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Intervenciones de apoyo para adolescentes con asma a cargo de otros pacientes con asma o personas no especializadas

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References

Al‐sheyab 2012 {published data only}

Al‐Sheyab N, Gallagher R, Crisp J, Shah S. Peer‐led education for adolescents with asthma in Jordan: a cluster‐randomized controlled trial. Pediatrics 2012;129(1):e106‐12. [CENTRAL: 804288; CRS: 4900100000056279; PUBMED: 22157137]CENTRAL
Al‐Sheyab NA, Shah S, Gallagher R, Crisp J. Effectiveness of a peer‐led education program for adolescents with asthma in Jordanian schools [Abstract]. American Journal of Respiratory and Critical Care Medicine 2010;181(Meeting Abstracts):A2253. [CENTRAL: 756278; CRS: 4900100000025092]CENTRAL

NCT01161225 {published data only}

NCT01161225. Teen Asthma Project (TAP). clinicaltrials.gov/ct2/show/NCT01161225 (first received 9 July 2010). [CRS: 4900132000030033]CENTRAL
Rhee H, Belyea MJ, Hunt JF, Brasch J. Effects of a peer‐led asthma self‐management program for adolescents. Archives of Pediatrics and Adolescent Medicine 2011;165(6):513‐9. [CENTRAL: 793213; CRS: 4900100000026761; EMBASE: 2011309793]CENTRAL
Rhee H, McQuillan BE, Belyea MJ. Evaluation of a peer‐led asthma self‐management program and benefits of the program for adolescent peer leaders. Respiratory Care 2012;57(12):2082‐9. [CENTRAL: 839956; CRS: 4900100000070664; EMBASE: 2012722950; PUBMED: 22710616]CENTRAL
Rhee H, Pesis‐Katz I, Xing J. Cost benefits of a peer‐led asthma self‐management program for adolescents. Journal of Asthma 2012;49(6):606‐13. [CENTRAL: 832704; CRS: 4900100000062830; EMBASE: 2012417278; PUBMED: 22758599]CENTRAL

NCT01169883 {published data only}

Mosnaim G, Li H, Martin M, Belice PJ, Avery E, Ryan N, et al. The use of coping peer support and mp3 technology to improve adherence to inhaled corticosteroids among low‐income minority adolescents. Journal of Allergy and Clinical Immunology 2013;131(2):AB133 [478]. [CENTRAL: 841332; CRS: 4900100000072731; EMBASE: 70984536]CENTRAL
Mosnaim G, Li H, Martin M, Richardson D, Belice PJ, Avery E, et al. The impact of peer support and mp3 messaging on adherence to inhaled corticosteroids in minority adolescents with asthma: a randomized, controlled trial. Journal of Allergy and Clinical Immunology: In Practice 2013;1(5):485‐93. [CENTRAL: 874493; CRS: 4900100000090940; EMBASE: 2013557461; PUBMED: 24565620]CENTRAL
NCT01169883. Coping peer intervention for adherence. clinicaltrials.gov/show/NCT01169883 (first received 23 July 2010). [CRS: 4900132000022879]CENTRAL
Powell L. The impact of peer support and mp3 messaging on adherence to inhaled corticosteroids in minority adolescents with asthma: a randomized, controlled trial. Journal of Allergy and Clinical Immunology 2013;1(5):485‐93. [CENTRAL: 1051000; CRS: 4900126000026208; EMBASE: 24565620]CENTRAL

NCT01938976 {published data only}

Al‐Sheyab N, Alomari M, Shah S, Gallagher R. 'Class smoke‐free' pledge impacts on nicotine dependence in male adolescents: a cluster randomized controlled trial. Tropical Medicine and International Health 2015;20:255‐6. [CENTRAL: 1106778; CRS: 4900132000012443; EMBASE: 72054834]CENTRAL
Al‐Sheyab N, Alomari MA, Shah S, Gallagher R. “Class smoke‐free” pledge impacts on nicotine dependence in male adolescents: a cluster randomized controlled trial. Journal of Substance Misuse 2016;21(6):566‐74. CENTRAL
NCT01938976. Efficacy of school‐based, peer‐led asthma and smoking prevention program on CO1 levels, nicotine dependence, and smoking behavior among early adolescents in Jordan. clinicaltrials.gov/show/NCT01938976 (first received 5 September 2013). [CRS: 4900132000030032]CENTRAL

Shah 2001 {published data only}

Shah S, Peat J, Cantwell G, Wang H, Sindusake P, Gibson P. Peer‐led asthma education improves quality of life in adolescents [abstract]. American Journal of Respiratory and Critical Care Medicine 2000;161(3 Suppl):A902. [CENTRAL: 429158; CRS: 4900100000014676]CENTRAL
Shah S, Peat J, Wang H, Sindusake P, Henry R, Gibson P. Peer‐led asthma education improves quality of life in adolescents. Journal of Paediatrics and Child Health 2001;37(6):A2. [CENTRAL: 451330; CRS: 4900100000015641; 4900100000015641]CENTRAL
Shah S, Peat JK, Mazurski EJ, Wang H, Sindhusake D, Bruce C, et al. Effect of peer led programme for asthma education in adolescents: cluster randomised controlled trial. BMJ (Clinical Research Ed.) 2001;322(7286):583‐5. [CENTRAL: 328135; CRS: 4900100000009995; PUBMED: 11238152]CENTRAL

Bruzzese 2008 {published data only}

Bruzzese JM, Unikel L, Gallagher R, Evans D, Colland V. Feasibility and impact of a school‐based intervention for families of urban adolescents with asthma: results from a randomized pilot trial. Family Process 2008;47(1):95‐113. [CENTRAL: 631279; CRS: 4900100000021863; PUBMED: 18411832]CENTRAL

Bryant‐Stephens 2008 {published data only}

Bryant‐Stephens T, Kurian C, Guo R, Zhao H. Impact of a household environmental intervention delivered by lay health workers on asthma symptom control in urban, disadvantaged children with asthma. American Journal of Public Health 2009;99(Suppl 3):S657‐65. [CENTRAL: 731813; CRS: 4900100000024437; PUBMED: 19890172]CENTRAL
Bryant‐Stephens T, Li Y. Outcomes of a home‐based environmental remediation for urban children with asthma. Journal of the National Medical Association 2008;100(3):306‐16. [CENTRAL: 631173; CRS: 4900100000021860; PUBMED: 18390024]CENTRAL

Chernoff 2002 {published data only}

Chernoff RG, Ireys HT, DeVet KA, Kim YJ. A randomized, controlled trial of a community‐based support program for families of children with chronic illness: pediatric outcomes. Archives of Pediatrics and Adolescent Medicine 2002;156(6):533‐9. [CENTRAL: 380315; CRS: 4900100000011365; EMBASE: 2002199460; PUBMED: 12038883]CENTRAL

