Educational Interventions For Asthma in Children

Educational interventions for asthma in children (Review)
Wolf F, Guevara JP, Grum CM, Clark NM, Cates CJ
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 4
http://www.thecochranelibrary.com

Copyright 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Self-management vs. Usual Care, Outcome 1 Lung Function. . . . . . . . . . .
Analysis 1.2. Comparison 1 Self-management vs. Usual Care, Outcome 2 Exacerbations (% Patients). . . . . .
Analysis 1.3. Comparison 1 Self-management vs. Usual Care, Outcome 3 Exacerbations (Mean). . . . . . . .
Analysis 1.4. Comparison 1 Self-management vs. Usual Care, Outcome 4 School Absences (% Patients). . . . . .
Analysis 1.5. Comparison 1 Self-management vs. Usual Care, Outcome 5 School Absences (mean days). . . . . .
Analysis 1.6. Comparison 1 Self-management vs. Usual Care, Outcome 6 Restricted Activity (% Patients). . . . .
Analysis 1.7. Comparison 1 Self-management vs. Usual Care, Outcome 7 Restricted Activity (Mean Days). . . . .
Analysis 1.8. Comparison 1 Self-management vs. Usual Care, Outcome 8 Nights Nocturnal Asthma (% Patients). .
Analysis 1.9. Comparison 1 Self-management vs. Usual Care, Outcome 9 Nights Nocturnal Asthma. . . . . . .
Analysis 1.10. Comparison 1 Self-management vs. Usual Care, Outcome 10 Self-efficacy Scale. . . . . . . . .
Analysis 1.11. Comparison 1 Self-management vs. Usual Care, Outcome 11 Asthma Severity Score. . . . . . .
Analysis 1.12. Comparison 1 Self-management vs. Usual Care, Outcome 12 General Practitioner Visits. . . . . .
Analysis 1.13. Comparison 1 Self-management vs. Usual Care, Outcome 13 ED Visits (% Patients). . . . . . .
Analysis 1.14. Comparison 1 Self-management vs. Usual Care, Outcome 14 ED Visits (mean). . . . . . . . .
Analysis 1.15. Comparison 1 Self-management vs. Usual Care, Outcome 15 Hospitalization (% patients). . . . .
Analysis 1.16. Comparison 1 Self-management vs. Usual Care, Outcome 16 Hospitalizations (mean). . . . . . .
Analysis 2.1. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 1 Lung Function.
Analysis 2.2. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.3. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.4. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.5. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 5 School Absences
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.6. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 6 Restricted Activity
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.7. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.8. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.9. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.10. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 10 Self-Efficacy
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.11. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Analysis 2.12. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.13. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 13 ED Visit (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.14. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 14 ED Visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.15. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.16. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.1. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 1 Lung Function.
Analysis 3.2. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.3. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.4. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 4 School Absences
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.5. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 5 School Absences
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.6. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 6 Restricted Activity
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.7. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.8. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.9. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.10. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 10 Self-Efficacy
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.11. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.12. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 12 General
Practitioner visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.13. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 13 ED Visit (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.14. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 14 ED Visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.15. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 15 Hospitalization
(% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.16. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.1. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 1 Lung Function. . .
Analysis 4.2. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.3. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 3 Exacerbations (Mean).
Analysis 4.4. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.5. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 5 School Absences (mean
days).
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.6. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.7. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 7 Restricted Activity (mean
days).
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Analysis 4.8. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 8 Nights Nocturnal Asthma
(% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.9. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 9 Nights Nocturnal Asthma
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.10. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 10 Self-Efficacy Scale.
Analysis 4.11. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.12. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.13. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 13 ED Visit (% patients).
Analysis 4.14. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 14 ED Visits (mean).
Analysis 4.15. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 4.16. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.1. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 1 Lung Function. .
Analysis 5.2. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.3. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.4. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.5. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 5 School Absences (mean
days).
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.6. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.7. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.8. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.9. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.10. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 10 Self-Efficacy
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.11. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.12. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.13. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 13 ED Visit (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.14. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 14 ED Visits (mean).
Analysis 5.15. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 5.16. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.1. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 1 Lung Function. . . . . .
Analysis 6.2. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 2 Exacerbation (% patients). .
Analysis 6.3. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 3 Exacerbations (Mean). . .
Analysis 6.4. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 4 School Absences (% patients).
Analysis 6.5. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 5 School Absences (mean days).
Analysis 6.6. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 6 Restricted Activity (% patients).
Analysis 6.7. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 7 Restricted Activity (mean days).
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Analysis 6.8. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 8 Nights Nocturnal Asthma (%
Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.9. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 9 Nights Nocturnal Asthma
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.10. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 10 Self-Efficacy Scale. . . .
Analysis 6.11. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 11 Asthma Severity Scale. .
Analysis 6.12. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 12 General Practitioner visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 6.13. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 13 ED Visit (% patients). .
Analysis 6.14. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 14 ED Visits (mean). . . .
Analysis 6.15. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 15 Hospitalization (% patients).
Analysis 6.16. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 16 Hospitalizations (mean). .
Analysis 7.1. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 1 Lung
Function. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.2. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 2
Exacerbation (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Exacerbations (Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.4. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 4 School
Absences (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.5. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 5 School
Absences (mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Restricted Activity (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . .
Restricted Activity (mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.8. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 8 Nights
Nocturnal Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.9. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 9 Nights
Nocturnal Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.10. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 10 SelfEfficacy Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Asthma Severity Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
General Practitioner visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.13. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 13 ED
Visit (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 7.14. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment, Outcome 14 ED
Visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospitalization (% patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Hospitalizations (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.1. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 1 Lung Function.
Analysis 8.2. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 2 Exacerbation (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.3. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 3 Exacerbations
(Mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.4. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.5. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 5 School Absences
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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Analysis 8.6. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.7. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 7 Restricted Activity
(mean days). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.8. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 8 Nights Nocturnal
Asthma (% Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.9. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 9 Nights Nocturnal
Asthma (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.10. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 10 Self-Efficacy
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.11. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 11 Asthma Severity
Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.12. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 12 General Practitioner
visits (mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.13. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 13 ED Visit (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.14. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 14 ED Visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.15. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 8.16. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.1. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 1 Lung Function. . . .
Analysis 9.2. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 2 Exacerbation (% patients).
Analysis 9.3. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 3 Exacerbations (Mean).
Analysis 9.4. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 4 School Absences (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.5. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 5 School Absences (mean
days).
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.6. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 6 Restricted Activity (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.7. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 7 Restricted Activity (mean
days).
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.8. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 8 Nights Nocturnal Asthma (%
Patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.9. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 9 Nights Nocturnal Asthma
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.10. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 10 Self-Efficacy Scale. .
Analysis 9.11. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 11 Asthma Severity Scale.
Analysis 9.12. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 12 General Practitioner visits
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.13. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 13 ED Visit (% patients).
Analysis 9.14. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 14 ED Visits (mean). .
Analysis 9.15. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 15 Hospitalization (%
patients). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 9.16. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 16 Hospitalizations
(mean). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
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v
[Intervention Review]
Educational interventions for asthma in children

Fredric Wolf1 , James P Guevara2 , Cyril M Grum3 , Noreen M Clark4 , Christopher J Cates5
1 Department
of Medical Education & Biomedical Informatics, University of Washington School of Medicine, Seattle, WA, USA.
of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. 3 University of Michigan, Ann
Arbor, MI 48109-0368, USA. 4 School of Public Health, University of Michigan, Ann Arbor, MI 48109-2029, USA. 5 Community
Health Sciences, St Georges, University of London, London, UK
2 Department
Contact address: Fredric Wolf, Department of Medical Education & Biomedical Informatics, University of Washington School of
Medicine, E-312 Health Sciences, Box 357240, Seattle, WA, 98195-7240, USA. wolf@u.washington.edu.
Editorial group: Cochrane Airways Group.
Publication status and date: Edited (no change to conclusions), published in Issue 4, 2008.
Review content assessed as up-to-date: 31 July 2002.
Citation: Wolf F, Guevara JP, Grum CM, Clark NM, Cates CJ. Educational interventions for asthma in children. Cochrane Database
of Systematic Reviews 2002, Issue 4. Art. No.: CD000326. DOI: 10.1002/14651858.CD000326.
ABSTRACT
Background
Self-management education programs have been developed for children with asthma, but it is unclear whether such programs improve
outcomes.
Objectives
To determine the efficacy of asthma self-management education on health outcomes in children.
Search strategy
Systematic search of the Cochrane Airways Groups Special Register of Controlled Trials and PSYCHLIT, and hand searches of the
reference lists of relevant review articles.
Selection criteria
Randomized and controlled clinical trials of asthma self-management education programs in children and adolescents aged 2 to 18
years.
Data collection and analysis
All studies were assessed independently by two reviewers. Disagreements were settled by consensus. Study authors were contacted for
missing data or to verify methods. Subgroup analyses examined the impact of type and intensity of educational intervention, selfmanagement strategy, trial type, asthma severity, adequacy of follow-up, and study quality.
Main results
Of 45 trials identified, 32 studies involving 3706 patients were eligible. Asthma education programs were associated with moderate
improvement in measures of airflow (standardized mean difference [SMD] 0.50, 95% confidence interval [CI] 0.25 to 0.75) and selfefficacy scales (SMD 0.36, 95% CI 0.15 to 0.57). Education programs were associated with modest reductions in days of school absence
(SMD -0.14, 95% CI -0.23 to -0.04), days of restricted activity (SMD -0.29, 95% CI -0.49 to -0.08), and emergency room visits
(SMD -0.21, 95% CI -0.33 to -0.09). There was a reduction in nights disturbed by asthma when pooled using a fixed-effects but
not a random-effects model. Effects of education were greater for most outcomes in moderate-severe, compared with mild-moderate
asthma, and among studies employing peak flow versus symptom-based strategies. Effects were evident within the first six months, but
for measures of morbidity and health care utilization, were more evident by 12 months.
Authors conclusions
Asthma self-management education programs in children improve a wide range of measures of outcome. Self-management education
directed to prevention and management of attacks should be incorporated into routine asthma care. Conclusions about the relative
effectiveness of the various components are limited by the lack of direct comparisons. Future trials of asthma education programs should
focus on morbidity and functional status outcomes, including quality of life, and involve direct comparisons of the various components
of interventions.
PLAIN LANGUAGE SUMMARY

Learning self-management strategies related to asthma prevention or attack management can help improve childrens lung function
and feelings of self-control, as well as reduce school absences and days of restricted activity and decrease emergency room utilization.
There were no differences in the risk or frequency of hospitalizations between usual care and care supplemented with self-management
education. These types of more rare and serious events may be beyond the ability of education to influence. While more research is needed
to make direct comparisons between different types of interventions, the limited evidence currently available suggests that in general,
self-management education works well for persons with moderate-to-severe asthma as well as for those with mild-to-moderate asthma.
Peak flow-based educational strategies generally show greater effects than symptom-based strategies. Beneficial effects on measures of
physiological function were apparent within six months, but benefits did not become fully apparent on measures of morbidity or health
care utilization until 7 to 12 months following enrolment in an educational program.
BACKGROUND
Asthma is the most prevalent chronic pulmonary disorder afflicting children (Shamssain 1999; Habbick 1999; McFadden 1992).
The prevalence of diagnosed asthma has been growing over the
past 20 years (Magnus 1997; Senthilselvan 1998). Of greater concern is that both asthma morbidity and mortality appear to be
increasing (Ng 1999). This increase is seen particularly in lower
socioeconomic groups and in minority populations (Cunningham
1996). Children with asthma suffer a high number of school absences (Doull 1996), endure a high and increasing rate of disability (Perrin 1999; Newacheck 2000), and incur substantial health
care costs (Lozano 1997).
Self-management educational programs for children with asthma
have been developed in recent years in recognition of the need to
improve health care practices, reduce morbidity, and lower costs of
care (Hurd 1992; Clark 1989). To be successful, programs must be
based on a sound theoretical understanding of behavior change and
employ self-management strategies designed to improve knowledge, skills, and feelings of self-control (Clark 1994). A number
of educational programs have been the subject of rigorous evaluations (Lewis 1984; Wilson-Pessano 1985; Clark 1986a; Clark
1986b; Evans 1987; Creer 1976; Hindi-Alexander 1984; Parcel
1980). These programs incorporate a variety of educational strategies, are designed for different clinical settings, and are targeted to
different patient groups.
While it has become increasingly clear that limited asthma education involving only information transfer is ineffective (Gibson
1999), the effectiveness of self-management education programs
in children with asthma is unclear. In adults with asthma, the use
of a self-management education program that includes self-monitoring, regular medical review, and an asthma action plan does
appear to improve measures of morbidity and reduce health care
utilization (Gibson 1998). In children, however, a published metaanalysis of 11 self-management teaching programs concluded that
asthma self-management programs do not reduce morbidity or
decrease health care utilization (Bernard-Bonnin 1995). This research synthesis was limited to trials published prior to 1992, and a
large number of studies have been published subsequently. Therefore, a new review that incorporates more recent studies may help
to clarify the uncertainty regarding the effectiveness of asthma education in children.
The purpose of this study was to systematically review the research
literature on the efficacy of self-management educational inter-

ventions in modifying health outcomes for children with asthma.

We hypothesized that self-management programs would be associated with improvements in measures of lung function, decreases
in measures of morbidity, and lead to reductions in health care
utilization.
OBJECTIVES
The specific study objectives were two-fold:
(1) To determine the effectiveness of self-management education
programs on measures of physiological function, morbidity and
functional status, self-perception, and health care utilization in
children and adolescents with asthma.
(2) To determine the characteristics of self-management education programs and trials that are associated with improvements in
health outcomes in children and adolescents with asthma.
METHODS
Criteria for considering studies for this review
Types of studies
Randomized controlled trials (RCTs) and controlled clinical trials
(CCTs) were considered in this systematic review.
Types of participants
Studies of children and adolescents with asthma from two to 18
years of age were included.
Types of interventions
Any educational intervention targeted to children or adolescents
(and/or their parents) designed to teach one or more self-management strategies related to prevention, attack management, or social
skills using any instructional strategy or combination of strategies
(problem solving, role-playing, videotapes, computer assisted instruction, booklets, etc.) presented either individually or in group
sessions was included in the review.
Types of outcome measures
Categories of outcomes examined for this review are based on a
consensus of clinically relevant outcomes from the Asthma Outcomes Conference and adapted from Clark and Starr-Schneidkrauts model of patient management (Clark 1994). These outcome categories are (1) physiological function, (2) morbidity and
functional status, (3) self-perception measures, and (4) health care

utilization. Two additional outcome categories from the conference, adverse effects of medications and quality of life, are not included here because they were not reported in any eligible trial. A
full listing of more specific outcomes within each category is provided below. We have selected one outcome from each category as
primary outcomes. These decisions were typically made because
the most data were available for these outcomes, both in terms of
the number of studies and sample sizes for the individual studies
and because these outcomes were considered the most salient in
each category. The primary outcomes are a combined measure of
lung function (1c), days of school absence (2b), self-efficacy (3b),
and emergency department visits (4b).
(1) Physiological function
(a) forced expiratory volume in 1 second (FEV1): exact number
or percent of predicted
(b) peak expiratory flow rate (PEF): exact number or percent of
predicted
(c) a combined measure of lung function: defined as either FEV1
or PEF
(2) Morbidity and functional status
(a) exacerbations: defined as asthma attacks or episodes of asthma
(b) days of school absence: defined as days of school non-attendance due to asthma or other causes
(c) days of restricted activity: defined as days of asthma symptoms
or days of activity restriction
(d) nights disturbed by asthma: defined as nights of sleep interruption due to asthma or nights with asthma symptoms
(3) Self-perception measures
(a) asthma severity: defined as subjective measures of asthma severity and includes asthma symptom or severity scores
(b) self-efficacy: Self-efficacy is the belief in ones capabilities to
organize and execute the sources of action required to manage
prospective situations (Bandura 1996). A strong sense of personal
efficacy has been shown to be related to a variety of outcomes,
including better health, higher achievement, and more social integration (Schwarzer 1995). For purposes of this systematic review,
we have included measures of coping scores and health locus of
control scales.
(4) Health care utilization
(a) general practitioner visits: defined as routine and urgent ambulatory clinic visits to a general practitioner, family physician,
pediatrician, or other related health care provider
(b) emergency department visits: defined as urgent visits to a hospital emergency department
(c) hospitalizations: defined as any inpatient hospital stay
If outcomes were reported separately by time, the outcome corresponding to six months or later post-enrollment was selected.
Regarding measures of lung function, if outcomes were reported
at multiple times during the day, the morning measurement was
selected.

Search methods for identification of studies
Electronic searches
We identified studies from the Cochrane Airways Groups trials register comprised of references from MEDLINE, EMBASE,
CINAHL, and hand searched airways-related journals. This
database was searched using the following terms:
asthma OR wheez* AND education* OR self management OR
self-management.
The Airways Group databases combine EMBASE, CINAHL and
MEDLINE records. We identified the EMBASE records through
keyword or text word (in title or abstract fields) searches on
asthma* or on the term wheez*. In Medline and CINAHL, the
text word searches (in title or abstract fields) were made on
terms asthma* or wheez*. The MeSH searches in MEDLINE and
CINAHL were made on the following two MeSH terms: respiratory sounds and asthma. The MEDLINE records cover the period
1966 to 1998, EMBASE records span 1980 to 1998, and the earliest CINAHL records date from 1982. The main Airways Group
databases include the records downloaded from the three electronic systems. We searched the main Airways Group databases
using the following terms: placebo* OR trial* OR random* OR
double-blind OR double blind OR single-blind OR single blind
OR controlled study OR comparative study) and we exported
those records to a separate RCT register.
In addition, we identified asthma-related studies from PSYCHLIT using the Cochrane Schizophrenia Groups search strategy to
identify trials in that behavioral sciences database. We searched
this database using the following terms: asthma* OR asthma- in
DE OR wheez* OR [(bronchial*) near (hyper-reactiv* or hyperreactiv*)] AND randomi* OR [(singl* OR doubl* OR trebl* OR
tripl*) near (blind* OR mask*)] OR crossover.
Searching other resources
Finally, we hand searched the reference lists from relevant reviews that had been identified (Clark 1993; Clark 1994; BernardBonnin 1995).
Data collection and analysis
Selection of studies
One reviewer screened the title and abstract of each citation that
we identified through the search strategy to determine possible
eligibility for inclusion. We then obtained the complete article
of each citation identified as eligible or possibly eligible. At least
two investigators (FW, CG, JG, MR) independently assessed each
article to determine study eligibility. Disagreement was settled by
consensus.
Studies were included if (a) they were published randomized controlled trials (RCTs) or controlled clinical trials (CCTs); (b) they
included children or adolescents ages 2 to 18 years old; (c) they had
an educational intervention designed to teach one or more selfmanagement strategies related to prevention, attack management,
or social skills; (d) they included outcomes on pulmonary function tests, morbidity, functional status, or health care utilization.
We excluded studies if they included participants with pulmonary
diagnoses other than asthma, lacked suitable control populations
for comparison, used non-standard educational interventions, or
did not report on any outcomes of interest.
Data extraction and management

We abstracted all eligible studies onto preprinted data collection
forms. Information on randomization methods, participants, follow-up procedures, nature of educational interventions, and outcomes was collected. We also contacted, by mail, authors of all
eligible studies to verify the accuracy of published data or to obtain
missing data. Twenty authors (63%) provided additional information on allocation concealment procedures or missing information
that was then incorporated into this review.
Assessment of risk of bias in included studies

We based the methodological quality of included trials primarily
on an assessment of allocation concealment. Allocation concealment refers to whether trials sufficiently concealed group allocation prior to randomization and was measured using the Cochrane
approach (Clarke 1999):
Category A: Adequate concealment using formal
randomization procedures (e.g. sealed envelopes or random
numbers).
Category B: Uncertain or unclear concealment.
Category C: Clearly inadequate concealment using nonrandom procedures (e.g. alternation).
Methodological quality of included trials was also based on assessments of studies indicating whether performance bias, exclusion
bias, or detection bias were present. Performance bias refers to
whether differences in care may have existed between treatment
and control groups apart from the intervention and was measured
as present or absent. Exclusion bias refers to whether significant
differences in withdrawal existed between treatment and control
groups (generally at least 10%) or whether withdrawal rates in the
combined group were large (generally greater than 20%) and was
measured as present or absent. Detection bias refers to whether
differences in outcome assessment may have existed between treatment and control groups and was measured as present or absent.
Dealing with missing data

In addition, if continuous outcomes were reported without standard deviations, we imputed pooled standard deviations from the
following generalized formula for the t-statistic (Rosenthal 1991):
t = [M1 - M2 / S] X [ 1/ sq root (1/n1 + 1/n2 ) ]
Where t refers to the t-statistic, M refers to the mean of the treatment and control groups, S refers to the pooled standard deviation, and n refers to the sample size of the treatment and control
groups. If the t-statistic was not reported in a given paper, the tstatistic corresponding to the exact p-value with the appropriate
degrees of freedom was used. If the t-statistic and exact p-value
were not reported in a given paper, the t-statistic corresponding
to p = 0.05 (for a reported p<0.05) or p = 0.50 (for a reported p
> 0.05) with the appropriate degrees of freedom was used.
Data synthesis
For continuous outcomes, we used the standardized weighted
mean difference (SMD) to estimate a pooled effect size, since in all
cases, outcomes were reported in different units or scales. We reported the pooled effect sizes with 95% confidence intervals (CI).
We used both a fixed-effects model (Hasselblad 1995) and a random-effects model (DerSimonian 1986) to pool the data, since
there does not appear to be general consensus as to which method
is superior. In general, the random-effects method is a more conservative approach than the fixed-effects method and results in
larger CIs.
For consistency and simplicity, We reported the SMDs based on
the fixed-effects model in the text of the review and in the table of
comparisons. Where effect sizes differed statistically, we reported
the pooled effect size from the random-effects model in footnotes
to the tables and in the text of the review. For dichotomous outcomes, we used the odds ratio (OR) with 95% CIs to estimate
a pooled effect size (Greenland 1985). We also used both fixedeffects and random-effects models to pool data on dichotomous
outcomes. We calculated the number needed to treat (NNT) to
prevent an adverse event for all statistically significant dichotomous outcomes (Altman 1998).
Where necessary, we computed standard deviations from standard
errors of the mean or confidence intervals using standard statistical
formulas (Hedges 1985; Wolf 1986).
asthma if they had mean FEV1 < 0.50 of predicted, mean PEFR
< 0.60 of predicted, or reported daily asthma symptoms. We categorized studies as moderate to severe if asthmatics with severe
asthma were enrolled in the study population and mild-moderate
otherwise.
(2) Educational program characteristics: Subgroup analyses were
performed on the effect of educational interventions by (a) intervention type (individual vs. group); (b) intensity of intervention
(single vs. multiple sessions); (c) time since enrolment (one to six
months vs. seven to twelve months vs. > twelve months); and (d)
self-management strategy (peak flow-based vs. symptom-based) to
estimate the effect of various intervention characteristics.
(3) Study quality characteristics: Subgroup analyses were performed on the effect of educational interventions by (1) trial type
(RCT vs. CCT); (2) allocation concealment (adequate vs. unclear
vs. inadequate); and (3) adequacy of follow-up (adequate vs. inadequate) to estimate the effects of study characteristics.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
Results of the search
The search identified 318 titles and abstracts of potentially eligible studies. After preliminary review, a total of 45 randomized or
controlled clinical trials were identified from the literature search
and review of bibliographies as possibly eligible for inclusion. After review of the full text of these studies, 13 were excluded for
the following reasons: absence of a suitable control population (N
= 2), inclusion of children less than two years old (N = 2), use of
non-standard or information only educational interventions (N =
4), inclusion of children with conditions other than asthma (N =
1), and no outcomes of interest (N = 4).
Subgroup analysis and investigation of heterogeneity
Included studies
We performed subgroup analyses by stratifying studies on key patient-level, study quality, and program variables in order to estimate the magnitude of these effects.
(1) Patient characteristics: Subgroup analysis was performed on
the effect of educational interventions by asthma severity. Asthma
severity (mild-moderate vs. moderate-severe) was determined by
study self-report, examination of mean FEV1 or PEFR baseline
measurements, or chronicity of asthma symptoms at baseline (ATS
1991; NAEP 1997). Patients were determined to have severe
A total of 32 trials involving 3706 children and adolescents with

asthma were selected for inclusion (see Characteristics of included
studies). Twenty-six (81%) of these trials were RCTs, and the remainder were non-randomized CCTs. The trials varied in size
(mean 116, range 20 to 451 participants), severity of asthma
among participants (15 with moderate-to-severe asthma, four with
mild-to-moderate asthma, and 13 with unclear severity), and the
proportion of participants with complete follow-up (range 43
to 100%). Fifteen of the trials reported inclusion of adolescents

(age 13 years old and above), while twelve reported inclusion of

preschool age children (ages two to five years old). The self-management educational programs employed by the trials differed by
type of educational session (15 employing group sessions, 14 employing individual sessions, three employing both), intensity (five
employing only a single session, two employing two sessions, 25
employing three or more sessions), self-management strategy (13
employing peak flow-based strategies, 19 employing symptombased strategies), and length of the intervention (mean 3.8, range
one to twelve months). While thirteen trials incorporated social
skills development into their educational strategy, all trials focused
on asthma prevention measures (e.g. identification and avoidance
of asthma triggers) and/or attack management plans (e.g. use of
an asthma action plan).
Outcomes assessed
(1) Measures of physiological function:

Forced expiratory volume in 1 second (FEV1) (N = 2)
Peak expiratory flow rate (PEF) (N = 4)
Combined measure of lung function (N = 7)
(2) Measures of morbidity and functional status:
Proportion with exacerbations (N = 2)
Exacerbations (N = 5)
Proportion with School Absences (N = 1)
Days of School absence (N = 17)
Proportion with restricted activity (N = 1)
Days of restricted activity (N = 6)
Proportion with Nights disturbed by asthma (N = 1)
Nights disturbed by asthma (N = 3)
(3) Measures of self-perception:
Self-efficacy scales (N = 10)
Asthma severity scores (N = 5)
(4) Measures of health care utilization:
Physician visits (N = 10)
Proportion with ED visits (N = 6)
ED visits (N = 14)
Proportion with hospitalization (N = 4)
Hospitalizations (N = 9)
Risk of bias in included studies

The methodological quality of the studies varied. Twelve trials
were felt to have adequate concealment of allocation of patients
to intervention or control groups, while six trials had clearly inadequate or no concealment methods (eg allocation based on alternating sites or sequential assignment). In fourteen trials, it was
not possible to determine the method of allocation concealment
based on published methods. Six studies had differences in the
care provided to treatment and control groups apart from the intervention. Eight studies had systematic differences in withdrawal
between treatment and control groups. There did not appear to
be systematic differences in the assessment of outcomes between

treatment and control groups in any of the studies.
Effects of interventions
AUTHOR VERIFICATION
An attempt was made to contact corresponding authors of all
studies in order to verify allocation concealment procedures and
to obtain missing data. A total of twenty authors (63%) responded
to requests for additional information.
OUTCOMES: SELF-MANAGEMENT VERSUS
USUAL CARE (N = 32 trials)
(1) PHYSIOLOGICAL FUNCTION
Four trials involving 258 patients reported complete data on the

effect of self-management education programs on measures of
physiological function. There was a significant improvement on
a combined measure of lung function (SMD 0.50, 95% CI 0.25
to 0.75) as well as on individual measures of FEV1 (SMD 0.46,
95% CI 0.08 to 0.84) and PEF (SMD 0.53, 95% CI 0.19 to
0.86) associated with self-management education programs when
the trials were pooled. Three additional trials involving 192 patients, which could not be pooled due to missing data, reported
no significant effect of education on measures of lung function
(Hughes 1991; Dahl 1990; Szczepanski 1996). The pooled estimates obtained by the random-effects model were consistent with
those from the fixed-effects analyses. There was no significant heterogeneity among the trials reporting on the combined measure of
lung function (Chi-square = 2.44; p = 0.49) and PEF (Chi-square
= 2.38; p = 0.3).
(2) MORBIDITY AND FUNCTIONAL STATUS
Eighteen trials involving 1649 patients reported complete data on

the effect of self-management education programs on measures of
morbidity and functional status. There was a small but significant
reduction in the days of school absence (SMD -0.14, 95% CI 0.23 to -0.04) and days of restricted activity (SMD -0.29, 95% CI
-0.49 to -0.08) when the 16 and six trials respectively reporting on
these outcomes were pooled by either the fixed effect or randomeffects model. One additional trial involving 84 patients which
could not be pooled, due to missing data, reported statistically significantly less school absenteeism (p < 0.05) among the education
group than the control group (Szczepanski 1996). There was a
significant reduction in the nights disturbed by asthma when the
three trials reporting on this outcome were pooled by the fixedeffect model (SMD -0.34, 95% CI -0.62 to -0.05) but not by

the random-effects model (SMD -0.39, 95% CI -1.07 to 0.28).

There was no significant reduction in the number of exacerbations
(SMD -0.21, 95% CI -0.43 to 0.01) when the five trials reporting
on this outcome were pooled. In addition, there was no significant
reduction in the proportion of patients experiencing an exacerbation (OR 1.43, 95% CI 0.94 to 2.18), day of school absence
(OR 0.78, 95% CI 0.36 to 1.66), day of restricted activity (OR
2.51, 95% CI 0.61 to 10.29), or night disturbed by asthma (OR
0.65, 95% CI 0.29 to 1.44). However, few studies reported on
dichotomous morbidity outcomes. There was significant heterogeneity among the trials pooled for nights disturbed by asthma
(Chi-square = 11.19, p = 0.004), but not among trials pooled for
exacerbations, days of school absence, or days of restricted activity.
(3) SELF PERCEPTION
Nine trials involving 522 patients reported complete data on the

effect of self-management education programs on measures of selfperception. There was improvement on measures of self-efficacy
(SMD 0.36, 95% CI 0.15 to 0.57) when the six trials reporting
this outcome were pooled using the fixed effect or random effects
model. Four additional trials that could not be pooled, due to
missing data, reported that education was beneficial on scales of
self-efficacy in three studies involving 313 patients (Evans 1987;
Kubly 1984; Szczepanski 1996) but not in one study involving
43 patients (Rakos 1985). There was no significant reduction by
education on asthma severity scores (SMD -0.15, 95% CI -0.43
to 0.12) when the four trials were pooled. One additional trial
involving 84 patients which could not be pooled due to missing
data reported a decrease in asthma severity scores in the education
plus follow-up group (p < 0.05) but not in the education only
or control groups (Szczepanski 1996). There was no significant
heterogeneity among the trials pooled for self-efficacy scales but
there was heterogeneity among trials pooled for asthma severity
scores (Chi-square = 6.72, p = 0.08).
(4) HEALTH CARE UTILIZATION
Eighteen trials involving 1899 patients reported complete data on

the effect of self-management education programs on measures of
health care utilization. There was a significant reduction in the
number of emergency department (ED) visits (SMD -0.21, 95%
CI -0.33 to -0.09) associated with education when the 12 trials reporting complete data on this outcome were pooled using
both fixed effect and random effects models. Two additional trials which could not be pooled due to missing data reported no
benefit of education in one study involving 43 patients (Rakos
1985) but a benefit of education in one study involving 84 patients (Szczepanski 1996). There was no significant reduction in
the number of general practitioner visits (SMD -0.15, 95% CI 0.31 to 0.01) when the six trials reporting complete data on this
outcome were pooled. Four additional trials that could not be
pooled due to missing data reported a significant benefit of education on general practitioner visits in one study involving 78
patients (Colland 1993) but not in three studies involving 141
patients (McNabb 1985; Rakos 1985; Szczepanski 1996). There
was no significant reduction in the number of hospitalizations
associated with education (SMD -0.08, 95% CI -0.21 to 0.05)
when the eight trials reporting complete data on this outcome were
pooled. One additional trial involving 84 patients which could not
be pooled due to missing data reported no significant reduction
in hospitalizations associated with education (Szczepanski 1996).
Moreover, there was no significant reduction in the proportion of
patients who experienced an ED visit (OR 1.30, 95% CI 0.93
to 1.84) or a hospitalization (OR 1.00, 95% CI 0.70 to 1.42)
when the six trials and four trials respectively reporting data on
these outcomes were pooled. There was significant heterogeneity
among the trials pooled for hospitalizations (Chi-square = 13.03,
p = 0.07) and ED visits (Chi-square = 19.68, p = 0.05) but not
for general practitioner visits.
SUBGROUP ANALYSES
OUTCOMES: SELF-MANAGEMENT VERSUS USUAL

CARE BY TIME SINCE ENROLLMENT (N = 32 TRIALS)
When self-management education programs were examined by

time since enrollment, effects of education versus usual care on
measures of physiological function were evident within the first
six months of enrollment ((SMD 0.50, 95% CI 0.25 to 0.75).
However, effects on measures of morbidity [exacerbations (SMD
-0.28, 95% CI -0.53 to -0.03), days of school absence (SMD 0.16, 95% CI -0.29 to -0.04), days of restricted activity (SMD
-0.26, 95% CI -0.48 to -0.04), and nights disturbed by asthma
(SMD -0.86, 95% CI -1.38 to -0.35)], self-perception [self-efficacy scales (SMD 0.54, 95% CI 0.28 to 0.80)], and health care
utilization [ED visits (SMD -0.19, 95% CI -0.32 to -0.05), and
hospitalizations (SMD -0.26, 95% CI -0.44 to -0.08)] became
more evident at seven to twelve months post-enrollment. Evidence
for effectiveness from longer term follow-up was sparse.
CARE BY SELF-MANAGEMENT STRATEGY (N = 32
TRIALS)
When comparing the effectiveness of self-management strategies,

studies that employed peak flow-based strategies and studies that
employed symptom-based strategies were similar with respect to
improvements in self efficacy scales and reductions in ED visits.
However, studies that employed peak flow based strategies demonstrated greater improvement in a measure of physiological function [combined lung function (SMD 0.50, 95% CI 0.25 to 0.75)]
and greater reductions in measures of morbidity [days of school
absence (SMD -0.22, 95% CI -0.40 to -0.04), days of restricted

activity (SMD -0.68, 95% CI -1.13 to -0.23), and nights disturbed

by asthma (SMD -0.72, 95% CI -1.09 to -0.36)], and health care
utilization [general practitioner visits (SMD -0.24, 95% CI -0.55
to 0.06) and risk of hospitalization (OR 0.41, 95% CI 0.21 to
0.81; NNT 9.0, 95% CI 6.4 to 30.5)] than studies that employed
symptom based strategies after stratification and pooling. No studies reported on direct comparisons of symptom based versus peak
flow based strategies.

