Behavioral Interventions to Improve Asthma Outcomes for Adolescents

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Addressing the Research Question

The present paper analyzes a systematic review conducted by Mosnaim et al. (2016). The chosen article addresses a clearly focused issue, namely, health outcomes in young asthma patients after behavioral interventions. Thus, even though it was not clearly mentioned in the body of the paper, one may easily define the PICO question. It may sound as follows: “Do adolescent asthma patients (P – patient problem) who underwent behavioral intervention (I – intervention) improve asthma management (O – desired outcome) as opposed to those who did not receive such type of counseling (C – comparison)?”

The topic chosen by Mosnaim et al. (2016) is narrow enough for the findings to have practical implications. The researchers focus on a specific age group, adolescents, that experience unique challenges related to this chronic condition. The target aggregate is defined as children and teenagers between the ages of nine and sixteen. Further, Mosnaim et al. (2016) do not merely outline the contributing factors to exacerbation and improvement of asthma symptoms in the chosen demographic. Instead, they acknowledge the wide variety of environmental and social triggers and clearly communicate that their factor of interest is behavioral interventions.

Further, Mosnaim et al. (2016) clearly operationalize the notion of improvement in asthma patients as enhanced self-management and adherence to corticosteroid medications. Drawing on previous literature on the topic, the researchers define four levels of asthma intervention:

  1. Child and family (family support, knowledge, and self-management);
  2. Home environment (exposure to allergens, irritants, pollutants, and other triggers);
  3. Medical care (health workers’ compliance with national asthma guidelines);
  4. Community (school-based programs to promote asthma self-management) (Ashley, Freemer, Garbe, & Rowson, 2017).

The study’s findings match the initial research question and provide recommendations for allergists and immunologists dealing with adolescents with asthma. Mosnaim et al. (2016) showed that school-based interventions prevailed over home-based interventions. Lectures, training sessions, ongoing monitoring and counseling were found to be mostly useful in reducing asthma flare ups and addressing common triggers (Mosnaim et al., 2016). On the other hand, some studies from the sample were not conclusive enough to make any generalizations.

Study Search Quality

Mosnaim et al. (2016) state that they completed the systematic review of the literature in full compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reference standards. Upon further investigation, one may conclude that the present review follows all of the essential guidelines. First, as Stewart et al. (2015) state, all information sources should be properly described. Mosnaim et al. (2016) list all the databases they consulted, namely, PubMed Medline, Ovid Medline, Scopus, PsycINFO, and CINAH. Further, they explain the appropriate data coverage: the electronic search includes titles and abstracts.

Articles were limited to those addressing human health and published in the English language between January 1, 2000, and August 10, 2014. However, they do not give any information on whether they contacted study authors to identify additional studies that might have been absent from the databases.

According to Moher, Altman, Schulz, Simera, and Wager (2014), the second essential recommendation to follow is present full electronic search strategy for at least one database, which Mosnaim et al. (2016) did. The researchers provided a full list of keywords and search requests they used when compiling the sample of articles. Some of the most frequently used combinations included education, self-management, behavioral, trigger reduction, and technology. All these strategies served the purpose, which was to identify and single out behavioral interventional studies in adolescent asthma patients.

Originally, Mosnaim et al. (2016) did not impose any limits on the acceptable age range. This allowed them to view articles with cross age ranges and those that focused on multiple age groups. However, eventually, Mosnaim et al. (2016) only reviewed the articles whose sample populations had a mean or median age between 11 and 16. Further, the researchers applied the following eligibility criteria:

  1. Teenage populations with asthma;
  2. Studies that focused on behavioral interventions;
  3. Described interventions could be conducted at any of the four levels: child and family, home, medical setting, and community;
  4. National and international studies.

The exclusion criteria helped discern the appropriate studies from those that were not exactly asthma-focused or where the interventions were performed on a population other than the target age group.

To make sure that their review is complete. Mosnaim et al. (2016) checked the cited references at the end of the selected articles. The researchers went even further and expanded the scope of their investigation to include the references used in the references. However, they did not include unpublished data and abstracts, nor did they contact experts in the field for further evidence not available in databases.

Thus, one may conclude that the results of this systematic review might be skewed due to selection bias (Malone, Nicholl, & Tracey, 2014). Admittedly, a study that shows a positive association between the chosen variables is more likely to be published. This tendency leads to the phenomenon when studies with negative or inconclusive results are ignored by the scientific community even though they are needed for the full picture.

High Methodological Quality and Validity of the Studies

After the extensive search, Mosnaim et al. (2016) selected 24 articles, some of which yielded multiple publications. However, each behavioral intervention (n=21) was only counted once. For each article, Mosnaim et al. (2016) outlined the sample size, intervention, patient population, control, outcomes and results, timeframe, setting, and intervention level (out of four). Further, if specified, the outcomes were defined as primary and/ or secondary and positive or negative.

Researchers addressed the validity of each of the studies analyzed and checked its methodology for potential bias and limitations. One of the most frequent problems associated with the compiled sample was insufficient numbers of participants, which did not allow for easy inference. For instance, the study by Bruzzese, Unikel, Gallagher, Evans, and Colland (2008) only focused on 24 asthma patients. Even though the results were promising as they showed improvements in self-management after the intervention, the small sample size remains a major flaw.

Another significant drawback of the present systematic review is the lack of stated compliance to the evidence-based practice guidelines which are generally used for critical appraisal of peer-reviewed articles (LoBiondo-Wood & Haber, 2017). Further, Mosnaim et al. (2016) acknowledge the high subjectivity of the chosen studies. Namely, they note that while the overwhelming majority of the studies showed positive results, none of these were demonstrated using an objective measurement. The latter may entail spirometry to measure lung function or electronic monitoring of medication adherence. There was not much discrepancy in study results as they all employed approximately the same experimental design with no control. This lack of the point of reference can also be seen as one of the review’s flaws.


Ashley, P. J., Freemer, M., Garbe, P., & Rowson, D. (2017). Coordinated federal actions are needed to reduce racial and ethnic disparities in childhood asthma. Journal of Public Health Management and Practice, 23(2), 207-209.

Bruzzese, J.M., Unikel, L., Gallagher, R., Evans, D., & Colland, V. (2008). Feasibility and impact of a school-based intervention for families of urban adolescents with asthma: Results from a randomized pilot trial. Family Process, 47, 95–113.

LoBiondo-Wood, G., & Haber, J. (2017). Nursing research-E-book: Methods and critical appraisal for evidence-based practice. Amsterdam, Netherlands: Elsevier Health Sciences.

Malone, H., Nicholl, H., & Tracey, C. (2014). Awareness and minimisation of systematic bias in research. British Journal of Nursing, 23(5), 279-282.

Moher, D., Altman, D. G., Schulz, K. F., Simera, I., & Wager, E. (Eds.). (2014). Guidelines for reporting health research: A user’s manual. Hoboken, NJ: Wiley.

Mosnaim, G. S., Pappalardo, A. A., Resnick, S. E., Codispoti, C. D., Bandi, S., Nackers, L.,… & Powell, L. H. (2016). Behavioral interventions to improve asthma outcomes for adolescents: A systematic review. The Journal of Allergy and Clinical Immunology: In Practice, 4(1), 130-141.

Stewart, L. A., Clarke, M., Rovers, M., Riley, R. D., Simmonds, M., Stewart, G., & Tierney, J. F. (2015). Preferred reporting items for a systematic review and meta-analysis of individual participant data: The PRISMA-IPD statement. Jama, 313(16), 1657-1665.

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NursingBird. "Behavioral Interventions to Improve Asthma Outcomes for Adolescents." March 25, 2022.