Systematic Review: Evaluating the Effectiveness of Self Management Strategies in Reducing Asthma Exacerbation Frequency Among Patients

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Journal of MedVerse Research & Practice

nurexus.com

Systematic Review: Evaluating the Effectiveness of Self-Management

Strategies in Reducing Asthma Exacerbation Frequency Among Patients

Dr. Nida

, Dr. Siva

Postgraduate, Professor,

Department of General Medicine, Dhanalakshmi Medical College & Hospital, Prembalur

Email ID: nidapremalu562@gmail.com

Submission Date: 21.11.2024

Accepted Date: 18.12.2024

Published Date: 30.12.2024

article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits

unrestricted use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.

Abstract

Introduction: Asthma, a long-term inflammatory condition, is characterized by constriction of the airways and

heightened sensitivity, resulting in symptoms such as coughing, difficulty breathing, chest constriction, and

wheezing. In Indonesia, asthma prevalence stands at 5% of the total population, equating to approximately 12.5

million individuals affected by the disease.

Objectives: In this systematic review, several exclusion criteria were applied. Articles were eliminated if they

were not published in international journals or fell outside the 2018-2023 time period. The review also

disregarded studies that did not investigate self-management interventions utilizing media, involved participants

beyond the 12-22 age range, lacked accessible full texts, were duplicate entries, employed non-RCT

methodologies, or were deemed non-scientific in nature.

Methods: A systematic review approach was adopted for this research, following the PRISMA (Preferred

Reporting Items for Systematic Reviews and Meta-Analyses) protocol. In December 2023, the investigators

performed a literature search using the query "Asthma And Self Management" in both Google Scholar and

PubMed databases. To ensure the studies included were relevant and of high quality, the researchers applied pre-

established inclusion and exclusion criteria during the article selection process.

Results: The critical appraisal evaluation revealed that all eight articles were of high quality. These articles are

presented in a tabular format, encompassing details such as the researcher's name and publication year, article

title, methodology, research objectives, intervention, and outcomes. The review examines the efficacy of

implementing self-management strategies for individuals with asthma to reduce asthma recurrences.

Conclusions: This systematic review demonstrates that self-management interventions have a positive impact on

individuals with asthma by reducing the frequency of exacerbations and associated treatment costs. Multiple

studies have corroborated these findings, albeit with varying research durations. Longer intervention periods are

associated with more substantial effects. While the media utilized for self-management interventions remain

consistent, the outcomes of these interventions may exhibit variability.

Keywords: Self-management, Reduction in frequency of asthma recurrence, Asthma, Randomized Control Trial,

PRISMA.

Introduction

Asthma is a chronic inflammatory disorder of the airways characterized by narrowing,

hyperresponsiveness, and obstruction that leads to recurrent symptoms such as coughing, breathlessness,

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chest tightness, and wheezing [1]. According to the World Health Organization, approximately 300

million individuals worldwide were affected by asthma in 2018, with the number continuing to rise

annually. In Indonesia, asthma affects about 5% of the population, which equates to roughly 12.5

million people. Data from 2018 revealed that 1,017,290 individuals in Indonesia suffered from asthma,

placing it among the top ten causes of morbidity and mortality in the country [2].

Recurrent asthma symptoms commonly include wheezing, shortness of breath, chest constriction, and

coughing, particularly during early morning hours. The condition can be triggered by both endogenous

and exogenous factors. Endogenous factors involve antigen-antibody reactions, whereas exogenous

triggers include environmental allergens such as dust, powder, and animal dander. Other contributing

factors include respiratory infections caused by influenza viruses and mycoplasma pneumonia, exposure

to cold or fluctuating temperatures, air pollutants such as carbon monoxide and cigarette smoke,

chemical irritants, fragrances, and even psychological stressors like fear, anxiety, and fatigue [3].

Among these, allergen exposure plays a particularly crucial role, especially in patients with IgE-

mediated hypersensitivity, often leading to recurrent asthma attacks.

Consequently, effective self-management practices are essential to reduce the frequency and severity of

asthma exacerbations. Self-management empowers patients to take an active role in monitoring and

controlling their condition through strategies such as trigger avoidance, medication adherence, and

recognizing early warning signs of exacerbation. The primary goal of self-management is to improve

patients’ quality of life, enabling them to perform routine activities without significant limitations [4–6].

Given that asthma remains a chronic condition with no complete cure and multiple potential triggers,

consistent and informed self-management is vital in preventing recurrent attacks and maintaining long-

term control over the disease [7].

Objectives

This systematic review excluded studies that were not published in international journals or between

2018-2023, did not examine self-management interventions utilizing media, involved participants

outside the 12-22 age range, lacked full-text availability, were duplicates, employed non-RCT designs,

or were not scientific in nature. The initial literature search conducted in Google Scholar and PubMed

databases yielded 1,173 articles. Following the identification and screening processes, 8 articles were

determined to meet the established inclusion and exclusion criteria.

