10.

1177/1090198104266895
Brown
ARTICLE
et al. / Home Visiting
Health Education & BehaviorFebruary
132(February 2005)

A Home Visiting Asthma Education Program:

Challenges to Program Implementation
Josephine V. Brown, PhD
Alice S. Demi, DNS
Marianne P. Celano, PhD
Roger Bakeman, PhD
Lisa Kobrynski, MD
Sandra R. Wilson, PhD

This study describes the implementation of a nurse home visiting asthma education program for low-income
African American families of young children with asthma. Of 55 families, 71% completed the program consisting of eight lessons. The achievement of learning objectives was predicted by caregiver factors, such as education, presence of father or surrogate father in the household, and safety of the neighborhood, but not by child factors, such as age or severity of asthma as implied by the prescribed asthma medication regimen. Incompatibility
between the scheduling needs of the families and the nurse home visitors was a major obstacle in delivering the
program on time, despite the flexibility of the nurse home visitors. The authors suggest that future home-based
asthma education programs contain a more limited number of home visits but add telephone follow-ups and
address the broader needs of low-income families that most likely function as barriers to program success.
Keywords: African American; asthma education; home visiting; pediatric asthma; program evaluation

Asthma is the most common chronic disease of childhood affecting 6.3 million children in the United States in the year 2001 (Centers for Disease Control and Prevention,
2003). Among children with chronic medical conditions, asthma is the most common
reason for hospitalization and school absence (Taylor & Newacheck, 1992). African
American children from low-income families are disproportionately affected by asthma
and evidence higher levels of morbidity and mortality (Halfon & Newacheck, 1993;

Josephine V. Brown, Department of Psychology, Georgia State University, Atlanta. Alice S. Demi, School of
Nursing, Georgia State University, Atlanta. Marianne P. Celano, Department of Psychiatry and Behavioral Sciences, Emory University School of Medicine, Atlanta, Georgia. Roger Bakeman, Department of Psychology,
Georgia State University, Atlanta. Lisa Kobrynski, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia. Sandra R. Wilson, Department of Health Services Research, Palo Alto Medical Foundation Research Institute, Palo Alto, California.
Address reprint requests to Josephine V. Brown, Department of Psychology, Georgia State University,
Atlanta, GA 30303-3083; phone: (404) 377-3290; e-mail: jvbrown@gsu.edu.
We thank the nurse home visitors for their dedication to the program and the families for their interest
and their willingness to make the time in their very busy lives to participate. This research was supported
by R01NR04431, awarded by the National Institute of Nursing Research, National Institutes of Health to
Josephine V. Brown.
Health Education & Behavior, Vol. 32 (1): 42-56 (February 2005)
DOI: 10.1177/1090198104266895
2005 by SOPHE

42

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Brown et al. / Home Visiting

43

Schwartz, Gold, Dockery, Weiss, & Speizer, 1990). The increased morbidity found
among low-income, urban children with asthma is due to suboptimal therapy, lack of continuity between routine and acute asthma care, exposure to environmental tobacco
smoke, poor adherence to peak flow monitoring at home, asthma management shared by
multiple caregivers, and high levels of child and caregiver adjustment problems (Kattan
et al., 1997; Redline, Wright, Kattan, Kercsmar, & Weiss, 1996; Wade et al., 1997).
Asthma management requires assessment and monitoring of symptoms, pharmacologic therapy, and control of factors (e.g., environmental triggers) contributing to asthma
severity (National Institutes of Health, 1997). Modern methods of controlling asthma
symptoms rely primarily on medications to reduce inflammation and secondarily on
medications to reduce airway smooth muscle contraction (National Heart, Lung, and
Blood Institute [NHLBI], 1997). In general, inhaled anti-inflammatory agents are prescribed daily to prevent asthma exacerbations, whereas inhaled bronchodilators are prescribed for use before exercise and as needed for symptom relief.
Asthma education programs have increased parents and/or childrens knowledge of
asthma (Hindi-Alexander & Cropp, 1984; Parcel, Nader, & Tiernan, 1980) and their
asthma self-management behavior (Clark et al., 1986; Evans et al., 1987; Lewis,
Rachelefsky, Lewis, de la Sota, & Kaplan, 1984; McNabb, Wilson-Pessano, Hughes, &
Scamagas, 1985). Such programs have reduced emergency room visits and hospitalizations, decreased school absences, and improved school performance (Evans et al., 1999;
Hindi-Alexander & Cropp, 1984; Hughes, McLeod, Garner, & Goldbloom, 1991; Lewis
et al., 1984; McNabb et al., 1985). Unfortunately, parents of low-income African American children are confronted with many barriers to participation in asthma education programs (Evans et al., 1987; Kaplan et al., 1989). Indeed, asthma education programs that
target low-income families fail to secure consistent parental attendance, regardless of
whether the program is offered at a clinic (Kaplan et al., 1989; Lewis et al., 1984), a hospital (Taggart et al., 1991), or an elementary school (Evans et al., 1987).
Home visiting has been effectively used as an early intervention strategy with pregnant and postpartum women, families with young children deemed at risk for health and
developmental problems, and with hard-to-reach populations (Olds et al., 1999; St. Pierre
& Layzer, 1999). Three home-based asthma intervention studies with school-age children have been described in the literature (Baxmann & Klimo, 1989; Evans et al., 1999;
Hughes et al., 1991); one was a pre-post designed study (Baxmann & Klimo, 1989), and
the other two included home visiting as one component of a comprehensive asthma intervention program (Evans et al., 1999; Hughes et al., 1991). We conducted the only randomized control study to examine the efficacy of home-based asthma education (Wee
Wheezers at Home) for low-income African American parents of 1- to 6-year-old children with asthma (Brown et al., 2002). Results from the study suggest that home-based
asthma education may be most effective with families of very young children.
In the Statement of Purpose of a relatively recent collection of evaluations of home visiting programs (Behrman, 1999), the following problems with program implementation
were noted: lack of delivery of the intended program curriculum; difficulty engaging
families in the program, resulting in missed home visits and withdrawal of enrolled families prior to program completion; and variability in staff skills, training, and turnover. The
purpose of this article, therefore, is to identify problems and challenges in the implementation of the Wee Wheezers at Home program, so that future developers of home visiting
programs may benefit from our experience. Specifically, we will describe (a) the extent to
which the program was delivered as specified; (b) the extent to which families participated in the lessons and attained the programs learning objectives; and (c) issues related

