and eventually included in a future review of potentially effective interventions.
• A lack of clarity exists regarding what constitutes effectiveness.
  Among the evaluated interventions, little consistency existed in the definition and operation of outcome measures. For instance, improving quality of life for a person with asthma was an objective of most interventions; however, the definition of “quality of life” differed between studies, as did indicators of improvement. Similarly, numerous instruments and tools were identified to determine whether improvements had been achieved. Often the instruments were not consistent or comparable and, in many instances, they had not been validated.
• Interventions are not formatted in a user-friendly way.
  Of the evaluated interventions that were identified as potentially effective, most are not formatted in a manner that encourages widespread application, nor are the protocol and materials readily accessible.
• Some studies do not generate products that can be readily translated into a community-based asthma intervention.
  Investigators often develop protocols and educational materials that are sufficient for their particular research study, but are not sufficiently documented to enable others, not involved with the study, to make use of them in an intervention setting. Written instructions for trainers that describe how to use the course materials, detailed and sequenced lesson plan outlines, handouts, and visual aids are costly and time consuming to produce. In the absence of special funding for instructional development, they often are not adequately developed.
• The focus of intervention is education and self-management.
  Most of the community-based interventions identified were aimed at increasing the knowledge and self-management skills of people with asthma. Group and individual educational sessions were the most popular mechanisms used to achieve this goal. Most of these educational interventions were based on the concepts of self-efficacy and modeling, components of Bandura’s theory of social learning. The review identified few evaluated interventions either designed for or tailored to Spanish or other non-English speaking populations.
• Live, stand-up delivery by a trained health professional in front of small groups of participants is the most common instructional style.
  Group discussions, questions and answers, audio-visual support, demonstrations, and skill practice with trainer feedback are characteristic of most adult education courses. Role-plays, games, stories, puppetry, and other learning activities are characteristic of many children’s education programs. Surprisingly, almost no video-based instruction or computer-based instruction is documented as being used in the literature. Web-based instruction and distance-learning approaches are also lacking in asthma clinical studies. When produced, they rarely are assessed regarding impact on health outcomes.
• A trend appears to be emerging in which experienced parents who have a child with asthma teach other parents about asthma management.
  Hand picked because they model exceptionally good asthma management behaviors and communicate well with others, peer-instructors attend a train-the-trainer course and teach under the direction of a senior instructor for a time. These peer-instructors usually live in the same neighborhoods as their students, share similar cultural and socio-economic backgrounds as their students, and readily identify with them.

Although some interventions have been demonstrated to be potentially effective, the interventions should be implemented in an environment that is conducive to optimal health of persons with asthma. For example, it may be of limited or no value to implement Open Airways for Schools in a school or school system that does not permit ready access to asthma medications, does not have written policies in place about care for children with asthma, does not educate its teachers and staff about asthma, and does not limit exposure to potential asthma triggers (e.g., tobacco smoke, pet dander, and mold).

Case Studies

Reading about effective intervention research is much different than knowing whether the intervention is feasible for a particular community. To aid in understanding the interventions, a description of the implementation of some effective interventions has been prepared in case study format. Case studies are provided on the following interventions:

1. Open Airways for Schools as implemented in Anne Arundel County, Maryland (https://www.cdc.gov/asthma/interventions/openairway.htm)
2. Asthma Care Training for Kids (ACT) as implemented in Anchorage, Alaska (https://www.cdc.gov/asthma/interventions/act.htm)
3. Wee Wheezers as implemented in Fort Hood, Texas (https://www.cdc.gov/asthma/interventions/wee_wheezers.htm)
4. The Roaring Adventures of Puff as implemented in Edmonton, Alberta, Canada (https://www.cdc.gov/asthma/interventions/childhood_asthma.htm)
5. The Inner City Asthma Intervention as implemented in Tucson, Arizona (https://www.cdc.gov/asthma/interventions/inner_city_asthma.htm)
6. YES WE CAN Children’s Asthma Program as implemented in San Francisco, California (https://www.cdc.gov/asthma/interventions/yes_we_can.htm)

As a result of the careful review that focused on implementation of some of these effective interventions in community (non-research) settings, the following common “good practices” emerged.

