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School-based self-management interventions for asthma among primary school children: a systematic review

School-based self-management interventions for asthma among primary school children: a systematic... www.nature.com/npjpcrm ARTICLE OPEN School-based self-management interventions for asthma among primary school children: a systematic review 1,2 1 3 1 1 2 Siti Nurkamilla Ramdzan , Julia Suhaimi , Katherine M. Harris , Ee Ming Khoo , Su May Liew , Steve Cunningham and Hilary Pinnock A Cochrane review of school-based asthma interventions (combining all ages) found improved health outcomes. Self- management skills, however, vary according to age. We assessed effectiveness of primary school-based self-management interventions and identified components associated with successful programmes in children aged 6–12 years. We updated the Cochrane search (March 2020) and included the Global Health database. Two reviewers screened, assessed risk-of-bias and extracted data. We included 23 studies (10,682 participants); four at low risk-of-bias. Twelve studies reported at least one positive result for an outcome of interest. All 12 positive studies reported parental involvement in the intervention, compared to two- thirds of ineffective studies. In 10 of the 12 positive studies, parental involvement was substantial (e.g. attending sessions; phone/video communication) rather than being provided with written information. School-based self-management intervention can improve health outcomes and substantial parental involvement in school-based programmes seemed important for positive outcomes among primary school children. npj Primary Care Respiratory Medicine (2021) 31:18 ; https://doi.org/10.1038/s41533-021-00230-2 INTRODUCTION RESULTS Asthma, the commonest long-term condition among children, Figure 1 illustrates the article selection process using the PRISMA causes significant morbidity and mortality globally . Asthma guide- diagram. We included 23 studies; 16 studies from the Cochrane 13–28 29–33 review , five studies from the updated database search and lines recommend supported self-management to improve asthma 34,35 2–4 two studies from the pre-publication update . The total number control and reduce the use of urgent healthcare services . of participants was 10,682. Some studies did not report numbers in Supported self-management, which includes discussion about self- 13,14,24 each group so we cannot provide number by allocation .We management and provision of a personalised asthma action plan contacted all authors for information not reported in the papers, and supported by regular asthma review, can be delivered effectively in 13,14,25,27,29,30,32–34 5,6 nine (39%) responded . diverse cultural and demographic groups . School-based asthma self-management interventions have been reported to improve asthma control and reduce school Characteristics of included studies 7–11 absenteeism and asthma exacerbations . However, most The interventions were conducted from 1992 to 2019. Seventeen systematic reviews analysed combined data from primary and studies were randomised controlled trials (RCTs) (14 cluster 7–10 13–15,18–26,31,32 27,29,34 secondary schools (5–18 years) . One scoping review con- RCT , three individual RCTs ), three were non- 28,30,35 randomised studies and three were uncontrolled pre-and- ducted in 2014 focused on primary school children, but the aim 16,17,33 post studies . Fifteen studies were conducted in the United was to identify research gaps rather than assess outcomes . The 15–18,21,23–25,27–31,34,35 13,14,19,20 States , four in Canada , one each in Cochrane review (Harris, 2019) used meta-analyses to assess 32 26 Spain and United Kingdom , and two in low- and middle- intervention effectiveness and qualitative comparative analysis to 22,33 17 7 income countries (China and Thailand) . All but one of the examine the components of successful implementations . The studies in the United States were conducted in minority authors identified a number of components as being important: 15,16,18,21,23–25,27–31,34,35 populations , two Canadian studies were theoretical underpinning, parental involvement, child satisfaction 19,20 conducted in majority population ; none of the and conducting the intervention during lesson time. However, the 13,14,22,26,32,33 others reported ethnicity of population studied. Cochrane review included interventions directed at children and adolescents (5–18 years), and did not distinguish the components Overall intervention characteristics associated with effective interventions in primary school children, The programmes were used to deliver self-management intervention which may differ from adolescents . Educational intervention varied. Eight studies used standard programmes (Open Airway for needs to be age-appropriate as primary school children will have 15,17,21–24,28,29 School (OAS) or tailored OAS ,fourstudies used Roaring less autonomy and capability to self-manage asthma compared to 13,14,19,20 12 Adventures of Puff (RAP) or tailored RAP , and the other adolescents . Thus, we aimed to review the effectiveness of 16,18,25–27,29–35 studies developed novel interventions . The programmes school-based self-management interventions for primary school ranged from one to eight sessions, and all were delivered by children with asthma and to examine the components associated healthcare personnel, (school nurse, asthma educator, community with successful programmes. nurse, respiratory therapist, physician) except for two that were 1 2 Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, University of Edinburgh, Edinburgh, UK. Centre for Child Health, Blizard Institute, Queen Mary University of London, London, UK. email: Hilary.Pinnock@ed.ac.uk Published in partnership with Primary Care Respiratory Society UK 1234567890():,; SN Ramdzan et al. 1484 records identified from forward and 1306 records identified backward citation of studies included in from databases 7 the Cochrane review 117 records removed after de- duplication 140 records removed after de-duplication 36 records removed as studies were already included/excluded in the Cochrane review 2497 titles and abstract screened 2448 records excluded (did not meet 55 studies from the criteria, duplicates) Cochrane review 104 records screened for full text 83 records excluded 29 not primary education children 23 no outcome of interest 11 non self-management education school-based intervention 11 non-experimental 5 duplicates 4 proceeding/thesis 21 records 2 from pre-publication update (forward citation of 21 studies and the Cochrane review ) 23 records included Fig. 1 PRISMA diagram. This figure illustrates the article selection process using the PRISMA diagram. 22,32 delivered by trained school teachers . Fifteen studies delivered the Effectiveness of interventions 13–17,19–26,28,34 intervention in group sessions , four used individual face- The effect of the interventions on each outcome of interest is 27,29,30,35 to-face sessions , one used individual computer-assisted detailed in Supplementary Table 1, with an explanation of how 18 31 programme and another used individual telemedicine sessions . the direction of the effect was interpreted and the overall effect of 23,33 Two studies were unclear . the study assessed. Twelve studies (two at low risk-of-bias) were assessed as having an overall positive (beneficial) 13–17,21,22,29,30,33–35 effect and eleven studies (two at low risk-of- 18–20,23–28,31,32 Risk of bias in the included studies bias) as having no effect . No study was categorised as harmful or mixed effect. The Harvest plot (Fig. 2) illustrates the The overall RoB is given in summary Supplementary Table 1 (first effect of varying degrees of parental involvement on school column) and illustrated in the Harvest plot (Fig. 2). Details of the absenteeism, asthma control and urgent healthcare use. RoB are in Supplementary Table 2. Four studies had low overall 13,14,20,32 15–17,21,27–30,33–35 risk of bias , eleven had high risk of bias 18,19,22–26,31 Study components according to CFIR sub-domains and eight were unclear . Only seven (30%) studies were categorised at low risk in random sequence genera- The CIFR domains addressed in the studies are summarised in 13,14,20,21,23,32,34 13 tion . All uncontrolled studies were categorised