Evaluation of a Pilot School Health Education Program for Asthmatic Children

Guy S. Parcel, PhD Philip R. Nader, MD

The traditional approach to school health education is to provide broadly based instruction within the school curriculum. This type of instruction has presented two major problems: (1) lack of specific application to identified health needs of children, and (2) difficulty in establishing measures to evaluate effectiveness. The purpose of this paper is to describe the pilot phase of a project that attempts to determine approaches to over- come these two problems by focusing on a population of children with identified health needs. This approach to program development and evaluation is intended to contribute to the understanding of critical skills needed to influence behavior change.

Children with asthma were selected as a target group to develop and evaluate a school based health education program jointly planned and conducted by health and educational personnel. Asthmatic children were selected because they constitute the largest group of school age children with a single chronic condition, and there is some limited evidence that special educational programs for asthmatics have contributed to an improvement in their health ~tatus. ' '~

GOALS AND OBJECTIVES The overall educational goals of the program are to

assist children in understanding their asthmatic condi- tion and to help them assume greater responsibility and involvement in the management of their asthma. Specific objectives for the children participating in the program are: (1) reduction in the number of emergency asthma attacks requiring emergency medical treatment; (2) decrease in the number of school days missed; (3) reduction in the level of anxiety associated with illness; (4) improvement in attitudes toward self; and ( 5 ) improvement in perception of self-control for health behavior. In addition, the program attempted to demonstrate a model for school health education that: (1) focuses on target groups with identified health needs; (2) produces measurable results that may indicate improved health status or individual functioning; (3) involves parents, health care providers in the school and community, teachers and other school personnel; and

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(4) provides training for health care and educational personnel.

PROGRAM DESCRIPTION The pilot phase of the project involved one

elementary school (grades K-5). A health educator from the Department of Pediatrics and the school pediatric nurse practitioner conducted weekly 40 minute sessions for seven months of the school year. Thirteen children participated in the program in two different age groups (grades K-2 and 3-5). Structured lessons were developed and piloted to attempt to assist the children in under- standing concepts related to the nature of asthma, causes of attacks, prevention and treatment measures. Lessons also dealt with decision making and feelings about asthma. In addition, a published, structured program in affective education (Dimensions of Person- ality) was used to assist children in learning about themselves and for reinforcing positive attitudes toward self.

A pediatric allergist and a school social worker offered parents an opportunity to meet to learn about asthma and discuss some of their concerns about having an asthmatic child. Parent meetings were poorly attended and eventually were dropped from the program. One exception to the poor attendance was a family evening when the children showed their parents a T V tape of their classes and examples of their learing activities. Almost all of the mothers and one father attended this meeting and participated in teaching the children breathing exercises.

SUBJECTS Twelve boys and one girl, ages five to ten years with a

mean age of 7.7 years, participated in the program. Ethnic distribution of the children was five Blacks, four Mexican-Americans, and four Anglo-Americans. A diagnosis of asthma was confirmed for all children. They were reported to have experienced symptoms during the year previous to the program. Nine of the mothers rated their children's asthma as moderate in severity and four rated it as mild.

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EVALUATION METHODS Results were measured by preprogram and postpro-

gram administration of instruments to measure the variables identified by the stated objectives. The number of school days missed by subjects in the study were obtained from official records of the school district. The number of emergency asthma attacks were obtained from physician and hospital treatment records. Self-concept was measured by the Piers-Harris Self-concept Scale. ’” The Children’s Illness Anxiety Scale was used to measure the level of anxiety associated with asthma. Perception of ability to control one’s own health behavior was measured by Children’s Health Locus of Control Scale. Health locus of control is based on Rotter’s Social Learning Theory and is conceptualized as perceived internal or external sources of reinforcement for health behavior. l 3 The instruments for measuring self-concept, anxiety, and health locus of control were administered in the school by interview for the younger children and self-response for the older children.

A repeated measures design was used to test for significant differences in premeasurement to post- measurement of the outcome variables. Except for school attendance, a Willcoxon Matched Pairs Signed- Ranks Test was used to determine significant change^.'^ The paired test statistic was used to determine significant change in the percent of school absences. A ratio of school days enrolled and days missed was used to calculate percent of school absences.

