evaluation of an education program for elementary school children with asthma

©2003 Marcel Dekker, Inc. All rights reserved. This material may not be used or reproduced in any form without the express written permission of Marcel Dekker, Inc.

MARCEL DEKKER, INC. • 270 MADISON AVENUE • NEW YORK, NY 10016

JOURNAL OF ASTHMA

Vol. 40, No. 5, pp. 523–533, 2003

ORIGINAL ARTICLE

Evaluation of an Education Program for Elementary School

Children with Asthma

S. L. McGhan, R.N., M.N., C.A.E.,1,2,* E. Wong, M.D., M.Sc.,3

G. S. Jhangri, M.Sc.,4 H. M. Wells, R.N., M.N., C.A.E.,1,3

D. R. Michaelchuk, M.A.,1,4 V. L. Boechler, R.N., M.N.,5,6

A. D. Befus, Ph.D.,1,3,7 and P. A. Hessel, Ph.D.1,4

1Alberta Asthma Centre, 2Faculty of Nursing, 3Division of Pulmonary Medicine,

Department of Medicine, and 4Department of Public Health Sciences, Faculty of

Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada5SEARCH, Alberta Heritage Foundation for Medical Research,

Edmonton, Alberta, Canada6Capital Health Region

7AstraZeneca Canada Inc.

ABSTRACT

To evaluate the effectiveness of a comprehensive asthma management education

program for 7- to 12-year-old children with asthma, entitled Roaring Adventures of

Puff (RAP), 18 elementary schools in Edmonton were randomized to intervention and

control groups. Participating in the program were 76 students with asthma in the

intervention schools and 86 in the control schools. Children in the intervention schools

had statistically significant improvements in unscheduled doctor visits, missed school

days, moderate-to-severe parent rating of severity, severity of shortness of breath,

limitations in the kind of play, and correct use of medications. Unscheduled doctor

visits and missed school days were the only significant improvements in the control

group; however, improvements were about half that of the intervention group. The

results showed that a comprehensive, school-based asthma education program is

feasible and improves outcomes.

*Correspondence: Shawna McGhan, R.N., M.N., C.A.E., Alberta Asthma Centre, Box 4033, 11402 University Ave.,

Edmonton, AB T6E 6K2, Canada; Fax: (780) 407-3608; E-mail: [email protected].

523

DOI: 10.1081/JAS-120018785 0277-0903 (Print); 1532-4303 (Online)

Copyright & 2003 by Marcel Dekker, Inc. www.dekker.com

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Key Words: Asthma education; Childhood asthma; School-based program; Social

cognitive theory.

INTRODUCTION

Asthma is the most common chronic diseasein children and is on the rise (1). The prevalence ofchildhood asthma in Edmonton, Alberta, Canada, is13% (2). In Alberta, children account for 60% ofhospital separations for asthma (3). Within 4 yearsof a hospitalization for asthma, 36.4% of Alberta’schildren were readmitted for asthma (4). Despitethe availability of effective asthma treatmentsand evidence-based clinical practice guidelines forthe management of asthma (5,6), recent data indicatethat asthma is not optimally controlled amongCanadian children (2), and both the prevalenceand burden of the disease have increased in recentyears (7).

Health-related quality of life in those withasthma is improved by minimizing symptoms, activ-ity limitations, and emotional dysfunction (8).Children with asthma are twice as likely to missschool, and almost two-thirds have health-relatedlimitation of activities (9). Ninety percent ofthose with asthma have symptoms during exerciseor activity (10), and one in three children withasthma experience pain, discomfort, or upset fre-quently (11). Thus, for many children, asthma controlfalls below accepted guidelines (5).

Asthma education is generally accepted aspractical and valuable, and many asthma educationservices are available. Studies that have examinedbehavior change after educational interventions sug-gest that asthma education may be effective inimproving disease control (12–17). The CanadianAsthma Consensus Guidelines (5) emphasize thateducation is a critical component in asthma careand can assist in reducing morbidity and improvingcontrol of symptoms.

Asthma Education

Despite recommendations to provide asthmaeducation and a written action plan to manageexacerbations (5), few families receive individual(10.3%) or group (8.1%) education sessions or aregiven personal asthma self-management plans(7.2%). Less than half (46%) are told when to go toan emergency department (ED) for an exacerbation

(2). Failure to have or use criteria for deciding to seekemergency care is strongly associated with high use ofthe ED (18).

Childhood asthma educational programs havebeen shown to improve self-care behaviors(12,19–21); reduce emergency visits (12–17); reducedays of hospitalization (12,15–17,19,22); improveschool grades (13,23); reduce asthma episodes(23,24); reduce symptoms that limit activity(14,22,25); reduce school absenteeism (19,24,25);improve lung function (19); enhance locus of control(26); and reduce anxiety about asthma (13,23,27).However, these outcomes are not seen in everystudy. Furthermore, a meta-analysis of 11 studiesrevealed that the interventions had little effect onmorbidity (28). Many of the asthma self-managementeducation programs have evolved from a passivelearning style that primarily focuses on parents, toa more child-centered, age-appropriate behaviormodification approach (29). As researchers learnmore about factors that influence behavior, studieshave attempted to examine the effects of a multi-faceted approach (29–31).

