The effectiveness of the use of video games and software-based programs for asthma education and self-management for children and teenagers

Introduction: Asthma is a chronic disease of the lower airways characterized by usually reversible airflow obstruction, inflammation, and hyperreactivity to various types of stimuli. It is one of the most common chronic respiratory diseases among children and adults, with an incidence of 300 million people worldwide. Objective: To evaluate the quality of the existent evidence in the literature in order to support the use of videogames and software-based programson asthmatic children and teenager’s knowledge capacity and self-management compared with standard education. Methods: Search, selection and analysis (starting March 2016) of all the original articles on virtual reality (VR) concerning asthmatic children and adolescents (ages 3 to 18), published up to October 2017, in Portuguese, English and Spanish, at the electronic databases Pubmed, Web of Science, MedlLine and LILACS, obtained by using the descriptors: asthma, video game, virtual reality, pulmonary rehabilitation, physical training. Results: Only six original articles were obtained. Of these, five (80%) presented level of evidence A, and one (20%) presented level of evidence B. All authors point out the treatment of asthma from VR as a safe and innovative therapy considering that the motivation and intensity of treatment from the use of VR improves the self-management capacity and aerobic capacity of asthmatic patients. Conclusion: The present study seeks to contribute to the literature by demonstrating that videogames and other software-based systemscan be used to improve knowledge capacity and self-management skills in children and teenagers with asthma diagnosis.


Introduction
Asthma is a chronic disease of the lower airways characterized by usually reversible airflow obstruction, inflammation, and hyperreactivity to various types of stimuli, manifested by episodes of wheezing, shortness of breath, chest tightness, and cough, having a higher incidence at night or soon after waking up. Asthma is one of the most common chronic respiratory diseases among children and adults, with an incidence of 300 million people worldwide. For the evaluation of the methodological quality of the articles found, it was decided to use the GRADE system of qualification of scientific evidence, which is a clear and explicit system, which takes into account the study design, its execution, consistency and linear direction in the evaluation of the evidence quality for each important outcome/consequence.
According to the GRADE system, the quality of the evidence is classified according to the levels: high,  The judicious evaluation of the quality of the evidence was performed by two reviewers independently, with no disagreement between them, and the final result is presented in Table 1.

Results and discussion
Asthma is a chronic inflammatory airway disease in which many cells and cell elements play a role. Chronic inflammation is associated with airway hyperresponsiveness, which leads to recurrent episodes of wheezing, dyspnea, chest oppression, and cough, particularly at night or early in the morning. These episodes are a consequence of generalized and variable intrapulmonary airflow obstruction that is spontaneously reversible or treated. 1 Treatment should aim at increasing respiratory muscle strength and increasing respiratory muscle resistance to fatigue.  Randomized clinical trial with random distribution. Sample 54 children with moderately severe asthma randomly assigned to two groups.

Intervention
Both groups were seen approximately six times during one year of the study. The control group (n = 29) played routine computer games. The experimental group (n = 25)played Asthma Command, which was specifically design for this study. The game emphasizes four principles in the management of childhood asthma: the recognition of symptoms and allergens, the appropriate use of medications, the appropriate use of the emergency room and physician's office, and the encouragement of school attendance.

Results
Compared with children in the control group, experimental subjects showed improved knowledge of asthma (p < 0.001), behavior related to asthma management (p < 0.008), and a tendency to reduce acute asthma visits (p < 0.13). Children in the experimental group also had higher results in assessing asthma management-related behaviors that were specifically addressed by the intervention provided by the Asthma Command (p < 0.01). Differences between the control and experimental groups showed an improvement in the experimental group in 21 (84%) of the 25 outcome variables in the study (p = 0.004, Sign test).

Conclusion
The study indicates that a standardized educational intervention, through asthma-specific computer gaming, can significantly affect knowledge and behavior related to the management of asthma.