• A full-time asthma education coordinator.
  The coordinator is responsible for the course scheduling; arranging for instructors and facilities; enrolling participants; sending a note or calling with reminders of class time and location; preparing handouts, visual aids, and attendance records; attending all the sessions to support the instructors; and ensuring continued quality from course to course. The asthma education coordinator (likely a registered nurse or respiratory therapist) is also a ready resource to asthma patients in the program to answer questions, help resolve education-related issues, and make needed referrals. Finally, this coordinator usually is responsible for intervention feedback and evaluation.
• High quality instructional materials.
  The instructional materials are fully developed with scripted outlines for instructors use, including sequenced information that moves logically from simple statements and ideas to the more complex concepts and applications. The lesson plans support stated learning objectives in each lesson that describe what participants are expected to know and to be able to do following the instruction. When the outcome of the instruction is a learned skill, a step-by-step description of the task is included, usually with accompanying visuals. Common failings when performing the task are explained and cautions are addressed as applicable. The instructor guides and lesson plans have been tested and shown to be effective. The materials have been consciously selected for the intended audiences; reading level, cultural appropriateness, and visual correctness have been taken into consideration when selecting the materials. The materials are available for use by others.
• Inspired leadership.
  These programs are directed by one or more senior-level health professional (usually physicians) with a clinical research background. Typically, this leader has professional duties beyond treating patients which might include managing a hospital clinic, teaching, or doing research. These professionals have demonstrated inspired leadership by pioneering the development of their programs and gaining the sustained financial and resource support from within their institutions and within their communities to consistently carry out these asthma interventions. They are individuals with high energy levels, outstanding managerial capabilities, dauntless commitment, and resolve. They are champions of the work in which they are engaged and are leaders in their professions.
• Careful selection and thorough training of instructors and counselors.
  In each asthma intervention program, the directors recognize that each and every instructor and asthma counselor must have not only the aptitude for teaching, have good listening and communication skills, be well organized, and have the ability to work well with people, but they must exhibit leadership and possess the character strengths needed to help others with behavior changes. These people are positive role models and are looked up to by program participants and others. Once selected, they undergo formal and on-the-job training to learn how to deliver the asthma messages most effectively. Following training they are introduced to teaching gradually under the direction of a more senior instructor. At no time are new instructors in these programs expected to teach without first being trained, whether formally or informally, to perform the work.
• Recognition, celebration, and rewards.
  Participants who acquire certain behaviors and/or complete the asthma intervention are consistently recognized and rewarded in these programs. A certificate of completion with the child’s name, the program name, and the date of completion is signed by the program director and presented to the participants in an informal setting, usually on the last meeting or education date. When groups of children complete the program at the same time, parents and invited guests often celebrate in organized parties; other programs give the children gift certificates to a department store or a fast-food restaurant. Parents can be awarded a food market gift certificate as recognition for completing the education. Recognition in the form of something of value is a cultural tradition that cross-cuts our society and is considered to be crucial to keeping participants active and interested in any program, especially in the early stages.
• Safe, pleasant, and inviting meeting places.
  Much care is taken to secure classrooms where people easily can assemble. Location of the buildings (e.g., near bus lines, on lighted streets, and in areas recognized by participants as safe meeting places) is important when selecting venues in the community, especially for evening meetings. Classrooms are made inviting by decorating with educational props, posters, and familiar program symbols and slogans used during the sessions. Seating and tables used in the children’s sessions are of appropriate size for children’s use. Seating in adult sessions usually consists of a large table(s); all meeting participants have the same access to the instructor and can make eye-to-eye contact with other participants, helping to create an egalitarian relationship among fellow students.
• Program evaluation for quality.
  Because the implemented interventions already have been demonstrated to be effective, program evaluation can focus on process elements that ensure that the intervention was implemented as originally designed and tested. Every program for which a case study was prepared received participant feedback at the end of the program as a way to assess the quality of instruction. Questions generally centered on what elements were considered the most and least beneficial and what was liked and not liked about the experience. Some of these programs use a written quiz to assess instructional effectiveness. Quiz scores provided an important point of reference about the participants’ cognitive learning levels. When several people miss the same question, the instructional materials, the delivery of the materials, or the way the question is worded could be to blame.

CDC welcomes information regarding additional known effective interventions. Such information or any questions or comments may be directed to Dr. Leslie Boss at lboss@cdc.gov.

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