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Public Health Nursing Vol. 22 No. 3, pp. 189—199
0737-1209/05 # Blackwell Publishing, Inc.
POPULATIONS AT RISK: EMPIRICAL STUDIES
Home-Based Asthma
Self-Management Education for
Inner City Children
Arlene M. Butz, Laura Syron, Betty Johnson,
Joanne Spaulding, Melissa Walker, and Mary Elizabeth Bollinger
ABSTRACT Optimal home self-management in young children with asthma includes accurate symptom
identification followed by timely and appropriate treatment. The objective of this study was to evaluate a
home-based asthma educational intervention targeting symptom identification for parents of children with
asthma. Two hundred twenty-one children with asthma were enrolled into an ongoing home-based clinical
trial and randomized into either a standard asthma education (SAE) or a symptom/nebulizer education
intervention (SNEI). Data included home visit records and parents self-report on questionnaires. Symptom
identification and self-management skills significantly improved from preintervention to postintervention
for parents in both groups with the exception of checking medications for expiration dates and the
frequency of cleaning nebulizer device and equipment. However, significantly more parents of children
in the SNEI group reported treating cough symptoms as compared with the SAE group (p = 0.05). Of
concern is that only 38% of all parents reported having an asthma action plan in the home. A targeted
home-based asthma education intervention can be effective for improving symptom identification and
appropriate use of medications in children with asthma. Home asthma educational programs should
address accurate symptom identification and a demonstration of asthma medication delivery devices.
Key words: asthma, children, self-management, symptom identification.
Background
Low-income, minority children have disproportionately high morbidity and mortality rates for
Arlene M. Butz, Sc.D., M.S.N., R.N., is Associate Professor,
Department of Pediatrics, The Johns Hopkins University
School of Medicine, Baltimore, Maryland. Laura Syron,
B.S.N., M.P.H., Department of Pediatrics, The Johns
Hopkins University School of Medicine, Baltimore,
Maryland. Betty Johnson, B.S.N., Department of
Pediatrics, The Johns Hopkins University School of
Medicine, Baltimore, Maryland. Joanne Spaulding,
B.S.N., Department of Pediatrics, The Johns Hopkins
University School of Medicine, Baltimore, Maryland.
Melissa Walker, B.S.N., Department of Pediatrics, The
Johns Hopkins University School of Medicine, Baltimore,
Maryland. Mary Elizabeth Bollinger, D.O., Division of
Pediatric Pulmonology and Allergy, School of Medicine,
University of Maryland, Baltimore, Maryland.
Correspondence to:
Arlene M. Butz, The Johns Hopkins University Department
of Pediatrics, 600 North Wolfe Street, Park 358, Baltimore,
MD 21287, E-mail: [email protected]
asthma when compared with nonminority children. Low-income children with decreased access
to outpatient care, as compared with children with
private health insurance, tend to rely on hospital
emergency rooms as their primary source of
asthma care and are more likely to incur a hospital
admission (Halfon & Newacheck, 1993; Lieu et al.,
1997). Early and accurate identification of asthma
symptoms, when linked to timely and appropriate
asthma medication use, is associated with a
decrease in emergency room and hospital admissions. The parent or childs ability to accurately
identify or perceive symptoms and pulmonary
function compromise is critical for optimal asthma
management in the home and necessary for clinicians to prescribe appropriate asthma medication
therapy (Yoos, Kitzman, McMullen, & Sidora,
2003).
In a study of children with persistent asthma,
significant errors in accurately perceiving the
childs asthma severity were made by one third of
parents possibly resulting in treatment errors
(Yoos et al., 2003). Studies of home-based asthma
189
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educational programs reinforcing appropriate
parental self-management decisions have been
shown to improve adherence to asthma medication
use and reduce asthma morbidity in children
(Bendefy, 1991; Nides et al., 1993; Zimo, Gaspar,
& Akhter, 1989).
Home asthma medication use in young children
often includes administering medications via a
nebulizer device. Prevalence of nebulizer use in
young children with chronic asthma ranges from 33
to 71% (Butz et al., 2000; Dawson, Jandera, & Penna,
1992; Zach & Karner, 1989). Current recommendations for asthma home management encourage early
initiation of nebulizer therapy for children with
moderate to severe asthma (Barry & OCallaghan,
1997), because nebulizer therapy provides a portal of
entry and direct delivery to the respiratory system for
both rescue and controller asthma medications (Barry
& OCallaghan, 1997).