A number of asthma education interventionstargeting children with asthma have been studied inschools (23,29,32–36). Schools offer an ideal settingto reach a large number of children with asthma andenhance participation. Overall, these programs havebeen well-received and well-attended. Althoughschool-based asthma education programs haveshown positive results for key morbidity outcomes(29,31), these results were not noted in all studies.This inconsistency occurred regardless of whetherthe program was given by the teacher (37) or schoolnurse (32). Given the inconsistency, we soughtto evaluate a comprehensive school-based asthmaeducation program that considered the limitationsof previous programs. We designed the programusing the principles of the Social CognitiveTheory (SCT) and appropriate child educationapproaches.

The purpose of our study was to determinewhether an interactive childhood asthma educationprogram, ‘‘Roaring Adventures of Puff’’ (RAP),which was based on the principles of the SCT (38),improved asthma management behaviors and healthstatus, and quality of life in elementary schoolchildren.

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METHODS

The study compared children with asthma inrandomly assigned intervention schools with thosein control schools. The RAP intervention schoolsreceived parent and teacher asthma awarenessevents, recommendations for school asthma guide-lines, and six educational sessions for the childrenwith asthma. Those in the control schools receivedregular medical care. It was hypothesized thatchildren with asthma who participated in RAPwould exhibit greater asthma self-managementbehavior, improved quality of life, reduced asthmasymptoms, and health care utilization in comparisonwith the children with asthma in the control schools.

Intervention

The theoretical principles of SCT (38) guided thedevelopment of the RAP program. SCT has beenused successfully in other asthma education programs(8,39). It assumes that an individual’s behavior isdetermined by a complex interaction among environ-mental, personal (physiological and cognitive), andbehavioral factors. To influence these factors inchildren with asthma, RAP integrated the followingprinciples: self-regulation, the process whereby anindividual performs self-observation (monitoring),self-judgment, and self-reaction (40); observationallearning, the process of acquiring new behaviors bywatching the behaviors and consequences of rolemodels or learning through imitation (41); reinforce-ment, the effect a stimulus has that increases theprobability that a response will occur (41); environ-mental influences including peers, family, friends, andschool and home surroundings (40); and perceivedself-efficacy, an individual’s assessment of his or hercapability to perform certain behaviors or skills (42).Self-efficacy is enhanced by performance attainments(most influential), observation, overcoming a physio-logical state—such as anxiety or physical limitation—and verbal persuasion (least powerful) (43). The theo-retical framework underlying the RAP program hasbeen discussed in detail elsewhere (44).

Parents and teachers in the intervention schoolswere invited to participate in a RAP parent/teacherasthma awareness event at the school. The event pro-vided information on asthma management, schoolasthma issues, and the RAP program. Parents andchildren in the intervention schools received informa-tion letters to share with their doctors, includingsuggested guidelines for a written action plan for the

parents and their child to use at home and school.The doctor was encouraged to write additional com-ments or directions to the RAP educator team. TheRAP instructor consulted the child’s physicians asneeded to clarify recommendations and pass onimportant assessments. The physician also receiveda summary letter at the end of the program fromthe instructor outlining the child’s asthma goals,providing an overview of the course content andinforming the physician of specific needs of theirpatient.

As part of their third-year practicum, nursingand pharmacy students were asked to be RAPinstructors under the guidance of the supervisor.Each instructor attended a 2-day workshop on child-hood asthma and teaching RAP in a manner consis-tent with the principles outlined in this article. Theworkshop included scenarios, simulations, practice,and a written exam. Instructors were provided withsession checklists and other materials outlining thecourse content and the specific learning goals foreach child. Using the 300-page manual, the instruc-tors taught six 60-minute sessions: (1) getting to knoweach other, goal setting, use of a peak flow meter,diary monitoring; (2) trigger identification, controland avoidance, basic pathophysiology; (3) medica-tions and proper use of inhalers; (4) symptom recog-nition and action plan; (5) lifestyle, exercise,managing an asthma episode; and (6) sharing thisinformation with teachers and parents. Each sessionwas interactive and followed the principles of Piaget’sCognitive Development Stages (45) and Bandura’s(38) SCT. Teaching strategies included puppetry,games, role play, model building, discussions, andasthma diary recording. Over the course of theinstructional period, the instructor liaised with tea-chers and parents (as needed, for individual childconcerns), teachers and principals (to develop practi-cal school guidelines for asthma), and the child’sphysician.

Study Population

The target population was children with asthmaages 7–12 years; however, other ages were included ifthe parent and child were interested in participating.Criteria for selection included: (1) a diagnosis ofasthma by a physician, (2) informed consent fromthe parent/guardian, (3) ability to speak English,and (4) no previous participation in RAP.