Methods

This research adopts a systematic review methodology based on the Preferred Reporting Items for

Systematic Reviews and Meta-Analyses (PRISMA) guidelines, ensuring transparency, rigor, and

reproducibility throughout the review process [1]. The study commenced with the formulation of a well-

defined PICO framework, which served as the foundation for identifying and selecting relevant

studies. The PICO components are as follows: P (Population) – individuals diagnosed with asthma; I

(Intervention) – implementation of game-based self-management strategies aimed at improving asthma

control and patient adherence; C (Comparison) – absence of similar interventions or use of

conventional asthma education and management methods; and O (Outcome) – reduction in the

frequency and severity of asthma exacerbations, along with improvements in self-efficacy and overall

quality of life [2].

A comprehensive literature search was conducted using the keywords “Asthma” AND “Self-

Management”, with a specific focus on studies that incorporated interactive or game-based educational

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tools designed to enhance self-management behaviors among asthma patients [3]. The search was

performed in December 2023, utilizing reputable electronic databases such as Google Scholar and

PubMed to ensure broad coverage of both peer-reviewed and open-access studies [4].

The selection process followed a multi-stage screening procedure. Initially, duplicate studies were

identified and removed. Subsequently, the titles and abstracts of the remaining articles were screened for

relevance based on the inclusion criteria [5]. Studies were included if they (1) involved human

participants diagnosed with asthma, (2) evaluated a form of game-based or digital self-management

intervention, (3) reported measurable outcomes related to asthma control or exacerbation reduction, and

(4) were published in English within the last ten years [6]. Studies focusing on non-asthma populations,

animal studies, or those lacking measurable outcomes were excluded [7].

Full-text reviews were then conducted for the shortlisted studies to assess their methodological quality

and relevance to the research objectives [8]. Data extraction focused on key study characteristics,

including author information, year of publication, sample size, intervention type, duration, outcome

measures, and main findings [9]. Any disagreements between reviewers during the selection or

extraction process were resolved through discussion to ensure consensus [10].

Finally, all eligible studies were critically appraised to evaluate their quality, risk of bias, and

contribution to understanding the effectiveness of game-based self-management interventions for

asthma [11]. The synthesized findings aim to provide evidence-based insights into the potential of

gamified approaches in enhancing patient engagement, adherence to treatment, and reduction in asthma

exacerbations, thereby contributing to improved clinical outcomes and patient empowerment [12-15].

Figure 1 Schematic Representation of Article Selection Process Following PRISMA 2020

Guidelines

Results

The identification and screening process yielded 8 articles, which were subsequently subjected to a

critical evaluation to assess the appropriateness of the research methodologies employed. The

assessment employed the CASP JBI 2020 (Critical Appraisal Skills Program 2020) tool. Since this

systematic review adopted a randomized controlled trial (RCT) methodology, a questionnaire

comprising 13 items was applied to assess the caliber of each investigation. The quality rating system

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categorized articles as follows: 100-80% was considered good, 79-50% was deemed adequate, and less

than 50% was classified as poor based on the critical assessment results.

The quality assessment process determined that all eight studies were of superior caliber. These studies

are subsequently displayed in a table format, encompassing information such as the authors' names and

publication dates, study titles, research methods, study aims, interventions, and results. Numerous

research efforts have investigated novel methods for enhancing asthma self-care through the use of

digital technologies, educational initiatives, and organized interventions.

A randomized controlled trial (RCT) was performed by Landesberger et al.

(2023) to assess the

effectiveness of the APOLLO application, which was created to support individuals suffering from

pollen-induced allergic rhinitis and asthma. The app incorporated game-like features and offered users

up-to-date pollen information from Bavaria, Germany. For a period of 60 days, participants utilized the

app on a daily basis to monitor their allergy symptoms, with the results displayed through indices and

visual representations. Approximately two-thirds of the study participants (N=46) stated that they felt

more knowledgeable about their allergies and pollen levels, while more than 80% expressed

contentment with the app's user interface and indicated they would suggest it to others.

A pragmatic, decentralized randomized controlled trial (RCT) was conducted by Silberman et al

(2022) to evaluate a digital asthma self-management (DASM) program for adults in the United States.

The study, which lasted 24 months and included 900 participants, compared a group using the DASM

intervention to a control group. The researchers examined two primary outcomes at the one-year mark:

the costs associated with acute asthma care and the changes in Asthma Control Test™ scores. This

investigation aimed to shed light on the potential advantages of implementing digital tools for managing

asthma.