In addition, records were kept to document process and problems in developing and carrying out the program. These consisted of memorandums, written plans, attendance records, a TV tape, and notes about the piloted instructional material. No systematic analysis of this information was attempted; however, the information was used subjectively as part of revision and future planning for the program.

II

12

RESULTS Children’s health locus of control was the only out-

come variable that significantly changed from pre- measurements to postmeasurements. The children as a group became more internal or less external in their perceived source of reinforcement for health behavior (p 4 .02). Of the 13 subjects, ten moved in the internal direction, two changed in the external direction, and one remained the same (see Table 1).

Total scores and subscale scores of the Piers-Harris Self-concept Scale and the Illness Anxiety Scale did not significantly change. Absences for the school year 1974-1975 were compared with those for year 1975-1976 for ten of the subjects. The remaining three subjects were not enrolled in the school district the first year. The percent of absences for the total school year and for each quarter were not significantly different from one year to the next. A per subject average of 9.6% of the school days was missed the first year and 9.2% the second year.

Emergency treatment for asthma attacks was defined as requiring epinephrine injection. Hospital records and private physician records were the sources for these data. The number of emergency attacks during the school year 1974-1975 were compared with those in 1975-1976. There was no significant decrease in the recorded number of attacks requiring emergency treat- ment. The actual number of emergency attacks were very low: a total of 15 the first year and 11 the second year for the entire group of 13 children.

DISCUSSION A major goal for the participants in the health

education program for children with asthma was to help them assume greater responsibility and involvement in the management of their asthma. One planned step toward this goal was the objective that children would perceive that they can do things about their health and

Table I

Pre/Post Data Analysis for Outcome Measures

Outcome Measure PmF Post x

Number of emergency asthma attacks School attendance (absentee data) Illness Anxiety Self-concept Health locus of control

1.25 .92 N.S. 9.6% 9.2% N.S. 8.23 8.46 N.S.

62.85 63.54 N.S. -7.08 -1.77 p e .02

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that they are not necessarily dependent on others. The findings obtained from the analysis support the possibility that the children in the program did become more internal in their health locus of control. However, in this pilot phase, there is no comparable control group that would allow for the change to be attributed to the health education program.

The limitations of the evaluation design do not permit an explanation of the negative findings for the other outcome variables. It might be concluded that the health education program did not influence the health status or improve individual functioning of the children. It is also possible that the instrument used to measure change may not be sensitive enough to detect change. This is especially true for emergency asthma attacks. For most of the children, the actual number of emergency attacks were so small that little change could be expected.

These findings and the subjective information collected during this pilot phase have provided a means for making recommendations for changes and improve- ments before offering the program to a larger number of children. From the experience gained through the pilot program, it was possible to identify the need for modification in three areas: planning, staffing, and evaluation. These modifications will be implemented into an expansion of the program to three schools next year and five more the following year.

Planning Some of the difficulties experienced in the pilot were

the result of inadequate preparation including insuffi- cient training, lack of clearly defined learning objectives or development of skills related to self-care for asthma, lack of structure for learning materials, and insufficient alternatives for parental involvement and reinforcement of children’s learning experience. To deal with some of these problems, an in-service training workshop is included for staff teaching in the program in the schools.

Another outcome of the pilot was the development of a patient education book for children with asthma. It is titled “Teaching My Parents About Asthma” and is designed to develop five skills areas applied to self-care for asthma.15 These include:

1. being able to observe situations that might lead to an asthma attack (observation skills);

2. being able to notice changes that would indicate a pending or actual asthma attack (discrimination skills);

3. being able to make decisions to take action them- selves or to get help to prevent or stop an asthma attack (decision making skills);

4. being able to tell parents, doctors, or others what is happening to them just before and during an asthma attack (communication skills); and

5 . having a strong positive attitude about being able

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to do things to help themselves with asthma (self- reliance). The book includes information and learning experiences for the children on the right side of the page and on the left side more detailed information for parents and suggested activities for helping the child learn and develop skills.

It is hoped that the book will provide an alternative means of encouraging parental involvement and reinforcement for the children. For the children in grades three, four, and five, the book will provide the structure for the group teaching. In the lower grades, stories based on the concepts in the book will be used to provide the structure. Affective learning (attitudes and feelings) will be included with these teaching materials about asthma and will be emphasized with the structured materials from the Dimensions of Personality series.