CARE BY INTERVENTION TYPE (N = 32 TRIALS)
When comparing studies by the type of intervention, both individual and group interventions demonstrated similar beneficial effects on a combined measure of lung function, self-efficacy scales,
and ED visits when compared to usual care. The reductions in
morbidity measures [days of school absence (SMD -0.20, 95% CI
-0.35 to -0.04), days of restricted activity (SMD -0.68, 95% CI 1.13 to -0.23), nights disturbed by asthma (SMD -0.86, 95% CI
-1.38 to -0.35)] and a measure of health care utilization [general
practitioner visits (SMD -0.29, 95% CI -0.56 to -0.03)] were generally stronger among trials pooled for individual interventions
as opposed to group interventions. There was a reduction in a
measure of health care utilization [hospitalizations (SMD -0.22,
95% CI -0.44 to -0.01)] that was stronger among trials pooled for
group interventions as opposed to individual interventions. However, there were no trials reporting on direct comparisons of individual versus group interventions. Two studies employed a combination of individual and group interventions (Fireman 1981;
Shields 1990), and the results from these two studies were consistent with those obtained from the other studies. Overall, the
number of trials available for individual and group comparisons
of most outcomes were relatively sparse (eg between one and three
trials).

CARE BY INTERVENTION INTENSITY (N = 32 TRIALS)
When the intensity of the programs were compared, both single

and multiple session interventions were associated with similar
improvements in measures of combined lung function, exacerbations, and days of school absence. However, studies employing
single sessions were associated with greater reductions in certain
morbidity measures [days of restricted activity (SMD -0.61, 95%
CI -1.12 to -0.11) and nights disturbed by asthma (SMD -0.86,
95% CI -1.38 to -0.35)] than studies employing multiple sessions.
On the other hand, studies employing multiple sessions were associated with improvement in a measure of self-perception [selfefficacy scales (SMD 0.36, 95% CI 0.15 to 0.57)] and reductions
in measures of health care utilization [general practitioner visits
(SMD -0.17, 95% CI -0.35 to 0.00) and ED visits (SMD -0.21,
95% CI -0.33 to -0.09)] that were not seen in studies employing
single sessions. There were no direct comparisons of single sessions versus multiple sessions for any reported outcome, and most
outcomes were sparse after stratification by session number.
OUTCOMES: SELF-MANAGEMENT VS. USUAL CARE BY
TRIAL TYPE (N = 32 TRIALS)
When comparing studies by trial type, both RCTs and CCTs were
similar with regard to improvements in combined lung function
and self-efficacy scales and reductions in days of school absence.
CCTs were generally associated with greater reductions in certain
morbidity measures [exacerbations (SMD -0.47, 95% CI -0.90 to
-0.04), days of restricted activity (SMD -0.58, 95% CI -1.00 to 0.15), and nights disturbed by asthma (SMD -0.86, 95% CI -1.38
to -0.35)] and a measure of health care utilization [hospitalizations
(SMD -0.41, 95% CI -0.90 to 0.09)] than RCTs when studies
were stratified by trial type and pooled. Only for a single measure
of health care utilization [ED visits (SMD -0.23, 95% CI -0.36 to 0.09)] were RCTs generally stronger than CCTs after stratification
and pooling of trials.
OUTCOMES: SELF-MANAGEMENT VS. USUAL CARE BY
ADEQUACY OF ALLOCATION CONCEALMENT (N = 32
TRIALS)
When studies were compared by the adequacy of allocation concealment, studies judged to have both adequate and inadequate
concealment demonstrated similar improvements in combined
lung function and self-efficacy scales, and reductions in days of
school absence and ED visits. However, studies with inadequate
concealment generally had greater reductions in certain measures
of morbidity [exacerbations (SMD -0.47, 95% CI -0.90 to -0.04),
days of restricted activity (SMD -0.58, 95% CI -1.00 to -0.15) and
nights disturbed by asthma (SMD -0.86, 95% CI -1.38 to -0.35)]
and a measure of health care utilization [hospitalization (SMD 0.41, 95% CI -0.90 to 0.09)] than studies with adequate concealment when studies were stratified by the adequacy of allocation
concealment and pooled. Studies judged to have unclear concealment performed better than studies in either of the other two categories for some outcome measures [combine lung function (SMD
1.24, 95% CI 0.26 to 2.22), general practitioner visits (SMD 0.72, 95% CI -1.45 to 0.01), and ED visits (SMD -0.29, 95%
CI -0.47 to -0.11)] and worse than studies in either of the other
two categories for other measures [days of school absence (SMD
-0.09, 95% CI -0.22 to 0.04), days of restricted activity (SMD 0.12, 95% CI -0.47 to 0.24), nights disturbed by asthma (SMD
0.24, 95% CI -0.21 to 0.68), self-efficacy scales (SMD 0.23, 95%
CI -0.09 to 0.54), and hospitalizations (SMD -0.01, 95% CI 0.16 to 0.15)]. Studies judged to have adequate concealment had
a greater decrease in a single measure of health care utilization [the
risk of hospitalization (OR 0.41, 95% CI 0.21 to 0.81; NNT 9.0,
95% CI 6.4 to 30.5)]. Generally, most outcomes were sparse after
stratification by the adequacy of allocation concealment.


CARE BY ADEQUACY OF FOLLOW-UP (N = 32 TRIALS)
When studies were compared by the adequacy of follow-up of

participants, studies judged to have adequate and inadequate follow-up of participants had similar reductions in days of school
absence, days of restricted activity, self-efficacy scales, and ED visits. However, studies judged to have adequate follow-up were associated with improvements in a measure of physiological functioning [combined lung function (SMD 0.50, 95% CI 0.25 to
0.75)] and a measure of morbidity [nights disturbed by asthma
(SMD -0.34, 95% CI -0.62 to -0.05)] and had greater reductions
in two measures of health care utilization [risk of hospitalization
(OR 0.38, 95% CI 0.20 to 0.73; NNT 7.8, 95% CI 5.8 to 19.6)
and hospitalizations (SMD -0.25, 95% CI -0.42 to -0.07)] than
studies judged to have inadequate follow-up after stratification by
adequacy of follow-up and pooling of trials. Studies judged to
have inadequate follow-up of participants had greater reduction
in a measure of health care utilization [general practitioner visits
(SMD -0.55, 95% CI -0.99 to -0.11)] than studies judged to have
adequate follow-up after stratification and pooling. Overall, few
studies were judged to have inadequate follow-up and this created
outcomes with sparse numbers.
CARE BY ASTHMA SEVERITY (N = 32 TRIALS)
When studies were compared by the degree of asthma severity

of participants, trials that enrolled subjects with mild to moderate and moderate to severe asthma had similar improvements in
a measure of combined lung function and similar reductions in
exacerbations. However, studies with participants who had moderate to severe asthma were associated with greater reductions in
measures of morbidity [days of school absence (SMD -0.24, 95%
CI -0.37 to -0.10), days of restricted activity (SMD -0.64, 95% CI
-1.02 to -0.25), nights disturbed by asthma (SMD -0.72, 95% CI
-1.09 to -0.36)] and health care utilization [general practitioner
visits (SMD -0.48, 95% CI -0.82 to -0.15), ED visits (SMD 0.34, 95% CI -0.52 to -0.16), and hospitalizations (SMD -0.35,
95% CI -0.60 to -0.09)] than studies with participants with mild
to moderate asthma. However, trials stratified by asthma severity
were sparse for most outcomes, and no trials reported on direct
comparisons of asthma severity for any outcome. For a number
of studies, it was not possible to determine the asthma severity of
the participants, and the results of outcomes for these studies were
similar to those obtained for studies with participants who had
mild to moderate asthma.
DISCUSSION
In this systematic review of 32 trials involving 3706 pediatric patients, asthma education programs compared to usual care were
found to improve measures of physiological function and self-efficacy; reduce days of school absence and days of restricted activity,
decrease emergency department utilization, and perhaps reduce
nights disturbed by asthma. However, the effects of asthma education on the average number of nights disturbed by asthma symptoms was only apparent when results were pooled using a fixedeffects model but not when a more conservative random-effects
model was employed. In addition, it was almost inevitable that
there was significant statistical heterogeneity of results for some
outcome measures (eg, nights disturbed by asthma was reported
as nights with asthma symptoms or nights of sleep interruption),
given the diversity of ways the same outcome is operationally defined and measured.
Subgroup analyses were conducted to examine the impact of patient or educational factors that may be important in the design
of interventions and good quality research. These results are best
viewed as tentative given the small number of pooled trials for
each subgroup post-stratification. In addition, since no studies
included direct comparisons of the different components of patient or educational factors, subgroup analyses were conducted to
compare the magnitude of effects for each subgroup. In general,
self-management education worked well for persons with moderate-to-severe asthma as well as for those with mild-to-moderate
asthma, although several outcomes were stronger for those with
greater asthma severity. In looking at the characteristics of the interventions, both individual and group interventions, and single
and multiple educational sessions were effective, but not necessarily for the same outcomes. Peak flow-based strategies generally
showed greater effect sizes than symptom-based strategies. In looking at the effects of the interventions by time, beneficial effects
on measures of physiological function were apparent within the
first six months following enrolment, but benefits did not become
fully apparent on measures of morbidity or health care utilization
until 7 to 12 months following enrolment.
Subgroup analyses were also conducted to look at the effects of
study design and methodological quality on outcomes. Both RCTs
and CCTs showed beneficial results but not necessarily for the
same outcomes. CCTs appeared to be associated with greater reductions in many measures of morbidity and health care utilization
than RCTs. The adequacy of allocation concealment was unclear
for a large number of studies (43%), however studies judged to
have inadequate concealment performed better on many morbidity and health care utilization measures than studies judged to have
adequate or unclear concealment. Studies with adequate followup generally showed greater effects than studies with inadequate
follow-up, however studies with inadequate follow-up were few
(23%). For four outcome measures (combined lung function, days
of school absence, self-efficacy scales, and ED visits), the effects
of self-management education were consistently as beneficial or
better among pooled studies of higher quality (eg. RCTs, adequate
concealment, adequate follow-up) than among pooled studies of

lower quality.
AUTHORS CONCLUSIONS
Implications for practice
(1) Evidence from this systematic review of existing clinical trials supports the conclusion that self-management educational interventions for children and adolescents with asthma compared
to usual care result in improved physiological function, decreased
asthma morbidity, improved self-perception, and reduced health
care utilization. The educational programs included in this review
all incorporate prevention and attack management components as
part of their interventions. A small subset of the studies included a
social skills component. The results suggest the desirability of incorporating self-management education consisting of prevention
and attack management components into routine asthma care for
children and adolescents.
(2) Evidence from this systematic review suggests that on average patients who receive self-management education would incur
moderate improvements in their physiological function over those
who receive usual care.
(3) Evidence from this systematic review suggests that on average patients who receive self-management education would have
modest reductions in school absences and days with restricted activity, and may reduce the nights in which asthma symptoms occur
compared to those who receive usual care.
(4) Evidence from this systematic review suggests that on average patients who receive self-management education would have
moderate improvements in their feelings of self-control compared
to those who receive usual care.
(5) Evidence from this systematic review suggests that on average patients who receive self-management education would incur
modest decreases in their utilization of the emergency department
compared to those who receive usual care.
(6) This systematic review found no reliable differences in the
risk or frequency of hospitalizations between usual care and care
supplemented with self-management education. These types of
more rare and serious events may be beyond the ability of education
to influence.
(7) There is not enough evidence to reliably discern differences
in the effectiveness of self-management education as a function of
differences in asthma severity or the components of educational
programs. There were no direct comparisons evaluating these differences head-to-head. However, tentative results from this review
suggest that patients with more severe asthma may derive greater
benefits from education than those with milder forms of asthma.
In addition, tentative results from this review suggest that peak
flow-based interventions may outperform symptom-based interventions. In general, benefits of education on physiological outcomes became apparent within the first six months following enrolment, but benefits of education on morbidity and health care
utilization measures did not become apparent until seven to twelve
months following enrolment.
Implications for research

(1) More than half of the intervention studies identified were either
poorly reported or of less than desired quality, or both. Much more
attention needs to be paid to good reporting and high quality study
design in the future. Tentative results from this review suggest that
studies judged to be of poorer quality generally reported results
that were stronger than studies judged to be of higher quality.
(2) Many studies contained missing information on outcomes of
interest that either precluded the incorporation of their data into
pooled estimates of effect or resulted in the use of a conservative
method of imputation to obtain pooled measures of variance. Future research efforts should assess the reliability of various methods
of imputation and encourage more complete reporting of study
results.
(3) Given that evidence supports the conclusion that education is
more effective than no education, future studies should directly test
alternative interventions against one another rather than against
no education controls.
(4) Evidence was insufficient to adequately and reliably estimate
effects for many of the important subgroups for which information would be useful to enhance the quality of provider and patient decision making. Future studies of asthma education should
directly assess important components of asthma education (e.g.
peak flow-based vs. symptom-based interventions).
(5) It would be desirable to reach international consensus on preferred measurement approaches for assessing lung function, morbidity, quality of life, functional status, health care utilization, etc.,
so as to enhance comparability and interpretability across studies.
(6) Future trials of asthma education programs should focus on
morbidity and functional status outcomes as these outcomes were
generally under-reported.
ACKNOWLEDGEMENTS
The authors would like to thank the Cochrane Airways Collaborative Review Group Editorial Office, including Steve Milan, Anna
Bara, Jane Dennis, and Professor Paul Jones for their helpful comments and for assistance in identifying trials. We also thank Margo
Rankin for assistance with coding the data, Toby Lasserson for
his excellent translation of the Szczepanski study from German to
English, and Drs. Francine M. Ducharme and Mike McKean for

10
their helpful comments and suggestions. We also would like to

thank Alison Whitton for her careful reading of the Synopsis as
a member of the Airways Review Group consumer panel to help
ensure that the Synopsis is understandable from a patients point of
view. This systematic review was supported in part by the National
Institutes of Health, Grant number NIH 1 F06 TW02123 from
the Fogerty International Center and Grant number NIH 1 K07
HL03046 from the National Heart, Lung, and Blood Institute.
This review has been copy edited by Kirsty Olsen.
REFERENCES
References to studies included in this review

Alexander 1988 {published data only}
Alexander JS, Younger RE, Cohen RM, Crawford LV.

Effectiveness of a nurse-managed program for children with chronic
asthma. Journal of Pediatric Nursing 1988;3(5):3127.
Carswell 1989 {published data only}
Carswell F, Robinson EJ, Hek G, Shenton T. A Bristol

Experience: Benefits and cost of an Asthma Nurse visiting the
Homes of Asthmatic Children. Bristol Medico-Chirurgical Journal
1989;104:112.
Charlton 1994 {published data only}
Charlton I, Antonio AG, Atkinson J, Campbell MJ, Chapman E,

Mackintosh T, et al.Asthma at the interface: bridging the gap
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Christiansen 1997 {published data only}
Christiansen SC, Martin SB, Schleicher NC, Koziol JA, Mathews

KP, Zuraw BL. Evaluation of a school-based asthma education
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Clark 1986 {published data only}
Clark NM, Feldman CH, Evans D, Levison MJ, Wasilewski Y,

Mellins RB. The impact of health education on frequency and cost
of health care use by low income children with asthma. Journal of
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Colland 1993 {published data only}
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Counseling 1993;22(3):14152.
Dahl 1990 {published data only}
Dahl J, Gustafsson D, Melin L. Effects of a behavioral treatment

program on children with asthma. Journal of Asthma 1990;27(1):
416.
Deaves 1993 {published data only}
Deaves DM. An assessment of the value of health education in the
prevention of childhood asthma. Journal of Advanced Nursing 1993;
18:35463.
Evans 1987 {published data only}
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MJ, et al.A School Health Education Program for Children with
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Fireman 1981 {published data only}
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Teaching self-management skills to asthmatic children and their
parents in an ambulatory care setting. Pediatrics 1981;68(3):3418.
Hill 1991 {published data only}
Hill R, Williams J, Britton J, Tattersfi LD. Can morbidity

associated with untreated asthma in primary school children be
reduced?: a controlled intervention study. British Medical Journal
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about asthma: comparing the effectiveness of a developmentally
appropriate asthma education videotape and picture book. Child:
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Hughes 1991 {published data only}
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trial of a home and ambulatory program for asthmatic children.
Pediatrics 1991;87(1):5461.
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Kubly LS, McClellan MS. Effects of self-care instruction on

asthmatic children. Issues in Comprehensive Pediatric Nursing 1984;
7:12130.
LeBaron 1985 {published data only}
LeBaron S, Zeltzer LK, Ratner P, Kniker WT. A controlled study

of education for improving compliance with cromolyn sodium
(Intal(Reg.trademark)): the importance of physician-patient
communication. Annals of Allergy 1985;55(6):8118.
Lewis 1984 {published data only}
Lewis CE, Rachelefsky G, Lewis MA, De la Sota MA, Kaplan M.

A randomized trial of A.C.T. (Asthma Care Training) for Kids.
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management training programme in children admitted to hospital
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McNabb 1985 {published data only}
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Mitchell 1986 {published data only}
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community child health nurses. Archives of Disease in Childhood
1986;61(12):11849.
Parcel 1980 {published data only}
Parcel GS, Nader PR, Tiernan K. A health education program for

children with asthma. Developmental and Behavioral Pediatrics
1980;1(3):12832.
Perrin 1992 {published data only}
Perrin JM, MacLean WE, Gortmaker SL, Asher KN. Improving

the psychological status of children with asthma: a randomized
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1992;13(4):2417.
Persaud 1996 {published data only}
Persaud DI, Barnett SE, Weller SC, Baldwin CD, Niebuhr V,

McCormick DP. An asthma self-management program for children,
including instruction in peak flow monitoring by school nurses.
Journal of Asthma 1996;33(1):3743.
Rakos 1985 {published data only}
Rakos RF, Grodek MV, Mack KK. The impact of a selfadministered behavioral intervention program on pediatric asthma.
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Ronchetti 1997 {published data only}
Ronchetti R, Indinnimeo L, Bonci E, Corrias A, Evans D, HindiAlexander M, et al.Asthma self-management programmes in a

population of italian children: a multicentric study. European
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Rubin 1986 {published data only}
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Clemente I, et al.Educational intervention by computer in
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(1):110.
Shields 1990 {published data only}
Shields MC, Griffin KW, McNabb WL. The effect of a patient

education program on emergency room use for inner-city children
with asthma. American Journal of Public Health 1990;80(1):368.
Szczepanski 1996 {published data only}
Szczeanski R, Gebert N, Hummelink R, Konning J, Schmidt S,

Runde B, et al.Outcome of structured asthma education in
childhood and adolescence [Ergebnis einer strukturlerten
asthmaschulung im kindesund jugendalter]. Pneumologie 1996;50
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Talabere 1993 {published data only}
Talabere, Laurel R. The effects of an asthma education program

on selected health behaviors of school-aged children with asthma.
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hospital and home. New York: Springer Publications, 1993:31930.
Toelle 1993 {published data only}
Toelle BG, Peat JK, Salome CM, Mellis CM, Bauman AE,
Woolcock AJ. Evaluation of a community-based asthma
management program in a population sample of schoolchildren.

The Medical Journal of Australia 1993;158(11):7426.
Weingarten 1985 {published data only}
Weingarten MA, Goldberg J, Teperberg Y. A pilot study of the

multidisciplinary management of childhood asthma in a family
practice. Journal of Asthma 1985;22(5):2615.
Whitman 1985 {published data only}
Whitman N, West D, Brough FK, Welch M. A study of a selfcare rehabilitation program in pediatric asthma. Health Education
Quarterly 1985;12(4):33342.
Wilson 1996 {published data only}
Wilson SR, Latini D, Starr NJ, Fish L, Loses LM, Page A, et

al.Education of parents of infants and very young children with
asthma: a developmental evaluation of the Wee Wheezers program.
References to studies excluded from this review

Aleman 1992 {published data only}
Aleman Mendez S, Sanchez Palacios A. An integrated approach to
the psychological aspects of the asthmatic child. Allergologia et
Immunopathologia 1992;20(6):2405.
Brazil 1997 {published data only}
Brazil K, McLean L, Abbey D, Musselman C. The influence of

health education on famly management of childhood asthma.
Patient Education and Counseling 1997;30(2):10718.
Brook 1993 {published data only}
Brook U, Mendelberg A, Heim M. Increasing parental knowledge
of asthma decreases the hospitalization of the child: a pilot study.
Carson 1991 {published data only}
Carson DK, Council JR, Schauer RW. The effectiveness of a

family asthma program for children and parents. Child Health Care
1991;20(2):1149.
Gibson 1998 {published data only}
Gibson PG, Shah S, Mamoon HA. Peer-led asthma education for
adolescents: impact evaluation. The Journal of Adolescent Health
1998;22:6672.
Indinnimeo 1987 {published data only}
Indinnimeo L, Midulla F, Hindi-Alexander M, Bonci E, Tancredi

GC, Cutrera R, et al.Controlled studies of childhood asthma selfmanagement in Italy using the open airways and living with
asthma programs: a preliminary report. Health Education
Quarterly 1987;14(3):291308.
Kotses 1991 {published data only}
Kotses H, Harver A, Segreto J, Glus KD, Creer TL, Young GA.

Long-term effects of biofeedback-induced facial relaxation on
measures of asthma severity in children. Biofeedback and Self
Regulation 1991;16(1):121.
Lewis 1994 {published data only}
Lewis MA, de la Sota A, Rachelefsky G, Lewis CE, Quinones H,
Richards W. ACT-asthma control y tratamiento para ninos: a
progress report. Health Education Quarterly 1987;14(3):28190.
Lewis MA, Rachelefsky G, Lewis CE, Leake B, Richards W. The

termination of a randomized clinical trial for poor hispanic children.
Archives of Pediatrics & Adolescent Medicine 1994;148:3647.

12
Mesters 1995 {published data only}

Mesters I, Meertens R, Kok G, Parcel GS. Effectiveness of a
multidisciplinary education protocol in children with asthma (0-4
years) in primary health care. Journal of Asthma 1994;31(5):
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Mesters I, Van Nunen M, Crebolder H, Meertens R. Education of

parents about paediatric asthma: effects of protocol on medical
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Moe 1992 {published data only}
Moe EL, Ches JD, Vollmer WM, Wall MA, Stevens VJ, Hollis JF.
Implementation of Open Airways as an educational intervention
for children with asthma in an HMO. Journal of Pediatric Health
Care 1992;6:2515.
Clark 1993
Clark N, Gotsch A, Rosenstock I. Patient, professional, and public
education on behavioral aspects of asthma: a review of strategies for
change and needed research. Journal of Asthma 1993;30:24155.
Clark 1994
Clark N, Starr-Schneidkraut N. Management of asthma by patients
and families. American Journal of Respiratory and Critical Care
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Clarke 1999
Clarke M, Oxman A. Cochrane Reviewers Handbook 4.0 (updated
July 1999). 4th Edition. Oxford: The Cochrane Collaboration,
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Sly 1975 {published data only}
Sly RM. Evaluation of a sound-slide program for patient

education. Annals of Allergy 1975;34:947.
Creer 1976
Creer T, Renne C, Christian W. Behavioral contributions to
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Smith 1986 {published data only}
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intervention on medication compliance in children with asthma.
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Cunningham 1996
Cunningham J, Dockery D, Speizer F. Race, asthma, and persistent
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childhood asthma: a preliminary study of need and efficacy.
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DerSimonian R, Laird N. Meta-analysis in clinical trials. Controlled
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Altman DG. Confidence intervals for the number needed to treat.
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ATS 1991
American Thoracic Society. Lung function testing: selection of
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Bandura 1996
Bandura A. Social foundations of thought and action. Englewood
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Bernard-Bonnin 1995
Bernard-Bonnin A, Stachenko S, Bonin D, Charette C, Rousseau
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Clark 1986a
Clark N, Feldman C, Evans D, Levison M, Wasilewski Y, Mellins
R. The impact of health education on frequency and cost of health
care use by low income children with asthma. Journal of Allergy and
Clinical Immunology 1986;78:10815.
Clark 1986b
Clark N, Feldman C, Evans D, Duzey O, Levison M, Wasilewski Y.
Managing better: parents, children and asthma. Patient Education
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Clark 1989
Clark N. Asthma self-management education. Research and
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Walters EH, Wilson AJ. The effects of self-management education
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Gibson 1999
Gibson PG, Coughlan J, Wilson AJ, Hensley MJ, Abramson M,
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The Cochrane Library 2000, Issue 1.[Art. No.: CD001005. DOI:
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Greenland S, Robins J. Estimation of a common effect parameter
from sparse follow-up data. Biometrics 1985;41:5568.
Habbick 1999
Habbick B, Pizzichini M, Taylor B, Rennie D, Senthilselvan A,
Sears M. Prevalence of asthma, rhinitis, and eczema among children
in 2 canadian cities: the International Study of Asthma and
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Hasselblad V, Hedges L. Meta-analysis of screening and diagnostic
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Hedges L, Olkin I. Statistical methods for meta-analysis. Orlando:
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Hindi-Alexander 1984
Hindi-Alexander M, Cropp G. Evaluation of a family asthma
program. Journal of Allergy and Clinical Immunology 1984;74:
505510.
Hurd 1992
Hurd S, Lenfant C. The National Heart, Lung, and Blood Institute
Asthma Program. Chest 1992;101:359S361S.
Lozano 1997
Lozano P, Fishman P, VonKorff M, Hecht J. Health care utilization
and cost among children with asthma who were enrolled in a health
maintenance organization. Pediatrics 1997;99:75764.
Magnus 1997
Magnus P, Jaakkola J. Secular trend in the occurrence of asthma
among children and young adults: critical appraisal of repeated
cross sectional surveys. BMJ 1997;314:17959.
McFadden 1992
McFadden E, Gilbert I. Asthma. New England Journal of Medicine
1992;327:192837.
NAEP 1997
National Asthma Education Program. Guidelines for the diagnosis
and management of asthma. Betheseda, Maryland: National
Institutes of Health, 1997.
Newacheck 2000
Newacheck P, Halfon N. Prevalence, impact, and trends in
childhood disability due to asthma. Archives of Pediatric &
Adolescent Medicine 2000;154:28793.
Ng 1999
Ng T, Tan W. Temporal trends and ethnic variations in asthma
mortality in Singapore, 1976-1995. Thorax 1999;54:9904.
Perrin 1999
Perrin J, Kuhlthau K, McLaughlin T, Ettner S, Gortmaker S.
Changing patterns of conditions among children receiving
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Pediatric & Adolescent Medicine 1999;153:804.
Rosenthal 1991
Rosenthal R. Meta-analytic procedures for social research. revised.
Newbury Park, CA: Sage Publications, 1991.
Schwarzer 1995
Schwarzer R, Fuchs R. Self-Efficacy and Health Behaviours. In:
Conner M, Norman P editor(s). Predicting Health Behaviour:
Research and Practice with Social Cognition Models. Buckingham:
Open University Press.
Senthilselvan 1998
Senthilselvan A. Prevalence of physician-diagnosed asthma in
Saskatchewan, 1981-1990. Chest 1998;114:38892.
Shamssain 1999
Shamssain M, Shamsian N. Prevalence and severity of asthma,
rhinitis, and atopic eczema: the northeast study. Archives of Disease
in Childhood 1999;81:3137.
Wilson-Pessano 1985
Wilson-Pessano S, McNabb W. The role of patient education in the
management of childhood asthma. Preventive Medicine 1985;14:
67087.
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London: Sage Publications, 1986.
Indicates the major publication for the study

14
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Alexander 1988
Methods
RCT: After a treatment conference, children were randomized into a control or clinical nurse specialist
group.
Blinded assessment: no
Assessment: Pre- and 4, 8, 12 months post-intervention.
Participants
Treatment: 11 assigned, 11 completed (100%).

Control: 10 assigned, 10 completed (100%).
Eligibility criteria: (1) one or more documented ER visits @ LeBonheuer Childrens medical center in the
prior 12 mos for tx of acute asthma, and (2) no consistent source for asthma management other than ER
during past 12 mos.
Asthma severity: moderate to severe based on mean ER visits in year prior to enrolment.
Locale: Memphis, TN, USA.
Age: range 15 mos to 13 yrs, mean not given.
Gender: Not reported.
Other demographics: the children were mostly of low income families.
Interventions
Description: A Clinical Nurse Specialist (CNS) counselled children and parents in the fundamental
concepts of asthma self-care.
Program topics: (1) Assessment of self-care deficit, (2) basic lung anatomy and asthma pathophysiology,
(3) review of medications, actions, potential side effects, and therapeutic usage, (4) importance of a parentrecorded daily symptom chart to assist families to gain insight into specific asthma triggers for the child,
and (5) importance of avoidance measures and environmental control (avoiding inhaled irritants and
allergens).
Setting: clinic
Session type: individual (parent & child together)
Number of sessions: 4
Session length: not reported.
Time span of intervention: 12 months.
Self-management strategy: Symptom-based. Educational Strategy: Prevention, attack management.
Instructional methods/tools: Visual aids, printed handouts.
Additional information: All subject contact with the CNS occurred in the general pediatric clinic which
met one-half day weekly under the supervision of the Pediatric Allergy Division.
Outcomes
Lung function: None.

Morbidity:
Functional status: None.
Health care utilization: Emergency visits, hospitalization, proportion hospitalized
Other: None.
Notes
Possible biases: Performance Bias (care may have been systematically different between CNS and continuity
clinics apart from educational intervention) and Selection bias (allocation concealment unclear).
Risk of bias

15
Alexander 1988
(Continued)
Item
Authors judgement
Description
Allocation concealment?
Unclear
Information not available
Carswell 1989
Methods
RCT: Families of children with asthma were randomly allocated by computer-generated random numbers
to either receive visits by an asthma nurse or not.
Blinded assessment: Yes
Assessment: Pre- and 6 months post-enrolment.
Participants

Eligibility criteria: Families with children ages 5 to15 who received an asthma diagnosis through a selfreport questionnaire from one suburban and one urban group practice.
Asthma severity: mild to moderate based on baseline PEFs.
Locale: Bristoll & Weston, England
Age:
Mean 11.2 yrs, Range 5-15.
Gender: 59 male (68.6%). 27 female (31.4%).
Other demographics: Suburban = higher SES. Urban = lower SES.
Interventions
Description: Education program delivered by District Health Authority nurses, trained in asthma.
Program topics: (1) Asthma, (2) asthma risks, (3) treatment factors likely to provoke an attack, (4)
preventing and curtailing an attack.
Setting: home
Session type: Individual.
Number of sessions: 1 or more.
Session length: Mean time 29 minutes.
Time span of intervention: 6 mos
Self-management strategy: Peak Flow-based. Educational Strategy: Prevention, attack management.
Instructional methods/tools: Didactic.
Additional information: None
Outcomes
Lung function: %PEF of predicted.

Morbidity: Symptoms, school days missed, work days missed.
Health care utilization: Family practitioner visits to home, patient visits to surgery/hospital, direct cost of
nurse, drug costs.
Other: Asthma Knowledge = Theoretical Knowledge Score (TKS) which measures the familys ability to
use objective signs of asthma severity. Costs borne by families.
Notes
Possible biases: selection bias (allocation concealment was unclear).
Risk of bias
Item
Authors judgement

Description
16
Carswell 1989
(Continued)
Unclear
Charlton 1994
Methods
RCT: Subjects were stratified on age, gender, and previous asthma prophylaxis and then randomized to
intervention or control group using sealed envelopes containing the intervention assignment.
Blinded assessment: no.
Assessment: pre- and 12 months post-enrolment.
Participants

Eligibility criteria: (1) diagnosis of asthma, (2) age 3 to 16, and (3) hospital admission or outpatient
department visit for asthma.
Asthma severity: unclear.
Locale: Winchester, New South Wales, Australia.
Age: mean 6.5 years, range 3 to 16 years.
Gender: 52 M (57%), 39 F (43%).
Other demographics: None.
Interventions
Description: Nurse-led educational intervention delivered at outpatient clinic or during inpatient stay.
Program topics: (1) inhaler technique,
(2) mechanisms of asthma, 3) functions of medications, 4) self-management plan involving peak flow
meter and diary card.
Setting: clinic or hospital ward.
Session type: individual.
Session length: 45 minutes
time span of intervention: 1 day.
Self-management strategy: peak flow-based.
Educational strategy: prevention and attack management.
Instructional methods/tools: diary cards and didactic sessions.
Additional information: none.
Outcomes
Lung function: peak expiratory flow rates.