GRADE High (A) Authors
Homer et al., 2000 7 Delimitation Randomized Controlled Clinical Trial. Sample 137 children aged between 3 and 12 years old with physician-diagnosed asthma, randomly assigned into two groups Intervention An interactive educational computer program, Asthma Control, designed to teach children about asthma and its management. Using a graphical display of a child going through simulated daily events, the game emphasizes: 1) monitoring; 2) identification of allergens; 3) use of medicines; 4) use of health services; and 5) maintenance of normal activity. Control group participants reviewed printed educational materials with a research assistant. The children were asked to return for three visits to play the game (intervention group) or review an age-appropriate asthma education book and play a noneducational computer game. The study did not specify the duration of each visit, nor the timespan between each visit.

Results
Both intervention and control groups showed substantial improvement in all outcomes during the 12-month follow-up period. In addition to improving knowledge, after using the computer program, no differences between the two groups in primary or secondary outcome measures were demonstrated. Children reported satisfaction with the program use.

Conclusion
This test of an educational software program found that it produced no greater improvement than revised traditional written materials because both groups showed substantial improvement over baseline, computer-based education. Randomized Clinical Trial Sample 101 children with a medical diagnosis of mild intermittent, mild persistent and moderate/severe persistent asthma, divided into two groups (control and intervention). The individuals ranged from 7 to 12 years old, English speaking, ability to complete questionnaires and perform needed tasks, presence of a telephone in the home or access to a telephone in a neighbor's home. The only exclusion criteria was the presence of chronic illnesses other than asthma that impair lung function. Most participants were non-Hispanic Black with a mean age of 9.6 years.

Intervention
Wee Willie Wheezie was the Computer-Assisted Instructional (CAI) used for the study. It focused on reducing environmental irritants/allergens and the correct use of prescription drugs to prevent asthma symptoms was used with 101 children (56 in the intervention group and 45 in the control group). The primary outcome assessed a change in childhood asthma symptoms as measured by responses to nine symptom questions in the Juniper Pediatric Asthma Quality of Life Questionnaire (PAQOL) and measures of lung function. The intervention group received conventional education through written asthma materials and nonasthma-related computer program, and the computer-based instructional asthma game. The control group received only the conventional education. All subjects received an initial home visit, a 6-week reinforcement phone call, and a follow-up home visit at least 12 weeks after the initial visit. The study did not specify the duration of each visit, nor the timespan between each visit.

Results
There were no significant changes in asthma symptoms between the two groups before and after the intervention. There were no significant changes in PAQOL scores for activities, emotions and total PAQOL score, lung function measurements, and asthma severity between the two groups. Knowledge about asthma in both groups was high before the intervention, but there were no significant changes between groups after the intervention.

Conclusion
Findings indicate that although there were some positive effects of the intervention on children's knowledge of asthma, the CAI game did not have the effects on asthma symptoms and quality of life that was predicted. Also, there were no significant changes in the severity of asthma between pre and posttest periods for the intervention and control groups.

Shames et al., 2004 9 Delimitation
Randomized Clinical Trial Sample 119 children aged 5 to 12, from low-income urban areas, with a medical diagnosis of moderate to severe asthma. More specifically, these were children diagnosed as having asthma at least 6 months before enrollment, had parental reports of significant asthma symptoms at least three times a week, or at least two asthma attacks per week, or daily use of bronchodilator therapy, and had required substantial health care utilization for asthma hospitalization or two acute care or emergency department visits for asthma during the past year.

Intervention
Subjects were randomized to participate in the disease management intervention or to receive their usual care (control group) in a 1:1 assignment. Randomization was performed within four strata defined by sex and age (5-8 years old and 9 -12 years old). The subjects were assessed for clinical and quality of life outcomes at weeks 8, 32, and 52 of the study. Children in the intervention group followed a disease management program, which included (1) assignment to an asthma case manager, who delivered a 3-session, standardized curriculum on asthma self-management based on the education goals recommended by the National Heart, Lung, and Blood Institute; (2) a Super Nintendo asthma video game (Bronkie's Asthma Adventure) designed to teach children self-management strategies and provide feedback on their performance; (3) two visits to a boardcertified pediatric allergist/immunologist affiliated with the study (at weeks 2 and 4), including a full history and physical examination, allergen skin testing, and development of an acute and chronic asthma management plan that was provided to the family, the case manager, and the primary care provider; and (4) access to an 18-hour per day toll-free hotline staffed by pediatric nurses who had access to each participant's individualized asthma management plan. Control group subjects received their usual care and the use of a nonviolent Super Nintendo video game. The objective was to determine the effectiveness of an asthma education video game in reducing morbidity among high risk, school-aged children with asthma.