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Health Education & Behavior (February 2005)

to staff skills, training, and turnover. In addition, we will examine whether program delivery and attainment of the learning objectives differed as a function of selected characteristics of the caregiver (e.g., education) or the severity of the childs asthma. Finally, because
the Wee Wheezers at Home program was most effective with families of younger (1-3
years) children (Brown et al., 2002), we will determine whether program delivery and
attainment of learning objectives differed for families of younger and older children (1-3
vs. 4-6 years of age).
METHOD
Participants in the current study consisted of low-income, urban, primarily African
American families and their children who had been randomized to the treatment arm in
the controlled trial of the Wee Wheezers at Home (WWH) asthma education program
(Brown et al., 2002). For that trial, children and their families were recruited at clinics that
were associated with the Emory University School of Medicine or a childrens hospital in
metropolitan Atlanta. Eligibility criteria were the following: (a) The child was at least 1
but not yet 7 years of age at study entry, (b) the child had made a health care visit for
asthma in the preceding year, (c) the child had been prescribed medication for asthma on a
daily basis, (d) the primary caregiver spoke English, and (e) the primary caregiver had no
known involvement with illegal drugs. Between September 1997 and June 1999, 144 eligible children and their families were identified and invited to participate in the original
study (Brown et al., 2002). Of these, 33 caregivers (23%) refused and 10 (7%) consented
but could not be contacted for the baseline data collection visit, resulting in a 70% rate of
acceptance.
Caregivers gave written informed consent at the outset of the baseline visit and
received $25 for the completed baseline data-collection visit. The protocol and study procedures, including the informed consent procedure, were approved by the Institutional
Review Boards of Georgia State University, the Emory University School of Medicine,
Grady Memorial Hospital, and the Palo Alto Medical Foundation Research Institute. Following baseline assessments, families were randomized to either treatment (n = 55) or
usual care (n = 46). Six families, all from the treatment group, withdrew from the study at
various points, leaving 49 treatment families. These 49 families constitute the participants of the current report. Except for the fact that all of the children of families that withdrew were male, the 6 families that withdrew did not differ significantly from the 49 families that continued on any of the family or child background variables described below
and in Table 1.
The Families and Children
The caregivers (see also Table 1) were mostly the childrens mothers (86%) and African American (90%). About half of the caregivers were employed, 84% received
Medicaid for the target child and 37% received public assistance, and 71% had a high
school diploma. More than 70% of the households included at least one other adult, 45%
included the target childs (surrogate) father, and 53% included one other person with
asthma. About 26% of families lived in neighborhoods that were rated as somewhat to
very unsafe by the projects social worker. Compared to other family problems, 35% of
the families considered their childs asthma as a small problem, 33% considered it a
medium problem, and 33% considered it a big problem.

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Brown et al. / Home Visiting

Table 1.