as column 2 in Supplementary Table 1. Cicutto et al. was the only high-risk in four domains (random sequence generation, alloca- study that explicitly addressed all the CFIR sub-domains in their tion concealment, baseline outcome similar and baseline char- intervention; in contrast, Spencer et al. addressed only two sub- 16,17,33 acter similar) . domains. All included studies used and measured the impact of at npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK 1234567890():,; SN Ramdzan et al. Urgent healthcare service (e.g. no of Asthma control (e.g. symptoms, School absenteeism emergency visits, days of asthma category, PEFR) (e.g. no of days absent from school) hospitalisation, unscheduled visits) Positive Positive Negative No effect Negative Positive Negative No effect No effect - - ? ? ? ? Substantial ? - + - - - + parental ? ? ? - ? involvement - - - ? ? - - - Minimal parental - - involvement - No parental - - - involvement - Longest duration Longest duration Longest duration To indicate that the outcomes (13 - 24 months) (7 - 12 months) (<7months) were not all consistent The height of the bars describes the number of participants The overall risk of bias within the study is relected on top of the bars ( Low, - high, ? unclear) Fig. 2 Harvest plot illustrating effectiveness of included studies across parental involvement. Harvest plot illustrating the effectiveness on school absenteeism, asthma control and urgent healthcare services across parental involvement for school-based self-management asthma educational intervention. The shading of the bars indicates the duration of the study and the height of the bars describes the number of participants. The overall risk of bias is reflected on top of the bars. least one specific component in their intervention, e.g. information school, had positive effects in school absenteeism and urgent provision assessed as improvement of knowledge and self- healthcare service use at 12 months. No difference was found in management behaviour. The other commonly addressed sub- other CFIR subdomains between studies with positive and no 13–25,29–31,33–35 domain was parental involvement (19/23) , though effects. this varied in intensity (We use the term ‘parents’ to describe parents, guardians or other care-givers). See Supplementary Table DISCUSSION 3 for definitions of involvement. Some studies had substantial We identified 23 studies (four at low RoB) that evaluated the involvement e.g. parents attending session or actively involved 13–15,17,19–22,24,25,29–31,33,35 effectiveness of school-based asthma self-management interven- in phone/video communication , while tion among primary school children. Twelve of the studies were others had minimal parental involvement e.g. passive information 16,18,23,29,34 categorised as being overall positive, though individual outcomes in a letter . Ten studies used theory to guide the varied; no study reported overall negative impact. The number of development of the interventions; six used social cognitive 13,14,18–20,22 28,34 CFIR sub-domains addressed varied between studies, but the only theory , two used Orem self-care theory , one used component that seemed to be associated with positive outcomes life stress model , and another was guided by Bruhn’s theoretical was substantial parental involvement. This was particularly model . Nine studies considered access to healthcare of their 13–15,24,25,27,30,32,33 apparent in studies at low RoB. study population . We found substantial parental involvement to be a crucial component of a school-based asthma self-management interven- Association of CFIR sub-domains and effectiveness tion among primary school children. Reviews that included Tables 1 and 2 are summary matrices comparing use of the 12 interventions targeted at teenagers, in whom parental influence CFIR sub-domains in studies with overall positive or no effect (See might be expected to be less important, have reached similar 7,8 Supplementary Table 4 for more detail). The number of CFIR sub- conclusions . Parental involvement was also found to be domains used varied widely (2 to 12) and was similar in the studies important in other school-based interventions for obesity preven- 36,37 38 with positive/no effect. tion studies , self-management of mental health/disorders , All studies with positive effects (12/12) reported parental and academic enhancement . 13–17,21,22,29,30,33–35 involvement in their intervention compared to However, we did not find other components of interventions 18–20,23–25,31 seven studies with no effects (7/11) . The Harvest plot (theory-driven, conducted during lesson time, and child satisfac- (Fig. 2) illustrates the direction of effect with the varying degrees of tion) to be essential for successful intervention, as was found in parental involvement of each study intervention. Studies without the Cochrane review . The differences in the findings were most parental involvement (including one at low RoB ) showed no probably due to a difference in the age group of the children as 26–28,32 effect in any of the outcomes of interest . Of the five the Cochrane review included studies among older school 16,18,23,29,34 interventions with minimal parental involvement , the children. Our review defined fun, interactive delivery of interven- three positive studies were at high RoB and of short duration tion, as a strategy promoting child satisfaction and engagement, (≤ 6 months), and either small in sample (study population less whereas the Cochrane review examined measurement of child 29,34 16 than 100 children) or pre/post design . Studies with satisfaction, an evaluation used mainly in studies targeting 13–15,17,19–22,24,25,29–31,33,35 7 substantial parental involvement were adolescents . Primary school children had good participation the only studies to report reduction in absenteeism, though rates when the sessions were conducted during school hours impact on clinical outcomes varied. Cicutto et al. (cluster RCT at including during recess, in contrast to adolescents who were less 7,13,16 low risk of bias, 170 schools and 1316 children), an example of a willing to devote their free time including during recess . study that included parents in care coordination and a showcase at Social cognitive and Orem self-care theories were the most used Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2021) 18 + + + SN Ramdzan et al. theories, adapted from adults which focuses on self-efficacy and 40–42 skills of individuals . These theories may be suitable for interventions targeting parents and adolescents, but may not be age-appropriate for primary school children with limited decision- 12,43 making abilities and independent self-management skills . Primary school years are a critical time for children as they spend increasing time away from their parents and begin to learn 44,45 asthma self-management for themselves . Six-year-old children can express opinions, typically reflecting their parents’ actions and views . Over primary school years, they learn from their own experiences and gain the confidence to make independently 44,45 decisions . Although involving parents to support and empower their children’s self-management behaviour is a key 2,3 concept in the clinical management of children , direct parental involvement was not always included in school-based interven- 27,28,32 tion among primary school children . A key challenge for involving parents is the difficulty of engaging them to attend 24,46 session(s) delivered in school . With the ease of modern telecommunication, alternative methods of engagement such as the use of telephone calls or video sessions could be explored as a convenient alternative to enable substantial parental involvement 31,47 in the intervention . Although parental involvement is important, an aim of a school- based intervention is to shift the focus of self-management 48,49 education from parents to children . Studies in this review included up to eight educational sessions for children compared 13,27,30 to only one to two sessions for parents . A recent school- based health intervention has recommended the socio-ecological theory where children are the primary focus of an intervention that also involves the children’s social network, e.g. parents, 48,50 teachers, friends and the school plan/policy . Schools could be an ideal setting for