Educating young children about asthma: comparing
the effectiveness of a developmentally appropriate
asthma education video tape and picture book
L Holzheimer, H Mohay and I B Masters*
Centre for Applied Studies in Early Childhood, School of Early Childhood, Queensland
University of Technology, and
*Respiratory Department, Mater Children's Hospital, Brisbane, Queensland, Australia
Accepted for publication 31 July 1997
Summary
Asthma self-management programmes have been shown to increase children's
knowledge about asthma and improve their management practices and health
status. However, existing programmes have rarely addressed the unique
learning needs of very young children. This study aimed to develop and assess
the effectiveness of a video tape and picture book designed to teach children
about the prevention and management of acute episodes of asthma. The
information content of the educational resources was determined by analysis of
relevant medical information and asthma management skills. Social Learning
Theory and consideration of the developmental stage of the target population
informed the format and style of presentation of the resources. Eighty children
aged between 2 and 5 years who had been diagnosed with asthma by their
medical practitioner and who required daily asthma medication participated in a
controlled experimental study. The study evaluated the impact of the asthma
education resources on children's knowledge about asthma, compliance with
medication regimens and health status. Children were randomly allocated to one
of three experimental groups. Children in these groups were exposed to either
the video tape alone, the book alone or both the video tape and book, or to a
control group who viewed materials unrelated to asthma. The results for the
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Correspondence
L Holzheimer
Centre for Applied Studies
in Early Childhood
School of Early Childhood
Queensland University of
Technology
Victoria Park Road
Kelvin Grove
Brisbane
Queensland
Australia 4059
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three experimental groups were compared with the control group who did not
receive exposure to any of the asthma education resources. The results showed
that children in each experimental group had significantly greater gains in
asthma-related knowledge than children in the control group and children
exposed to both resources showed the greatest increases in knowledge.
Children in each of the three experimental groups also had better compliance
and health than children in the control group. These findings indicate that
carefully designed asthma education resources are useful for providing even the
youngest children with information about asthma and its management.
Keywords: asthma education, asthma management, childhood asthma, compli-
ance, health knowledge, health status
Introduction
Childhood asthma is a significant health problem in Australia. The condition
affects � 25% of children (Robertson et al. 1991; Bauman et al. 1992) and
many of these children require daily medication for symptom control
(Comino et al. 1996). Asthma is also associated with high rates of morbidity in
all sectors of the population and significant mortality rates within adolescent
and adult groups (Australian Bureau of Statistics 1995).
Well developed self-management skills are essential for coping with asthma.
It is now well accepted that all individuals can successfully contribute to their
own health care by becoming proficient in use of these skills (McNabb
Wilson-Pessano & Jacobs 1986; Conboy 1989). However, studies indicate few
individuals are sufficiently informed about asthma self-management skills or
competently apply these when needed (Eiser et al. 1988; Dawson et al. 1992).
Non-compliance with prescribed medication regimens is also prevalent.
Studies within paediatric populations have reported non-compliance rates
ranging from 17% to 90%, with cessation of prophylactic medication being
common during asymptomatic periods (Christiaanse et al. 1989; Lemanek
1990).The lack of awareness of essential management skills and widespread
non-compliance results in unwarranted morbidity and mortality (Robertson et
al. 1992).
As a chronic disease which is sometimes difficult to manage, asthma presents
many challenges for young children and their families. Daily treatment
routines, regular medical consultations and periods of hospitalization place
additional strain on the family unit and are costly in terms of time and
financial expenditure (Wells 1994). The pervasive impact which asthma has
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on young children and their families is of concern to many health professionals.
While appropriate medical care and treatment are essential for effective
asthma management, the challenge of improving the management practices
and health status of people with asthma appears to lie in the provision of
appropriate asthma education. Medical and allied health professionals now
regularly employ health education strategies to support existing modes of
medical management. An array of education programmes which address the
cause, symptoms and management of asthma have been developed to increase
children's understanding of the condition and facilitate their active and co-
operative participation in condition management. Improved compliance with
prescribed medication regimens and enhanced health status and quality of life
are therefore amongst the expected outcomes of educational programmes.