45

Characteristics of Caregivers and Children (N = 49)

Variable
Age of caregiver (years)
Educationa
Father or stepfather lives with family
Safety of neighborhood
Age of child (years)
Age at first symptoms (months)
Severity of asthmab
Medical visits in previous year
Caregivers rating of asthma

M or %

SD

Range

31
0.9
45
4.0
4.3
9.4
2.1
5.0
2.0

9.3
0.7

1.2
1.7
9.9
.7
4.1
0.8

17-65
0-2

0-5
1.3-6.9
0-48
1-4
0-17
1-3

a. Rated as follows: 0 = no high school diploma, 1 = high school diploma, 2 = some college.
b. As implied by the prescribed medication regimen; see text for details.

The children (see also Table 1) averaged 4.3 years of age (ranging from 1.3 to 6.9),
with 45% and 55% being respectively 1 to 3 and 4 to 6 years of age; about half were male
(55%). The majority (75%) of the 49 children received their asthma-related medical care
in two asthma and allergy specialty clinics (n = 32) or the pulmonary specialty clinic associated with the medical school (n = 5). The remaining children received their asthma care
in neighborhood clinics associated with the childrens hospital (n = 9) or were enrolled
from the Emergency Department of the childrens hospital (n = 3). The children had made
an average of five medical visits for acute asthma (ranging from 0 to 17) in the 12 months
prior to the onset of the study. At study onset, 84% of the children had been prescribed one
or more daily anti-inflammatory medications (Cromolyn [43%], an inhaled
corticosteroid [ICS; 78%], an aleukotriene modifier [6%], and/or a long-acting beta agonist [6%]). In addition, some of the children had been prescribed Theophylline (8%) and/
or a brief course of an oral steroid (26%), and all but one of the children (98%) had been
prescribed a short-acting beta agonist (SABA; 16% of the children were using a SABA
daily and no other asthma medication).
Educational Intervention
WWH consists of eight 90-minute educational lessons, to be delivered at weekly intervals (Brown, Demi, & Wilson, 2003). Although educational objectives are specified for
each lesson and home visitors are required to document the extent to which lesson objectives are met, home visitors are encouraged to adapt their teaching strategy to the specific
needs of the families and to teach the caregiver and the child together. Others present in
the household at the time of the visit are also invited to participate. Families receive
printed materials (tailored to a 5th-grade reading level) and are assigned homework at
each lesson; they view a videotape at some lessons.
The Nurse Home Visitors
Criteria for the position of nurse home visitor were being a registered nurse and having
experience working with low-income urban clients. Three nurses were diploma prepared,
five held a BS in nursing; of the latter, three were enrolled in a graduate program in nursing and one had a masters degree in public health. Six nurses were African American,
two were European American, and all were female.

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Health Education & Behavior (February 2005)

We trained the nurses on a variety of topics: management of pediatric asthma, including correct use of metered dose inhalers, nebulizers, and peak flow meters; child development; family dynamics; home visiting skills; data collection requirements; research ethics; assuring safety during visits in the community; and how to cope with suspected child
abuse or neglect. Didactic instruction and role-play were used to teach the implementation of the WWH curriculum. The nurses received ongoing education and support
through individual supervision provided by the nurse educator (ASD) and through
biweekly team meetings. At the team meetings, the projects child clinical psychologist
(MPC) provided insight, guidance, and support to the nurses. The psychologist was also
available, on request, for individual support of the nurses. Physicians (e.g., LK) were
occasionally invited to address specific issues related to asthma management.
Measures
Background and Medical Data. The project social worker obtained background data
at the baseline home visit. In addition, she rated the safety of the familys neighborhood
on a 5-point scale (1 = very unsafe, 5 = very safe).
A graduate student in nursing who was blind to initial group assignment abstracted
asthma-related information from the childs medical records of all health care providers,
including emergency departments and hospitals, identified by the childs caregiver. We
used three measures to rate the childs asthma morbidity: (a) asthma severity, as implied
by the childs prescribed medication regimen in effect at the time of the baseline visit (see
the paragraph below for a description of this variable); (b) the number of medical visits
for acute asthma exacerbations for the year prior to baseline; and (c) the caregivers perception of asthma as a problem compared with other family problems, coded as 1 = small
problem, 2 = medium problem, or 3 = big problem.
Following the practice of Wilson and her colleagues (2001), we used the level of the
prescribed medication regimen, coded according to National Asthma Education and Prevention Program (NAEPP) criteria (NHLBI, 1997), as an indicator of the severity of
the childs asthma (1 = mild intermittent, prn bronchodilator alone; 2 = mild persistent,
prn bronchodilator together with inhaled corticosteroid [ICS; low dose] or cromolyn/
nedocromil or leukotriene modifier; 3 = moderate persistent, prn bronchodilator together
with ICS [medium dose] or with ICS [low-medium dose] long-acting beta-agonist or
theophylline; 4 = moderate/severe persistent, prn bronchodilator together with ICS [high
dose] long-acting beta-agonist or theophylline; 5 = severe persistent, prn bronchodilator together with oral steroids ICS, long-acting beta-agonist or theophylline). The
appropriateness of defining asthma severity in this manner depends to a large extent on
the fact that the NAEPP guidelines were in routine use in the asthma specialty clinics in
which the majority of the participating children had been receiving their care for a considerable period of time. Hence, the physicians had applied a stepped approach to treatmentincreasing the level of medication as appeared necessary in order to achieve control of symptoms. Even so, the prescribed regimen is not necessarily an unambiguous
measure of the underlying severity of the childs disease. Poor control of asthma symptoms may occur despite an appropriately prescribed medication regimen, if adherence is
poor. In some cases, undertreatment may have resulted in poor control. In such instances,
our procedure of using the prescribed medication regimen as an indicator would tend to
underestimate asthma severity.
In the current study, the severity of asthma as implied by the medication regimen was
rated mild intermittent for 16% of the children, mild persistent for 57%, moderate persis-

