PEDIATRICS Vol. 117 No. 4 April 2006, pp. 1046-1054 (doi:10.1542/peds.2005-0666)
A Randomized, Controlled Trial of an Interactive Educational Computer Package for Children With Asthma
a School of Nursing
b Division of Psychiatry
e Division of Child Health,University of Nottingham, Nottingham, United Kingdom
c Department of Pediatrics, Nottingham City Hospital, Nottingham, United Kingdom
d Apple Tree Medical Practice, Nottingham, United Kingdom
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ABSTRACT |
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 TOP ABSTRACT METHODSRESULTSDISCUSSIONREFERENCES |
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OBJECTIVE. The purpose of this study was to evaluate the impact and acceptability of an educational multimedia program designed to promote self-management skills in children with asthma.
METHODS. We conducted a randomized, controlled trial with measures at baseline and 1- and 6-month follow-up. The trial was conducted in pediatric outpatient respiratory clinics in 3 United Kingdom hospitals. Participants included 101 children aged 7 to 14 years under the care of hospital-based asthma services. The children were randomly assigned to receive an asthma information booklet alone or the booklet plus The Asthma Files, an interactive CD-ROM for children with asthma. Asthma knowledge was the primary outcome measure. Other measures included asthma locus of control, lung function, use of oral steroids, and school absence.
RESULTS. At the 1-month follow-up (n = 99), children in the computer group had improved knowledge compared with the control group and a more internal locus of control. There were no differences in objective lung-function measures, hospitalizations, or oral steroid use. The study participants were positive in their evaluation of the intervention. At the 6-month follow-up (n = 90), significantly fewer children in the intervention group had required oral steroids and had had time off school for asthma in the previous 6 months. The difference did not reach statistical significance in the intention-to-treat analysis for both steroid use and school absence.
CONCLUSION. The Asthma Files was found to be an effective and popular health education tool for promoting asthma self-management skills within pediatric care.
Key Words: asthma • self-management • multimedia
Abbreviations: GP—general practitioner • AKA—Asthma Knowledge Assessment • CALOC—Children's Asthma Locus of Control • CI—confidence interval • FEV1—forced expiratory volume in the first second • PEF—peak expiratory flow • BPVS—British Picture Vocabulary Scale • ANOVA—analysis of variance • df—degrees of freedom • OR—odds ratio
The World Health Organization estimates that asthma affects 150 million people worldwide,1 and it is particularly prevalent in children and adolescents.2,3 The estimated cost of childhood asthma in the United Kingdom alone is £254 million, half of which stems from management of acute asthma attacks.4 Hospitalization of children accounts for substantial use of secondary health care resources, and asthma is considered a major cause of disability.5
Effective asthma treatment is widely available, and symptom-free asthma control is a realistic goal for many children and young people,6 yet school absence rates among children with asthma are high.7,8 Furthermore, a significant proportion of children perceive their symptoms to be less severe than they actually are,9 which can delay vital treatment.
Research suggests that "self-management" techniques are effective for controlling asthma symptoms in both adults10–12 and children.6 However, if children lack faith in their own intrinsic capacity to manage their asthma, they may be unlikely to engage in appropriate self-management behavior.13 Thus, the child's beliefs about the forces that control their health, their "health locus of control," are critical.14 Educational programs for children with asthma must strive to impart knowledge about asthma and aid development of the child's "internal" locus of control.
A recent systematic review of 32 educational self-management interventions for children with asthma reported compelling evidence of improved physiological function, decreased school absence, greater physical activity, and reduced use of emergency health services after such initiatives.15 There are drawbacks, however. Staff time and running costs can be prohibitive, and busy lifestyles often mean that parents struggle to find the extra time to participate in evening or weekend health education.
