Objective: To develop and validate a Portuguese-language version of the Asthma Control Test (ACT) for use in Brazil. Methods: The study comprised 290 asthma outpatients over 12 years of age. The patients completed the ACT questionnaire and had an appointment with a pulmonologist in order to assess asthma control in two visits. In the first visit, the patients also underwent spirometry. The second visit took place at least four weeks later. Results: We found that a cut-off score of 18 points-to differentiate between subjects with controlled asthma and those with uncontrolled asthma-had a sensitivity of 93%, a specificity of 74%, a negative predictive value of 86% and a positive predictive value of 85%. The positive and negative likelihood ratios were 3.58 and 0.09, respectively. The questionnaire has an outstanding capacity to differentiate uncontrolled asthma from controlled asthma, with an area under the ROC curve of 0.904. The patients whose symptoms remained stable between the two visits had similar scores, demonstrating good test-retest reproducibility, with an intraclass correlation coefficient of 0.93. The patients whose symptoms improved in the second visit had significantly higher scores, demonstrating good responsiveness of the questionnaire in the identification of changes in disease control. Conclusions: The Portuguese-language version of the ACT showed good test-retest reproducibility and was capable of discriminating the levels of asthma control and detecting changes in asthma control in a population of patients with a low level of education and low family income at a public health facility in Brazil.

Keywords: Asthma; Questionnaires; Validation studies; Signs and symptoms.

Objective: To validate a Portuguese-language version of the COPD assessment test (CAT) for use in Brazil and to assess the reproducibility of this version. Methods: This was multicenter study involving patients with stable COPD at two teaching hospitals in the city of Fortaleza, Brazil. Two independent observers (twice in one day) administered the Portuguese-language version of the CAT to 50 patients with COPD. One of those observers again administered the scale to the same patients one week later. At baseline, the patients were submitted to pulmonary function testing and the six-minute walk test (6MWT), as well as completing the previously validated Portuguese-language versions of the Saint George's Respiratory Questionnaire (SGRQ), modified Medical Research Council (MMRC) dyspnea scale, and hospital anxiety and depression scale (HADS). Results: Inter-rater and intra-rater reliability was excellent (intraclass correlation coefficient [ICC] = 0.96; 95% CI: 0.93-0.97; p < 0.001; and ICC = 0.98; 95% CI: 0.96-0.98; p < 0.001, respectively). Bland & Altman plots showed good test-retest reliability. The CAT total score correlated significantly with spirometry results, 6MWT distance, SGRQ scores, MMRC dyspnea scale scores, and HADS-depression scores. Conclusions: The Portuguese-language version of the CAT is a valid, reproducible, and reliable instrument for evaluating patients with COPD in Brazil.

Keywords: Pulmonary disease, chronic obstructive; Questionnaires; Validation studies; Quality of life; Reproducibility of results.

Objective: The aim of this study was to develop a Portuguese-language version of the Epworth sleepiness scale (ESS) for use in Brazil. Methods: The steps involved in creating the ESS in Brazilian Portuguese (ESS-BR) were as follows: translation; back-translation; comparison (by a committee) between the translation and the back-translation; and testing in bilingual individuals. The ESS-BR was applied to a group of patients who were submitted to overnight polysomnography in order to identify obstructive sleep apnea-hypopnea syndrome (OSAHS), insomnia and primary snoring. A control group was composed of subjects with a history of normal sleep habits, without reported snoring. Results: A total of 114 patients and 21 controls were included. The 8-item scores of the ESS-BR had an overall reliability coefficient of 0.83. The study group was composed of 59 patients with OSAHS, 34 patients with primary snoring and 21 patients with insomnia. One-way ANOVA demonstrated significant differences in ESS-BR scores among the four diagnostic groups (p < 0.001). Post-hoc tests between groups showed that the ESS-BR scores of the patients with insomnia did not differ from those of the controls (p > 0.05). The ESS-BR scores were significantly higher for OSAHS patients and for primary snorers than for controls (p < 0.05). In addition, the scores for OSAHS patients were significantly higher than were those for primary snorers (p < 0.05). Conclusions: The results of the present study demonstrate that the ESS-BR is a valid and reliable instrument for the assessment of daytime sleepiness, equivalent to its original version when applied to individuals who speak Brazilian Portuguese.