Duncan 2013 {published data only}

Duncan CL, Hogan MB, Tien KJ, Graves MM, Chorney JM, Zettler MD, et al. Efficacy of a parent‐youth teamwork intervention to promote adherence in pediatric asthma. Journal of Pediatric Psychology 2013;38(6):617‐28. [CENTRAL: 870963; CRS: 4900100000088253; EMBASE: 23248342; PUBMED: 23248342]CENTRAL

Flores 2009 {published data only}

Flores G, Bridon C, Torres S, Perez R, Walter T, Brotanek J, et al. Improving asthma outcomes in minority children: a randomized, controlled trial of parent mentors. Pediatrics 2009;124(6):1522‐32. [CENTRAL: 728227; CRS: 4900100000024362; EMBASE: 2009639668; PUBMED: 19948624]CENTRAL

Gibson 1998 {published data only}

Gibson PG, Shah S, Mamoon HA. Peer‐led asthma education for adolescents: impact evaluation. Journal of Adolescent Health 1998;22(1):66‐72. [CENTRAL: 146910; CRS: 4900100000005938; PUBMED: 9436069]CENTRAL

Horner 2008 {published data only}

Horner SD, Fouladi RT. Improvement of rural children's asthma self‐management by lay health educators. Journal of School Health 2008;78(9):506‐13. [CENTRAL: 651040; CRS: 4900100000022529; 4900100000022529; PUBMED: 18786043]CENTRAL

JPRN‐UMIN000018186 {published data only}

Feasibility and efficacy of peer education for children with asthma: a pilot study. https://upload.umin.ac.jp/cgi‐open‐bin/ctr_e/ctr_view.cgi?recptno=R000020982 (accessed 12 September 2016). CENTRAL

Krieger 2009 {published data only}

Krieger J, Takaro TK, Song L, Beaudet N, Edwards K. A randomized controlled trial of asthma self‐management support comparing clinic‐based nurses and in‐home community health workers: the Seattle‐King County Healthy Homes II Project. Archives of Pediatrics and Adolescent Medicine 2009;163(2):141‐9. [CENTRAL: 668378; CRS: 4900100000022903; EMBASE: 2009074863; 4900100000022903; PUBMED: 19188646]CENTRAL

Martin 2015 {published data only}

Martin MA, Mosnaim GS, Olson D, Swider S, Karavolos K, Rothschild S. Results from a community‐based trial testing a community health worker asthma intervention in Puerto Rican youth in Chicago. Journal of Asthma 2015;52(1):59‐70. [CENTRAL: 1000001; CRS: 4900126000018344; PUBMED: 25162304]CENTRAL

Mosnaim 2010 {published data only}

Mosnaim G, Sharp L, Damitz M, Li Z, Africk J, Powell LH. Evaluation of the fight asthma now (FAN!) program to improve asthma knowledge in urban youth and teenagers [Abstract]. Journal of Allergy and Clinical Immunology 2010;125(2 Suppl 1):AB59. [CENTRAL: 765101; CRS: 4900100000025609; EMBASE: 70155340]CENTRAL

NCT00214669 {published data only}

NCT00214669. Can education for South Asians with asthma and their clinicians reduce unscheduled care? A randomised trial (OEDIPUS). clinicaltrials.gov/ct2/show/NCT00214669 (first received 14 September 2005). CENTRAL

NCT01725815 {published data only}

NCT01725815. The health access and recovery peer program (HARP) [A peer‐led, medical disease self‐management program for mental health consumers]. clinicaltrials.gov/show/NCT01725815 (first received 25 April 2012). [CRS: 4900132000006212]CENTRAL

NCT02747706 {published data only}

NCT02747706. Childhood asthma mentoring program for parents (CAMPP) [Peer mentor training to reduce hospitalizations for children with asthma]. clinicaltrials.gov/show/NCT02747706 (first received 18 April 2016). [CRS: 4900132000030034]CENTRAL

Partridge 2008 {published data only}

Partridge MR, Caress AL, Brown C, Hennings J, Luker K, Woodcock A, et al. Can lay people deliver asthma self‐management education as effectively as primary care based practice nurses?. Thorax 2008;63(9):778‐83. [CENTRAL: 647700; CRS: 4900100000022467; PUBMED: 18281394]CENTRAL
Roberts NJ, Boyd K, Briggs A, L Caress A, Partridge MR. Is it cost‐effective to replace nurses with lay asthma educators in primary care? [Abstract]. Thorax 2010;65(Suppl 4):S10. [CENTRAL: 783533; CRS: 4900100000026310; EMBASE: 70325700]CENTRAL
Roberts NJ, Boyd KA, Briggs AH, Caress AL, Partridge MR. Nurse led versus lay educators support for those with asthma in primary care: a costing study. BMC Pulmonary Medicine 2012;12:52. [CENTRAL: 839481; CRS: 4900100000068575; EMBASE: 2012687840; PUBMED: 22958541]CENTRAL

Pulgaron 2010 {published data only}

Pulgaron ER, Salamon KS, Patterson CA, Barakat LP. A problem‐solving intervention for children with persistent asthma: a pilot of a randomized trial at a pediatric summer camp. Journal of Asthma 2010;47(9):1031‐9. [CENTRAL: 769411; CRS: 4900100000025766; EMBASE: 2010618216; PUBMED: 20858029]CENTRAL

Rice 2015 {published data only}

Rice JL, Matlack KM, Simmons MD, Steinfeld J, Laws MA, Dovey ME, et al. Leap: a randomized‐controlled trial of a lay‐educator inpatient asthma education program. Patient Education and Counseling 2015;98(12):1585‐91. [CENTRAL: 1087159; CRS: 4900132000005351; EMBASE: 2015216121; PUBMED: 26210342]CENTRAL

Srof 2012 {published data only}

Srof BJ, Velsor‐Friedrich B, Penckofer S. The effects of coping skills training among teens with asthma. Western Journal of Nursing Research 2012;34(8):1043‐61. [CENTRAL: 845573; CRS: 4900100000071982; EMBASE: 21511980; PUBMED: 21511980]CENTRAL

Valery 2010 {published data only}

Valery PC, Masters IB, Taylor B, Laifoo Y, O'Rourke PK, Chang AB. An education intervention for childhood asthma by Aboriginal and Torres Strait Islander health workers: a randomised controlled trial. Medical Journal of Australia 2010;192(10):574‐9. [CENTRAL: 751730; CRS: 4900100000024907; EMBASE: 2010294628; PUBMED: 20477733]CENTRAL

Wallis 2015 {published data only}

Wallis EM, Salek EC, Steinway C, Stollon N, Trachtenberg SW, Schwartz LA, et al. Transition from pediatric to adult healthcare for youth with complex chronic conditions: a primary care pilot study. Journal of Adolescent Health 2015;56(2 Suppl 1):S125. [CENTRAL: 1066946; CRS: 4900126000025855; EMBASE: 71770915]CENTRAL

NCT00217776 {published data only}

NCT00217776. School‐based approaches to help pre‐teens manage asthma. clinicaltrials.gov/show/NCT00217776 (first received 19 September 2005). [CRS: 4900132000030030]CENTRAL

NCT02293499 {published data only}

NCT02293499. Peer led asthma self management for adolescents: PLASMA. clinicaltrials.gov/show/NCT02293499 (first received 24 October 2014). [CRS: 4900132000006187]CENTRAL

Al‐Sheyab 2012

Al‐Sheyab N. Power of peer leaders in improving self‐management skills among adolescents with asthma. Evidence‐Based Nursing 2012;15(2):45‐6.