Home nebulizer use is favored over use of
metered dose inhalers (MDIs) by many parents
because the nebulizer does not require young children to coordinate respiration with aerosol delivery (Canny & Levison, 1988). This preference is
contrary to studies indicating MDIs with spacers
are as effective as nebulizers in administering
medications to young children with asthma
(Chou, Cunningham, & Cramer, 1995; Kerem et al.,
1993; Lewis & Fleming, 1985; Schuh et al.,
1999), and nebulizer devices continue to be prescribed at high rates (33%) for young children with
asthma (Butz et al., 2000). Although appropriate
nebulizer use has been associated with a decrease
in emergency department (ED) care and hospitalizations (Zimo et al., 1989), many asthma educational programs fail to address correct home
nebulizer use. We hypothesized that appropriate
home asthma management in young children can
be improved or supplemented by a home-based
intervention addressing accurate symptom identification and appropriate nebulizer use in a group
of children with primarily persistent asthma and
who use a nebulizer to administer their asthma
medications.
Organizing Framework
The study was based on the conceptual framework
adapted from the model of symptom management
May/June 2005
(University of California, San Francisco School of
Nursing Symptom Management Faculty Group,
1994). The goal of symptom management is to avoid
or delay negative outcomes of an illness or disease.
Early and accurate identification of asthma symptoms
(symptom experience), if allied with appropriate treatment and accurate use of asthma medications including administering medications via a nebulizer device
(symptom management), is hypothesized to improve
outcomes defined as a decrease in frequency of asthma
symptoms and decrease in number of ED visits. This
model is the clinical basis for long-term asthma selfmanagement for young children (Fritz, Klein, & Overholser, 1990). Specific components of the asthma
symptom educational intervention, in this study,
targeted symptom experience, that is, how parents
evaluated the intensity, location, temporal nature, and
frequency of asthma symptoms. Symptom management strategies include teaching parents appropriate
decision-making strategies regarding what symptoms
require administering asthma medications via a nebulizer or MDI and when to seek ED care. Several child
and parent characteristics such as the childs age,
ethnicity, asthma severity, type of medical insurance,
current symptom frequency, and parent educational
level may influence the association between the home
symptom education intervention and the symptom
and ER use outcomes. These child and parent factors
were taken into consideration when the community
health nurses delivered the educational intervention.
This article describes the process and content involved
in teaching parents and children (a) asthma symptom
identification and (b) appropriate use of a nebulizer
device to administer asthma medications as reported
by the community health nurses.
Methods
This is a cross-sectional analysis of parents and children enrolled in an ongoing randomized clinical trial
of an asthma educational intervention, comparing
the frequency of asthma home management skills,
that is, asthma symptom identification skills, appropriate use of a nebulizer, and asthma symptoms used
to decide to administer medication. The educational
intervention was delivered by community health
nurses to the parents during home visits. Home
visit data presented in this article were collected by
Butz et al.: Home-Based Asthma Self-Management Education
four community health nurses between October 2001
and December 2003. Parents self-reports of symptoms, ED visits, and medication use preintervention
were collected by trained interviewers during the
same time period. Institutional Review Board (IRB)
approval was obtained from the Johns Hopkins University School of Medicine Institutions and the University of Maryland School of Medicine. Informed
consent was obtained from all participating parents,
and assent was obtained from all children aged 7
years and above.
Study population and randomization.
Two hundred twenty-one families (child/parent
families) with children aged 2—8 years who have
asthma were recruited into an ongoing intervention
study testing the effectiveness of a home-based
asthma educational intervention. The mother was
primarily the parent in 92% of the families; thus,
she was targeted to receive the intervention. Child/
parent families were recruited from universityaffiliated pediatric practices including pulmonary/
allergy specialty (50%), pediatric emergency room
(20%), and community pediatric practices (30%), all
serving inner city children in Baltimore, Maryland.