Keywords: Validation studies; Sleep disorders; Cross-cultural comparison; Disorders of excessive somnolence.

Objective: To translate the Pediatric Asthma Control and Communication Instrument (PACCI) to Portuguese and adapt it for use in Brazil, ensuring the cultural validity of the content and semantic equivalence of the target version. Methods: The Brazilian Portuguese-language version of the PACCI was developed according to the most commonly used methodology, which included the following steps: translation; synthesis of the translation; review by the author of the original questionnaire; back-translation; synthesis of the back-translation; review by a native external researcher who is a native speaker of English; approval of the author of the original questionnaire; review by a specialist in Portuguese; review by a multidisciplinary committee of experts to determine the agreement of the items, considering the clarity of each and its appropriateness in the cultural context; cognitive debriefing; and development of the final version. The cognitive debriefing involved 31 parents/legal guardians of children 1-21 years of age with a clinical diagnosis of asthma, as defined by the Global Initiative for Asthma, with the objective of determining the comprehensibility and clarity of the items for the target population. Results: The multidisciplinary committee of experts indicated that the items on the questionnaire were clear and comprehensible, with kappa values above 0.61, indicating substantial agreement. In the cognitive debriefing, the parents/legal guardians presented no difficulties in understanding any of the items (agreement > 0.90); therefore, no further changes were needed.Conclusions: The translation and cross-cultural adaptation of the PACCI for use in Brazil were successful.

Keywords: Surveys and questionnaires; Translating; Asthma; Child; Adolescent.

Objective: To evaluate whether the Portuguese version of the Asthma Control Questionnaire (ACQ) is a valid instrument to measure asthma control in adult outpatients in Brazil. Methods: We selected 278 outpatients diagnosed with asthma. All of the patients completed the questionnaire, underwent spirometry and were clinically evaluated by a physician in order to characterize the control of the disease in the first visit. The questionnaire was evaluated in three versions, with 5, 6 and 7 questions, respectively, and scores of 0.75 and 1.50 were used as cut-off points. Results: Of the 278 patients, 77 (27.7%) had intermittent asthma, 39 (14.0%) had mild persistent asthma, 40 (14.4%) had moderate persistent asthma and 122 (43.9%) had severe persistent asthma. The sensitivity of ACQ to identify uncontrolled asthma ranged from 77% to 99%, and the specificity ranged from 36% to 84%. The positive predictive value ranged from 73% to 90%, and the negative predictive value ranged from 67% to 95%. The positive likelihood ratio ranged from 1.55 to 4.81, and the negative likelihood ratio ranged from 0.03 to 0.27. In the 5- and 6-question versions of the ACQ, the intraclass correlation coefficient was 0.92. These two versions were both responsive to clinical changes in the patients. Conclusions: All three versions of the ACQ satisfactorily discriminated between patients with uncontrolled asthma and those with controlled asthma. The 5- and 6-question versions also presented good reliability and responsiveness. Therefore, the ACQ is a valid tool for evaluating asthma control in adult outpatients in Brazil.

Keywords: Asthma; Therapeutics; Diagnosis; Questionnaires; Reproducibility of results.

Objective: To assess the psychometric properties of the official Brazilian Portuguese-language version of the Paediatric Asthma Quality of Life Questionnaire (PAQLQ) in a representative group of Brazilian children and adolescents with asthma. Methods: A total of 125 individuals with asthma, aged 8-17 years and being monitored at a pediatric pulmonology outpatient clinic in the city of Porto Alegre, Brazil, completed the PAQLQ. Validity was assessed by means of convergent validity (correlation between PAQLQ domains and those of the Pediatric Quality of Life Inventory (PedsQL) 4.0. Reliability was assessed by determining internal consistency (Cronbach's alpha coefficient), reproducibility (intraclass correlation coefficient), sensitivity to change (effect size), and discriminatory power (floor/ceiling effects). Results: The mean age was 11 years, and 75 (60%) of the participants were male. The mean PAQLQ total score was 5.1, with floor/ceiling effects < 10%. Correlations between PAQLQ domains and the PedsQL 4.0 domains were acceptable (r = 0.37-0.40). The Cronbach's alpha coefficient for the total score was 0.93, ranging from 0.72 to 0.88 for the domains. The overall effect size was 0.60 (range: 0.45-0.60), whereas the overall intraclass correlation coefficient was 0.80 (range: 0.66-0.79). Conclusions: The official Brazilian Portuguese-language version of the PAQLQ showed good psychometric performance, confirming its cultural adequacy for use in Brazil.

