How useful is it to deliver asthma education to children, or their caregivers, or both, in the home?

Key messages

– There is limited evidence that home-based education improves quality of life compared with education delivered out of the home, and reduces admissions to hospital compared with a less-intensive education.

– There is not enough evidence to show whether education delivered in the home is better or worse than education delivered outside the home for exacerbations (worsening of asthma) requiring an emergency department visit, treatment with oral corticosteroids (medicine used to treat asthma that reduces inflammation (swelling) in the airways), changes in asthma symptoms or how well the lungs work.

– Well-designed trials are needed to address the exact components of asthma education that are linked with improved asthma knowledge and outcomes.

What is asthma?

Asthma is a chronic (long term) lung condition. People with asthma have inflammation (swelling) in the airways in the lungs. The symptoms are wheeze, shortness of breath, chest tightness and cough.

What is asthma education?

Asthma education aims to teach children and caregivers how to manage their asthma using a partnership between the patient and healthcare professionals. Components of asthma education include information about asthma; training in managing asthma, including how to use inhalers effectively; a management strategy; and encouragement to use medications correctly. Monitoring of asthma, such as with a peak flow meter (a hand-held device that measures how quickly you can breathe out fully) and regular healthcare professional reviews are also components of asthma education.

Why do we think the home might be a good place to give children asthma education?

The home setting allows educators to reach populations (such as those with poorer backgrounds) that may experience barriers to care (such as lack of transportation) within a familiar environment, and prevents a need for attendance at healthcare settings.

This review update is timely because following the COVID-19 pandemic, healthcare policymakers are thinking more broadly about how and where care is delivered.

What did we want to find out?

While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care (no education or education delivered elsewhere). We wanted to consider if the intensity of the education (e.g. how many education sessions were given) had any impact on children with asthma.

What did we do?

We searched for studies delivering home-based education about asthma to children or their caregivers. The education had to be compared to control (either no education or education delivered at a healthcare centre), or to a less-intensive education delivered at home.

We compared and summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We found 26 studies involving 5122 children. Most studies were done in North America. Most families were from poorer areas. Children differed in terms of age, severity of asthma and type of educational intervention.

Results

We found that home-based education may result in little to no difference in exacerbations leading to emergency department visits, but the evidence is very uncertain. We found that there may be little or no difference in the number of courses of oral corticosteroids prescribed (a medicine used to treat asthma that reduces inflammation (swelling) in the airways).

We found there may be some improvement in quality of life with home-based education compared to control, and reduced admissions to hospital with an asthma exacerbation compared to less-intensive education, but the evidence is uncertain.

Asthma symptom-free days and days missed from school or work also showed considerable uncertainty when compared with either control or less-intensive education, and there may be little or no difference in these outcomes.

What are the limitations of the evidence?

The children and families may have known which treatment they received.

There were many differences between the children's asthma severity, the types of education delivered and other factors. There were also many differences between the control groups of the included studies (that is, who the education group was compared to). This makes it difficult to know whether treatments had any impact on children with asthma because the studies were so different.

The aims of a treatment might be different too. For some children whose families have little asthma knowledge, the aim may have been to improve their knowledge of symptoms. This may encourage them to go to the emergency department more often. However, for some children who have poorly controlled asthma and may be going to the emergency department a lot, the aim may have been to decrease the number of emergency department visits. This might be by teaching them how to use their medications properly so they have improved asthma control. This makes thinking about the evidence more complicated.

How up to date is this evidence?

This is the first update of a Cochrane review first published in 2011. The information is current to October 2022.

Authors' conclusions: 

We found uncertain evidence for home-based asthma educational interventions compared to usual care, education delivered outside the home or a less-intensive educational intervention. Home-based education may improve quality of life compared to control and reduce the odds of hospitalisation compared to less-intensive educational intervention. Although asthma education is recommended in guidelines, the considerable diversity in the studies makes the evidence difficult to interpret about whether home-based education is superior to none, or education delivered in another setting. This review contributes limited information on the fundamental optimum content and setting for educational interventions in children. Further studies should use standard outcomes from this review and design trials to determine what components of an education programme are most important.

Read the full abstract...
Background: 

Asthma is a chronic airway condition with a global prevalence of 262.4 million people. Asthma education is an essential component of management and includes provision of information on the disease process and self-management skills development such as trigger avoidance. Education may be provided in various settings. The home setting allows educators to reach populations (e.g. financially poor) that may experience barriers to care (e.g. transport limitations) within a familiar environment, and allows for avoidance of attendance at healthcare settings. However, it is unknown if education delivered in the home is superior to usual care or the same education delivered elsewhere. There are large variations in asthma education programmes (e.g. patient-specific content versus broad asthma education, number/frequency/duration of education sessions). This is an update of the 2011 review with 14 new studies added.

