Home-based educational interventions for children with asthma.

backgroundAsthma 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.

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

methodsWe 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

resultsThis 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. AUTHORS'

conclusionsWe 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.