Inclusion criteria were (a) having a diagnosis of
mild, moderate, or severe persistent asthma, based
on national guidelines (National Asthma Education
Prevention Program [NAEPP], 1997, 2002) and
(b) use of a nebulizer for administration of at least
one asthma medication. Asthma severity was based
on national guidelines (NAEPP, 1997) using day
and night symptom reports and current asthma
medication use.
Data are presented for the 210 (95%) child/
parent families who completed the home visit educational intervention study. Child/parent families
were randomized into one of two educational groups:
(a) the standard asthma education (SAE) intervention (n = 105) or (b) the symptom/nebulizer
education intervention (SNEI) (n = 105) based on
even or odd digits from a random digit list.
Description of standard asthma education.
The SAE intervention, delivered during three home
visits, was designed to assist families in establishing
regular primary care for their childs asthma and
understanding basic asthma management principles.
SAE included facilitating access to preventive and
191
acute asthma care, encouraging parents to obtain
an asthma action plan from their childs health care
provider, and teaching use of a peak flow meter
(PFM) to children over 5 years of age. The SAE
intervention did not include any symptom identification or nebulizer-use education.
Description of the symptom identification/
nebulizer educational intervention.
The focus and goal of the SNEI was to teach accurate
symptom identification, that is, persistent cough,
wheeze, intercostal retractions, and appropriate
treatment of these symptoms including the use of a
home nebulizer device. The SNEI intervention was
delivered during six home visits over a 6-month
period. The intervention was based on the WEE
Wheezers Program (Wilson et al., 1996), the A+
Asthma Club Program (Schneider et al., 1997), teaching pediatric symptom identification in children with
asthma (Yoos & McMullen, 1999), and recommendations for nebulizer therapy (Barry & OCallaghan,
1997; Canny & Levison, 1988). Initially, parents
were taught accurate asthma symptom identification
including review of early (cough) and late (intercostal retractions, inability to talk) symptoms. The
specific care plan addressing asthma symptoms
requiring treatment and the home medication protocol were verified by the community heath nurses
with each childs primary care provider when possible. The parent component of the educational intervention included teaching comparison of a childs
normal breathing to breathing patterns noted during
an acute asthma episode. Parents were taught to
recognize each asthma symptom, that is, cough,
wheeze, inability to talk, and signs including intercostal retractions, counting the childs respiratory
rate, and use of a PFM in children over 5 years of
age, so that they could make accurate treatment
decisions. Specific nebulizer-use education targeted
accurate medication dispensing including measuring
accurate amount of medication, pouring medication
in nebulizer cup, the frequency of changing nebulizer
mask and tubing, and the cleaning and maintenance
of the nebulizer device.
Procedures.
Following each home visit, the community health
nurse completed the SAE Home Visit Checklist
(Table 1) or the SNEI Home Visit Checklist (Table 2)
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TABLE 1. Standard Asthma Education (SAE) Home Visit Checklista
Childs name
Nurses name
Standard Asthma Educational
Home Visit Checklista
____________________________________ ID ____________________________________
____________________________________ Date of visit______________________________
Done
Not done
&
&
&
&
&
&
&
&
&
&
&
&
&
&
Introduction
Review purpose of home visit (to help parent manage childs asthma at home in collaboration with the
childs health care provider).
Review patients information sheet (address, phone, and contact list)
Basic asthma education
Review asthma medications in home that child is currently using (type of medication, dosage, and
frequency of administration)
Review how each medication works (controller or rescue medication) and how administered
(oral, metered dose inhaler, diskus, and nebulizer)
Review asthma action plan with parent. For families with no asthma action plan, encourage family
to have health care provider complete for home use.
If child is above 5 years of age teach use of peak flow meter (PFM) or review technique. Provide child
with PFM if not in home.
Access to health care for child
Ask parent when is childs next primary care appointment or appointment with allergy or pulmonology
specialist. Remind parent that child should be evaluated for asthma at least every 4—6 months.
Time visit started:_ __:_ _.
Time visit ended:_ __:_ _.
a
Boxes checked during home visit when teaching completed.
to document the specific teaching material imparted
during each session with the family. Home visits for
each educational group were conducted by four community health nurses adept in working with inner
city populations and specifically trained in teaching
symptom identification and nebulizer use in families
of children diagnosed with persistent asthma. Both
educational interventions were delivered by all four
community health nurses to control for differences
in teaching style of each community health nurse.