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Brown et al. / Home Visiting

47

tent for 22%, moderate/severe persistent for 4%, and severe persistent for 0% of the
children.
Program Delivery. We recorded the number of lessons delivered to each family and the
number of days between home visits. Note, because sometimes more than one lesson was
delivered during one home visit, we will make a distinction between home visits and lessons, where appropriate.
Family Participation. The nurse home visitor rated the engagement of the family in the
educational process following each home visit and the attainment of the learning objectives at the end of each lesson. Family engagement was rated with three 5-point scales (1 =
F to 5 = A) that measured the extent to which the caregiver was (a) prepared (i.e., ready to
start the session on time, educational materials were accessible), (b) attentive (i.e., not
distracted by phone calls, other children, personal events, or crises), and (c) involved (i.e.,
eager for information, motivated to learn, engaged in session activities). The scores for
each of these scales were averaged across all home visits made to the family. The three
summary scores were strongly correlated (r = .63, .72, and .89, p < .001; using the terminology of Cohen (1988), who refers to correlations greater than .50 absolute as strong, to
those between .31 and .50 absolute as moderate, and to those between .10 and .30 absolute as weak). For that reason, the three summary scores were subsequently averaged into
one caregiver participation score. Also, the nurse rated the extent to which the caregiver
had completed the assigned homework and the extent of the childs participation in the
home visit. These two scores were similarly averaged across all home visits delivered to
the family.
The attainment of learning objectives was assessed as follows. At the end of each lesson, the nurse asked the caregiver and the child (when age appropriate) a series of questions based on the material covered in the lesson. For instance, the caregiver was asked to
describe what happens in the lungs when a child has asthma (Lesson 1), to list three early
warning signs of the childs asthma (Lesson 2), or to describe two issues that need to be
discussed with the childs other caregivers (Lesson 6). When the child was sufficiently
verbal (mostly 3.5 years of age and older), he or she was also asked questions about the
materials just covered, such as identifying three early warning signs of asthma from a
chart (Lesson 2), to describe how to avoid his or her asthma triggers (Lesson 5), or to
explain what asthma is (Lesson 6). All materials were reviewed in Lessons 7 and 8. The
review in Lesson 7 consisted of 22 questions about asthma management techniques, and
that in Lesson 8 consisted of 17 questions related to communicating about asthma with
other caregivers, teachers, or physicians. The nurse home visitor rated the caregivers or
childs answer to each of the questions on a 5-point scale (1 = objective not achieved, 2 =
minimal, 3 = satisfactory, 4 = good, 5 = very good). As the number of questions varied
with each lesson, we used a mean learning objective score for each lesson. Learning
objective scores were then averaged over Lessons 1-6 and over Lessons 7-8 (the reviews),
separately for the caregiver and the child.
Finally, the nurse documented each (attempted or successful) contact made to schedule a home visit. The total number of contacts was averaged for each family over the total
number of home visits.
The Nurse Home Visitors. We used six measures to describe the activities of each
nurse: (a) her completion ratio, the number of families that completed the program divided by the number of families assigned to her; (b) the number of days between home

