Effect of asthma education on health outcomes in children: a systematic review

Abstract

Background

It remains unknown whether child-oriented asthma education is associated with better health outcomes. This meta-analysis investigated the effects of asthma education on hospitalisation and emergency department and clinic visits.

Methods

We searched the Cochrane Library, PubMed and EMBASE for relevant studies from inception to 4 July 2021, and selected studies that reported hospitalisation or emergency department or clinic visits as outcomes. The participants were only children. Two authors independently selected the studies, assessed the quality of the included studies and retrieved the data. A third senior author was engaged to resolve disagreements. Fifteen longitudinal studies were included for the systematic review and meta-analysis. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 was used as the standard of reporting (PRISMA registration ID is 284509).

Findings

Compared with the control group, the asthma education group had 54% lower hospitalisation risk (95% CI 0.32 to 0.66), and 31% lower emergency department visit risk (95% CI 0.59 to 0.81). Sensitivity analysis showed that the asthma education group had a reduced clinic visit risk (risk ratio (RR)=0.80, 95% CI 0.67 to 0.97). Subgroup analysis showed that asthma education involving both children and parents/guardians was associated with fewer hospitalisations (RR=0.38, 95% CI 0.24 to 0.59) and emergency department visits (RR=0.69, 95% CI 0.57 to 0.83). Asthma education in hospitals or non-hospitals can reduce the risk of hospitalisation and emergency department visits. However, only education in the hospitals was associated with the reduction of clinical visits (RR=0.45, 95% CI 0.22 to 0.92).

Interpretation

Education is effective for controlling asthma, especially for reducing hospitalisation and emergency department and clinic visits. Education involving both children and parents/guardians is more effective than that involving only children. The setting of asthma education does not impact its effect to a large extent.

Introduction

Asthma is a common chronic condition in children with symptoms such as shortness of breath, oppression in the chest, coughing and wheezing, as well as episodes of sudden aggravation.^{1 2} It is widespread and affects 6.1 million children globally, which has a large impact on the quality of life and results in significant death.^{2 3} Asthma-related hospitalisation may also have an impact on educational achievements of children,⁴ and asthma in children is significantly associated with later risk of becoming obese,⁵ which is a risk factor of several chronic diseases.^6–8 In the context of COVID-19, being alert and following the treatment guidelines, as well as implementing preventive measures, are of great importance for improving the outcomes among children with asthma.⁹ Asthma education is one of the preventive measures.¹⁰ The participants and the settings of asthma education vary; some sessions may include only children,¹¹ while some include both children and parents/guardians.¹² The setting of asthma education also differs.^{13 14} Some prior studies have shown that asthma education targeted at children can reduce unscheduled visits and hospitalisations.^15–17 One study found that asthma education was a useful tool for controlling asthma. However, it is not significantly effective in reducing healthcare utilisation when compared with usual care.¹⁸ Another study found no change in emergency department (ED) visits and hospitalisations after paediatric asthma education.¹⁹

As a result, it is still unclear whether asthma education is useful for controlling asthma, and the impact of participants and the setting has also not been established. We conducted this systematic review and meta-analysis to assess the overall effects of child-centred asthma education on health outcomes, including hospitalisations and ED and clinic visits.

Materials and methods

Literature search

We performed this meta-analysis to study the effect of asthma education on hospitalisation and emergency room and clinic visits of children. The Cochrane Library, PubMed and EMBASE were searched for relevant studies from inception to 4 July 2021. The search string was “(child OR pediatric OR kid) AND (asthma) AND education AND (hospitalization OR emergency department visit OR urgent physician visit OR outpatient)” for all three databases (online supplemental table 1). The language was not restricted. Based on the PRISMA 2020 statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses),²⁰ we also conducted additional research on relevant studies (figure 1). The protocol for this systematic review was recorded in PROSPERO with identification number 284509.

Figure 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow chart.

Inclusion criteria and exclusion criteria

Types of participants

The participants were children. Studies that recorded the health outcomes of children and adults were not included. The participants had to be diagnosed with asthma, but hospitalisation in the past was not a restriction.

Asthma education intervention

We did not limit the tools, settings and instructors for asthma education. Some of the included studies focused on drugs, and others focused on the triggers of asthma in the environment. All the included studies assessed the basic information of asthma, such as causes and treatment. The education could involve just children, caregivers, or both children and caregivers.

