Kids learn about asthma with Huff and Puff’
With the help of two specialists, Glaxo Wellcome is teaching asthma management to children who are much younger than those targeted by established education campaigns.
The two specialists, Huff and Puff, are puppets used to teach younger patients how to self-manage the disease. Education efforts already are aimed at the five million children who suffer asthma, but most target patients ages 8 years and older. These programs have demonstrated improvement in managing behaviors and have, in turn, reduced use of health care services.
Yet, most children are diagnosed with asthma by age 5 and have already experienced symptoms and even suffered asthma attacks. So, why not provide education programs to younger children? For one, questions remain about how much younger patients can learn and apply to realistic situations when they happen. Also, it’s difficult to survey young children on how much they learned from a program.
Colorful characters teach basic concepts
But the company is offering these younger patients a program called Huff and Puff: The Children’s Asthma Program. A study determined it can be effective in boosting knowledge about the disease and improving attitudes toward it.
"We want to introduce them to concepts and introduce parents to concepts," says Pete Derovin, RRT, the company’s associate manager for care management in respiratory program development. "Hopefully, that will give them a good basis for when they become older asthmatics."
In 1996, Glaxo Wellcome licensed the program, developed by Linda Murphy Boston, RRT, of Creative Health Concepts Inc.
Huff and Puff star in their own video. One character is yellow with blue hair and blue eyebrows, the other is blue with yellow hair and eyebrows.
Huff ignores his early warning signals, forgets what he’s supposed to do, and then starts to wheeze. At first, children may relate best to this puppet. They also learn the consequences of Huff not handling the situation properly.
But then they meet Puff, a role model who knows how to prevent and control his asthma symptoms. He shows Huff and the children they also can handle their asthma responsibly and not suffer the scary consequences. The children should learn to tell an adult if they have symptoms, know which medications to take for an attack, and breathe slowly and relax. "If they can remember those three things, this will really have a benefit on those children," Derovin says. "At least they have the knowledge of the right thing to do. Hopefully, that will translate into behaviors."
Parents attend all four sessions of the program. The first two are only for parent orientation. For many parents, this is the first training they receive about their children’s asthma. Then, they bring their young patients for the remaining sessions and attend them together. "We feel that’s very important because it helps the parent work with the child at home," Derovin says. "Parents are the primary communication vehicle and advocate for their children with the physician."
Various methods reinforce learning
Techniques used by the Huff and Puff program are similar to those used in programs aimed at older children — interaction, games, role-playing simulation, and making models. Beside puppets, the program uses a felt board called Puff’s Path that shows children a model of their airways and how they work. Games teach the children about how to handle situations that can cause trouble. (For details on the program, see related story, p. 32.)
Other materials include:
- a workbook called "Huff and Puff and Me" to supplement what children learned during the sessions and to provide individualized learning;
- "Huff and Puff and Stuff," an audiocassette with four songs that reinforce lessons learned, especially breathing and relaxation techniques.
"Children get to see and feel and touch an activity," Derovin says. "It’s very entertaining and also very educational."
The program begins with 4-year-olds because at that age children start spending more time away from their parents, whether in day care or elementary school. "Children at this age are beginning to separate from their parents for a portion of the day," Derovin says. "There’s a lot of anxiety for parents knowing they aren’t going to be there. It’s a very important age."
The program also aims to improve children’s quality of life. "They might think it’s normal that they can’t run across a field," says Donna Jones, RN, MBA, senior manager for program development for the respiratory group at Glaxo Wellcome’s care management division. "They don’t realize that it doesn’t have to be that way" if the disease is managed properly.
The company has not collected enough information to provide outcomes data yet. But program participants among the Tri-State Business Group on Health rated these elements as excellent: the Huff and Puff workbook, video, music, helpfulness, and an overall program rating.
The Tri-State group, which insures 71 employers in the Midwest, last year decided to use the program to help children in Evansville, IN. Huff and Puff was initially offered to 80 children, funded by a grant from the Foundation for Community Health.
Maxicare, the managed-care company, also agreed late last year to implement Huff and Puff, along with Glaxo Wellcome’s Asthma Self-Management Program for adults.
In addition, a 1994 study published in the journal Respiratory Care highlights areas where the program can benefit the younger patients. The study was conducted by Boston, who is the clinical instructor and supervisor of Specialty Services at Southern Illinois University, School of Medicine in Springfield, IL; Daniel A. Detwiler, PhD, clinical assistant professor also in the Department of Pediatrics at Southern Illinois University; and Steven J. Verhulst, PhD, assistant professor in the Division of Statistics and Research Consulting at Southern Illinois University.
The study includes data on 128 of the 130 children who completed the program held at 19 sites in Illinois between Jan. 1 and July 21, 1991.
Facilitators gave children a test before the first session and again after they completed the last session. The children answered five questions about how often they used behaviors that could help manage their asthma. Their parents were given similar, though more extensive, tests. Children and their parents also were asked to evaluate their attitudes about asthma, such as feelings of embarrassment and worry. And medical care utilization data were collected reviewing charts a year back and again for a year after the study.
The result: statistically significant changes in all categories of learning. And children who completed the program experienced reduced use of medical services, including hospitalization, emergency department visits, and trips to the doctor for "out-of-control" asthma.
After the program, the children showed statistically significant improvement in likelihood they would stop and relax, breathe slowly, relax, and drink fluids. Their ability to tell someone didn’t show similar improvement, but the authors note children were doing so before they entered the program.
The children’s knowledge also improved. For instance, before the program 39% of children could identify signals. After the program, 89% could.
[For more information about Huff and Puff, call (888) 550-HUFF (4833). Or, write Glaxo Wellcome Care Management Division at Five Moore Drive, P.O. Box 13398, Research Triangle Park, NC. 27709.]
The Huff and Puff Sessions
The first two Huff and Puff sessions, which last two hours each, are aimed at the parents, since they assume primary responsibility for the day-to-day management of their children’s asthma.
Children join parents in during Sessions 3 and 4, which each last 90 minutes. Sessions are spaced one week apart. Here’s the emphasis of each session:
SESSION 1
Parents learn about the respiratory system and how asthma affects airways, how to monitor asthma signals, and how to identify the factors that trigger their children’s signals. They also learn about asthma medications, proper use and maintenance of inhaled medication, and the importance of medication compliance. Color slides and workbook exercises are used to reinforce learning.
SESSION 2
Parents learn the importance of individualized action plans to prevent and control their children’s signals. They’re taught how to use peak flow meters and discuss prevention strategies and management plans.
SESSION 3
During this session, children join in. They use a felt board called Puff’s Path to learn about breathing and how asthma affects their lungs. They complete workbook exercises to help them identify their own early warning signals and asthma-attack signals.
SESSION 4
Children learn how to use steps to control asthma signals. They learn to tell an adult, take medications, and breathe slowly and relax. The session uses discussions with Huff and Puff and workbook and exercises to try and teach children to identify possible triggers for their asthma attacks.
Children also learn the meaning of prevention and specific ways to prevent their signals. By playing a board game, they make decisions about asthma and learn that their behaviors have consequences. Typical questions put children in situations and teach them about how to handle them, such as what would you do if you go over to a friend’s house, and your friend has a dog or cat?
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