this approach, smoothing children’s transition to independent self-management by being located in the child’s environment and including parents as part of the children’s social 51–53 network . Schools also provide a platform for interactive fun groups activities and peer support for children with similar conditions, which could reduce stigma and support self- 13,32 management practices . The effectiveness of self-management also depends on access and adherence to evidence-based treatments such as controller asthma medications, which is conventionally delivered in health- 2,5 care settings . ‘Access to healthcare’, however, was a sub-domain least likely to be addressed in the studies included in this review. Although most US-based studies were conducted among minority deprived populations, in whom poor health outcomes may be due to the large disparities in healthcare provision , only five studies reported the access of the children to effective controller 15,24,25,27,30 medication . Even in countries with universal health coverage, such as Canada and United Kingdom, equitable access to high quality healthcare for children cannot be assumed .In low- and middle-income countries, socio-cultural beliefs, physical inaccessibility and lack of education and information are extremely common barriers to healthcare despite universal health 56,57 coverage . Similar barriers are widely described in the 30,31,34 US . Encouragingly, bridging school-based education with the children’s healthcare providers has been a core component of 53,58 recent school-based interventions . A strength of this review is that we used comprehensive search terms similar to the Cochrane review and searched seven relevant databases. Two reviewers conducted full text screening and data collection was duplicated. A pre-publication update was per- formed to ensure the findings was up to date this review. This review has some limitations. Despite a rigorous search strategy, it is possible that we may miss some studies. The screening of title and abstract was conducted by one reviewer, but good agreement resulted after training. Only two studies were conducted in low- and middle-income countries and many studies (15/23) were conducted in the US, reducing generalisability of the npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK Table 1. Summary matrix comparing 12 sub-domains of CFIR in overall positive studies. CFIR domains and subdomains Cicutto Cicutto Clark Clark, Isik Levy Magzamen Marsland Marsland Simoneau, Spencer Suwannakeree Szetler Total with 2005 2013 2004 2005 2020 2006 2008 2019 (ICC) 2019 (OAS) 2020 2000 2016 2019 this domain Intervention Theory-driven ✓✓ ✓ ✓ ✓ 5 characteristics Evidence-based ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ 8 Stakeholder involvement ✓✓ ✓ ✓ ✓ ✓ ✓ 7 Tailored ✓✓✓ ✓ ✓ ✓ ✓ ✓ 8 Outer setting Substantial parental involvement ✓✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 10 Minimal parental involvement ✓✓ ✓ 3 Access to asthma care ✓✓ ✓ ✓ ✓ 5 Coordination with child’s health provider ✓✓ ✓ ✓ ✓ ✓ 6 Inner setting School participation ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ 8 Done during school hours ✓✓ ✓ ✓ ✓ ✓ ✓ 7 Individual Measurement of knowledge, skill or practice ✓✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 12 characteristics Process Fidelity ✓✓ ✓ ✓ ✓ 5 Child satisfaction ✓✓ ✓ ✓ ✓ ✓ ✓ 7 Total sub-domains met in individual study 11 12 4 7 9 6 6 8 6 5 2 8 11 2–12 (range is in final column) SN Ramdzan et al. review. The included studies were variable in methodologies, instrumentation and data analysis. However, three low RoB studies coincided with the findings and some variability was illustrated in the Harvest plot with the other details described in Supplemen- tary Table 1. Poor reporting of interventions was a challenge and we may have overlooked some intervention components that were not explicitly described. We contacted all the authors to reduce the number of missing information and obtained 39% responses. A multi-level intervention focusing on the children and involving their social network could provide a useful self- management interventions framework for primary school children and their parents. Specifically, there is a gap in our current understanding of school-based self-management education in younger children in low- and middle-income countries. Future research needs to focus on implementation strategies and effectiveness using this framework. Partnership between schools, parents and healthcare services could create a pragmatic and effective school plan/policy to improve asthma control among children. School-based self-management interventions for asthma among primary education children can improve asthma outcomes and reduce absenteeism. Parental participation is an important component in this age group, but other features highlighted in secondary school interventions proved less relevant, perhaps reflecting the greater role of parents in younger children. METHODS This systematic review follows Cochrane methodology , and PRISMA reporting standards. The protocol is registered with the PROSPERO database (registration number: CRD42019131955). Study eligibility criteria We used a Population, Intervention, Comparator/Control, Outcomes and Study Design (PICOS) strategy to define eligible studies (Table 3) , using 3,7,61 definitions similar to the Cochrane review . Self-management inter- vention was defined as the active transfer of information to children with asthma to enhance their self-management skills; this was interpreted with reference to components of self-management recommended by global 2,3 guidelines (Table 3) . In line with the Cochrane review, we included non- randomised trials to capture a broader range of studies and thence components used. Outcomes of interest We chose three outcomes of interest (school absenteeism and two health outcomes - asthma control and urgent use of healthcare services) to reflect 2,7,61 the impact on children with poorly controlled asthma . Search strategy The details of the search terms and databases used are in Supplementary Table 5. The Cochrane review conducted searches in August 2017 using search terms developed by the Cochrane Airway Information Specialist in 23 electronic databases from 1995 onwards and included 55 papers . Using the same search terms, with no language limitations, we updated the search in February 2019 in six-core databases (CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, AMED) . In addition, we searched the Global Health database using similar search terms without date limits to include studies from low- and middle-income countries. We included all studies identified in the review that met our eligibility criteria (principally excluding those not delivered to primary school children). We checked the reference list and undertook forward citation of studies in the Cochrane review conducted among primary school children . A pre-publication update was conducted on 17th March 2020 using forward citation of the Cochrane review (published 28 January 2019) and all the studies included in this review . Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2021) 18 Table 2. Summary matrix comparing 12 sub-domains of CFIR in no effect studies. CFIR domains and subdomains Bartholomew Clark Clark 2010 Gerald Horner McCann McGhan McGhan Praena-Crespo Perry Persaud Velsor-Friedrich Total with 2006 2010 (OAS) (OAS plus) 2006 2016 2000 2003 2010 2016 2018 1996 2005 this domain Intervention Theory-based ✓✓ ✓✓ ✓ 5 characteristics Evidence-based ✓✓✓✓✓✓ ✓✓✓ 9 Stakeholder involvement ✓✓ ✓ ✓ ✓ 5 Tailored ✓✓ ✓ ✓ ✓ ✓ ✓✓ ✓ 9 Outer setting Substantial parental ✓✓ ✓ ✓ ✓ 5 involvement Minimal parental ✓✓ 2 involvement Access to asthma care ✓✓ ✓ ✓ 4 Coordination with child’s✓✓ ✓✓✓ ✓✓✓ 8 health provider Inner setting School participation✓✓ ✓✓✓✓ ✓✓ 8 Done during school hours ✓✓ ✓ ✓ ✓ ✓ 6 Individual Measurement of ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓✓ ✓ 11 characteristics knowledge/skills/behaviour Process Fidelity ✓✓ ✓ 3 Child satisfaction ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 9 Total sub-domains met in individual study 84 6 8 10 6 7 7 9 7 9 7 4–11 (range is in final column) SN Ramdzan et al. Table 3. PICO study strategy and definition of terminology. Participant/population Children with asthma aged 6–12 years Intervention School-based self-management education intervention. Definition as active transfer of information to enhance self-management of asthma containing at least one of the 2,3 core-components of self-management education : � A basic explanation about asthma, triggers and the factors that influence control � Training about correct inhalation technique � Information on the importance of the child’s adherence to the prescribed medication regimen � Written asthma action plan Children with asthma had to be the primary target for the intervention, though others (such as peers without asthma, parents, school staff) could also be included. Comparator(s) Standard care or other (non-asthma, or not related to self-management or delayed intervention) education intervention or none Outcomes School absenteeism or/and asthma control or/and urgent use of healthcare service The definition of the three categories of outcomes of interest were guided by the American Thoracic Society/European Respiratory Society statement : 1. School absenteeism: Number of days a participant was absent from school (priority due to asthma). 