Paediatric programmes, such as those developed by Fireman et al. (1981),
Hindi-Alexander and Cropp (1984) and the National Heart Lung & Blood
Institute (1984a, 1984b, 1984c, 1985) provided the impetus for development
of numerous other educational programmes. Recognition of the need for, and
acceptance of asthma education by the medical profession has resulted in the
ongoing development of a diverse range of programmes. Programmes
currently available vary in content and mode of presentation and are suitable
for use in a wide range of medical and non-medical settings including
hospitals, clinics and general medical practices, community agencies, schools
and specialized camps, and family homes (Baxmann & Klimo 1989; Deaves
1993; Punnett 1993; Capan et al. 1994; Collins 1994; Henry et al. 1994; Alaniz
1995).
Paediatric education programmes have been found to increase knowledge
about asthma and its management, reduce the frequency and severity of
symptoms and need for medical consultations for asthma, and improve quality
of life (Rolnick 1988), but relatively few programmes have been subjected to
rigorous evaluation. Furthermore many programmes only target children aged
over 7 years of age (e.g. Hindi-Alexander & Cropp 1984) or only provide
education for parents (Mesters et al. 1994). Few programmes have been
specifically designed for very young children or developed with an
understanding of their unique development and learning needs. For example,
the Self Care Rehabilitation in Paediatric Asthma programme (Whitman et al.
1985) requires children aged 2±5 years and their parents to attend four, 1 h
long education sessions.
Applicability of existing American and British programmes to the Australian
context is questionable (Deaves 1993). Attempts to implement an American
asthma self-management programme in Italy highlighted problems related to
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differences in culture and health care delivery (Indinnimeo et al. 1987). The
uniqueness of the Australian demography, culture and health system
necessitated the development of resources specifically for this context.
Programmes requiring repeated attendance at group sessions held at a
central location incur considerable administration and co-ordination costs and
attendance may be time consuming and inconvenient for families with young
children.
The lack of appropriate education for children in the early childhood years is
attributed to a belief that young children are incapable of understanding health
and illness concepts and developing health related skills. This underestimation
arose from Piaget's (1932) cognitive development theory which suggested
children were unable to understand the concept of causality until reaching the
stage of Concrete Operations, at approximately 7 years of age. Hence, Bibace
and Walsh (1981) proposed that children use magical thinking, immanent
justice or immediate temporal or physical proximity to explain illness. In
contrast, Schultz (1982) reported children aged 3 years could understand
principles of causality when placed in a non-threatening environment.
Similarly, Siegal, Waters and Dinwiddy (1988) argued that children's apparent
failure to understand such concepts resulted from children's perception of the
experimental procedures and their desire to be compliant subjects.
Subsequent research (Siegal 1988) has indicated that pre-school children have
some understanding of contagion and contamination. Young children's ability
to understand illness related concepts is also thought to be strongly influenced
by personal experience (Parmelee 1986). Other evidence available from Croft
(1989) suggested that young children can learn health-related skills, such as
using a spacer device to correctly deliver asthma medication, when the
technique is taught through appropriate modelling by a parent. These findings
indicate young children have a much greater capacity to understand the
nature of illness and learn relevant health behaviours than was previously
believed.
While young children can not and should not be expected to assume full
responsibility for their condition management, they can be encouraged to
become cooperative managers of their asthma together with family members
and health professionals (Conboy 1989). Therefore it seems necessary to
provide quality asthma education appropriate to the developmental stage of
children during the early childhood years. Early education is particularly
important as many children with asthma experience their first symptomatic
episode early in life and may continue to experience symptoms on an
intermittent and variable basis throughout their childhood and adult years
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(Oswald et al. 1994). Failure to increase understanding of the condition and its
management at this time may result in the development of inappropriate and
incorrect management practices and negative illness beliefs. The provision of
developmentally appropriate asthma education for young children aims to
maximize the benefits derived from education, obviate the need to correct
inappropriate practices and beliefs, and reduce associated health care costs.
