Wee Wheezers Asthma Education Program

Implemented in Darnell Army Community Hospital, Ft. Hood, Texas by MAS Consultants Inc., P.O. Box 5130 Aiken, South Carolina 29804.

Wee Wheezers: Research Base

Introduction

The pediatric asthma education program known today as Wee Wheezers: An Asthma Education Program for Parents of Young Children has been in existence since 1995. The program grew out of original asthma research, and it has been fully developed into a complete educational package. The program targets parents of children under the age of seven years who have asthma. It is designed for delivery in connection with a community-based asthma initiative. Departments of Health, research studies, hospitals, medical centers, and primary care providers also may use the program.

Investigators seeking to better understand the behaviors of parents whose infants and young children have asthma received a grant from the National Heart, Lung and Blood Institute of the National Institutes of Health. The grant proposal outlined tasks supporting the study of parents’ asthma management practices and whether behaviors could be changed. This work was published by S.R. Wilson, J.H. Mitchell, S. Rolnick and L. Fish in a manuscript titled "The Effective and Ineffective Management Behaviors of Parents of Infants and Young Children With Asthma" in 1993 in volume 18 of the Journal of Pediatric Psychology. The proposal also included development of an asthma education program to be tested in a clinical trial to determine the effectiveness of education in changing parents’ management behaviors. Investigators carried out this study in the early 1990s. The trial was described in detail by S.R. Wilson, D. Latini, N.J. Starr and others in "Education of Parents of Infants and Very Young Children with Asthma: A Developmental Evaluation of the Wee Wheezers Program" that was published in 1996 in volume 33 of the Journal of Asthma.

Wee Wheezers is based on the premise that many families of very young children experience significant stress related to the child’s asthma. This premise suggests that families need help in coping with the asthma when the disease first becomes apparent. Furthermore, because ineffective asthma management practices of parents of very young children can result in life-threatening and even fatal consequences, parents need sound education about asthma directed at improving the manner in which they manage this disease at home. Changing the way parents manage their children’s asthma requires addressing various underlying attitudinal and situational factors that often present barriers to more effective practices. Such factors may include denial of the child’s illness by one or both parents, fears about routine use of medications, tobacco use, and issues related to family pets.

In 1995, Dr. Sandra Wilson and colleagues conducted a randomized control trial of the Wee Wheezers asthma education prototype for parents with children aged less than 7 years who had asthma. This program comprised two brief educational sessions for children aged 5 and 6 years. The behavior change strategies used in Wee Wheezers were derived from psychological principles embodied in Bandura’s social cognitive theory, which includes the construct of self-efficacy as a determinant of behavior. (Self-efficacy refers to one’s belief in his/her ability to perform a task effectively as a prerequisite to undertaking that task.) The in-class practice, behavioral contracts, and at-home activities were structured to ensure successful completion by all class members, thus enhancing self-efficacy and promoting the willingness to try other new behaviors. The small group format also facilitated vicarious mastery experience, modeling, social comparison, and information sharing.

The clinical trial demonstrated the asthma education to be effective in helping parents to manage their children’s asthma better. Subsequently, the researchers fully documented the education program (including a complete asthma curriculum with instructor guide, scripted lesson plans, visual aids, and handouts) so that it could be implemented in other settings.

The following sections present the goals of this intervention, educational content, evaluation design, important characteristics of the study population, and results of the intervention.

Goals of the Intervention Research

Wee Wheezers addresses a void in asthma self-management education programs, namely the lack of appropriate education for parents with infants and young children with asthma. Despite the unique medical and developmental needs of young asthma patients and their parents, no educational program existed in the early to mid-1990s that was especially designed for parents of children under age 4. Thus, Wee Wheezers was developed specifically to meet the educational needs of parents with children under age 7. Specifically, program goals aimed to give parents the knowledge, skills, and motivation to:

• Prevent asthma symptoms
• Appropriately manage symptoms
• Use medical, educational, and interpersonal resources appropriately for asthma care
• Communicate effectively with all adults responsible for the child’s care
• Promote the psychosocial well-being of the family unit

Intervention Research

Educational Content of the Intervention
The educational package is composed of four small-group sessions of approximately 2 hours each, conducted at 1-week intervals by nurses experienced in the management of pediatric asthma. The parents of children aged less than four years and 4-6 years met in separate groups.