Alanasari 2004

Alanasari BM. Factor structure of the Arabic version of the self‐administered nicotine dependence scale. Social Behavior and Personality 2004;32(3):255‐62.

Bagnall 2015

Bagnall AM, South J, Hulme C, Woodall J, Vinall‐Collier K, Raine G, et al. A systematic review of the effectiveness and cost‐effectiveness of peer education and peer support in prisons. BMC Public Health 2015;15(1):290.

Bender 2006

Bender BG. Risk taking, depression, adherence, and symptom control in adolescents and young adults with asthma. American Journal of Respiratory and Critical Care Medicine 2006;173(9):953‐7.

BTS/SIGN 2016

British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. A national clinical guideline. SIGN 153. https://www.brit‐thoracic.org.uk/document‐library/clinical‐information/asthma/btssign‐asthma‐guideline‐2016/ (accessed 9 December 2016).

Butz 1994

Butz AM, Malveaux FJ, Eggleston P, Thompson L, Schneider S, Weeks K, et al. Use of community health workers with inner‐city children who have asthma. Clinical Pediatrics 1994;33(3):135‐41.

Cain 2006

Cain JJ, Dickinson WP, Fernald D, Bublitz C, Dickinson LM, West D. Family physicians and youth tobacco‐free education: outcomes of the Colorado Tar Wars program. Journal of the American Board of Family Medicine 2006;19(6):579‐89.

Davis 1994

Davis LJ, Hurt RD, Offord KP, Lauger GG, Morse RM, Bruce BK. Self‐administered Nicotine‐Dependence Scale (SANDS): item selection, reliability estimation, and initial validation. Journal of Clinical Psychology 1994;50(6):918‐30.

Dennis 2003

Dennis CL. Peer support within a health care context: a concept analysis. International Journal of Nursing Studies 2003;40(3):321‐32.

Department of Health 2001

Department of Health. The expert patient: a new approach to chronic disease management for the 21st century. http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4018578.pdf (accessed 22 February 2016).

GINA 2016

Global Initiative for Asthma. Global strategy for asthma management and prevention, 2016. http://ginasthma.org/ (accessed 21 March 2016).

Glenton 2011

Glenton C, Scheel IB, Lewin S, Swingler GH. Can lay health workers increase the uptake of childhood immunisation? Systematic review and typology. Tropical Medicine and International Health 2011;16(9):1044‐53.

Global Asthma Network 2014

Global Asthma Network. The Global Asthma Report 2014. http://globalasthmareport.org/resources/Global_Asthma_Report_2014.pdf (accessed 29 April 2016).

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Haines A, Sanders D, Lehmann U, Rowe AK, Lawn JE, Jan S, et al. Achieving child survival goals: potential contribution of community health workers. The Lancet 2007;369(9579):2121‐31.

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Kaunonen M, Hannula L, Tarkka MT. A systematic review of peer support interventions for breastfeeding. Journal of Clinical Nursing 2012;21(13‐14):1943‐54.

Koster 2015

Koster ES, Philbert D, de Vries TW, van Dijk L, Bouvy ML. "I just forget to take it": asthma self‐management needs and preferences in adolescents. The Journal of Asthma 2015;52(8):831‐7.

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Pfeiffer PN, Heisler M, Piette JD, Rogers MA, Valenstein M. Efficacy of peer support interventions for depression: a meta‐analysis. General Hospital Psychiatry 2010;33(1):29‐36.

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References to other published versions of this review

Kew 2016

Kew KM, Carr R, Crossingham I. Lay‐led and peer support interventions for adolescents with asthma. Cochrane Database of Systematic Reviews 2016, Issue 8. [DOI: 10.1002/14651858.CD012331]

Characteristics of studies

Characteristics of included studies [ordered by study ID]

Al‐sheyab 2012

Methods

Study design: 3‐month open‐label cluster RCT

Setting: 4 high schools in Irbid, Jordan

Participants

Population: 4 schools including 261 included students; 2 schools took part in the Triple A programme (132 students) and 2 schools provided no intervention (129 students)

Age range: approximately 14 to 16 years based on included school years

Baseline characteristics

Triple A students: 72.7% had asthma; 63.6% male; 20.5% took ICS (23.5% took a reliever); 25% student smokers; 72% family member smokes

Control students: 68.2% had asthma; 49% male; 23.3% took ICS (43.3% took a reliever); 30% student smokers; 71.3% family member smokes

Inclusion criteria: Students from years 8, 9 and 10 were eligible for participation in the study if they had reported wheezing in the past 12 months as identified by the Arabic version of the International Study for Asthma and Allergy Committee (ISAAC) written questionnaire; were physically and cognitively capable of completing the survey; were able to read and converse in both Arabic and English; attended regular school classes; were free of any other major diseases that could affect quality of life measures; and were not concurrently involved in another health‐related study

Exclusion criteria: not regularly attending in year 8, 9 or 10; did not experience wheezing in the past 12 months; had other chronic conditions

Interventions

Intervention: Bilingual Jordanian health workers delivered the content of the peer leader training programme in both English and Arabic. Health workers trained 11 peer leaders from year 11 at each of the intervention schools to deliver the 3 Triple A lessons to year 10 students

Control: standard care ‐ no intervention

Outcomes

The main study outcomes (health‐related quality of life (Arabic PAQLQ), self‐efficacy to resist smoking (subscale of the Self‐Administered Nicotine Dependence Scale) and knowledge of self‐management of asthma (Arabic Asthma Knowledge Consumer Questionnaire)) were collected at baseline and at 3 months after the intervention

"Baseline data included demographic characteristics, smoking habits of students and their families, presence of asthma diagnosis by health professionals, and medications using a self‐reporting checklist developed by the researchers. Data on asthma symptoms and severity were collected using the Arabic version of the ISAAC written questionnaire (8 questions about symptoms, diagnosis and severity over past 12 months)"

Notes

Trial registration: ISRCTN63833842

Funding: The study was supported by Jordan University of Science and Technology, Irbid, Jordan. We also thank the Nursing Council in Jordan for financial support provided throughout the study

