Online Asthma Education Aimed at Urban Teens Improves Outcomes

DETROIT, May 1 -- Asthma symptom control for urban African-American teens appears to improve via an Internet-based program tailored for them specifically, researchers here found.

High school students who completed the multimedia "Puff City" asthma management program had significantly fewer symptomatic days over a two-week period compared with controls (2.1 versus 2.8 days, P=0.003), they researchers reported in the May 1 issue of the Journal of Respiratory and Critical Care Medicine.

The results indicate that a targeted program can be effective for a traditionally tough-to-reach but high-risk group, said Christine L.M. Joseph, Ph.D., of the Henry Ford Health System, and colleagues.

"Traditionally, urban youth are believed to be difficult to engage in health-related programs, both in terms of connecting and convincing," they wrote. However, urban African-American teens have higher asthma fatality rates than whites and younger children.

So the Henry Ford team evaluated outcomes among 314 students in six Detroit high schools randomized to four sessions of the targeted program or an equal number of sessions browsing generic asthma web sites.

The students had been identified as having asthma by their responses to the Lung Health Survey administered during English classes.

The mean age of participants was 15; 98% were African American and 49% were enrolled in Medicaid.

Both groups completed their sessions over about six months using existing school computers.

The study program focused on controller medication adherence, rescue inhaler availability, and smoking cessation or reduction. Each session gave students feedback comparing their responses with norms from other students and with their responses in the previous session. Feedback was also provided in audio form to accommodate students with low literacy levels.

A study coordinator received periodic risk assessment reports generated from student responses and then made referrals to the appropriate agency or community resource.

The coordinator proactively contacted students in the treatment group but only initiated contact with control-group students in potentially high-risk situations, such as a high depression scale score or a report of severe symptoms going unmedicated.

After adjustment for baseline measures including asthma severity, school, and referral coordinator contact, the findings for treatment versus control at one year follow-up were:

• Fewer symptom days in the preceding two weeks, the primary endpoint (2.1 versus 2.8 days, risk ratio 0.5, 95% confidence interval 0.4 to 0.8, P=0.003).
• Fewer symptomatic nights in the preceding two weeks (0.9 versus 1.5, RR 0.4, 95% CI 0.2 to 0.8, P=0.009).
• Fewer school days missed in the prior month (0.4 versus 1.2, RR 0.3, 95% CI 0.1 to 0.7, P=0.006).
• Less frequent days with restricted over the preceding two weeks (1.3 versus 2.3, RR 0.5, 95% CI 0.3 to 0.8, P=0.02).
• Fewer hospitalizations over the year before (0.2 versus 0.6, RR 0.2, 95% CI 0.2 to 0.9, P=0.01).
• More improvements in rescue inhaler availability (38.8% versus 32.2%, P=0.01).
• More likely to obtain a controller asthma medication if they did not have one before (RR 2.4, 95% CI 1.0 to 5.7, P=0.04) irrespective of seeing the referral coordinator (RR 1.0, 95% CI 0.4 to 2.3, P=0.97).

Most of the students met criteria for contact by the referral coordinator (82.7% study program group and 70.4% control group). The most common referral reasons were lack of a physician, lack of an inhaler, and possible depression.

"The study suggests that socioeconomic or contextual factors are often obstacles to managing asthma among adolescents," the researchers noted.

"As such, we feel strongly that inclusion of this referral mechanism is necessary, and caution against excluding this aspect of the program as a cost savings," they continued. Each contact by the referral coordinator averaged 31 minutes and was estimated to cost .73.

Generalizability of the findings may be limited because of the low diversity of students included, the researchers acknowledged.

However, the study demonstrated that African American students in urban schools could be effectively targeted for asthma education as recommended by National Asthma Education and Prevention Program guidelines.

"A web-based, tailored approach to changing negative asthma management behaviors is economical, feasible, and effective in improving asthma outcomes in a traditionally hard-to-reach population," the researchers concluded.