The current study investigated the most effective medium for presenting
information about the prevention and management of acute episodes of
asthma to children aged 2±5 years by developing and evaluating educational
resources in video tape and picture book form.
Development of the asthma education resources
The information content of the video tape `Young Children Managing Asthma'
(Mohay & Masters 1993) and the picture book `What's That Noise?'
(Holzheimer 1993) was informed by expert medical knowledge and a review of
relevant literature regarding the asthma management competencies of young
children (McNabb et al. 1986). The resources provide information about
triggers; need for prophylactic medications to prevent acute episodes and
allow full participation in daily activities; correct terminology for spacers and
nebulizers; correct technique for delivering medication via a spacer;
appropriate use of a nebulizer to manage acute episodes; promotion of a
positive attitude towards nebulizer use; and engagement in pleasant relaxing
activities while using a nebulizer.
Principles of Social Learning Theory (Bandura 1977, 1986) and awareness of the
qualities of effective asthma education (Howell et al. 1992) guided resource
development in order to maximize children's learning. Appropriately aged
children with whom the target population could identify were chosen to give
medical information and demonstrate asthma management skills. The child actors
received praise from a prestigious adult for demonstrating competency in asthma
management. Educational messages were presented in an entertaining manner
and Australian themes were used to appeal to the target audience. Important
educational messages were repeated and emphasized throughout each resource.
Resource format and length were influenced by the developmental stage of
the target population. The video tape was restricted to a length of 4 min and
the picture book was concisely written and simply illustrated in a format that
was appealing and appropriate to the developmental stage of young children.
A limited amount of text appears on each page of the book and the colourful
illustrations are directly related to the text.
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Video tapes and picture books were selected as the media most suitable and
accessible to children in Australia, particularly those living in remote areas.
Whilst the resources target young children, they were designed for joint use by
children and parents, as parents are recognized as important teachers of
children in this age group.
Methods
Sample
Eighty children aged 2±5 years requiring daily medication for asthma were
enrolled into the study. The age of children ranged from 24 months to
71 months, with the mean age being 48.6 months. At the study's
commencement, the mean length of time since children had been diagnosed
with asthma was 29.4 months. The children were recruited through
information brochures mailed to early childhood care and education centres,
playgroups and medical centres located in Brisbane. Participation in the study
was voluntary and informed consent was obtained from the children's parents.
Procedure
The children were randomly allocated to one of three experimental groups or a
control group to compare and contrast the effectiveness of use of the video tape
alone, use of the book alone and combined use of the video tape and book. The
researchers were blind to the group membership of each child.
Each child's knowledge of asthma and its management was individually
assessed (pre-test) to establish baseline levels of knowledge prior to exposure
to the educational resources. Asthma related knowledge was assessed using an
eight question pictorial multiple choice test designed for the purposes of this
study. Question content was directly related to the information presented in
the educational resources and responses were coded as correct and incorrect.
Following the initial assessment (pre-test 1), each child attended to the
educational resources in the presence of a parent. Experimental group 1
children viewed the asthma education video tape and read the asthma book,
experimental group 2 children viewed the asthma video tape and read an
unrelated book, experimental group 3 viewed an unrelated video tape and
read the asthma book and the control group viewed an unrelated video tape
and read an unrelated book. The resources unrelated to asthma were
comparable in length and format. Each child's knowledge about asthma and
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its management was again assessed following intervention (post-test 1). These
assessments and viewing and reading of the resources were repeated 1 month
later (pre- and post-tests 2) and again after 3 months (pre- and post- tests 3).
Additionally, the resources were evaluated in terms of children's asthma
management practices. Throughout the 4 months of the study, parents were
asked to maintain a daily diary record of their child's non-compliance with
medication, experience of asthma symptoms and need for medical care
(phone calls and/or consultations with a medical practitioner for asthma).