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Four high schools in the Irbid region in northern Jordan were selected using a closed‐envelope technique, from a total of 54 public schools that included Year 8 through Year 11, by an individual independent of the research team. Two schools were randomly selected from all the eligible high schools for girls, and the other 2 schools were randomly selected from all the eligible high schools for boys. Schools were stratified according gender to ensure a balanced sample. The selected schools, which were all single gender (2 for boys and 2 for girls), agreed to participate in the study"

"Allocation to groups occurred by using the cluster method of randomization at the school level and the closed‐envelope technique stratified for the gender at the school (2 each)"

Allocation concealment (selection bias)

Low risk

Most of the information given relates to blinding of sampling rather than to group allocation

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Participants and personnel could not be kept blind to group allocation

Blinding of outcome assessment (detection bias)
All outcomes

High risk

All outcomes were self‐reported by participants who could not be blinded to treatment assignment

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Six students from the intervention group (4.6%) and 11 (8.5%) from the control group did not complete the trial because they were absent from school on the day of outcome data collection. As school absence due to asthma was one of the outcomes the intervention was intended to impact, it is possible that exclusion of these children from the analysis

Selective reporting (reporting bias)

Low risk

Trial was retrospectively (ISRCTN63833842), not prospectively, registered. Named outcomes are reported in full, but the study was not prospectively registered. Study authors responded to contact and confirmed that they possess no additional data relevant to our analyses

Other bias

Unclear risk

School selection is described in detail but may have introduced a selection bias before randomisation

NCT01161225

Methods

Study design: 9‐month single‐blind parallel RCT

Setting: an urban city and adjacent suburbs in upstate New York

Participants

Population: 112 adolescents were randomised to an asthma programme led by peers (n = 59) or by adults (n = 53)

Age range: 13 to 17 years

Baseline characteristics

71% on at least 1 controller medicine

Peer‐led: 44.1% male; mean age 14.9 years (SD 1.4); 45.8% white

Adult‐led: 41.5% male; mean age 14.5 years (SD 1.3); 47.2% white

Inclusion criteria: (1) age 13 to 17 years; (2) mild, moderate or severe persistent asthma specified by NHLBI guidelines; (3) asthma diagnosis ≥ 1 year; (4) no other chronic/emotional health conditions (e.g. diabetes, cystic fibrosis, major depression); and (5) ability to understand spoken and written English

Exclusion criteria: "Adolescents with learning disabilities based on reports from parents, teachers or clinicians were excluded, because this could influence the implementation and outcomes of the intervention program"

Interventions

Intervention: The Intervention group attended a 1‐day camp in which group activities were facilitated by 12 peer leaders. Peers (10 females, 2 males) were 16 to 20 years old, were nominated by school teachers/nurses or clinicians and attended 3‐week intensive structured training sessions (5 hours/wk). Paired peer leaders facilitated learning activities in small groups of 6 to 10 campers, overseen by adults. Younger leaders (16 to 17 years of age) led younger groups (13 to 14 years of age); older leaders (18 to 20 years of age) led older groups (15 to 17 years of age). Three 45‐ to 60‐minute sessions based on Power Breathing™ programme covered basic asthma education, psychosocial issues and asthma self‐management skills. Group activities involved discussion, strategic thinking, knowledge‐testing games and role playing. At completion of camp, peer leaders conducted monthly phone follow‐ups to provide continuous peer support and encouragement using a checklist. Approximately 49% were successfully reached each month, and average length of the interaction was 2 to 5 minutes for each contact

Control: The control group attended an adult‐led day camp that was held at the same camp site on a different day. Two nurse practitioners and a physician offered the campers didactic asthma education. The length of the day camp and the content of the asthma programme were comparable with those of the intervention group

Outcomes

The Children's Attitude toward Asthma Scale and the Pediatric Asthma‐related Quality of Life Questionnaire were administered at baseline, and immediately and 3, 6 and 9 months post intervention. Spirometry was conducted twice ‐ before the intervention and 9 months after the intervention

Notes

Trial registration: NCT01161225

Funding: supported by a grant from the NIH/NINR (R21 NR009837), awarded to Hyekyun Rhee

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"A total of 112 adolescents were randomly assigned using a computer generated random table to either the intervention (peer‐led camp) or control (adult‐led camp) group"

Allocation concealment (selection bias)

Unclear risk

No details

Blinding of participants and personnel (performance bias)
All outcomes

High risk

Study states, "Participants were blind to their group assignment", and is described as "single blind (subject)" on clinicaltrials.gov. Study personnel's knowledge of group assignment may have introduced bias

Blinding of outcome assessment (detection bias)
All outcomes

High risk

Most outcomes were rated by participants, who were unaware of their group assignment

Incomplete outcome data (attrition bias)
All outcomes

Low risk

A fair quantity of data were missing by the 9‐month measurement (27.1% and 22.6% in intervention and control groups) but the quantity was less at earlier time points and "analyses were performed using all available data (i.e., intent to treat), including participants who subsequently dropped out". Risk of bias is likely to be different depending on the outcome and the time point of interest, which will be considered in the Grade rating for each outcome individually

Selective reporting (reporting bias)

Low risk

Study was prospectively registered (NCT01161225), and as planned, all named outcomes were reported in published papers or on clinicaltrials.gov

Other bias

Low risk

None noted

NCT01169883

Methods

Study design: 10‐week open‐label parallel RCT

Setting: 3 primary care practices at Rush University Medical Center in Chicago, Illinois

Participants

Population: 68 adolescents were randomised to a peer support and messaging intervention (n = 34) or to an attention control group (n = 34)

Age range: 11 to 16 years

Baseline characteristics

Peer support:: 50% male; mean age 13.3 (range 11 to 16) years; 85% had uncontrolled asthma; 26.5% had 2 or more OCS courses in past 12 months and 57.6 had 1 or more ED visit or hospital admission in past 12 months; 5.9% current smokers; 8.8% family member smokes

Attention control: 47.1% male; mean age 13.6 (range 11 to 16) years; 76.5% had uncontrolled asthma (76.5%); 29.4% had 2 or more OCS courses in past 12 months and 44.1% had 1 or more ED visit or hospital admission in past 12 months; 0 current smokers; 5.9% family member smokes

Inclusion criteria: 11 to 16 years of age and self‐identified as African American or Hispanic, diagnosis of persistent asthma and possessing an active prescription for a daily ICS for asthma. Persistent asthma was defined as asthma symptoms (e.g. cough, wheeze, shortness of breath, chest tightness) more than 2 days per week or night‐time awakening more than twice a month; or being on a prescribed daily ICS for asthma. The latter requirement was met when the adolescent within the past 12 months had (1) an outpatient visit to Rush University Medical Center with asthma listed as a diagnosis code for that visit; and (2) a prescription for ICS