Training for the community health nurses occurred
over a 3-day period and included (a) pathophysiology of asthma, (b) appropriate asthma treatment, (c)
update on current medications, (d) asthma symptom
identification including PFM use, setting each childs
personal best, and (e) nebulizer use and care, that
is, mechanics of several nebulizer brand devices, care
of nebulizer tubing, mouthpieces, and masks, checking air flow rate, changing filter, appropriate cleaning and maintenance of a nebulizer, and accurate
medication dispensing into nebulizer medication
cup. Monthly supervision of the community health
nurses was conducted by a pediatric nurse specialist
in asthma, in addition to a pediatric allergy nurse.
Both nurses were available to the community health
nurses by beeper 24 hr a day for immediate problems
or questions.
Evaluation of the home asthma educational
interventions.
Parents were tested for their ability to recognize
symptoms and their nebulizer-use technique by the
community health nurses after the midpoint of the
educational sessions (home visit number two for SAE
and visit number four for SNEI groups) using a
structured questionnaire (Home Asthma Educational
Intervention form) and demonstration of nebulizer
use. Additionally, parents answered the following
questions in the subsequent order. What symptoms
do you use to decide when your child needs to use a
nebulizer? Do you count the number of times your
child is breathing when he/she is coughing or wheezing? Do you give your child asthma medication when
he or she starts to cough? Do you give your child
asthma medication when your child starts to
wheeze? Do you make an appointment for your
child with their pediatric health care provider for
asthma care even if your child is not sick, that is,
preventive asthma care? Do you check the expiration
dates of your childs asthma medications? How often
do you usually clean the mouthpiece and cup that
holds the medicine for your childs nebulizer? At the
end of the evaluation session, each parent was rated
on an 8-point checklist for demonstrating the setup
of a nebulizer treatment.
Butz et al.: Home-Based Asthma Self-Management Education
193
TABLE 2. Symptom/Nebulizer Educational Intervention (SNEI) Home Visit Checklist
Symptom/Nebulizer Educational Intervention Home Visit Checklista
Childs name
Nurses name
____________________________________ ID ____________________________________
____________________________________ Date of visit _____________________________
Done
Not done
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
&
Introduction
Review purpose of home visit.
Review patients information sheet (address, phone, and contact list).
Current asthma management using nebulizer
Review all asthma medications in home that child is currently using (type of medication, dosage,
and frequency of administration).
Review how each medication works (controller or rescue medication) and how administered
(oral, metered dose inhaler, diskus, and nebulizer).
Review nebulizer administration techniques:
* Measure correct amount of medication and put in the nebulizer cup.
* Attach the mouthpiece to the T-piece and then attach this unit to the cup OR attach
the mask to the cup.
* Turn on air compressor machine.
* Put the mouthpiece into the childs mouth. Seal the lips tightly around the mouthpiece OR place
the mask on the childs face.
* Take slow deep breaths holding breath for 1—2 seconds before breathing out.
* Continue breathing with mouthpiece or mask until the medicine is gone from the nebulizer cup.
This usually will take 10—12 min.
* Store the medicine in a safe place after each use.
Check flow rate of nebulizer machine: use flow meter. If flow rate is low, assist family in obtaining
new nebulizer.
Nebulizer cleaning and maintenance (ask parent to demonstrate how they clean
the childs nebulizer after each use or once a day)
Remove mask or mouthpiece and T-piece from the cup; and rinse the mask or mouthpiece and
T-piece in warm running water for 30 seconds. Remind parent that tubing should not be washed
or rinsed.
Shake off excess water and air dry on clean cloth or towel.
Put mask or mouthpiece and T-piece, cup, and tubing back together and connect to compressor.
Run compressor for 10—20 seconds to dry inside of tubing.
Disconnect tubing from compressor, store in nebulizer machine, and place cover on compressor.
Nebulizer cleaning and maintenance (ask parent to demonstrate how they clean
the childs nebulizer once or twice a week)
Remove mask or mouthpiece and T-piece from the cup.
Wash the mask or mouthpiece and T-piece with a mild dishwashing soap and warm water.
Rinse under a strong stream of water for 30 seconds.