At the completion of the study all children were shown the asthma video tape
and given a copy of the asthma book for at home use.
Results
The results of the study are considered in terms of the effects of the asthma
education materials upon children's asthma-related knowledge and
compliance and health status.
Asthma-related knowledge
Scores for each group at pre-test 1 indicated that all groups possessed some
knowledge of asthma and its management prior to the commencement of the
study. The completion of a one-way ANOVA found no statistically significant
difference between the four groups at a significance level of 0.05.
Means were calculated for the total test scores of subjects within each of the
four groups for the six assessments of asthma-related knowledge. Table 1
presents the mean scores for all groups at each assessment.
Following the baseline assessment (pre-test 1) changes in the children's
Table 1. Mean total scores and standard deviations for groups 1±4 at each assessment of asthma-related knowledge
Group
1 2 3 4
Test Mean SD Mean SD Mean SD Mean SD
Pre 1 3.90 1.83 5.05 1.40 4.20 1.61 4.95 1.40
Post 1 4.80 1.58 5.10 1.65 4.05 1.82 4.63 1.98
Pre 2 5.50 1.91 5.55 1.32 4.40 2.26 4.40 1.88
Post 2 5.50 1.93 6.00 1.34 5.25 1.48 4.50 1.84
Pre 3 5.20 1.99 5.90 1.52 5.50 1.67 5.40 1.76
Post 3 5.90 1.68 6.35 1.76 5.90 1.97 5.60 1.50
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knowledge about asthma were considered as improvement scores, calculated by
subtracting test scores from pre-test 1 scores. Table 2 shows the mean
improvement scores for each groups at each assessment following pre-test 1
and indicates that all groups had improved knowledge of asthma and its
management. These data are presented in Fig. 1.
Table 2. Mean improvement scores and standard deviations for groups 1±4 at Post Test 1 to PostTest 3
Group 1 Group 2 Group 3 Group 4
Test Mean SD Mean SD Mean SD Mean SD
Post 1 0.90 1.33 0.05 1.15 0.15 0.93 0.37 1.70
Pre 2 1.60 1.47 0.50 1.28 0.25 1.48 ÿ0.55 1.73
Post 2 1.60 1.64 0.95 1.50 1.05 1.43 ÿ0.45 1.67
Pre 3 1.30 1.66 0.85 1.50 1.30 1.59 0.45 1.70
Post 3 2.00 1.52 1.30 1.45 1.70 1.66 0.65 1.50
21
0
1
2
3
Posttest 1
, Group 1: asthma video and asthma book;
, Group 2: asthma video and control book;
, Group 3: control video and asthma book;
, Group 4: control video and control book.
Pretest 2
Posttest 2
Time of assessment
Pretest 3
Posttest 3
Group 4
Group 3
Group 1
Group 2
Mea
n im
pro
vem
ent
sco
re
Fig. 1. Knowledge of asthma and its management.
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Improvement scores for each experimental group were compared with each
other and with the control group using two-way repeated measures ANOVA.
The results of this analysis are shown in Table 3 and indicate that all
experimental groups showed significantly greater improvement in knowledge
than the control group. The greatest improvement in knowledge was shown
by experimental group 1, that is those children who viewed the asthma video
tape and read the asthma book.
Asthma-related knowledge was acquired more slowly by groups of children
exposed to only one asthma education resource and substantial improvements
were noted after the second and third viewings of the resources. Comparison
of the effectiveness of the video tape and book indicated the book to be a
more effective medium. Knowledge scores also improved between viewings of
the resources, suggesting parents taught and reinforced the educational
messages at other times.
Children's compliance and health status
To evaluate the effectiveness of the resources in improving children's
compliance with prescribed asthma regimens and health all parents were
provided with a diary which was to be completed daily. Parents recorded
information about the number of days their child was non-compliant with
prescribed medication regimens, number of days their child experienced
asthma symptoms and the frequency of communication and consultation with
a medical practitioner about their child's asthma.