2. Asthma control: Clinical level of asthma control based on symptoms and capability to perform daily activities measured using asthma symptoms questionnaire/asthma diary with/without objective validation of asthma control, e.g. peak flows or lung function test. 3. Urgent use of healthcare service: Number of an unscheduled visit to a general practitioner and/or emergency department due to asthma, and the number of days of hospitalisation due to asthma. Setting School (primary, elementary or middle school) Study designs Experimental study e.g., randomised controlled trial (RCT), cluster RCT, non-randomised study and uncontrolled before-and-after study. Study selection and data extraction We used a structured approach to divide the studies into four categories according to the change in the outcomes of interest . This was a two-step We imported the list of articles from the electronic databases into Endnote process. software (version 7) to facilitate screening, de-duplication and overall First, we determined the direction of effect in each of the three management of the results. SNR and JS independently screened a random outcomes of interest (school absenteeism; asthma control; urgent use of selection of 10% of the titles and abstracts . A 96.3% agreement was healthcare service) for each included study. In some studies, several achieved prior to discussion, which reached total agreement after measures mapped to each outcome of interest: for example, emergency clarification of the screening criteria. SNR then completed title and room visits and hospitalisation are both measures of unscheduled care abstract screening. Both reviewers independently conducted full-text potentially with conflicting findings. The rules at the top of Supplementary screening (which included all the studies in the Cochrane review and those Table 1 define how we prioritised outcomes defined as ‘primary’ in the satisfying title and abstract screening), met to discuss discrepancies and included study, outcomes measured with a validated instrument, and decided on the final included papers. Supplementary Table 6 lists studies results that were clinically as well as statistically significant. The table then excluded from this review. A modified Cochrane data extraction form was describes how the decision process was applied for each outcome of used for duplicate data extraction (SNR and JS) . SNR contacted authors interest in each study. for missing data by email and any further information received was added Second, we categorised the overall effect of the intervention in each to the data extraction forms . study as positive, negative, no effect or mixed effects, as follows: At all stages, any discrepancies not resolved by discussion between the two reviewers were arbitrated by the study team (HP, KEM, LSM, SC). Positive (beneficial): Studies with a positive effect in ≥1 of the outcomes and no negative effects. Negative (harmful): Studies with a negative effect in ≥1 of the Risk of bias of included studies outcomes and no positive effects. We used the Cochrane Effective Practice and Organisation of Care (EPOC) No effect: Studies with no positive effects in any of the outcomes. Risk of Bias (RoB) tool to categorise risk into low, high and unclear risk in Mixed: Studies with at least one positive and one negative outcome. nine domains, which were then used to generate an overall assessment of the RoB for each study. The Cochrane EPOC RoB tool applies to randomised trials and non-randomised trials . Studies with at least one high-risk domain were summarised as high risk; studies with no high-risk Data synthesis domains but at least one unclear domain were summarised as unclear risk Our preliminary scoping suggested that the studies would be and studies at low risk in all domains were summarised as low risk . heterogenous in terms of context, components delivered and study design, so we undertook a narrative analysis. We used a Harvest plot Data handling (coded to indicate number of participants, RoB and follow-up duration) to illustrate the effectiveness of the interventions on the three The Consolidated Framework for Implementation Research (CFIR) is a outcomes of interest for each study. A Harvest plot graphically displays comprehensive framework that systematically identifies factors (sub- not only outcomes but also the weight of the evidence in complex and domains) that influence the effectiveness of implementation in multi- diverse studies by illustrating selected methodological criteria .We level interventions . Supplementary Table 3 outlines the 12 CFIR sub- used a matrix to examine the association of the CIFR sub-domains with domains. We used CFIR sub-domains to identify context and components the overall effectiveness of the interventions. Supplementary Table 4 in each study (e.g., intervention characteristics, features of the setting and lists the CFIR sub-domains and how we interpreted them in our strategies for implementation) that might influence effectiveness of the 66,67 analysis. interventions . npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK SN Ramdzan et al. Reporting summary 21. Clark, N. M. et al. Effects of a comprehensive school-based asthma program on symptoms, parent management, grades, and absenteeism. Chest 125, 1674–1679 Further information on research design is available in the Nature Research (2004). Reporting Summary linked to this article. 22. Clark, N. M. et al. A trial of asthma self-management in Beijing schools. Chronic Illn. 1,31–38 (2005). 23. Clark, N. M. et al. An evaluation of asthma interventions for preteen students. J. DATA AVAILABILITY Sch. health 80,80–87 (2010). 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Using the Open Access This article is licensed under a Creative Commons Consolidated Framework for Implementation Research (CFIR) to produce Attribution 4.0 International License, which permits use, sharing, actionable findings: a rapid-cycle evaluation approach to improving imple- adaptation, distribution and reproduction in any medium or format, as long as you give mentation. Implement Sci. 12, 15 (2017). 68. Burns, J. et al. Looking beyond the forest: using harvest plots, gap analysis, and appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party expert consultations to assess effectiveness, engage stakeholders, and inform material in this article are included in the article’s Creative Commons license, unless policy. Res. Synth. Methods 9, 132–140 (2018). indicated otherwise in a credit line to the material. If material is not included in the 69. Ogilvie, D. et al. The harvest plot: a method for synthesising evidence about the article’s Creative Commons license and your intended use is not permitted by statutory differential effects of interventions. BMC Med. Res. Methodol. 8, 8 (2008). regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons. org/licenses/by/4.0/. ACKNOWLEDGEMENTS We would like to acknowledge all the authors of included studies who provided the information to aid in synthesising the data. We also acknowledge the RESPIRE © The Author(s) 2021 npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png npj Primary Care Respiratory Medicine Springer Journals

School-based self-management interventions for asthma among primary school children: a systematic review

