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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: Patient Educ Couns. 2020 Sep 15;104(4):865–870. doi: 10.1016/j.pec.2020.09.011

The Development and Preliminary Impact of CAMP Air: A Web-based Asthma Intervention to Improve Asthma Among Adolescents

Jean-Marie Bruzzese 1, Maureen George 1, Jianfang Liu 1, David Evans 2, Sylvie Naar 3, Melissa E DeRosier 4, James M Thomas 4
PMCID: PMC7956908  NIHMSID: NIHMS1633356  PMID: 33004234

Abstract

Objective:

Describe the development and preliminary impact of CAMP Air, a web-based intervention for adolescents with uncontrolled asthma.

Materials and Methods:

CAMP Air was developed using an iterative process with input from stakeholders and incorporating usability testing results (n=14 adolescents). To test CAMP Air’s initial impact, 61 adolescents from two New York City public high schools (n=37) and from clinics, community-based organizations, and third-party recruitment services (i.e., community sample; n=24) were enrolled in a randomized pilot trial. Participants were randomized to CAMP Air (n=30) or information-and-referral control intervention (n=31). A point-person worked with school participants to complete CAMP Air.

Results:

CAMP Air participants were satisfied with the intervention and its value for supporting self-management, completing on average 6 of 7 modules. Relative to controls, CAMP Air participants demonstrated significantly improved asthma knowledge, asthma control, night wakening and school absences, and less risk for urgent care visits. Adolescents enrolled in schools completed more modules and had significantly fewer nights woken and school absences than community enrollees.

Conclusion:

CAMP Air improves asthma outcomes among adolescents with uncontrolled asthma.

Practice Implications:

A web-based intervention CAMP Air is a promising intervention. When a point-person works with adolescents, CAMP Air’s access and impact are improved.

Keywords: Web-based program, adolescents, asthma, treatment

1. Introduction

Asthma is the most common pediatric chronic illness and has high prevalence and morbidity among adolescents [1–3], with some studies documenting greater asthma-related morbidity and mortality among adolescents than younger children [4–6]. Asthma-related activity limitations increase with age [7]. Compared to peers without asthma, adolescents with asthma miss more school days and have lower graduation rates [6, 8, 9]. The economic burden of uncontrolled asthma is substantial [10], and adolescents (ages 12–17) have higher asthma-related annual health care expenditures than children (ages 6–11) [11].

Adolescence encompasses distinct biological, social, emotional, and cognitive changes [12, 13] that render teenagers ready to be effective self-managers [14, 15]. It is a critical time for reaching developmental milestones, including establishing healthy behaviors with lifelong self-care patterns forming at this time [12–14]. Thus, there is a need to leverage adolescent’s developmental strengths to improve asthma self-management. Yet, there are few scalable asthma interventions tailored to adolescents, representing a significant gap given the high asthma prevalence and morbidity among this population.

Online learning has been shown to be effective for adolescents, enhancing learning over traditional instruction (e.g., in-person) [16]. Adolescents with asthma report that they want e-health interventions that are engaging and informative with practical solutions they can incorporate into their daily life to support self-management strategies (e.g., visual aids, ways to cope with stress) [17–20]. Despite this, there is a dearth of asthma e-health interventions for adolescents,[18, 21] and these interventions have only used apps, do not teach self-management skills, often fail to use behavior change mechanisms, and have shown mixed results [21–25]. The exception to this is Puff City [26], but it has only been tested with African American youths limiting application to others.

To address this, we developed Controlling Asthma Program for Adolescents (CAMP Air), an innovative e-health intervention to improve asthma outcomes among adolescents with uncontrolled asthma. This paper (1) describes the development of CAMP Air and (2) presents feasibility, acceptability and preliminary outcome data from a randomized pilot trial. We hypothesized that CAMP Air will be feasible to implement, be acceptable to adolescents, and improve asthma outcomes among adolescents with uncontrolled asthma.

2. Methods

The Institutional Review Boards of the Columbia University Irving Medical Center, 3C Institute, New York University Medical Center, and the New York City Department of Education approved study procedures. Caregiver consent and adolescent assent were obtained from all participants. A Data Safety and Monitoring Board comprised of four members with no direct study involvement oversaw the study.