Soak for 30 min in solution of one part white vinegar and two parts distilled water and
throw out vinegar water solution after use. Teach parent
NOT TO REUSE VINEGAR SOLUTION.
Rinse nebulizer parts, excluding tubing under warm running water for 1 min.
Shake off excess water and air dry on clean cloth or towel
Put mask, mouthpiece, T-piece, cup, and tubing back together and connect to compressor.
Run machine for 10—20 seconds to dry inside of nebulizer.
Disconnect tubing from compressor, store in ziplock bag.
Clean surface of compressor with well-wrung, soapy cloth or sponge.
May use alcohol or disinfectant wipe. Teach parent that
NEVER PUT COMPRESSOR IN WATER.
Place cover on compressor.
Call the telephone number on the nebulizer machine to schedule a delivery for new tubing and
masks when needed.
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Symptom identification teaching
Discuss how parent identifies symptoms of asthma episode (retractions, nasal flaring, wheeze,
fatigue, and irritability)
Discuss rate of breathing and teach normal respiratory rates for children. Discuss what is a
high respiratory rate for children.
Age (years)
Breaths per minute (Siberry and Iannone, 2000)
2—4
20—30
5—9
20—25
10—14
17—22
15 years+
15—20
If child is also 5 years of age, teach use of peak flow meter (PFM) or review technique. Provide child
with PFM if not in home.
Discuss how to recognize a severe asthma attack (Eggleston 2001):
* Flared nostrils with blue or gray lips
* Tendency to lean forward with shoulders held high
* Over-inflated chest with depressed rib spaces
* High breathing rate (see above)
* Inability to say more than a few words between breaths
* A PFM reading less than half of the childs personal best (for children who use PFM)
Ask parent to list how child looks and acts when having a BAD breathing day. Put symptoms in order
of importance.
Ask parent to list how child looks and acts when having a GOOD breathing day. Compare answers
with BAD breathing day.
Discuss the symptoms of BAD breathing day as warning signs of difficulty breathing.
Access to health care for child
Ask parent when is childs next primary care appointment or appointment with allergy or
pulmonology specialist. Remind parent that child should be evaluated for asthma at least
every 4—6 months.
Time visit started:_ __:_ _.
Time visit ended:_ __:_ _.
&
&
a
Boxes checked during home visit when teaching completed.
Statistical analysis.
The evaluation data, obtained from the Home
Asthma Educational Intervention forms, were
analyzed using SPSS PC version 11.5 statistical
program (Statistical Package for Social Scientists,
2000). Initially, frequency distributions were examined for all sociodemographic, health, asthma management, and treatment variables included in the
conceptual model. We then used the chi-square
test to compare the distribution of categorical variables and the t test for comparisons of continuous
variables, that is, symptom identification, decision
to treat, and nebulizer use, by the asthma educational group (SAE versus SNEI). For severity level,
children were categorized into two groups based on
frequency distributions of asthma severity: mild
intermittent and mild persistent (n = 137) versus
moderate to severe persistent (n = 73). Asthma
management variables were then compared
between the two severity groups using chi-square
test and t test.
Findings
Sociodemographic and health
characteristics of the child sample.
As summarized in Table 3, children enrolled in this
study and receiving all home visits (n = 210) were
young, and primarily male, African American and
reported medical assistance as their type of health insurance. Overall, the asthma morbidity was high in this
group of inner city children, in that most children were
categorized under mild to severe persistent asthma and
reported a mean of almost three courses of oral steroid
use during the past year. After enrollment, six children
were classified under mild intermittent asthma and
were included in the analysis. Nebulizer use had been
low to moderate during the past month for each child. Of
note is that less than half of the families reported having
an asthma action plan for their childs asthma in the
home. There were no significant differences in any
sociodemographic or health characteristics between
the two educational groups (SAE and SNEI).