Keywords: Keywords: Quality of life; Asthma; Validation studies.

Objective: To develop and validate an asthma knowledge questionnaire for use in adult asthma patients in Brazil. Methods: A 34-item self-report questionnaire was constructed and administered to adult asthma patients and adult controls. The maximum total score was 34. Results: The questionnaire was shown to be discriminatory, with good reliability and reproducibility. The mean score for asthma patients and controls was, respectively, 21.47 ± 4.11 (range: 9-31) and 17.27 ± 5.11 (range: 7-28; p < 0.001). The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.53, and the Bartlett's test of sphericity demonstrated a satisfactory suitability of the data to factor analysis (p < 0.001). There was no significant difference between the total scores obtained in the first and in the second application of the questionnaire within a two-week interval (p = 0.43). The internal consistency reliability (KR-20 coefficient) was 0.69. Conclusions: This study has validated an asthma knowledge questionnaire for use in Brazil.

Keywords: Asthma; Questionnaires; Validation studies; Reproducibility of results.

Objective: To assess asthma patients in Brazil in terms of the level of asthma control, compliance with maintenance treatment, and the use of rescue medication. Methods: We used data from a Latin American survey of a total of 400 asthma patients in four Brazilian state capitals, all of whom completed a questionnaire regarding asthma control and treatment. Results: In that sample, the prevalence of asthma was 8.8%. Among the 400 patients studied, asthma was classified, in accordance with the Global Initiative for Asthma criteria, as controlled, partially controlled, and uncontrolled in 37 (9.3%), 226 (56.5%), and 137 (34.3%), respectively. In those three groups, the proportion of patients on maintenance therapy in the past four weeks was 5.4%, 19.9%, and 41.6%, respectively. The use of rescue medication was significantly more common in the uncontrolled asthma group (86.9%; p < 0.001). Conclusions: Our findings suggest that, in accordance with the established international criteria, asthma is uncontrolled in the vast majority of asthma patients in Brazil. Maintenance medications are still underutilized in Brazil, and patients with partially controlled or uncontrolled asthma are more likely to use rescue medications and oral corticosteroids.

Keywords: Asthma/therapy; Asthma/prevention and control; Medication adherence.

Objective: To quantify the use of health care resources among patients enrolled in the Bahia State Asthma and Allergic Rhinitis Control Program. Methods: As of January of 2006, 1405 patients had enrolled in the program, which is carried out in four referral centers in the city of Salvador. These patients formed the basis of this retrospective/prospective, observational cohort study. The preliminary analysis involved 269 consecutive patients, all above the age of 12 and diagnosed with severe asthma. After being seen by pulmonologists, nurses, pharmacologists and psychologists, the patients received inhaled asthma medications. Based on patient interviews and charts, the year preceding enrollment in the program was compared with the first year enrolled in the program in terms of the following quantifiable parameters: hospital admissions; emergency room visits; courses of oral corticosteroids; and days of school/work missed due to asthma attacks. Results: In this sample of patients with severe asthma, enrollment in the program resulted in significant reductions in the number of emergency room visits and hospital admissions (of 85% and 90%, respectively). There were also reductions in the number of school/work days missed due to asthma attacks and in the number of courses of oral corticosteroids (of 86% and 67%, respectively). Conclusion: A program designed to control severe asthma in referral outpatient clinics and including pharmacological services at no charge can lead to a pronounced reduction in the demand for Unified Health Care System resources.

Keywords: Asthma/therapy; Asthma/prevention  control; Hospitalization; National Health System (BR)