Recognizing that many children spend much of their time in front of computers and game consoles, a number of researchers and clinicians have sought to develop computer packages dealing with a range of illnesses, including asthma.16–18 Such computer packages have many documented advantages for pediatric education. They aim to present information to children in an engaging, attractive format using technology familiar to them.19 Packages can include representations of an "expert" role, helping children assimilate and understand information or concepts that they might fail to comprehend otherwise. They are intrinsically flexible and easily tailored to suit a broad range of knowledge and informational needs. There is also evidence that skills learnt through a desktop "virtual" environment do generalize to real-world situations.20
Rigorous evaluations of multimedia packages are few. Many studies suffer high participant attrition rates, whereas others restrict participation to those who already own computers, compromising the representativeness of the sample. Clearly, multimedia technology offers the field of pediatric education many exciting possibilities, but the efficacy of its application must be carefully evaluated.
We set out to examine the acceptability and efficacy of a multimedia education program (The Asthma Files). Our hypothesis was that the intervention would lead to greater knowledge, a more internal locus of control, and improved clinical outcomes.
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METHODS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Participants and Settings
Children aged 7 to 14 years were identified from the clinic lists of 3 pediatric respiratory outpatient clinics in the East Midlands, United Kingdom, and invited to participate. The clinics take direct referrals from general practitioners (GPs) in the surrounding area and also referrals of children with difficult asthma from other hospital consultants. Children were recruited to the study if they had a scheduled follow-up appointment at 1 of the 3 clinics in the study period between May 2001 and May 2002. Children were excluded from the study if they did not have a diagnosis of asthma, were not currently receiving treatment for asthma, or were assessed by parents or clinician to have significant learning or behavioral difficulties. Written parental consent and the child's assent were both mandatory for inclusion in the study. Ethical approval was obtained from the ethics committees of each of the 3 hospitals: Nottingham City Hospital National Health Service Trust (ref: EC00/187), Queen's Medical Centre University Hospital NHS Trust (ref: CS010101), and Southern Derbyshire Acute Hospitals National Health Service Trust (ref: SDAH/2002/017).
Measures
Asthma Knowledge Assessment
Asthma knowledge was the primary outcome. A protocol-specific 2-part Asthma Knowledge Assessment (AKA) inventory was developed for this study. Part 1 poses 6 open-ended questions relating to basic asthma physiology, leading to a potential maximum score of 22 points. Part 2 includes 15 true/false questions covering treatment, management, and causation domains (maximum: 15 points). Total possible scores ranged from 0 to 37, with higher scores indicating greater asthma knowledge. Construct validity, the extent to which a test correlates with related variables,21 was demonstrated by significant correlations between knowledge scores and age and verbal ability but not with gender. The duration of asthma did not contribute to the variance in knowledge scores once age had been accounted for. The questionnaire also discriminated between those expected to have low asthma knowledge (children without asthma) and high asthma knowledge (children with asthma). Agreement between scorers was calculated for individual item agreement (
= 0.93) and total score agreement (intraclass correlation = 0.96). Internal consistency was moderate (
= .503).
Children's Asthma Locus of Control
The Children's Asthma Locus of Control22 (CALOC) is a 10-item questionnaire inviting children to agree or disagree with statements assessing perceived control over personal asthma management; for example, "People with asthma who are never wheezy are just plain lucky" and "There are things I can do to control my asthma." A response in accordance with an internal locus of control scores 1 point, giving a maximum possible score of 10, with higher scores indicating a greater degree of perceived control over asthma and asthma symptoms. Lower scores suggest that the child perceives other individuals or luck to be the primary determinants of their asthma control. The CALOC was derived from the generic 20 item Children's Health Locus of Control Scale23 and adapted for this study to provide a brief, valid, and reliable measure of asthma-related locus of control for use in a United Kingdom sample of children. Scores on the CALOC were moderately correlated with scores for Children's Health Locus of Control Scale (r = 0.47; n = 19; P = .04), indicating concurrent validity. It also demonstrated excellent test-retest reliability (intraclass correlation coefficient = 0.90; 95% confidence interval [CI] = 0.74 to 0.96; P < .01) and good internal consistency (Cronbach's = .69).