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Health Education & Behavior (February 2005)

visits; (c) the mean number of contacts made to schedule each home visit; (d) her rating
(on the exit questionnaire) of the amount of effort she had expended to implement the program (1 = very little to 4 = a great deal); (e) her rating (on the exit questionnaire) of how
safe she felt while implementing the program (1 = very unsafe to 4 = very safe); and (f) the
mean rating of the objectives of Lessons 1-6 attained by the caregivers served by her. In
addition, each nurse described on the exit questionnaire the greatest gain resulting from
program participation and the greatest barrier to successful program implementation for
each family served by her.
Data Reduction
For purposes of multiple regression, and given an N of 49, it was necessary to reduce
the number of variables to a manageable number. To accomplish this, we selected variables for further analysis based on the pattern of correlations within each set. We chose
this marker variable strategy, instead of an index creation strategy, for its greater
descriptive value.
Characteristics of the Caregiver. Older caregivers had more education (r = .35), and
families on public assistance were less likely to include the childs father or stepfather in
the household (r = .43) and lived in neighborhoods that were less safe (r = .35). Consequently, caregiver education, presence of father in the household, and safety of the neighborhood were selected as predictor background variables for subsequent analysis.
Characteristics of the Child. The three measures of asthma morbidity were moderately correlated: severity of asthma implied by the prescribed medical regimen with medical visits for acute asthma (r = .36) and with asthma as a problem compared with other
family problems (r = .38), and medical visits for acute asthma with asthma as a problem
(r = .32). The number of medical visits for acute asthma was also moderately correlated
with the childs age (r = .32). Thus, severity of asthma as implied by the prescribed medication regimen was selected as a predictor variable for subsequent analysis.
Program Delivery. Number of lessons completed and the mean number of days between home visits were not correlated (r = .03), thus both were selected as outcome
variables.
Family Participation. Attainment of objectives of Lessons 1-6 and Lessons 7-8 was
strongly correlated for the caregiver (r = .72) and moderately for the child (r = .43). Furthermore, caregiver and child objectives for Lessons 1-6 were moderately correlated (r =
.38). Because of this pattern of correlations and because the samples for child attainment
of objectives of Lessons 1-6 and 7-8 and/or caregiver attainment objectives of Lessons 78 were reduced (only verbal children were able to answer the questions, and not all families completed Lessons 7 and 8), caregiver attainment of objectives of Lessons 1-6 (hereafter referred to as caregiver attainment of objectives) was selected as a third outcome
variable.
Both homework completion and family participation were strongly related to caregiver attainment of objectives (r = .64 and .69). For this reason, mean number of nurse
contacts, which was not related to caregiver attainment of objectives (r = .11), was
selected as the fourth outcome variable.

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Brown et al. / Home Visiting

Table 2.

49

Summary Statistics for Outcome Variables

Variable

SD

Range

Lessons completed
Days between home visitsa
Caregiver attainment of objectives
Number of nurse contacts per home visita

49
44
45
49

6.8
13.3
4.6
4.8

2.6
6.0
0.4
5.9

0-8
4.3-29.3
3.2-5.0
0.3-30.0

a. Nurses sometimes presented two lessons in one home visit. Therefore, days between home visits
and number of nurse contacts were averaged over the total number of home visits, rather than over
the lessons completed.

RESULTS
Descriptive statistics for selected caregiver and child characteristics are given in
Table 1 and for selected outcome variables in Table 2.
Program Delivery
The educational program specified eight lessons to be delivered. Of the original 55
families, 39 (71%) completed all eight lessons. Of the remaining 16 families, 6 (11%)
completed part of the program (1 family each completed five and four lessons; 3 completed three, and 1 completed one lesson); 4 families (7%) did not complete any lessons;
and, as noted above, 6 families (11%) refused to participate further (1 each after seven and
six lessons, 2 after one lesson, and 2 after no lessons).
The eight lessons were to be delivered during home visits spaced at weekly intervals.
However, the average time interval between home visits was 1.9 weeks and ranged from
0.6 to 4.2 weeks. This time interval did not differ for families that did and did not complete the program. For the 39 families completing all eight lessons, the average number of
weeks needed to complete them was 12.9 weeks (median = 10). One family completed
the eight lessons in 1.9 weeks (this mother was anxious to finish the program before her
babys due date), one took 24.4 weeks, but the range for the remaining families was 6.0 to
21.3 weeks. To determine whether program delivery was associated with selected family
characteristics, we regressed the number of lessons completed and the days between
home visits separately on caregivers education (rated 0-2), whether the childs (surrogate) father lived in the home (coded 1 for yes, 0 for no), the environmental safety rating
(1-5), the childs age (coded 0 for ages 1-3, 1 for ages 4-7), and the severity of asthma (as
implied by the prescribed medication regimen) rating (1-4). These predictor variables did
not account for a significant proportion of the variance in the two outcome variables (see
Tables 2 and 3).
Family Participation
To determine whether family participation was associated with selected background
characteristics of the families, we regressed two outcomescaregiver attainment of
objectives and mean number of nurse contactsseparately on caregivers education,
whether the childs (surrogate) father lived in the home, the environmental safety rating,
the childs age, and the severity of asthma rating (as implied by the prescribed medication

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Health Education & Behavior (February 2005)

Table 3.

