A eficácia do uso de videogames e programas baseados em software na educação e autogestão em asma para crianças e adolescentes

Inchauspe, Ramiro Marques; Maróstica, Paulo José Cauduro; Barreto, Sergio Saldanha Menna; Silva, Matteo Marques da; Rabaioli, Caroline Talhietti

Resumo

Introdução:

A asma é uma doença crônica das vias aéreas inferiores, caracterizada por obstrução ao fluxo aéreo geralmente reversível, inflamação e hiper-reatividade a vários tipos de estímulos. É uma das doenças respiratórias crônicas mais comuns entre crianças e adultos, com incidência de 300 milhões de pessoas em todo o mundo.

Objetivo:

Avaliar a qualidade das evidências existentes na literatura a fim de apoiar o uso de videogames e programas baseados em software na capacidade de conhecimento e autogestão de crianças e adolescentes asmáticos em comparação com a educação padrão.

Métodos:

Pesquisa, seleção e análise (a partir de março de 2016) de todos os artigos originais sobre realidade virtual (RV) utlizada com crianças e adolescentes asmáticos (idades de 3 a 18), publicados até outubro de 2017, em português, inglês e espanhol, nas bases de dados eletrônicas Pubmed, Web of Science, MedlLine e LILACS, obtidas por meio dos descritores: asma, videogame, realidade virtual, reabilitação pulmonar, treinamento físico.

Resultados:

Apenas seis artigos originais foram obtidos. Destes, cinco (80%) apresentaram nível de evidência A e um (20%) apresentou nível de evidência B. Todos os autores apontam o tratamento da asma por RV como uma terapia segura e inovadora, considerando que a motivação e intensidade do tratamento com o uso da RV melhora a capacidade de autogerenciamento e capacidade aeróbia do paciente asmático.

Conclusão:

O presente estudo busca contribuir com a literatura ao demonstrar que videogames e outros sistemas baseados em software podem ser utilizados para melhorar a capacidade de conhecimento e autogeren-ciamento de crianças e adolescentes com diagnóstico de asma.

Palavras-chave:
Asma; Crianças; Reabilitação pulmonar; Revisão sistemática; Videogame

[1] * Correspondence: ramiro.i@hotmail.com

Authors	Rubin et al., 1986⁶
Delimitation	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., 2000⁷7 Homer C, Susskind O, Alpert HR, Owusu C, Schneider L, Rappaport LA, et al. An evaluation of an innovative multimedia educational software program for asthma management: report of a randomized, controlled trial. Pediatrics. 2000;106(1 Pt 2): 210-5. Full text link Full text link...
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.
GRADE	High (A)
Authors	Huss et al., 2003⁸8 Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city children does not improve asthma outcomes. J Pediatr Health Care. 2003;17(2): 72-8. DOI DOI...
Delimitation	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.
GRADE	High (A)
Authors	Shames et al., 2004⁹9 Shames RS, Sharek P, Mayer M, Robinson TN, Hoyte EG, Gonzalez-Hensley F, et al. Effectiveness of a multicomponent self-management program in at-risk, school-aged children with asthma. Ann Allergy Asthma Immunol. 2004;92(6):611-8. DOI DOI...
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., 2000¹⁰10 Yawn BP, Algatt-Bergstrom PJ, Yawn RA, Wollan P, Greco M, Gleason M, et al. An in-school CD-ROM asthma education program. J Sch Health. 2000;70(4):153-9. DOI DOI...
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.
GRADE	High (A)
Authors	Bartholomew et al., 2000¹¹11 Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, et al. Watch, Discover, Think, and Act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns. 2000; 39(2-3):269-80. DOI DOI...
Delimitation	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 asthma-specific 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.
GRADE	Moderate (B)

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