Clinical Outcome Measures
Lung function was measured specifically for the study. Forced expiratory volume in the first second (FEV1) and peak expiratory flow (PEF) were assessed by the researcher (A.C.M.) using a Micromedical Super-Spiro spirometer and Mini-Wright peak flow meter, respectively, according to US guidelines.24
Verbal Ability
The British Picture Vocabulary Scale (BPVS)20 was used to assess each child's verbal ability. The test is suitable for children aged 3 to 15 years and is a norm-referenced, age-adjusted test of hearing vocabulary for Standard English. Children were allocated to lower BPVS verbal IQ (standardized score < 100) or higher BPVS verbal IQ group (standardized score > 99).
Parental Information
At baseline, each child's parents or guardians provided demographic details, information about their child's asthma, and incidence of asthma in the family via a questionnaire, which they undertook while their child completed baseline measures. The researcher was available to answer questions if necessary.
Intervention
The Asthma Files is an interactive computer game with a secret-agent theme, developed by a multidisciplinary team including health professionals, behavioral scientists, and technologists (Figs 1 and 2). The program was developed and extensively piloted with children over the course of a year and has a lively and colorful style. It has 8 sections, which users can look at in any order: sections 1 to 3 provide basic asthma information; sections 4 to 6 look at self-management; and sections 7 and 8 engage the child in role play. As "secret agents," users are encouraged to explore all of the sections, finding out as much about asthma self-management as possible, by listening to voiceovers, completing quizzes, and engaging with interactive problem solving tasks. A "personal digital assistant" records which sections they have visited and can produce a printed version of information collected in those sections at any time. The child has the opportunity to enter his/her own peak flow score and personal asthma triggers, which are collated into a printable self-management plan, demonstrating which steps they should take when their peak flow and symptoms reach different levels (according to British Thoracic Society and Scottish Intercollegiate Guidelines Network guidelines6). When all 8 of the sections have been explored, the child is given access to a "secret level," where quizzes and games reinforce key messages. The game takes 
90 minutes to complete over 1 or more sittings.
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Asthma Booklet
A simple 15-page, A5 booklet titled "Asthma at Home" was also used. This had been written by asthma nurse specialists at 2 of the hospitals and is still used widely in both clinics. It covers similar self-management information to the CD-ROM and provides space to write down details of the child's usual treatment, as well as contact details of the local hospital and appropriate health care professionals.
Procedure
Baseline (Time 1)
Each child was weighed and measured as part of clinic routine, then interviewed by the researcher as they waited to see the respiratory consultant. Part 1 of the AKA was completed using the child's answers. Most of the older children were able to complete part 2 and the CALOC scale by themselves. Younger children were given assistance with reading when necessary. The BPVS was administered and the child's lung function recorded.
Assignment and Masking
Participants were randomized to either the intervention arm (information booklet plus The Asthma Files) or the control arm (booklet alone) of the study using pre-prepared, sealed envelopes containing random numbers, such that participants had an equal chance to being allocated to either group. The same researcher conducted the intervention and follow-up visits and was not blind to allocation at the 1-month follow-up visit or 6-month telephone interview.
Intervention
One month after recruitment, the researcher visited all of the children in the intervention group in their homes, taking with her The Asthma Files on a laptop computer. The children were free to use the package in any way they chose without interference or suggestion, although the researcher did answer direct queries.
Afterward, the children were asked to rate the acceptability and usability of the package using a brief checklist. All of the children were given a copy of the CD-ROM to keep, and it was installed on a personal computer if requested. Because of lack of printing facilities, the child's reported best peak flow score was incorporated into a preprinted self-management plan (or "Action Plan") following the British Thoracic Society and Scottish Intercollegiate Guidelines Network guidelines by the researcher (a psychologist), although it was not discussed with the child. This was left in addition to a copy of the asthma information booklet. Children in the control group received the asthma information booklet by mail.
