Puff City, an asthma education program for teens, demonstrates that web-based support is a promising way to deliver health information to inner-city youth and other hard-to-reach and underserved populations. 


Puff City Article PhotoPuff City, a web-based education program, uses hip language and graphics to encourage teens with asthma to use their inhalers, take their medications, and stop smoking. Teens involved in the first evaluation of the program from 2001-05 reduced their emergency department (ED) visits and hospitalizations by 50 percent.

“Few asthma management programs target the 15- to 19- year-old age group. Puff City was developed in an attempt to reduce the high rate of morbidity and mortality in this neglected age group,” says Christine Joseph, PhD, MPH, public health sciences and researcher at Detroit-based Henry Ford Health System (HFHS) and the principal investigator for the Puff City Asthma Management System.

HFHS developed the program with the Detroit Public Schools, the University of Michigan, and George Health Sciences. In 2012, the partnership was awarded a NOVA award from the American Hospital Association for their collaborative efforts toward improving community health.

View a video overview of Puff City 

Keeping Students Engaged

Based on recommended patient content from the National Asthma Education and Prevention Program and reviewed by a medical team headed by Dennis R. Ownby, MD, of the Georgia Health Sciences Center, Puff City content focuses on three core behaviors: controller medication adherence, rescue inhaler availability, and smoking cessation/reduction. The program is voiced over to accommodate low literacy.

A total of 736 Detroit high school students participated in the Puff City program. “It is a challenge to get kids to try the program. Although, once we get them into it, they are engaged. In the last program evaluation, more than 80 percent of teens completed all four of the computer sessions,” Joseph says.

Thanks to a partnership between HFHS and the Detroit Public Schools, students can complete the Puff City coursework at school. The school system also provided advice and support to help HFHS reach students with asthma.

Other key elements in the program’s success include the following:

Guidance and counseling. To increase the chances that students will complete the Puff City program, school staff assist with computer use and technology problems. Students must finish four 20-30 minute educational sessions in 180 days. In addition, an asthma counselor based at HFHS is available by phone to all students enrolled in Puff City, which accounts for much of the program’s $6.66 cost per student.

Customized content. The program uses an online assessment to determine users’ beliefs, attitudes, and resistance to change. Questions include “In the last week, how many times did you take controller medication as prescribed,” and “How much support do you feel you have from your friends and family when it comes to controlling your asthma?”

Educational sessions and health messages are then customized based on each teen’s answers. For example, if teens indicate they don’t keep their rescue inhaler nearby, the narrator says, “If you are like me, you don’t want to be told what to do. Maybe asthma isn’t your top priority right now, but you never know when your symptoms will start or your next asthma attack will happen? What are some of the good things that can happen by giving up those smokes, having your inhaler nearby, and taking those controller meds?” 

Expanding the Program

In addition to cutting ED visits and hospitalizations in half, students participating in the Puff City program experienced fewer symptom days and nights and fewer days of restricted activity than a control group.

Based on those positive results, Joseph’s team created pilot projects in EDs at HFHS and Children’s Hospital of Michigan. After teens receive care, they can complete the Puff City baseline survey on an iPad or from a laptop in the ED and view a short segment from the course on managing their asthma symptoms. Other plans include testing Puff City’s effectiveness in rural high schools and as a widely available program on the Internet.

Joseph and her team believe that Puff City can be adapted to raise health awareness and manage other illnesses. “Now that we have the basic framework, it will be possible to adapt the program for other diseases and for other populations. We are planning to develop a version for Latino teens. We would also like to develop a tailored intervention to retain teens with HIV/AIDS in care and to remind teens engaged in high-risk behavior to be tested for HIV on a regular basis,” Joseph says.


Betty Hintch is editor, HFMA newsletters and forums.

Interviewed for this article:
Christine Joseph, PhD, MPH, public health sciences and researcher at Henry Ford Health System, Detroit (Cjoseph1@hfhs.org).

Publication Date: Thursday, February 28, 2013