2.1. Development of CAMP Air

We developed CAMP Air using a rigorous, iterative process. A team of asthma experts (n=3), a motivational interviewing expert, and experts in the development of e-learning tools (n=4) first wrote seven online modules. Modules use the main tenets of Asthma Self-Management for Adolescents (ASMA) [14, 27], our team’s empirically-based in-person intervention. Stakeholders, comprised of pediatric pulmonologists (n=2), behavioral medicine experts (n=2), teachers (n=3), and high school students (n=2), reviewed each module; we revised the modules based on their feedback. Briefly, each module provides asthma self-management strategies followed by a set of interactive games and exercises for practice and personalized feedback. Adolescents complete a daily asthma checklist online or through a smartphone app recording symptoms, medication use and trigger exposure; responses prompt a tailored report regarding their asthma control, which the adolescents can view online or download to share with family and/or medical providers. Module completion is spaced by one week to allow adolescents time to practice the skills taught, to complete the checklist and to teach their family about asthma.

Next, we conducted usability testing with 14 adolescents with asthma; three dropped out, resulting in a final sample size of 11 (mean age=15; 73% female; 64% Black). Adolescents rated each module for usability, acceptability and understanding, and provided feedback on ways to improve CAMP Air. They receive email and/or telephone reminders to complete modules. Adolescents spent approximately 30 minutes completing each module. All participants completed all seven modules in an average of three months (95 days) with 15.8 days between modules. They were sent on average 1.3 email and/or telephone reminders per module. Adolescents reported few problems completing the modules: slow or unreliable Internet connections resulted in connectivity issues (n=3) and/or difficulty streaming audio/video (n=1). Adolescents who completed the checklist via the app were more likely to complete the checklist every day or by the next day than those who only completed the checklist online (71% vs. 23%). They gave the program strong ratings, finding it informative, engaging, and appealing; 80% reported wanting to use CAMP Air outside of this study to help them control their asthma. All found the email reminders to complete the modules helpful; 33% wanted additional reminders by telephone. A few adolescents offered suggestions to improve CAMP Air, which we incorporated into the next iteration of the modules when possible. For example, we now make telephone calls on the day the next module is available to the adolescents to inform them the module is ready for completion.

2.2. The Randomized Pilot Study

2.2.1. Participants.

We enrolled 61 adolescents (mean age 15.2; 67% female; 36% Hispanic; 32% Black/African American; 16% White; 16% More than 1 race/ethnicity) with uncontrolled asthma from (1) two New York City public high schools (n=37) and (2) geographically diverse clinics, community-based organizations and third-party recruitment services (n=24). Inclusion criteria included: (1) a prior asthma diagnosis; (2) use of asthma medication in the past 12 months; and (3) uncontrolled asthma, defined as having in the past 12 months (a) daytime symptoms 3+ days a week, (b) night awakenings 1+ nights per week, or (c) 2 or more exacerbations [i.e., steroid bursts or asthma-related ED visits or hospitalization]; and (5) English proficient because the intervention is currently available only in English. To allow broad generalization of study findings, the only exclusion criterion was co-morbid diseases that affect lung functioning.

2.2.2. Randomization.

Participants within each enrollment modality were randomized to CAMP Air (n=30) or information-and-referral control intervention (n=31). Randomization took place following completion of baseline assessments to conceal assignment to participants and study staff during baseline assessments.

2.2.3. The CAMP Air Intervention.

The final version of CAMP Air consists of seven modules with core instructional topics and tailored sessions, embedded hands-on interactive activities, personalized feedback, and dynamically generated supplemental resources geared towards adolescents with uncontrolled asthma. Intervention tailoring is essential because asthma presents with inter-individual variations in symptom presentation and management based on lifestyles and disease characteristics [28]. Grounded in social cognitive theory [29, 30] and motivational interviewing [31], each module intermixes instruction (for definition and description of concepts) with self-assessments, videos, and interactive practice opportunities (for exploration and application of learned concepts, which is needed to build asthma self-management skills). In a step-wise fashion, the user experiences a series of brief videos with motion graphics, real video, voiceover to accommodate low literacy, music, and sound effects punctuated with interactive exercises tailored to learning goals. Consistent with the notion of developing a population-based intervention, we used animated animals in the videos and games to increase generalizability to different cultural groups.