One-Month Follow-up (Time 2)
One month after intervention, all of the children in the study were visited at home, and baseline measures (AKA, CALOC, FEV1, and PEF) were repeated. In addition, parents were asked to rate their child's use of medication, admissions to hospital, and unscheduled visits to the doctor in the previous month.
Six-Month Follow-up (Time 3)
All of the parents were interviewed by telephone to record hospital admissions, unscheduled visits to the hospital or general practitioner, school absence, and use of oral steroids in the 6 months since intervention.
Sample Size
A minimum of 50 participants in each group was required to demonstrate a 0.5 SD difference in knowledge scores, which was the primary outcome (P < .05, power = .80).
Statistical Methods
At baseline, t tests or Mann Whitney tests were used to compare the characteristics of the 2 groups, depending on whether the data had a Gaussian distribution. Repeated measures analysis of variance (ANOVA) was used to investigate the effect of the intervention on change in knowledge and on locus of control. Logistic regression was used to examine the impact of intervention on the clinical outcomes (school absence, oral steroids, and emergency visits) at the 6-month follow-up (time 3). Mann-Whitney tests were used for univariate comparisons between groups for number of emergency visits, number of courses of steroids, and number of days of school in the previous 6 months.
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RESULTS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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Participant Flow
Letters were sent to 192 children in the appropriate age range. One hundred and sixty three met the inclusion criteria, of which 101 (61.9%) children consented to take part in the study. Nineteen refused, and 43 either did not attend their appointment or were missed because of time constraints in the clinic. See Fig 3 for flow of participants through the trial.
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Follow-up and Analysis
Baseline (Time 1)
Characteristics of Participants
Responders had a similar age and gender profile to nonresponders. Comparisons between participants from the 3 different clinics revealed no significant differences in terms of demographics or baseline outcome variables, and so the data were combined.
The groups (computer intervention/control) differed significantly in terms of age (z = –2.50; P = .012) at baseline, with the intervention group older than the control group. Baseline knowledge was also higher in the intervention group (t = –1.97; degrees of freedom [df] = 99; P = .051), but this was accounted for by age. A 1-way ANOVA with group as the independent factor and total knowledge at time 1 as the dependent variable showed no main effect of group (F = 0.2; df = 1,98; P = .65) but a significant relationship between age and knowledge at baseline (F = 62.8; df = 1,98; P < .001). Characteristics of the 2 groups can be found in Table 1.
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One-Month Follow-up (Time 2) Scores
Knowledge
Repeated measures ANOVA was performed, with group and gender as independent factors and total knowledge score at times 1 and 2 as dependent variables. Age was entered as a covariate. Analysis revealed a significant interaction between time and group allocation, with the intervention group having greater improvement in knowledge between baseline and the 1-month follow-up compared with control (F = 12.7; df = 1,96; P = .001). The analysis was repeated to include verbal IQ group as an additional independent factor to determine whether children with better verbal ability benefited more from the intervention. Because there were 2 missing values for BPVS score, this reduced the sample to 50 in control and 49 in the intervention group. The effect of the intervention remained (F = 11.76; df = 1,90; P = .001). Verbal IQ group had no impact on knowledge gain, and there was an interaction between time and gender with girls showing more improvement in knowledge (F = 4.4; df = 1,90; P = .037), independent of group allocation.
Asthma Locus of control
In this analysis, CALOC scores at times 1 and 2 were the dependent variables, with group and gender entered as independent variables and age as a covariate. Again, there was a significant interaction between time and group allocation, with children in the intervention group showing a significantly greater increase in their ratings of internal control of asthma between baseline and the 1-month follow-up (F = 7.53; df = 1,95; P = .007). Gender had no impact on CALOC scores. See Table 2 for a summary of changes in outcome variables at the 1-month follow-up.
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Clinical Measures
There was no significant effect of intervention on PEF or FEV1 scores (Table 2). There were also no significant differences in school absence, GP visits, or hospital admissions between the groups at time 2.