Standardized Regression Coefficients and R2s

Criterion Variable

Predictor Variable or R2

Lessons
Completed

Days Between
Home Visits

Caregiver
Objectives

Number of
Nurse Contacts

Education
Father lives with family
Safety of neighborhood
Childs agea
Severity of asthma
R2

.12
.02
.16
.02
.01
.05

.14
.01
.20
.29
.03
.14

.28*
.35*
.39**
.00
.19
.34**

.19
.00
.05
.01
.15
.05

a. Childs age was coded 0 = 1-3 years and 1 = 4-6 years.

*p < .05. **p < .01.

regimen). Together, these predictor variables accounted for a significant proportion of the
variance in caregiver attainment of objectives; R2 = .34, R2adj = .25, F(5, 39) = 4.0, p < .01
(see also Table 3). However, proportion of variance accounted for in nurse contacts was
not statistically significant.
Caregiver education, (surrogate) father living in the home, and environmental safety,
but not age of child or the severity of the childs asthma (as implied by the prescribed
medication regimen), contributed significantly to the prediction of caregiver attainment
of objectives (see the regression coefficients listed in Table 3). Surprisingly, (surrogate)
father living in the home was negatively related to caregiver attainment of objectives. In
exploratory analyses, we found one potentially interesting correlation: Fathers presence
was negatively associated with homework completion (.25, p = .14; homework completion correlated .61 with attainment of objectives). The negative correlation is suggestive
but does not achieve a conventional level of statistical significance in this sample.
The Nurse Home Visitors
During the 2 years of home visits, eight nurses were employed part-time for a period
ranging from 2 to 24 months (mean 12.6); two or three nurses were on staff at any one
time. The caseload consisted of 2 to 4 families, depending on the availability of families
and other time demands made on the nurses. Nurses were assigned to 2 to 18 families (one
to 2; four to 4; and one each to 10, 11, and 18 families) during the time of their
employment.
Six nurses completed the program, with an average of 72% of the families assigned to
them (range = 50-100). These nurses scheduled the home visits at intervals of 12.7 days
and required 5.1 contacts to schedule each home visit (see Table 4). Their mean rating for
effort needed to deliver the program, 2.3, fell between a little (2) and a moderate amount
of effort (3); their mean rating for feeling safe, 3.6, fell between somewhat (3) and very
safe (4), whereas their mean rating of caregiver objectives, 4.6, fell between the Grades B
and A. Two additional nurses did not complete the program with any of the families
assigned to them. One nurse resigned after completing no lessons with one family and 6
lessons with a second family; this second family withdrew from the project following the
resignation of the nurse. A second nurse, who had been assigned four families, left the
project before completing any lessons; her families were reassigned.

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Brown et al. / Home Visiting

Table 4.

51

Summary Statistics for Activities of the Nurse Home Visitors (N = 6)

Variable
Completion ratio
Number of days between home visits
Number of contacts to schedule each visit
Effort needed to deliver the program
Feeling safe (as perceived by the nurse)
Caregiver attainment of objectives

SD

Range

72.1
12.7
5.1
2.3
3.6
4.6

20.8
2.2
2.7
0.7
0.4
0.3

50-100
9.8-15.2
2.1-9.7
1.5-3.3
3.0-4.0
4.1-4.8

The nurses completion ratio was strongly related to the number of days between home
visits, the number of nurse contacts, and her rating of feeling safe during home visits (r =
.64, .81, and .52); it was moderately and negatively related to her rating of the amount of
effort needed to deliver the program (r = .42). The nurses ratings of feeling safe and
effort expended to intervene were almost perfectly and negatively related (r = .92).
The nurses rating of caregiver attainment of objectives was strongly related to the two
other nurse ratings, effort expended and feeling of safety (r = .78 and .70). Her rating of
caregiver attainment of objectives was moderately to weakly related to the three more
objective nurse variables, completion ratio, number of days between home visits, and
number of contacts (r = .42, .32, and .17).
Nurses considered increased knowledge of asthma and increased self-esteem (listed
for 73% and 32% of the families, respectively) as the most significant gains for the caregivers. Finally, nurses considered the caregivers poor time management (38% of families), personal problems (38% of families), and the familys living environment (42% of
families) as the greatest barriers to successful program implementation.
Relationship Between Outcome Variables
Four of the six possible pairwise correlations between the four outcome variables were
greater than .20, with three of them being significant. Families who completed more lessons required fewer nurse contacts to schedule each lesson (r = .82, p < .001); 2.6 versus
13.5 contacts, respectively, for families that did and did not complete the program (p < .01).
Furthermore, caregivers who completed more lessons scored higher on the caregiver attainment of objectives (r = .34, p < .05). Finally, the mean number of days between home visits was positively correlated with caregiver attainment of objectives (r = .31, p < .05).
Age of Child
None of the family characteristics described in the Methods section or Table 1 differed
significantly between younger and older children (i.e., 1-3 vs. 4-6). However, younger
and older children differed significantly on two of the child characteristics in Table 1.
Compared with older children, younger children were reported to have exhibited their
first asthma symptoms at an earlier age (5.8 vs. 12.3 months) and had made more medical
visits for acute asthma in the year prior to the baseline visit (6.5 vs. 3.8).

