July 14, 2007

Testing an Intervention to Promote Children’s Adherence to Asthma Self-Management

By Burkhart, Patricia V Rayens, Mary Kay; Oakley, Marsha G; Abshire, Demetrius A; Zhang, Mei

Purpose: To test the hypothesis that compared with the control group, 7 through 11-year-old children with persistent asthma who received asthma education plus a contingency management behavioral protocol would show higher adherence to peak expiratory flow (PEF) monitoring for asthma self-management and would report fewer asthma episodes. Design and Methods: A randomized, controlled trial was conducted with 77 children with persistent asthma in a southeastern U.S. state. Both the intervention and control groups received instruction on PEF monitoring. Only the intervention group received asthma education plus contingency management, based on cognitive social learning theory, including self-monitoring, a contingency contract, tailoring, cueing, and reinforcement. At-home adherence to daily PEF monitoring during the 16-week study was assessed with the AccuTrax Personal Diary Spirometer, a computerized hand-held meter. Adherence was measured as a percentage of prescribed daily PEF uses at Weeks 4 (baseline), 8 (postintervention), and 16 (maintenance).

Results: At the end of the baseline period, the groups did not differ in adherence to daily PEF monitoring nor at Week 8. At Week 16, the intervention group's adherence for daily electronically monitored PEF was higher than that of the control group. Children in either group who were >/= 80% adherent to at least once-daily PEF monitoring during the last week of the maintenance period (weeks 8 to 16) were less likely to have an asthma episode during this period compared with those who were less adherent.

Conclusions: The intervention to teach children to adhere to the recommended regimen for managing their asthma at home was effective.


[Key words: asthma, children, adherence, peak flow monitoring, cognitive social learning theory]

Asthma is a chronic lung disease characterized by inflammation, airway constriction, and mucous secretion resulting in reduced airflow (National Asthma Education and Prevention Program [NAEPP], 2003). It is the most prevalent chronic condition of childhood, affecting 9 million U.S. children (12%) under 18 years of age. Nearly 4 million U.S. children (6%) reported having had an asthma attack in the previous 12 months (Centers for Disease Control and Prevention, 2006). Asthma can be a life-threatening disease if it is not properly managed. In 2002, over 4,000 deaths were attributed to asthma, 170 who died were children (American Lung Association [ALA], 2005). The annual cost of treating asthma was $11.4 billion, and indirect costs (e.g., related to lost productivity) added another $4.6 billion (ALA, 2005).

Monitoring airflow is integral to asthma self-management since symptom perception of airway constriction is generally poor for asthmatic children and their parents (Yoos & McMullen, 1999). Daily peak expiratory flow (PEF) monitoring is recommended for people with moderate-to-severe persistent asthma, and for those with mild or intermittent asthma who do not perceive their symptoms until airflow obstruction is severe (National Asthma Education and Prevention Program [NAEPP], 1997, 2003). However, few people with asthma have a PEF meter at home, and even when one is available, reports have indicated that most did not use it (Legoretta et al., 1998). The purpose of this randomized, controlled trial was to test the effectiveness of an intervention consisting of asthma education plus a contingency management protocol, designed to promote children's adherence to recommended asthma self-management, specifically daily monitoring of PEF, and to assess the prevalence of asthma episodes.


Adherence to therapies for chronic illnesses has been reported as about 50% for adults (World Health Organization [WHO], 2003) and children (Burkhart & Dunbar-Jacob, 2002). Improving adherence to recommended asthma selfmanagement requires multiple strategies because no single strategy appears to be effective (Burkhart & Dunbar-Jacob, 2002; Peterson, Takiya, & Finley, 2003; Roter et al., 1998). The cornerstone of adherence interventions is education. According to the NAEPP (1997), asthma education should include basic facts about asthma, actions of medications, skills (e.g., using an inhaler and self-monitoring), environmental control measures, and when and how to take rescue medications. Individual rather than group sessions can be better adapted to the specific needs of patients and therefore have greater effects on health outcomes (Bender Sc MiIgrom, 1996; Bernard-Bonnin, Stachenko, Bonin, Charette, & Rousseau, 1995).

However, education alone is not sufficient to improve adherence. Adherence to recommended treatment improved an average of 25% when behavioral strategies were used in conjunction with patient education (Burkhart & DunbarJacob, 2002). Interventions including the cognitive, behavioral, and affective domains were the most effective in improving adherence and patient outcomes (Roter et al., 1998).