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www.nature.com/npjpcrm ARTICLE OPEN School-based self-management interventions for asthma among primary school children: a systematic review 1,2 1 3 1 1 2 Siti Nurkamilla Ramdzan , Julia Suhaimi , Katherine M. Harris , Ee Ming Khoo , Su May Liew , Steve Cunningham and Hilary Pinnock A Cochrane review of school-based asthma interventions (combining all ages) found improved health outcomes. Self- management skills, however, vary according to age. We assessed effectiveness of primary school-based self-management interventions and identified components associated with successful programmes in children aged 6–12 years. We updated the Cochrane search (March 2020) and included the Global Health database. Two reviewers screened, assessed risk-of-bias and extracted data. We included 23 studies (10,682 participants); four at low risk-of-bias. Twelve studies reported at least one positive result for an outcome of interest. All 12 positive studies reported parental involvement in the intervention, compared to two- thirds of ineffective studies. In 10 of the 12 positive studies, parental involvement was substantial (e.g. attending sessions; phone/video communication) rather than being provided with written information. School-based self-management intervention can improve health outcomes and substantial parental involvement in school-based programmes seemed important for positive outcomes among primary school children. npj Primary Care Respiratory Medicine (2021) 31:18 ; https://doi.org/10.1038/s41533-021-00230-2 INTRODUCTION RESULTS Asthma, the commonest long-term condition among children, Figure 1 illustrates the article selection process using the PRISMA causes significant morbidity and mortality globally . Asthma guide- diagram. We included 23 studies; 16 studies from the Cochrane 13–28 29–33 review , five studies from the updated database search and lines recommend supported self-management to improve asthma 34,35 2–4 two studies from the pre-publication update . The total number control and reduce the use of urgent healthcare services . of participants was 10,682. Some studies did not report numbers in Supported self-management, which includes discussion about self- 13,14,24 each group so we cannot provide number by allocation .We management and provision of a personalised asthma action plan contacted all authors for information not reported in the papers, and supported by regular asthma review, can be delivered effectively in 13,14,25,27,29,30,32–34 5,6 nine (39%) responded . diverse cultural and demographic groups . School-based asthma self-management interventions have been reported to improve asthma control and reduce school Characteristics of included studies 7–11 absenteeism and asthma exacerbations . However, most The interventions were conducted from 1992 to 2019. Seventeen systematic reviews analysed combined data from primary and studies were randomised controlled trials (RCTs) (14 cluster 7–10 13–15,18–26,31,32 27,29,34 secondary schools (5–18 years) . One scoping review con- RCT , three individual RCTs ), three were non- 28,30,35 randomised studies and three were uncontrolled pre-and- ducted in 2014 focused on primary school children, but the aim 16,17,33 post studies . Fifteen studies were conducted in the United was to identify research gaps rather than assess outcomes . The 15–18,21,23–25,27–31,34,35 13,14,19,20 States , four in Canada , one each in Cochrane review (Harris, 2019) used meta-analyses to assess 32 26 Spain and United Kingdom , and two in low- and middle- intervention effectiveness and qualitative comparative analysis to 22,33 17 7 income countries (China and Thailand) . All but one of the examine the components of successful implementations . The studies in the United States were conducted in minority authors identified a number of components as being important: 15,16,18,21,23–25,27–31,34,35 populations , two Canadian studies were theoretical underpinning, parental involvement, child satisfaction 19,20 conducted in majority population ; none of the and conducting the intervention during lesson time. However, the 13,14,22,26,32,33 others reported ethnicity of population studied. Cochrane review included interventions directed at children and adolescents (5–18 years), and did not distinguish the components Overall intervention characteristics associated with effective interventions in primary school children, The programmes were used to deliver self-management intervention which may differ from adolescents . Educational intervention varied. Eight studies used standard programmes (Open Airway for needs to be age-appropriate as primary school children will have 15,17,21–24,28,29 School (OAS) or tailored OAS ,fourstudies used Roaring less autonomy and capability to self-manage asthma compared to 13,14,19,20 12 Adventures of Puff (RAP) or tailored RAP , and the other adolescents . Thus, we aimed to review the effectiveness of 16,18,25–27,29–35 studies developed novel interventions . The programmes school-based self-management interventions for primary school ranged from one to eight sessions, and all were delivered by children with asthma and to examine the components associated healthcare personnel, (school nurse, asthma educator, community with successful programmes. nurse, respiratory therapist, physician) except for two that were 1 2 Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia. NIHR Global Health Research Unit on Respiratory Health (RESPIRE), Usher Institute, University of Edinburgh, Edinburgh, UK. Centre for Child Health, Blizard Institute, Queen Mary University of London, London, UK. email: Hilary.Pinnock@ed.ac.uk Published in partnership with Primary Care Respiratory Society UK 1234567890():,; SN Ramdzan et al. 1484 records identified from forward and 1306 records identified backward citation of studies included in from databases 7 the Cochrane review 117 records removed after de- duplication 140 records removed after de-duplication 36 records removed as studies were already included/excluded in the Cochrane review 2497 titles and abstract screened 2448 records excluded (did not meet 55 studies from the criteria, duplicates) Cochrane review 104 records screened for full text 83 records excluded 29 not primary education children 23 no outcome of interest 11 non self-management education school-based intervention 11 non-experimental 5 duplicates 4 proceeding/thesis 21 records 2 from pre-publication update (forward citation of 21 studies and the Cochrane review ) 23 records included Fig. 1 PRISMA diagram. This figure illustrates the article selection process using the PRISMA diagram. 22,32 delivered by trained school teachers . Fifteen studies delivered the Effectiveness of interventions 13–17,19–26,28,34 intervention in group sessions , four used individual face- The effect of the interventions on each outcome of interest is 27,29,30,35 to-face sessions , one used individual computer-assisted detailed in Supplementary Table 1, with an explanation of how 18 31 programme and another used individual telemedicine sessions . the direction of the effect was interpreted and the overall effect of 23,33 Two studies were unclear . the study assessed. Twelve studies (two at low risk-of-bias) were assessed as having an overall positive (beneficial) 13–17,21,22,29,30,33–35 effect and eleven studies (two at low risk-of- 18–20,23–28,31,32 Risk of bias in the included studies bias) as having no effect . No study was categorised as harmful or mixed effect. The Harvest plot (Fig. 2) illustrates the The overall RoB is given in summary Supplementary Table 1 (first effect of varying degrees of parental involvement on school column) and illustrated in the Harvest plot (Fig. 2). Details of the absenteeism, asthma control and urgent healthcare use. RoB are in Supplementary Table 2. Four studies had low overall 13,14,20,32 15–17,21,27–30,33–35 risk of bias , eleven had high risk of bias 18,19,22–26,31 Study components according to CFIR sub-domains and eight were unclear . Only seven (30%) studies were categorised at low risk in random sequence genera- The CIFR domains addressed in the studies are summarised in 13,14,20,21,23,32,34 13 tion . All uncontrolled studies were categorised as column 2 in Supplementary Table 1. Cicutto et al. was the only high-risk in four domains (random sequence generation, alloca- study that explicitly addressed all the CFIR sub-domains in their tion concealment, baseline outcome similar and baseline char- intervention; in contrast, Spencer et al. addressed only two sub- 16,17,33 acter similar) . domains. All included studies used and measured the impact of at npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK 1234567890():,; SN Ramdzan et al. Urgent healthcare service (e.g. no of Asthma control (e.g. symptoms, School absenteeism emergency visits, days of asthma category, PEFR) (e.g. no of days absent from school) hospitalisation, unscheduled visits) Positive Positive Negative No effect Negative Positive Negative No effect No effect - - ? ? ? ? Substantial ? - + - - - + parental ? ? ? - ? involvement - - - ? ? - - - Minimal parental - - involvement - No parental - - - involvement - Longest duration Longest duration Longest duration To indicate that the outcomes (13 - 24 months) (7 - 12 months) (<7months) were not all consistent The height of the bars describes the number of participants The overall risk of bias within the study is relected on top of the bars ( Low, - high, ? unclear) Fig. 2 Harvest plot illustrating effectiveness of included studies across parental involvement. Harvest plot illustrating the effectiveness on school absenteeism, asthma control and urgent healthcare services across parental involvement for school-based self-management asthma educational intervention. The shading of the bars indicates the duration of the study and the height of the bars describes the number of participants. The overall risk of bias is reflected on top of the bars. least one specific component in their intervention, e.g. information school, had positive effects in school absenteeism and urgent provision assessed as improvement of knowledge and self- healthcare service use at 12 months. No difference was found in management behaviour. The other commonly addressed sub- other CFIR subdomains between studies with positive and no 13–25,29–31,33–35 domain was parental involvement (19/23) , though effects. this varied in intensity (We use the term ‘parents’ to describe parents, guardians or other care-givers). See Supplementary Table DISCUSSION 3 for definitions of involvement. Some studies had substantial We identified 23 studies (four at low RoB) that evaluated the involvement e.g. parents attending session or actively involved 13–15,17,19–22,24,25,29–31,33,35 effectiveness of school-based asthma self-management interven- in phone/video communication , while tion among primary school children. Twelve of the studies were others had minimal parental involvement e.g. passive information 16,18,23,29,34 categorised as being overall positive, though individual outcomes in a letter . Ten studies used theory to guide the varied; no study reported overall negative impact. The number of development of the interventions; six used social cognitive 13,14,18–20,22 28,34 CFIR sub-domains addressed varied between studies, but the only theory , two used Orem self-care theory , one used component that seemed to be associated with positive outcomes life stress model , and another was guided by Bruhn’s theoretical was substantial parental involvement. This was particularly model . Nine studies considered access to healthcare of their 13–15,24,25,27,30,32,33 apparent in studies at low RoB. study population . We found substantial parental involvement to be a crucial component of a school-based asthma self-management interven- Association of CFIR sub-domains and effectiveness tion among primary school children. Reviews that included Tables 1 and 2 are summary matrices comparing use of the 12 interventions targeted at teenagers, in whom parental influence CFIR sub-domains in studies with overall positive or no effect (See might be expected to be less important, have reached similar 7,8 Supplementary Table 4 for more detail). The number of CFIR sub- conclusions . Parental involvement was also found to be domains used varied widely (2 to 12) and was similar in the studies important in other school-based interventions for obesity preven- 36,37 38 with positive/no effect. tion studies , self-management of mental health/disorders , All studies with positive effects (12/12) reported parental and academic enhancement . 13–17,21,22,29,30,33–35 involvement in their intervention compared to However, we did not find other components of interventions 18–20,23–25,31 seven studies with no effects (7/11) . The Harvest plot (theory-driven, conducted during lesson time, and child satisfac- (Fig. 2) illustrates the direction of effect with the varying degrees of tion) to be essential for successful intervention, as was found in parental involvement of each study intervention. Studies without the Cochrane review . The differences in the findings were most parental involvement (including one at low RoB ) showed no probably due to a difference in the age group of the children as 26–28,32 effect in any of the outcomes of interest . Of the five the Cochrane review included studies among older school 16,18,23,29,34 interventions with minimal parental involvement , the children. Our review defined fun, interactive delivery of interven- three positive studies were at high RoB and of short duration tion, as a strategy promoting child satisfaction and engagement, (≤ 6 months), and either small in sample (study population less whereas the Cochrane review examined measurement of child 29,34 16 than 100 children) or pre/post design . Studies with satisfaction, an evaluation used mainly in studies targeting 13–15,17,19–22,24,25,29–31,33,35 7 substantial parental involvement were adolescents . Primary school children had good participation the only studies to report reduction in absenteeism, though rates when the sessions were conducted during school hours impact on clinical outcomes varied. Cicutto et al. (cluster RCT at including during recess, in contrast to adolescents who were less 7,13,16 low risk of bias, 170 schools and 1316 children), an example of a willing to devote their free time including during recess . study that included parents in care coordination and a showcase at Social cognitive and Orem self-care theories were the most used Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2021) 18 + + + SN Ramdzan et al. theories, adapted from adults which focuses on self-efficacy and 40–42 skills of individuals . These theories may be suitable for interventions targeting parents and adolescents, but may not be age-appropriate for primary school children with limited decision- 12,43 making abilities and independent self-management skills . Primary school years are a critical time for children as they spend increasing time away from their parents and begin to learn 44,45 asthma self-management for themselves . Six-year-old children can express opinions, typically reflecting their parents’ actions and views . Over primary school years, they learn from their own experiences and gain the confidence to make independently 44,45 decisions . Although involving parents to support and empower their children’s self-management behaviour is a key 2,3 concept in the clinical management of children , direct parental involvement was not always included in school-based interven- 27,28,32 tion among primary school children . A key challenge for involving parents is the difficulty of engaging them to attend 24,46 session(s) delivered in school . With the ease of modern telecommunication, alternative methods of engagement such as the use of telephone calls or video sessions could be explored as a convenient alternative to enable substantial parental involvement 31,47 in the intervention . Although parental involvement is important, an aim of a school- based intervention is to shift the focus of self-management 48,49 education from parents to children . Studies in this review included up to eight educational sessions for children compared 13,27,30 to only one to two sessions for parents . A recent school- based health intervention has recommended the socio-ecological theory where children are the primary focus of an intervention that also involves the children’s social network, e.g. parents, 48,50 teachers, friends and the school plan/policy . Schools could be an ideal setting for this approach, smoothing children’s transition to independent self-management by being located