Modules include (1) information and feelings about asthma (e.g., adolescent friendly graphics and definitions to understand that asthma is a chronic, lifelong disease involving inflammation; learning how uncontrolled asthma limits them); (2) the importance of seeing a medical provider and tips on how to talk to their family about their asthma; (3) purposes of quick-reliever and controller medications and how to use them; (4) review to reinforce the messages taught to date and provide feedback on self-management skills, their specific barriers to seeing a medical provider and tips to overcome them, and asthma action plans; (5) addressing concerns over taking asthma medication (e.g., addictive); (6) trigger management, including resources to help the teenagers stop smoking cigarettes or marijuana; and (7) the role of stress in triggering asthma and controlling stress using relaxation techniques. The motivational interviewing strategies allow for personalized feedback. Examples include having the adolescent complete confidence rulers regarding self-management tasks (e.g., take medication properly) or rate how ready they are to take certain actions (e.g., make an appointment to see a medical provider), and choose reasons why.

Responses to the daily asthma checklist prompt a tailored report providing feedback on the adolescents’ self-management efforts and asthma control over the past seven days. The report is accessible via smartphone or the web-based program, and can be printed to share with a medical provider. Adolescents are also guided in their transition to being consumers and teaching them to navigate the health system. Throughout CAMP Air, the importance of seeing their medical provider for an evaluation and appropriate treatment is emphasized. A research assistant asked each adolescent if he/she had a medical provider and referrals were made as needed.

2.2.4. The information-and-referral intervention.

Adolescents randomized to the information-and-referral control intervention were given written educational materials used in our prior studies regarding asthma and stress. They learned about (1) asthma symptoms, medications and triggers, and ways to control their asthma, and (2) stress, including what stress is, when stress can be good for us and when it becomes harmful, sources of stress, the impact of stress on health (including asthma, diet, and sleep), and ways to reduce stress. They were also encouraged to access asthma education websites which were provided to them, and were asked to monitor their asthma and/or sleep by using daily paper-and-pencil diaries. In a 15-minute orientation session, trained health educators walked the adolescents through the educational handouts, provided them with a list of relevant asthma websites, and taught them how to use the diaries. The health educator asked each adolescent if he/she had a medical provider and made a referral if they did not.

2.2.5. Intervention delivery.

CAMP Air school participants worked closely with a study staff member who served as a point-person bringing participants to a room with a computer to complete each module; while this person may have established rapport with participants as they walked to and from the intervention room and may have provided the adolescents with a referral for a medical provider, the point-person did not intervene in any other way. CAMP Air community participants did not live in one location, precluding a point-person from working with them. Instead, they received an email informing them when it was time to complete each module; reminders were sent via telephone, text, and/or email. The health educator met with control participants as detailed above in person (school sample) or by telephone (community sample).

To reduce student to student contamination, we emphasized the importance of minimizing discussion of intervention content with other students and instructed CAMP Air students to not share their CAMP Air passwords with others or share the materials they may download. The risk of staff to student contamination was low given staff were not delivering the intervention. However, to be cautious, we trained staff to be mindful of contamination and how to handle scenarios where there is potential risk for it.

2.2.6. Measures and interview schedule.

Research assistants blind to treatment-control status interviewed adolescents in person for the school sample or by phone for the community sample. Assessments were completed pre-intervention, immediate post-intervention and 1-month follow-up. Participants were compensated $20 for each completed assessment. Adolescents answered 40 true/false questions assessing their asthma knowledge [14, 27]. We assessed asthma control several ways. Adolescents completed the Asthma Control Test (ACT) [32–34], a 5-item patient-centric survey that utilizes continuous scores and classifies participants as having well-controlled asthma (yes/no). Using questions from our prior research,[27, 35–37] they also reported the past two-week frequency of symptom days, nights woken due to asthma, and days with asthma-related activity limitations, including school absences, as well if they had an asthma-related urgent care visit (i.e., acute care office visits, emergency room visits and hospitalizations) in the past 12 months at baseline, and the frequency of such visits since the last assessment at each follow-up interview (i.e., immediate post-test = since the baseline interview and 1-month follow-up = since the immediate post-intervention assessment). Because of the relatively few post-test urgent care visits reported due to the short assessment period, we combined data from immediate post-test and 1-month follow up, and collapsed urgent care visits into yes/no for baseline and follow-up. We also used Whalgren’s asthma symptom scale[38] to measure the past two week symptom severity. Adolescents completed the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) [39], which has three subscales: (a) symptoms; (b) emotions; and (c) degree of interference with physical activities. To assess the acceptability of CAMP Air, adolescents randomized to CAMP Air rated at immediate post-test CAMP Air’s quality, usefulness, and relevance to real-life. We used software usage metrics to assess CAMP Air’s reach.