User Satisfaction
The children's comments about the multimedia package indicated that they found it to be both an interesting and acceptable form of asthma education. Almost all of the children who were asked (35 of 37) felt that The Asthma Files was a good way to learn about asthma, and the majority (31 of 37) believed that they had learned more about their asthma from using the package. Most children (32 of 37) reported that the illustrations had helped them understand what was happening in their bodies and said that they would recommend the use of The Asthma Files to other people (33 of 37). Over half (27 of 49) of the children reported using the computer program again after the initial visit. On average they had used it once more, although some children reported using it up to 10 times. There were no particular variables that predicted repeated use (beyond owning a computer), although those who had used The Asthma Files again had significantly higher knowledge scores on part 1 of the AKA at time 2 than others in the computer group who had not used the package again (t = –2.67; df = 47; P = .01).
Six-Month Follow-up (Time 3) Scores
Of 101 enrolled participants, 90 (89.1%) participated in the 6-month follow-up interview. Those who were lost to follow-up at 6 months did not differ from the rest of the sample on any of the baseline or time 2 measures.
Children in the intervention group had had fewer courses of steroids (z = –2.22; P = .026) and fewer days off school (z = 2.1; P = .034). There was also a trend for the intervention group to have had fewer emergency visits, but this failed to reached significance (z = 1.92; P = .054). Logistic regression was used to identify characteristics predicting any use of oral steroids, any school absence because of asthma over the 6-month period, and any unscheduled emergency visit. Children in the control group were significantly more likely to have required oral steroids (
2 = 4.24; df = 1; P = .047; odds ratio [OR]: 2.956; 95% CI: 1.014 to 8.612) and to have had time off school (2 = 4.127; df = 1; P = .045; OR: 2.394; 95% CI: 1.021 to 5.618) than children in the intervention group. Age and gender made no contribution to steroid use or school absence. Data were then analyzed on an intention-to-treat basis, where nonresponders at 6 months were coded as having an adverse outcome. The intention-to-treat analysis showed only a trend toward the control group having a greater chance of receiving at least 1 course of oral steroids (2 = 3.419; df = 1; P = .068; OR: 2.217; 95% CI: 0.942 to 5.216) and a trend toward at least 1 school absence because of asthma (2 = 3.587; df = 1; P = .061; OR: 2.144; 95% CI: 0.967 to 4.753). Age, gender, knowledge, or CALOC scores at time 2 did not contribute to the variance in outcome. Intention-to-treat analyses found no differences between the groups in terms of hospital admissions or unscheduled visits to their GP or outpatients. See Table 3 for participant outcomes at the 6-month follow-up (time 3).
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DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONREFERENCES |
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This study demonstrated that the use of an educational multimedia package about asthma was associated with increased knowledge levels and enhanced feelings of control over asthma after 1 month and a lower use of oral steroids and school absence in the 6 months after use. Those who had used the package more than once showed higher knowledge scores at time 2.
The improved perception of control is particularly encouraging, given evidence of links between feelings of control over illness and improved outcomes.13,25 The interactive elements of the package engage the child in decision-making and problem-solving exercises that both encourage the development of cognitive skills and afford the child scope to practice effective responses to asthma-related situations.