Rhee et al7. (2021) conducted research to evaluate the effectiveness of a peer-led asthma self-

management education initiative for adolescents aged 12–17 years (N=259) residing in urban areas

across three U.S. cities. The program consisted of educational sessions held at a day camp, with

subsequent bi-monthly follow-ups over a 12-month period. Peer leaders effectively conveyed 85–95%

of asthma knowledge and skills information but omitted 14% of psychosocial content compared to adult

educators, who covered all material. The PLASMA intervention group showed high content and time

adherence (94%–97.6%) during educational sessions, although follow-up communication rates were

superior in the attention control group.

In their study, Poowuttikul and Seth

(2020) underscored the significance of smartphone health apps in

improving asthma self-care. Their analysis revealed that these digital tools, including devices for

tracking inhaler usage, led to better adherence to medication regimens, improved overall well-being, and

potentially lowered medical expenses. These technological solutions offer promising avenues for asthma

management across various demographic groups.

A randomized controlled trial was performed by Kohler et al

. (2020) to compare the effectiveness of an

online asthma self-management program (eAEP) with a traditional clinic-based program (pAEP). The

study revealed that participants in the eAEP group demonstrated notable improvements in their asthma

knowledge. Their Asthma Knowledge Test (AKT) scores increased significantly from an initial 41.57

(SD = 5.63) to 45.82 (SD = 3.84) upon completion of the program (p < 0.001). These knowledge gains

continued to grow, reaching 47.20 (SD = 3.78) after the pAEP was completed. Although participants in

the pAEP group also showed improvements in their AKT scores.

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A study by Schneider et al

. (2019) investigated the effectiveness of an asthma management application

designed specifically for teenagers. The research involved a 20-participant trial lasting three months.

The application was designed to assist users in tracking their asthma condition, provide reminders for

peak flow measurements, and enhance communication with medical professionals. Although

participants acknowledged the app's usefulness in managing their condition, various external elements

hindered its regular usage. The adolescents in the study proposed changes to enhance the app's appeal to

their age group.

A study by Sazlina et al.

(2019) investigated the viability of an assisted asthma self-management

initiative incorporating visual action plans. The research evaluated asthma control at 1, 3, and 6-month

intervals, along with additional outcomes such as adherence to medication, asthma attacks, and hospital

admissions. After six months, the number of participants with well-controlled asthma rose from 30.4%

to 64.4%. The study also observed substantial decreases in severe asthma episodes, emergency

department visits, and hospitalizations. These improvements resulted in estimated cost savings of

RM15,866.22 (USD 3,755.36) for 59 participants over the half-year period.

Finally, Harris et al.

(2019) created a self-management intervention for teenagers based on theoretical

principles, utilizing the COM-B model. The initiative incorporated theater workshops for all students in

grades 7 and 8, along with specialized self-management sessions for asthmatic individuals. Information

was gathered at the start and at 3, 6, and 12 months following the intervention. The study's outcomes

were intended to guide public health policies, with plans to share the results at conferences and with

local health authorities.

Discussion

An analysis of eight studies examining the impact of self-management on asthma recurrence revealed

that self-management significantly reduces the frequency of asthma episodes while also lowering overall

treatment costs. Studies by Sazlina et al [14], Schneider et al [15], and Silberman et al [16] reported that

self-management interventions are practical and easily applicable for individuals with asthma and their

families, as the required tools and resources are portable and accessible at any time.

Self-management has been shown to enhance family knowledge regarding asthma care, with more than

80% of participants reporting improved understanding of asthma management techniques. Sazlina et al

[14] demonstrated that structured action plans significantly improve patient and caregiver awareness of

symptom control and medication use. Similarly, Schneider et al [15] observed that mobile app–based

self-management programs increased patient confidence and engagement in daily asthma care.

Evidence further suggests that self-management promotes independence among asthma patients,

particularly in identifying triggers and implementing preventive strategies to reduce recurrence.

Silberman et al [16] highlighted that digital self-management interventions improved adherence to

treatment protocols and facilitated timely decision-making during symptom exacerbations. Improved

adherence to self-management practices was consistently observed when compared to baseline levels.

Overall, the findings indicate that self-management not only enhances knowledge but also improves the

quality of life and clinical outcomes of asthma patients. By providing clear guidance on medication

schedules, trigger avoidance, and symptom monitoring, self-management programs play a critical role in

reducing asthma recurrence and supporting long-term disease control for patients and their families [14–

16].

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Conclusion

This systematic review shares a common focus with previous research on utilizing self-management

interventions for asthma patients. These interventions have shown beneficial effects for individuals with

asthma, as they lead to a decrease in the frequency of asthma episodes. Furthermore, they contribute to

reducing the financial burden associated with asthma treatment. The study also revealed variations in

outcomes between adolescent and adult participants or control groups. Notwithstanding these variations,

the overall results indicated that interventions focused on self-management were successful in reducing

the frequency of asthma exacerbations across all cohorts.

Conflict of interest: Nil

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