Guiding Question 1. Structure and Content of Asthma Self-Management Education Packages

Our review of 14 asthma self-management education (AS-ME) packages currently available in the United States found that robust packages exist for adults, adolescents, children, and parents of children with asthma. A few widely used packages are designed for use in schools, while numerous packages are intended for implementation in community-based sites, healthcare facilities, patient homes, or all of these settings. A few packages focus on specific asthma populations including Latino patients, women, multicultural or minority communities, or low-income areas. Three packages focused on patients with severe asthma, but we did not identify any packages designed specifically for patients with significant comorbidity.

Most packages require or offer education facilitated in-person by a trained instructor, while fewer packages rely mainly on self-directed education by a patient at home. In-person programs are usually led by a nurse, school nurse, respiratory therapist, community health worker, or other trained asthma educator. Learning materials are typically paper-based and include workbooks and handouts for patients, and useful tools such as asthma action plans and checklists to identify asthma triggers at home. All packages are available in English and many have been translated into Spanish, but materials are not available in other languages. Most packages are freely accessible and can be downloaded by anyone, but some are only available for a fee. We note that we were unable to access several potentially relevant packages.

Educational content across AS-ME packages had many similarities, addressing basic knowledge of asthma, medication and device use, symptom management, environmental and behavioral triggers, goal setting, and learner evaluation. However, specific details vary between packages, including techniques for device use or medication guidelines. Most packages were developed or updated in the past 6 years, but older packages may require revision or updating. Additionally, an update to widely disseminated guidelines for asthma care is expected soon and may require review and revision of packages to ensure content is evidence-based.

Guiding Question 2. Implementation of AS-ME Packages

Implementation of AS-ME packages varies widely. Instructors often tailor packages to best suit their patients, settings, or available resources, an affirmation of the importance of adaptability for successful packages. Numerous homegrown packages also exist, though we know less about those efforts as they are generally more difficult for the general public to access. Guidance for facilitators also varies, with some packages providing comprehensive instructional manuals while others supply minimal or no instruction. Prominent organizations including the American Lung Association, Asthma and Allergy Foundation of America, and Association of Asthma Educators, offer online or in-person courses to prepare educators to implement AS-ME. Three packages we reviewed were train-the-trainer programs intended specifically for clinicians, community health workers, and other asthma educators.

Most packages were developed or are disseminated by a small number of leading professional or patient advocacy organizations. Little is known about the financial resources, staffing, and time needed to develop AS-ME packages. Many of the packages currently available were funded in part by government agencies, especially the Centers for Disease Control and Prevention.

Guiding Question 3. Effectiveness of AS-ME Packages

We identified a substantial evidence base assessing the effectiveness of AS-ME in the United States. Our searches identified 7 systematic reviews published since 2007, as well as 16 randomized controlled trials, 16 observational studies, and 1 descriptive study. Half of published studies evaluated school-based packages, while community- or hospital-based packages accounted for most of the remainder. Only a few studies examined home-based interventions. Similarly, three-quarters of the studies were conducted in child and/or adolescent populations, while far fewer studies focused on adult patients. Most studies occurred in communities with large racial and/or ethnic minority populations and low markers of socioeconomic status.

Outcomes most frequently reported in primary studies were asthma knowledge, asthma-related quality of life, and asthma symptoms. Numerous studies also reported asthma-related hospitalizations, emergency department use, and asthma control. Few studies examined asthma-related school absences, use of maintenance or rescue medications, or avoidance of asthma triggers. In general, AS-ME packages were associated with improved asthma control, reduced symptom frequency, increased asthma knowledge, and fewer school absences. Results across the studies were mixed when examining hospitalizations, emergency department visits, and quality of life.

Only 4 of 14 AS-ME packages included in this Technical Brief were evaluated in the research studies we identified. Instead, nearly half of studies examined homegrown AS-ME packages, which we were unable to access. However, of the studies assessing four packages evaluated in this Technical Brief, 7 of 8 studies found that AS-ME packages were associated with substantial improvement in key outcomes.

Guiding Question 4. Next Steps

Developers and Disseminating Organizations can:

• address patient population needs by expanding translation of AS-ME materials to audiovisual components and additional languages; indicating the literacy level required for comprehension; designing packages for learners with differing learning styles; and developing packages for patients across the spectrum of asthma severity and with substantial comorbidity
• ensure current content through revision and updating
• inform future AS-ME initiatives by sharing data on costs, staffing, and time needed for development, testing, and dissemination
• expand availability of materials by reducing or eliminating barriers to access
• improve cross-pollination of ideas and foster innovation by sharing homegrown approaches
• invest in technological platforms that can expand the reach of AS-ME packages in a variety of ways, including web-based programs, mobile apps, and telehealth
• improve usability by identifying components of a package that may require specific skills or knowledge by a facilitator
• develop content to address the challenges of managing asthma across different settings and coordinating care among across providers and caregivers

Researchers can:

• address patient population needs by evaluating AS-ME packages designed for adult asthma patients; increase study of home-based, community-based and self-directed packages; routinely report asthma severity, comorbidity, and socioeconomic factors in published studies; and examine how patient literacy/health literacy, cultural competence of AS-ME educators/providers, and social determinants of health influence the use and effectiveness of AS-ME packages
• examine the extent to which current AS-ME packages are being used, for all asthma patients and among higher risk subgroups
• describe and evaluate how packages are modified and adapted to local circumstances
• improve the rigor of outcome reporting by including standard measures of asthma control and absenteeism, and developing methods to more effectively assess and report medication use and trigger avoidance
• strengthen the body of evidence for AS-ME packages by researching packages that have not been widely studied, and conducting head-to-head studies that compare packages to other packages and to other widely used interventions
• examine how current evidence could guide development of model AS-ME packages for different audiences and patient populations

Policymakers can:

• support new research and development with increased and new funding sources
• promote training for asthma educators and other instructional facilitators by exploring payment models to reimburse their services
• foster innovation by supporting the coordination of strategic efforts by developers to share data and ideas
• amplify the work of developers and disseminators through the nation’s public health infrastructure
• encourage and guide standardization or alignment of AS-ME components across packages to enable more efficient implementation