Providing positive reinforcement and rewards or tokens to children for performing expected behaviors are effective behavioral strategies to improve self-management (Burkhart, Dunbar-Jacob, Fireman, & Rohay, 2002). Reminders such as Post-It(TM) notes and parents' verbal cues help children remember to take their asthma medications (Burkhart et al, 2002; Penza-Clyve, Mansell, & McQuaid, 2004). Contracting is a strategy in which a written agreement is made between the people who want a particular behavioral change and those whose behavior needs to change. One study with a contingency contract that indicated a reward for children adhering to recommended asthma treatment showed improved adherence (Weinstein, 1995). Tailoring the treatment regimen to the patient's lifestyle, such as taking medications with meals, also has improved adherence (Fish & Lung, 2001; Niggemann, 2005). Children have often cited a lack of motivation and forgetting as barriers to consistent adherence (Leickly et al., 1998; Penza-Clyve et al., 2004). Parents can help their children with asthma overcome these barriers by partnering with them in managing their asthma at home (Bartlett, Lukk, Butz, LamprosKlein, & Rand, 2002).

Because asthma self-management is predicated on early recognition of airway obstruction, poor perception of asthma symptoms can interfere with the effectiveness of a self-management program. A peak flow meter is a simple device to detect airway obstruction, often before the appearance of clinical signs (i.e., coughing, wheezing, shortness of breath, or chest tightness). When airflow is obstructed, a peak flow meter can be used to measure the extent of the obstruction. The meter provides important data to: (a) assess the severity of asthma exacerbations; (b) detect early stages of asthma episodes; (c) monitor response to medication; and (d) establish an objective measure for detecting asthma triggers (NAEPP, 1997). A written management protocol (i.e., Asthma Action Plan) for early intervention can be prescribed based on peak flow assessment. Monitoring is achieved by comparing daily PEF to the child's personal best PER Personal best is the highest peak flow value a child can achieve over a 2- to 3-week period when the child's asthma is under good control. Most children 5 years and older can learn to use a peak flow meter accurately (American Academy of Allergy, Asthma and Immunology [AAAAI], 1999).

A limitation of using PEF monitoring to guide asthma self- management is difficulty in maintaining adherence (Chmelik & Doughty, 1994; Kamps, Roorda, & Brand, 2001). Only one intervention study was found in which children were taught strategies for adhering to daily PEF monitoring and PEF adherence was measured electronically (Burkhart et al., 2002). Research on the efficacy of intervention strategies to enhance adherence to recommended asthma treatment, such as PEF monitoring, will contribute to knowledge of how best to assist children with the management of their asthma at home. This study was done to test an intervention to promote children's adherence to PEF monitoring, recommended as part of asthma self-management. The specific aim of the study was to test the effects of a multicomponent intervention on children's adherence to PEF monitoring and the prevalence of asthma episodes.


Design and Sample

A randomized, controlled clinical trial was conducted to test the effectiveness of asthma education plus a contingency management protocol on adherence to PEF monitoring for asthma self-management in children. The study tested the hypothesis that, compared with a control group receiving peak flow monitoring instruction only, children with asthma who received asthma education plus the contingency management protocol would have higher adherence to daily electronic PEF monitoring. In addition, we hypothesized that children who were adherent to daily PEF monitoring would have fewer self-reported asthma episodes.

A volunteer sample of 89 children was recruited primarily from pediatrie practices in a southeastern U.S. state. Power considerations were based on a preliminary study contrasting a similar intervention and usual care conditions that showed adherence means of 70.6% (SD-29.3) and 62.9% (SD=35.3) for the intervention and control groups, respectively (Burkhart et al., 2002). With an alpha of .05 and a total of 72 subjects (at least 36 per group), the power of the Mann Whitney U test to detect a group difference would be at least 83%, assuming that the probability that a control subject has lower adherence than an intervention participant is at least 70%. Given that the contingency management protocol had been strengthened for the current study, differences of this magnitude could be reasonably expected. Oversampling by 20% was done to compensate for potential attrition or significant data loss because of malfunctioning of the electronic PEF monitor. Parents of children with persistent asthma were contacted after they had indicated an interest in having their child participate. To be eligible for participation, the children had to be 7 through 11 years of age; English speaking; diagnosed with asthma for at least 6 months before enrolling; and both the parent and child willing to participate. Excluded were siblings of participants, children with other chronic conditions besides asthma, and children using a PEF meter daily at the time of enrollment. Of the 214 children screened over a 2-year recruitment period, 128 were eligible, and 89 agreed to participate.