Objectives: 

To assess the effects of educational interventions for asthma, delivered in the home to children, their caregivers, or both, on asthma-related outcomes.

Search strategy: 

We searched Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, two additional databases and two clinical trials registries. We searched reference lists of included trials/review articles (last search October 2022), and contacted authors of included studies.

Selection criteria: 

We included randomised controlled trials of education delivered in the home to children and adolescents (aged two to 18 years) with asthma, their caregivers or both. We included self-management programmes, delivered face-to-face and aimed at changing behaviour (e.g. medication/inhaler technique education). Eligible control groups were usual care, waiting list or less-intensive education (e.g. shorter, fewer sessions) delivered outside or within the home. We excluded studies with mixed-disease populations and without a face-to-face component (e.g. telephone only).

Data collection and analysis: 

Two review authors independently selected trials, assessed trial quality, extracted data and used GRADE to rate the certainty of the evidence. We contacted study authors for additional information. We pooled continuous data with mean difference (MD) and 95% confidence intervals (CI). We used a random-effects model and performed sensitivity analyses with a fixed-effect model. When combining dichotomous and continuous data, we used generic inverse variance, using a Peto odds ratio (OR) and fixed-effect model. Primary outcomes were exacerbations leading to emergency department visits and exacerbations requiring a course of oral corticosteroids. Six months was the primary time point for outcomes. The summary of findings tables reported on the primary outcomes, and quality of life, daytime symptoms, days missed from school and exacerbations leading to hospitalisations.

Main results: 

This review includes 26 studies with 5122 participants (14 studies and 2761 participants new to this update). Sixteen studies (3668 participants) were included in meta-analyses. There was substantial clinical diversity. Participants differed in age (range 1 to 18 years old) and asthma severity (mild to severe). The context and content of educational interventions also varied, as did the aims of the studies (e.g. reducing healthcare utilisation, improving quality of life) and there was diversity in control group event rates. Outcomes were measured over various time points specified in the original studies. All studies were at risk of bias due to the nature of the intervention. It is possible that the participants/educators may not have been aware of their allocation, so all studies were judged at unclear risk for performance bias.

Home-based education versus usual care, waiting list or less-intensive education programme delivered outside the home

Primary outcomes

Home-based education may result in little to no difference in exacerbations leading to emergency department visits at six-month follow-up compared to control, but the evidence is very uncertain (Peto OR 1.22, 95% CI 0.50 to 2.94; 5 studies (2 studies with 2 intervention arms), 855 participants; very low-certainty evidence). Home-based education results in little to no difference in exacerbations requiring a course of oral corticosteroids compared to control (mean difference (MD) −0.18, 95% CI −0.63 to 0.26; 1 study (2 intervention arms), 250 participants; low-certainty evidence).

Secondary outcomes

Home-based education may improve quality-of-life scores compared to control, but the evidence is very uncertain (standardised mean difference (SMD) 0.32, 95% CI 0.08 to 0.56; 4 studies, 987 participants; very low-certainty evidence).

The evidence is very uncertain about the effects of home-based education on mean symptom-free days, days missed from school/work and exacerbations leading to hospitalisation compared to control (all very low-certainty evidence).

Home-based education versus less-intensive home-based education for children with asthma

Primary outcomes

A more-intensive home-based education intervention did not reduce exacerbations leading to emergency department visits (Peto OR 1.36, 95% CI 0.35 to 5.30; 4 studies, 729 participants; low-certainty evidence) or exacerbations requiring a course of oral corticosteroids (MD 0.08, 95% CI −0.14 to 0.30; 3 studies, 605 participants; low-certainty evidence), compared to a less-intensive type of home-based education.

Secondary outcomes

A more-intensive home-based asthma education intervention may reduce hospitalisation due to an asthma exacerbation (Peto OR 0.14, 95% CI 0.04 to 0.55; 4 studies, 689 participants; low-certainty evidence), but not days missed from school (low-certainty evidence), compared with a less-intensive home-based asthma education intervention.

A more intensive home-based education intervention had no effect on quality of life and symptom-free days (both very low certainty), compared with a less-intensive home-based asthma education intervention, but the evidence is very uncertain.