in the child’s environment and including parents as part of the children’s social 51–53 network . Schools also provide a platform for interactive fun groups activities and peer support for children with similar conditions, which could reduce stigma and support self- 13,32 management practices . The effectiveness of self-management also depends on access and adherence to evidence-based treatments such as controller asthma medications, which is conventionally delivered in health- 2,5 care settings . ‘Access to healthcare’, however, was a sub-domain least likely to be addressed in the studies included in this review. Although most US-based studies were conducted among minority deprived populations, in whom poor health outcomes may be due to the large disparities in healthcare provision , only five studies reported the access of the children to effective controller 15,24,25,27,30 medication . Even in countries with universal health coverage, such as Canada and United Kingdom, equitable access to high quality healthcare for children cannot be assumed .In low- and middle-income countries, socio-cultural beliefs, physical inaccessibility and lack of education and information are extremely common barriers to healthcare despite universal health 56,57 coverage . Similar barriers are widely described in the 30,31,34 US . Encouragingly, bridging school-based education with the children’s healthcare providers has been a core component of 53,58 recent school-based interventions . A strength of this review is that we used comprehensive search terms similar to the Cochrane review and searched seven relevant databases. Two reviewers conducted full text screening and data collection was duplicated. A pre-publication update was per- formed to ensure the findings was up to date this review. This review has some limitations. Despite a rigorous search strategy, it is possible that we may miss some studies. The screening of title and abstract was conducted by one reviewer, but good agreement resulted after training. Only two studies were conducted in low- and middle-income countries and many studies (15/23) were conducted in the US, reducing generalisability of the npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK Table 1. Summary matrix comparing 12 sub-domains of CFIR in overall positive studies. CFIR domains and subdomains Cicutto Cicutto Clark Clark, Isik Levy Magzamen Marsland Marsland Simoneau, Spencer Suwannakeree Szetler Total with 2005 2013 2004 2005 2020 2006 2008 2019 (ICC) 2019 (OAS) 2020 2000 2016 2019 this domain Intervention Theory-driven ✓✓ ✓ ✓ ✓ 5 characteristics Evidence-based ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ 8 Stakeholder involvement ✓✓ ✓ ✓ ✓ ✓ ✓ 7 Tailored ✓✓✓ ✓ ✓ ✓ ✓ ✓ 8 Outer setting Substantial parental involvement ✓✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 10 Minimal parental involvement ✓✓ ✓ 3 Access to asthma care ✓✓ ✓ ✓ ✓ 5 Coordination with child’s health provider ✓✓ ✓ ✓ ✓ ✓ 6 Inner setting School participation ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ 8 Done during school hours ✓✓ ✓ ✓ ✓ ✓ ✓ 7 Individual Measurement of knowledge, skill or practice ✓✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 12 characteristics Process Fidelity ✓✓ ✓ ✓ ✓ 5 Child satisfaction ✓✓ ✓ ✓ ✓ ✓ ✓ 7 Total sub-domains met in individual study 11 12 4 7 9 6 6 8 6 5 2 8 11 2–12 (range is in final column) SN Ramdzan et al. review. The included studies were variable in methodologies, instrumentation and data analysis. However, three low RoB studies coincided with the findings and some variability was illustrated in the Harvest plot with the other details described in Supplemen- tary Table 1. Poor reporting of interventions was a challenge and we may have overlooked some intervention components that were not explicitly described. We contacted all the authors to reduce the number of missing information and obtained 39% responses. A multi-level intervention focusing on the children and involving their social network could provide a useful self- management interventions framework for primary school children and their parents. Specifically, there is a gap in our current understanding of school-based self-management education in younger children in low- and middle-income countries. Future research needs to focus on implementation strategies and effectiveness using this framework. Partnership between schools, parents and healthcare services could create a pragmatic and effective school plan/policy to improve asthma control among children. School-based self-management interventions for asthma among primary education children can improve asthma outcomes and reduce absenteeism. Parental participation is an important component in this age group, but other features highlighted in secondary school interventions proved less relevant, perhaps reflecting the greater role of parents in younger children. METHODS This systematic review follows Cochrane methodology , and PRISMA reporting standards. The protocol is registered with the PROSPERO database (registration number: CRD42019131955). Study eligibility criteria We used a Population, Intervention, Comparator/Control, Outcomes and Study Design (PICOS) strategy to define eligible studies (Table 3) , using 3,7,61 definitions similar to the Cochrane review . Self-management inter- vention was defined as the active transfer of information to children with asthma to enhance their self-management skills; this was interpreted with reference to components of self-management recommended by global 2,3 guidelines (Table 3) . In line with the Cochrane review, we included non- randomised trials to capture a broader range of studies and thence components used. Outcomes of interest We chose three outcomes of interest (school absenteeism and two health outcomes - asthma control and urgent use of healthcare services) to reflect 2,7,61 the impact on children with poorly controlled asthma . Search strategy The details of the search terms and databases used are in Supplementary Table 5. The Cochrane review conducted searches in August 2017 using search terms developed by the Cochrane Airway Information Specialist in 23 electronic databases from 1995 onwards and included 55 papers . Using the same search terms, with no language limitations, we updated the search in February 2019 in six-core databases (CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, AMED) . In addition, we searched the Global Health database using similar search terms without date limits to include studies from low- and middle-income countries. We included all studies identified in the review that met our eligibility criteria (principally excluding those not delivered to primary school children). We checked the reference list and undertook forward citation of studies in the Cochrane review conducted among primary school children . A pre-publication update was conducted on 17th March 2020 using forward citation of the Cochrane review (published 28 January 2019) and all the studies included in this review . Published in partnership with Primary Care Respiratory Society UK npj Primary Care Respiratory Medicine (2021) 18 Table 2. Summary matrix comparing 12 sub-domains of CFIR in no effect studies. CFIR domains and subdomains Bartholomew Clark Clark 2010 Gerald Horner McCann McGhan McGhan Praena-Crespo Perry Persaud Velsor-Friedrich Total with 2006 2010 (OAS) (OAS plus) 2006 2016 2000 2003 2010 2016 2018 1996 2005 this domain Intervention Theory-based ✓✓ ✓✓ ✓ 5 characteristics Evidence-based ✓✓✓✓✓✓ ✓✓✓ 9 Stakeholder involvement ✓✓ ✓ ✓ ✓ 5 Tailored ✓✓ ✓ ✓ ✓ ✓ ✓✓ ✓ 9 Outer setting Substantial parental ✓✓ ✓ ✓ ✓ 5 involvement Minimal parental ✓✓ 2 involvement Access to asthma care ✓✓ ✓ ✓ 4 Coordination with child’s✓✓ ✓✓✓ ✓✓✓ 8 health provider Inner setting School participation✓✓ ✓✓✓✓ ✓✓ 8 Done during school hours ✓✓ ✓ ✓ ✓ ✓ 6 Individual Measurement of ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓✓ ✓ 11 characteristics knowledge/skills/behaviour Process Fidelity ✓✓ ✓ 3 Child satisfaction ✓✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ 9 Total sub-domains met in individual study 84 6 8 10 6 7 7 9 7 9 7 4–11 (range is in final column) SN Ramdzan et al. Table 3. PICO study strategy and definition of terminology. Participant/population Children with asthma aged 6–12 years Intervention School-based self-management education intervention. Definition as active transfer of information to enhance self-management of asthma containing at least one of the 2,3 core-components of self-management education : � A basic explanation about asthma, triggers and the factors that influence control � Training about correct inhalation technique � Information on the importance of the child’s adherence to the prescribed medication regimen � Written asthma action plan Children with asthma had to be the primary target for the intervention, though others (such as peers without asthma, parents, school staff) could also be included. Comparator(s) Standard care or other (non-asthma, or not related to self-management or delayed intervention) education intervention or none Outcomes School absenteeism or/and asthma control or/and urgent use of healthcare service The definition of the three categories of outcomes of interest were guided by the American Thoracic Society/European Respiratory Society statement : 1. School absenteeism: Number of days a participant was absent from school (priority due to asthma). 