In this single-center multi-methods study, we demonstrated the successful implementation of a novel, virtual asthma education program for patients and caregivers of children with a recent asthma hospitalization or newly diagnosed asthma. Asthma education was effective for improving perceived knowledge and confidence for asthma self-management. Virtual asthma education was equally effective for achieving these outcomes as in-person education. Participants described their experience in asthma education according to three main themes: information, value, and experience. We did not identify significant differences between groups with respect to the first two themes, but in-person versus virtual education attendees had different experiences, specifically related to sub-themes of safety, convenience, and accessibility.

The demonstration of improved knowledge and confidence among caregivers in our study is in keeping with the prior literature on telemedicine in asthma. While most previous studies focus on the outcomes of remote clinical care, a small number do focus on education interventions alone. A recent study in adult patients with obstructive lung disease, including asthma, demonstrated the efficacy of an asynchronous patient-initiated virtual video education intervention for teaching correct inhaler technique [9]. Only a limited number of prior studies have examined synchronous video telemedicine compared to in-person comprehensive asthma education, with most conducted as school-based interventions among lower income children. A systematic review that included 5 studies conducted in children 3–17 years old demonstrated inconsistent and inconclusive effects of virtual asthma education on clinical outcomes, asthma knowledge and satisfaction compared to usual care. However, there was some evidence of improved quality of life, symptom management ability and symptom burden in the intervention groups, indicating that virtual asthma education is likely at least as beneficial as in-person education interventions [10, 11].

Experiences of participants of virtual or in-person education differed in relation to safety, convenience, and accessibility. The majority of patients and families who participated in virtual asthma education (and some who attended in-person during the pandemic) preferred the virtual option, for the reason of improved safety and infection exposure avoidance. From a provider perspective, infection prevention was the reason for our program’s reliance on this modality since the COVID-19 pandemic. Our study results indicate our virtual education program allowed uninterrupted delivery of high-quality comprehensive asthma education for eligible patients despite reductions to in-person interactions for safety and infection control reasons. However, a small minority of caregivers expressed safety and privacy concerns with the use of social media (i.e. Zoom) and preferred an in-person education experience.

Beyond infection avoidance, there were additional unanticipated benefits of virtual asthma education, including convenience for families. Participants expressed their preference in receiving asthma education from the comfort of home, thereby avoiding the inconveniences of travel time and cost, and organizing care for other children while attending an appointment at the hospital. These findings were similar to a small (n = 30) pre-pandemic study in which 84% of caregivers of preschoolers with asthma who participated in a single synchronous 1-hour telemedicine asthma education session found it convenient and useful, though emergency room visits and hospitalizations were not impacted [12].

Another obstacle overcome by virtual care was accessibility, which is traditionally limited by lack of space and educators. While small classroom sizes limit the number of attendees for in-person education sessions, many participants expressed the desire for additional family members to attend. In contrast, the virtual space is unlimited and caregivers appreciated the ability for multiple family members to attend. Small classroom sizes pose an infection control/safety risk, even pre-pandemic, and have restricted the access of the virally-triggered hospitalized adolescent patient and symptomatic caregivers to attend group education. However, there is limited capacity for one on one bedside education and many caregivers find it difficult to concentrate and absorb bedside teaching while also tending to their sick child [7]. Providing adequate supervision of preschool patients while their parent attends a classroom education session is an ongoing challenge, and further limits access to education during the hospital stay. Conversely, virtual education, scheduled after hospital discharge, alleviated the issue of organizing childcare and optimized attendance. High cost and time for travel for in-person clinical care are additional recognized barriers in access to care, and in Canada, have been addressed through the (infrequent) use of specialized telemedicine sites and government travel grants (restricted to those living  > 200 km from a care facility) [13]. However, the inconveniences of travel for those living closer to the hospital continue to limit in-person attendance.

A few barriers in access to virtual education identified by participants included the requirement for reliable high-speed internet access which was an impediment for some families [14] and detracted from the quality of the education experience. To mitigate this, and avoid inequity related to the ‘digital divide’ [15] it would be important to continue to offer in-person education for certain families; those without adequate internet access, and those who may not prioritize attendance after hospital discharge for financial and other psychosocial reasons.

Limitations of the current study include the lack of true randomization and the likelihood that many patients who engaged in virtual education may have been biased towards a positive response to this modality given the current pandemic situation. Whether positive uptake will continue months to years after COVID-19 related physical distancing restrictions have eased and there is resumption of previous levels of in-person medical care is unclear. Our study was also conducted during a period when asthma symptom burden was generally reduced due to the reduction in viral respiratory triggers compared to previous years [16] and this may have influenced results. For this reason, we were unable to compare health outcomes such as symptom burden, quality of life and exacerbation frequency among patients who receive virtual versus in-person education though this could be studied in future.

Despite some limitations, the results of this study suggest a potential for harnessing virtual care delivery to broaden the reach of our asthma education program to include a larger number of patients, including those in the community. Wide acceptance of virtual education and studies in adults demonstrating the efficacy of group asthma education [10] support increasing the size of group virtual sessions, participation, and impact. However, larger groups may lead to less personalization. Determining a threshold maximum number of participants per virtual session beyond which the quality of the teaching diminishes is an additional area for future study.

A shift to virtual clinical care in a variety of medical settings across North America, and the receptiveness of patients and families provided a unique opportunity to establish a virtual asthma education program at our tertiary care pediatric center. This program was well received by participants, as it provides a safe and infection-free setting for asthma education. We anticipate that this virtual education program will have continued good uptake given its multiple additional benefits, including convenience, and accessibility, without compromise on quality. However, allowing families the option of in-person or virtual education remains an important consideration as some families continue to prefer care in-person, or may have limited digital access. For the care provider, virtual asthma education has the potential to enhance and broaden the reach of our tertiary care asthma program and in future, allow us to offer high quality, expertly delivered asthma education to a broader group of patients, including those living in rural and remote communities.