Butz et al.: Home-Based Asthma Self-Management Education
195
TABLE 3. Sociodemographic and Health Characteristics of Children by Educational Group Status
Characteristic
Sociodemographic characteristics
Ethnicity/race
African American
Gender
Male
Mean child age (SD)
Parent (n = 202)
Mother
Father
Relative/legal guardian
Missing
Type of health insurance
Medical assistance
Private
Self-insured or other
Parent educational level
Some high school
High school graduate/GED
Some college or trade
College graduate
Child health characteristics
Asthma severity
Mild intermittent
Mild persistent
Moderate persistent
Severe persistent
Number of oral steroid courses
used past year (mean, SD)
Number of ED visits past
six months (mean, SD)
Nebulizer use in last month
(number of days/week) (mean, SD)
Asthma action plan in home (yes)
SAE (n = 105)
n (%)
SNEI (n = 105)
n (%)
Total sample (n = 210)
n (%)
97 (92.4)
90 (85.7)
187 (89.0)
66 (62.9)
4.51 (2.0)
71 (67.6)
4.54 (2.1)
137 (65.2)
4.53 (2.0)
94 (91.3)
3 (2.9)
6 (5.8)
1 (0.9)
90 (91.8)
2 (2.0)
6 (5.1)
184 (91.5)
5 (2.5)
12 (5.9)
1 (0.5)
81 (77.1)
21 (20.2)
3 (2.9)
84 (80.0)
18 (18.4)
2 (2.0)
165 (78.6)
40 (19.0)
5 (2.4)
21 (20.0)
43 (40.9)
34 (32.3)
7 (6.7)
29 (27.6)
39 (35.1)
30 (28.6)
7 (6.7)
50 (23.8)
82 (39.0)
64 (30.5)
14 (6.7)
2 (1.9)
62 (59.0)
27 (25.7)
14 (13.3)
2.73 (2.1)
4 (3.8)
69 (65.7)
18 (17.1)
14 (13.3)
3.06 (4.8)
6 (2.9)
131 (62.4)
45 (21.4)
28 (13.3)
2.89 (3.7)
2.10 (3.0)
1.92 (2.6)
2.0 (2.8)
2.72 (2.8)
3.12 (2.7)
2.92 (2.8)
43 (41.0)
38 (36.2)
81 (38.6)
Note: SAE, standard asthma education; SNEI, symptom/nebulizer education intervention; ED, emergency department.
Asthma symptom management practices by
educational group.
Most families completed all assigned educational
home visits with a mean of 2.86 (SD 0.5, range 0—3)
out of three visits for the SAE group and a mean of 5.6
(SD 1.2, range 0—6) out of six visits for the SNEI group.
As summarized in Table 4, overall, symptom identification and self-management skills significantly
improved from preintervention to postintervention
for all variables (give child asthma medication when
child starts to have cough, wheeze, and inability to
talk; count child respirations when child is coughing
or wheezing; and make an appointment with childs
physician for asthma care even when child is not sick).
The two asthma management skills that were not dif-
ferent between preintervention and postintervention
were (a) checking their childs medications for expiration dates and (b) cleaning the nebulizer medicine cup
and mouthpiece after each use, both endorsed by the
majority of parents. Rates of parents reporting yes to
symptom identification skills, for example, giving children medication for wheeze, giving children medication for inability to talk, giving children medication for
cough, and counting the childs respirations when he/
she is coughing or wheezing were all significantly
higher at postintervention as compared with preintervention rates. Of note is that significantly more children in the post-SNEI group reported they would treat
cough symptoms than those in the post-SAE group
(post-SAE: 75% versus post-SNEI: 84%, p = 0.05).
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In general, most parents demonstrated appropriate nebulizer use at postintervention. Measurement of parent nebulizer-use technique was not
collected at preintervention. Mean scores for both
educational groups were 7 on the 8-point checklist
indicating appropriate technique when using the
nebulizer. There were no significant differences in
the nebulizer-cleaning frequency by educational
group or between preintervention and postintervention time periods. Only one family reported it had
never cleaned their childs nebulizer.
Asthma symptom management practices by
severity level.
There were no significant differences by asthma
severity group (mild intermittent to mild persistent
versus moderate to severe persistent) related to having an asthma action plan in the home, administering asthma medication for asthma symptoms,
counting the number of times the child breathes
when he/she is coughing or wheezing, making an
May/June 2005
appointment with the childs physician for asthma
care even if the child is not sick, and checking if the
childs medications are outdated.