Morbidity: night cough, night wheeze, daytime wheeze, nasal symptoms, time lost from school,
Health care utilization: visits to the general practitioner
Other: medications, parent/patient response to acute episodes.
Notes
Possible biases: selection bias (intervention group had greater proportion with severe symptoms and higher
health care visits at baseline).
performance bias (nurse consulted physicians regarding medication management for treatment group but
not for control group).
Risk of bias
Item
Authors judgement

Description
17
Charlton 1994
(Continued)
Yes
Third party randomisation
Christiansen 1997
Methods
CCT: Subjects were assigned non-randomly in block by school site to an educational program or a control
group with schools alternating as treatment or control groups in successive years.
Blinded assessment: Not specified
Assessment: Pre- and 6 months post-intervention.
Participants
Treatment: 32 assigned, 27 completed (84.4%).

Control: 18 assigned, 15 completed (83.3%).
Eligibility criteria: 4th grade student enrolled at 4 schools in the San Diego Unified School District
Asthma severity: Moderate to severe based on PEF scores and asthma severity scores.
Locale: San Diego, CA, USA.
Age: Range: 9 to 12, Mean: 10.4 years.
Gender: not specified
Other demographics: Majority population Hispanic Mexican-American.
Interventions
Description: An asthma education program based on the consensus report guidelines for asthma care
published by the NHLBI and delivered by school nurses.
Program topics: (1) Basic information about asthma, identification of asthma warning signs, reduction of
asthma triggers, and use of an inhaler, (2) asthma medication (bronchodilators), (3) asthma medications
(anti-inflammatory agents), use of a peak flowmeter, development of an action plan, and development of
an emergency plan for asthma.
Setting: school
Session type: group
Time span of intervention: 5 weeks
Self-management strategy: Peak Flow-based. Educational Strategy: prevention, attack management
Instructional methods/tools: Booklets, handouts covering the key points of each lesson, reference materials.
Additional information: Sessions held in bilingual interaction.
Outcomes
Lung function: PEF and % predicted PEF.

Morbidity: school absences.
Functional status: Asthma severity score, Asthma symptom score.
Health care utilization: emergency visits, hospitalizations.
Other: asthma knowledge, inhaler technique, and peakflow meter technique
Notes
Possible biases: selection biases (schools were not randomly assigned to treatment group).
Risk of bias
Item
Authors judgement
Description
No
Open allocation process

18
Clark 1986
Methods
RCT: After initial interviews, children were randomly assigned in a 2:1 ratio either to the experimental
or control.
Blinded assessment: Yes.
Participants

Eligibility criteria: (1) Dx of asthma made by a physician by use of commonly accepted clinical criteria,
(2) one or more visits made to the clinic in the previous 12 mos, (3) one or more episodes of wheezing
reported in the last year, (4) age 4 to 17, (5) no major handicap that would prevent benefit from an
educational program.
Asthma severity: not specified.
Locale: New York City, NY, USA
Age: Mean 9.2 years, range 4 to 17 years.
Gender: 64% male, 36% female
Other demographics: low income urban children, predominantly black or Hispanic, most families received
public assistance.
Interventions
Description: Open Airways education program to improve asthma management at home delivered by
health educator.
Program topics: (i) Managing the asthma attack, (ii) taking medicine, (iii) communicating with the physician, (iv) improving school performance,(v) maintaining a healthy home environment, (vi) establishing
guidelines for the childs physical activities.
Setting: outpatient allergy clinic
Session type: group.
Time span of intervention: 6 mos (1 session per month)
Self-management strategy: Symptom-based. Educational Strategy: Prevention, attack management, social
skills.
Instructional methods/tools: Group discussion including a process for problem solving led by a health
educator.
Outcomes

Morbidity;
Functional status: none
Health care utilization: Number of ER visits and hospitalizations.
Other: cost savings.
Notes
Risk of bias
Item
Authors judgement
Description
Unclear

19
Colland 1993
Methods
RCT: Subjects were randomly allocated to an experimental group or one of two control groups (limited
asthma education and control).
Blinded assessment: No
Assessment: Preliminary test and evaluation post training, 6 months later, and one year later.
Participants

Control: 64 assigned (34 placebo control, 30 control), 64 completed (100%).
Eligibility criteria: (i) child had been treated by a paediatrician >1 yr, (ii) diagnosis asthma was evident
(min. score on 1 on a 9 pt asthma severity scale), (iii) between 8-13 years, (iv) child fluent in Dutch,
(v) child absent from school because of asthma more than once a year, (vi) inadequate self-management
abilities.
Asthma severity: unclear
Locale: 6 various areas of the Netherlands
Age: Range 8 to 12 years 7 months, Mean: 10 years.
Gender: 119 boys (61%), 76 girls (39%)
Other demographics Dutch.
Interventions
Description: The program consisted of a combination of behavioral techniques, self-management training,

developmental psychology and group therapy techniques for children with insufficient or inadequate
asthma self-management abilities in a 3 phase format taught by a behavioral therapist.
Program topics: Phase 1: information about asthma medicine and practicing the correct inhalation technique; learn a positive attitude toward asthma; learn the need for complying with drug therapy; learn selfefficacy in asthma management such as identifying early signals, how to act in the early stage, dealing
with an episode at home and school, how to talk to an unfamiliar doctor. Phase 2: how to communicate
with assertiveness about asthma to coaches, teachers, family who smoke, classmates; learning relaxation
techniques. Phase 3: learning healthy behavior, diet, appropriate sports & warm-up exercises; learning
preventative and curative activities; practicing situations; explaining what children have learned to families
and teachers.
Setting: out-patient clinic
Session length: one hour
Time span of intervention: 10 weeks.
Self-management strategy: Symptom-based. Educational Strategy: prevention, attack management, social
skills
Instructional methods/tools: problem solving, role-playing, booklets, games, quizzes, puzzles.
Additional information: Phase 1: sessions 1 to 4; Phase 2: sessions 5 to 7; Phase 3: sessions 8 to 10.
Outcomes
Lung function: No data reported

Morbidity: manageability of asthma, night awakening due to asthma, daily activity restrictions, school
absenteeism.
Functional status: self-efficacy, anxiety levels.
Health care utilization: number of first aid post visits, number of paediatrician visits.
Other: knowledge, compliance, parents psychological strength, parents feeling of burden, inhaler technique.
Notes
Risk of bias
20
Colland 1993
(Continued)
Item
Authors judgement
Description
Unclear
Dahl 1990
Methods
RCT: Subjects were randomized equally into a behavioral intervention group or a non-intervention control
group.
Blinded assessment: Not specified.
Assessment: A four-week baseline period, a four-week intervention period, and a four-week follow-up
period.
Participants
Treatment: 10 assigned; 9 completed (90%).

Control: 10 assigned; 10 completed (100%).
Eligibility criteria: All children had severe asthma and were using continual beta2 agonists.
Severity: Severe.
Locale: Uppsala, Sweden
Age:
Mean 12.2 years, (ranges not indicated)
Gender: 11 males (55%), 9 females (45%).
Other demographics: Swedish.
Interventions
Description: Behavior therapy treatment was tailored for each child according to his/her behavior analysis
during the 4 week baseline period
Program topics: (1) discrimination training of correct asthma signals, (2)self-management techniques of
breathlessness, (3)counter-conditioning of any learned fear response to asthma symptoms, (4) contingency
management of acute asthma-related behavior for overusers of hospital facilities, (5) social skills training,
(6) medication compliance training.
Setting: childs home or school environment.
Session length: one hour.
Self-management strategy: Peak Flow-based. Educational Strategy: Prevention, Attack management, Social
skills.
Instructional methods/tools: Problem solving, role-playing, biofeedback training using a PFM to correctly
discriminate asthma signals, time-out techniques for over-utilizers admitted to ER/hospital, homework
assignments in between sessions.
Outcomes
Lung function: Peak expiratory flow (AM & PM). Exhalation frequency (AM & PM).
Morbidity
Functional status: Number of days of school absences, psychological status (observed panic behavior in
asthma situations), number of days in which asthma was subjectively experienced.
Health care utilization: none
Other: Number of as-needed spray doses per day.

21
Dahl 1990
(Continued)
Notes
Possible biases: Exclusion bias (10% difference in follow-up between treatment and control groups),
Selection (Subjects in intervention group appear to have more severe asthma at baseline than controls
based on school absenteeism and days experiencing symptoms).
*Pooled standard deviations were imputed for days of school absence and days of restricted activity using
the exact value of the reported t-statistic.
Risk of bias
Item
Authors judgement
Description
Unclear
Deaves 1993
Methods
CCT: Subjects attending two general group practices were recruited. Subjects in one practice received the
intervention while subjects in the other served as controls.
Assessment: pre- and 12 months post-intervention.
Participants

Eligibility criteria: 1) diagnosis of asthma, 2) aged 3-16 years, 3) attend 2 general group practices participating in study.
Asthma severity: mild to severe.
Locale: Staffordshire, UK.
Age: mean not given, range 3-16 years.
Gender: not reported.
Other demographics: none.
Interventions
Description: Educational intervention delivered by health visitor (nurse) at subjects homes.

Program topics: (1) peak flow meter use, (2) mechanisms of asthma, (3) review of individualized asthma
plan.
Setting: home.
Number of sessions: 1.
Time span of intervention: 1 day.
Instructional methods/tools: booklets and didactic sessions.
Outcomes
Lung function: variability in peak flow readings.

Morbidity: number of attacks, days lost at school, night symptoms, restricted activities, severity of asthma
attacks.
Functional status: none.
Health care utilization: none.
Other: knowledge of asthma, knowledge of asthma treatment, value of health education.

22
Deaves 1993
(Continued)
Notes
Possible biases: selection bias (non-randomized study in which control had greater number of days lost
from school and asthma attacks at baseline.
*Pooled standard deviations were imputed for exacerbations, days of school absence, days of restricted
activity, and nights disturbed by asthma using the t-statistic conforming to the reported p-value with
appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
No
Non-random allocation based on severity
Evans 1987
Methods
RCT: 12 schools were paired on ethnicity and size and one school within each pair was randomly selected
by coin toss to receive intervention, while the other served as a waiting list control.
Assessment: Pretest and follow-up 12 months post-intervention.
Participants

Control: 105 assigned,
87 completed (82.9%).
Eligibility criteria: (1) Enrollment in 3rd, 4th or 5th grade, (2) parental report of at least 3 asthma episodes
in past yr, (3) written parental consent for participation.
Asthma severity: Mild asthma
Locale: New York City, NY, USA.
Age:
mean age = 9.1 yrs
range 8 to 11 yrs
Gender:
59% male; 41% female.
Other demographics: Inner-city low income families (71% on medicaid/public assistance). 70% Hispanic,
28% non-Hispanic black, 2% white.
Interventions
Description: Elementary school health education program based on Open Airways Program delivered
by health educator.
Program topics: (a) basic information and feelings about asthma, (b) how to recognize and respond to
symptoms of asthma, (c) using asthma medicines and deciding when to seek help, (d) how to keep active
physically, (e) identifying and controlling triggers to asthma symptoms, and (f ) handling problems related
to asthma and school
Setting: school
Session type: Group.
Time span of intervention: 2-3 weeks.
Self-management strategy: Symptom-based. Educational Strategy: prevention, attack management, social
skills.
Instructional methods/tools: Problem solving, role playing (in class & at home). Didactic sessions: in-

23
Evans 1987
(Continued)
class skills practice, at home practice assignments. Other: stories, games, physical and artistic.
Additional information: Physical and artistic activities were based on Piagets stage of concrete operations
for ages 8 to 11.
Outcomes
Lung function: none

Morbidity:
Functional status: (1) Wheezing Episodes: No. of episodes treated at home in the previous year, No. of
annual episodes, average duration (No. of days) of episodes, annual frequency of days w/ asthma symptoms.
(2) School Absenses: No. of times absent during the year. (3) Psychologial Status: self-efficacy levels
(index of self-efficacy with respect to ability to perform self-management behaviors), teacher rating of
classroom behavior, use of asthma management skills. Index of self-management activities, influence of
children on parents decisions (re: the childs asthma-parents rated and specific to decision about school
attendance and ER usage). (4) Grade Index: constructed by teacher on 11 subjects/skills, standardized
math & reading achievement tests.
Health care utilization: No. of asthma episodes requiring a visit to a physician.
Other: none.
Notes
Possible biases: Selection (Authors detected baseline differences on some measured variables, notably
asthma self-management skills and behavior ratings between intervention and control group).
Risk of bias
Item
Authors judgement
Description
Yes
Third party allocation
Fireman 1981
Methods
CCT: Subjects were sequentially assigned to either the study or the comparison group and matched for
age after an evaluation and observation by a pediatric allergist.
Blinded Assessment: No
Assessment: Pre- & 12 months post-enrolment.
Participants
Treatment: 13
assigned, 13 completed (100%).
Control: 13
Eligibility Criteria: Pt. population selected from a pediatric allergists office practice with a history of 6 or
more asthmatic episodes.
Asthma Severity: moderate to severe asthma based on symptom frequency.
Locale: Pittsburgh, PA, USA.
Age: range 2 to 14 yrs. Mean 7.4 years.
Other demographics: middle income.
Interventions
Description: An educational program designed to teach self-management skills to asthmatic children and
their parents delivered by a nurse educator.
Program topics: (1) lung anatomy description,(2) review of elementary pulmonary physiology and patho-

24
Fireman 1981
(Continued)
physiology, (3) factors that can provoke asthma (i.e. allergens, infections, exercise, etc), (4) asthma drug
therapy , (5) avoidance and control of exposure to environmental allergens, (6) psycho-sociologic factors,
(7) skills in asthma self-management, (8) parental behavior to promote childs self-managment.
Setting: doctors office; reinforced with telephone follow-up.
Session type: both individual (patient & family) & group.
Session length: Individual instruction: one hour. Group: two hours.
Self-management Strategy: Symptom-based.Educational strategy: prevention, attack management, social
skills.
Instructional methods/tools: didactic sessions, booklet.
Outcomes
Lung function: none.

Morbidity: asthma attacks, wheezing days per patient, absent school days.
Helath care utilization: ER visits, hospitalizations.
Other: medication diary, costs of care.
Notes
Possible biases: selection (parental educational level was higher in control group than in intervention
group).
*Pooled standard deviations were imputed for exacerbations, days of school absence, days of restricted
activity, emergency room visits, and hospitalizations using the t-statistic conforming to the reported pvalue with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
No
Non-randomised allocation on sequential basis
Hill 1991
Methods
RCT: Parallel group controlled intervention study: Schools were randomized by computer generated
random numbers to receive the intervention or to be a control according to their school nurse team.
Blinded assessment: Not specified
Assessment: Pre- and 6, 9, 12 months post- intervention.
Participants
Treatment: 228 assigned, 149 completed

(65%).
Control: 223 assigned, 147 completed (66%),
Eligibility criteria: Children from 102 schools not included in a previous study who were particularly
likely to have under-diagnosed or under-treated asthma, this including:
(a) absent from school because of wheezing at any time in the past year and taking no treatment for asthma,
(b) all children who had lost more than 5 days schooling because of wheezing and not taking prophylactic
drugs, and (c) all children who lost more than 10 days schooling because of wheezing, irrespective of
treatment.
Asthma severity: not reported, but moderate to severe suspected secondary to inclusion criteria.
Locale: Nottingham, UK
Age: range 5 to 10 years, mean not reported.

25
Hill 1991
(Continued)
Gender: 130 male (57%), 98 female (43%)

Interventions
Description: Two part medical appraisal and teacher education program. Children suspected of undertreated asthma were asked to visit their family physician for diagnosis and treatment. Teachers from
intervention schools attended an education program on asthma taught by school nurse.
Program topics:
Medical Appraisal: Peak flow meters for assessment of symptoms, value of prophylaxis and inhalation
route of drugs
Teacher Education Session: information on asthma and correct use of inhalers.
Setting:
Medical Appraisal:doctors office/clinic
Teacher Education Session: school
Session type:
Medical Appraisal - individual.
Teacher Education Session - group
Number of sessions:
Medical Appraisal - not reported
Teacher Education Session - 63 teaching sessions were delivered to 44 intervention schools.
Session length:
Teacher Education Session - 1 hr. during school lunch break
Time span of intervention:
Teacher Education Session - not reported
Self-management strategy: Symptom-based.
Educational Strategy: Attack Management.
Instructional methods/tools:
Teacher Education Session - didactic, visual aids
Additional information: Nurses giving instruction to teachers also checked children to make sure that
they were using their inhalers correctly and appropriately. Nurses checked inhaler technique of two-thirds
of children known to take inhalers to school.
Outcomes
Lung function: none

Morbidity: School absences, missed games, missed swimming lessons.
Health care utilization: None.
Other: management of asthma in schools, childrens access to medications.
Notes
Possible biases:
selection (Control group had greater proportion female, greater mean days of school absence, games
missed, and swimming lessons missed), performance (practitioners of intervention children were asked to
review their subjects diagnoses and modify their treatment plans according to a guideline).
Risk of bias
Item
Authors judgement

Description
26
Hill 1991
(Continued)
Yes
Third party allocation process
Holzheimer 1998
Methods
RCT: Subjects were randomly assigned to one of three experimental groups (1. video + book, 2. video
only, 3. book only) or control group.
Blinded assessment: Yes.
Assessment: pre-test, 4 months post-test.
Participants
Treatment: 60 assigned into each of 3 treatment groups, 16 completed group 1 (80%), 13 completed
group 2 (65%), and 12 completed group 3 (60%).
Eligibility criteria: Children aged 2 to 5 yrs requiring daily medication for asthma.
Asthma severity: Not described.
Locale: Queensland, Australia
Age: Range 24 to 71 mos. Mean 48.6 mos.
Gender: not specified.
Other demographics: not specified.
Interventions
Description: An educational program consisting of Video tape Young Children Managing Asthma and
the picture book Whats That Noise?
Program topics: Need for prophylactic medications to prevent acute episodes and allow full participation in
daily activities; correct terminology for spacers and nebulizers; correct technique for delivering medication
via a spacer; appropriate use of the nebulizer to manage acute episodes; promotion of a positive attitude
towards nebulizer use; and engagement in pleasant relaxing activities while using the nebulizer.
Setting: outpatient (childrens hospital).
Session length: Video-4 minutes
Time span of intervention: 4 mos.
Self-management strategy: symptom-based. Educational strategy: prevention, attack management.
Instructional methods/tools: videotapes, booklets
Additional information: Group 1--asthma tape & asthma book. Group 2--asthma tape & unrelated book.
Group 3--unrelated tape & asthma book. Group 4 (control)--unrelated tape and book.
Outcomes
Lung function: none

Morbidity: non-compliance days, days with wheeze or cough.
Health care utilization: phone calls and visits to the doctor.
Other: Knowledge scores and improvement scores.
Notes
Possible biases: Exclusion bias (differences in follow-up between the 4 groups) and selection bias (allocation
concealment was unclear).
*Pooled standard deviations were imputed for days of restricted activity and physician visits using the tstatistic corresponding to the reported p-value with appropriate degrees of freedom.
Risk of bias

27
Holzheimer 1998
(Continued)
Item
Authors judgement
Description
Unclear
Hughes 1991
Methods
RCT: Subjects were stratified on age group and number of previous hospitalizations and then randomly
assigned by coin toss to treatment or control groups.
Blinded assessment: No.
Assessment: Pre-intervention, intervention, and 6, 9, 12, and 24 mos. post-intervention.
Participants

Eligibility criteria: (1) Age 6 to 16, (2) Residence in Halifax Cty, (3) Absence of other major health
problems, (4) No previous tx by the authors.
Asthma severity: Mild to Severe.
Locale: Halifax County, Nova Scotia, Canada.
Age: Range 6 to 16 years, mean 9.7 years.
Gender: 60 males (63.2%), 35 females (36.8%).
Interventions
Description: Comprehensive home and ambulatory program for asthma management consisting of:
(1) Regular 3-monthly clinic visits with pediatric respirologist and nurse coordinator to outline an asthma
management (i) avoidance of triggers, (ii) promotion of exercise, (iii) proper medication use, (iv) proper
inhaler use, and (v) home management of exacerbations. and administer the asthma education program
(i) review of anatomy, (ii) acute episodes, (iii) treatments
(2) 2 home visits by nurse coordinator to evaluate environmental triggers, smoking, MDI technique, and
asthma management plan.
(3) Additional clinic or home visits and school contact as needed.
Setting: Clinic and home.
Number of sessions: 4 scheduled in clinic, 2 scheduled at home. More visits as needed.
Session length: not reported
Self-management strategy: Peak flow-based. Educational Strategy: prevention, attack management
Instructional methods/tools: didactic, pamphlets
Additional information: Control attended clinic at 3 mo. intervals for assessment only. Pts. in tx group
were seen by study MD or RN for emergency or inpatient care at IWK Childrens hospital.
Outcomes
Lung function: FEV1.

Morbidity: wheeze-free nights, wheeze-free days, cough-free nights, school absenteeism.
Health care utilization: Clinic, office and ER visits, hospital admissions.
Other: Children taking responsibility for asthma management and Metered aerosol technique.
Notes
Possible biases: Performance (medications and asthma plan managed by respirologists in study group and
by primary care physicians in control group).
*Pooled standard deviations were imputed for physician visits, emergency room visits, and hospitalizations

28
Hughes 1991
(Continued)
using the t-statistic corresponding to the reported p-value with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
Yes
Third party allocation
Kubly 1984
Methods
RCT: Parent-child dyads were randomly assigned by draw to treatment and control groups.
Assessment: Pre- and 2 mos post-enrolment.
Participants

Eligibility criteria: Convenience sample from a list of all asthmatic children in 2nd, 3rd, 4th grade from
12 elementary schools in the same district.
Asthma severity: Unclear
Locale: Southwestern US.
Age: mean 8.2 years; range not given.
Gender: 21 males (75%), 7 females (25%)
Other demographics: 87% white, 5% Hispanic, 2.5% black, 5.5% other.
Family Income: Mean/Median: $20-30,000.
Interventions
Description: Nursing instructional program designed to promote self-care delivered by nurse educators.
Program topics: CONTROL & TREATMENT
(1) Parents - developmental tasks of school-aged child, physiologic occurrences in asthma, myths about
asthma, overview of asthma management.
(2) Children - feelings and asthma, basic A&P related to asthma, asthma management.
TREATMENT ONLY
(A) Parents - asthma care self-care skill instruction including practice in breathing exercises and promoting
self-medication in the child.
(B) Children - instruction in breathing exercises and self-medication
Setting: school
Session type: Group.
Number of sessions: 3 to 4
Session length: 60 to 90 minutes.
Time span of intervention: 3 to 4 weeks.
Self-management strategy: symptom-based.Educational strategy: prevention and attack management.
Lecture discussion format. Use of worksheets from Teaching Myself About Asthma book for discussion.
Handout How to Take Your Medicine for self-medication skill instruction.
Outcomes

Morbidity: None.
Functional status:Health locus of control and self-care activity.

29
Kubly 1984
(Continued)
Health care utilization:None.

Other: None.
Notes
Possible biases:
Exclusion bias (over 50% withdrawal in both treatment and control groups) and
Selection bias (experimental group had substantially greater mean annual emergency visits relative to
control group).
Risk of bias
Item
Authors judgement
Description
Unclear
LeBaron 1985
Methods
RCT: Subjects were randomly assigned to an intervention or control group.

Blinded assessment:
yes
Assessment: pre and at 1, 2, 3, 4 months post-intervention.
Participants

Eligibility criteria: (1) Mild to moderate asthma, (2) receiving theophylline and/or beta-adrenergic agents
and cromolyn, (3) recruited from 3 private allergy practices.
Asthma severity: Mild to moderate
Locale: San Antonio, TX, USA.
Age: Mean = 10.6 years, Range 6 to 17 years.
Other demographics: 1 black, 4 Mexican-american, 26 Anglo. All families lower middle income or greater.
Interventions
Description: Educational program delivered by nurse educators to increase compliance with cromolyn.
Program topics: Demonstrations on the use of cromolyn and discussions about how, why, and when to use
cromolyn and how to anticipate problems with its use. Patients were then asked to demonstrate their use
of cromolyn. Patients received instruction in the cleaning of their Spinhaler turbo inhaler. Other issues
related to asthma were included (not reported), but the main focus was on the mechanics of cromolyn
administration.
Setting: Allergy clinic offices
Session type: Indvidual (children & parents).
Session length: Not reported.
Self-management strategy: peak flow-based. Educational strategy: prevention.
Instructional methods/tools: didactic (demonstration)
Outcomes
Lung function: Peak expiratory flow, FEV1, FEVC, FEF25 to 75, pulmonary function tests.
Morbidity: asthma severity
Functional status: wheezing episodes, activity level, exercise tolerance, night cough, need for increased

30
LeBaron 1985
(Continued)
asthma meds.
Other: Patient symptoms: (1) patient medical history score, (2) allergist medical history score, (3)
Overall control of asthma .
Notes
Possible biases:
selection bias (allocation concealment was unclear).
Risk of bias
Item
Authors judgement
Description
Unclear
Lewis 1984
Methods
RCT: Subjects were randomly assigned using a table of random numbers into control and experimental
groups.
Assessment: 12 mos pre- and 3, 6, and 12 mos. post-intervention.
Participants

Eligibility criteria: Severe asthma (def. requiring medication for at least 25% of days of the month), age
7 to 12 years, verbal fluency in English.
Asthma severity: Severe
Locale: Los Angeles & West Los Angeles, CA, USA.
Age: range 7-12 years, mean 10.3 years.
Gender: 59 males (77%) and 17 females (23%).
Other demographics:
Middle-class, working families, HMO patients.
ethnicity: white 33%, Black 33%, Latino 30%, Asian 10%. Mean time dx w/asthma 7 years.
Interventions
Description: Asthma Care Training, (ACT) educational curriculum for children and their parents.
Uses an automobile analogy and a traffic light system of colored stickers to code medication and other
techniques.
Program topics: (i) Mechanism of asthma and resultant symptoms and signs, (ii) Feelings about having
asthma and bronchospasm episodes, (iii) Environmental control and allergens, (iv) Relaxation skills,
breathing exercises, (v) review prescribed drugs with MD, (vi) Decision making skills, (vii) Concept of
balanced living.
Setting: clinic
Session type: group
Number of sessions: 5 (weekly)
Session length: 1 hour.
Self-management strategy: symptom-based. Educational strategy: prevention, attack management, social
skills.
Instructional methods/tools: Games, role playing, simulation modelling (social learning), automobile and

31
Lewis 1984
(Continued)
traffic light (with stickers) analogy.

Additional information: None
Outcomes
Lung function: None

Morbidity None
Functional status: None
Health care utilization: ER visits, number of hospitalizations, total days of hospitalization, program and
other health care costs.
Other: Knowledge of asthma symptoms, triggers, relaxation skills, family dynamics (understanding asthma
and management, communication, smoking behavior in parents, parents accompanying children to tx
sessions), parents attack response, parents recognition of attack sx, self-reported compliance behaviors.
Notes
Possible biases: None

*Pooled standard deviations were imputed for emergency room visits and hospitalizations using the tstatistic corresponding to the reported p-value with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
Yes
Madge 1997
Methods
RCT: Subjects were randomly assigned prior to study to intervention or control group by drawing cards.
Assessment: Pre- and 14 months post-intervention.
Participants

Eligibility criteria: Children over 2 years of age admitted with acute asthma between 1/94 and 1/95.
Asthma severity:
Unclear
Locale: Glasgow, Scotland, UK.
Age: range 2 to 15 years, Median for treatment group was 6.0 years and for control group was 4.23 years.
Other demographics: lower income.
Interventions
Description: Asthma home management training program consisted of review discussion sessions, written
information, and advice, subsequent follow up and telephone advice delivered by asthma nurse.
Program topics: (i) Nature of asthma, (2) its triggers, (3) and its treatment including the use and side
effects of corticosteroids, (iv) signs commonly present in impending asthma attacks, (v) recognition of
signs in children.
Setting: Inpatient and outpatient clinic.
Session type: individual
Session length: total of 45 min.
Time span of intervention: 2 to 3 weeks.

32
Madge 1997
(Continued)
Self-management strategy: peak flow-based. Educational strategy: prevention, attack management.

Instructional methods/tools: didactic, booklet, peak flow meter for children over five (see below), a written
summary of the agreed management plan, a course of oral steroids with guidance.
Additional information: Parents of children over five were provided with a peak flow meter and instructed
about flow monitoring. They were free to choose whether they preferred a plan based on peak flow
measurements or symptoms or both.
Outcomes

Morbidity: Day disturbance, night disturbance.
Functional status:Disability.
Health care utilization: Admission to hospital, attendance to ER, attendance at the family practitioner for
urgent asthma treatment.
Other: none.
Notes
Possible biases: Selection (the treatment group was slightly older (6.0) compared to the control group
(4.23)).
Risk of bias
Item
Authors judgement
Description
Unclear
McNabb 1985
Methods
RCT: Subjects were paired and randomly assigned to either an experimental or control group by coin
toss.
Assessment: Pre- and at 12 mos post-treatment.
Participants

Control: 8 assigned 7 completed (88%).
Eligibility criteria: Children with asthma, age 9 to 13 years, on a regimen of bronchodilators, one ER visit
for treatment of asthma in past year, no known developmental or behavioral problems.
Asthma severity: not reported.
Locale: Northern California, US.
Age: range 9 to 13 years, mean 10.4 years.
Interventions
Description: Individually tailored AIR WISE educational program based on a diagnostic/prescriptive

teaching technique that identifies self-managment problems administered by nurse educator.
Program topics: Self-managment practices for children with asthma utilizing goal setting, self-evaluation,
and self-monitoring.
Setting: Outpatient allergy clinic.
Number of sessions: 1 30min diagnostic interview followed by 4 educational sessions.
Session length: 45 minutes.

33
McNabb 1985
(Continued)

Instructional methods/tools: didactic
Outcomes

Morbidity: none.
Functional status: not reported.
Health care utilization: No. of emergency visits for asthma/month, No. of non-emergency physician
contacts for asthma/month, current asthma drug regimen, health-care cost.
Other: knowledge of asthma, self-management behavior.
Notes
Possible biases:
none
*Pooled standard deviations were imputed for emergency room visits using the t-statistic corresponding
to p=0.05 with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
Yes
Mitchell 1986
Methods
RCT: Subjects stratified by ethnicity (European vs. Polynesian), then randomized into treatment and
control groups using random numbers table.
Assessment: 6 and 18 months post-enrolment.
Participants

Eligibility criteria: discharged from pediatric medical hospital wards for asthma from April 15, 1983 to
April 14, 1984. Exclusion criteria: less than 2 years, home was outside the hospital catchment area, history
of life threatening asthma attacks.
Asthma severity: Unclear
Locale: Manukau City, Auckland, New Zealand.
Age: range 2 to 14 years, mean 5.5 years for Polynesians and 6.1 years for Europeans.
Gender: European male:female 1.4:1. Polynesian male:female 1.6:1
Other demographics: European children were significantly socio-economically advantaged as compared
to Polynesians.
Interventions
Description: Educational program for children with asthma and their families delivered by community
health nurses.
Program topics: a) lung function, pathophysiology, factors that provoke asthma, b) description of asthma
drugs, c) stimuli that provoke asthma, controlling the environment, d) drug compliance check and correct
use of aerosols, e) contacting general practitioner rather than the ER when an asthma attack does not
respond to home bronchodilator therapy.