Children were randomly assigned via a computer-generated randomization schedule to the control (n=45) or intervention (n=44) group. Twelve children (13.5%, n=6 children in each group) withdrew from the study, primarily because of time constraints with other activities or some disruption in the family (e.g., divorce, relocation, illness). Seventy-five percent of those dropping out did so during the baseline period (weeks 1 to 4) before the intervention began. Seventy-seven children (n=38 intervention group; n=39 control group) completed the 16-week study.

Demographic and asthma characteristics at baseline for children who completed the study, compared with those who withdrew, did not differ except for parent education, the child's need for medication with exercise, and knowledge of a peak flow meter. That is, the mother's education (Mann Whitney U=4.0, p -.05) and father's education (Mann Whitney U=4.5, p=.03) for completers tended to be higher than for the dropouts. Parents of children who withdrew from the study were more likely than were parents of children who completed the study to indicate at baseline that their child did not know what a peak flow meter was (chi^sup 2^=8.3, p =.04), and that their child needed asthma medication more often for exercise (Mann Whitney U=5.9, p =.02). The completers and dropouts did not differ according to any other demographic or asthma variables.

Baseline demographic characteristics of the 77 children completing the study did not differ by group. The mean age of the children completing the study was 9.1 years (SD=1.4), with a range of 7 through 11.9 years. The children were predominantly male (58%, n =45) and from two-parent families (73%, n =56). Most of the children were Caucasian (79%, n =61); the majority of the remaining participants were African American (13%, n =10). Many of the mothers (83%, n =64) and fathers (73%, n =56) had at least some college education. Annual household income ranged from over $60,000 (42%, n =32) and $30,000 to $60,000 (30%, n =23) to less than $15,000 (10%, n =8). The majority of families had private health insurance (81%, n =62).


Asthma characteristics. Asthma characteristics (based on a 2- month recall) were collected at the Week 1 session for baseline characteristics of the child using items from the Children's Health Survey for Asthma (CHSA; American Academy of Pediatrics, 2000). Some examples include: age when asthma was diagnosed; family history of asthma or allergies; the child's exposure to second-hand smoke; emergency department visits or hospitalizations for asthma; wheezing episodes during a 2-month period before study participation; previous use of a peak flow meter; frequency of and adherence to medication use.

Demographic characteristics. During the Week 1 session, data were collected from parents on the child's age, race, and sex, as well as marital status and educational level of the parents, household income, and the family's main source of insurance at baseline.

Adherence to PEF monitoring. Adherence to PEF monitoring was measured electronically by the AccuTrax Personal Diary Spirometer (Ferraris Medical and Pulmonary Data Services Instrumentation, Louisville, CO). It is a lightweight, handheld electronic device to measure PEF and FEVi. A built-in microchip recorded the date, time, and PEF value each time the device was used. The meter showed an objective measure of PEF monitoring adherence, with data stored in the device and downloaded to a computer for analysis. The AccuTrax met or exceeded all of the performance requirements set forth by the American Thoracic Society ( 1995 ) standardization in spirometry, including measurement of forced expiratory volume, 1st second (FEVi) accuracy (+- 5% of reading or +-.10L, whichever is greater) and PEF (+- 10% or +- 20 liters/minute, whichever is greater). The standard for PEF adherence was the performance of PEF monitoring twice a day (two uses at least 6 hours apart) during the first 4 weeks of the study (baseline) and then once a day for the remaining 12 weeks. Adherence was defined as the percentage of prescribed PEF uses in the last week of each of the three study periods, Weeks 4, 8, and 16.

Asthma episodes. Asthma episodes were measured as the number of asthma attacks recorded daily in the asthma diary, a one-page 2- week data form with simple information in four categories: (a) asthma symptoms; (b) number of attacks; (c) peak flow values for morning and evening; and (d) asthma medications taken that day (Creer et al., 1989). It has been used extensively for self- monitoring of symptoms in self-management studies of children with asthma (Burkhart et al., 2002; Creer et al., 1989). In previous studies, children's reports of asthma episodes were strongly correlated with reports of parents and health personnel (Creer, 1992). The children and their parents were asked to record each day the number of asthma episodes that occurred. Thus, each child had a series of three yes-or-no variables indicating their asthma episode status, one for each time interval (Weeks 1 to 4, 5 to 8, and 13 to 16; baseline, intervention, and maintenance periods respectively).


Approval to conduct the 16-week study was obtained from the university's medical institutional review board. Recruitment of the sample and implementation of the study occurred over a 2 ^-year period. Recruitment fliers describing the study and the inclusion and exclusion criteria were available at pediatrie clinics and private practices with a phone number for parents to call to express interest in participating. During the initial phone interview with parents, the research associate, a registered nurse and asthma educator, briefly explained the purpose and nature of the study, determined eligibility, obtained verbal consent, and scheduled the Week 1 session.