Discussion and Implications
Overall, this group of inner city children with persistent asthma experienced a high rate of asthma
morbidity and reported some deficient asthma selfmanagement practices. The goal of symptom management, the clinical foundation for this study, is to
avoid and delay negative outcomes of asthma including wheeze and cough symptoms. One component of
the model of symptom management targets symptom experience, including how parents evaluate
when to treat their childs asthma symptoms. Despite
most families reporting that they would treat symptoms of wheeze and inability to talk while breathing,
at postintervention, over 20% still reported they
would not treat cough symptoms. Treating cough
TABLE 4. Asthma Symptom Identification, Self-Management, and Nebulizer-Use Variables by Educational Group Status
Home symptom management characteristic
Symptom identification and
self-management variables
Give child asthma medication
when child starts to cough (yes)
Give child asthma medication
when child starts to wheeze (yes)
Give asthma medicine for
Child Unable to Talk (yes)
Count child respirations when child is
coughing or wheezing (yes)
Make an appointment with child’s physician
for asthma care even if child is not sick (yes)
Check child’s medications to make sure
not outdated (yes)
Nebulizer-use variables
Nebulizer-use checklist—range 1—8 (mean, SD)
How often clean medicine cup and
mouthpiece/mask of nebulizer
After each use
Every 2—3 days
Weekly
Monthly/when dirty/never
Total sample
preintervention
(n = 221)
n (%)
SAE
postintervention
(n = 99)
n (%)
SNEI
postintervention
(n = 93)
n (%)
Total sample
postintervention
(n = 192)
n (%)
96 (43.4)
74 (74.7)
78 (83.9)
152 (78.8)a,b
204 (93.2)
99 (100)
88 (94.6)
187 (98.4)a
188 (85.8)
94 (97.9)
89 (97.8)
183 (97.9)a
75 (33.9)
68 (70.8)
59 (65.6)
127 (68.3)a
153 (69)
88 (88.9)
86 (92.5)
174 (90.6)a
217 (98.2)
98 (99)
91 (97.8)
189 (98.4)
6.97 (1.6)
7.14 (1.7)
7.05 (1.6)
75 (80.6)
9 (9.7)
6 (6.4)
3 (3.3)
77 (85.6)
3 (3.3)
6 (6.7)
2 (2.3)
152 (83.1)
12 (6.6)
12 (6.6)
5 (2.4)
167 (75.9)
22 (10)
9 (4.1)
22 (10)
Note: SAE, standard asthma education; SNEI, symptom/nebulizer education intervention.
a
p < 0.01 between baseline, SAE, and SNEI groups.
b 2
w = 4.02, df = 1, p = 0.045 between SAE and SNEI groups.
Butz et al.: Home-Based Asthma Self-Management Education
symptoms with asthma medication was the only
significant educational content associated with receiving the symptom management/nebulizer intervention educational program. This is significant
because cough is thought to be a marker of airway
inflammation and increased cough frequency may be
a sensitive clinical marker of airway inflammation
(Li et al., 2003; Wamboldt, 1998). Underestimation
of symptom severity and delay in treatment of symptoms are associated with increased asthma morbidity
and mortality (Halterman, Aligne, Auinger, McBride,
& Szilagyi, 2000; Halterman et al., 2002; Lieu et al.,
1997). Furthermore, cough was the most prevalent
asthma symptom reported by children during an
acute asthma episode (Burkhart & Ward, 2003;
Yoos & McMullen, 1999). Appreciation of cough as
an early asthma symptom is often not emphasized in
asthma self-management or clinic educational programs (Burkhart & Ward, 2003). Moreover, accurate
symptom identification by the parent is critical information for the childs health care provider to accurately determine the childs asthma severity level and
prescribe appropriate therapy (Yoos et al., 2003).
Inaccurate symptom identification, noted in this
study, did not occur at levels reported in previous studies. In a study of children diagnosed with mild to
moderate asthma, one third of their parents made clinically significant errors in judging the severity of their
childs asthma symptoms including both overestimating and underestimating the symptom severity (Yoos
et al., 2003). Families at risk for inaccurately identifying
asthma symptoms included children with the greatest
asthma severity (Yoos et al., 2003), a finding not supported by our data. This may be explained in that our
child sample included over one third of children with
moderate to severe persistent asthma.