The four educational sessions for adults covered the following topics:

• Basic concepts of asthma: epidemiology and physiology
• Coping in a crisis: fears of having a child with asthma and fear of taking the child to the emergency department
• Action plan for asthma management: recognition of early warning signs, use of the peak flow meter, asthma medications
• Symptoms of an acute episode: treatment of early symptoms, and appropriate time to seek medical help
• Feelings about having a child with a chronic health problem
• Prevention of symptoms: trigger identification and control, use of preventive medications
• Communication about asthma with teachers, child-care workers, physicians, family

The parents and children ages 4-6 years together attended the first 45 minutes of the adult sessions 3 and 4. These sessions covered the following topics:

• Asthma physiology
• Early warning signs and symptoms
• Asthma medications
• Belly breathing
• Asthma self management and triggers
• Use of the metered-dose inhaler

The children were then cared for in a separate room while their parents completed the adult sessions, lasting about 90 minutes.

Evaluation Design
Data collection instruments (questionnaires, 2-week symptom-medication diaries, physical examination forms, and medical record abstraction forms) were used to collect information from parents about each child at enrollment in the program and at a 3-month follow-up visit. The primary clinical endpoints were selected to reflect asthma status in a population primarily of children too young for reliable standard pulmonary function testing. The following outcome measures were used to detect changes in the children’s asthma condition and to assess disease management practices.

• Number of days in which the child was free of asthma symptoms in the preceding 2 weeks and in the preceding month
• Number of nights in which the parents’ sleep was interrupted because of the child’s asthma during a typical week
• Degree to which the child was bothered by symptoms of asthma in the preceding month
• Number of days the child was sick at home because of asthma during the preceding month
• Frequency with which parents performed each of 17 asthma symptom management and prevention practices using a 5-point scale ranging from 1 (almost always) to 3 (sometimes) to 5 (rarely)
• Frequency with which parents rated how much of the time they had each of 16 feelings about their child’s asthma and its effect on the child and the family using a 5-point scale ranging from 1 (almost never) to 3 (about half the time), to 5 (most of the time)

Recruitment and Characteristics of the Study Population
To recruit participants for the study, researchers identified and screened children and their families from the medical records of members of the Aspen Medical Group, Minneapolis, Minnesota and patients of St. Paul Children’s Hospital in St. Paul, Minnesota. Eligibility criteria for children included 1) age 1-6.5 years, 2) patient of the medical group for at least the preceding year and had been hospitalized, 3) documented history of airways obstruction that was reversible with bronchodilator treatment, and 4) mention of any anti-asthma medications.

A computer search of potential participants meeting the age and medical diagnosis requirements identified 129 eligible families, of which 76 agreed to participate and were enrolled in the program. Families were randomly assigned to the education group (41) or the control group (35). The children were predominantly white (minorities accounted for less than 11%) and from middle class families of educated parents (52% of mothers were college educated). Sixty-four percent were boys, and the average age of the children was 3.8 years. The children’s asthma severity was determined on the basis of a medication regimen: 31% with mild asthma, 54% with moderate asthma, and 18% with moderately severe or severe asthma. Eighty-one percent of the children were in generally excellent health, and 19% were in good health.

Research Results

The intervention improved three measures of asthma symptoms. Morbidity among children in the intervention group increased less between baseline and follow-up (and in some cases, actually showed a decrease) than did that of controls. The mean number of symptom-free days in the preceding 2 weeks increased in the intervention group from 8.5 to 10.2 and decreased in the control group from 11.9 to 9.3. Likewise, the number of symptom-free days in the preceding month increased from 20.2 to 22.2 in the intervention group and decreased from 24.6 to 20.8 in the control group.

The impact of the education intervention also was evident in parental sleep interruption. The increase in the number of nights of parental sleep interruption at follow-up was significantly greater in the control group than in the intervention group, although both groups showed significant increases between enrollment and follow-up. At enrollment, intervention and control group parents averaged, respectively, 0.6 and 0.8 nights of sleep interruption in a typical week. Sleep interruption more than tripled at the follow-up: to 2.6 nights per week for the control group compared with an increase to only 1.3 nights per week for the intervention group – less than twice their baseline (summer) rate.

Parents rated how much their children had been bothered by asthma in the preceding 3 months and the mean number of reported days the children were sick because of asthma during the preceding month. Pre- and post-intervention changes did not differ significantly between the two groups.

Research Funding

The development and evaluation of Wee Wheezers was supported by Grant #R01 HL41819 from the Division of Lung Diseases, National Heart, Lung and Blood Institute, National Institutes of Health. Upon validation of the Wee Wheezers program, the principal investigator, Dr. Sandra R. Wilson, of the Palo Alto Medical Foundation Research Institute (PAMFRI), Palo Alto, California, acquired copyright for the educational package. In 1997, the copyright was transferred to PAMFRI.