We did not record any measures of the child's behavior, so it is difficult to know whether the interactive computer program directly enhanced self-management skills, such as the identification and avoidance of asthma triggers, nor do we know whether improvements in knowledge and perceived control influenced the child's adherence to treatment. Although lung function did not vary in either group over the course of the study, the participants had started with good lung function (mean FEV1 and PEF over 90% at baseline in both groups), and so it was unlikely that behavioral change would lead to a measurable improvement in lung function over a short period of time. Furthermore, we were unable to standardize the time of day measurements were taken, which may have compromised assessments. However, the study findings suggest that the intervention did influence asthma control, because reported oral steroid use and school absence were lower in this group at the 6-month follow-up (time 3). Although the data were no longer statistically significant at the .05 level in the intention-to-treat analysis, a trend toward better outcomes in the intervention group was evident. Parental report of this information is, of course, not always accurate, but our findings are consistent with those from the systematic review of Wolf et al15 that suggested that positive outcomes peak at 7 to 12 months postintervention. This augurs well for The Asthma Files, which has the further strength that it is readily available for "refresher sessions" at any time. Such reinforcement is valuable in maintaining asthma knowledge and positive health behaviors.26
We might speculate that had children spent 60 to 90 minutes reading the asthma information booklet, the amount of time typically spent on the package, their outcomes would have been equivalent. This illustrates one of the foremost documented strengths of multimedia education for children: an entertaining, interactive format can encourage both engagement and receptiveness to new information in children.27 Of course, if health professionals were to take the time to talk children through printed material, similar outcomes may also be observed. Because resources prohibit this, a computer package is potentially a cost-effective substitute. Research comparing the 2 approaches might generate useful findings.
Although the researcher was not blind to the allocation of children at follow-up, which may potentially have opened the study to bias, measures of lung function were objective, and the structured nature of the AKA part 2 and CALOC provided little scope for biased results. In addition, interrater reliability on the semistructured questions in the AKA part 1 showed a high level of agreement.
Many evaluations of multimedia packages exclude children without home computers or require them to make special trips to hospital or school. Here, such children were explicitly catered for, making the trial as inclusive as possible. There was, in fact, a high rate of computer ownership in the study sample (41 of 50), which may suggest that computer access is no longer a limiting factor. An alternative explanation is that our sample was socially biased. Examination of verbal IQ scores, however, revealed a normal profile, and because verbal ability is a good indicator of socioeconomic status,28 we believe that our sample was adequately representative.
By taking a computer out to homes, we also obviated problems commonly found in evaluations of multimedia packages, where children do not use the program at all because of technical difficulties. In this study, we wanted to ensure a rigorous evaluation of the package based on actual use. It is acknowledged, however, that the home visit was important for motivating the children to use the package and may have caused an effect in itself. Nevertheless, theory suggests that the opportunity to practice asthma-related skills and receive feedback, albeit virtually, helped children to become more proficient and feel more in control of their asthma,20 whereas children in the book group had no such opportunities.
Although in the "real world," clinicians will be distributing CD-ROMs at clinics and, thus, will be unable to ensure children are able to install/use the CD-ROM, we would argue that our findings are still generalizable. Additional work to identify the components of multimedia programs that are particularly effective, and which children benefit most from programs such as these, would be useful in informing future multimedia programs, both for asthma and for children with other chronic conditions. The Asthma Files package was found to be an effective and popular educational tool for use with children with asthma, which points to an encouraging future for such packages in pediatric education initiatives.
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ACKNOWLEDGMENTS |
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The Asthma Files CD-ROM was developed in association with the National Asthma Campaign (now Asthma UK). The CD-ROM was developed and evaluated with funding from an unrestricted, educational grant from Merck, Sharp & Dohme Limited. None of the research team were employed by Merck, Sharp & Dohme Limited, and no identifiable products were included in the CD-ROM.
We thank the children and their families who took part in the study; the clinicians, Harish Vyas, David Thomas, Nigel Ruggins, and Terence Stephenson, who allowed children attending their clinics to participate; and the staff at all of the outpatient clinics. The CD-ROM was produced by Ian and Deborah Crook at Showme Multimedia Ltd.
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FOOTNOTES |
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Accepted Sep 28, 2005.
Address correspondence to Amy McPherson, PhD, School of Nursing, University of Nottingham, B Floor Medical School, Queen's Medical Centre, Derby Road, Nottingham NG7 2UH, United Kingdom. E-mail: amy.mcpherson{at}nottingham.ac.uk
Financial Disclosure: Dr Smyth has received support for attending conferences from Merck, Sharp, & Dohme Limited, and Glaxo Smith Kline. The other authors have indicated they have no financial relationships relevant to this article to disclose.
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