Exclusion criteria: caregiver or child unable to speak English, comorbidities that could interfere with study participation, or ≥ 48% adherence over 2 weeks during the run‐in period. Participants with ≥ 48% adherence were excluded, as the aim of the study was to target children with poor adherence (i.e. who could benefit most from this behavioural intervention)

Interventions

Intervention: peer support and mp3 messaging. Those in the intervention group received music tracks and attended coping peer group sessions led by social workers during weeks 1 to 4 and 6 to 9. Session leaders were trained to use a motivational interviewing approach and to follow the study guide. During the session, participants developed and recorded 2 to 4 messages from the discussion to encourage daily use of ICS, to be played at random between music tracks

Control: attention control. All participants received medical supervision, peak flow meters and an iPod during the run‐in. Those in the attention control group attended weekly individual sessions with a research assistant who did not promote adherence. They received the same number of iPod messages as those in the active intervention group with content promoting adherence to ICS, also played at random between music tracks, but recorded by an asthma doctor rather than by peers

Outcomes

The primary study outcome was ICS adherence (average daily adherence over the previous 14 days) measured with the electronic medication monitor for ICS, measured at baseline and at 5 and 10 weeks. Secondary outcomes were asthma knowledge (ZAP Caregiver Asthma Knowledge Instrument), ICS knowledge, ICS self‐efficacy, social support and asthma exacerbations.

Asthma exacerbations included self‐reported missed schooldays; oral prednisone bursts; unscheduled urgent visits to the doctor’s office; emergency department visits; hospitalisations; intensive care unit admissions; and intubations

Notes

Trial registration: NCT01169883

Funding: National Heart Lung and Blood Institute grants K23 HL092292 and R21 HL098812. Support in the form of study drug was provided by a grant from GlaxoSmithKline (FLV114794)

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Blocked group randomization, using a computer‐generated allocation schedule"

Allocation concealment (selection bias)

Unclear risk

No details

Blinding of participants and personnel (performance bias)
All outcomes

High risk

It was not possible to blind participants, although adherence, the only outcome reported that is of interest in this review, was measured objectively. However, awareness of the intervention group and of monitoring may have affected adherence behaviour beyond the effect intended by the intervention

Blinding of outcome assessment (detection bias)
All outcomes

Low risk

"Outcomes data were collected at baseline and at 5 and 10 weeks post‐randomization (during the active treatment phase) by research assistants blinded to the participants’ group assignment"

Incomplete outcome data (attrition bias)
All outcomes

Low risk

More than 80% in both arms attended at least 1 follow‐up visit (at 5 or 10 weeks) and were included in the analysis; reasons for dropping out were similar between groups

Selective reporting (reporting bias)

High risk

Prospectively registered trial (NCT01169883) and outcomes listed on trial register clearly reported (although medians and IQRs used, so unable to include in meta‐analysis). Several outcomes of interest in this review were listed as measured in the methods section of the published report but were not reported in the results (e.g. unscheduled visits, exacerbations)

Other bias

Low risk

None noted

NCT01938976

Methods

Study design: 4‐month open‐label cluster RCT

Setting: 4 male schools in Irbid, Jordan

Participants

Population: 4 schools, 2 randomised to Triple A + smoking pledge, 2 randomised to Triple A alone. 53 peer leaders and 433 students (215 Triple A + smoking pledge, 218 Triple A alone) included

Age range: 12 to 13 years

Baseline characteristics

Whole population: all male, 13% with diagnosed asthma and a further 13% with reported recent wheezing; 37% were “ever” smokers

Inclusion criteria: Students from grades 7 and 8 (ages 12 to 13) were eligible to participate if they were capable of completing the survey, were able to read and write in the Arabic language and were free of any major disease that could affect their responses

Exclusion criteria: Students who were concurrently involved in another health‐related study were excluded

Interventions

Intervention: The Triple A programme uses a 3‐step cascade process plus a smoke‐free pledge. Trained health educators trained senior students from grade 10 to be peer leaders (n = 53) who deliver 3 sessions to peers in grades 7 and 8 (n = 433). Sessions focused on asthma knowledge, smoking refusal and resistance skills, empowerment and leadership. Resources of the Triple A programme included standardised training manuals for educators and leaders, DVDs about asthma management and smoking and an asthma first aid kit. Motivational strategies included interactive teaching, role‐playing, group discussion and a quiz show. Volunteer peers then developed asthma and smoking messages to be presented to the school community as creative performances. Peer leaders also implemented the smoke‐free pledge for peers who voluntarily signed the pledge for 4 months. The class, facilitated by peer leaders, monitored adherence on a fortnightly basis for 4 months

Control: The comparison group received the same intervention components as the intervention group, minus the smoke‐free pledge

Outcomes

Smoking‐related knowledge and perceptions (for all selected students), smoking behaviour (for all selected students), level of nicotine dependence (for selected students who reported ever cigarette smoking), screening questionnaire for asthma and recent wheezing; students from this sample who had an asthma diagnosis or recent wheezing in the past 12 months also completed the questionnaire on level of asthma control

Notes

Trial registration: not reported

Funding: The Deanship of Scientific Research at Jordan University of Science and Technology, Irbid, Jordan (96/2012)

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"The four selected schools were randomly assigned to either the TAJ or the TAJ‐Plus using an opaque envelope technique to ensure allocation was blinded (Hedges, 2007)." Students were then allocated using "simple random assignment allocation using opaque envelope technique". Of all those allocated (815), a random selection was chosen by "every second student in the alphabetical class list"

Allocation concealment (selection bias)

Low risk

"The four selected schools were randomly assigned to either the TAJ or the TAJ‐Plus using an opaque envelope technique to ensure allocation was blinded (Hedges, 2007). The opaque envelope technique is a method used to blind the personnel who were (1) selecting the schools to be approached to join the study and (2) allocating the schools to the experimental and control groups. For the allocation to group, an independent researcher undertook the creation of four allocations (two experimental and two control) and sealed them in opaque envelopes. Once the school principal agreed that the school would participate in the study, an envelope was opened by the independent researcher and the result recorded and the chief investigator advised"

"The random sampling and allocation technique was conducted by a trained, independent researcher"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

"The cluster design made it possible to blind students to the intervention type as all participating students within the same school received the same intervention"

However, it would not be possible to blind personnel to group allocation, and this may have introduced performance bias

Blinding of outcome assessment (detection bias)
All outcomes

High risk

All questionnaires were self‐report and hence were subject to detection bias

Incomplete outcome data (attrition bias)
All outcomes

Low risk

Overall, the trial is at low risk of attrition bias, as 195/215 (9.3% dropout) students in the 2 intervention schools and 202/218 (7.3% dropout) students in the 2 control schools were included in the analyses, but lower numbers were available depending on the outcome, as "Only students who provided both baseline and follow‐up data were analyzed"