Objective: To evaluate the use of inhaler devices by patients with severe asthma treated via the Programa para o Controle da Asma e Rinite Alérgica na Bahia (ProAR, Bahia State Asthma and Allergic Rhinitis Control Program), recording the frequency of their errors in performing key steps and the relationship between such errors and the lack of asthma control. Methods: A cross-sectional study involving 467 patients enrolled in the ProAR in the city of Salvador, Brazil. The devices evaluated were metered dose inhalers (MDIs), with or without a spacer, and dry powder inhalers (DPIs; Pulvinal® or Aerolizer®). For the assessment of the inhalation technique, a checklist was used; the patients were asked to demonstrate the technique so that an interviewer could observe all of the steps performed. For the assessment of asthma control, we used the 6-item asthma control questionnaire. Results: Most of the patients showed appropriate inhalation techniques when using the devices. When using an MDI, few patients made mistakes in the key step of "coordinating activation and inhalation" (5.2% and 9.1% with and without the use of a spacer, respectively). During Pulvinal® use, 39% of the patients did not inhale quickly and deeply, compared with only 5.8% during Aerolizer® use. Of the patients that made use of Aerolizer® alone, 71.3% appropriately performed all of the essential steps, and their asthma was controlled. Conclusions: Most of the patients in this sample, all of whom had been submitted to periodic checks of their inhalation technique (as part of the program), used the devices appropriately. Proper inhalation technique is associated with asthma symptom control.

Keywords: Asthma; Administration, inhalation; Metered dose inhalers; Dry powdered inhalers.

Objective: The translation and cross-cultural adaptation of a specific scoring instrument for the comprehensive control of asthma, the Asthma Control Scoring System (ACSS), for use in Brazil. Methods: The protocol included ten steps: acquisition of written permission from the author of the ACSS; translation of the instrument to Brazilian Portuguese, carried out by three separate translators; analysis and comparison of the three versions by a review committee; literal back-translation to English; review and harmonization of the back-translation; acquisition of the approval of the original author; review of the translation by specialists; cognitive debriefing: test of clarity to, understanding by, and acceptance of the target population (evaluation of the translation by 10 health care workers); second cognitive debriefing: review of the revised version by a second group of health care workers; and reconciliation and preparation of the final version by the review committee. Results: The Brazilian Portuguese-language version of the ACSS showed clarity, understandability, and acceptability. The instrument was considered to be comprehensive because it includes the clinical manifestations of asthma, as well as the functional and inflammatory aspects of the disease. Conclusions: With the use of this careful methodology in the translation and cross-cultural adaptation of the ACSS, we have ensured its cultural adequacy for Brazil. The use of this instrument could facilitate future studies on asthma control.

Keywords: Asthma/classification; Asthma/prevention & control; Questionnaires.

Objective: To assess the agreement among asthma control measures and functional exercise capacity in children and adolescents with uncontrolled and controlled asthma. Methods: Children and adolescents with asthma from 7-17 years old were selected, and they were attended in the "Pediatric Pulmonology Outpatient Clinic of State University of Campinas", in Brazil. All patients had asthma control level assessed by Global Initiative for Asthma questionnaire (GINAq), Asthma Control Test (ACT), spirometry and six-minute-walk-test (6MWT). Patients were classified as uncontrolled or controlled asthma in each test and agreement among measures was assessed by kappa statistics. The ROC curve was calculated for the 6MWT. The spirometric index obtained from spirometry was composed by FEV1, FEV1/FVC and FEF25-75%. Spirometry and 6MWT results were compared between uncontrolled and controlled asthma group by GINAq. Results: Of the 138 subjects included, 78 (56.5%) were male with median age of 11 (7-17) years old. GINAq detected 68.8% of patients with uncontrolled asthma. Moderate agreement (p < 0.001; k = 0.56) and high specificity (100%) was observed between GINAq and ACT. In 6MWT, the cut-off point of 82.03% of predicted distance was able to distinguish patients with controlled and uncontrolled asthma. Spirometric index presented 73.4% of sensitivity according to GINAq. The results for 6MWT in patients with uncontrolled asthma were the worst of all. Conclusion: This study highlights the importance of assessing more than one measure to differentiate asthma control level. GINAq identified more patients with uncontrolled asthma and presented moderate agreement with ACT. Spirometric index was associated with uncontrolled asthma according to GINAq. 6MWT was a suitable measure to distinguish patients with controlled and uncontrolled asthma.

Keywords: Asthma; Asthma control; Spirometry; Walk test; Children.