2.2.7. Data analysis.

Following the intent-to-treat principle [40], to test treatment effects we used general linear, logistic, and Poisson mixed effect regression models controlling for baseline value of outcomes with enrollment method as a fixed effect; to aid in the interpretation of the results, odds ratios estimated from the logistic regression models were converted to risk ratios. For school absences, because a given two-week reporting period did not always have 10 school days due to days off, we calculated a proportion of school absences by dividing the number of school absences reported by the number of days school was in session during the two-week time period. We also explored differences in enrollment method on module completion and outcomes.

3. Results

3.1. CAMP Air’s Acceptability

The vast majority of participants (96%) believed CAMP Air’s information would be easy to understand for most teenagers and the amount of information was not too much for teenagers to process (92.3%). They reported it was easy to relate to the characters (84%) and the examples (72%), and that the activities were interesting (92%) and easy to complete (92%). With respect to usability, they all reported the time needed to complete modules was just right, 96% reported the website was easy to navigate, and 92% liked the website’s layout. Most (92%) would recommend CAMP Air to other teenagers with asthma, reporting that the intervention would help them learn ways to manage asthma (92%) and follow their health care provider’s instructions (100%).

3.2. CAMP Air’s Reach

On average, CAMP Air participants completed 6.0 modules (SD=2.1; range=0–7), with an average of 8.8 days between modules (SD=3.2, range=7–27). Completion of each module took on average 17.9 minutes (SD=7.6). While there were no differences in completion rate by race/ethnicity, females completed more modules than males (mean of 6.6 vs. 4.7, p<.05).

3.3. Preliminary Short-term Treatment Effects

Table 1 details treatment effects over 1-month follow-up. Relative to controls, controlling for baseline values, CAMP Air participants reported significantly improved asthma knowledge and had significantly higher follow-up ACT scores, indicating better asthma control. A greater proportion of CAMP Air participants than controls (40% VS 26%, respectively) were classified as having well-controlled asthma on the ACT with marginal significance, and while there was no improvement in daytime symptoms, CAMP Air participants had significantly lower incidence of waking at night in the prior two weeks. CAMP Air participants and controls did not differ on days with activity limitations, but CAMP Air participants had a significantly lower proportion of school absences in the prior two weeks. The risk of asthma-related urgent care visits was lower by 69% for CAMP Air participants. There were trends towards less severe symptoms among CAMP Air participants who also reported significantly improved PAQLQ scores in the symptom domain.

Table 1.

Treatment Effects Over One Month

Raw Data Model-based Inferences
CAMP Air Post-test Mean (SD) Control Post-test Mean (SD) Adjusted Mean Differencea (95% CI) P Value
Asthma knowledge 34.88 (2.21) 31.98 (3.3) 2.84 (1.90, 3.77) <.0001b
ACT Score 18.42 (3.10) 16.83 (4.16) 1.93 (0.83, 3.03) <.0001b
Proportion of school absences in prior 2 weeks 0.03 (0.062) 0.14 (0.30) 0.07 (−0.14, −0.009) 0.03b
Symptom severity 5.02 (2.86) 6.09 (3.36) −1.07 (−2.17, 0.02) 0.08b
PAQLQ: symptom domain 5.21 (1.00) 4.74 (1.30) 0.42 (0.01, 0.82) 0.04b
Adjusted Risk Ratio or Incidence Rate Ratio (95% CI)
% with well controlled asthma as measured by the ACT (% (SD)) 40 (49) 26 (45) 1.86 (0.97, 3.19)c 0.06
# days with symptoms in prior 2 weeks. 3.90 (3.08) 4.78 (3.59) 0.86 (0.64, 1.14)d 0.29
# night wakening in prior 2 weeks 1.08 (1.44) 3.07 (3.34) 0.36 (0.22, 0.61)d 0.0002
# days with activity limitations in prior 2 weeks 1.44 (1.86) 2.09 (3.42) 0.76 (0.43–1.34)d 0.34
% with asthma-related urgent care visit (% (SD)) 12 (32) 41 (49) 0.31 (0.10, 0.99)c 0.04
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Definition of abbreviations: ACT = Asthma Control Test; PAQOL = Pediatric Asthma Quality of Life Questionnaire; SD = standard deviation

a =

Adjusted mean difference = CAMP Air model-based mean – control model-based mean

b =

General linear regression adjusting for baseline level

c =

Risk ratio estimated from logistic regression adjusting for baseline level

d =

Incidence ratio estimated from Poisson regression adjusting for baseline level

3.4. Enrollment Method Differences (Schools versus Community)

School participants completed significantly more modules than community participants (mean=7.0 VS 4.6, p<.001). Compared to school participants, community participants reported more nights woken (β=0.53; 95% CI=0.08, 0.97; p=0.023) and a greater proportion of school absence (β=0.09; 95% CI=0.02, 0.16; p=0.0133). There was no other difference between school and community participants.