At the baseline session, written consent from the parent and assent from the child were obtained. Each individual session with the child and parent was scripted to ensure consistent implementation of the protocol. Portions of the scripts were pretested during a preliminary study (Burkhart et al., 2002). All scripts were pilot-tested before initiation of this study. Each session lasted approximately 60 minutes and was conducted in a child- friendly intervention room designed for the study and located in the university's center for nursing research.

The protocol for the Week 1 session was the same for both groups. Children and their parents were shown the 5-minute video entitled I'm a Meter Reader (Allergy and Asthma Network Mothers of Asthmatics [AANMA], 2001; Sander, 1994). The animated video showed the purpose of a PEF meter and asthma diary related to asthma selfmanagement. Using demonstration, rehearsal, and practice (Bandura, 1986, 1997), the research associate showed the child and parent dyads in both groups how to use the AccuTrax Personal Diary Spirometer, and taught the children to record daily with parent supervision the PEF, symptoms, asthma episodes, and medications in the Asthma Diary. Written instructions on PEF monitoring and self-reporting, along with the asthma diary, were placed in a binder for the children and their parents to use at home. Parents in both groups were asked to return the diary to the investigator at 2-week intervals in stamped, addressed envelopes provided in the binder. Copies of the diary were returned to the child to be kept in the binder for future reference and to share PEF numbers with the child's primary healthcare provider.

Randomization to group occurred at Week 4 so that the research associate was blind to group assignment for the baseline PEF teaching session. Children and their parents were asked not to reveal their study group protocol to others in the study or to the healthcare provider, unless medically necessary. Both the intervention and control group children had a 4-week baseline period during which they performed recommended PEF monitoring twice a day (i.e., in the morning and evening before taking asthma medication) and recorded the PEF numbers in their asthma diary.

During the Week 4 session, the previous 4 weeks of twice-daily recordings of PEF were reviewed in person with the intervention group and by phone with the usual care group. Based on an assessment of the PEF recorded in the diary, the research associate determined the child's personal best PEF. Three zones, corresponding to a stoplight, were identified and shared with the parent and the child both verbally and in written form. PEF values > 80 of the child's personal best are considered the "green zone," which is normal, and the child was advised to continue the prescribed daily asthma routine. Parents were told that if the PEF value dropped into the "yellow zone" (between 50% and 80% of the child's personal best), it indicated "caution" and the need for intervention with prescribed asthma medications. Less than 50% of the child's personal best is considered the "red zone," indicating the child needs immediate medical attention (NAEPP, 1997). Once the child's PEF personal best was established, parents and children were told that PEF self- monitoring could be performed just once daily (in the morning) unless asthma symptoms were present. Parents were instructed to report the zones to their healthcare providers for determination of appropriate interventions for each zone, as recommended in NAEPP guidelines. At Week 16, the AccuTrax monitor was exchanged for a Truzone (Monaghan Medical Corporation; AANMA, 2001) manual PEF meter for continued home use after the study. The child and parent received instruction on manual PEF monitoring by viewing a video on PEF meter use, observing a demonstration on using the meter, and practicing with the new meter. The children were instructed to continue to record in their daily Asthma Diary the PEF numbers with the Truzone meter and to return the final diary by mail to the research associate, who contacted the family to confirm the child's personal best PEF on the new meter and reviewed the asthma action plan based on the child's personal PEF number.

Experimental intervention. Intervention group children (w=38) had five face-to-face sessions (Weeks 1, 4, 6, 8, and 16) with the research associate for data collection and implementation of the intervention. Intervention group children received asthma education recommended by the NAEPP (1997) using short educational videos, followed by individualized teaching related to the child's specific triggers and medications. The format of the intervention included behavioral rehearsal, which is teaching, observing, and then practicing (Bandura, 1986, 1997). Children were given homework assignments from the Asthma Wizard Activity Book (National Jewish Medical and Research Center [NJMRC], 2001) to reinforce their learning. Parent homework included supervising the child's PEF monitoring, reinforcing the asthma education, and validating and rewarding the child's expected self-management behaviors.