The primary educational content presented to the
parent in this study included symptom identification,
home self-management skills, and accurate use of a nebulizer device. Traditional home asthma educational interventions often do not adequately address symptom
identification, when to initiate self-management strategies, or when to seek medical care. This suggests that
parents of young children with persistent asthma may
require more targeted, interactive asthma education on a
regular basis rather than brief review of symptoms and
medication use during an acute episode or well-child visit.
While we acknowledge that most families may have
received adequate information regarding appropriate
nebulizer use during office or clinic visits, we found that
197
many families did not know how to obtain new nebulizer
tubing or masks and frequently requested these supplies
from the community health nurse. Furthermore, in our
study, one out of six children did not report cleaning the
nebulizer medication cup or mask after each use as
recommended by nebulizer device companies.
Despite the high morbidity noted in these children, only one third of the families reported having
an asthma action plan in the home to direct parents
what, when, and how to treat symptoms at home.
Although written asthma action plans may not directly
improve asthma outcomes (Lefevre et al., 2002),
families are more likely to treat early symptoms of
asthma with clear instructions on an asthma action
plan. Initiation of an asthma action plan in the home
and encouraging families to review the plan with the
childs health care provider at each clinic and emergency room visit theoretically should improve appropriate self-management of asthma in the home and
prevent progression to more serious episodes. On the
other hand, we may have underestimated the presence
of asthma action plans in the home because some
families did not recognize the asthma action plan
when shown the form. In either case, teaching parents
to post the asthma action plan in common areas such
as the refrigerator provides clear instructions as to how
to treat the childs acute asthma episodes at home.
Of note is the high completion rate of the home
visits. Ninety-five percent of families were located,
and most children received a complete course of the
educational intervention for each group. The high
home visit completion rates are attributed to experienced community health nurses with flexible schedules and excellent tracking skills and educational
content that was novel to most families. Parents
were not compensated for the home visits as a condition of enrolling in the study. While both interventions were delivered by all of the community health
nurses, this may have resulted in the SAE group
receiving more than basic asthma education and
account for the lack of significant difference between
the two educational groups for most symptom management characteristics. We attempted to control for
this with monthly review of the separate educational
protocols with each community health nurse.
Several issues may limit the generalizability of
this studys findings beyond inner city children with
mild to severe persistent asthma. Home asthma
management practices including symptom identification were based on parents self-report rather than
198
Public Health Nursing
Volume 22
Number 3
objective measures of cough, wheeze, and shortness
of breath symptoms. In addition, our data may
underestimate asthma symptom and health care
utilization. However, a previous report indicates that
parental self-reports of childrens urgent care visits
for asthma were in high agreement (91%) with medical record data (Pless & Pless, 1995). Nonetheless,
even if we underestimated symptom reports, other
measures of symptoms including use of a nebulizer
for a mean of 3 days in last month suggest that the
children in this sample are symptomatic and perhaps
their parents are underestimating their asthma
symptoms. One additional caveat with this study is
that we are unable to determine if the improvement
in parent knowledge was due to the specific educational content delivered in the home, the dose of the
educational intervention, or simply having a nurse
conduct a home visit. Last, we were unable to measure appropriate nebulizer use preintervention for
comparison with postintervention behavior.
When working with parents of children with persistent asthma, nurses routinely need to teach early
identification and treatment of both cough and
wheeze symptoms. In addition, home asthma educational programs should address accurate symptom
identification, address when to initiate appropriate
treatment for symptoms, and provide a demonstration of the various asthma medication delivery devices
including MDIs, nebulizers, and diskus.
In summary, this group of inner city children
with persistent asthma experienced a high rate of
asthma morbidity and reported some deficient
asthma self-management practices. Despite most
families reporting that they would treat late symptoms of asthma, that is, wheeze and inability to talk,
over 20% reported they would not treat cough symptoms at postintervention. Despite the high morbidity
noted in these children, only one third of the families
reported having an asthma action plan in the home
to direct parents what, when, and how to treat symptoms. Initiation of an asthma action plan in the
home and reviewing the plan with the childs health
care provider may promote appropriate self-management of asthma in the home.
Acknowledgments
This study was funded by the National Institute of
Nursing Research, NIH (NR05060). The authors
May/June 2005
acknowledge the participation of the families and
children in the study.
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