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DISCUSSION
This report examines the implementation of WWH (Brown et al., 2003), the only
existing home-based asthma education program for low-income families and children
younger than 7 years.
Program Delivery and Family Participation
Overall, 70% of caregivers invited agreed to participate; this acceptance rate is similar
to rates reported for other asthma education programs targeting low-income families
(Kaplan et al., 1989; Lewis et al., 1984). Subsequently, 71% of caregivers (of the 55 initially assigned to the treatment group) completed the program. This completion rate is
much higher than that reported for clinic- and school-based asthma education programs
for low-income families (Kaplan et al., 1989; Lewis et al., 1984). The results of our study
compare favorably to the experience of a number of home visiting family support and
prenatal programs (Gomby, Culross, & Berhman, 1999) and demonstrate that it is feasible to deliver an intensive asthma education program to low-income, inner-city families
via home visits. Although 70% of families invited by us were sufficiently motivated to
agree to participate, families frequently found it difficult to either schedule or follow
through with scheduled lessons. As a result, the mean interval between home visits was
nearly twice the prescribed interval (1.9 weeks rather than 1 week).
Like other low-income families, the lives of our families were complex (Rosier &
Corsaro, 1993). For instance, more than half of the caregivers in our program were single
parents, nearly one-third lacked a high school diploma, and 26% lived in unsafe neighborhoods. Indeed, on the exit questionnaire, nurses identified poor time management,
personal problems, or the familys living environment as the greatest barriers to program
success for about 40% of the families. In light of these circumstances, it is not surprising
that one-third of the caregivers rated the childs asthma as a small problem, compared
with other family problems.
We found that caregiver and community characteristics, such as caregiver education,
father living in the household, and environmental safety, rather than child characteristics
(age and asthma severity implied by the medical regimen), predicted the caregivers
attainment of the educational objectives (a measure of family participation). Others have
found a significant relationship between psychosocial factors and asthma morbidity in
inner-city children with asthma (Weil et al., 1999).
Staff Issues: The Nurse Home Visitors
The completion ratio of the nurse home visitors varied widely, with two nurses not
completing the program with any of their assigned families and the remaining six nurses
completing the program with 50% to 100% of their assigned families. More successful
nurses (as measured by the completion ratio) made fewer telephone contacts to schedule
lessons and let more days elapse between lessons. Also, nurses with a higher completion
ratio gave higher ratings to the caregiver attainment of objectives, felt that they had
expended less effort to deliver the program, and felt safer when in the homes of families.
Measures of caregiver attainment of objectives, effort, and feeling of safety, however,
were based on ratings made by nurses, who may have had a tendency to rate families that
completed the program high in all areas. Finally, unmeasured nurse factors, such as personality and prior training and experience, may have been critical in achieving success

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with families. The nurse who was most successful, in terms of longevity and her ability to
retain clients and complete the intervention (16/18 or 89% of assigned families completed the program), was a diploma-prepared psychiatric mental health nurse who had a
very outgoing personality and a very direct yet humorous way of interacting with families. This nurse was also willing to help families cope with non-asthma-related problems.
The least successful nurse (0% of her four assigned families completed the program) used
a more structured approach and at times appeared judgmental toward the families.
Program delivery required continued commitment and skill on the part of the nurse
home visitors and extensive support from other members of the home visiting team. The
commitment of the nurse home visitors did pay off, however: 82% of the families completed at least one home visit, whereas only 41% of the families who had been assigned to
the usual care group in our previous study (Brown et al., 2002) completed one educational
home visit when it was offered following the final data collection visit. In their summary
of the evaluations of a number of home visiting programs, Gomby and colleagues (1999)
pointed out that effective home visitors need interpersonal skills to establish rapport with
families, organizational skills to carry out the curriculum, problem-solving skills to cope
with family crises, and cognitive skills to complete the required paperwork. We certainly
concur. In this time of national nursing shortage, it is difficult to hire and retain nurses
with all these skills.
Barriers to program implementation interacted with certain characteristics of the
nurses. Nurses were hired on a part-time basis because many families were only available
late afternoons or weekends. The nurses attracted to these positions tended to be ambitious conscientious nurses with other commitments, either full-time or part-time jobs,
graduate school, family responsibilities, or all of these. The nurses many commitments
together with the families situations (especially following the initiation of the welfareto-work program) often made the scheduling of home visits difficult.
Some of the difficulty in implementing the program may be related to conflicts
between the culturally influenced beliefs and attitudes of the health care professionals
and those of the health care receivers. Health care professionals tend to value structure in
their time management and hold a future orientation. Although the home visitors felt a
professional obligation to fulfill their responsibilities when an appointment had been
made with a family, they were not as flexible in scheduling home visits as might have
been desirable because they worked part-time. In contrast, the participating families valued flexibility in time scheduling and would fail to keep appointments in favor of what
they perceived as more urgent responsibilities or activities. We had hoped to hire nurses
who would have very flexible schedules, but our nurses also had many other commitments. Thus, when a family canceled a visit, the nurse was often not able to reschedule the
visit immediately. Other programs have reported a similar incompatibility between the
scheduling needs of the families and the program staff (Gomby et al., 1999). Given the
nature of our health care system, it is unrealistic to expect that any program can provide a
great deal of flexibility in scheduling services.
Limitation of the Study
The children who participated in the current study formed the treatment arm of a previous randomized control study of the efficacy of the WWH (Brown et al., 2002). In that
study, it was important to ensure that the children received optimal medical care at the
onset of the study, so that any changes in asthma morbidity could be attributed to the educational program rather than to changes in the prescribed medical regimens. In fact, 75%