2. Asthma control: Clinical level of asthma control based on symptoms and capability to perform daily activities measured using asthma symptoms questionnaire/asthma diary with/without objective validation of asthma control, e.g. peak flows or lung function test. 3. Urgent use of healthcare service: Number of an unscheduled visit to a general practitioner and/or emergency department due to asthma, and the number of days of hospitalisation due to asthma. Setting School (primary, elementary or middle school) Study designs Experimental study e.g., randomised controlled trial (RCT), cluster RCT, non-randomised study and uncontrolled before-and-after study. Study selection and data extraction We used a structured approach to divide the studies into four categories according to the change in the outcomes of interest . This was a two-step We imported the list of articles from the electronic databases into Endnote process. software (version 7) to facilitate screening, de-duplication and overall First, we determined the direction of effect in each of the three management of the results. SNR and JS independently screened a random outcomes of interest (school absenteeism; asthma control; urgent use of selection of 10% of the titles and abstracts . A 96.3% agreement was healthcare service) for each included study. In some studies, several achieved prior to discussion, which reached total agreement after measures mapped to each outcome of interest: for example, emergency clarification of the screening criteria. SNR then completed title and room visits and hospitalisation are both measures of unscheduled care abstract screening. Both reviewers independently conducted full-text potentially with conflicting findings. The rules at the top of Supplementary screening (which included all the studies in the Cochrane review and those Table 1 define how we prioritised outcomes defined as ‘primary’ in the satisfying title and abstract screening), met to discuss discrepancies and included study, outcomes measured with a validated instrument, and decided on the final included papers. Supplementary Table 6 lists studies results that were clinically as well as statistically significant. The table then excluded from this review. A modified Cochrane data extraction form was describes how the decision process was applied for each outcome of used for duplicate data extraction (SNR and JS) . SNR contacted authors interest in each study. for missing data by email and any further information received was added Second, we categorised the overall effect of the intervention in each to the data extraction forms . study as positive, negative, no effect or mixed effects, as follows: At all stages, any discrepancies not resolved by discussion between the two reviewers were arbitrated by the study team (HP, KEM, LSM, SC). Positive (beneficial): Studies with a positive effect in ≥1 of the outcomes and no negative effects. Negative (harmful): Studies with a negative effect in ≥1 of the Risk of bias of included studies outcomes and no positive effects. We used the Cochrane Effective Practice and Organisation of Care (EPOC) No effect: Studies with no positive effects in any of the outcomes. Risk of Bias (RoB) tool to categorise risk into low, high and unclear risk in Mixed: Studies with at least one positive and one negative outcome. nine domains, which were then used to generate an overall assessment of the RoB for each study. The Cochrane EPOC RoB tool applies to randomised trials and non-randomised trials . Studies with at least one high-risk domain were summarised as high risk; studies with no high-risk Data synthesis domains but at least one unclear domain were summarised as unclear risk Our preliminary scoping suggested that the studies would be and studies at low risk in all domains were summarised as low risk . heterogenous in terms of context, components delivered and study design, so we undertook a narrative analysis. We used a Harvest plot Data handling (coded to indicate number of participants, RoB and follow-up duration) to illustrate the effectiveness of the interventions on the three The Consolidated Framework for Implementation Research (CFIR) is a outcomes of interest for each study. A Harvest plot graphically displays comprehensive framework that systematically identifies factors (sub- not only outcomes but also the weight of the evidence in complex and domains) that influence the effectiveness of implementation in multi- diverse studies by illustrating selected methodological criteria .We level interventions . Supplementary Table 3 outlines the 12 CFIR sub- used a matrix to examine the association of the CIFR sub-domains with domains. We used CFIR sub-domains to identify context and components the overall effectiveness of the interventions. Supplementary Table 4 in each study (e.g., intervention characteristics, features of the setting and lists the CFIR sub-domains and how we interpreted them in our strategies for implementation) that might influence effectiveness of the 66,67 analysis. interventions . npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK SN Ramdzan et al. Reporting summary 21. Clark, N. M. et al. Effects of a comprehensive school-based asthma program on symptoms, parent management, grades, and absenteeism. Chest 125, 1674–1679 Further information on research design is available in the Nature Research (2004). Reporting Summary linked to this article. 22. Clark, N. M. et al. A trial of asthma self-management in Beijing schools. Chronic Illn. 1,31–38 (2005). 23. Clark, N. M. et al. An evaluation of asthma interventions for preteen students. J. DATA AVAILABILITY Sch. health 80,80–87 (2010). 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Using the Open Access This article is licensed under a Creative Commons Consolidated Framework for Implementation Research (CFIR) to produce Attribution 4.0 International License, which permits use, sharing, actionable findings: a rapid-cycle evaluation approach to improving imple- adaptation, distribution and reproduction in any medium or format, as long as you give mentation. Implement Sci. 12, 15 (2017). 68. Burns, J. et al. Looking beyond the forest: using harvest plots, gap analysis, and appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The images or other third party expert consultations to assess effectiveness, engage stakeholders, and inform material in this article are included in the article’s Creative Commons license, unless policy. Res. Synth. Methods 9, 132–140 (2018). indicated otherwise in a credit line to the material. If material is not included in the 69. Ogilvie, D. et al. The harvest plot: a method for synthesising evidence about the article’s Creative Commons license and your intended use is not permitted by statutory differential effects of interventions. BMC Med. Res. Methodol. 8, 8 (2008). regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this license, visit http://creativecommons. org/licenses/by/4.0/. ACKNOWLEDGEMENTS We would like to acknowledge all the authors of included studies who provided the information to aid in synthesising the data. We also acknowledge the RESPIRE © The Author(s) 2021 npj Primary Care Respiratory Medicine (2021) 18 Published in partnership with Primary Care Respiratory Society UK

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