Contingency management is a set of behavioral strategies to effect behavioral change. Cognitive social learning theory (Bandura, 1986, 1997) was the basis for development of the contingency management protocol. The contingency management portion of the intervention consisted of self-monitoring, contingency contracting, reinforcing, tailoring, and cueing, over several weeks. In addition, emphasis was placed on parent supervision of the child's PEF monitoring, because previous research has indicated that a lack of parental supervision of prescribed treatment contributed to children's inaccurate self-reporting of data in the asthma symptom diary (Burkhart et al., 2001) and to non-adherence (Rapoff, 1999). The contingency management protocol and asthma education were delivered to the children and parents during Weeks 4 and 6 with a "booster" reinforcement of the asthma education at Weeks 8 and 16.

Control group. The control group (n=39) received three individual sessions with the research associate and one phone call after the 4- week baseline period to identify the child's personal best PEF and zones for their Asthma Action Plan. At the Week 1 session the parent and child received instruction on the use of the Accutrax PEF meter with review sessions at Weeks 8 and 16, but did not receive the asthma education or the contingency management protocol. This group received only the asthma education that may have previously been delivered by the child's healthcare provider. At the completion of the study, children in the control group were offered the asthma education received by the other children during the study. Seventy- four percent (n=29) of the children and their parents accepted the education. Those who did not (26%,

Data Analysis

Descriptive analysis of the demographic and baseline asthma characteristics of the sample included frequency distributions, means, standard deviations, and ranges, as appropriate for the level of measurement of the variables. Differences in the demographic and baseline asthma characteristics between children who completed the study and those who dropped out, and between those randomly assigned to the intervention and those in the control group, were assessed using chi-square tests of association for nominal variables, Mann Whitney U tests for ordinal data, and t tests for continuous measures. Data were analyzed with SAS for Windows, Version 9.1; an alpha level of .05 was used throughout.

Given the non-normal distribution of the adherence data and the inability to transform the data, the non-parametric Mann-Whitney U test was used to compare the groups on median adherence at all three times. Changes in the prevalence of asthma episodes over time (i.e., whether the child had one or more episodes in a designated time period) were assessed with generalized estimating equations (GEE) modeling for nominal data.

The ordinal measure of number of days of adherence in the last week of the period (baseline, intervention, and maintenance) was dichotomized at 80%: children who used the PEF as prescribed for 6 or 7 days of the particular weeklong period were included in one group and were compared to those who used the monitor less. The rationale for this criterion of 80% adherence was that it is the minimum level of PEF use associated with improved health outcomes (compared with less adherent participants) in the present study. In particular, when lower levels of adherence were considered in this study, no differences were found in the prevalence of asthma episodes between the more and less adherent groups. In addition, other researchers have used 80% as a standard for adherence (Rapoff, 1999). The chi-square test of association was used to test for an association between whether the child had at least one asthma episode in a given time period and the binary measure of adherence to PEF monitoring (at least 80% adherent versus less than 80%) in the corresponding period.


Asthma Characteristics

Baseline asthma characteristics for the two groups, collected at the first session were equivalent with one exception: the number of wheezing episodes experienced by the children during the 2 months before participating in the study. Intervention children reported more wheezing episodes (M=11.5, SD=IS.9) than did control children (M=5.1, SD=6A; i=2.0, p=.05). On average, the children had been diagnosed with asthma at about age 4 years (M=4.4, SD=2.7). More than half of the children had a previous emergency department visit for asthma (58%, n=45), but only a third had ever been hospitalized because of their asthma (33%, n=25). The majority of the children had family members with asthma (53%, n =41) or allergies (82%, n =63). Eighty-seven percent of the parents (n =67) reported that their child was not exposed to second-hand smoke in the home. Daily asthma medications for almost all of the children were prescribed (97%, n=75), including inhaled corticosteroids (61%, n =47); but only 48% (n =37) of the parents reported that the participants took the medications as they should. Eighty-eight percent (n =65) of the children reported not using a peak flow meter at home; three said they did not know what a peak flow meter was.

Adherence to PEF Monitoring

During Week 4 (baseline), the intervention (Man-43%) and control groups (Mdn =43%; U=.1, p=.S) did not differ in adherence to twice- daily monitoring, nor did they differ at Week 8 (postintervention) in adherence to once-a-day monitoring (intervention group Mdn-S6% vs. control group Mdn=71%; U=.8, p=A). At Week 16 (maintenance), the intervention group adherence (Mdn=71%) for daily electronically monitored PEF was higher than that of the control group (Mdn=57%; 17=3.8, p -.05; see Figure 1).

