Poor compliance to asthma medication is a major contributor to children’s asthma morbidity.1-3
The evidence suggests poor compliance can lead to a lack of asthma control. Large studies indicate that patients on oral steroids who land in the emergency department (ED) because of asthma symptoms suffer from a lack of compliance with daily controller medications.4
“I really believe we live in a time [when] if the correct medications are used appropriately, most kids will be able to stay out of the hospital for asthma exacerbations,” says pediatric allergist Alex Thomas, MD, clinical instructor in pediatrics at the University of Wisconsin School of Medicine and Public Health, Madison. “Oftentimes, when there are kids who are having these exacerbations, it can be related to either a lack of access to the appropriate medications, or, in a lot of cases, a lack of education about the use of the medications, which can lead to poor compliance with the medications.”
Thomas says studies back up his thinking. There’s a lot of evidence, he says, suggesting patients get confused about which medications they should be taking, and when.4
He remembers talking with asthma patients’ families about why their children ended up in the hospital. They’d often say things such as: “We were only taking albuterol.” Or, “We thought the albuterol was the one we had to take every day, and the inhaled steroid was just for emergencies.”
Introducing ‘Iggy and the Inhalers’
Thomas was a resident when he began to search for kid-friendly educational materials about asthma to give patients. He came up empty-handed.
A talented cartoonist, he created a comic strip of characters to help tell the story of what kids need to know about their asthma and medications. What started as a doodle and labor of love in 2008 has grown into Booster Shot Comics, a partnership between Thomas and health communication expert Gary Ashwal. The creative duo develops educational materials focused on asthma education for kids, including a video library, comic strips, trading cards, stickers, and more.
“The main premise we had in creating our asthma education project was to teach kids and families the difference between a rescue inhaler versus a controller, because we identified that as the most important lesson that needs to be learned with a newly diagnosed child,” Thomas says.
Booster Shot Comics’ centerpiece project is the “Iggy and the Inhalers” comic strip featuring Broncho the Bronchodilator. Broncho is a fast-talking, quick-moving cowboy who uses his lasso to loosen the muscle bands in an airway. In contrast, there’s Coltron the Controller—a more powerful, but slower-moving, slower-speaking robot character.
“[Coltron] has a mechanical arm that turns into a fire extinguisher, and with that he sprays medicine into the inside of the airways to decrease the inflammation involved in asthma,” Thomas says. “The idea was that we wanted to create these characters that were very much tied to the medication's underlying mechanism of action. If the child knew the character . . . they would almost intuitively understand how that medication worked.”
Iggy to the rescue
The Iggy and the Inhalers project is a comprehensive education program. It includes a 12-minute video, which the patient can see as an inpatient or at clinic visits. There are printed comic books that review the content of the video, adding more of a storyline and narrative to keep kids’ interest, that patients can take home.
“We have trading cards that correlate with different inhalers, as well as different allergen triggers, that are featured in both the comic and the video,” Thomas says.
Although there are charges for the printed materials and introductory DVD, patients, families, and their pediatricians get free access to selected white board videos, which are simulations of what Thomas does, in person, with patients at his University of Wisconsin-Madison allergy, asthma, and immunology clinic. In essence, he talks and draws messages simultaneously.
“Often, when I’m teaching a patient or family about asthma or asthma pathophysiology, I’ll draw the diagram as I’m speaking. What we’ve found is that interaction of what you’re saying connects with images as you’re creating them, in a really meaningful way. The white board video is a way to simulate that one-on-one experience [and] to broadcast it to a larger audience,” Thomas explains.
The lessons do sink in
Thomas says the biggest lesson from developing the Iggy and the Inhalers project was that kids really could understand relatively in-depth information about their inhalers.
“A lot of the existing materials basically treat an inhaler like a magical cure-all medication, where you take it and your asthma gets better. We feel that children actually can learn about the pathophysiology of asthma and the mechanisms of action of inhaled steroids and bronchodilators, a little more in-depth. We just need to find the right way to convey that information to make it interesting and meaningful,” Thomas says. “That’s why we created these characters.”
To test the project, Thomas and colleagues have been using the comics and videos as teaching tools for 3 years at the annual Madison Asthma Camp, which hosts children from the community with asthma. Children attending the camp took a test of their asthma knowledge at the beginning of the camp and the same test at camp’s end. Although the testing was informal and Thomas doesn’t have hard numbers, he reports that the majority of children taking the pretest and posttest improved notably and were able to differentiate between the 2 medications when they left camp.
“We will have to do more formal testing at University of Wisconsin in the next year or 2,” says Thomas, who also works full time as a pediatric allergist at the UW Health 20 South Park Clinic, Madison.
