educating young children about asthma: comparing the effectiveness of a developmentally appropriate...

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

# 1998 Blackwell Science Ltd

1998

PAGES 85±99

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

Holzheimer, Mohay and Masters . Educating young children about asthma

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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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