Selective reporting (reporting bias)

Low risk

Named outcomes were reported appropriately but no prospective protocol was available. Study authors responded to contact and confirmed that they possess no additional data relevant to our analyses

Other bias

Unclear risk

"The outcome analyses were adjusted for clustering effects as well as any baseline differences between the two groups using the split‐plot design"

"All baseline differences between the study groups were adjusted for in the analyses"

Shah 2001

Methods

Study design: 8‐month cluster RCT (baseline measures taken in February 1998 and follow‐up in October 1998)

Setting: 6 high schools in rural Australia

Participants

Population: 272 adolescents were randomised to the Triple A programme (n = 124) or to a control group (n = 148)

Age range: year 7 (12 to 13 years of age) and year 10 (15 to 16 years of age) students

Baseline characteristics

Triple A: mean age 12.5 for year 7's, 15.5 for year 10's; 34.5% male; 40.7% taking ICS

Control: mean age 12.5 for year 7's, 15.5 for year 10's; 54.3% male; 32.6% taking ICS

Inclusion criteria: A video questionnaire from the International Study of Asthma and Allergies in Childhood was administered to all students in years 7 and 10 who were present on the test day (1379 students) at each school in February 1998. Consenting students reporting recent wheeze (272 students) underwent baseline spirometry and completed questionnaires on asthma quality of life and asthma symptoms

Exclusion criteria: not reported

Interventions

Intervention: The Triple A programme involved a 3‐step approach to educating and empowering students with asthma. In step 1, year 11 student volunteers were trained as asthma peer leaders during a 6‐hour workshop conducted by the study team. Students learnt how to educate their peers about asthma and its management using games, videos, worksheets and discussions as teaching tools. In step 2, teams of 3 to 4 peer leaders conducted three 45‐minute health lessons for each year 10 class in their school. In step 3, year 10 students developed and presented key messages learnt in lessons to the year 7 students. Presentations by year 10 students included short acts, dramas and songs, with titles such as “don't smoke,” “asthma can kill” and “visit your doctor”

Control: Before the study, all schools received first aid kits for asthma and asthma workshops for school staff. All students known to have asthma were issued a record card to be completed by their doctor. In addition, a workshop on adolescent asthma was held for local doctors, and regular reports of the study appeared in local print and electronic media

Outcomes

Quality of life, school absenteeism, asthma attacks and lung function

Notes

Trial registration: not reported

Funding: The Commonwealth Department of Health and Aged Care and Asthma New South Wales

Risk of bias

Bias

Authors' judgement

Support for judgement

Random sequence generation (selection bias)

Low risk

"Concealed random allocation was performed...using a random number generator"

Allocation concealment (selection bias)

Low risk

"Concealed random allocation was performed by PGG (who was not involved with the administration of the study), using...the closed envelope technique"

Blinding of participants and personnel (performance bias)
All outcomes

High risk

No description of any blinding procedures. Participants and personnel would have been aware of group assignment

Blinding of outcome assessment (detection bias)
All outcomes

High risk

No description of any blinding procedures. Participants and personnel would have been aware of group assignment, and outcomes were self‐reported

Incomplete outcome data (attrition bias)
All outcomes

High risk

10/148 who had baseline measurements in the intervention group (6.8%) and 11/124 in the control group (8.9%) had matched data at the end of the trial. It is not clear at which point randomisation took place.

"Overall 1379 (91%) students completed the asthma screening questionnaire; 325 reported recent wheeze and 272 (83.7%) participated in baseline testing (fig 1). Matched data at both baseline and after the intervention were available for 251 students. Missing data occurred owing to misclassification, students moving schools or being absent on the day of testing, or failure to complete the questionnaire. These students were similar to the participants in terms of quality of life and related morbidity measures"

Selective reporting (reporting bias)

High risk

Exacerbations are not reported for year 7 pupils in the population, just that "The intervention had no effect on school absenteeism and asthma attacks in year 7 students" Other outcomes are reported, but no associated trial protocol was provided

Other bias

Low risk

None noted

ED: emergency department; ICS: inhaled corticosteroid; ISAAC: International Study for Asthma and Allergy Committee; NHLBI: National Heart, Lung, and Blood Institute; OCS: oral corticosteroid; PAQLQ: Paediatric Asthma Quality of Life Questionnaire; RCT: randomised controlled trial; SD: standard deviation.

Characteristics of excluded studies [ordered by study ID]

Study

Reason for exclusion

Bruzzese 2008

Intervention does not match inclusion criteria. Peers and lay leaders not involved

Bryant‐Stephens 2008

Population does not match inclusion criteria. Children between 2 and 16 years included, with mean age of 6 (i.e. not adolescents)

Chernoff 2002

Population does not match inclusion criteria. Children between 7 and 11 years included (i.e. not adolescents), with a range of chronic illnesses

Duncan 2013

Intervention does not match inclusion criteria. Peers and lay leaders not involved; interventions were education and parent/child teamwork

Flores 2009

Population does not match inclusion criteria. Intervention aimed at parents of children 2 to 18 years of age; mean age was around 7 (i.e. not adolescents)

Gibson 1998

Design does not match inclusion criteria. "One school received the peer‐led Triple A (Adolescent Asthma Action) program, and the second school served as a comparison school".

Horner 2008

Population does not match inclusion criteria. Children in grades 2 to 6 (USA and Canada), with mean age of 8.8 (SD 1.2) (i.e. not adolescents)

JPRN‐UMIN000018186

Design does not match inclusion criteria. Single‐arm/uncontrolled

Krieger 2009

Population does not match inclusion criteria ‐ children were between 3 and 13 years of age (mean age 8)

Martin 2015

Intervention does not match inclusion criteria ‐ home visit community health worker educational intervention for families

Mosnaim 2010

Design does not match inclusion criteria ‐ non‐randomly allocated to groups

NCT00214669

Population does not match inclusion criteria ‐ people of all ages (3 to 65), not just adolescents

NCT01725815

Population does not match inclusion criteria ‐ adults only (18+), and eligible participants could have any of a range of chronic diseases (hypertension, arthritis, coronary artery disease, hepatitis, diabetes, asthma, hyperlipidaemia, HIV)

NCT02747706

Population does not match inclusion criteria ‐ children between 3 and 12 and intervention aimed at mentoring parents

Partridge 2008

Population does not match inclusion criteria ‐ adults only (18+)

Pulgaron 2010

Population does not match inclusion criteria. Mean age was 10.4, which is just at the lower limit of adolescence, but study included children as young as 7 and as old as 14. Judged to not be an adolescent population

Rice 2015

Population does not match inclusion criteria. Children 2 to 17 years of age, with mean age of 6.9 (SD 3.9) (i.e. not adolescents)