Obstacles in education
A big obstacle in terms of teaching the effective use of inhalers and spacers is the lack of actual demonstration of the devices in clinic, Thomas notes.
“In a busy general pediatric clinic or allergy clinic, a lot of times, there isn’t the time or the resources to be able to sit down with [children] and show them the inhaler; show them the spacer; and have them demonstrate appropriate use—both with the aid of the parent and on their own. These kids are being sent home with a prescription, without any good one-on-one teaching about the appropriate use,” Thomas says.
One of the premises for creating the Iggy and the Inhaler project was the lack of one-on-one teaching in the clinic. The idea behind the video, Thomas says, is that it can serve as a proxy. If there is no one-on-one teaching available, then the child and caregiver can watch the video and do the comic books at home.
“Ideally, I still think one-on-one teaching is the ideal way to teach a child about asthma,” Thomas says.
Pediatricians or nurses who give one-on-one asthma education should consider using visuals, Thomas says. If they don’t use the materials from Booster Shot Comics, they can use other widely available pictures. “There are diagrams available that show a normal airway versus an asthmatic airway. Even using a visual as simple as that can be helpful,” he says.
Age-appropriate messages, advice
Thomas uses different approaches to educate kids about asthma, depending on patients’ ages. The comics appeal to children aged 6 years and older, he says.
“Elementary and middle school are appropriate times to focus more on teaching kids about what exactly is going on when they have asthma or an asthma attack and how their medications work,” he says. “We did a lot of focus group testing in the early development of our comics and found even kids who couldn’t read—if the comics were being read to them—could still retain a lot of the major lessons from the comics.”
When teaching children aged younger than 6 years, Thomas focuses more on parents because they’ll be administering the medications to their children.
On the other end of the pediatric age spectrum, the teenaged years can be especially challenging when it comes to compliance. “It’s a lot harder for parents to be in complete control of their [kids’] medication, and often teenagers are just not as interested in being compliant,” he says.
To overcome the challenges, Thomas uses different strategies. He reviews the consequences of uncontrolled asthma, telling adolescents about the issues of morbidity. Then, he helps teenagers identify things they can do to become more compliant.
“For example, most controller inhalers need to be taken twice a day or every 12 hours. One strategy for teens that I’ve found really works well is to have the teens attach their controller inhalers to their cell phones or iPad chargers. That can be a very good cue for them to take their controller inhaler,” Thomas says.
Thomas recommends that pediatricians monitor asthma patients’ compliance by asking open-ended questions, rather than questions that kids can answer with a simple yes or no. Instead of asking a patient if he or she has taken the medication every day, Thomas will ask the patient: “How many days are you taking your medication?” Or, “How many days a week do you forget to take your medicine?”
More comics to come
Booster Shot Comics has a lot more in store for pediatricians, hospitals, and patients, according to Thomas.
“Our Iggy and the Inhalers project will be released to the general public in May. Our online store will be open in May. We also are working on a series of whiteboard videos beyond the ones we have on asthma physiology, including whiteboard drawing videos of all the different kinds of lessons to be learned about asthma. We’re going to go into asthma exacerbations, asthma triggers, symptoms, and emergencies that patients should be aware of,” he says.
Pediatricians in the community and at hospitals can use Booster Shot Comics’ online animated educational cartoons and white board videos on asthma pathophysiology for free. Go to YouTube.com, or visit the Booster Shot Comics’ website, boostershotcomics.com, for printed materials and DVDs.
1. Finkelstein JA, Lozano P, Farber HJ, Miroshnik L, Lieu TA. Underuse of controller medications among Medicaid-insured children with asthma. Arch Pediatr Adolesc Med. 2002;156(6):562-567.
2. Wilson SE, Leonard A, Moomaw C, Schneeweiss S, Eckman MH. Underuse of controller medications among children with persistent asthma in the Ohio Medicaid population: evolving differences with new medications. Ambul Pediatr. 2005;5(2):83-89.
3. Adams RJ, Fuhlbrigge A, Finkelstein JA, et al. Use of inhaled anti-inflammatory medication in children with asthma in managed care settings. Arch Pediatr Adolesc Med. 2001;155(4):501-507.
4. Donahue JG, Weiss ST, Livingston JM, Goetsch MA, Greineder DK, Platt R. Inhaled steroids and the risk of hospitalization for asthma. JAMA. 1997;277(11):887-891.
5. American Lung Association. Asthma. Available at: www.lung.org/associations/states/colorado/asthma/Asthma.html. Accessed April 30, 2014.