Asthma Episodes

In the longitudinal GEE analysis, the intervention group did not differ from the control group (chi^sup 2^=3.4, p=.07; df=1] in the prevalence of one or more reported asthma episodes. However, among all children who participated, a decrease was found in the percentage of children reporting asthma episodes (one or more during the period) from beginning to end of the study period. At baseline (Weeks 1 to 4), 74% (n =57) of the children reported one or more episodes; 50% (n=37) of the children reported one or more asthma episodes during Weeks 5 to 8 (the period after they were given their personal best PEF value and zones); and 28% (w=21 children) reported one or more episodes during the PEF maintenance period, Weeks 13 to 16. Thus, a 63% decrease was found in the number of children reporting one or more attacks from baseline to maintenance. The time main effect in the GEE model was significant (chi^sup 2^=31.0, p

Adherence and Asthma Episodes

Prior research has shown that adherence to PEF monitoring has been linked to fewer asthma episodes (Burkhart et al., 2002; Tinkelman & Schwartz, 2004). For the present study, as shown in Figure 2, of the children who were at least 80% adherent to PEF monitoring during Week 16, 33% had one or more asthma episodes during the last 8 weeks, compared with an asthma episode rate of 57% during this 8-week period among those who were less than 80% adherent during Week 16 (chi^sup 2^=4.3, p =.04, df=2). No differences were found in the incidence of asthma episodes during ear lier periods of the study according to whether the child was at least 80% adherent to PEF monitoring during that same period. Discussion

Children in the intervention group receiving the nurse- administered asthma education and contingency management protocol had higher adherence to PEF monitoring after implementation than did children in the control group not receiving the intervention. Children in both groups benefited from participating in the study (both received information on how to use the PEF meters and both were encouraged to do so); however, the effect of study participation was stronger over time for those who were randomized to the intervention group, as indicated by greater level of adherence at Week 16 (the end of the maintenance period). The study was limited by a sample that was predominantly Caucasian, highly educated, and from two-parent families with private health insurance. Although most studies benefit from a larger sample size and a longer follow-up period, the sample size, the length of the study, and the low rate of attrition for this study compared favorably to other studies to assess adherence and measure it electronically. Future studies with larger, more diverse samples might be able to detect even more subtle effects of the intervention.

Interventions to effectively promote children's adherence to the recommended treatment regimen for managing their asthma at home might be clinically significant in reducing asthma morbidity and mortality. This possibility was evident in the findings of this study that showed a reduction in asthma episodes overall for children who, before the study, relied on symptom monitoring and were not using PEF meters at home. In particular, for those children who were at least 80% adherent to PEF monitoring in the final week of the study, fewer experienced asthma episodes during the maintenance period. An important finding is that adherence improved for all children after Week 4 when the parents and children received an Asthma Action Plan based on the children's personal-best PEF number. This finding shows the importance of providing families with information on the relevance of self-monitoring in the form of an action plan to guide asthma symptom management based on PEF data.

Based on our preliminary work (Burkhart et al., 2002), we strengthened the contingency management intervention for the current study by emphasizing the parents' partnership in the child's asthma self-management, increasing the number and intensity of sessions to teach the behavioral strategies (from one session in the preliminary study to three sessions in the current study (Weeks 4, 6, and 8) and delivering the protocol incrementally. This change made sense conceptually because behavioral change takes time and is reinforced through mastery experiences that enhance selfefficacy (Bandura, 1997). Also, participants and their parents identified all of the contingency management strategies (e.g., self-monitoring, contingency contracting, reinforcing, tailoring, and cueing) as helpful in their adherence to daily PEF monitoring. Parents also reported that receiving the intervention over time helped to reinforce and sustain adherence behaviors. Children and their parents said that learning to self-monitor asthma symptoms with the PEF meter empowered them, because they believed they had better control over their asthma.

Although no recent comparable pediatric asthma intervention studies were found, treatment group adherence in this study was consistent with early studies done to test similar strategies to improve children's adherence to taking medications (e.g., using telephone reminders, rewards, and parent encouragement; Weinstein & Cuskey, 1985), and adherence studies that specifically indicated cognitive social learning theory as the organizing framework for the asthma self-management intervention (Creer et al., 1988; Taggart, Zuckerman, Lucas, Acty-Linsey, & Bellanti, 1987). The paucity of theory-based research shows the need to design studies based on theoretical models for building knowledge to predict or explain children's adherence behaviors.


Adherence to recommended treatment continues to be a significant problem. Unfortunately, the dearth of pediatric adherence intervention studies, based on theory, precludes generalizing successful theoretically based outcomes to practice. The multiple component behavioral approach in this study appeared to be more effective than single behavioral strategy interventions for improving children's adherence. The theory indicates that human functioning is an interaction of behavior, environment, and cognition so that in this study, behavior was motivated by reinforcers and consequences that were interpreted by individual participants through cognitive processes. Environmental factors provide cues, signals, and stimuli for shaping behavior. Cognition allows people to anticipate consequences and reinforcement of the behavior.