Srof 2012

Intervention does not match inclusion criteria ‐ not peer supported or lay led

Valery 2010

Population does not match inclusion criteria. Children 1 to 17 years of age, with mean age of 6.9 (SD 4.0) (i.e. not adolescents)

Wallis 2015

Intervention does not match inclusion criteria ‐ aimed at adolescents and young adults 19 years of age and older to help transition into adult services

Characteristics of studies awaiting assessment [ordered by study ID]

NCT00217776

Methods

Study design: 12‐month double‐blind parallel randomised controlled trial (RCT)

Setting: 19 public middle schools in Detroit, Michigan

Participants

Population: 1292 early adolescents planned ‐ unclear whether recruitment started

Age range: 11 to 12 years

Baseline characteristics

None. Unclear whether this study was ever completed

Inclusion criteria: 6th grade students (11 to 12 years of age) enrolled in 19 public middle schools in Detroit, Michigan, who meet the following criteria: attend a participating school; based on National Asthma Education and Prevention Program (NAEPP) guidelines, (1) have a diagnosis of asthma and have active asthma symptoms and/or have received a prescription for asthma medications in the past year, or (2) report the presence of 3 of 5 non‐exercise‐related asthma symptoms in the past year on 5 or more occasions, or (3) report 2 or more exercise‐related asthma symptoms in the past year on 5 or more occasions or (4) have a severity classification of persistent disease (mild, moderate, severe) based on night‐time questions

Exclusion criteria: not reported

Interventions

Intervention: "Peer Asthma Action Educational Intervention". Children in this arm will receive BOTH the Open Airways asthma education programme and the Peer Asthma Action education programme. A 6‐week asthma educational self‐management programme is provided for middle school students plus a Peer Asthma Action Educational Intervention, which is a peer‐led training programme for children in multiple grades provided to teach them about asthma and asthma management

Control: "Open Airways Educational Intervention". Children in this arm will receive the Open Airways educational programme, which is an evidence‐based asthma educational programme for children, developed by the investigator. A 6‐week asthma educational self‐management programme is provided for middle school students

Outcomes

Use of healthcare services will be self‐reported in telephone interviews with parents at baseline, 12 months and 24 months. Additional primary outcomes listed in the protocol include asthma‐related quality of life, disease management behaviour and academic performance. Secondary outcomes include peer support, school attendance, physical activity, use of healthcare services and smoking behaviour

Notes

*No results reported or publications listed. Principal investigator deceased (2013). Contacted University of Michigan on 12/10/2016*

Trial registration: NCT00217776

Funding: University of Michigan and National Heart, Lung, and Blood Institute (NHLBI)

Characteristics of ongoing studies [ordered by study ID]

NCT02293499

Trial name or title

Peer Led Asthma Self Management for Adolescents: PLASMA (PLASMA)

Methods

15‐month open‐label parallel randomised controlled trial (RCT)

Participants

Estimated enrolment: 420

Inclusion criteria: adolescent (camp) participants 12 to 17 years of age; physician‐diagnosed asthma that has required use of healthcare services within 12 months; persistent asthma determined by current use of a control medication or > 2 days/wk of daytime symptoms, >3 to 4 times of night‐time awakening, >2 days/wk of short‐acting beta‐agonist (SABA) use or any interference with normal activities due to asthma. Investigators will include those with chronic health conditions, except those with conditions affecting respiratory system, heart disease, pneumonia, etc., and those with moderate to severe cognitive impairment; primary residence located in participating inner cities based on zip codes; and ability to understand spoken and written English

Eligibility criteria for peer leaders include age 16 to 20 years; nomination from school teachers/nurses or healthcare providers for candidates' exemplary asthma self‐management, leadership and emotional intelligence; and fulfilment of eligibility criteria prescribed for adolescent participants

Exclusion criteria: adolescents who are pregnant or incarcerated at enrolment; have learning disabilities based on reports from teachers or clinicians due to possible confounding of results; or have serious health (other than asthma) and emotional preconditions (e.g. severe depression, anxiety disorders, schizophrenia)

Interventions

Intervention: peer‐led asthma self‐management for adolescents: PLASMA will be implemented in small groups at a camp setting where paired peer leaders will facilitate learning activities. Paired peer leaders will share and coordinate the responsibilities of facilitating group activities. Training content includes the following: Day 1: asthma basics and prevention; Day 2: asthma monitoring and management; Day 3: communication/ psychosocial issue management/leadership training/hands‐on practice in simulated peer‐led group settings (role‐play)

Control: Adult‐led asthma self‐management will take place within 2 weeks of the peer‐led camp to minimise the history effect. Two healthcare professionals will attend peer leader training sessions to become familiar with programme content, then will lead instructional activities. As in PLASMA, adult leaders will base their instruction on the programme manual to ensure comparable programme content. Adult leaders will adopt mainly a didactic format and skill demonstration

Outcomes

Primary outcome measures: Pediatric Asthma Quality of Life Questionnaire (PAQLQ)
Secondary outcome measures: Adolescent Asthma Knowledge Questionnaire (AAK); Attitude Toward Asthma Scale (ATA); Asthma Self‐Efficacy (ASE); Asthma Outcome Expectation Scale (AOE); Asthma Self‐Management Skills (ASM); Asthma Control Test (ACT); Peak Expiratory Flow Rate (PEFR); Perceived Family Support
Other outcome measures: Camp Program Evaluation; Overall Program Evaluation; Peer Leader Rating Scale; Perceived Peer Leader Support Scale

Starting date

November 2014. Final data collection estimated by May 2018. Estimated completion November 2019

Contact information

Hyekyun Rhee, PhD; [email protected]

Notes

Currently recruiting participants. Sponsored by University of Rochester. Collaborators listed as Johns Hopkins University and University of Tennessee

Data and analyses

Open in table viewer
Comparison 1. Peer‐led vs control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Change in asthma‐related quality of life (PAQLQ) Show forest plot

3

Mean Difference (Random, 95% CI)

0.40 [‐0.02, 0.81]

Analysis 1.1

Comparison 1 Peer‐led vs control, Outcome 1 Change in asthma‐related quality of life (PAQLQ).

Comparison 1 Peer‐led vs control, Outcome 1 Change in asthma‐related quality of life (PAQLQ).

2 Asthma‐related quality of life (MCID) Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Totals not selected

Analysis 1.2

Comparison 1 Peer‐led vs control, Outcome 2 Asthma‐related quality of life (MCID).

Comparison 1 Peer‐led vs control, Outcome 2 Asthma‐related quality of life (MCID).

3 Asthma control Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Totals not selected

Analysis 1.3

Comparison 1 Peer‐led vs control, Outcome 3 Asthma control.

Comparison 1 Peer‐led vs control, Outcome 3 Asthma control.

4 Smoking Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Totals not selected

Analysis 1.4

Comparison 1 Peer‐led vs control, Outcome 4 Smoking.