34
Mitchell 1986
(Continued)
Setting: patients home.

Session length: not specified.
Instructional methods/tools: didactic.
Outcomes

Health care utilization: re-admissions after treatment, duration of hospital stay.
Other: none.
Notes
Possible biases:
Exclusion (9% greater follow-up in treatment than in control group), selection (greater asthma severity
in intervention group based on mean days off school and proportions with readmissions).
Risk of bias
Item
Authors judgement
Description
Unclear
Parcel 1980
Methods
CCT: Schools were non-randomly assigned to intervention or waiting list control group.
Assessment: Pre- and 7 mos post-enrolment.
Participants

Eligibility criteria: Confirmed dx of asthma with symptoms during the previous year.
Asthma severity:not reported.
Locale: Galveston, TX, US.
Age: Range 5 to 11 years, mean 7.7 years.
Gender: 63 males (61%); 41 females (39%).
Other demographics: Socioeconomic status: majority from lower socioeconomic status.
Interventions
Description: School-based educational program, designed to involve children, parents, teachers, physicians, & other health care providers.
Program topics: 5 skills for children (1) observing situations that might lead to an asthma attack, (2)
discriminating changes that would indicate a pending/actual attack, (3) communication with parents,
doctors, others what is happening just before/during an attack, (4) decision-making to take action that
prevents/stops an attack, (5) self-reliance help with asthma.
Setting: School
Session type: group

35
Parcel 1980
(Continued)

Self-management strategy: symptom-based.
Educational strategy: Attack management, prevention, social skills.
Instructional methods/tools: Specific patient education book, Teaching My Parents About Asthma, role
playing, and problem solving.
Additional information: none
Outcomes
Lung function: none

Morbidity: none.
Functional status:locus of control, illness anxiety scale, self-concept scale.
Other: Asthma knowledge score.
Notes
Possible biases: selection (treatment group slightly older with higher socioeconomic status).
*Pooled standard deviations were imputed for self-efficacy scale using t-statistic corresponding to reported
p-value with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
No
Non-random allocation
Perrin 1992
Methods
RCT: Subjects were randomly assigned to an intervention or control group using a random numbers table.
Subjects were allocated to treatment groups by research assistants at separate site.
Assessment: pre- and 1 mos post-enrolment.
Participants
Treatment: 81 assigned to both groups but number assigned to treatment unclear, 29 completed.
Control: 81 assigned to both groups, but number assigned to control unclear, 27 completed.
Eligibility criteria: ages 6-14 years, diagnosed with asthma at least 6 months prior to study, receiving
hyposensitization injections or intermittent or continuous aminophylline, cromolyn, or B-andrenergic
bronchodilators.
Asthma severity mild, moderate, and severe.
Locale: US, specific locale not reported.
Age: mean 9.3 years, range 6-14 years.
Gender:
35 (62%) male, 21 (38%) female.
Other demographics: socioeconomic status predominately middle class, 85% white, upper-middle class.
90% recruited from community pediatric practice settings.
Interventions
Description: Combined education and stress management program for children with asthma.
Program topics: Educational portion: (1) lung function, breathing, breathing control, (2) changes in lungs
related to asthma and the effects of these changes on other bodily functions and feelings. (3) methods of
prevention, treatment and how meds and other therapy changes asthma symptoms. (4) review of sessions

36
Perrin 1992
(Continued)
1 to3, discussion of exercise, long-term outcomes, growing up with asthma. Stress-Management Portion:
Relaxation training, contingency coping exercises.
Setting: clinic
Session type: group
Session length: 2 hours.
Time span of intervention: one month.
Use of balloons, anatomic models, and encouraging questions from children.
Stress management: Emphasized deep breathing through guided imagery and muscular relaxation.
Additional information: parents and children both participated.
Outcomes
Lung function: none

Morbidity: school absences, participation in after school activities, amount of time playing with friends
out of school, number of daily chores.
Functional status: Child Behavioral Checklist.
Other: none.
Notes
Possible biases: Exclusion bias (31% were lost to follow-up but data on number of drop-outs in treatment
and control group not given) and selection bias (allocation concealment was unclear).
Risk of bias
Item
Authors judgement
Description
Yes
Persaud 1996
Methods
RCT: Subjects were randomly assigned by a random numbers chart to intervention or control group at
each of 10 participating elementary schools.
Blinded assessment:yes
Assessment: Pre-intervention and 8 weeks post-enrolment.
Participants

Eligibility criteria: (1) Several prior episodes of airway obstruction, (2) clinical response to bronchodilator,
(3) absence of other pulmonary disease.
Asthma severity: moderate to severe.
Locale: Galveston, Texas, US.
Other demographics:
25 Black (69%), 25 Medicaid insurance (69%).

37
Persaud 1996
(Continued)
Interventions
Description: Individualized educational sessions conducted by school nurses to review asthma diaries;
discuss progress, symptoms, and ability to take appropriate measures to control asthma.
Program topics: (i)Self-observation (being able to observe symptoms), (ii) discrimination (being able to
notice changes that would indicate an impending attack), (iii) communication (being able to tell nurses,
parents, and physicians what was occurring before and after an attack), (iv) decision making, and v) selfreliance.
Setting: school
Self-management strategy: peak flow-based. Educational strategy: prevention, attack management, social
skills.
Instructional methods/tools: open-ended interviews, role-playing, workbook.
Outcomes
Lung function: FEV1 and FVC (baseline only).

Functional status: child locus of control, functional impact.
Health care utilization: subjects with ER visits, number of ER visits per child.
Other: asthma attitude, parent and child knowledge of asthma.
Notes
Possible biases: Selection bias (Control group had a significantly earlier age of onset of asthma and tended
to have more asthma attacks in the preceding year).
Risk of bias
Item
Authors judgement
Description
Unclear
Rakos 1985
Methods
RCT: Subjects were randomly assigned to intervention or waiting list controls.

Blinded assessment: no for parental assessment but yes for physician assessment.
Assessment: pre-intervention, 2, 6, 12 mo post-intervention.
Participants
Treatment: 20
Eligibility criteria: (a) ages 7 to 12 years, (b) confirmed diagnosis of asthma, (c) physician expected
continued regular contact for the next year, (d) physician screening rating between 3 to 6 on the Asthma
Severity Scale (1 = minimal, 4 = moderate, 6 = severe, 7 = severe, refractory).
Asthma severity:
moderate to severe.
Locale: Cleveland, Ohio, US.
Age: range 7 to 12 years, mean age not given.

38
Rakos 1985
(Continued)

Interventions
Description: Superstuff , a self-administered, self-help asthma knowledge and management program for
parents and children. Program includes a Parents magazine and Childrens kit.
Program topics: Asthma facts and fallacies, internal and external signals and triggers, relaxation techniques,
personal control and decision making.
Setting: home
Time span of intervention: not reported.
Self-management strategy: symptom-based.Educational strategy: prevention, attack management, social
skills
Instructional methods/tools: Childrens Kit--riddles, games, toys, puzzles, signs, stickers, dolls, paper cut
outs, records. Parents Magazine--29 articles covering the same material as the childrens kit.
Outcomes

Functional status: childrens self-report (self-esteem inventory), asthma self-control inventory (locus of
control scale), parents report (asthma costs, triggers, etc).
Health care utilization: physicians report (scheduled and ER visits, medication, etc).
Other: none.
Notes
Possible biases:
Selection (control subjects improving more than intervention subjects at baseline).
Risk of bias
Item
Authors judgement
Description
Unclear
Ronchetti 1997
Methods
RCT: Subjects randomly assigned to intervention or control after stratification and pairing by age, gender,
and asthma severity.
Assessment: pre- and 11 and 12 mos post-intervention.
Participants

Eligibility criteria: (i) Outpatients attending the asthma clinic, (ii) who were seen for the first time and
iii) who received a diagnosis of asthma.
Asthma severity: mild to moderate to severe based on composite asthma severity score.
Locale: 14 centers in North, South, and Central Italy
Age: range 6 to 14 years, mean 9.6 years.
Gender: female 73 (35%), male 136 (65%).
Other demographics: homogeneous urban class.

39
Ronchetti 1997
(Continued)
Interventions
Description: Two asthma education programs (Living with Asthma and Open Airways) delivered by
physicians.
Program topics: i) Lung anatomy, ii) asthma patho-physiology, iii) trigger factors, iv) warning signs and
symptoms of asthma attacks, v) how to deal with attacks, vi) how to rationalize use of emergency rooms,
and vii) how to reduce the social consequences of asthma.
Setting: Outpatient (asthma clinic)
Session type: group
Number of sessions: 4-8
Session length: 1 hour.
Time span of intervention: 4-8 weeks.
Self-management strategy: symptom-based. Educational strategy: prevention, attack management, social
skills.
Instructional methods/tools: written diaries, group sharing of problems, and group solutions.
Outcomes

Morbidity: none.
Functional status: none
Health care utilization: emergency treatments.
Other: medications taken.
Notes
Possible biases: exclusion bias (only 67% of enrollees completed the program).
Risk of bias
Item
Authors judgement
Description
Yes
Rubin 1986
Methods
RCT: Subjects were randomly assigned with the aid of a random number table to the experimental or
control group.
Blinded assessment: yes.
Assessment: pre- and 12 months post-enrolment.
Participants

Eligibility criteria: (1) all children with asthma at Yale-New Haven Hospital, Hospital of St. Raphael, Yale
Health Plan, Community Health Care Plan, and at one private pediatricians office, (2) English-speaking,
(3) 7 to 12 years old, (4) at least 3 acute visits because of asthma during the preceding year of the study,
(5) living in Greater New Haven, Connecticut.
Asthma severity: Moderately Severe.
Locale: New Haven, Connecticut, US.
Gender:
Male 36 (55%). Female 29(45%).

40
Rubin 1986
(Continued)
Other demographics:
ethnicity, white 67%.
Socioeconomic status: lower.
Interventions
Description: Educational intervention for children using an interactive, asthma-specific computer game,
Asthma Command.
Program topics: (1) recognition of symptoms & allergens, (2) appropriate use of medications, (3) appropriate use of the emergency room and the physicians office, (4) encouragement of school attendance.
Setting: outpatient clinic.
Session type: Individual.
Instructional methods/tools: computer assisted instruction (40 minutes) and didactic, verbal information
about asthma management (5 to 10 minutes).
Outcomes
Lung function: none

Morbidity: school absences
Functional status: psychologic data (Pea-body Picture Vocabulary Test, Piers-Harris Self-Esteem, Childrens Locus of Control, Asthma Thermometer, Draw-A-Person). asthma knowledge.
Health care utilization: acute visits due to asthma, hospital days due to asthma.
Other: none
Notes
Possible biases: Exclusion bias (15% more subjects in control dropped out than in the treatment group)
and selection bias (allocation concealment was unclear).
Risk of bias
Item
Authors judgement
Description
Unclear
Shields 1990
Methods
RCT: Subjects were randomly assigned using a table of random numbers to the experimental or control
group.
Blinded assessment: yes
Assessment: Pre- and 12 and 29 months post-intervention.
Participants

Eligibility criteria: (i) 18 years or younger, (ii) at least one ER visit or hospitilzation for asthma during
prior 4 year period.
Asthma severity: not reported.
Locale: Chicago, Illinois, US.
Age: mean 8.8 years, range < 19 years.
Gender: 159 (63%) male, 94 (37%) female.

41
Shields 1990
(Continued)
Other demographics: 80% black, median income 6% less than overall city median income.
Interventions
Description: An educational program for parents and children delivered by nurse clinicians. Two part
approach, part one, classes for patients & parents. Part two, telephone instruction by protocol to patients
or parents.
Program topics: (i) attack prevention, (ii) medication management, (iii) intervention during an attack,
(iv) utilization of health care resources.
Setting: classes were at HMO while telephone instruction was at home.
Session type: Group for classes. Individual for telephone.
Number of sessions: Classes 4, telephone at least 4.
Session length: Classes 1.5 hours, telephone about 30 minutes.
Time span of intervention: Not clear, but methods suggest 1 to 2 months.
Instructional methods/tools: didactic, telephone reinforcement.
Outcomes

Morbidity: none.
Health care utilization: No. of office visits, No. of hospital days, No. of ER visits.
Other: none.
Notes
Possible biases:
None.
*Pooled standard deviations were imputed for emergency room visits using t-statistic corresponding to p=
0.50 (NS) with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
Yes
Szczepanski 1996
Methods
CCT: Families of children with asthma were randomized to one of two education interventions. Control
group included families who were adequately treated by their doctors.
Blinded assessment: no.
Assessments: pre-, 6, and 12 months post-enrolment.
Participants
Treatment: 27 assigned to intervention with follow-up, 27 completed (100%). 32 assigned to intervention

only, 29 completed (92%).
Eligibility criteria: school-age child with asthma.
Locale: Osnabruck and Berlin, Germany.
Age: school age, range and mean not reported.

42
Szczepanski 1996
(Continued)

Interventions
Description: A medical and family centered program to take into account individual family member
resources, relationships, generation gaps, socioeconomic status, and family rules. Confidence in management was at the core of the program along with self-evaluation using peak flow measurements and
symptom control. Individual delivering intervention was unclear.
Setting: asthma clinic.
Number of sessions: 11+.
Instructional methods/tools: lectures, problem-solving.
Outcomes
Lung function; not reported.

Morbidity: school absences, asthma severity score, asthma symptoms, symptoms in sport, medication use.
Other: anxiety, apprehension, adequate management, early intervention, coping, conviction of control.
Notes
Possible biases: selection (control group was handpicked), performance (individuals assigned to intervention with follow-up received care in asthma clinic while controls received care from their own doctors)
, and exclusion (24% difference in follow-up between intervention with follow-up and control groups)
biases.
Study published in German language publication.
Risk of bias
Item
Authors judgement
Description
No
Non-randomised allocation
Talabere 1993
Methods
RCT: Subjects were randomly assigned using block randomization by age, gender, and race.
Blinded assessment: none.
Assessments: 3 and 12 months pre- and 3 months post-enrolment.
Participants

control: 25 assigned, 25 completed (100%).
Eligibility criteria: age 8 to 12 years old, diagnosis of asthma, admitted for asthma or seen in emergency
room for asthma.
Locale: Columbus, Ohio, USA.
Age: range 8 to 12 years, mean not reported.

43
Talabere 1993
(Continued)
Interventions
Description: asthma education program delivered by registered nurses with previous experience in asthma
education who completed formal training in intervention. Program delivered to children while in hospital
or at home. Program topics include (1) anatomy and physiology of asthma, (2) triggers and avoidance, (3)
early warning signs, (4) medication effects, (5) breathing exercises and inhaler technique, (6) management
of asthma episode, (7) feeling of parent and child, (8) school concerns, (9) support groups and camps.
Setting: home or hospital.
session length: 1 hour.
Number of sessions: 2.
Time span of intervention: 1 week.
Self-managment strategy: symptom-based.
Educational strategy: prevention, attack management, and social skills.
Instructional methods/tools: problem solving, didactic, booklets and handouts, games.
additional information: none.
Outcomes

Morbidity: altered breathing episodes, parents perception of childs asthma. school absences.
Other: asthma knowledge, asthma attitudes.
Notes
Possible biases: none.
Risk of bias
Item
Authors judgement
Description
Unclear
Toelle 1993
Methods
CCT: Children attending randomly selected schools in one city district were invited to participate. Children in a similar district served as controls.
Assessment: baseline, 3 and 6 months post intervention.
Participants

Eligibility criteria: Satisfied 1 of the following, (1) physicians diagnosis of asthma, (2) currently using
asthma medications, (3) having current asthma measured from a previous study.
Asthma severity: Not reported, but FEV1 measurements suggest mild to moderate.
Locale: Sydney, Australia
Gender:
91 males (69%),
41 females (31%).
Other demographics: 119 Austrailian borne (90%);
54% lower income.

44
Toelle 1993
(Continued)
Interventions
Description: Educational program to provide information and develop skills necessary for management
of the childs asthma by both parent and child, physicians and pharmacists, and community nurses and
teachers.
Program topics: (1) mechanisms of asthma, (2) possible triggers of an asthma attack, (3) the mode of
action of asthma treatment medications, (4) Inhalation techniques assessed and corrected as needed. (5)
emphasized importance of monitoring airway function and using a written management plan based on
readings, (6) an overview of the management plan was given to discuss with family doctor.
Setting: childs school
Session type: group
Time span of intervention: one week.
Self-management strategy: peak flow-based. Educational strategy: prevention, attack management.
Instructional methods/tools: didactic sessions, skills assessment and practice, booklets.
Additional information: Subjects physicians, local pharmacists were invited to attend. Physicians who
attended were given a suggested management plan for his/her patient. In the intervention area all community nurses at local health centers and school teachers received an in-service education session at their
workplace. All families, children, physicians, & pharmacists who did not attend received the education
materials by mail.
Outcomes
Lung function: FEV1, bronchial responsiveness to histamine measured as dose-response ration (DRR)
and PD20FEV1, airflometer variability.
Morbidity: wheezing episodes, school absences, night cough.
Functional status: symptoms limiting activity.
Health care utilization: unscheduled doctor visits and ER visits.
Other: none.
Notes
Possible biases: selection (intervention group had significantly more symptoms of wheeze and night cough
at baseline than control group); performance (intervention consisted of patient education and physician
management suggestions).
Risk of bias
Item
Authors judgement
Description
No
Non-randomised allocation
Weingarten 1985
Methods
RCT: Children randomly assigned to experimental and control groups using a random numbers list.
Another group of children receiving only psychological assistance served as a further control.
Assessment: Pre- & 10 weeks post-enrolment.
Participants
Treatment: 11
Control: 9

45
Weingarten 1985
(Continued)
Eligibility criteria: Asthmatic children, ages 5 to 14 identified from the diagnostic register of a large family
practice clinic.
Asthma severity: not specified.
Locale: Rosh Haayin, Israel.
Age: 8 to 11 range, no mean given.
Gender: 21 boys (62%), 13 girls (38%).
Other demographics: Jews of Yemenite origin.
Interventions
Description: A multidisciplinary, non-pharmaceutical asthma management program delivered by physiotherapists, psychologists, and social workers.
Program topics: Physiotherapist--(1) behavior during an attack to decrease bronchospasm, (2) improving
lung ventilation and chest expansion, (3) clearance of bronchial secretions, (4) exercises for px fitness.
Psychologist: (1) relaxation during attacks, (2) reducing the feeling of helplessness, (3) mastering selfcontrol to lessen the emotional factors (fear) by means of ventilation. Social worker: (1) identify and
understand family behaviors and feelings connected with asthma, (2) the difficulties of an acute attack,
(3) searching ways of coping.
Setting: family practice clinic.
Number of sessions:
Physiotherapist = 12; Social worker = 10; Psychologist = 4.
Session length:
Physiotherapist = 60 minutes, 2x/week; Psychologist = 30 minutes;
Social worker = 2 hr, 1x/week.
Self-management strategy: peak flow-based. Educational strategy: Prevention, attack management, and
social skills.
Instructional methods/tools: drawing, role-play, sculpting, childrens literature, relaxation exercises.
Outcomes
Lung function: PEFR, Chest Wall Excursion.

Morbidity: Log scores of dyspnea, cough and sputum during day and night.
Health care utilization: record of medications.
Other: none.
Notes

*Pooled standard deviations were imputed for PEF using t-statistic corresponding to reported p-value
with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
Unclear

46
Whitman 1985
Methods
RCT: Subjects were paired after stratification on age group, gender, disease severity, and season of worst
asthma and randomly assigned to the study or control group.
Assessment: pre-, immediately post- and 3 months post-intervention.
Participants
Treatment: 19 assigned, 19 completed (100%). Control: 19 assigned, 19 completed (100%).

Eligibility criteria: children ages 6 to 14 years old and referred by community allergists, pediatricians,
family physicians, and general practitioners.
Asthma severity: mild, moderate, severe.
Locale: Salt Lake City, Utah, USA.
Age: mean 8.4, range 6 to 14.
Interventions
Description: Self-care Rehabilitation in Pediatric Asthma (SCRPA) is a self-managment training program

to develop asthma knowledge and skills.
Program topics: (1) Breathing control skills, (2) body relaxation skills, (3) bronchial hygiene skills, (4)
physical conditioning, (5) respiratory anatomy, physiology, and pathophysiology of asthma, (6) asthma
meds, (7) recognition of asthma triggers and warning symptoms and (8) the emotional/psychological
effects of asthma.
Setting: not specified.
Session type: group
Session length:
90 minutes.
Time span of intervention:
4 weeks.
Instructional methods/tools: didactic and other activities not specified.
Outcomes

Morbidity: asthma episodes, days of no asthma, days of mild asthma, days of moderate asthma, days of
severe asthma.
Functional status: Childrens and Parents attitude.
Health care utilization: none.
Other: Asthma knowledge test, SCRPA performance skills test.
Notes
Possible biases: Selection bias (intervention group had more asthma episodes and fewer days of severe
asthma than control group prior to intervention).
*Pooled standard deviations were imputed for exacerbations and self-efficacy scales using t-statistic corresponding to reported p-value with appropriate degrees of freedom.
Risk of bias
Item
Authors judgement
Description
Unclear

47
Wilson 1996
Methods
RCT: Subjects were stratified based on age group, number of medical visits for asthma in the past year,
ever hospitalized or not, and whether ever treated with corticosteroids or not and then randomly assigned
using randomly ordered consecutively numbered sealed envelopes containing group assignment to an
intervention or control group.
Participants

Eligibility criteria: (1) Born between 09/01/83 and 02/01/90, (2) seen in the preceding year for asthma,
bronchiolitis with bronchospasm, bronchitis, asthmatic bronchitis, etc. (3) Age between 6 mos and 6.5
yrs. (4) patient of St. Paul Childrent Hospital. (5) 3 or more asthma-related visits or 2 visits in the case of
children under 2 years of age or one visit requiring urgent or emergency care or one hospitalization, (6)
mention of any asthma medications.
Asthma severity: mild to severe.
Locale: St. Paul, Minnesota, USA.
Age: mean 3.8 years, range 6 months to 6.5 years.
Gender: Male 49 (65%). Female 27 (35%)
Other demographics: non-white or Hispanic (10.7%).
Interventions
Description: Wee Wheezer program, an educational program targeted to parents of preschool age children
with asthma, was administered by nurses.
Program topics: (1) Basic concepts of asthma, (2) development of action plan for asthma management,
(3) lung physiology, (4) changes in lungs during and following asthma attack, (5) asthma medications,
(6) trigger avoidance, (7) communication
with medical personnel. Setting: not stated.
Session type: group
Self-management strategy: peak flow-based. Educational strategy: prevention, attack management, and
social skills.
Instructional methods/tools: videotapes, booklets, didactic sessions, problem-solving, and written asthma
action plan.
Additional information: the control families were crossed over and offered the basic educational program
after the 3-month follow-up assessment.
Outcomes

Morbidity: asthma sick days, bother, symptom free days, parental nights of sleep interruption, asthma
sick days.
Other: none
Notes
Possible biases: Selection (Intervention group had fewer symptom free days and parental nights of sleep
interruption at baseline).
Risk of bias

48
Wilson 1996
(Continued)
Item
Authors judgement
Description
Yes
* Pooled standard deviations were imputed for outcomes with missing variance estimates for Dahl 1990, Deaves 1993, Fireman 1981,
Holzheimer 1998, Hughes 1991, Lewis 1984, McNabb 1985, Parcel 1980, Shields 1990, Weingarten 1985, and Whitman 1985.
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
Aleman 1992
Subjects included children with conditions other than asthma, eg. rhinitis.
Brazil 1997
Absence of suitable control population. The study compared an in-patient educational program with an outpatient day camp program.
Brook 1993
Intervention consisted of information transfer without self-management education.
Carson 1991
No outcomes of interest. Children and parents were evaluated on knowledge, behavioral assessment, parental
coping, family stress, and family cohesion
Gibson 1998
Intervention consisted of information transfer without self-management education.
Indinnimeo 1987
No outcomes of interest. Children and parents were evaluated on their knowledge of asthma.
Kotses 1991
Non-standard educational intervention employing 2 forms of biofeedback.
Lewis 1994
Absence of suitable control population. Trial was terminated 3 months into study after it became apparent to
study investigators that medical care was inadequate to support investigation of adjuvant educational intervention.
Mesters 1995
Subjects included those less than 2 years of age.
Moe 1992
No outcomes of interest. Study measured participants attendance and satisfaction with the intervention.
Sly 1975
Non-standard intervention employing allergen minimization strategy and no outcomes of interest.
Smith 1986
No outcomes of interest. Subjects were evaluated on their compliance with treatment and knowledge of asthma.
Van Asperen 1986
Subjects included those less than 2 years of age.

49
DATA AND ANALYSES
Comparison 1. Self-management vs. Usual Care
Outcome or subgroup title

1 Lung Function
1.1 FEV1
1.2 PEFR
2 Exacerbations (% Patients)
3 Exacerbations (Mean)
4 School Absences (% Patients)
5 School Absences (mean days)
6 Restricted Activity (% Patients)
7 Restricted Activity (Mean Days)
8 Nights Nocturnal Asthma (%
Patients)
9 Nights Nocturnal Asthma
10 Self-efficacy Scale
11 Asthma Severity Score
12 General Practitioner Visits
13 ED Visits (% Patients)
14 ED Visits (mean)
15 Hospitalization (% patients)
16 Hospitalizations (mean)
No. of
studies
No. of
participants
4
1
3
2
5
1
16
1
6
1
258
110
148
363
338
114
1633
79
379
103
Std. Mean Difference (IV, Fixed, 95% CI)

Odds Ratio (M-H, Fixed, 95% CI)
0.50 [0.25, 0.75]

0.46 [0.08, 0.84]
0.53 [0.19, 0.86]
1.43 [0.94, 2.18]
-0.21 [-0.43, 0.01]
0.78 [0.36, 1.66]
-0.14 [-0.23, -0.04]
2.51 [0.61, 10.29]
-0.29 [-0.49, -0.08]
0.65 [0.29, 1.44]
3
6
4
6
6
12
4
8
202
360
212
619
904
1114
679
928

-0.34 [-0.62, -0.05]

0.36 [0.15, 0.57]
-0.15 [-0.43, 0.12]
-0.15 [-0.31, 0.01]
1.30 [0.93, 1.84]
-0.21 [-0.33, -0.09]
1.00 [0.70, 1.42]
-0.08 [-0.21, 0.05]
Statistical method
Effect size
Comparison 2. Self-Management vs. Usual Care by Time Since Enrollment

1 Lung Function
1.1 Mos 1-6
2 Exacerbation (% patients)
2.1 Mos 1-6
3.1 Mos 1-6
3.2 Mos 7-12
4 School Absences (% patients)
4.1 Mos 1-6
5.1 Mos 1-6
5.2 Mos 7-12
5.3 Mos 13-24
6 Restricted Activity (% patients)
6.1 Mos 1-6
7 Restricted Activity (mean days)
No. of
studies
4
4
2
2
5
2
3
1
1
16
7
9
1
1
1
6
No. of
participants
258
363
88
250
114
593
1040
89
79
Statistical method

Effect size
Subtotals only
0.50 [0.25, 0.75]
Subtotals only
1.43 [0.94, 2.18]
Subtotals only
-0.01 [-0.43, 0.41]
-0.28 [-0.53, -0.03]
Subtotals only
0.78 [0.36, 1.66]
Subtotals only
-0.09 [-0.25, 0.07]
-0.16 [-0.29, -0.04]
-0.24 [-0.66, 0.18]
Subtotals only
2.51 [0.61, 10.29]
Subtotals only
50
7.1 Mos 1-6

7.2 Mos 7-12
Patients)
8.1 Mos 1-6
(mean)
9.1 Mos 1-6
9.2 Mos 7-12
10 Self-Efficacy Scale
10.1 Mos 1-6
10.2 Mos 7-12
11 Asthma Severity Scale
11.1 Mos 1-6
11.2 Mos 7-12
12 General Practitioner visits
(mean)
12.1 Mos 1-6
12.2 Mos 7-12
12.3 Mos 13-24
13 ED Visit (% patients)
13.1 Mos 1-6
13.2 Mos 7-12
13.3 Mos 13-24
14 ED Visits (mean)
14.1 Mos 1-6
14.2 Mos 7-12
14.3 Mos 13-24
15.1 Mos 1-6
15.2 Mos 7-12
15.3 Mos 13-24
16.1 Mos 1-6
16.2 Mos 7-12
16.3 Mos 13-24
2
4
1
50
329

-0.48 [-1.05, 0.09]

-0.26 [-0.48, -0.04]
Subtotals only
1
3
103

0.65 [0.29, 1.44]

Subtotals only
2
1
6
3
3
4
4
1
6
139
63

-0.11 [-0.45, 0.23]

-0.86 [-1.38, -0.35]
Subtotals only
0.05 [-0.31, 0.40]
0.54 [0.28, 0.80]
Subtotals only
-0.15 [-0.43, 0.12]
-0.11 [-0.53, 0.30]
Subtotals only
1
4
1
6
3
3
1
12
3
9
1
4
1
3
2
8
2
6
2
31
499
89

-0.72 [-1.45, 0.01]

-0.05 [-0.23, 0.12]
-0.50 [-0.92, -0.08]
Subtotals only
1.27 [0.78, 2.04]
1.35 [0.82, 2.20]
0.40 [0.15, 1.07]
Subtotals only
-0.31 [-0.60, -0.03]
-0.19 [-0.32, -0.05]
-0.14 [-0.56, 0.27]
Subtotals only
1.44 [0.91, 2.29]
0.59 [0.33, 1.03]
1.45 [0.94, 2.22]
Subtotals only
0.12 [-0.07, 0.31]
-0.26 [-0.44, -0.08]
0.19 [0.01, 0.38]
124
236
212
89
409
495
89
200
914
89
368
311
457
418
510
457
Comparison 3. Self-management vs. Usual Care by Self-management Strategy

1 Lung Function
1.1 Peak Flow-based Strategies
2.2 Symptom-based Strategies
3.2 Peak Flow-based strategies
No. of
studies
4
4
2
1
1
5
4
1
No. of
participants
258
104
259
275
63
Statistical method

Effect size
Subtotals only
0.50 [0.25, 0.75]
Subtotals only
3.04 [1.27, 7.25]
1.12 [0.69, 1.83]
Subtotals only
-0.20 [-0.44, 0.04]
-0.26 [-0.76, 0.24]
51

Patients)
(mean)
10.1 Peak Flow-based
Strategies
10.2 Symptom-based
Strategies
Strategies
11.2 Symptom-based
Strategies
(mean)
12.1 Symptom-based
Strategies
Strategies
Strategies
13.2 Symptom-based
Strategies
14 ED Visits (mean)
Strategies
14.2 Symptom-based
Strategies
Strategies
15.2 Symptom-based
Strategies
Strategies
1
1
16
8
8
1
1
6
4
2
1
114
501
1132
79
297
82

Subtotals only
0.78 [0.36, 1.66]
Subtotals only
-0.22 [-0.40, -0.04]
-0.10 [-0.22, 0.02]
Subtotals only
2.51 [0.61, 10.29]
Subtotals only
-0.18 [-0.41, 0.05]
-0.68 [-1.13, -0.23]
Subtotals only
1
3
103

0.65 [0.29, 1.44]

Subtotals only
2
1
6
1
123
79
36

-0.72 [-1.09, -0.36]

0.24 [-0.21, 0.68]
Subtotals only
0.46 [-0.20, 1.13]
324
0.35 [0.13, 0.58]
4
3
162

Subtotals only
-0.04 [-0.35, 0.27]
50
-0.52 [-1.08, 0.04]
Subtotals only
6
4
451
-0.11 [-0.30, 0.07]
168
-0.24 [-0.55, 0.06]
6
4
440

Subtotals only
0.88 [0.55, 1.43]
464
1.99 [1.20, 3.31]
12
4
281

Subtotals only
-0.15 [-0.39, 0.08]
833
-0.23 [-0.37, -0.09]
4
2
290

Subtotals only
0.41 [0.21, 0.81]
389
1.30 [0.83, 2.02]
8
2
131

Subtotals only
-0.15 [-0.50, 0.20]

52
16.2 Symptom-based
Strategies
797
-0.07 [-0.21, 0.07]
Comparison 4. Self-management vs. Usual Care by Intervention Type

1 Lung Function
1.1 Group Interventions
1.2 Individual Interventions
3.1 Group Intervention
3.2 Individual and Group
Intervention
6.1 Group Intervention
Interventions
Patients)
(mean)
(mean)
No. of
studies
4
3
1
2
1
1
5
2
1
2
1
1
16
8
7
1
1
1
6
3
2
1
No. of
participants
172
86
104
259
199
26
113
114
649
958
26
79
271
82
26
Statistical method
Effect size

Subtotals only
0.52 [0.21, 0.83]
0.47 [0.04, 0.90]
Subtotals only
3.04 [1.27, 7.25]
1.12 [0.69, 1.83]
Subtotals only
-0.10 [-0.38, 0.18]
-1.06 [-1.89, -0.23]

-0.23 [-0.60, 0.14]

Subtotals only
0.78 [0.36, 1.66]
Subtotals only
-0.20 [-0.35, -0.04]
-0.08 [-0.21, 0.05]
-0.78 [-1.59, 0.02]
Subtotals only
2.51 [0.61, 10.29]
Subtotals only
-0.15 [-0.39, 0.09]
-0.68 [-1.13, -0.23]
-0.50 [-1.28, 0.28]
Subtotals only
1
3
103

0.65 [0.29, 1.44]

Subtotals only
2
1
6
3
3
4
1
3
6
139
63

-0.11 [-0.45, 0.23]

-0.86 [-1.38, -0.35]
Subtotals only
0.39 [0.12, 0.66]
0.32 [-0.01, 0.66]
Subtotals only
-0.64 [-1.28, 0.01]
-0.05 [-0.35, 0.26]
Subtotals only
2
3
192
222

-0.06 [-0.35, 0.22]

-0.29 [-0.56, -0.03]
220
140
42
170

53

Interventions
Interventions
14 ED Visits (mean)
Interventions
Interventions
205
-0.07 [-0.34, 0.21]
6
1
4
1
114
585
205

Subtotals only
0.86 [0.41, 1.82]
1.44 [0.90, 2.31]
1.49 [0.75, 2.95]
12
5
5
2
673
210
231