The majority of parents completed the diary task. During the first month
91.02% of the diaries were completed and 90.15% during the second to fourth
months. Some parents failed to complete the diary task. Many diaries were
partially incomplete and four showed excessive recording of information. In
Table 3. Comparison of the mean improvement scores of groups 1±4
F P-level
Video and book vs control 14.062 0.001*
Video vs control 4.143 0.049*
Book vs control 4.943 0.032*
Video and book vs video 4.723 0.036*
Video and book vs book 3.303 0.077
Video vs book 0.089 0.767
*P0.05
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cases where parents failed to complete the diary, verbal reports were accepted for
the number of phone calls and visits to the doctor as parental recall of significant
events such as contact with a medical practitioner was likely to be quite accurate
despite the lack of written records. However, it was unlikely that parents would
accurately recall the days when a child may have refused medication or
experienced the symptoms of asthma, particularly if symptoms were mild.
A number of children discontinued daily prophylactic medication during the
study. Children who ceased taking daily medication for more than 14 days were
excluded from data analysis relevant to compliance and health. The number of
children from groups 1±4 who continued daily medication for the duration of
the study was 16, 13, 12, 15 for groups 1±4, respectively.
Table 4 shows the mean number of days for which children from groups 1±4
did not comply with medication regimens and experienced asthma symptoms
and the mean number of times parents telephoned or consulted their medical
practitioner for their child's asthma.
t-tests were calculated to compare differences in the mean number of days
children were non-compliant and experienced asthma symptoms for each
group. Each experimental group was contrasted against two other
experimental groups and the control group. Children in the experimental
groups experienced, on average, less non-compliant days, less days with
wheezes or coughs and sought medical advice less often than children in the
control group. However, the only statistically significant difference (P < 0.05)
found was between groups one and four with regard to the number of medical
consultations for asthma. Children and parents exposed to both the asthma
education resources sought medical advice less frequently than children and
parents who were exposed to the unrelated control resources.
Discussion
The results of this study suggest that the asthma education video tape and
picture book can serve as an important adjunct to the medical management of
Table 4. Means for non-compliance, asthma symptoms and medical consultation for groups 1±4
Group
Means for diary items 1 2 3 4
Non-compliance days 9.75 7.62 9.08 14.87
Days with wheezes or coughs 37.31 40.15 29.10 51.47
Phone calls and visits to the doctor 3.00 4.54 6.00 7.87
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asthma. Baseline assessments of children's knowledge of asthma and its
management indicated that children in all research groups possessed relevant
knowledge. It is probable, that since being diagnosed with asthma, children
were presented with informal opportunities to develop related knowledge. As
increases in children's knowledge of asthma do not appear to be age-related
(Eiser et al. 1988), personal experience of the condition may have influenced
children's ability to comprehend the information presented in the resources
(Parmelee 1986).
Children who viewed the asthma video tape and read the asthma book (group 1)
showed the greatest increases in knowledge and acquired knowledge more rapidly
than children exposed to either the video tape (group 2) or book alone (group 3).
Significant increases in children's knowledge were noted after initial exposure to
the combined resources, and it appears that children benefited from presentation
of the educational messages in two different formats.
The picture book was found to be a more effective educational medium.
Superiority of the book in communicating messages about asthma may be
explained through the self-pacing nature of the media. The book allows
parents to direct children's attention to content areas in which knowledge
may be lacking, to review relevant information and subsequently reinforce
the messages. In contrast, parents and children have no control over the
pace at which educational messages are presented in the video tape, and
thus have limited opportunity to reinforce relevant content. This
explanation is consistent with comparisons of the effectiveness of an asthma
education audio tape and book developed for adult populations (Jenkinson
et al. 1988).
Asthma-related knowledge was acquired slower by children exposed to only
one education resource. Following the first exposure, the resources had only
minimal impact, with more substantial increases occurring after repeated
exposure (post-tests 2 and 3). Therefore, use of one resource appears to have
limited short-term impact upon children's knowledge.