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Health Education & Behavior (February 2005)

of the children who participated in the current study received their asthma-related medical care in university-affiliated specialty clinics, resulting in the prescription of a daily
anti-inflammatory medication to a much higher percentage of children (84%) than is usually the case with low-income children (e.g., 24% in the National Cooperative Inner-City
Asthma Study sample [Kattan et al., 1997]; see also Warman, Silver, McCourt, & Stein,
1999). Thus, the findings of the current study may not generalize to a population of lowincome urban children receiving asthma care from primary care physicians.
Additional limitations may be related to the narrow range of some of our outcome variables, such as number of lessons completed (80% of the 49 families who remained in the
program completed all eight lessons) or caregiver attainment of objectives (ranging from
3.2 to 5).
Implication for Practice
Our asthma education program may have been too broadly focused and too timeconsuming, on one hand, and too narrow, on the other hand. In addition to asthma management objectives related to recognition of asthma symptoms, asthma triggers, and
correct administration of prescribed medications, we included objectives such as communicating effectively with other caregivers and with health care professionals. Because
a major problem in asthma management is the incorrect administration of prescribed
asthma medications, it could be argued that primary emphasis should be given to this
topic. For example, the program might be shortened to four sessions, with more limited
objectives, and perhaps with telephone follow-ups that focus on other important asthmamanagement objectives as well as other family needs. Our concentration on asthma and
not (in most cases) on a broader range of family needs that may indirectly affect asthma
control and capacity of the family to prioritize asthma management may have been too
limited. We agree with others (Evans et al., 1999; Weil et al., 1999) who suggest that comprehensive programs that address the economic, social, psychological, and physical
health needs of the family are likely to be the most effective in improving asthma management and decreasing asthma symptoms and health care costs.
Shortening the number of visits has the potential risk of not allowing enough time for
the development of rapport with the family and/or time to address other needs. Hence,
another potentially useful strategy would be to provide greater involvement of the home
visiting nurses with clinic staff. That way, the clinic staff could reinforce the goals of the
home visiting program so that families might be referred for additional assistance with
needs beyond the scope of the asthma home visiting program.
Surprisingly, caregivers who lived with the childs father or father figure received
lower ratings on attainment of objectives than those who did not. Perhaps fathers acted as
a distracter, as the moderate, albeit not significant, negative correlation between homework completion and father presence might suggest. However, this matter would require
further investigation. Although our nurses were trained to deliver the educational program to the primary caregiver and the child and to involve family members as appropriate, other aspects of our study design and intervention may have minimized involvement
of family members, especially father figures. For example, only the primary caregiver
signed the consent form, the home visits were conducted by a single nurse, and incentives
were provided for only the primary caregiver and child. To achieve greater family participation and retention, researchers may need to use a multisystem recruitment approach
(Holder et al., 1998) and staffing patterns that accommodate participation of more family
members (i.e., two nurse home visitors) and incentives for each caregiver.

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Successful asthma management results in an increased quality of life for the children
and their families and in decreased health care costs. Home visiting may produce only
modest improvement in outcomes (Brown et al., 2002) but is still worthy of consideration
for families who do not have access to clinic- or school-based asthma education programs. To be successful with low-income children with asthma, home visiting programs
need to be flexibly tailored to individual families needs and implemented by nurses who
are trained to work with families facing multiple stressors associated with living in poverty and caring for a child with a chronic disease.
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