Staffing To give the program a broader base of support in the

school and to tap the skills of other professionals, the approach to staffing the program will be changed to a “program team.” The team will consist of the school nurse, the school physician or a community physician consultant, school psychologist, resource teacher and/ or classroom teacher, and the physical education teacher. It is hoped that this approach will add to the effectiveness of the teaching as well as develop ways for reinforcing the childen outside of the period of instruction. This also requires the school to give the program a high enough priority to commit the resources to the program.

Evaluation The evaluation will include schools that will not

receive the program until the second year. The same data will be collected the first year on all asthmatic children, making it possible to have a comparison group. A premeasurement and postmeasurement of knowledge about asthma and management procedures will be added to the measured variables. In addition, parents will be asked to keep a simple log so that days of wheezing can be recorded as well as emergency attacks.

SUMMARY A pilot program was conducted and evaluated as a

part of the development of a health education program designed to meet the needs of a specified target population. By focusing on a group of children with a common chronic health problem, it was possible to measure specific variables to evaluate the effectiveness of the program. Outcome evaluation together with subjective process information resulted in modification

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and changes in the program prior to implementation with a larger number of children and schools. The pilot phase conducted with a small number of children was demonstrated to be a critical part of the overall program development.

REFERENCES

I . Blumenthal MN, Cushing RT, Fashingbauer TJ: A community program for the management of bronchial asthma. Ann Allergy 30:391, 1972.

2. Falliers CJ: Treatment of asthma in a residential center: A fifteen year study. Ann Allergy 28513, 1970.

3. Hennepin County Tuberculosis and Health Association: Physical conditioning program for asthmatic children. J Sch Health 37:107, 1967.

4. McElhenney TR, Peterson JH: Physical fitness for asthmatic boys. JAMA 185:142, 1963.

5 . Peterson JH, McElhenney TR: Effects of a physical fitness program upon asthmatic boys. Ped 353295, 1969.

6. Scherr MS: Camp bronco junction-Second year of experience. Ann Allergy 28:423, 1970.

7. Scherr MS: Role of summer camp in rehabilitation of the asthmatic patient. Rev Allergy 22:169, 1968.

8. Scherr MS, Frankel L: Physical conditioning program for asthmatic children. J A M A 168: 1996, 1958.

9. Sly RM, Harper RT, Rosselot I: The effect of physical conditioning upon asthmatic children. Ann Allergy 30:86, 1972.

10. Piers E, Harris D: The Piers-Harris Children’s Self-concept Scale. Nashville, Tennessee, Counselor Recordings and Tests, 1969.

1 1 . Brodie B: Views of health children toward illness. A m J Public Health 64: 1156, 1974.

12. Parcel GS, Meyer MP: Toward an intermediate outcome evaluation instrument for health education. J Sch Health, to be published.

13. Rotter JB: Generalized expectancies for internal versus external control of reinforcement. Psychological Monographs, General and Applied 80: 1, 1966.

14. Blalock HM: Social Statistics. New York, McGraw-Hill Book Co, 1972, p 265.

15. Parcel GS, Tiernan K, Nader PR, et al: Teaching M y Parents About Asthma. Galveston, Texas, The University of Texas Medical Branch, 1976.

ACKNOWLEDGMENT

A very sincere appreciation for their participation in this program is expressed to: Mildred Williamson, RN (Coordinator of School Health Services); Dolores King, PNP (School Nurse); Don Gottlob, MEd (Director of Elementary Education), Galveston Independent School District; and Kathy Tiernan, BS (Health Educator), The University of Texas Medical Branch.

This project was funded, in part, by a grant from the Robert Wood Johnson Foundation. This paper was presented, in part, at the IXth International Conference on Health Education, Ottawa, Canada, September 2, 1976.

Guy S. Parcel, PhD, is Assistant Professor of Pedi- atrics, Preventive Medicine and Community Health; Health Educator, School Health Programs, Department of Pediatrics, The University of Texas Medical Branch, 1202 Market Street, Galveston, Texas 77550 (corre- sponding author). Philip R. Nader, MD, is Associate Professor of Pediatrics and Psychiatry, and Director, School Health Programs, Department of Pediatrics, The University of Texas Medical Branch, 1202 Market Street, Galveston, Texas 77550.

456 THE JOURNAL OF SCHOOL HEALTH OCTOBER 1977