Although progress has been made in understanding and modifying children's adherence, much is yet to be learned. Providing education alone is not sufficient to change adherence behaviors and sustain treatment adherence over time. Findings to date indicate that practitioners should discuss adherence with families, tailor adherence interventions to the family's particular needs, and encourage a parent partnership with the child in the performance of selfmanagement behaviors. Education and developmentally appropriate behavioral strategies, tailored to the particular needs of children and their families (such as those designed for this study, based on cognitive social learning theory), show promise for increasing adherence to recommended treatment. Theoretically based randomized controlled trials to evaluate interventions that foster and maintain adherence to recommended treatment regimens for children of different ages and cultural backgrounds will contribute to evidence- based practice for children's self-management of asthma.


Allergy and Asthma Network Mothers of Asthmatics. (2001). Learning resource center. Retrieved August 8, 2006, from www.aanma.org

American Academy of Allergy, Asthma and Immunology. (1999). Pediatrie asthma: Promoting best practice: Guide for managing asthma in children. Milwaukee, WI: Author.

American Academy of Pediatrics. (2000). The children's health survey for asthma. Elk Grove Village, IL: Author.

American Lung Association. (2005). Search lung USA: Asthma in children fact sheet. Retrieved January 24, 2006, from http:// www.lungusa.org/site/apps/s/content.asp?c=dvLUK9O0E&b=347 06&ct=67462

American Thoracic Society. (1995). Standardization of spirometry. American Journal of Respiratory Critical Care Medicine, 152, 1107- 1136.

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Englewood Cliffs, NJ: Prentice-Hall.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York: Freeman.

Bartlett, S., Lukk, P., Butz, A., Lampros-Klein, E, & Rand, C. (2002). Enhancing medication adherence among inner-city children with asthma: Results from pilot studies. Journal of Asthma, 39(1), 47-54.

Bender, B., & Milgrom, H. (1996). Compliance with asthma therapy: A case for shared responsibility. Journal of Asthma, 33(4), 199- 202.

Bernard-Bonnin, A., Stachenko, S., Bonin, D., Charette, C., & Rousseau, E. (1995). Self-management teaching programs and morbidity of pediatrie asthma: A meta-analysis. Journal of Allergy and Clinical Immunology, 95(1), 34-41.

Burkhart, P. V., & Dunbar-Jacob, J. (2002). Adherence research in the pediatrie and adolescent populations: A decade in review. In L. Hayman, M. Mahon, &C R. Turner (Eds.), Chronic illness in children: An evidence-based approach (pp. 199-229). New York: Springer.

Burkhart, P. V., Dunbar-Jacob, J., Fireman, P., & Rohay, J. (2002). Children's adherence to recommended asthma self-management. Pediatrie Nursing, 28, 409-414.

Burkhart, P. V., Dunbar-Jacob, J., & Rohay, J. (2001). Accuracy of children's self-reported adherence to treatment. Journal of Nursing Scholarship, 33(1), 27-32.

Centers for Disease Control and Prevention. (2006). Summary health statistics for U.S. children: National Health Interview Survey, 2004. Retrieved June 15, 2006, from http://www.cdc.gov/nchs/ data/ series/sr.10/sr10.227.pdf

Chmelik, F., & Doughty, A. (1994). Objective measurements of compliance in asthma treatment. Annals of Allergy, 73(6), 527-532.

Creer, T. (1992). Psychological and behavioral assessment of childhood asthma. Part II: Behavioral approaches. Pediatrie Asthma, Allergy & Immunology, 6(1), 21-34.

Creer, T., Backial, M., Burns, K. L., Leurg, P., Mariow, R. J., Miklich, A. R., et al. (1988). Living with asthma I: Genesis and development of a self-management program for childhood asthma. Journal of Asthma, 25(6), 335-362.

Creer, T., Kotses, H., & Reynolds, R. (1989). Living with asthma: Part II. Beyond CARIH. Journal of Asthma, 26(1), 31-52.

Fish, L., & Lung, C. L. (2001). Adherence to asthma therapy. Annals of Allergy, Asthma, & Immunology, 86(6 Suppl. 1), 24-30.

Kamps, A., Roorda, R., 8c Brand, P. (2001). Peak flow diaries in childhood asthma are unreliable. Thorax, 56, 180-182.