Objective: The objective of this study was to evaluate the applicability of a modified version of the Saint George's Respiratory Questionnaire. The version evaluated elicits "agree" and "do not agree", rather than "yes" and "no", responses. The intention is to facilitate the comprehension of double-negative questions and to promote better recollection of symptoms by patients by shortening their symptom histories from 12 months to 3 months. Methods: A total of 30 clinically stable patients with chronic obstructive pulmonary disease were evaluated. The Saint George's Respiratory Questionnaire and the modified version of the same were administered 15 days apart. Results: All of the patients presented health-related alterations in their quality of life. Comparing mean scores between the two questionnaires, the greatest difference was seen in the Symptoms domain. No significant differences were found in any of the remaining domains or in the total scores. In a subsequent analysis, significant correlations between the two questionnaires were found in all domains: Symptoms (r = 0.71; p < 0.001); Activity (r = 0.75; p < 0.001); Impact (r = 0.73; p < 0.001) and Total (r = 0.86; p < 0.001). Conclusion: The modified version of the Saint George's Respiratory Questionnaire is as effective as the original in gauging quality of life. However, various symptoms recollection time frames should be investigated in order to determine which would be the best time frame to employ in the analysis.

Keywords: Pulmonary disease, chronic obstructive; Quality of life; Reproducibility of results; Cross-cultural comparison; Questionnaires

Objective: To investigate the reliability, internal consistency and validity of the Brazilian Portuguese version of the University of California San Diego Shortness of Breath Questionnaire (UCSD SOBQ) in patients with interstitial lung disease (ILD). Methods: Patients with ILD completed the questionnaire at three different time points, one week apart, with the assistance of two independent assessors. Intra- and inter-rater reliability were analysed via the intraclass correlation coefficient (ICC). Internal consistency was assessed with the Cronbach's alpha coefficient. For the validity analysis, associations between variables were assessed with Spearman's or Pearson's correlation coefficient. Results: Thirty patients with ILD (idiopathic pulmonary fibrosis, connective tissue disease-associated pulmonary fibrosis, sarcoidosis, asbestosis or non-specific interstitial pneumonia) were included (15 men; mean age, 59 ± 10 years; DLCO: 46 [33-64] % predicted). UCSD SOBQ scores showed excellent agreement and internal consistency in the intra-rater analysis (ICC: 0.93 [0.85-0.97]; Cronbach alpha: 0.95) and in the inter-rater analysis (ICC: 0.95 [0.89-0.97]; Cronbach alpha: 0.95), as well as correlating significantly with dyspnoea (as assessed by the Medical Research Council scale; r = 0.56); Medical Outcomes Study 36-item Short-Form Health Survey domains bodily pain, general health, vitality and physical functioning (-0.40 = r = -0.74); six-minute walk distance (r = -0.38); and quadriceps muscle strength (r = -0.41). Conclusions: The Brazilian Portuguese version of the UCSD SOBQ is valid, is reliable and has internal consistency in patients with ILD in Brazil.

Keywords: Lung diseases, interstitial; Dyspnea; Surveys and questionnaires.

Objective: To adapt the PROactive Physical Activity in COPD-clinical visit (C-PPAC) instrument to the cultural setting in Brazil and to determine the criterion validity, test-retest reliability agreement, and internal consistency of this version. Methods: A protocol for cultural adaptation and validation was provided by the authors of the original instrument and, together with another guideline, was applied in a Portuguese-language version developed by a partner research group from Portugal. The adapted Brazilian Portuguese version was then cross-sectionally administered twice within a seven-day interval to 30 individuals with COPD (57% were men; mean age was 69 ± 6 years; and mean FEV1 was 53 ± 18% of predicted) to evaluate internal consistency and test-retest reliability. Participants also completed the International Physical Activity Questionnaire (IPAQ), the modified Medical Research Council scale, the COPD Assessment Test, and Saint George's Respiratory Questionnaire to evaluate criterion validity. Results: The C-PPAC instrument showed good internal consistency and excellent test-retest reliability: "amount" domain = 0.87 (95% CI, 0.73-0.94) and "difficulty" domain = 0.90 (95% CI, 0.76-0.96). Bland & Altman plots, together with high Lin's concordance correlation coefficients, reinforced that agreement. Criterion validity showed moderate-to-strong correlations of the C-PPAC with all of the other instruments evaluated, especially with the IPAQ (rho = -0.63). Conclusions: The Brazilian Portuguese version of the C-PPAC is a reliable and valid instrument for evaluating the experience of Brazilian individuals with COPD with their physical activity in daily life.