The superiority of combined resource use is attributed to the additional
exposure to the educational messages received. Group 1 children received 10
min exposure at each of three research sessions, while children in groups 2
and 3 received only 5 min at each session as they were exposed to one asthma
education and one control resource. Therefore, groups 2 and 3 may require
equivalent time of exposure to the materials if they are to increase their
knowledge at a rate similar to group 1.
The control group (group 4) which was not exposed to any asthma education
resources, showed modest but statistically significant improvements in asthma-
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related knowledge. Other researchers noted similar effects, concluding that
increases in baseline knowledge assessments may stimulate both experimental
and control group participants to consider and seek further information about
text content (Heringa et al. 1987).
Parental influence also seems applicable to the experimental groups as
knowledge increases were found for each experimental group at pre-test 2.
Thus, it is assumed that parents who viewed the educational resources with
children became more aware that asthma-related management information
was appropriate for young children and set about reinforcing this information
in the interval between the first and second research sessions. As parents play
a key role in young children's asthma management (Whitman et al. 1985), it
seems beneficial to capitalise upon this effect and continue to involve parents
in the educational process.
Additionally, results of the study were considered in terms of the impact of
the asthma education resource on children's compliance and health. Children
in each experimental group had better medication compliance, experienced
less days with asthma symptoms and required fewer medical consultations for
asthma than children in the control group. However, differences between the
experimental and control groups were not statistically significant, except for
group 1 (asthma video tape and asthma book) and group 4 (control) with
regard to the mean number of medical consultations. Results of this study are
consistent with previous studies which reported that asthma education is a
useful mechanism for reducing related morbidity (Whitman et al. 1985;
Rolnick 1988).
Improving asthma-related knowledge amongst children and parents appears
to increase their control and self-efficacy in condition management. Greater
compliance with medication regimens seems to have stemmed from increased
understanding of asthma and resulted in less asthma symptoms and need for
fewer medical consultations. Increasing patients' self-efficacy in managing
asthma is a common aim of many educational materials (Fireman et al. 1981;
Hindi-Alexander & Cropp 1984) and these education resources have been
successful in this regard. Improvements in asthma-related knowledge can
therefore be associated with reduced health care costs.
While the asthma education resources positively impacted upon children's
management practices and health, baseline information about the children's
management practices and health, against which post- intervention data could
be compared, was not recorded. The potential value of the education
resources may be further substantiated through collection of pre-intervention
data regarding management and health.
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Anecdotal reports from parents suggested that children's attitudes towards
asthma management procedures were improved following resource use, and
that future studies may systematically collect such relevant and important
qualitative data from the parents and children to further examine the benefits
of asthma education for young children.
In conclusion, the present study highlighted the value of these materials
when used in a controlled environment, where the frequency of children's
exposure to the resources was regulated. In order for the educational process
to be maximally cost effective, the materials need to be incorporated into
standard medical management. Thus it is necessary to assess the effectiveness
of the materials when used independently by community members such as
health care professionals, educators and families of children with asthma.
The results of this study may be applicable to other areas of illness
management, and medical and allied health professionals must therefore be
challenged to examine the level of education currently provided for children in
this age group. The theoretical principles applied to the development of
education material in this study might be equally well applied to the
production of materials relevant to other chronic illnesses, or health issues
such as nutrition and dental education.
Health professionals are encouraged to provide young children with age
appropriate explanations of the causes, symptoms and treatments of disease.
In so doing, paediatric health care practitioners may be better able to assist
children to develop an accurate understanding of and attitude towards the
condition while also increasing their level of compliance with and control over
appropriate medical treatment.
Acknowledgements
This study was funded by a grant from The Asthma Foundation of Queensland.
An earlier version of this paper was presented at the Seventh National Health
Promotion Conference held in Brisbane, Australia, February 1995.
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