4. Discussion and conclusions

4.1. Discussion

CAMP Air represents a shift in clinical practice. It was developed using an iterative process that included feedback from stakeholders, including adolescents, and it capitalizes on the strengths of adolescence to improve how adolescents care for their asthma. In this pilot study we found that CAMP Air was feasible and acceptable, and had positive short-term impact.

Usability scores were mostly high, suggesting that adolescents were generally satisfied with the intervention and its value for supporting self-management. CAMP Air had good reach with, on average, 6 of the 7 modules being completed. The fact that females completed more modules than males is in-line with gender differences in coping among adolescents [41, 42]. For example, females are more likely to engage in problem solving and use approach strategies, while males are more likely to use avoidance strategies [42]. We found significant treatment effects in asthma knowledge and asthma morbidity, including better asthma control and symptom-related quality of life and fewer nights woken, school absences and urgent care visits, and trends in lessened symptom severity.

Of interest is our finding that school participants had better completion rates and treatment outcomes relative to community participants. This suggests that even when using an intervention modality that is adolescent-friendly (i.e., a web-based platform), having a point-person assist the adolescents by providing direct access to the intervention (i.e., picking them up from class and bringing them to a room with a computer where they can complete the modules) may help to improve engagement in CAMP Air and enhance its impact. As such, schools are a logical venue for CAMP Air because they provide adolescents access to computers and have paraprofessionals and health aides who can serve as a point-person at a relatively low cost. Additionally, schools reach a large number of youth [43, 44]. Also, because of the interdependence of health and education (i.e., healthier students are better learners), schools offer a variety of health services, including education for chronic illnesses [45, 46].

Despite the rigor of using a randomized control design, this pilot study has limitations that should be recognized. It was implemented in only two schools, and while the community sample enrollment was open to all those in the United States, the sample is not representative. We are also likely to have had selection bias in that adolescents motivated to control their asthma enrolled in the study. As a pilot study, we had a short follow-up period which precluded us from accounting for the seasonal incidence of asthma [47] or understanding the long-term effects of CAMP Air. Additionally, we did not evaluate the cost-effectiveness of CAMP Air or study factors associated with implementation, both of which are needed to inform CAMP Air’s broad dissemination.

4.2. Conclusions

Results indicate that CAMP Air, a web-based asthma intervention for adolescents with uncontrolled asthma that is grounded in social cognitive theory and motivational interviewing, is feasible to implement and acceptable to adolescents. CAMP Air is a compelling intervention to assist adolescents with uncontrolled asthma improve asthma control and reduce negative outcomes, and is ready for testing in a full scale randomized clinical trial with a longer follow up period [48].

4.3. Practice Implications

CAMP Air is a promising intervention to improve asthma outcomes among adolescents with uncontrolled asthma. When adolescents have someone working with them to provide access to the intervention, CAMP Air’s reach and impact are enhanced. This suggested that schools are an ideal setting for CAMP Air because they not only offer computer access to students and often allocate time for health interventions, but they also have staff who can help students access CAMP Air.

Highlights.

  • CAMP Air is a novel web-based asthma intervention for adolescents.

  • Relative to a control intervention, CAMP Air improves short-term asthma outcomes.

  • Access to CAMP Air at school enhances its reach and potential impact.

Funding Information:

This work was funded by NHLBI, NIH (R44 HL127826; PI’s = Thomas and Bruzzese). Dr. Bruzzese’s preparation of this paper was partial supported by NHLBI, NIH (R01 HL136753; PI = Bruzzese).

Footnotes

Author Disclosure Statement: The authors declare no conflict of interest for this study. The authors confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Trial Registration: Registered at clinicaltrials.gov as NCT02816216 (Usability Testing) and NCT02835300 (Randomized Pilot Trial)

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