Subtotals only
-0.20 [-0.36, -0.04]
-0.49 [-0.77, -0.21]
0.00 [-0.26, 0.26]

Subtotals only
0.90 [0.62, 1.29]
Subtotals only
-0.22 [-0.44, -0.01]
0.04 [-0.13, 0.21]
-0.79 [-1.59, 0.01]
4
4
8
3
4
1
679
374
528
26
Comparison 5. Self-management vs. Usual Care by Intervention Intensity

1 Lung Function
1.1 Single Sessions
1.2 Multiple Sessions
3.2 Single Sessions
5.1 Single Sessions
7.2 Single Sessions
Patients)
(mean)
9.2 Single Sessions
No. of
studies
4
1
3
2
2
5
4
1
1
1
16
3
13
1
1
6
5
1
1
No. of
participants
86
172
363
275
63
114
546
1087
79
316
63
Statistical method
Effect size

Subtotals only
0.47 [0.04, 0.90]
0.52 [0.21, 0.83]
Subtotals only
1.43 [0.94, 2.18]
Subtotals only
-0.20 [-0.44, 0.04]
-0.26 [-0.76, 0.24]
Subtotals only
0.78 [0.36, 1.66]
Subtotals only
-0.20 [-0.37, -0.03]
-0.10 [-0.22, 0.02]
Subtotals only
2.51 [0.61, 10.29]
Subtotals only
Not estimable
-0.61 [-1.12, -0.11]
Subtotals only
1
3
103

0.65 [0.29, 1.44]

Subtotals only
2
1
139
63

-0.11 [-0.45, 0.23]

-0.86 [-1.38, -0.35]

54
(mean)
12.2 Single Sessions
14 ED Visits (mean)
15.1 Multiple sessions
6
6
4
4
6
5
1
6
6
12
12
4
4
8
8
360
212
540
79
904
1114
679
928

Subtotals only
0.36 [0.15, 0.57]
Subtotals only
-0.15 [-0.43, 0.12]
Subtotals only

-0.17 [-0.35, -0.00]

0.04 [-0.40, 0.48]
Subtotals only
1.30 [0.93, 1.84]
Subtotals only
-0.21 [-0.33, -0.09]
Subtotals only
0.90 [0.62, 1.29]
Subtotals only
-0.08 [-0.21, 0.05]
Comparison 6. Self-management vs. Usual Care by Trial Type

1 Lung Function
1.1 RCT
1.2 CCT
2.1 CCT
2.2 RCT
3.1 RCT
3.2 CCT
4.1 CCT
5.1 RCT
5.2 CCT
6.1 CCT
7.1 RCT
7.2 CCT
Patients)
8.1 CCT
(mean)
9.1 RCT
9.2 CCT
10.1 RCT
No. of
studies
4
2
2
2
1
1
5
3
2
1
1
16
12
4
1
1
6
4
2
1
No. of
participants
106
152
104
259
249
89
114
1388
245
79
290
89
Statistical method
Effect size

Subtotals only
0.59 [0.20, 0.99]
0.44 [0.11, 0.76]
Subtotals only
3.04 [1.27, 7.25]
1.12 [0.69, 1.83]
Subtotals only
-0.12 [-0.37, 0.13]
-0.47 [-0.90, -0.04]
Subtotals only
0.78 [0.36, 1.66]
Subtotals only
-0.13 [-0.23, -0.02]
-0.20 [-0.45, 0.06]
Subtotals only
2.51 [0.61, 10.29]
Subtotals only
-0.20 [-0.43, 0.04]
-0.58 [-1.00, -0.15]
Subtotals only
1
3
103

0.65 [0.29, 1.44]

Subtotals only
2
1
6
5
139
63

-0.11 [-0.45, 0.23]

-0.86 [-1.38, -0.35]
Subtotals only
0.33 [0.08, 0.58]
256

55
10.2 CCT
11.1 RCT
11.2 CCT
(mean)
12.1 RCT
13.1 RCT
13.2 CCT
14 ED Visits (mean)
14.1 RCT
14.2 CCT
15.1 RCT
16.1 RCT
16.2 CCT
1
4
3
1
6
104
6
6
5
1
12
9
3
4
4
8
6
2
619
170
42
790
114
932
182
679
860
68

0.45 [0.06, 0.84]

Subtotals only
-0.05 [-0.35, 0.26]
-0.64 [-1.28, 0.01]
Subtotals only

-0.15 [-0.31, 0.01]

Subtotals only
1.46 [0.99, 2.15]
0.86 [0.41, 1.82]
Subtotals only
-0.23 [-0.36, -0.09]
-0.13 [-0.42, 0.17]
Subtotals only
0.90 [0.62, 1.29]
Subtotals only
-0.06 [-0.19, 0.08]
-0.41 [-0.90, 0.09]
Comparison 7. Self-management vs. Usual Care by Adequacy of Allocation Concealment

1 Lung Function
1.1 Allocation Concealment
Adequate
Inadequate
Unclear
Inadequate
Unclear
Adequate
Unclear
Inadequate
Inadequate
Adequate
No. of
studies
No. of
participants
4
1
86

Subtotals only
0.47 [0.04, 0.90]
152
0.44 [0.11, 0.76]
20
1.24 [0.26, 2.22]
2
1
104

Subtotals only
3.04 [1.27, 7.25]
259
1.12 [0.69, 1.83]
5
1
161

Subtotals only
-0.18 [-0.49, 0.13]
88
-0.01 [-0.43, 0.41]
89
-0.47 [-0.90, -0.04]
1
1
114

Subtotals only
0.78 [0.36, 1.66]
16
6
521

Subtotals only
-0.18 [-0.36, -0.01]
Statistical method

Effect size
56

Unclear
Inadequate
Inadequate
Adequate
Unclear
Inadequate
Patients)
Inadequate
(mean)
Adequate
Unclear
Inadequate
Adequate
Unclear
Inadequate
Adequate
Unclear
Inadequate
(mean)
Adequate
Unclear
Adequate
Unclear
867
-0.09 [-0.22, 0.04]
245
-0.20 [-0.45, 0.06]
1
1
79

Subtotals only
2.51 [0.61, 10.29]
6
1
161

Subtotals only
-0.27 [-0.58, 0.05]
129
-0.12 [-0.47, 0.24]
89
-0.58 [-1.00, -0.15]
Subtotals only
0.65 [0.29, 1.44]
Subtotals only
1
1
103
3
1
60
-0.58 [-1.10, -0.07]
79
0.24 [-0.21, 0.68]
63
-0.86 [-1.38, -0.35]
6
2
90

Subtotals only
0.51 [0.09, 0.93]
166
0.23 [-0.09, 0.54]
104
0.45 [0.06, 0.84]
4
1
89

Subtotals only
0.20 [-0.21, 0.62]
81
-0.33 [-0.77, 0.11]
42
-0.64 [-1.28, 0.01]
Subtotals only
6
5
588
-0.12 [-0.28, 0.04]
31
-0.72 [-1.45, 0.01]
6
4
531

Subtotals only
1.13 [0.72, 1.79]
259
2.82 [1.30, 6.12]

57

Inadequate
14 ED Visits (mean)
Adequate
Unclear
Inadequate
Adequate
Unclear
Unclear
Inadequate
Adequate
114
0.86 [0.41, 1.82]
12
5
420

Subtotals only
-0.16 [-0.35, 0.04]
512
-0.29 [-0.47, -0.11]
182
-0.13 [-0.42, 0.17]
4
2
290

Subtotals only
0.41 [0.21, 0.81]
389
1.30 [0.83, 2.02]
8
4
695

Subtotals only
-0.01 [-0.16, 0.15]
68
-0.41 [-0.90, 0.09]
165
-0.27 [-0.58, 0.04]
Comparison 8. Self-management vs. Usual Care by Adequacy of Follow-up

1 Lung Function
1.1 Adequate Follow-up
2.2 Inadequate Follow-up
Patients)
(mean)
No. of
studies
4
4
2
1
1
5
5
1
1
16
13
3
1
1
6
5
1
1
1
3
No. of
participants
258
104
259
338
114
914
719
79
348
31
103
Statistical method
Effect size

Subtotals only
0.50 [0.25, 0.75]
Subtotals only
3.04 [1.27, 7.25]
1.12 [0.69, 1.83]
Subtotals only
-0.21 [-0.43, 0.01]
Subtotals only
0.78 [0.36, 1.66]
Subtotals only
-0.16 [-0.29, -0.03]
-0.11 [-0.26, 0.04]
Subtotals only
2.51 [0.61, 10.29]
Subtotals only
-0.29 [-0.51, -0.08]
-0.24 [-0.95, 0.47]
Subtotals only

0.65 [0.29, 1.44]

Subtotals only

58

(mean)
14 ED Visits (mean)
3
6
5
1
4
4
6
202
4
2
6
5
1
12
11
1
4
3
1
8
7
1
534
85
306
54
212
645
259
905
209
311
368
560
368

-0.34 [-0.62, -0.05]

Subtotals only
0.33 [0.10, 0.56]
Not estimable
Subtotals only
-0.15 [-0.43, 0.12]
Subtotals only

-0.09 [-0.26, 0.09]

-0.55 [-0.99, -0.11]
Subtotals only
1.05 [0.71, 1.55]
2.82 [1.30, 6.12]
Subtotals only
-0.19 [-0.33, -0.06]
-0.28 [-0.55, -0.00]
Subtotals only
0.38 [0.20, 0.73]
1.44 [0.91, 2.29]
Subtotals only
-0.25 [-0.42, -0.07]
0.15 [-0.05, 0.36]
Comparison 9. Self-management vs. Usual Care by Asthma Severity

1 Lung Function
1.1 Mild-moderate Asthma
1.2 Moderate-Severe Asthma
1.3 Unclear Severity
2.1 Mild-Moderate Asthma
3.2 Moderate-Severe Severity
5.2 Moderate-Severe Asthma
7.1 Mild-Moderate Severity
No. of
studies
4
2
1
1
2
1
1
5
1
3
1
1
1
16
2
10
4
1
1
6
1
2
No. of
participants
196
42
20
104
259
161
127
50
114
318
848
467
79
161
110
Statistical method

Effect size
Subtotals only
0.47 [0.18, 0.75]
0.35 [-0.28, 0.99]
1.24 [0.26, 2.22]
Subtotals only
3.04 [1.27, 7.25]
1.12 [0.69, 1.83]
Subtotals only
-0.18 [-0.49, 0.13]
-0.26 [-0.61, 0.10]
-0.18 [-0.74, 0.37]
Subtotals only
0.78 [0.36, 1.66]
Subtotals only
-0.02 [-0.24, 0.20]
-0.24 [-0.37, -0.10]
-0.03 [-0.22, 0.15]
Subtotals only
2.51 [0.61, 10.29]
Subtotals only
-0.27 [-0.58, 0.05]
0.01 [-0.37, 0.39]
59

Patients)
(mean)
(mean)
14 ED Visits (mean)
3
1
108

-0.64 [-1.02, -0.25]

Subtotals only
1
3
103

0.65 [0.29, 1.44]

Subtotals only
2
1
6
3
3
4
2
1
1
6
123
79

-0.72 [-1.09, -0.36]

0.24 [-0.21, 0.68]
Subtotals only
0.27 [-0.08, 0.63]
0.41 [0.15, 0.68]
Subtotals only
-0.04 [-0.39, 0.31]
-0.03 [-0.73, 0.68]
-0.52 [-1.08, 0.04]
Subtotals only
2
1
3
6
2
1
3
12
1
7
4
4
2
2
8
5
3
143
161
315

-0.48 [-0.82, -0.15]

0.06 [-0.26, 0.37]
-0.10 [-0.32, 0.12]
Subtotals only
0.81 [0.38, 1.74]
0.86 [0.41, 1.82]
1.80 [1.14, 2.84]
Subtotals only
-0.07 [-0.44, 0.30]
-0.34 [-0.52, -0.16]
-0.11 [-0.29, 0.07]
Subtotals only
0.65 [0.23, 1.84]
0.94 [0.64, 1.38]
Subtotals only
-0.35 [-0.60, -0.09]
0.02 [-0.14, 0.17]
128
232
131
31
50
125
114
665
114
499
501
110
569
254
674

60
Analysis 1.1. Comparison 1 Self-management vs. Usual Care, Outcome 1 Lung Function.
Review:
Comparison: 1 Self-management vs. Usual Care

Outcome: 1 Lung Function
Study or subgroup
Education
Control
Std. Mean Difference
Mean(SD)
Mean(SD)
60
2.13 (0.51)
50
1.9 (0.47)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 FEV1
Toelle 1993
Subtotal (95% CI)
60
50
43.6 %
0.46 [ 0.08, 0.84 ]
43.6 %
0.46 [ 0.08, 0.84 ]
Heterogeneity: not applicable

Test for overall effect: Z = 2.39 (P = 0.017)
2 PEFR
Carswell 1989
43
109 (19)
43
100 (19)
34.3 %
0.47 [ 0.04, 0.90 ]
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
15.6 %
0.35 [ -0.28, 0.99 ]
Weingarten 1985
11
276.6 (33.86)
232.8 (33.86)
6.6 %
1.24 [ 0.26, 2.22 ]
Subtotal (95% CI)
81
67
56.4 %
0.53 [ 0.19, 0.86 ]
117
100.0 %
0.50 [ 0.25, 0.75 ]
Heterogeneity: Chi2 = 2.38, df = 2 (P = 0.30); I2 =16%

Total (95% CI)
141
Heterogeneity: Chi2 = 2.44, df = 3 (P = 0.49); I2 =0.0%

Test for subgroup differences: Chi2 = 0.06, df = 1 (P = 0.81), I2 =0.0%
-4
-2
Favours control

Favours education
61
Analysis 1.2. Comparison 1 Self-management vs. Usual Care, Outcome 2 Exacerbations (% Patients).
Review:

Outcome: 2 Exacerbations (% Patients)
Study or subgroup
Education
Control
n/N
n/N
64/133
57/126
84.0 %
1.12 [ 0.69, 1.83 ]
48/60
25/44
16.0 %
3.04 [ 1.27, 7.25 ]
193
170
100.0 %
1.43 [ 0.94, 2.18 ]
Mitchell 1986
Toelle 1993
Total (95% CI)
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Total events: 112 (Education), 82 (Control)

0.01
0.1
Favours education
10
100
Favours control
Analysis 1.3. Comparison 1 Self-management vs. Usual Care, Outcome 3 Exacerbations (Mean).
Review:

Outcome: 3 Exacerbations (Mean)
Study or subgroup
Education
Control
Weight
3.1 (2.06)
19.0 %
-0.26 [ -0.76, 0.24 ]
68
11.8 (16.5)
47.6 %
-0.18 [ -0.49, 0.13 ]
1.5 (4.1)
13
6 (4.1)
6.8 %
-1.06 [ -1.89, -0.23 ]
25
6.68 (18.67)
25
10.04 (17.13)
15.1 %
-0.18 [ -0.74, 0.37 ]
19
6.26 (8.08)
19
4.47 (8.08)
11.5 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.21 [ -0.43, 0.01 ]
Mean(SD)
Mean(SD)
Deaves 1993
32
2.56 (2.06)
31
Evans 1987
93
9 (14.7)
Fireman 1981
13
Talabere 1993
Whitman 1985
Total (95% CI)
182
IV,Fixed,95% CI
IV,Fixed,95% CI
156

-10
-5
Favours education

10
Favours control
62
Analysis 1.4. Comparison 1 Self-management vs. Usual Care, Outcome 4 School Absences (% Patients).
Review:

Outcome: 4 School Absences (% Patients)
Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
100.0 %
0.78 [ 0.36, 1.66 ]
63
51
100.0 %
0.78 [ 0.36, 1.66 ]
Toelle 1993
Total (95% CI)
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

0.01
0.1
Favours education
10
100
Favours control
Analysis 1.5. Comparison 1 Self-management vs. Usual Care, Outcome 5 School Absences (mean days).
Review:

Outcome: 5 School Absences (mean days)
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
Charlton 1994
42
2.1 (11.4)
37
4.7 (15.5)
4.9 %
-0.19 [ -0.63, 0.25 ]
Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
2.4 %
-0.19 [ -0.82, 0.44 ]
Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
4.7 %
0.32 [ -0.12, 0.77 ]
0.8 (0.32)
10
0.9 (0.32)
1.2 %
-0.30 [ -1.21, 0.61 ]
32
3.69 (4.8)
31
5.19 (4.8)
3.9 %
-0.31 [ -0.81, 0.19 ]
117
19.4 (13.9)
87
19.7 (12.6)
12.4 %
-0.02 [ -0.30, 0.26 ]
13
0.5 (5.06)
13
4.6 (5.06)
1.5 %
-0.78 [ -1.59, 0.02 ]
211
5.43 (4.07)
193
6.23 (4.72)
24.9 %
-0.18 [ -0.38, 0.01 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
5.4 %
-0.44 [ -0.86, -0.02 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
16.1 %
-0.03 [ -0.27, 0.22 ]
Dahl 1990
Deaves 1993
Evans 1987
Fireman 1981
Hill 1991
IV,Fixed,95% CI
-1
-0.5
Favours education
0.5
IV,Fixed,95% CI
Favours control
(Continued . . . )

63
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
3.5 %
0.02 [ -0.50, 0.54 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
2.2 %
-0.24 [ -0.89, 0.42 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
3.3 %
-0.30 [ -0.83, 0.24 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
3.0 %
-0.38 [ -0.94, 0.18 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
7.0 %
-0.02 [ -0.38, 0.35 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
3.6 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.14 [ -0.23, -0.04 ]
Total (95% CI)
867
IV,Fixed,95% CI
(. . . Continued)
IV,Fixed,95% CI
766

-1
-0.5
Favours education
0.5
Favours control
Analysis 1.6. Comparison 1 Self-management vs. Usual Care, Outcome 6 Restricted Activity (% Patients).
Review:

Outcome: 6 Restricted Activity (% Patients)
Study or subgroup
Toelle 1993
Total (95% CI)
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
8/43
3/36
100.0 %
2.51 [ 0.61, 10.29 ]
43
36
100.0 %
2.51 [ 0.61, 10.29 ]
M-H,Fixed,95% CI

0.01
0.1
Favours education
10
100
Favours control

64
Analysis 1.7. Comparison 1 Self-management vs. Usual Care, Outcome 7 Restricted Activity (Mean Days).
Review:

Outcome: 7 Restricted Activity (Mean Days)
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
45
2.27 (4.87)
34
1.79 (3.58)
21.2 %
0.11 [ -0.34, 0.55 ]
5.9 (1.86)
10
7.7 (1.86)
4.6 %
-0.92 [ -1.88, 0.03 ]
Deaves 1993
32
1.41 (1.63)
31
2.42 (1.63)
16.4 %
-0.61 [ -1.12, -0.11 ]
Evans 1987
93
18.1 (33.5)
68
30.3 (58.3)
42.6 %
-0.27 [ -0.58, 0.05 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
6.9 %
-0.50 [ -1.28, 0.28 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
8.4 %
-0.24 [ -0.95, 0.47 ]
Total (95% CI)
208
100.0 %
-0.29 [ -0.49, -0.08 ]
Colland 1993
Dahl 1990
IV,Fixed,95% CI
IV,Fixed,95% CI
171

-4
-2
Favours education
Favours control
Analysis 1.8. Comparison 1 Self-management vs. Usual Care, Outcome 8 Nights Nocturnal Asthma (%
Patients).
Review:

Outcome: 8 Nights Nocturnal Asthma (% Patients)
Study or subgroup
Toelle 1993
Total (95% CI)
Education
Control
n/N
n/N
Odds Ratio
Weight
22/59
21/44
100.0 %
0.65 [ 0.29, 1.44 ]
59
44
100.0 %
0.65 [ 0.29, 1.44 ]
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

0.01
0.1
Favours education
10
100
Favours control

65
Analysis 1.9. Comparison 1 Self-management vs. Usual Care, Outcome 9 Nights Nocturnal Asthma.
Review:

Outcome: 9 Nights Nocturnal Asthma
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
Colland 1993
45
1.82 (2.54)
34
1.08 (3.69)
40.2 %
0.24 [ -0.21, 0.68 ]
Deaves 1993
32
2.16 (1.99)
31
3.9 (1.99)
29.9 %
-0.86 [ -1.38, -0.35 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
29.9 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.34 [ -0.62, -0.05 ]
Total (95% CI)
109
IV,Fixed,95% CI
IV,Fixed,95% CI
93

-4
-2
Favours education
Favours control
Analysis 1.10. Comparison 1 Self-management vs. Usual Care, Outcome 10 Self-efficacy Scale.
Review:

Outcome: 10 Self-efficacy Scale
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
20.3 %
0.66 [ 0.19, 1.13 ]
Parcel 1980
53
30.2 (5.91)
51
27.5 (5.91)
29.3 %
0.45 [ 0.06, 0.84 ]
Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
10.1 %
0.46 [ -0.20, 1.13 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
14.9 %
0.54 [ 0.00, 1.09 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
14.5 %
-0.01 [ -0.56, 0.55 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
10.9 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.36 [ 0.15, 0.57 ]
Total (95% CI)
192
IV,Fixed,95% CI
IV,Fixed,95% CI
168

-4
-2
Favours control

Favours education
66
Analysis 1.11. Comparison 1 Self-management vs. Usual Care, Outcome 11 Asthma Severity Score.
Review:

Outcome: 11 Asthma Severity Score
Study or subgroup
Education
Control
Weight
4.36 (2.21)
17.9 %
-0.64 [ -1.28, 0.01 ]
45
2.04 (0.88)
43.3 %
0.20 [ -0.21, 0.62 ]
-8.87 (1.64)
16
-8.81 (2.46)
15.2 %
-0.03 [ -0.73, 0.68 ]
-49.68 (6.87)
25
-45.86 (7.57)
23.6 %
-0.52 [ -1.08, 0.04 ]
100.0 %
-0.15 [ -0.43, 0.12 ]
Mean(SD)
Mean(SD)
Christiansen 1997
27
2.87 (2.34)
15
Hughes 1991
44
2.23 (0.96)
LeBaron 1985
15
Talabere 1993
25
Total (95% CI)
111
IV,Fixed,95% CI
IV,Fixed,95% CI
101

-4
-2
Favours education
Favours control
Analysis 1.12. Comparison 1 Self-management vs. Usual Care, Outcome 12 General Practitioner Visits.
Review:

Outcome: 12 General Practitioner Visits
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
12.9 %
0.04 [ -0.40, 0.48 ]
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
25.8 %
0.06 [ -0.26, 0.37 ]
Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
4.7 %
-0.72 [ -1.45, 0.01 ]
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
14.2 %
-0.50 [ -0.92, -0.08 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
8.6 %
-0.46 [ -1.00, 0.08 ]
Shields 1990
101
1.63 (2.28)
104
1.86 (4.24)
33.7 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.15 [ -0.31, 0.01 ]
Total (95% CI)
325
IV,Fixed,95% CI
IV,Fixed,95% CI
294

-4
-2
Favours education

Favours control
67
Analysis 1.13. Comparison 1 Self-management vs. Usual Care, Outcome 13 ED Visits (% Patients).
Review:

Outcome: 13 ED Visits (% Patients)
Study or subgroup
Education
Control
n/N
n/N
Hughes 1991
13/44
11/45
13.4 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
10.8 %
1.10 [ 0.37, 3.26 ]
Mitchell 1986
26/133
10/126
14.4 %
2.82 [ 1.30, 6.12 ]
Persaud 1996
4/18
9/18
12.2 %
0.29 [ 0.07, 1.21 ]
Shields 1990
24/101
18/104
23.6 %
1.49 [ 0.75, 2.95 ]
Toelle 1993
36/63
31/51
25.6 %
0.86 [ 0.41, 1.82 ]
455
449
100.0 %
1.30 [ 0.93, 1.84 ]
Total (95% CI)
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

0.01
0.1
Favours education
10
100
Favours control

68
Analysis 1.14. Comparison 1 Self-management vs. Usual Care, Outcome 14 ED Visits (mean).
Review:

Outcome: 14 ED Visits (mean)
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
Alexander 1988
11
0.6 (0.9)
10
2.4 (2.1)
1.7 %
-1.09 [ -2.02, -0.16 ]
Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
3.7 %
0.10 [ -0.53, 0.73 ]
159
1.72 (4.2)
73
2.49 (6.26)
19.0 %
-0.16 [ -0.43, 0.12 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
2.3 %
-0.78 [ -1.58, 0.02 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
8.4 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
6.5 %
-0.47 [ -0.94, 0.00 ]
McNabb 1985
1.9 (4.72)
7.4 (4.72)
1.1 %
-1.09 [ -2.24, 0.06 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
3.2 %
-0.76 [ -1.44, -0.08 ]
Ronchetti 1997
114
0.07 (0.32)
95
0.23 (0.78)
19.5 %
-0.28 [ -0.55, 0.00 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
19.4 %
0.09 [ -0.18, 0.37 ]
Talabere 1993
25
0.44 (0.77)
25
1.08 (1.32)
4.5 %
-0.58 [ -1.15, -0.02 ]
Toelle 1993
63
1.51 (2.31)
51
1.67 (2.4)
10.7 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.21 [ -0.33, -0.09 ]
Clark 1986
Total (95% CI)
630
IV,Fixed,95% CI
IV,Fixed,95% CI
484

-4
-2
Favours education

Favours control
69
Analysis 1.15. Comparison 1 Self-management vs. Usual Care, Outcome 15 Hospitalization (% patients).
Review:

Outcome: 15 Hospitalization (% patients)
Study or subgroup
Education
Control
n/N
n/N
1/11
4/10
6.1 %
0.15 [ 0.01, 1.68 ]
Hughes 1991
15/44
9/45
9.4 %
2.07 [ 0.79, 5.40 ]
Madge 1997
8/96
26/105
36.4 %
0.28 [ 0.12, 0.65 ]
55/178
45/190
48.1 %
1.44 [ 0.91, 2.29 ]
329
350
100.0 %
1.00 [ 0.70, 1.42 ]
Alexander 1988
Mitchell 1986
Total (95% CI)
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

0.01
0.1
Favours education
10
100
Favours control

70
Analysis 1.16. Comparison 1 Self-management vs. Usual Care, Outcome 16 Hospitalizations (mean).
Review:

Outcome: 16 Hospitalizations (mean)
Study or subgroup
Education
Control
Weight
Mean(SD)
Mean(SD)
Alexander 1988
11
0.09 (0.3)
10
0.6 (0.84)
2.2 %
-0.79 [ -1.69, 0.10 ]
Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
4.4 %
-0.17 [ -0.80, 0.46 ]
175
0.11 (0.43)
81
0.21 (0.85)
25.2 %
-0.17 [ -0.43, 0.10 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
2.7 %
-0.79 [ -1.59, 0.01 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
10.1 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
7.9 %
-0.43 [ -0.90, 0.04 ]
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
41.8 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
5.7 %
-0.13 [ -0.68, 0.43 ]
100.0 %
-0.08 [ -0.21, 0.05 ]
Clark 1986
Total (95% CI)
521
IV,Fixed,95% CI
IV,Fixed,95% CI
407

-1
-0.5
Favours education

0.5
Favours control
71
Analysis 2.1. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 1 Lung
Function.
Review:
Comparison: 2 Self-Management vs. Usual Care by Time Since Enrollment

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Carswell 1989
43
109 (19)
43
100 (19)
34.3 %
0.47 [ 0.04, 0.90 ]
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
15.6 %
0.35 [ -0.28, 0.99 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
43.6 %
0.46 [ 0.08, 0.84 ]
Weingarten 1985
11
276.6 (33.86)
232.8 (33.86)
6.6 %
1.24 [ 0.26, 2.22 ]
1 Mos 1-6
-4
-2
Favours control
Favours education
Analysis 2.2. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 2
Exacerbation (% patients).
Review:

Outcome: 2 Exacerbation (% patients)
Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
64/133
57/126
84.0 %
1.12 [ 0.69, 1.83 ]
48/60
25/44
16.0 %
3.04 [ 1.27, 7.25 ]
M-H,Fixed,95% CI
1 Mos 1-6
Mitchell 1986
Toelle 1993
0.01
0.1
Favours education
10
100
Favours control

72
Exacerbations (Mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Talabere 1993
25
6.68 (18.67)
25
10.04 (17.13)
56.9 %
-0.18 [ -0.74, 0.37 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
43.1 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.01 [ -0.43, 0.41 ]
1 Mos 1-6
Subtotal (95% CI)
44
44

2 Mos 7-12
Deaves 1993
32
2.56 (2.06)
31
3.1 (2.06)
25.9 %
-0.26 [ -0.76, 0.24 ]
Evans 1987
93
9 (14.7)
68
11.8 (16.5)
64.9 %
-0.18 [ -0.49, 0.13 ]
Fireman 1981
13
1.5 (4.1)
13
6 (4.1)
9.2 %
-1.06 [ -1.89, -0.23 ]
100.0 %
-0.28 [ -0.53, -0.03 ]
Subtotal (95% CI)
138
112

Test for subgroup differences: Chi2 = 1.18, df = 1 (P = 0.28), I2 =15%
-4
-2
Favours education
Favours control
Analysis 2.4. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 4 School
Absences (% patients).
Review:

Outcome: 4 School Absences (% patients)
Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 Mos 1-6
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
0.78 [ 0.36, 1.66 ]
100
Favours control

73
Analysis 2.5. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 5 School
Absences (mean days).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
0.8 (0.32)
10
0.9 (0.32)
3.2 %
-0.30 [ -1.21, 0.61 ]
133
7.92 (16.48)
126
8.48 (26.69)
43.9 %
-0.03 [ -0.27, 0.22 ]
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
9.5 %
0.02 [ -0.50, 0.54 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
6.1 %
-0.24 [ -0.89, 0.42 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
8.3 %
-0.38 [ -0.94, 0.18 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
19.1 %
-0.02 [ -0.38, 0.35 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
9.9 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.09 [ -0.25, 0.07 ]
1 Mos 1-6
Dahl 1990
Mitchell 1986
Subtotal (95% CI)
307
286

2 Mos 7-12
Charlton 1994
42
2.1 (11.4)
37
4.7 (15.5)
7.7 %
-0.19 [ -0.63, 0.25 ]
Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
3.8 %
-0.19 [ -0.82, 0.44 ]
Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
7.5 %
0.32 [ -0.12, 0.77 ]
Deaves 1993
32
3.69 (4.8)
31
5.19 (4.8)
6.1 %
-0.31 [ -0.81, 0.19 ]
117
19.4 (13.9)
87
19.7 (12.6)
19.6 %
-0.02 [ -0.30, 0.26 ]
13
0.5 (5.06)
13
4.6 (5.06)
2.3 %
-0.78 [ -1.59, 0.02 ]
211
5.43 (4.07)
193
6.23 (4.72)
39.4 %
-0.18 [ -0.38, 0.01 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
8.5 %
-0.44 [ -0.86, -0.02 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
5.2 %
-0.30 [ -0.83, 0.24 ]
100.0 %
-0.16 [ -0.29, -0.04 ]
Evans 1987
Fireman 1981
Hill 1991
Subtotal (95% CI)
560
480

-1
-0.5
Favours education
0.5
Favours control
(Continued . . . )

74
Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
44
9.8 (7.6)
45
12.2 (11.7)
Weight
IV,Fixed,95% CI
(. . . Continued)
IV,Fixed,95% CI
3 Mos 13-24
Hughes 1991
Subtotal (95% CI)
44
45
100.0 %
-0.24 [ -0.66, 0.18 ]
100.0 %
-0.24 [ -0.66, 0.18 ]

-1
-0.5
Favours education
0.5
Favours control
Restricted Activity (% patients).
Review:

Outcome: 6 Restricted Activity (% patients)
Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 Mos 1-6
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
2.51 [ 0.61, 10.29 ]
100
Favours control

75
Restricted Activity (mean days).
Review:

Outcome: 7 Restricted Activity (mean days)
Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
5.9 (1.86)
10
7.7 (1.86)
35.2 %
-0.92 [ -1.88, 0.03 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
64.8 %
-0.24 [ -0.95, 0.47 ]
Subtotal (95% CI)
25
100.0 %
-0.48 [ -1.05, 0.09 ]
1 Mos 1-6
Dahl 1990
25

2 Mos 7-12
Colland 1993
45
2.27 (4.87)
34
1.79 (3.58)
24.3 %
0.11 [ -0.34, 0.55 ]
Deaves 1993
32
1.41 (1.63)
31
2.42 (1.63)
18.9 %
-0.61 [ -1.12, -0.11 ]
Evans 1987
93
18.1 (33.5)
68
30.3 (58.3)
49.0 %
-0.27 [ -0.58, 0.05 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
7.9 %
-0.50 [ -1.28, 0.28 ]
100.0 %
-0.26 [ -0.48, -0.04 ]
Subtotal (95% CI)
183
146

-4
-2
Favours education

Favours control
76
Analysis 2.8. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 8 Nights
Nocturnal Asthma (% Patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 Mos 1-6
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.65 [ 0.29, 1.44 ]
100
Favours control
Analysis 2.9. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 9 Nights
Nocturnal Asthma (mean).
Review:

Outcome: 9 Nights Nocturnal Asthma (mean)
Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
45
1.82 (2.54)
34
1.08 (3.69)
57.4 %
0.24 [ -0.21, 0.68 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
42.6 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.11 [ -0.45, 0.23 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
1 Mos 1-6
Subtotal (95% CI)
77
62