Keywords: Pulmonary disease, chronic obstructive; Validation study; Activities of daily living; Psychometrics.

Objective: To evaluate the impact of the Programa de Controle da Asma e Rinite Alérgica em Feira de Santana (ProAR-FS, Program for the Control of Asthma and Allergic Rhinitis in Feira de Santana) on the frequency of hospitalizations for asthma in patients monitored at a referral center for one year. Methods: This was a historical control study involving 253 consecutive patients with asthma, ages ranging from 4 to 76 years. We compared the frequency of hospital admissions and visits to the emergency room (ER) in the 12 months prior to and after their admission to the ProAR-FS. During the program, patients received free treatment, including inhaled medications and education on asthma. Demographic and socioeconomic aspects were also assessed. Results: There was a significant reduction in the number of hospitalizations (465 vs. 21) and of visits to the ER (2,473 vs. 184) after their admission to ProAR-FS (p < 0.001 for both). Of the 253 patients who had been hospitalized and had had ER visits within the year prior to the admission to ProAR-FS, only 16 were hospitalized and 92 visited the ER during the follow-up year, representing a reduction of 94% and 64%, respectively. Conclusions: Implementing a referral center for the treatment of asthma and rhinitis in the Unified Health Care System, with the free distribution of inhaled corticosteroids and the support of an education program, is a highly effective strategy for the control of asthma.

Keywords: Hospitalization; Asthma; Rhinitis; Health services; Public health.

Our objective was to evaluate the reproducibility of Asthma Control Questionnaire 7 (ACQ-7) in asthma patients, comparing our results against those obtained with the Global Initiative for Asthma (GINA) criteria. We evaluated 52 patients. Patients completed the ACQ-7, underwent spirometry, and were clinically assessed to determine the level of asthma control according to the GINA criteria, in two visits, 15 days apart. The ACQ-7 cutoff for uncontrolled asthma was a score of 1.5. The ACQ-7 showed good reproducibility, with a correlation coefficient of 0.73. The ACQ-7 identified a greater number of patients with uncontrolled asthma than did the GINA criteria; according to the GINA criteria, 47 patients (90.4%) presented with partially controlled asthma.

Keywords: Asthma/prevention and control; Asthma/classification; Questionnaires.

Objective: To compare the accuracy of the amplified Mycobacterium tuberculosis direct (AMTD) test with reference methods for the laboratory diagnosis of tuberculosis in HIV-infected patients. Methods: This was a study of diagnostic accuracy comparing AMTD test results with those obtained by culture on Löwenstein-Jensen (LJ) medium and by the BACTEC Mycobacteria Growth Indicator Tube 960 (BACTEC MGIT 960) system in respiratory samples analyzed at the Bioassay and Bacteriology Laboratory of the Oswaldo Cruz Foundation Evandro Chagas Clinical Research Institute in the city of Rio de Janeiro, Brazil. Results: We analyzed respiratory samples collected from 118 patients, of whom 88 (74.4%) were male. The mean age was 36.6 ± 10.6 years. Using the AMTD test, the BACTEC MGIT 960 system, and LJ culture, we identified M. tuberculosis complex in 31.0%, 29.7%, and 27.1% of the samples, respectively. In comparison with LJ culture, the AMTD test had a sensitivity, specificity, positive predictive value, and negative predictive value of 87.5%, 89.4%, 75.7%, and 95.0%, respectively, for LJ culture, whereas, in comparison with the BACTEC MGIT 960 system, it showed values of 88.6%, 92.4%, 83.8%, and 94.8%, respectively. Conclusions: The AMTD test showed good sensitivity and specificity in the population studied, enabling the laboratory detection of M. tuberculosis complex in paucibacillary respiratory specimens.

Keywords: Molecular diagnostic techniques; Tuberculosis; HIV; Molecular probe techniques.

There is much discussion about effective public policies that allow the proper treatment of asthma, providing care that is comprehensive and centered on asthma patients within their social context. Educating health professionals and asthma patients provides better recognition of symptoms and the triggers of asthma exacerbations, as well as disseminating strategies for avoiding such triggers, thereby ensuring better treatment and quality of life for asthma patients. Asthma imposes an ever-increasing burden on society, in terms of impaired quality of life, morbidity, and health care costs, making this a very important discussion in the field of public policy.

Keywords: Health policy; Asthma; Consensus.