Legoretta, A., Christian-Herman, J., O'Connor, R., Hasan, M., Evans, R., & Leung, K. (1998). Compliance with national asthma management guidelines and specialty care: A health maintenance organization experience. Archives of Internal Medicine, 158, 457- 464.

Leickly, E, Wade, S., Grain, E., Kruszon-Moran, D., Wright, E., & Evans, R. (1998). Self-reported adherence, management behavior, and barriers to care after an emergency department visit by inner city children with asthma. Pediatrics, 101(5), e8. Retrieved May 16, 2005, from http://pediatrics.aappublications.Org/cgi/content/full/ 101/5/ e8 National Asthma Education and Prevention Program. (1997). Expert Panel Report 2: Guidelines for the diagnosis and management of asthma. National Heart, Lung and Blood Institute, National Institutes of Health: NIH Publication No: 98-4051.

National Asthma Education and Prevention Program. (2003). Expert panel report: Guidelines for the diagnosis and management of asthma, update on selected topics 2002. Bethesda, MD: National Heart, Lung, and Blood Institute, National Institutes of Health: NIH Publication No. 02-5074.

National Jewish Medical and Research Center. (2001 ). The asthma wizard activity book. Denver, CO: Author.

Niggemann, B. (2005). How can we improve compliance in pediatrie pneumology and allergology. Allergy, 60, 735-738.

Penza-Clyve, S., Mansell, C., & McQuaid, E. (2004). Why don't children take their asthma medications? A qualitative analysis of children's perspectives on adherence. Journal of Asthma, 41(2), 189- 197.

Peterson, A., Takiya, L., & Finley, R. (2003). Meta-analysis of trials of interventions to improve medication adherence. American Journal of Health-System Pharmacy, 60, 657-665.

Rapoff, M. (1999). Adherence to pediatrie medical regimens. New York: Plenum.

Roter, D., Hall, J., Merisca, R., Nordstrom, B., Cretin, D., & Svarstad, B. (1998). Effectiveness of interventions to improve patient compliance: A meta-analysis. Medical Care, 36(8), 1138- 1161.

Sander, N. (1994). I'm a meter reader. Research Triangle Park, NC: Alien & Hanburys.

Taggart, V., Zuckerman, A., Lucas, S., Acty-Linsey, A., & Bellanti, J. (1987). Adapting a self-management education program for asthma for use in an outpatient clinic. Annals of Allergy, 58(3), 173-178.

Tinkelman, D., & Schwartz, A. (2004). School-based asthma disease management. Journal of Asthma, 41, 455-462.

Weinstein, A. ( 1995 ). Clinical management strategies to maintain drug compliance in asthmatic children. Annals of Allergy, Asthma, and Immunology, 74, 304-310.

Weinstein, A., & Cuskey, W. (1985). Theophylline compliance in asthmatic children. Annals of Allergy, 54, 19-24.

World Health Organization. (2003). Adherence to long-term therapies: Evidence for action. Geneva, Switzerland: Author. Retrieved April 8, 2007, from http://whqlibdoc.who.int/publications/ 2003/9241545992.pdf

Yoos, Y., & McMullen, A. (1999). Symptom perception and evaluation in childhood asthma. Nursing Research, 48(1), 2-8.

Patricia V. Burkhart, RN, PhD, Delta Psi, Associate Professor and Director of the undergraduate program, College of Nursing, University of Kentucky; Mary Kay Rayens, PhD, Associate Professor, Colleges of Nursing and Public Health, University of Kentucky; Marsha G. Oakley, RN, WlSN, Research Associate; Demetrius A. Abshire, RN, BSN, Staff Nurse, University of Kentucky Chandler Hospital; Mei Zhang, WlSN, MPH, RNMs, Statistician, College of Nursing.This study was supported by a grant from the National Institute of Nursing Research, National Institutes of Health, Grant R15 NR08106-01 awarded to Drs. Burkhart and Rayens. Dr. Jacqueline Dunbar-Jacob, Professor and Dean of the School of Nursing and Dr. Philip Fireman, Professor in the School of Medicine both at the University of Pittsburgh were consultants for the study. The authors gratefully acknowledge the editorial review of the manuscript by Dr. Lynne A. Hall, Professor and Associate Dean for Research and Scholarship, College of Nursing, University of Kentucky. Correspondence to Dr. Burkhart, University of Kentucky, 517 College of Nursing, Lexington, KY 40536-0232. E-mail: [email protected]@uky.edu

Accepted for publication December 4,2006.

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