2 Mos 7-12
Deaves 1993
Subtotal (95% CI)
32
2.16 (1.99)
32
31
3.9 (1.99)
31

-4
-2
Favours education

Favours control
77
Analysis 2.10. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 10 SelfEfficacy Scale.
Review:

Outcome: 10 Self-Efficacy Scale
Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
28.5 %
0.46 [ -0.20, 1.13 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
40.8 %
-0.01 [ -0.56, 0.55 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
30.7 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.05 [ -0.31, 0.40 ]
1 Mos 1-6
Subtotal (95% CI)
62
62

2 Mos 7-12
Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
31.4 %
0.66 [ 0.19, 1.13 ]
Parcel 1980
53
30.2 (5.91)
51
27.5 (5.91)
45.4 %
0.45 [ 0.06, 0.84 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
23.2 %
0.54 [ 0.00, 1.09 ]
100.0 %
0.54 [ 0.28, 0.80 ]
Subtotal (95% CI)
130
106

-4
-2
Favours control

Favours education
78
Asthma Severity Scale.
Review:

Outcome: 11 Asthma Severity Scale
Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
2.87 (2.34)
15
4.36 (2.21)
17.9 %
-0.64 [ -1.28, 0.01 ]
Hughes 1991
44
2.23 (0.96)
45
2.04 (0.88)
43.3 %
0.20 [ -0.21, 0.62 ]
LeBaron 1985
15
-8.87 (1.64)
16
-8.81 (2.46)
15.2 %
-0.03 [ -0.73, 0.68 ]
Talabere 1993
25
-49.68 (6.87)
25
-45.86 (7.57)
23.6 %
-0.52 [ -1.08, 0.04 ]
100.0 %
-0.15 [ -0.43, 0.12 ]
100.0 %
-0.11 [ -0.53, 0.30 ]
100.0 %
-0.11 [ -0.53, 0.30 ]
1 Mos 1-6
Subtotal (95% CI)
111
101

2 Mos 7-12
Hughes 1991
Subtotal (95% CI)
44
44
2.07 (1.62)
45
2.22 (0.97)
45

-4
-2
Favours education

Favours control
79
General Practitioner visits (mean).
Review:

Outcome: 12 General Practitioner visits (mean)
Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
Subtotal (95% CI)
16
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Mos 1-6
15
100.0 %
-0.72 [ -1.45, 0.01 ]
100.0 %
-0.72 [ -1.45, 0.01 ]

2 Mos 7-12
Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
16.0 %
0.04 [ -0.40, 0.48 ]
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
31.9 %
0.06 [ -0.26, 0.37 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
10.6 %
-0.46 [ -1.00, 0.08 ]
Shields 1990
101
1.63 (2.28)
104
1.86 (4.24)
41.6 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.05 [ -0.23, 0.12 ]
100.0 %
-0.50 [ -0.92, -0.08 ]
100.0 %
-0.50 [ -0.92, -0.08 ]
Subtotal (95% CI)
265
234

3 Mos 13-24
Hughes 1991
Subtotal (95% CI)
44
44
0.59 (1.75)
45
1.47 (1.75)
45

-4
-2
Favours education

Favours control
80
Analysis 2.13. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 13 ED
Visit (% patients).
Review:

Outcome: 13 ED Visit (% patients)
Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Mitchell 1986
26/133
10/126
27.6 %
2.82 [ 1.30, 6.12 ]
Persaud 1996
4/18
9/18
23.4 %
0.29 [ 0.07, 1.21 ]
36/63
31/51
49.0 %
0.86 [ 0.41, 1.82 ]
214
195
100.0 %
1.27 [ 0.78, 2.04 ]
M-H,Fixed,95% CI
1 Mos 1-6
Toelle 1993
Subtotal (95% CI)

2 Mos 7-12
Hughes 1991
13/44
11/45
28.0 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
22.6 %
1.10 [ 0.37, 3.26 ]
Shields 1990
24/101
18/104
49.4 %
1.49 [ 0.75, 2.95 ]
241
254
100.0 %
1.35 [ 0.82, 2.20 ]
8/44
16/45
100.0 %
0.40 [ 0.15, 1.07 ]
44
45
100.0 %
0.40 [ 0.15, 1.07 ]
Subtotal (95% CI)

3 Mos 13-24
Hughes 1991
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

81
Analysis 2.14. Comparison 2 Self-Management vs. Usual Care by Time Since Enrollment, Outcome 14 ED
Visits (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
17.2 %
-0.76 [ -1.44, -0.08 ]
Talabere 1993
25
0.44 (0.77)
25
1.08 (1.32)
24.7 %
-0.58 [ -1.15, -0.02 ]
Toelle 1993
63
1.51 (2.31)
51
1.67 (2.4)
58.1 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.31 [ -0.60, -0.03 ]
1 Mos 1-6
Subtotal (95% CI)
106
94

2 Mos 7-12
Alexander 1988
11
0.6 (0.9)
10
2.4 (2.1)
2.1 %
-1.09 [ -2.02, -0.16 ]
Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
4.5 %
0.10 [ -0.53, 0.73 ]
159
1.72 (4.2)
73
2.49 (6.26)
23.2 %
-0.16 [ -0.43, 0.12 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
2.8 %
-0.78 [ -1.58, 0.02 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
10.3 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
8.0 %
-0.47 [ -0.94, 0.00 ]
1.9 (4.72)
7.4 (4.72)
1.4 %
-1.09 [ -2.24, 0.06 ]
Ronchetti 1997
114
0.07 (0.32)
95
0.23 (0.78)
23.9 %
-0.28 [ -0.55, 0.00 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
23.8 %
0.09 [ -0.18, 0.37 ]
100.0 %
-0.19 [ -0.32, -0.05 ]
100.0 %
-0.14 [ -0.56, 0.27 ]
100.0 %
-0.14 [ -0.56, 0.27 ]
Clark 1986
McNabb 1985
Subtotal (95% CI)
524
390

3 Mos 13-24
Hughes 1991
Subtotal (95% CI)
44
44
0.27 (2.16)
45
0.58 (2.16)
45

-4
-2
Favours education

Favours control
82
Hospitalization (% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
55/178
45/190
100.0 %
1.44 [ 0.91, 2.29 ]
178
190
100.0 %
1.44 [ 0.91, 2.29 ]
1/11
4/10
11.7 %
0.15 [ 0.01, 1.68 ]
Hughes 1991
15/44
9/45
18.1 %
2.07 [ 0.79, 5.40 ]
Madge 1997
8/96
26/105
70.2 %
0.28 [ 0.12, 0.65 ]
151
160
100.0 %
0.59 [ 0.33, 1.03 ]
M-H,Fixed,95% CI
1 Mos 1-6
Mitchell 1986
Subtotal (95% CI)

2 Mos 7-12
Alexander 1988
Subtotal (95% CI)

3 Mos 13-24
Hughes 1991
6/44
6/45
14.8 %
1.03 [ 0.30, 3.46 ]
Mitchell 1986
57/178
45/190
85.2 %
1.52 [ 0.96, 2.40 ]
222
235
100.0 %
1.45 [ 0.94, 2.22 ]
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

83
Hospitalizations (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
88.0 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
12.0 %
-0.13 [ -0.68, 0.43 ]
100.0 %
0.12 [ -0.07, 0.31 ]
1 Mos 1-6
Subtotal (95% CI)
203
215

2 Mos 7-12
Alexander 1988
11
0.09 (0.3)
10
0.6 (0.84)
4.2 %
-0.79 [ -1.69, 0.10 ]
Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
8.4 %
-0.17 [ -0.80, 0.46 ]
175
0.11 (0.43)
81
0.21 (0.85)
48.0 %
-0.17 [ -0.43, 0.10 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
5.2 %
-0.79 [ -1.59, 0.01 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
19.3 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
15.0 %
-0.43 [ -0.90, 0.04 ]
100.0 %
-0.26 [ -0.44, -0.08 ]
Clark 1986
Subtotal (95% CI)
318
192

3 Mos 13-24
Hughes 1991
44
0.18 (0.14)
45
0.16 (0.14)
19.5 %
0.14 [ -0.27, 0.56 ]
Mitchell 1986
178
0.75 (2.13)
190
0.39 (1.28)
80.5 %
0.21 [ 0.00, 0.41 ]
100.0 %
0.19 [ 0.01, 0.38 ]
Subtotal (95% CI)
222
235

-4
-2
Favours education

Favours control
84
Analysis 3.1. Comparison 3 Self-management vs. Usual Care by Self-management Strategy, Outcome 1
Lung Function.
Review:
Comparison: 3 Self-management vs. Usual Care by Self-management Strategy

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Carswell 1989
43
109 (19)
43
100 (19)
34.3 %
0.47 [ 0.04, 0.90 ]
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
15.6 %
0.35 [ -0.28, 0.99 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
43.6 %
0.46 [ 0.08, 0.84 ]
Weingarten 1985
11
276.6 (33.86)
232.8 (33.86)
6.6 %
1.24 [ 0.26, 2.22 ]
1 Peak Flow-based Strategies
-4
-2
Favours control

Favours education
85
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
48/60
25/44
100.0 %
3.04 [ 1.27, 7.25 ]
60
44
100.0 %
3.04 [ 1.27, 7.25 ]
64/133
57/126
100.0 %
1.12 [ 0.69, 1.83 ]
133
126
100.0 %
1.12 [ 0.69, 1.83 ]
M-H,Fixed,95% CI

Toelle 1993
Subtotal (95% CI)


2 Symptom-based Strategies
Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

86
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
93
9 (14.7)
68
11.8 (16.5)
58.8 %
-0.18 [ -0.49, 0.13 ]
Fireman 1981
13
1.5 (4.1)
13
6 (4.1)
8.4 %
-1.06 [ -1.89, -0.23 ]
Talabere 1993
25
6.68 (18.67)
25
10.04 (17.13)
18.7 %
-0.18 [ -0.74, 0.37 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
14.2 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.20 [ -0.44, 0.04 ]
100.0 %
-0.26 [ -0.76, 0.24 ]
100.0 %
-0.26 [ -0.76, 0.24 ]
Subtotal (95% CI)
150
125

2 Peak Flow-based strategies
Deaves 1993
Subtotal (95% CI)
32
2.56 (2.06)
31
32
3.1 (2.06)
31

-4
-2
Favours educaton
Favours control
School Absences (% patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

Toelle 1993
100.0 %
0.01
0.1
Favours education
10
0.78 [ 0.36, 1.66 ]
100
Favours control

87
School Absences (mean days).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Charlton 1994
42
2.1 (11.4)
37
4.7 (15.5)
15.9 %
-0.19 [ -0.63, 0.25 ]
Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
7.8 %
-0.19 [ -0.82, 0.44 ]
0.8 (0.32)
10
0.9 (0.32)
3.8 %
-0.30 [ -1.21, 0.61 ]
Deaves 1993
32
3.69 (4.8)
31
5.19 (4.8)
12.7 %
-0.31 [ -0.81, 0.19 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
17.7 %
-0.44 [ -0.86, -0.02 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
7.3 %
-0.24 [ -0.89, 0.42 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
22.9 %
-0.02 [ -0.38, 0.35 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
11.9 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.22 [ -0.40, -0.04 ]
Dahl 1990
Subtotal (95% CI)
265
236

Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
6.8 %
0.32 [ -0.12, 0.77 ]
117
19.4 (13.9)
87
19.7 (12.6)
17.8 %
-0.02 [ -0.30, 0.26 ]
13
0.5 (5.06)
13
4.6 (5.06)
2.1 %
-0.78 [ -1.59, 0.02 ]
Hill 1991
211
5.43 (4.07)
193
6.23 (4.72)
35.9 %
-0.18 [ -0.38, 0.01 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
23.1 %
-0.03 [ -0.27, 0.22 ]
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
5.0 %
0.02 [ -0.50, 0.54 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
4.7 %
-0.30 [ -0.83, 0.24 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
4.4 %
-0.38 [ -0.94, 0.18 ]
100.0 %
-0.10 [ -0.22, 0.02 ]
Evans 1987
Fireman 1981
Subtotal (95% CI)
602
530

-1
-0.5
Favours education

0.5
Favours control
88
Review:

Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

Toelle 1993
100.0 %
0.01
0.1
Favours education
10
2.51 [ 0.61, 10.29 ]
100
Favours control

89
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
45
2.27 (4.87)
34
1.79 (3.58)
26.8 %
0.11 [ -0.34, 0.55 ]
Evans 1987
93
18.1 (33.5)
68
30.3 (58.3)
53.9 %
-0.27 [ -0.58, 0.05 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
8.7 %
-0.50 [ -1.28, 0.28 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
10.6 %
-0.24 [ -0.95, 0.47 ]
100.0 %
-0.18 [ -0.41, 0.05 ]
Subtotal (95% CI)
167
130

Dahl 1990
Deaves 1993
Subtotal (95% CI)
5.9 (1.86)
10
7.7 (1.86)
21.8 %
-0.92 [ -1.88, 0.03 ]
32
1.41 (1.63)
31
2.42 (1.63)
78.2 %
-0.61 [ -1.12, -0.11 ]
100.0 %
-0.68 [ -1.13, -0.23 ]
41
41

-4
-2
Favours education

Favours control
90
Nights Nocturnal Asthma (% Patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.65 [ 0.29, 1.44 ]
100
Favours control
Nights Nocturnal Asthma (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Deaves 1993
32
2.16 (1.99)
31
3.9 (1.99)
50.1 %
-0.86 [ -1.38, -0.35 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
49.9 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.72 [ -1.09, -0.36 ]
100.0 %
0.24 [ -0.21, 0.68 ]
100.0 %
0.24 [ -0.21, 0.68 ]
Subtotal (95% CI)
64
59

Colland 1993
Subtotal (95% CI)
45
45
1.82 (2.54)
34
1.08 (3.69)
34

-4
-2
Favours education

Favours control
91
Self-Efficacy Scale.
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
18
2.2 (2.3)
18
0.8 (3.5)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Persaud 1996
Subtotal (95% CI)
18
18
100.0 %
0.46 [ -0.20, 1.13 ]
100.0 %
0.46 [ -0.20, 1.13 ]

Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
22.6 %
0.66 [ 0.19, 1.13 ]
Parcel 1980
53
30.2 (5.91)
51
27.5 (5.91)
32.6 %
0.45 [ 0.06, 0.84 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
16.6 %
0.54 [ 0.00, 1.09 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
16.1 %
-0.01 [ -0.56, 0.55 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
12.1 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.35 [ 0.13, 0.58 ]
Subtotal (95% CI)
174
150

-4
-2
Favours control

Favours education
92
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
2.87 (2.34)
15
4.36 (2.21)
23.5 %
-0.64 [ -1.28, 0.01 ]
Hughes 1991
44
2.23 (0.96)
45
2.04 (0.88)
56.7 %
0.20 [ -0.21, 0.62 ]
LeBaron 1985
15
-8.87 (1.64)
16
-8.81 (2.46)
19.8 %
-0.03 [ -0.73, 0.68 ]
100.0 %
-0.04 [ -0.35, 0.27 ]
100.0 %
-0.52 [ -1.08, 0.04 ]
100.0 %
-0.52 [ -1.08, 0.04 ]
Subtotal (95% CI)
86
76

Talabere 1993
Subtotal (95% CI)
25
-49.68 (6.87)
25
25
-45.86 (7.57)
25

-4
-2
Favours education

Favours control
93
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
35.5 %
0.06 [ -0.26, 0.37 ]
Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
6.5 %
-0.72 [ -1.45, 0.01 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
11.8 %
-0.46 [ -1.00, 0.08 ]
Shields 1990
101
1.63 (2.28)
104
1.86 (4.24)
46.2 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.11 [ -0.30, 0.07 ]
Subtotal (95% CI)
239
212

Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
47.7 %
0.04 [ -0.40, 0.48 ]
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
52.3 %
-0.50 [ -0.92, -0.08 ]
100.0 %
-0.24 [ -0.55, 0.06 ]
Subtotal (95% CI)
86
82

-1
-0.5
Favours education

0.5
Favours control
94
ED Visit (% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
13/44
11/45
21.6 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
17.4 %
1.10 [ 0.37, 3.26 ]
Persaud 1996
4/18
9/18
19.7 %
0.29 [ 0.07, 1.21 ]
36/63
31/51
41.3 %
0.86 [ 0.41, 1.82 ]
221
219
100.0 %
0.88 [ 0.55, 1.43 ]
M-H,Fixed,95% CI
Toelle 1993
Subtotal (95% CI)

Mitchell 1986
26/133
10/126
37.9 %
2.82 [ 1.30, 6.12 ]
Shields 1990
24/101
18/104
62.1 %
1.49 [ 0.75, 2.95 ]
234
230
100.0 %
1.99 [ 1.20, 3.31 ]
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

95
ED Visits (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
14.1 %
0.10 [ -0.53, 0.73 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
32.5 %
-0.14 [ -0.56, 0.27 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
12.2 %
-0.76 [ -1.44, -0.08 ]
Toelle 1993
63
1.51 (2.31)
51
1.67 (2.4)
41.2 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.15 [ -0.39, 0.08 ]
Subtotal (95% CI)
152
129

Alexander 1988
11
0.6 (0.9)
10
2.4 (2.1)
2.3 %
-1.09 [ -2.02, -0.16 ]
159
1.72 (4.2)
73
2.49 (6.26)
25.6 %
-0.16 [ -0.43, 0.12 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
3.1 %
-0.78 [ -1.58, 0.02 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
8.8 %
-0.47 [ -0.94, 0.00 ]
1.9 (4.72)
7.4 (4.72)
1.5 %
-1.09 [ -2.24, 0.06 ]
Ronchetti 1997
114
0.07 (0.32)
95
0.23 (0.78)
26.3 %
-0.28 [ -0.55, 0.00 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
26.3 %
0.09 [ -0.18, 0.37 ]
25
0.44 (0.77)
25
1.08 (1.32)
6.1 %
-0.58 [ -1.15, -0.02 ]
100.0 %
-0.23 [ -0.37, -0.09 ]
Clark 1986
McNabb 1985
Talabere 1993
Subtotal (95% CI)
478
355

-4
-2
Favours education

Favours control
96
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
6/44
6/45
18.4 %
1.03 [ 0.30, 3.46 ]
Madge 1997
8/96
26/105
81.6 %
0.28 [ 0.12, 0.65 ]
140
150
100.0 %
0.41 [ 0.21, 0.81 ]
1/11
4/10
11.2 %
0.15 [ 0.01, 1.68 ]
55/178
45/190
88.8 %
1.44 [ 0.91, 2.29 ]
189
200
100.0 %
1.30 [ 0.83, 2.02 ]
M-H,Fixed,95% CI
Subtotal (95% CI)

Alexander 1988
Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

97
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
30.2 %
-0.17 [ -0.80, 0.46 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
69.8 %
-0.14 [ -0.56, 0.27 ]
100.0 %
-0.15 [ -0.50, 0.20 ]
Subtotal (95% CI)
71
60

Alexander 1988
11
0.09 (0.3)
10
0.6 (0.84)
2.6 %
-0.79 [ -1.69, 0.10 ]
175
0.11 (0.43)
81
0.21 (0.85)
29.5 %
-0.17 [ -0.43, 0.10 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
3.2 %
-0.79 [ -1.59, 0.01 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
9.2 %
-0.43 [ -0.90, 0.04 ]
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
48.9 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
6.7 %
-0.13 [ -0.68, 0.43 ]
100.0 %
-0.07 [ -0.21, 0.07 ]
Clark 1986
Subtotal (95% CI)
450
347

-1
-0.5
Favours education

0.5
Favours control
98
Analysis 4.1. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 1 Lung
Function.
Review:
Comparison: 4 Self-management vs. Usual Care by Intervention Type

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
23.7 %
0.35 [ -0.28, 0.99 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
66.3 %
0.46 [ 0.08, 0.84 ]
Weingarten 1985
11
276.6 (33.86)
232.8 (33.86)
10.0 %
1.24 [ 0.26, 2.22 ]
Subtotal (95% CI)
98
100.0 %
0.52 [ 0.21, 0.83 ]
100.0 %
0.47 [ 0.04, 0.90 ]
100.0 %
0.47 [ 0.04, 0.90 ]
1 Group Interventions
74

2 Individual Interventions
Carswell 1989
Subtotal (95% CI)
43
43
109 (19)
43
100 (19)
43

-4
-2
Favours control

Favours education
99
Analysis 4.2. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 2
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
48/60
25/44
100.0 %
3.04 [ 1.27, 7.25 ]
60
44
100.0 %
3.04 [ 1.27, 7.25 ]
64/133
57/126
100.0 %
1.12 [ 0.69, 1.83 ]
133
126
100.0 %
1.12 [ 0.69, 1.83 ]
M-H,Fixed,95% CI
Toelle 1993
Subtotal (95% CI)


Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

100
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
93
9 (14.7)
68
11.8 (16.5)
80.6 %
-0.18 [ -0.49, 0.13 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
19.4 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.10 [ -0.38, 0.18 ]
100.0 %
-1.06 [ -1.89, -0.23 ]
100.0 %
-1.06 [ -1.89, -0.23 ]
1 Group Intervention
Subtotal (95% CI)
112
87

2 Individual and Group Intervention
Fireman 1981
Subtotal (95% CI)
13
1.5 (4.1)
13
13
6 (4.1)
13

Deaves 1993
32
2.56 (2.06)
31
3.1 (2.06)
55.6 %
-0.26 [ -0.76, 0.24 ]
Talabere 1993
25
6.68 (18.67)
25
10.04 (17.13)
44.4 %
-0.18 [ -0.74, 0.37 ]
100.0 %
-0.23 [ -0.60, 0.14 ]
Subtotal (95% CI)
57
56

-4
-2
Favours education

Favours control
101
Analysis 4.4. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 4 School
Review:

Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.78 [ 0.36, 1.66 ]
100
Favours control
Analysis 4.5. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 5 School
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
42
2.1 (11.4)
37
4.7 (15.5)
12.2 %
-0.19 [ -0.63, 0.25 ]
0.8 (0.32)
10
0.9 (0.32)
2.9 %
-0.30 [ -1.21, 0.61 ]
Deaves 1993
32
3.69 (4.8)
31
5.19 (4.8)
9.7 %
-0.31 [ -0.81, 0.19 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
13.5 %
-0.44 [ -0.86, -0.02 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
40.3 %
-0.03 [ -0.27, 0.22 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
5.6 %
-0.24 [ -0.89, 0.42 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
8.3 %
-0.30 [ -0.83, 0.24 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
7.6 %
-0.38 [ -0.94, 0.18 ]
100.0 %
-0.20 [ -0.35, -0.04 ]
Charlton 1994
Dahl 1990
Subtotal (95% CI)
332
317
-1
-0.5
Favours education
0.5
Favours control
(Continued . . . )

102
(. . .
Study or subgroup
Education
N
Control
Mean(SD)
Mean(SD)
Weight
IV,Fixed,95% CI
Continued)

IV,Fixed,95% CI

Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
4.1 %
-0.19 [ -0.82, 0.44 ]
Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
8.1 %
0.32 [ -0.12, 0.77 ]
Evans 1987
117
19.4 (13.9)
87
19.7 (12.6)
21.2 %
-0.02 [ -0.30, 0.26 ]
Hill 1991
211
5.43 (4.07)
193
6.23 (4.72)
42.6 %
-0.18 [ -0.38, 0.01 ]
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
5.9 %
0.02 [ -0.50, 0.54 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
12.0 %
-0.02 [ -0.38, 0.35 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
6.2 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.08 [ -0.21, 0.05 ]
100.0 %
-0.78 [ -1.59, 0.02 ]
100.0 %
-0.78 [ -1.59, 0.02 ]
Subtotal (95% CI)
522
436

3 Individual and Group
Fireman 1981
Subtotal (95% CI)
13
0.5 (5.06)
13
13
4.6 (5.06)
13

-1
-0.5
Favours education
0.5
Favours control
Analysis 4.6. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 6 Restricted
Activity (% patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 Group Intervention
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
2.51 [ 0.61, 10.29 ]
100
Favours control

103
Analysis 4.7. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 7 Restricted
Activity (mean days).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
45
2.27 (4.87)
34
1.79 (3.58)
29.3 %
0.11 [ -0.34, 0.55 ]
Evans 1987
93
18.1 (33.5)
68
30.3 (58.3)
59.0 %
-0.27 [ -0.58, 0.05 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
11.6 %
-0.24 [ -0.95, 0.47 ]
100.0 %
-0.15 [ -0.39, 0.09 ]
Subtotal (95% CI)
154
117

9
5.9 (1.86)
10
7.7 (1.86)
21.8 %
-0.92 [ -1.88, 0.03 ]
32
1.41 (1.63)
31
2.42 (1.63)
78.2 %
-0.61 [ -1.12, -0.11 ]
100.0 %
-0.68 [ -1.13, -0.23 ]
100.0 %
-0.50 [ -1.28, 0.28 ]
100.0 %
-0.50 [ -1.28, 0.28 ]
Dahl 1990
Deaves 1993
Subtotal (95% CI)
41
41

3 Individual and Group Interventions
Fireman 1981
Subtotal (95% CI)
13
13
3.1 (2.9)
13
4.6 (2.9)
13

-4
-2
Favours education

Favours control
104
Analysis 4.8. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 8 Nights
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.65 [ 0.29, 1.44 ]
100
Favours control
Analysis 4.9. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 9 Nights
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
45
1.82 (2.54)
34
1.08 (3.69)
57.4 %
0.24 [ -0.21, 0.68 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
42.6 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.11 [ -0.45, 0.23 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
Subtotal (95% CI)
77
62

Deaves 1993
Subtotal (95% CI)
32
2.16 (1.99)
32
31
3.9 (1.99)
31

-4
-2
Favours education

Favours control
105
Analysis 4.10. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 10 SelfEfficacy Scale.
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
33.5 %
0.66 [ 0.19, 1.13 ]
Parcel 1980
53
30.2 (5.91)
51
27.5 (5.91)
48.5 %
0.45 [ 0.06, 0.84 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
18.0 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.39 [ 0.12, 0.66 ]
Subtotal (95% CI)
120
100

Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
25.6 %
0.46 [ -0.20, 1.13 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
37.8 %
0.54 [ 0.00, 1.09 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
36.6 %
-0.01 [ -0.56, 0.55 ]
100.0 %
0.32 [ -0.01, 0.66 ]
Subtotal (95% CI)
72
68

-1
-0.5
Favours control

0.5
Favours education
106
Analysis 4.11. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 11 Asthma
Severity Scale.
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
Christiansen 1997
27
2.87 (2.34)
15
4.36 (2.21)
Subtotal (95% CI)
27
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
15
100.0 %
-0.64 [ -1.28, 0.01 ]
100.0 %
-0.64 [ -1.28, 0.01 ]

Hughes 1991
44
2.23 (0.96)
45
2.04 (0.88)
52.8 %
0.20 [ -0.21, 0.62 ]
LeBaron 1985
15
-8.87 (1.64)
16
-8.81 (2.46)
18.5 %
-0.03 [ -0.73, 0.68 ]
Talabere 1993
25
-49.68 (6.87)
25
-45.86 (7.57)
28.8 %
-0.52 [ -1.08, 0.04 ]
100.0 %
-0.05 [ -0.35, 0.26 ]
Subtotal (95% CI)
84
86

-4
-2
Favours education

Favours control
107
Analysis 4.12. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 12 General
Practitioner visits (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
84.5 %
0.06 [ -0.26, 0.37 ]
Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
15.5 %
-0.72 [ -1.45, 0.01 ]
100.0 %
-0.06 [ -0.35, 0.22 ]
Subtotal (95% CI)
109
83

Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
36.2 %
0.04 [ -0.40, 0.48 ]
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
39.7 %
-0.50 [ -0.92, -0.08 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
24.1 %
-0.46 [ -1.00, 0.08 ]
100.0 %
-0.29 [ -0.56, -0.03 ]
100.0 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.07 [ -0.34, 0.21 ]
Subtotal (95% CI)
115
107

Shields 1990
Subtotal (95% CI)
101
101
1.63 (2.28)
104
1.86 (4.24)
104

-4
-2
Favours education

Favours control
108
Analysis 4.13. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 13 ED Visit
(% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
36/63
31/51
100.0 %
0.86 [ 0.41, 1.82 ]
63
51
100.0 %
0.86 [ 0.41, 1.82 ]
Hughes 1991
13/44
11/45
26.3 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
21.3 %
1.10 [ 0.37, 3.26 ]
Mitchell 1986
26/133
10/126
28.4 %
2.82 [ 1.30, 6.12 ]
Persaud 1996
4/18
9/18
24.0 %
0.29 [ 0.07, 1.21 ]
291
294
100.0 %
1.44 [ 0.90, 2.31 ]
24/101
18/104
100.0 %
1.49 [ 0.75, 2.95 ]
101
104
100.0 %
1.49 [ 0.75, 2.95 ]
M-H,Fixed,95% CI
Toelle 1993
Subtotal (95% CI)

Subtotal (95% CI)

Shields 1990
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

109
Analysis 4.14. Comparison 4 Self-management vs. Usual Care by Intervention Type, Outcome 14 ED Visits
(mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
27
0.3 (1.2)
15
0.2 (0.43)
6.2 %
0.10 [ -0.53, 0.73 ]
Clark 1986
159
1.72 (4.2)
73
2.49 (6.26)
31.9 %
-0.16 [ -0.43, 0.12 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
11.0 %
-0.47 [ -0.94, 0.00 ]
114
0.07 (0.32)
95
0.23 (0.78)
32.8 %
-0.28 [ -0.55, 0.00 ]
63
1.51 (2.31)
51
1.67 (2.4)
18.0 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.20 [ -0.36, -0.04 ]
Christiansen 1997
Ronchetti 1997
Toelle 1993
Subtotal (95% CI)
411
262

Alexander 1988
11
0.6 (0.9)
10
2.4 (2.1)
8.9 %
-1.09 [ -2.02, -0.16 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
44.6 %
-0.14 [ -0.56, 0.27 ]
McNabb 1985
1.9 (4.72)
7.4 (4.72)
5.8 %
-1.09 [ -2.24, 0.06 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
16.7 %
-0.76 [ -1.44, -0.08 ]
Talabere 1993
25
0.44 (0.77)
25
1.08 (1.32)
24.0 %
-0.58 [ -1.15, -0.02 ]
100.0 %
-0.49 [ -0.77, -0.21 ]
Subtotal (95% CI)
105
105

Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
10.4 %
-0.78 [ -1.58, 0.02 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
89.6 %
0.09 [ -0.18, 0.37 ]
100.0 %
0.00 [ -0.26, 0.26 ]
Subtotal (95% CI)
114
117

-4
-2
Favours education

Favours control
110
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Alexander 1988
1/11
4/10
6.2 %
0.15 [ 0.01, 1.68 ]
Hughes 1991
6/44
6/45
8.3 %
1.03 [ 0.30, 3.46 ]
Madge 1997
8/96
26/105
36.8 %
0.28 [ 0.12, 0.65 ]
55/178
45/190
48.7 %
1.44 [ 0.91, 2.29 ]
M-H,Fixed,95% CI
Mitchell 1986
0.01
0.1
Favours education
10
100
Favours control

111
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
27
0.03 (1.4)
15
0.25 (0.98)
11.7 %
-0.17 [ -0.80, 0.46 ]
Clark 1986
175
0.11 (0.43)
81
0.21 (0.85)
67.2 %
-0.17 [ -0.43, 0.10 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
21.1 %
-0.43 [ -0.90, 0.04 ]
100.0 %
-0.22 [ -0.44, -0.01 ]
Christiansen 1997
Subtotal (95% CI)
250
124

Alexander 1988
11
0.09 (0.3)
10
0.6 (0.84)
3.6 %
-0.79 [ -1.69, 0.10 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
16.9 %
-0.14 [ -0.56, 0.27 ]
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
69.9 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
9.5 %
-0.13 [ -0.68, 0.43 ]
100.0 %
0.04 [ -0.13, 0.21 ]
100.0 %
-0.79 [ -1.59, 0.01 ]
100.0 %
-0.79 [ -1.59, 0.01 ]
Subtotal (95% CI)
258
270

Fireman 1981
Subtotal (95% CI)
13
13
0 (0.38)
13
0.31 (0.38)
13

-4
-2
Favours education]

Favours control
112
Analysis 5.1. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 1 Lung
Function.
Review:
Comparison: 5 Self-management vs. Usual Care by Intervention Intensity

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
43
109 (19)
43
100 (19)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Single Sessions
Carswell 1989
Subtotal (95% CI)
43
43
100.0 %
0.47 [ 0.04, 0.90 ]
100.0 %
0.47 [ 0.04, 0.90 ]

2 Multiple Sessions
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
23.7 %
0.35 [ -0.28, 0.99 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
66.3 %
0.46 [ 0.08, 0.84 ]
Weingarten 1985
11
276.6 (33.86)
232.8 (33.86)
10.0 %
1.24 [ 0.26, 2.22 ]
Subtotal (95% CI)
98
100.0 %
0.52 [ 0.21, 0.83 ]
74

