Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children

Abstract

An interactive multimedia computer game to enhance self-management skills and thereby improve asthma outcomes in inner city children with asthma was evaluated. Subjects aged 6–17 were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual-care comparison. The main character in the game could match the subject on gender and ethnicity. Characteristics of the protagonist’s asthma were tailored to be like those of the subject. Subjects played the computer game as part of regular asthma visits. Time between pre- and post-test varied from 4 to 15.6 months (mean, 7.6 months). Analysis of covariance, with pre-test scores, age, and asthma severity as covariates, found that the intervention was associated with fewer hospitalizations, better symptom scores, increased functional status, greater knowledge of asthma management, and better child self-management behavior for those in the intervention condition. Interactions with covariates were found and discussed in terms of variable efficacy of the intervention.

Introduction

Watch, Discover, Think and Act is a multimedia computer application to enable inner city African-American and Hispanic children to learn to better manage their asthma. We report the evaluation of this program, while an in-depth discussion of the program’s theoretical conceptualization and development is presented in “Watch, Discover, Think and Act: a model for patient education program development” [1].

Asthma is the most common chronic condition in children in the US and the major cause of school absenteeism and functional limitation [2]. The estimated annual prevalence of asthma among children in the US has been reported between 1% and 11%, and both morbidity and mortality have increased in children younger than 14 years since 1980, and the rates are disproportionately high among medically under-served, inner-city populations [3], [4], [5], [6], [7], [8], [9]. Asthma hospitalizations are associated with being poor and being a minority population [10], [11].

The major areas of focus for asthma control are (1) making appropriate diagnosis and categorization of severity, (2) addressing the significant role of inflammation, not just bronchospasm, in the pathogenesis of asthma, (3) matching pharmacologic management to severity, (4) identifying and reducing exposure to environmental asthma precipitants (triggers) (5) teaching self-management skills [11].

The self-management of asthma may be defined in part as the complex self-regulatory process of identifying symptoms, preventing symptoms, planning responses, and carrying out treatment [1], [12]. For optimal self-management, the child and family must have an appropriate diagnosis and treatment regimen, a well-defined role in care, and the necessary self-management skills. Some of these elements essential to good asthma care may be missing for inner-city children.

Asthma education programs have had effects on several variables, including anxiety about asthma, children’s responsibility for asthma management, school attendance, school performance, acute symptom episodes, and medical costs [13], [14], [15], [16], [17]. However, many approaches to education are provided separate from medical care. It may be more difficult for low-income and minority populations to sustain participation in these separate programs, especially if they require participation in multiple sessions over time. Further, most existing programs have difficulty accounting for the uniqueness of each child’s triggers and current management plan for asthma; they teach the same skills regardless of the characteristics of the child and of his or her asthma.

Asthma affects individuals differently, with varying frequency and severity of symptoms and impact on daily life. Thus, the program evaluated in this study represents the second generation of asthma self-management education [1], [18], [19]. It is tailored to the triggers and symptoms of an individual child and integrated with the child’s primary care. Further, it teaches a self-regulatory framework so children can adopt specific asthma management behaviors as they are needed for prevention and control. The future of asthma self-management lies in such programs that can be tailored to individual asthma characteristics and that can help patients and families learn the problem-solving skills needed to move to a more advanced stage of asthma self-management.