Outcomes

We generally included three outcomes, which are hospitalisation, emergency room visits and clinic visits. The outcomes were recorded as frequency instead of the number of patients. The clinic visit could be either routine or urgent.

Study design

To investigate the causal relationship between asthma education and health outcomes, longitudinal studies were included. Thus, the outcomes before and after the intervention were collected.

Data extraction and quality assessment

Two independent reviewers, Wen-Yi Liu and Zhu Liduzi Jiesisibieke, screened the studies for inclusion. Finally, 15 studies met the criteria. Author, study year, country, interventions, tools, outcomes, sample, educators, setting and outcomes were extracted from the 15 included studies. The Newcastle–Ottawa Scale was applied to analyse the quality of the included studies. For cohort studies, the selection of study groups (S), comparability (C) and outcome assessment (O) were used.²¹ For case–control studies, apart from the selection of participants (S) and comparability (C), exposure (E) was also used.²² We used funnel plots and Egger’s test to assess the publication bias of the included studies.

Characteristics of the excluded studies

During the screening, some studies were excluded because of incomplete data, and others were excluded for their study design^23–28; we only included longitudinal studies. Some studies were excluded because the participants of asthma education were not only children.^29–31 We just included studies that met our inclusion criteria.

Statistical analysis

Stata V.16.0 SE was used for the statistical analysis, and we presented the risk of health outcomes as risk ratio (RR) with 95% CI and analysed heterogeneity using the I² statistic. The I² statistic is an analytical test that measures the degree of variation between studies due to heterogeneity rather than by chance alone. I² values of 50% or more represent substantial heterogeneity.³²

Results

Characteristics of the included studies

The screening process is illustrated in figure 1. After removing the duplicates, 5200 studies were identified. We referred to the newest checklist of PRISMA to investigate whether the studies met our inclusion criteria. Overall, this study included 15 longitudinal studies, and after detailed analysis, their characteristics are shown in online supplemental table 2. These papers were published between 1991 and 2020, and 10 of them had been conducted in the USA. The outcomes of 12 papers included hospitalisations, and those of 13 papers were emergency visits as suitable outcomes; only six studies were related to the change in clinic visits. There were two main settings: medical establishments, such as hospitals and clinics, and other places. In the early studies, the most common teaching tools were sessions and handouts, so the asthma education all given face to face. Later, technological advancements enabled the internet and videos as useful tools, some of the education courses were online. The risks of bias and supporting evidence are shown in table 1 and online supplemental figure 1. All of these studies are longitudinal; thus, time and other factors may affect the outcomes, which is a bias that cannot be ignored.

Table 1.

GRADE summary of findings

Effect of asthma education on health outcomes in children
Patient or population: children with asthma Setting: USA, France, Spain Intervention: asthma education Comparison: not receiving asthma education
Outcomes	Anticipated absolute effects* (95% CI)		Relative effect (95% CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Risk in control	Risk in experiment
Risk of hospitalisation	814 per 1000	360 per 1000	RR 0.46 (0.32 to 0.66)	2122	⨁⨁⨁◯ Low	NA
Risk of ED visits	1462 per 1000	864 per 1000	RR 0.69 (0.59 to 0.81)	2040	⨁⨁⨁◯ Moderate	NA
Risk of clinic visits	1043 per 1000	1004 per 1000	RR 0.79 (0.67 to 0.97)	438	⨁⨁⨁◯ Low	NA

GRADE Working Group grades of evidence:

High quality: we are very confident that the true effect lies close to that of the estimate of the effect.

Low quality: our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.

Very low quality: we have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of effect.

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

ED, emergency department; GRADE, Grades of Recommendation, Assessment, Development, and Evaluation; RR, risk ratio.