Comparison 1 Peer‐led vs control, Outcome 4 Smoking.

4.1 Self‐efficacy to stop smoking

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4.2 Smoking‐related knowledge

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4.3 Nicotine dependence

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Study flow diagram.
Figures and Tables -
Figure 1

Study flow diagram.

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figures and Tables -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

Comparison 1 Peer‐led vs control, Outcome 1 Change in asthma‐related quality of life (PAQLQ).
Figures and Tables -
Analysis 1.1

Comparison 1 Peer‐led vs control, Outcome 1 Change in asthma‐related quality of life (PAQLQ).

Comparison 1 Peer‐led vs control, Outcome 2 Asthma‐related quality of life (MCID).
Figures and Tables -
Analysis 1.2

Comparison 1 Peer‐led vs control, Outcome 2 Asthma‐related quality of life (MCID).

Comparison 1 Peer‐led vs control, Outcome 3 Asthma control.
Figures and Tables -
Analysis 1.3

Comparison 1 Peer‐led vs control, Outcome 3 Asthma control.

Comparison 1 Peer‐led vs control, Outcome 4 Smoking.
Figures and Tables -
Analysis 1.4

Comparison 1 Peer‐led vs control, Outcome 4 Smoking.

Lay‐led and peer support interventions compared with usual care for adolescents with asthma

Patient or population: adolescents with asthma

Settings: school, day camp or primary care

Intervention: lay‐led and peer support interventions

Comparison: usual care/no intervention

Outcomes

Illustrative comparative risks* (95% CI)

Number of participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Usual care/no intervention

Lay‐led or peer support intervention

Asthma‐related quality of life (PAQLQ)

1 to 7 scale; higher = better

3 to 9 months

Mean change in control groups was 0.05

Mean change in intervention groups was
0.40 better (0.02 worse to 0.81 better)

578
(3 RCTs)

⊕⊕⊝⊝
LOWa,b

Asthma‐related quality of life (MCID)

8 months

123 per 1000

248 per 1000
(145 to 390)

251
(1 RCT)

⊕⊕⊝⊝
LOWa,c,d

Asthma control

Scale (range, score) ACT (5‐23) and ACQ (4‐16)

4 to 9 months

Not pooled. Two studies reported 2 different measures. Both effects favoured peer support, but neither result was statistically significant

166
(2 RCTs)

⊕⊕⊝⊝
LOWa,e

Unscheduled visits

9 months

Somewhat fewer mean visits per person in the intervention group than in the control group, but the data are skewed and are difficult to interpret

84
(1 RCT)

Not graded

Medication adherence

2.5 months

Skewed data reported non‐parametrically. Low baseline adherence (˜ 26%), which dropped further in both groups after the intervention, although it was less in the intervention group

68

(1 RCT)

Not graded

Adherence to ICS was measured objectively with a dose counter

Smoking

3 to 4 months

Mean self‐efficacy to stop smoking score in control group was 6.9

Mean score in intervention groups was 4.63 better (3.04 to 6.22 better)

244
(1 RCT)

⊕⊕⊝⊝
LOWa,e

SANDS subscale

Range 0 to 16

Mean smoking‐related knowledge score in control group was 10.1

Mean score in intervention groups was 0.62 better (‐0.17 worse to 1.41 better)

103
(1 RCT)

Modified Tar‐Wars scale

Range 0 to 13

Mean nicotine dependence score in control group was 23.3

Mean score in intervention groups was 1.88 better (‐0.49 worse to 4.25 better)

33
(1 RCT)

SANDS total

Range 0 to 32

Adverse events

No reports of adverse events, although only specifically mentioned in 1 study

Not graded

*The basis for the assumed risk (e.g. median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
ACQ: asthma control questionnaire; ACT: asthma control test; CI: confidence interval; ICS: inhaled corticosteroid; MCID: minimal clinically important difference; PAQLQ: Paediatric Asthma Quality of Life Questionnaire; RCT: randomised controlled trial; RR: risk ratio; SANDS: Self‐Administered Nicotine Dependence Scale.

GRADE Working Group grades of evidence.

High quality: We are very confident that the true effect lies close to the estimate of effect.
Moderate quality: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of effect but may be substantially different.
Low quality: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of effect.
Very low quality: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aDowngraded for risk of bias. Outcome measured on a self‐rated scale. Likely to be affected by both performance and detection biases.

bDowngraded for inconsistency (I2 = 71%). Random‐effects analysis used as planned, resulting in wide confidence intervals that just cross the line of no effect. Sensitivy analysis with a fixed‐effect model showed much tighter CIs around a mean difference of 0.16 (0.06 to 0.26). Not downgraded for imprecision.

cConfidence intervals favour the intervention, but the effect is based on one study of 251 people (downgraded for imprecision).

dTwo other studies reported the measure but did not plan a responder analysis (not downgraded for publication bias).

eDowngraded for imprecision. Point estimates favoured the intervention, but lower confidence limits do not rule out possible harm.

Figures and Tables -
Table 1. Summary of included studies

Study ID

Design

Observation

Age range, years

N

Intervention

Comparison

Country

Al‐sheyab 2012

Cluster OL

3 months

14 to 16

261 (4 clusters)

Triple A programme

No intervention

Jordan

NCT01938976

Cluster OL

4 months

12 to 13

433 (4 clusters)

Triple A programme + smoking pledge

Triple A programme alone

Jordan

NCT01169883

Individual OL

2.5 months

11 to 16

68

Peer support + mp3 messaging

Attention control

USA

NCT01161225

Individual SB

9 months

13 to 17

112

Peer‐led asthma camp

Adult‐led asthma camp

USA

Shah 2001

Cluster OL

8 months

12 to 16

272 (6 clusters)

Triple A programme

No intervention

Australia

OL = open‐label; SB: single‐blind.

Other details such as mean age, healthcare setting, measures of asthma severity, frequency and duration of sessions and baseline social support are described in the text (Included studies).

Figures and Tables -
Table 1. Summary of included studies
Comparison 1. Peer‐led vs control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Change in asthma‐related quality of life (PAQLQ) Show forest plot

3

Mean Difference (Random, 95% CI)

0.40 [‐0.02, 0.81]

2 Asthma‐related quality of life (MCID) Show forest plot

1

Odds Ratio (M‐H, Random, 95% CI)

Totals not selected

3 Asthma control Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Totals not selected

4 Smoking Show forest plot

2

Mean Difference (IV, Random, 95% CI)

Totals not selected

4.1 Self‐efficacy to stop smoking

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4.2 Smoking‐related knowledge

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

4.3 Nicotine dependence

1

Mean Difference (IV, Random, 95% CI)

0.0 [0.0, 0.0]

Figures and Tables -
Comparison 1. Peer‐led vs control