Results
Compared to controls, the intervention group showed significant improvements in physical domain (P .04 and P .01 at 32 and 52 weeks, respectively) and social activity domain (P .02 and P .05 at 32 and 52 weeks, respectively) of asthma quality of life in the Child Health Survey for Asthma and Child (P .02 at 8 weeks) and parent (P .04 and .004 at 32 and 52 weeks, respectively) with self-management knowledge.

Conclusion
A multicomponent educational, behavioral and medical intervention targeting high-risk children and asthma infants can improve knowledge and quality of life. Although the intervention achieved statistically significant improvements in asthma knowledge and quality of life, no statistically significant reductions in asthma morbidity measures were observed.

GRADE High (A) Authors
Yawn et al., 2000 10 Delimitation Randomized Controlled Clinical Trial Sample 87 fourth-grade children, divided into three groups, two experimental and one control.

Intervention
This randomized control study was based on a pretest and two posttest assessments of childhood asthma knowledge comparing the results of control and intervention room examinations. In the two intervention classrooms an interactive computer-based game designed specifically as na asthma educational tool was introduced (Air Academy: TM The Quest for Airtopia.) The game presents asthma disease knowledge and management skills, with tools for reinforcement, as it supports motivation for children to better understand the management of the disease. Children in intervention classrooms were allowed to play the game as desired for the last 20 minutes of computer labs held three times each week over a period of six weeks. Children in the control classroom continued with the usual fourth grade health and science education programs that did not include information on asthma. No other education programs dealing with asthma exist in the school health curriculum.

Results
After the intervention, both intervention classes had higher mean scores than the average control room scores, one class being more clearly different from the other (sum of p = 0.20 and 0.0009, respectively). Neither the inclusion of a 30-minute asthma conversation nor longer playing times (6-hour average versus 12-hour average) had a significant impact on pretest-posttest scores in the two intervention classrooms. Combining the two intervention classes, post-test 1 scores in the intervention classes were significantly higher than the control room score (sum of p = 0.008).

Conclusion
Using the game improved asthma awareness in intervention classes. Children in the active participation classroom gained significantly more knowledge about asthma during the observation period compared to the non-computer--playing classroom. The knowledge gained was maintained over a four-week period and the addition of physician-led discussions seemed to add little to the knowledge gained. Prospective pretest-posttest study with randomly allocated intervention Sample 171 children with a medical diagnosis of moderate to severe asthma. They were chosen from four inner-city asthma clinical site. The mean age was 10.9 years (range 7-17). A total of 112 males and 59 females.

Intervention
Subjects aged between 7 to 17 years old were recruited from four pediatric practices and randomly assigned to the computer intervention condition or to the usual care comparison. The chosen interactive multimedia application was "Watch, Discover, Think and Act", which was created to help children learn how to manage asthma, develop asthmaspecific skilss and incorporate self-regulatory processes into asthma management routines. The protagonist's asthma characteristics were adapted to be like those of the subject. The subjects played the computer game as part of their regular asthma visits. The time between pre and posttest ranged from 4 to 15.6 months (mean, 7.6 months).

Results
Covariance analysis, with pretest score, age and severity of asthma as covariates, found that the intervention was associated with fewer hospitalizations, better symptom outcomes, increased functional status, better knowledge of asthma management, and better self-management behavior in those in the condition of intervention.

Conclusion
This suggests that video game or computer gaming has had an impact on asthma knowledge and control, as well as decreasing the number of hospitalizations. However, the game was too complex for less able children.  Using video games requires little physical space, is easy to handle and has a huge acceptance. We believe that soon many other studies will be done through video games aiming at education, physical training and many other valences, as well as the use of virtual reality for the treatment of asthma and other pathologies will be effective.

Conclusion
The present study contributed to the literature by