Assessment of the effect of asthma education on hospitalisation

Thirteen studies reported on this outcome (figure 2A). The study by Taggart et al included 40 participants, and they discovered that asthma education could enlighten children on asthma, perceptions of asthma and the use of health services.³³ Shelledy et al conducted a pilot study and included 18 participants; they found a reduction in school days missed and healthcare utilisation.³⁴ Shaak et al included 81 patients and investigated the impact of asthma education on asthma knowledge test results, asthma control test results, healthcare use and Pediatric Asthma Caregiver’s Quality of Life scores, and they suggested that the community should employ asthma education.³⁵ The study by Safi et al found that asthma education was effective in reducing hospitalisation utilisation.³⁶ Riera et al analysed the effect of an asthma education fair and concluded that hospitalisations remained unchanged.¹⁹ In the study of Montalvo et al, an education programme, Children’s RESPIRA Education Program, was successful in reducing hospitalisation visits.³⁷ Marshall et al organised a multicomponent programme called Reducing Ethnic/Racial Asthma Disparities in Youth and found a positive effect on hospitalisations.³⁸ Lebras-Isabet et al conducted a retrospective study and found that asthma education for children was useful in reducing hospitalisation.³⁹ Condren and Boger found that multidisciplinary asthma education reduced hospitalisation by 82% and ED visits by 81%.⁴⁰ Davis et al found that asthma education for children could help with improving the knowledge of parents and guardians on asthma, and at the same time, it could reduce inpatient admissions.⁴¹ Espinoza-Palma et al conducted full education, as well as implemented a self-management plan, which could reduce hospitalisation and further rehospitalisations.⁴² Broquet et al conducted a prospective study and found that interactive asthma education could improve clinical outcomes, including reducing hospitalisations.⁴³ Johnson et al conducted a library-site asthma education programme that decreased asthma-related ED visits and hospitalisations.⁴⁴ This study showed that the asthma education group had a decreased risk of hospitalisation than the other two groups (RR=0.46, 95% CI 0.32 to 0.66). The study by Condren and Boger had a significantly different result; thus, we conducted a sensitivity analysis, and the result did not change (RR=0.41, 95% CI 0.29 to 0.58).

Figure 2.

(A) The results of the forest plot of the effect of asthma education on hospitalisation. (B) The results of the forest plot of the effect of asthma education on emergency department visits. (C) The results of the forest plot of the effect of asthma education on clinic visits.

Assessment of the effect of asthma education on emergency room visits

Thirteen studies reported on this outcome (figure 2B). Apart from the above-mentioned studies, Julian et al organised therapeutic education programmes and found that ED visits decreased significantly.⁴⁵ This study showed that the asthma education group had a decreased risk of ED visits than the other two groups (RR=0.69, 95% CI 0.59 to 0.81).

Assessment of the effect of asthma education on clinic visits

Six studies reported on this outcome (figure 2C). The study by Calvo et al found no reduction in hospitalisation, but the number of annual clinic visits decreased.⁴⁶ This result showed that the asthma education group had a decreased risk of clinic visits than the other two groups (RR=0.79, 95% CI 0.58 to 1.09), but the result was not significant. The study by Shelledy et al had a significantly different result; thus, we conducted a sensitivity analysis, and the result showed that asthma education could reduce the number of clinic visits significantly (RR=0.80, 95% CI 0.67 to 0.97).

Assessment of the impact of participants and setting on hospitalisation

As shown in online supplemental figure 2, asthma education targeted at both children and parents/guardians could significantly reduce hospitalisation (RR=0.38, 95% CI 0.24 to 0.59), while asthma education targeted at only children or parents/guardians did not result in a significant change (RR=0.69, 95% CI 0.32 to 1.48). The result also showed that asthma education held in hospital (RR=0.49, 95% CI 0.29 to 0.82) or in non-hospital settings (RR=0.41, 95% CI 0.23 to 0.73) did not affect hospitalisation.

Assessment of the impact of participants and setting on ED visits

As shown in online supplemental figure 2, asthma education targeted at both children and parents/guardians (RR=0.69, 95% CI 0.57 to 0.83) or just children or parents/guardians (RR=0.68, 95% CI 0.48 to 0.97) can significantly reduce ED visits. The result also showed that asthma education held in hospital (RR=0.58, 95% CI 0.44 to 0.77) or non-hospital settings (RR=0.81, 95% CI 0.68 to 0.97) may significantly reduce the number of ED visits.

Assessment of the impact of participants and setting on clinic visits

As shown in online supplemental figure 2, asthma education targeted at both children and parents/guardians (RR=0.74, 95% CI 0.45 to 1.22) or just children or parents/guardians (RR=0.86, 95% CI 0.67 to 1.10) was not significantly associated with a reduction in clinic visits. The result also showed that asthma education held in hospitals (RR=0.45, 95% CI 0.22 to 0.92) can significantly reduce clinic visits, while that held in non-hospital settings (RR=0.92, 95% CI 0.69 to 1.23) may not significantly reduce clinic visits. Because there were only 6 studies out of 15 which included this outcome, hence sample size was too small to detect a difference.