-4
-2
Favours control
Favours education
Analysis 5.2. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 2
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
64/133
57/126
84.0 %
1.12 [ 0.69, 1.83 ]
48/60
25/44
16.0 %
3.04 [ 1.27, 7.25 ]
M-H,Fixed,95% CI
1 Multiple Sessions
Mitchell 1986
Toelle 1993
0.01
0.1
Favours education
10
100
Favours control

113
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
93
9 (14.7)
68
11.8 (16.5)
58.8 %
-0.18 [ -0.49, 0.13 ]
Fireman 1981
13
1.5 (4.1)
13
6 (4.1)
8.4 %
-1.06 [ -1.89, -0.23 ]
Talabere 1993
25
6.68 (18.67)
25
10.04 (17.13)
18.7 %
-0.18 [ -0.74, 0.37 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
14.2 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.20 [ -0.44, 0.04 ]
100.0 %
-0.26 [ -0.76, 0.24 ]
100.0 %
-0.26 [ -0.76, 0.24 ]
1 Multiple Sessions
Subtotal (95% CI)
150
125

2 Single Sessions
Deaves 1993
Subtotal (95% CI)
32
32
2.56 (2.06)
31
3.1 (2.06)
31

-1
-0.5
Favours education

0.5
Favours control
114
Analysis 5.4. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 4 School
Review:

Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 Multiple Sessions
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.78 [ 0.36, 1.66 ]
100
Favours control
Analysis 5.5. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 5 School
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Charlton 1994
42
2.1 (11.4)
37
4.7 (15.5)
14.4 %
-0.19 [ -0.63, 0.25 ]
Deaves 1993
32
3.69 (4.8)
31
5.19 (4.8)
11.5 %
-0.31 [ -0.81, 0.19 ]
211
5.43 (4.07)
193
6.23 (4.72)
74.1 %
-0.18 [ -0.38, 0.01 ]
100.0 %
-0.20 [ -0.37, -0.03 ]
1 Single Sessions
Hill 1991
Subtotal (95% CI)
285
261

2 Multiple Sessions
Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
3.6 %
-0.19 [ -0.82, 0.44 ]
Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
7.2 %
0.32 [ -0.12, 0.77 ]
0.8 (0.32)
10
0.9 (0.32)
1.8 %
-0.30 [ -1.21, 0.61 ]
Dahl 1990
-1
-0.5
Favours education
0.5
Favours control
(Continued . . . )

115
Study or subgroup
Education
Control
Weight
(. . . Continued)
Mean(SD)
Mean(SD)
117
19.4 (13.9)
87
19.7 (12.6)
18.7 %
-0.02 [ -0.30, 0.26 ]
Fireman 1981
13
0.5 (5.06)
13
4.6 (5.06)
2.2 %
-0.78 [ -1.59, 0.02 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
8.1 %
-0.44 [ -0.86, -0.02 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
24.2 %
-0.03 [ -0.27, 0.22 ]
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
5.2 %
0.02 [ -0.50, 0.54 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
3.3 %
-0.24 [ -0.89, 0.42 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
5.0 %
-0.30 [ -0.83, 0.24 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
4.6 %
-0.38 [ -0.94, 0.18 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
10.6 %
-0.02 [ -0.38, 0.35 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
5.5 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.10 [ -0.22, 0.02 ]
Evans 1987
Subtotal (95% CI)
582
IV,Fixed,95% CI
IV,Fixed,95% CI
505

-1
-0.5
Favours education
0.5
Favours control
Review:

Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 Multiple Sessions
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
2.51 [ 0.61, 10.29 ]
100
Favours control

116
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
45
2.27 (4.87)
34
1.79 (3.58)
25.3 %
0.11 [ -0.34, 0.55 ]
Dahl 1990
5.9 (1.86)
10
7.7 (1.86)
5.5 %
-0.92 [ -1.88, 0.03 ]
Evans 1987
93
18.1 (33.5)
68
30.3 (58.3)
51.0 %
-0.27 [ -0.58, 0.05 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
8.2 %
-0.50 [ -1.28, 0.28 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
10.1 %
-0.24 [ -0.95, 0.47 ]
100.0 %
-0.22 [ -0.45, 0.00 ]
100.0 %
-0.61 [ -1.12, -0.11 ]
100.0 %
-0.61 [ -1.12, -0.11 ]
1 Multiple Sessions
Colland 1993
Subtotal (95% CI)
176
140

2 Single Sessions
Deaves 1993
Subtotal (95% CI)
32
32
1.41 (1.63)
31
2.42 (1.63)
31

-4
-2
Favours education

Favours control
117
Analysis 5.8. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 8 Nights
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 Multiple Sessions
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.65 [ 0.29, 1.44 ]
100
Favours control
Analysis 5.9. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 9 Nights
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
45
1.82 (2.54)
34
1.08 (3.69)
57.4 %
0.24 [ -0.21, 0.68 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
42.6 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.11 [ -0.45, 0.23 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
1 Multiple Sessions
Subtotal (95% CI)
77
62

2 Single Sessions
Deaves 1993
Subtotal (95% CI)
32
2.16 (1.99)
32
31
3.9 (1.99)
31

-4
-2
Favours education

Favours control
118
Analysis 5.10. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 10 SelfEfficacy Scale.
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
20.3 %
0.66 [ 0.19, 1.13 ]
Parcel 1980
53
30.2 (5.91)
51
27.5 (5.91)
29.3 %
0.45 [ 0.06, 0.84 ]
Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
10.1 %
0.46 [ -0.20, 1.13 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
14.9 %
0.54 [ 0.00, 1.09 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
14.5 %
-0.01 [ -0.56, 0.55 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
10.9 %
-0.27 [ -0.91, 0.37 ]
1 Multiple Sessions
-4
-2
Favours control
Favours education
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
2.87 (2.34)
15
4.36 (2.21)
17.9 %
-0.64 [ -1.28, 0.01 ]
Hughes 1991
44
2.23 (0.96)
45
2.04 (0.88)
43.3 %
0.20 [ -0.21, 0.62 ]
LeBaron 1985
15
-8.87 (1.64)
16
-8.81 (2.46)
15.2 %
-0.03 [ -0.73, 0.68 ]
Talabere 1993
25
-49.68 (6.87)
25
-45.86 (7.57)
23.6 %
-0.52 [ -1.08, 0.04 ]
1 Multiple Sessions
-4
-2
Favours education

Favours control
119
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
29.7 %
0.06 [ -0.26, 0.37 ]
Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
5.5 %
-0.72 [ -1.45, 0.01 ]
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
16.3 %
-0.50 [ -0.92, -0.08 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
9.9 %
-0.46 [ -1.00, 0.08 ]
Shields 1990
101
1.63 (2.28)
104
1.86 (4.24)
38.7 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.17 [ -0.35, 0.00 ]
100.0 %
0.04 [ -0.40, 0.48 ]
100.0 %
0.04 [ -0.40, 0.48 ]
1 Multiple Sessions
Subtotal (95% CI)
283
257

2 Single Sessions
Charlton 1994
Subtotal (95% CI)
42
42
2.3 (8.1)
37
2 (7.4)
37

-4
-2
Favours education

Favours control
120
Analysis 5.13. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 13 ED
Visit (% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
13/44
11/45
13.4 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
10.8 %
1.10 [ 0.37, 3.26 ]
Mitchell 1986
26/133
10/126
14.4 %
2.82 [ 1.30, 6.12 ]
Persaud 1996
4/18
9/18
12.2 %
0.29 [ 0.07, 1.21 ]
Shields 1990
24/101
18/104
23.6 %
1.49 [ 0.75, 2.95 ]
Toelle 1993
36/63
31/51
25.6 %
0.86 [ 0.41, 1.82 ]
M-H,Fixed,95% CI
1 Multiple Sessions
0.01
0.1
Favours education
10
100
Favours control

121
Analysis 5.14. Comparison 5 Self-management vs. Usual Care by Intervention Intensity, Outcome 14 ED
Visits (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Alexander 1988
11
0.6 (0.9)
10
2.4 (2.1)
1.7 %
-1.09 [ -2.02, -0.16 ]
Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
3.7 %
0.10 [ -0.53, 0.73 ]
159
1.72 (4.2)
73
2.49 (6.26)
19.0 %
-0.16 [ -0.43, 0.12 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
2.3 %
-0.78 [ -1.58, 0.02 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
8.4 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
6.5 %
-0.47 [ -0.94, 0.00 ]
McNabb 1985
1.9 (4.72)
7.4 (4.72)
1.1 %
-1.09 [ -2.24, 0.06 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
3.2 %
-0.76 [ -1.44, -0.08 ]
Ronchetti 1997
114
0.07 (0.32)
95
0.23 (0.78)
19.5 %
-0.28 [ -0.55, 0.00 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
19.4 %
0.09 [ -0.18, 0.37 ]
Talabere 1993
25
0.44 (0.77)
25
1.08 (1.32)
4.5 %
-0.58 [ -1.15, -0.02 ]
Toelle 1993
63
1.51 (2.31)
51
1.67 (2.4)
10.7 %
-0.07 [ -0.44, 0.30 ]
1 Multiple Sessions
Clark 1986
-4
-2
Favours education

Favours control
122
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Alexander 1988
1/11
4/10
6.2 %
0.15 [ 0.01, 1.68 ]
Hughes 1991
6/44
6/45
8.3 %
1.03 [ 0.30, 3.46 ]
Madge 1997
8/96
26/105
36.8 %
0.28 [ 0.12, 0.65 ]
55/178
45/190
48.7 %
1.44 [ 0.91, 2.29 ]
M-H,Fixed,95% CI
1 Multiple sessions
Mitchell 1986
0.01
0.1
Favours education
10
100
Favours control

123
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Alexander 1988
11
0.09 (0.3)
10
0.6 (0.84)
2.2 %
-0.79 [ -1.69, 0.10 ]
Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
4.4 %
-0.17 [ -0.80, 0.46 ]
175
0.11 (0.43)
81
0.21 (0.85)
25.2 %
-0.17 [ -0.43, 0.10 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
2.7 %
-0.79 [ -1.59, 0.01 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
10.1 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
7.9 %
-0.43 [ -0.90, 0.04 ]
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
41.8 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
5.7 %
-0.13 [ -0.68, 0.43 ]
1 Multiple Sessions
Clark 1986
-1
-0.5
Favours education

0.5
Favours control
124
Analysis 6.1. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 1 Lung Function.
Review:
Comparison: 6 Self-management vs. Usual Care by Trial Type

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Carswell 1989
43
109 (19)
43
100 (19)
83.9 %
0.47 [ 0.04, 0.90 ]
Weingarten 1985
11
276.6 (33.86)
232.8 (33.86)
16.1 %
1.24 [ 0.26, 2.22 ]
Subtotal (95% CI)
54
100.0 %
0.59 [ 0.20, 0.99 ]
1 RCT
52

2 CCT
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
26.3 %
0.35 [ -0.28, 0.99 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
73.7 %
0.46 [ 0.08, 0.84 ]
100.0 %
0.44 [ 0.11, 0.76 ]
Subtotal (95% CI)
87
65

-4
-2
Favours control

Favours education
125
Analysis 6.2. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 2 Exacerbation (%
patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
48/60
25/44
100.0 %
3.04 [ 1.27, 7.25 ]
60
44
100.0 %
3.04 [ 1.27, 7.25 ]
64/133
57/126
100.0 %
1.12 [ 0.69, 1.83 ]
133
126
100.0 %
1.12 [ 0.69, 1.83 ]
M-H,Fixed,95% CI
1 CCT
Toelle 1993
Subtotal (95% CI)


2 RCT
Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

126
Analysis 6.3. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 3 Exacerbations
(Mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
93
9 (14.7)
68
11.8 (16.5)
64.1 %
-0.18 [ -0.49, 0.13 ]
Talabere 1993
25
6.68 (18.67)
25
10.04 (17.13)
20.4 %
-0.18 [ -0.74, 0.37 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
15.5 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.12 [ -0.37, 0.13 ]
1 RCT
Subtotal (95% CI)
137
112

2 CCT
Deaves 1993
32
2.56 (2.06)
31
3.1 (2.06)
73.7 %
-0.26 [ -0.76, 0.24 ]
Fireman 1981
13
1.5 (4.1)
13
6 (4.1)
26.3 %
-1.06 [ -1.89, -0.23 ]
100.0 %
-0.47 [ -0.90, -0.04 ]
Subtotal (95% CI)
45
44

-4
-2
Favours education
Favours control
Analysis 6.4. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 4 School Absences (%
patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 CCT
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
0.78 [ 0.36, 1.66 ]
100
Favours control

127
Analysis 6.5. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 5 School Absences
(mean days).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Charlton 1994
42
2.1 (11.4)
37
4.7 (15.5)
5.7 %
-0.19 [ -0.63, 0.25 ]
Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
5.6 %
0.32 [ -0.12, 0.77 ]
0.8 (0.32)
10
0.9 (0.32)
1.4 %
-0.30 [ -1.21, 0.61 ]
Evans 1987
117
19.4 (13.9)
87
19.7 (12.6)
14.5 %
-0.02 [ -0.30, 0.26 ]
Hill 1991
211
5.43 (4.07)
193
6.23 (4.72)
29.3 %
-0.18 [ -0.38, 0.01 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
6.3 %
-0.44 [ -0.86, -0.02 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
18.9 %
-0.03 [ -0.27, 0.22 ]
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
4.1 %
0.02 [ -0.50, 0.54 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
2.6 %
-0.24 [ -0.89, 0.42 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
3.9 %
-0.30 [ -0.83, 0.24 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
3.6 %
-0.38 [ -0.94, 0.18 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
4.3 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.13 [ -0.23, -0.02 ]
1 RCT
Dahl 1990
Subtotal (95% CI)
732
656

2 CCT
Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
16.2 %
-0.19 [ -0.82, 0.44 ]
Deaves 1993
32
3.69 (4.8)
31
5.19 (4.8)
26.2 %
-0.31 [ -0.81, 0.19 ]
Fireman 1981
13
0.5 (5.06)
13
4.6 (5.06)
10.1 %
-0.78 [ -1.59, 0.02 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
47.5 %
-0.02 [ -0.38, 0.35 ]
100.0 %
-0.20 [ -0.45, 0.06 ]
Subtotal (95% CI)
135
110

-1
-0.5
Favours education

0.5
Favours control
128
Analysis 6.6. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 6 Restricted Activity
(% patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 CCT
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
2.51 [ 0.61, 10.29 ]
100
Favours control

129
Analysis 6.7. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 7 Restricted Activity
(mean days).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
45
2.27 (4.87)
34
1.79 (3.58)
27.6 %
0.11 [ -0.34, 0.55 ]
Dahl 1990
5.9 (1.86)
10
7.7 (1.86)
6.0 %
-0.92 [ -1.88, 0.03 ]
Evans 1987
93
18.1 (33.5)
68
30.3 (58.3)
55.5 %
-0.27 [ -0.58, 0.05 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
11.0 %
-0.24 [ -0.95, 0.47 ]
100.0 %
-0.20 [ -0.43, 0.04 ]
1 RCT
Colland 1993
Subtotal (95% CI)
163
127

2 CCT
Deaves 1993
32
1.41 (1.63)
31
2.42 (1.63)
70.5 %
-0.61 [ -1.12, -0.11 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
29.5 %
-0.50 [ -1.28, 0.28 ]
100.0 %
-0.58 [ -1.00, -0.15 ]
Subtotal (95% CI)
45
44

-4
-2
Favours education

Favours control
130
Analysis 6.8. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 8 Nights Nocturnal
Asthma (% Patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
1 CCT
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.65 [ 0.29, 1.44 ]
100
Favours control
Analysis 6.9. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 9 Nights Nocturnal
Asthma (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
45
1.82 (2.54)
34
1.08 (3.69)
57.4 %
0.24 [ -0.21, 0.68 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
42.6 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.11 [ -0.45, 0.23 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
1 RCT
Subtotal (95% CI)
77
62

2 CCT
Deaves 1993
Subtotal (95% CI)
32
2.16 (1.99)
32
31
3.9 (1.99)
31

-4
-2
Favours education

Favours control
131
Analysis 6.10. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 10 Self-Efficacy Scale.
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
28.7 %
0.66 [ 0.19, 1.13 ]
Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
14.3 %
0.46 [ -0.20, 1.13 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
21.1 %
0.54 [ 0.00, 1.09 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
20.5 %
-0.01 [ -0.56, 0.55 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
15.4 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.33 [ 0.08, 0.58 ]
100.0 %
0.45 [ 0.06, 0.84 ]
100.0 %
0.45 [ 0.06, 0.84 ]
1 RCT
Subtotal (95% CI)
139
117

2 CCT
Parcel 1980
Subtotal (95% CI)
53
53
30.2 (5.91)
51
27.5 (5.91)
51

-4
-2
Favours control

Favours education
132
Analysis 6.11. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 11 Asthma Severity
Scale.
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Hughes 1991
44
2.23 (0.96)
45
2.04 (0.88)
52.8 %
0.20 [ -0.21, 0.62 ]
LeBaron 1985
15
-8.87 (1.64)
16
-8.81 (2.46)
18.5 %
-0.03 [ -0.73, 0.68 ]
Talabere 1993
25
-49.68 (6.87)
25
-45.86 (7.57)
28.8 %
-0.52 [ -1.08, 0.04 ]
100.0 %
-0.05 [ -0.35, 0.26 ]
100.0 %
-0.64 [ -1.28, 0.01 ]
100.0 %
-0.64 [ -1.28, 0.01 ]
1 RCT
Subtotal (95% CI)
84
86

2 CCT
Christiansen 1997
27
Subtotal (95% CI)
27
2.87 (2.34)
15
4.36 (2.21)
15

-4
-2
Favours education

Favours control
133
Analysis 6.12. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 12 General
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
12.9 %
0.04 [ -0.40, 0.48 ]
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
25.8 %
0.06 [ -0.26, 0.37 ]
Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
4.7 %
-0.72 [ -1.45, 0.01 ]
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
14.2 %
-0.50 [ -0.92, -0.08 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
8.6 %
-0.46 [ -1.00, 0.08 ]
Shields 1990
101
1.63 (2.28)
104
1.86 (4.24)
33.7 %
-0.07 [ -0.34, 0.21 ]
1 RCT
-1
-0.5
Favours education

0.5
Favours control
134
Analysis 6.13. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 13 ED Visit (%
patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
13/44
11/45
18.0 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
14.5 %
1.10 [ 0.37, 3.26 ]
Mitchell 1986
26/133
10/126
19.4 %
2.82 [ 1.30, 6.12 ]
Persaud 1996
4/18
9/18
16.4 %
0.29 [ 0.07, 1.21 ]
24/101
18/104
31.7 %
1.49 [ 0.75, 2.95 ]
392
398
100.0 %
1.46 [ 0.99, 2.15 ]
36/63
31/51
100.0 %
0.86 [ 0.41, 1.82 ]
63
51
100.0 %
0.86 [ 0.41, 1.82 ]
M-H,Fixed,95% CI
1 RCT
Shields 1990
Subtotal (95% CI)

2 CCT
Toelle 1993
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

135
Analysis 6.14. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 14 ED Visits (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
11
0.6 (0.9)
10
2.4 (2.1)
2.0 %
-1.09 [ -2.02, -0.16 ]
159
1.72 (4.2)
73
2.49 (6.26)
22.7 %
-0.16 [ -0.43, 0.12 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
10.1 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
7.8 %
-0.47 [ -0.94, 0.00 ]
McNabb 1985
1.9 (4.72)
7.4 (4.72)
1.3 %
-1.09 [ -2.24, 0.06 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
3.8 %
-0.76 [ -1.44, -0.08 ]
Ronchetti 1997
114
0.07 (0.32)
95
0.23 (0.78)
23.4 %
-0.28 [ -0.55, 0.00 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
23.3 %
0.09 [ -0.18, 0.37 ]
25
0.44 (0.77)
25
1.08 (1.32)
5.4 %
-0.58 [ -1.15, -0.02 ]
100.0 %
-0.23 [ -0.36, -0.09 ]
1 RCT
Alexander 1988
Clark 1986
Talabere 1993
Subtotal (95% CI)
527
405

2 CCT
Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
22.0 %
0.10 [ -0.53, 0.73 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
13.6 %
-0.78 [ -1.58, 0.02 ]
Toelle 1993
63
1.51 (2.31)
51
1.67 (2.4)
64.4 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.13 [ -0.42, 0.17 ]
Subtotal (95% CI)
103
79

-4
-2
Favours education

Favours control
136
Analysis 6.15. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 15 Hospitalization (%
patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Alexander 1988
1/11
4/10
6.2 %
0.15 [ 0.01, 1.68 ]
Hughes 1991
6/44
6/45
8.3 %
1.03 [ 0.30, 3.46 ]
Madge 1997
8/96
26/105
36.8 %
0.28 [ 0.12, 0.65 ]
55/178
45/190
48.7 %
1.44 [ 0.91, 2.29 ]
M-H,Fixed,95% CI
1 RCT
Mitchell 1986
0.01
0.1
Favours education
10
100
Favours control

137
Analysis 6.16. Comparison 6 Self-management vs. Usual Care by Trial Type, Outcome 16 Hospitalizations
(mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
11
0.09 (0.3)
10
0.6 (0.84)
2.3 %
-0.79 [ -1.69, 0.10 ]
175
0.11 (0.43)
81
0.21 (0.85)
27.1 %
-0.17 [ -0.43, 0.10 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
10.9 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
8.5 %
-0.43 [ -0.90, 0.04 ]
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
45.0 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
6.1 %
-0.13 [ -0.68, 0.43 ]
100.0 %
-0.06 [ -0.19, 0.08 ]
1 RCT
Alexander 1988
Clark 1986
Subtotal (95% CI)
481
379

2 CCT
Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
61.7 %
-0.17 [ -0.80, 0.46 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
38.3 %
-0.79 [ -1.59, 0.01 ]
100.0 %
-0.41 [ -0.90, 0.09 ]
Subtotal (95% CI)
40
28

-1
-0.5
Favours education

0.5
Favours control
138
Analysis 7.1. Comparison 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment,
Outcome 1 Lung Function.
Review:
Comparison: 7 Self-management vs. Usual Care by Adequacy of Allocation Concealment

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
109 (19)
43
100 (19)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Allocation Concealment Adequate

Carswell 1989
Subtotal (95% CI)
43
43
43
100.0 %
0.47 [ 0.04, 0.90 ]
100.0 %
0.47 [ 0.04, 0.90 ]

2 Allocation Concealment Inadequate
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
26.3 %
0.35 [ -0.28, 0.99 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
73.7 %
0.46 [ 0.08, 0.84 ]
100.0 %
0.44 [ 0.11, 0.76 ]
100.0 %
1.24 [ 0.26, 2.22 ]
100.0 %
1.24 [ 0.26, 2.22 ]
Subtotal (95% CI)
87
65

3 Allocation Concealment Unclear
Weingarten 1985
11
Subtotal (95% CI)
11
276.6 (33.86)
232.8 (33.86)

-4
-2
Favours control

Favours education
139
Outcome 2 Exacerbation (% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
48/60
25/44
100.0 %
3.04 [ 1.27, 7.25 ]
60
44
100.0 %
3.04 [ 1.27, 7.25 ]
64/133
57/126
100.0 %
1.12 [ 0.69, 1.83 ]
133
126
100.0 %
1.12 [ 0.69, 1.83 ]
M-H,Fixed,95% CI

Toelle 1993
Subtotal (95% CI)


Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

140
Outcome 3 Exacerbations (Mean).
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
9 (14.7)
68
11.8 (16.5)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Evans 1987
Subtotal (95% CI)
93
93
68
100.0 %
-0.18 [ -0.49, 0.13 ]
100.0 %
-0.18 [ -0.49, 0.13 ]

Talabere 1993
25
6.68 (18.67)
25
10.04 (17.13)
56.9 %
-0.18 [ -0.74, 0.37 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
43.1 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.01 [ -0.43, 0.41 ]
Subtotal (95% CI)
44
44

Deaves 1993
32
2.56 (2.06)
31
3.1 (2.06)
73.7 %
-0.26 [ -0.76, 0.24 ]
Fireman 1981
13
1.5 (4.1)
13
6 (4.1)
26.3 %
-1.06 [ -1.89, -0.23 ]
100.0 %
-0.47 [ -0.90, -0.04 ]
Subtotal (95% CI)
45
44

-4
-2
Favours education

Favours control
141
Outcome 4 School Absences (% patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.78 [ 0.36, 1.66 ]
100
Favours control
Outcome 5 School Absences (mean days).
Review:

Study or subgroup
Education
N
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
42
2.1 (11.4)
37
4.7 (15.5)
15.3 %
-0.19 [ -0.63, 0.25 ]
117
19.4 (13.9)
87
19.7 (12.6)
39.0 %
-0.02 [ -0.30, 0.26 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
16.9 %
-0.44 [ -0.86, -0.02 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
7.0 %
-0.24 [ -0.89, 0.42 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
10.4 %
-0.30 [ -0.83, 0.24 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
11.4 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.18 [ -0.36, -0.01 ]

Charlton 1994
Evans 1987
Subtotal (95% CI)
280
241

-1
-0.5
Favours education
0.5
Favours control
(Continued . . . )

142
(. . .
Study or subgroup
Education
Control
Continued)
Weight
Mean(SD)
Mean(SD)
45
0.98 (1.56)
34
0.53 (1.08)
8.9 %
0.32 [ -0.12, 0.77 ]
0.8 (0.32)
10
0.9 (0.32)
2.2 %
-0.30 [ -1.21, 0.61 ]
Hill 1991
211
5.43 (4.07)
193
6.23 (4.72)
46.7 %
-0.18 [ -0.38, 0.01 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
30.1 %
-0.03 [ -0.27, 0.22 ]
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
6.5 %
0.02 [ -0.50, 0.54 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
5.7 %
-0.38 [ -0.94, 0.18 ]
100.0 %
-0.09 [ -0.22, 0.04 ]
Colland 1993
Dahl 1990
Subtotal (95% CI)
452
IV,Fixed,95% CI
IV,Fixed,95% CI
415

Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
16.2 %
-0.19 [ -0.82, 0.44 ]
Deaves 1993
32
3.69 (4.8)
31
5.19 (4.8)
26.2 %
-0.31 [ -0.81, 0.19 ]
Fireman 1981
13
0.5 (5.06)
13
4.6 (5.06)
10.1 %
-0.78 [ -1.59, 0.02 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
47.5 %
-0.02 [ -0.38, 0.35 ]
100.0 %
-0.20 [ -0.45, 0.06 ]
Subtotal (95% CI)
135
110

-1
-0.5
Favours education
0.5
Favours control
Outcome 6 Restricted Activity (% patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

Toelle 1993
100.0 %
0.01
0.1
Favours education
10
2.51 [ 0.61, 10.29 ]
100
Favours control

143
Outcome 7 Restricted Activity (mean days).
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
18.1 (33.5)
68
30.3 (58.3)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Evans 1987
Subtotal (95% CI)
93
93
68
100.0 %
-0.27 [ -0.58, 0.05 ]
100.0 %
-0.27 [ -0.58, 0.05 ]

Colland 1993
45
2.27 (4.87)
34
1.79 (3.58)
62.0 %
0.11 [ -0.34, 0.55 ]
5.9 (1.86)
10
7.7 (1.86)
13.4 %
-0.92 [ -1.88, 0.03 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
24.6 %
-0.24 [ -0.95, 0.47 ]
Subtotal (95% CI)
70
100.0 %
-0.12 [ -0.47, 0.24 ]
Dahl 1990
59

Deaves 1993
32
1.41 (1.63)
31
2.42 (1.63)
70.5 %
-0.61 [ -1.12, -0.11 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
29.5 %
-0.50 [ -1.28, 0.28 ]
100.0 %
-0.58 [ -1.00, -0.15 ]
Subtotal (95% CI)
45
44

-4
-2
Favours education

Favours control
144
Outcome 8 Nights Nocturnal Asthma (% Patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI

Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.65 [ 0.29, 1.44 ]
100
Favours control
Outcome 9 Nights Nocturnal Asthma (mean).
Review:

Study or subgroup
Education
N
Control
Mean(SD)
Mean(SD)
1.3 (1.7)
28
2.6 (2.65)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Wilson 1996
Subtotal (95% CI)
32
32
28
100.0 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.58 [ -1.10, -0.07 ]
100.0 %
0.24 [ -0.21, 0.68 ]
100.0 %
0.24 [ -0.21, 0.68 ]
100.0 %
-0.86 [ -1.38, -0.35 ]
100.0 %
-0.86 [ -1.38, -0.35 ]

Colland 1993
Subtotal (95% CI)
45
1.82 (2.54)
45
34
1.08 (3.69)
34

Deaves 1993
Subtotal (95% CI)
32
32
2.16 (1.99)
31
3.9 (1.99)
31
-4
-2
Favours education
Favours control
(Continued . . . )

145
(. . .
Study or subgroup
Education
Control
Mean(SD)

Mean(SD)
Weight
IV,Fixed,95% CI
Continued)

IV,Fixed,95% CI

-4
-2
Favours education
Favours control
Outcome 10 Self-Efficacy Scale.
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
40.4 %
0.46 [ -0.20, 1.13 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
59.6 %
0.54 [ 0.00, 1.09 ]
100.0 %
0.51 [ 0.09, 0.93 ]
Subtotal (95% CI)
47
43

Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
44.4 %
0.66 [ 0.19, 1.13 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
31.7 %
-0.01 [ -0.56, 0.55 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
23.9 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.23 [ -0.09, 0.54 ]
100.0 %
0.45 [ 0.06, 0.84 ]
100.0 %
0.45 [ 0.06, 0.84 ]
Subtotal (95% CI)
92
74

Parcel 1980
Subtotal (95% CI)
53
53
30.2 (5.91)
51
27.5 (5.91)
51

-4
-2
Favours control

Favours education
146
Outcome 11 Asthma Severity Scale.
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
2.23 (0.96)
45
2.04 (0.88)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Hughes 1991
Subtotal (95% CI)
44
44
45
100.0 %
0.20 [ -0.21, 0.62 ]
100.0 %
0.20 [ -0.21, 0.62 ]

LeBaron 1985
15
-8.87 (1.64)
16
-8.81 (2.46)
39.1 %
-0.03 [ -0.73, 0.68 ]
Talabere 1993
25
-49.68 (6.87)
25
-45.86 (7.57)
60.9 %
-0.52 [ -1.08, 0.04 ]
100.0 %
-0.33 [ -0.77, 0.11 ]
100.0 %
-0.64 [ -1.28, 0.01 ]
100.0 %
-0.64 [ -1.28, 0.01 ]
Subtotal (95% CI)
40
41

Christiansen 1997
27
Subtotal (95% CI)
27
2.87 (2.34)
15
4.36 (2.21)
15

-4
-2
Favours education

Favours control
147
Outcome 12 General Practitioner visits (mean).
Review:

Study or subgroup
Education
N
Control
Mean(SD)
Mean(SD)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
13.6 %
0.04 [ -0.40, 0.48 ]
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
27.1 %
0.06 [ -0.26, 0.37 ]
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
14.9 %
-0.50 [ -0.92, -0.08 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
9.0 %
-0.46 [ -1.00, 0.08 ]
Shields 1990
101
1.63 (2.28)
104
1.86 (4.24)
35.4 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.12 [ -0.28, 0.04 ]
100.0 %
-0.72 [ -1.45, 0.01 ]
100.0 %
-0.72 [ -1.45, 0.01 ]
Subtotal (95% CI)
309
279

Holzheimer 1998
16
Subtotal (95% CI)
16
3 (6.63)
15
7.87 (6.63)
15

-4
-2
Favours education

Favours control
148
Outcome 13 ED Visit (% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
13/44
11/45
22.3 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
18.0 %
1.10 [ 0.37, 3.26 ]
Persaud 1996
4/18
9/18
20.4 %
0.29 [ 0.07, 1.21 ]
24/101
18/104
39.3 %
1.49 [ 0.75, 2.95 ]
259
272
100.0 %
1.13 [ 0.72, 1.79 ]
26/133
10/126
100.0 %
2.82 [ 1.30, 6.12 ]
133
126
100.0 %
2.82 [ 1.30, 6.12 ]
36/63
31/51
100.0 %
0.86 [ 0.41, 1.82 ]
63
51
100.0 %
0.86 [ 0.41, 1.82 ]
M-H,Fixed,95% CI
Shields 1990
Subtotal (95% CI)

Mitchell 1986
Subtotal (95% CI)

Toelle 1993
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

149
Outcome 14 ED Visits (mean).
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI

Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
21.8 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
16.9 %
-0.47 [ -0.94, 0.00 ]
McNabb 1985
1.9 (4.72)
7.4 (4.72)
2.8 %
-1.09 [ -2.24, 0.06 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
8.2 %
-0.76 [ -1.44, -0.08 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
50.3 %
0.09 [ -0.18, 0.37 ]
100.0 %
-0.16 [ -0.35, 0.04 ]
Subtotal (95% CI)
218
202

11
0.6 (0.9)
10
2.4 (2.1)
3.8 %
-1.09 [ -2.02, -0.16 ]
Clark 1986
159
1.72 (4.2)
73
2.49 (6.26)
42.4 %
-0.16 [ -0.43, 0.12 ]
Ronchetti 1997
114
0.07 (0.32)
95
0.23 (0.78)
43.6 %
-0.28 [ -0.55, 0.00 ]
Talabere 1993
25
0.44 (0.77)
25
1.08 (1.32)
10.2 %
-0.58 [ -1.15, -0.02 ]
100.0 %
-0.29 [ -0.47, -0.11 ]
Alexander 1988
Subtotal (95% CI)
309
203

Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
22.0 %
0.10 [ -0.53, 0.73 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
13.6 %
-0.78 [ -1.58, 0.02 ]
Toelle 1993
63
1.51 (2.31)
51
1.67 (2.4)
64.4 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.13 [ -0.42, 0.17 ]
Subtotal (95% CI)
103
79

-1
-0.5
Favours education

0.5
Favours control
150
Outcome 15 Hospitalization (% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
6/44
6/45
18.4 %
1.03 [ 0.30, 3.46 ]
Madge 1997
8/96
26/105
81.6 %
0.28 [ 0.12, 0.65 ]
140
150
100.0 %
0.41 [ 0.21, 0.81 ]
1/11
4/10
11.2 %
0.15 [ 0.01, 1.68 ]
55/178
45/190
88.8 %
1.44 [ 0.91, 2.29 ]
189
200
100.0 %
1.30 [ 0.83, 2.02 ]
M-H,Fixed,95% CI
Subtotal (95% CI)

Alexander 1988
Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

151
Outcome 16 Hospitalizations (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
11
0.09 (0.3)
10
0.6 (0.84)
2.9 %
-0.79 [ -1.69, 0.10 ]
Clark 1986
175
0.11 (0.43)
81
0.21 (0.85)
33.6 %
-0.17 [ -0.43, 0.10 ]
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
55.8 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
7.6 %
-0.13 [ -0.68, 0.43 ]
100.0 %
-0.01 [ -0.16, 0.15 ]

Alexander 1988
Subtotal (95% CI)
389
306

Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
61.7 %
-0.17 [ -0.80, 0.46 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
38.3 %
-0.79 [ -1.59, 0.01 ]
100.0 %
-0.41 [ -0.90, 0.09 ]
Subtotal (95% CI)
40
28

Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
56.2 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
43.8 %
-0.43 [ -0.90, 0.04 ]
100.0 %
-0.27 [ -0.58, 0.04 ]
Subtotal (95% CI)
92
73

-1
-0.5
Favours education

0.5
Favours control
152
Analysis 8.1. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 1 Lung
Function.
Review:
Comparison: 8 Self-management vs. Usual Care by Adequacy of Follow-up

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Carswell 1989
43
109 (19)
43
100 (19)
34.3 %
0.47 [ 0.04, 0.90 ]
Christiansen 1997
27
331.37 (53.52)
15
313.53 (40.63)
15.6 %
0.35 [ -0.28, 0.99 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
43.6 %
0.46 [ 0.08, 0.84 ]
Weingarten 1985
11
276.6 (33.86)
232.8 (33.86)
6.6 %
1.24 [ 0.26, 2.22 ]
1 Adequate Follow-up
-4
-2
Favours control

Favours education
153
Analysis 8.2. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 2
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
48/60
25/44
100.0 %
3.04 [ 1.27, 7.25 ]
60
44
100.0 %
3.04 [ 1.27, 7.25 ]
64/133
57/126
100.0 %
1.12 [ 0.69, 1.83 ]
133
126
100.0 %
1.12 [ 0.69, 1.83 ]
M-H,Fixed,95% CI
Toelle 1993
Subtotal (95% CI)


2 Inadequate Follow-up
Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

154
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Deaves 1993
32
2.56 (2.06)
31
3.1 (2.06)
19.0 %
-0.26 [ -0.76, 0.24 ]
Evans 1987
93
9 (14.7)
68
11.8 (16.5)
47.6 %
-0.18 [ -0.49, 0.13 ]
Fireman 1981
13
1.5 (4.1)
13
6 (4.1)
6.8 %
-1.06 [ -1.89, -0.23 ]
Talabere 1993
25
6.68 (18.67)
25
10.04 (17.13)
15.1 %
-0.18 [ -0.74, 0.37 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
11.5 %
0.22 [ -0.42, 0.85 ]
-1
-0.5
Favours education
0.5
Favours control
Analysis 8.4. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 4 School
Review:

Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
0.78 [ 0.36, 1.66 ]
100
Favours control

155
Analysis 8.5. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 5 School
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Charlton 1994
42
2.1 (11.4)
37
4.7 (15.5)
8.8 %
-0.19 [ -0.63, 0.25 ]
Christiansen 1997
27
2.39 (2.9)
15
2.98 (3.29)
4.3 %
-0.19 [ -0.82, 0.44 ]
Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
8.6 %
0.32 [ -0.12, 0.77 ]
0.8 (0.32)
10
0.9 (0.32)
2.1 %
-0.30 [ -1.21, 0.61 ]
32
3.69 (4.8)
31
5.19 (4.8)
7.0 %
-0.31 [ -0.81, 0.19 ]
117
19.4 (13.9)
87
19.7 (12.6)
22.3 %
-0.02 [ -0.30, 0.26 ]
Fireman 1981
13
0.5 (5.06)
13
4.6 (5.06)
2.7 %
-0.78 [ -1.59, 0.02 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
9.7 %
-0.44 [ -0.86, -0.02 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
4.0 %
-0.24 [ -0.89, 0.42 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
5.9 %
-0.30 [ -0.83, 0.24 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
5.5 %
-0.38 [ -0.94, 0.18 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
12.6 %
-0.02 [ -0.38, 0.35 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
6.6 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.16 [ -0.29, -0.03 ]
Dahl 1990
Deaves 1993
Evans 1987
Subtotal (95% CI)
494
420

Hill 1991
211
5.43 (4.07)
193
6.23 (4.72)
56.1 %
-0.18 [ -0.38, 0.01 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
36.1 %
-0.03 [ -0.27, 0.22 ]
29
0.24 (0.9)
27
0.22 (1)
7.8 %
0.02 [ -0.50, 0.54 ]
100.0 %
-0.11 [ -0.26, 0.04 ]
Perrin 1992
Subtotal (95% CI)
373
346

-1
-0.5
Favours education

0.5
Favours control
156
Review:

Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
2.51 [ 0.61, 10.29 ]
100
Favours control
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
45
2.27 (4.87)
34
1.79 (3.58)
23.1 %
0.11 [ -0.34, 0.55 ]
5.9 (1.86)
10
7.7 (1.86)
5.0 %
-0.92 [ -1.88, 0.03 ]
Deaves 1993
32
1.41 (1.63)
31
2.42 (1.63)
17.9 %
-0.61 [ -1.12, -0.11 ]
Evans 1987
93
18.1 (33.5)
68
30.3 (58.3)
46.5 %
-0.27 [ -0.58, 0.05 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
7.5 %
-0.50 [ -1.28, 0.28 ]
100.0 %
-0.29 [ -0.51, -0.08 ]
100.0 %
-0.24 [ -0.95, 0.47 ]
Colland 1993
Dahl 1990
Subtotal (95% CI)
192
156

Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
-4
-2
Favours education
Favours control
(Continued . . . )

157
Study or subgroup
Education
N
Subtotal (95% CI)
Control
Mean(SD)
16

Mean(SD)
Weight
IV,Fixed,95% CI
(. . . Continued)
IV,Fixed,95% CI
15
100.0 %
-0.24 [ -0.95, 0.47 ]

-4
-2
Favours education
Favours control
Analysis 8.8. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 8 Nights
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
0.65 [ 0.29, 1.44 ]
100
Favours control

158
Analysis 8.9. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 9 Nights
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
45
1.82 (2.54)
34
1.08 (3.69)
40.2 %
0.24 [ -0.21, 0.68 ]
Deaves 1993
32
2.16 (1.99)
31
3.9 (1.99)
29.9 %
-0.86 [ -1.38, -0.35 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
29.9 %
-0.58 [ -1.10, -0.07 ]
-4
-2
Favours education
Favours control
Analysis 8.10. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 10 SelfEfficacy Scale.
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
23.8 %
0.66 [ 0.19, 1.13 ]
Parcel 1980
53
30.2 (5.91)
51
27.5 (5.91)
34.5 %
0.45 [ 0.06, 0.84 ]
Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
11.9 %
0.46 [ -0.20, 1.13 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
17.0 %
-0.01 [ -0.56, 0.55 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
12.8 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.33 [ 0.10, 0.56 ]
Subtotal (95% CI)
163
143

-4
-2
Favours control
Favours education
(Continued . . . )

159
Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
29
33.5 (3.8)
25
31.4 (3.8)
Weight
IV,Fixed,95% CI
(. . . Continued)
IV,Fixed,95% CI
Rubin 1986
Subtotal (95% CI)
29
25
100.0 %
0.54 [ 0.00, 1.09 ]
100.0 %
0.54 [ 0.00, 1.09 ]

-4
-2
Favours control
Favours education
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
2.87 (2.34)
15
4.36 (2.21)
17.9 %
-0.64 [ -1.28, 0.01 ]
Hughes 1991
44
2.23 (0.96)
45
2.04 (0.88)
43.3 %
0.20 [ -0.21, 0.62 ]
LeBaron 1985
15
-8.87 (1.64)
16
-8.81 (2.46)
15.2 %
-0.03 [ -0.73, 0.68 ]
Talabere 1993
25
-49.68 (6.87)
25
-45.86 (7.57)
23.6 %
-0.52 [ -1.08, 0.04 ]
-4
-2
Favours education

Favours control
160
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
14.9 %
0.04 [ -0.40, 0.48 ]
Evans 1987
93
3.6 (6.2)
68
3.3 (3.8)
29.8 %
0.06 [ -0.26, 0.37 ]
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
16.4 %
-0.50 [ -0.92, -0.08 ]
Shields 1990
101
1.63 (2.28)
104
1.86 (4.24)
38.9 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.09 [ -0.26, 0.09 ]
Subtotal (95% CI)
280
254

Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
35.6 %
-0.72 [ -1.45, 0.01 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
64.4 %
-0.46 [ -1.00, 0.08 ]
100.0 %
-0.55 [ -0.99, -0.11 ]
Subtotal (95% CI)
45
40

-4
-2
Favours education

Favours control
161
Analysis 8.13. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 13 ED
Visit (% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
13/44
11/45
15.6 %
1.30 [ 0.51, 3.31 ]
Madge 1997
7/96
7/105
12.6 %
1.10 [ 0.37, 3.26 ]
Persaud 1996
4/18
9/18
14.3 %
0.29 [ 0.07, 1.21 ]
Shields 1990
24/101
18/104
27.6 %
1.49 [ 0.75, 2.95 ]
Toelle 1993
36/63
31/51
29.9 %
0.86 [ 0.41, 1.82 ]
322
323
100.0 %
1.05 [ 0.71, 1.55 ]
26/133
10/126
100.0 %
2.82 [ 1.30, 6.12 ]
133
126
100.0 %
2.82 [ 1.30, 6.12 ]
M-H,Fixed,95% CI
Subtotal (95% CI)

Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

162
Analysis 8.14. Comparison 8 Self-management vs. Usual Care by Adequacy of Follow-up, Outcome 14 ED
Visits (mean).
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Alexander 1988
11
0.6 (0.9)
10
2.4 (2.1)
2.1 %
-1.09 [ -2.02, -0.16 ]
Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
4.5 %
0.10 [ -0.53, 0.73 ]
159
1.72 (4.2)
73
2.49 (6.26)
23.6 %
-0.16 [ -0.43, 0.12 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
2.8 %
-0.78 [ -1.58, 0.02 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
10.5 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
8.1 %
-0.47 [ -0.94, 0.00 ]
McNabb 1985
1.9 (4.72)
7.4 (4.72)
1.4 %
-1.09 [ -2.24, 0.06 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
3.9 %
-0.76 [ -1.44, -0.08 ]
Shields 1990
101
0.54 (1.68)
104
0.38 (1.68)
24.2 %
0.09 [ -0.18, 0.37 ]
Talabere 1993
25
0.44 (0.77)
25
1.08 (1.32)
5.6 %
-0.58 [ -1.15, -0.02 ]
Toelle 1993
63
1.51 (2.31)
51
1.67 (2.4)
13.3 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.19 [ -0.33, -0.06 ]
100.0 %
-0.28 [ -0.55, 0.00 ]
100.0 %
-0.28 [ -0.55, 0.00 ]
Clark 1986
Subtotal (95% CI)
516
389

Ronchetti 1997
Subtotal (95% CI)
114
114
0.07 (0.32)
95
0.23 (0.78)
95

-1
-0.5
Favours education

0.5
Favours control
163
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Alexander 1988
1/11
4/10
12.0 %
0.15 [ 0.01, 1.68 ]
Hughes 1991
6/44
6/45
16.2 %
1.03 [ 0.30, 3.46 ]
Madge 1997
8/96
26/105
71.8 %
0.28 [ 0.12, 0.65 ]
151
160
100.0 %
0.38 [ 0.20, 0.73 ]
55/178
45/190
100.0 %
1.44 [ 0.91, 2.29 ]
178
190
100.0 %
1.44 [ 0.91, 2.29 ]
M-H,Fixed,95% CI
Subtotal (95% CI)

Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

164
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Alexander 1988
11
0.09 (0.3)
10
0.6 (0.84)
3.7 %
-0.79 [ -1.69, 0.10 ]
Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
7.5 %
-0.17 [ -0.80, 0.46 ]
175
0.11 (0.43)
81
0.21 (0.85)
43.3 %
-0.17 [ -0.43, 0.10 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
4.7 %
-0.79 [ -1.59, 0.01 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
17.4 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
13.6 %
-0.43 [ -0.90, 0.04 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
9.8 %
-0.13 [ -0.68, 0.43 ]
100.0 %
-0.25 [ -0.42, -0.07 ]
100.0 %
0.15 [ -0.05, 0.36 ]
100.0 %
0.15 [ -0.05, 0.36 ]
Clark 1986
Subtotal (95% CI)
343
217

Mitchell 1986
Subtotal (95% CI)
178
178
0.5 (1.28)
190
0.33 (0.96)
190

-1
-0.5
Favours education

0.5
Favours control
165
Analysis 9.1. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 1 Lung
Function.
Review:
Comparison: 9 Self-management vs. Usual Care by Asthma Severity

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Carswell 1989
43
109 (19)
43
100 (19)
44.1 %
0.47 [ 0.04, 0.90 ]
Toelle 1993
60
2.13 (0.51)
50
1.9 (0.47)
55.9 %
0.46 [ 0.08, 0.84 ]
100.0 %
0.47 [ 0.18, 0.75 ]
100.0 %
0.35 [ -0.28, 0.99 ]
100.0 %
0.35 [ -0.28, 0.99 ]
100.0 %
1.24 [ 0.26, 2.22 ]
100.0 %
1.24 [ 0.26, 2.22 ]
1 Mild-moderate Asthma
Subtotal (95% CI)
103
93

2 Moderate-Severe Asthma
Christiansen 1997
27
Subtotal (95% CI)
27
331.37 (53.52)
15
313.53 (40.63)
15

3 Unclear Severity
Weingarten 1985
11
Subtotal (95% CI)
11
276.6 (33.86)
232.8 (33.86)

-4
-2
Favours control

Favours education
166
Analysis 9.2. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 2 Exacerbation
(% patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
48/60
25/44
100.0 %
3.04 [ 1.27, 7.25 ]
60
44
100.0 %
3.04 [ 1.27, 7.25 ]
64/133
57/126
100.0 %
1.12 [ 0.69, 1.83 ]
133
126
100.0 %
1.12 [ 0.69, 1.83 ]
M-H,Fixed,95% CI
1 Mild-Moderate Asthma
Toelle 1993
Subtotal (95% CI)


2 Unclear Severity
Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

167
Analysis 9.3. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 3
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
93
9 (14.7)
68
11.8 (16.5)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
Evans 1987
Subtotal (95% CI)
93
68
100.0 %
-0.18 [ -0.49, 0.13 ]
100.0 %
-0.18 [ -0.49, 0.13 ]

2 Moderate-Severe Severity
Deaves 1993
32
2.56 (2.06)
31
3.1 (2.06)
51.0 %
-0.26 [ -0.76, 0.24 ]
Fireman 1981
13
1.5 (4.1)
13
6 (4.1)
18.2 %
-1.06 [ -1.89, -0.23 ]
Whitman 1985
19
6.26 (8.08)
19
4.47 (8.08)
30.8 %
0.22 [ -0.42, 0.85 ]
100.0 %
-0.26 [ -0.61, 0.10 ]
100.0 %
-0.18 [ -0.74, 0.37 ]
100.0 %
-0.18 [ -0.74, 0.37 ]
Subtotal (95% CI)
64
63

3 Unclear Severity
Talabere 1993
Subtotal (95% CI)
25
25
6.68 (18.67)
25
10.04 (17.13)
25

-1
-0.5
Favours education

0.5
Favours control
168
Analysis 9.4. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 4 School
Review:

Study or subgroup
Education
Control
n/N
n/N
37/63
33/51
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.78 [ 0.36, 1.66 ]
100
Favours control
Analysis 9.5. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 5 School
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Evans 1987
117
19.4 (13.9)
87
19.7 (12.6)
63.9 %
-0.02 [ -0.30, 0.26 ]
Toelle 1993
63
2.62 (3.28)
51
2.67 (3.21)
36.1 %
-0.02 [ -0.38, 0.35 ]
100.0 %
-0.02 [ -0.24, 0.20 ]
Subtotal (95% CI)
180
138

2 Moderate-Severe Asthma
27
2.39 (2.9)
15
2.98 (3.29)
4.6 %
-0.19 [ -0.82, 0.44 ]
0.8 (0.32)
10
0.9 (0.32)
2.2 %
-0.30 [ -1.21, 0.61 ]
Deaves 1993
32
3.69 (4.8)
31
5.19 (4.8)
7.5 %
-0.31 [ -0.81, 0.19 ]
Fireman 1981
13
0.5 (5.06)
13
4.6 (5.06)
2.9 %
-0.78 [ -1.59, 0.02 ]
Christiansen 1997
Dahl 1990
-1
-0.5
Favours education
0.5
Favours control
(Continued . . . )

169
(. . .
Study or subgroup
Education
Control
Continued)
Weight
Mean(SD)
Mean(SD)
211
5.43 (4.07)
193
6.23 (4.72)
48.1 %
-0.18 [ -0.38, 0.01 ]
Hughes 1991
44
10.7 (6.9)
45
16 (15.4)
10.4 %
-0.44 [ -0.86, -0.02 ]
Perrin 1992
29
0.24 (0.9)
27
0.22 (1)
6.7 %
0.02 [ -0.50, 0.54 ]
Persaud 1996
18
6.4 (4.6)
18
7.6 (5.3)
4.3 %
-0.24 [ -0.89, 0.42 ]
Rubin 1986
29
11.9 (7.8)
25
15.4 (15)
6.4 %
-0.30 [ -0.83, 0.24 ]
Wilson 1996
30
0.8 (2.29)
29
1.4 (3.23)
7.0 %
-0.21 [ -0.72, 0.30 ]
100.0 %
-0.24 [ -0.37, -0.10 ]
Hill 1991
Subtotal (95% CI)
442
IV,Fixed,95% CI
IV,Fixed,95% CI
406

3 Unclear Severity
Charlton 1994
42
2.1 (11.4)
37
4.7 (15.5)
16.9 %
-0.19 [ -0.63, 0.25 ]
Colland 1993
45
0.98 (1.56)
34
0.53 (1.08)
16.5 %
0.32 [ -0.12, 0.77 ]
Mitchell 1986
133
7.92 (16.48)
126
8.48 (26.69)
55.9 %
-0.03 [ -0.27, 0.22 ]
Talabere 1993
25
1.36 (2.52)
25
2.6 (3.75)
10.6 %
-0.38 [ -0.94, 0.18 ]
100.0 %
-0.03 [ -0.22, 0.15 ]
Subtotal (95% CI)
245
222

-1
-0.5
Favours education
0.5
Favours control
Analysis 9.6. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 6 Restricted
Activity (% patients).
Review:

Study or subgroup
Education
Control
n/N
n/N
8/43
3/36
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
Favours education
10
2.51 [ 0.61, 10.29 ]
100
Favours control

170
Analysis 9.7. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 7 Restricted
Activity (mean days).
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
93
18.1 (33.5)
68
30.3 (58.3)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
1 Mild-Moderate Severity
Evans 1987
Subtotal (95% CI)
93
68
100.0 %
-0.27 [ -0.58, 0.05 ]
100.0 %
-0.27 [ -0.58, 0.05 ]

2 Unclear Severity
Colland 1993
45
2.27 (4.87)
34
1.79 (3.58)
71.6 %
0.11 [ -0.34, 0.55 ]
Holzheimer 1998
16
37.31 (57.6)
15
51.47 (57.6)
28.4 %
-0.24 [ -0.95, 0.47 ]
Subtotal (95% CI)
61
100.0 %
0.01 [ -0.37, 0.39 ]
49

Dahl 1990
5.9 (1.86)
10
7.7 (1.86)
16.4 %
-0.92 [ -1.88, 0.03 ]
Deaves 1993
32
1.41 (1.63)
31
2.42 (1.63)
58.9 %
-0.61 [ -1.12, -0.11 ]
Fireman 1981
13
3.1 (2.9)
13
4.6 (2.9)
24.6 %
-0.50 [ -1.28, 0.28 ]
100.0 %
-0.64 [ -1.02, -0.25 ]
Subtotal (95% CI)
54
54

-4
-2
Favours education

Favours control
171
Analysis 9.8. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 8 Nights
Review:

Study or subgroup
Education
Control
n/N
n/N
22/59
21/44
Odds Ratio
Weight
M-H,Fixed,95% CI
Odds Ratio
M-H,Fixed,95% CI
Toelle 1993
100.0 %
0.01
0.1
10
Favours education
0.65 [ 0.29, 1.44 ]
100
Favours control
Analysis 9.9. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 9 Nights
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Deaves 1993
32
2.16 (1.99)
31
3.9 (1.99)
50.1 %
-0.86 [ -1.38, -0.35 ]
Wilson 1996
32
1.3 (1.7)
28
2.6 (2.65)
49.9 %
-0.58 [ -1.10, -0.07 ]
100.0 %
-0.72 [ -1.09, -0.36 ]
100.0 %
0.24 [ -0.21, 0.68 ]
100.0 %
0.24 [ -0.21, 0.68 ]
Subtotal (95% CI)
64
59

2 Unclear Severity
Colland 1993
Subtotal (95% CI)
45
45
1.82 (2.54)
34
1.08 (3.69)
34

-4
-2
Favours education

Favours control
172
Analysis 9.10. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 10 SelfEfficacy Scale.
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Persaud 1996
18
2.2 (2.3)
18
0.8 (3.5)
28.1 %
0.46 [ -0.20, 1.13 ]
Rubin 1986
29
33.5 (3.8)
25
31.4 (3.8)
41.6 %
0.54 [ 0.00, 1.09 ]
Whitman 1985
19
34.47 (4.02)
19
35.58 (4.02)
30.3 %
-0.27 [ -0.91, 0.37 ]
100.0 %
0.27 [ -0.08, 0.63 ]
Subtotal (95% CI)
66
62

2 Unclear Severity
Colland 1993
48
42.72 (3.47)
30
40.28 (3.99)
31.7 %
0.66 [ 0.19, 1.13 ]
Parcel 1980
53
30.2 (5.91)
51
27.5 (5.91)
45.7 %
0.45 [ 0.06, 0.84 ]
Talabere 1993
25
79.94 (10.21)
25
80 (9.43)
22.6 %
-0.01 [ -0.56, 0.55 ]
100.0 %
0.41 [ 0.15, 0.68 ]
Subtotal (95% CI)
126
106

-4
-2
Favours control

Favours education
173
Analysis 9.11. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 11 Asthma
Severity Scale.
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Christiansen 1997
27
2.87 (2.34)
15
4.36 (2.21)
29.3 %
-0.64 [ -1.28, 0.01 ]
Hughes 1991
44
2.23 (0.96)
45
2.04 (0.88)
70.7 %
0.20 [ -0.21, 0.62 ]
100.0 %
-0.04 [ -0.39, 0.31 ]
100.0 %
-0.03 [ -0.73, 0.68 ]
100.0 %
-0.03 [ -0.73, 0.68 ]
100.0 %
-0.52 [ -1.08, 0.04 ]
100.0 %
-0.52 [ -1.08, 0.04 ]
Subtotal (95% CI)
71
60

LeBaron 1985
Subtotal (95% CI)
15
-8.87 (1.64)
15
16
-8.81 (2.46)
16

3 Unclear Severity
Talabere 1993
Subtotal (95% CI)
25
-49.68 (6.87)
25
25
-45.86 (7.57)
25

-4
-2
Favours education

Favours control
174
Analysis 9.12. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 12 General
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Hughes 1991
44
0.59 (1.75)
45
1.47 (1.75)
62.3 %
-0.50 [ -0.92, -0.08 ]
Rubin 1986
29
2.8 (4.3)
25
4.5 (2.7)
37.7 %
-0.46 [ -1.00, 0.08 ]
100.0 %
-0.48 [ -0.82, -0.15 ]
100.0 %
0.06 [ -0.26, 0.37 ]
100.0 %
0.06 [ -0.26, 0.37 ]
Subtotal (95% CI)
73
70

Evans 1987
Subtotal (95% CI)
93
3.6 (6.2)
93
68
3.3 (3.8)
68

3 Unclear Severity
Charlton 1994
42
2.3 (8.1)
37
2 (7.4)
25.2 %
0.04 [ -0.40, 0.48 ]
Holzheimer 1998
16
3 (6.63)
15
7.87 (6.63)
9.2 %
-0.72 [ -1.45, 0.01 ]
101
1.63 (2.28)
104
1.86 (4.24)
65.6 %
-0.07 [ -0.34, 0.21 ]
100.0 %
-0.10 [ -0.32, 0.12 ]
Shields 1990
Subtotal (95% CI)
159
156

-1
-0.5
Favours education

0.5
Favours control
175
Analysis 9.13. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 13 ED Visit (%
patients).
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Hughes 1991
13/44
11/45
52.3 %
1.30 [ 0.51, 3.31 ]
Persaud 1996
4/18
9/18
47.7 %
0.29 [ 0.07, 1.21 ]
62
63
100.0 %
0.81 [ 0.38, 1.74 ]
36/63
31/51
100.0 %
0.86 [ 0.41, 1.82 ]
63
51
100.0 %
0.86 [ 0.41, 1.82 ]
7/96
7/105
22.2 %
1.10 [ 0.37, 3.26 ]
Mitchell 1986
26/133
10/126
29.5 %
2.82 [ 1.30, 6.12 ]
Shields 1990
24/101
18/104
48.3 %
1.49 [ 0.75, 2.95 ]
330
335
100.0 %
1.80 [ 1.14, 2.84 ]
M-H,Fixed,95% CI
Subtotal (95% CI)


Toelle 1993
Subtotal (95% CI)

3 Unclear Severity
Madge 1997
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

176
Analysis 9.14. Comparison 9 Self-management vs. Usual Care by Asthma Severity, Outcome 14 ED Visits
(mean).
Review:

Study or subgroup
Education
Control
Mean(SD)
Mean(SD)
63
1.51 (2.31)
51
1.67 (2.4)
Weight
IV,Fixed,95% CI

IV,Fixed,95% CI
Toelle 1993
Subtotal (95% CI)
63
51
100.0 %
-0.07 [ -0.44, 0.30 ]
100.0 %
-0.07 [ -0.44, 0.30 ]

Alexander 1988
11
0.6 (0.9)
10
2.4 (2.1)
3.7 %
-1.09 [ -2.02, -0.16 ]
Christiansen 1997
27
0.3 (1.2)
15
0.2 (0.43)
8.1 %
0.10 [ -0.53, 0.73 ]
Fireman 1981
13
0.08 (1.14)
13
1 (1.14)
5.0 %
-0.78 [ -1.58, 0.02 ]
Hughes 1991
44
0.45 (1.05)
45
0.6 (1.05)
18.6 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
2.3 (2.98)
28
3.71 (2.98)
14.5 %
-0.47 [ -0.94, 0.00 ]
Persaud 1996
18
0.27 (0.57)
18
1 (1.2)
7.0 %
-0.76 [ -1.44, -0.08 ]
114
0.07 (0.32)
95
0.23 (0.78)
43.1 %
-0.28 [ -0.55, 0.00 ]
100.0 %
-0.34 [ -0.52, -0.16 ]
Ronchetti 1997
Subtotal (95% CI)
275
224

3 Unclear Severity
Clark 1986
McNabb 1985
Shields 1990
Talabere 1993
Subtotal (95% CI)
159
1.72 (4.2)
73
2.49 (6.26)
43.0 %
-0.16 [ -0.43, 0.12 ]
1.9 (4.72)
7.4 (4.72)
2.5 %
-1.09 [ -2.24, 0.06 ]
101
0.54 (1.68)
104
0.38 (1.68)
44.1 %
0.09 [ -0.18, 0.37 ]
25
0.44 (0.77)
25
1.08 (1.32)
10.3 %
-0.58 [ -1.15, -0.02 ]
100.0 %
-0.11 [ -0.29, 0.07 ]
292
209

-1
-0.5
Favours education

0.5
Favours control
177
Review:

Study or subgroup
Education
Control
Odds Ratio
n/N
n/N
M-H,Fixed,95% CI
Weight
Odds Ratio
Alexander 1988
1/11
4/10
42.6 %
0.15 [ 0.01, 1.68 ]
Hughes 1991
6/44
6/45
57.4 %
1.03 [ 0.30, 3.46 ]
55
55
100.0 %
0.65 [ 0.23, 1.84 ]
8/96
26/105
43.1 %
0.28 [ 0.12, 0.65 ]
55/178
45/190
56.9 %
1.44 [ 0.91, 2.29 ]
274
295
100.0 %
0.94 [ 0.64, 1.38 ]
M-H,Fixed,95% CI
Subtotal (95% CI)


2 Unclear Severity
Madge 1997
Mitchell 1986
Subtotal (95% CI)

0.01
0.1
Favours education
10
100
Favours control

178
Review:

Study or subgroup
Education
Control
Weight
IV,Fixed,95% CI
Mean(SD)
Mean(SD)
IV,Fixed,95% CI
Alexander 1988
11
0.09 (0.3)
10
0.6 (0.84)
8.0 %
-0.79 [ -1.69, 0.10 ]
Christiansen 1997
27
0.03 (1.4)
15
0.25 (0.98)
16.1 %
-0.17 [ -0.80, 0.46 ]
Fireman 1981
13
0 (0.38)
13
0.31 (0.38)
10.0 %
-0.79 [ -1.59, 0.01 ]
Hughes 1991
44
0.45 (0.77)
45
0.56 (0.77)
37.1 %
-0.14 [ -0.56, 0.27 ]
Lewis 1984
48
0.27 (0.76)
28
0.6 (0.76)
28.9 %
-0.43 [ -0.90, 0.04 ]
100.0 %
-0.35 [ -0.60, -0.09 ]
Subtotal (95% CI)
143
111

2 Unclear Severity
Clark 1986
175
0.11 (0.43)
81
0.21 (0.85)
34.6 %
-0.17 [ -0.43, 0.10 ]
Mitchell 1986
178
0.5 (1.28)
190
0.33 (0.96)
57.5 %
0.15 [ -0.05, 0.36 ]
Talabere 1993
25
0.08 (0.28)
25
0.12 (0.33)
7.8 %
-0.13 [ -0.68, 0.43 ]
100.0 %
0.02 [ -0.14, 0.17 ]
Subtotal (95% CI)
378
296

-1
-0.5
Favours education
0.5
Favours control
WHATS NEW
Last assessed as up-to-date: 31 July 2002.
Date
Event
Description
23 July 2008
Amended
Converted to new review format.

179
HISTORY
Protocol first published: Issue 3, 1996
Review first published: Issue 1, 2003
Date
Event
Description
1 August 2002
New citation required and conclusions have changed
Substantive amendment
CONTRIBUTIONS OF AUTHORS
Dr. Wolf contributed to the original design of this systematic review, the selection of studies for eligibility, data coding and analysis,
and the writing and editing of the text. Dr. Guevara contributed to the selection of studies for eligibility and the writing and editing of
the text, coded the studies, and performed the data analyses. Dr. Grum contributed to the original design of this systematic review, the
selection of studies for eligibility, and the writing and editing of the text. Dr. Clark contributed to the original design of this systematic
review and the writing and editing of the text. Dr Cates contributed to the data analysis and the methodology of the review.
DECLARATIONS OF INTEREST
None known
SOURCES OF SUPPORT
Internal sources
No sources of support supplied
External sources
Fogerty International Center, National Institutes of Health, Grant number NIH 1 F06 TW02123, USA.
National Heart, Lung, and Blood Institute, Grant number NIH 1 K07 HL 03046, USA.
Garfield Weston Foundation, UK.
INDEX TERMS
Medical Subject Headings (MeSH)
Patient Education as Topic; Self Care; Adolescent; Asthma [physiopathology; therapy]; Controlled Clinical Trials as Topic; Program
Evaluation; Randomized Controlled Trials as Topic

180
MeSH check words

Child; Child, Preschool; Humans

181

Educational Interventions For Asthma in Children

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Educational interventions for asthma in children (Review)

Wolf F, Guevara JP, Grum CM, Clark NM, Cates CJ