Publication bias

The funnel plot is shown in online supplemental figure 1. Egger’s test was used to assess the publication bias of the included studies. The results indicated a substantial publication bias for included studies related to hospitalisations (p=0.023), ED visits (p=0.005) and clinic visits (p=0.004).

GRADE summary of findings table

Table 1 presents a summary of the findings and an assessment of GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) for each outcome. The quality of evidence from the included studies was rated as moderate overall.

Discussion

Clinical implications

To the best of our knowledge, this is the first systematic review and meta-analysis to investigate the associations between asthma education and hospitalisation, ED visits and clinic visits of children. The study results suggested that asthma education was associated with 54% lower hospitalisation risk (95% CI 0.32 to 0.66) and 31% lower ED visit risk (95% CI 0.59 to 0.81) than usual care. Sensitivity analysis showed that the asthma education group had a lower clinic visit risk (RR=0.80, 95% CI 0.67 to 0.97). This decrease suggested that asthma was better controlled after an educational intervention.

Asthma is burdensome for children globally, and better diagnostics and management are needed particularly in low/middle-income countries, due to the growing prevalence of asthma.⁴⁷ The content of asthma education is related to inhaler technique assessment, written asthma treatment plans, self-monitoring of symptoms and regular medications.^48–50 Poor compliance is a major obstacle to the treatment of any chronic disease.⁵¹ There are mainly two reasons behind the poor compliance: the first one is the poor understanding of the disease due to lack of knowledge or lack of communication between the doctors and patients, and the other is the deliberate decision by the patient to not follow the treatment or find an alternative method of treatment.⁵² Through asthma education, children can overcome poor compliance related to the first reason; this result was inconsistent with the results of the study by Ng et al.⁵¹ While asthma education can help control asthma in several cases, it still cannot achieve the desired result if it fails to consider the real-life scenario due to non-adaptation to targeted participants or the enrolment of several children with moderate or severe asthma.⁵³

The asthma education intervention may be limited to children or both children and their parents or guardians. Educational interventions can take place in hospitals, at home and in the community. The subgroup analysis of our study showed that asthma education involving both children and parents/guardians was associated with decreased hospitalisations (RR=0.38, 95% CI 0.24 to 0.59) and ED visits (RR=0.69, 95% CI 0.57 to 0.83). Asthma education carried out in a hospital or non-hospital setting can reduce hospitalisations and ED visits. However, for clinic visits, only asthma education carried out in hospital settings could reduce the risk (RR=0.45, 95% CI 0.22 to 0.92). Parent involvement in education is good for the learning behaviour and emotional health of children⁵⁴; thus, based on our findings, asthma education involving both children and parents can increase compliance to asthma guidelines.

Methodological considerations

The findings were limited because of the following: first, the children could learn how to deal with asthma through some other sources of information over time; it is a kind of Hawthorne effect, and the findings of this study should be interpreted cautiously. Second, we did not conduct subgroup analysis according to different teaching tools, content, frequency and educators, and it is important to conduct further analysis about these factors to get a better understanding of asthma education. Third, the outcome for this review is on reduction of hospitalisation, ED and clinic visits hence it is about asthma exacerbation which can be objectively identified in studies in the systematic review; however, not all of the included studies described adherence to therapy after education, what daily symptoms were after education and how this translated to quality of life; the future studies about these topics are also needed. Finally, further studies on different stages of asthma are needed in the future.

Conclusion

Asthma education is effective for controlling asthma; in particular, it is effective for reducing hospital admissions, ED visits and clinic visits. Education involving both children and parents/guardians works better than that involving only children. The setting of asthma education has no significant impact on the effect, especially for hospitalisation and ED visits. Clinically, understanding the effect of education on asthma is critical for applying adequate preventive measures to control the prevalence of asthma in children. Furthermore, the subgroup analysis of the participants and the context of education is also useful in understanding the overall impact of education on asthma.

Ethics statements

Patient consent for publication

Not required.

Ethics approval

This study does not involve human participants.