To facilitate accessibility and to preventcross-contamination between groups, the unit of

Education Program for Children with Asthma 525

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randomization was the school. All participatingstudents in each school were assigned to the samegroup. Children were the primary unit of analysisinstead of the school for the following reasons: (1)every child’s asthma varies in level of control at anygiven time and affects quality of life differently; (2)the outcome measures are clinically significant for thechild, not the school; and (3) the treatment isdesigned primarily to influence the child withasthma, not the school. Ethics approval for thestudy was attained from the Community HealthEthics Review Committee of the Capital HealthAuthority, Edmonton, Alberta, Canada.

More than 100 letters were sent to Edmontonelementary schools inviting them to participate. Allschools that volunteered were enrolled (n¼ 18). Aletter was sent to all parents (approximatelyn¼ 4965) inviting them to enroll their child if theyhad been diagnosed with asthma. All children whovolunteered and met the inclusion criteria wereenrolled (n¼ 162). Based on the approximate popula-tion of students in grades 1–6 in the 18 schools andprevalence studies of asthma (2) in Edmonton (13%),we estimated that 646 students had asthma, suggest-ing a response rate of 25%.

Measurement Tools

All children with asthma in the interventionand control schools and their parents completedquestionnaires at the beginning of the project. Thequestionnaires included the Pediatric AsthmaQuality of Life Questionnaire (14), the ChildhoodAsthma Pictorial Scale (46), Parent’s RAPQuestionnaire, Childhood Asthma Self-EfficacyScale, and School Information Form. The Parent’sRAP Questionnaire assessed demographic informa-tion such as age, gender, ethnic background, andthe parents’ perception of their child’s symptomseverity, medication use, health care utilization,school absenteeism, and attitudes toward asthma.These questionnaires were repeated 9 months later.The data analysis focused on responses from theparents’ questionnaires.

Data Analysis

The primary analysis compared preinterventionand postintervention outcomes for the children withasthma receiving the education program and thosenot receiving the program. The comparability of the

intervention and control groups at baseline was testedusing the Pearson chi-square test. Similar analyseswere performed to assess the comparability of thosewho dropped out and those who continued in thestudy. Pre- versus postintervention values for dichot-omous outcome variables were assessed usingMcNemar’s test. Ordinal variables were assessedusing the Wilcoxon Rank test. The degree ofchange (delta) was calculated as pre- minus post-values. The delta was compared between the RAPand control group using the Pearson chi-square testfor categorical variables and Student t-test or theMann-Whitney test for continuous variables.

RESULTS

Of the study participants, 76 were in the inter-vention group and 86 in the control group. The twogroups, including those who dropped out, were com-parable for demographic and disease-relatedvariables (Table 1). Significantly more children inthe intervention group had previously received someeducation related to asthma (53% vs. 34%;p¼ 0.016). The most commonly mentioned sourceof asthma education was the child’s physician oranother health care professional (44%), and themajority (65.8%) stated that they received the educa-tion more than 4 years ago. Twenty-six families(16%) dropped out of the study (11 intervention, 15control), most often stating that the child no longerhad asthma or that they were not able to be contactedfor the follow-up interview. The dropouts were sig-nificantly less likely to have reported seasonal asthma(84% vs. 92%; p¼ 0.031), and unscheduled doctorvisits (44% vs. 68%; p¼ 0.021) in the previous year.

For most indicators of asthma control, the inter-vention group improved after RAP (Table 2; excludesdrop outs). Statistically significant improvementswithin the RAP group included overall parent ratedseverity, unscheduled physician visits in the last year,moderate-to-severe shortness of breath, limitations inthe kind of play, and any missed school days in thelast year. The improvement in limitations in the kindof play was more than 12% in the RAP group,whereas the control group worsened (–1.4%). TheRAP group was slightly worse at baseline but notsignificantly different than the control group. Thisdegree of change between the RAP and controlgroup for change in limitation of play was significant( p<0.001). Some characteristics of asthma improvedat follow-up among the controls, whereas othersremained the same or got worse. Unscheduled

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physician visits and any missed school days were theonly statistically significant improvements also seenin the control group. However, the improvement inthe control group was just over half that of the RAPgroup for both variables. Although not significant,the reduction in the number of emergency visits inthe RAP group ( p¼ 0.12) was more than twice thatof the control group.

Only the intervention group had significantimprovements with key medication and asthma man-agement indicators after RAP (Table 3). Althoughonly half of the participants had an action planfrom their physician after the program, the interven-tion group improved by 18.6%, whereas the controlgroup declined by 2.8%.

The intervention group demonstrated a signifi-cant improvement in use of appropriate medicationfor relief of symptoms (20.6% improvement) and

preventing symptoms (31.4% improvement) atfollow-up, in contrast to the control group (17.4%and 3.7%, respectively). A borderline improvementwas seen in the percent of children in the interventiongroup who used a peak flow meter ( p¼ 0.08). Nochange in this indicator was seen in the controlgroup. Parents of the RAP group indicated a statis-tically significant higher level of improvement in theirunderstanding and ability to control and cope withasthma than the control group (Fig. 1).

The data were also analyzed by considering theschool as a cluster instead of children as the primaryunit of analyses. The conclusions were similar in thetwo analyses. Several subgroups of participants wereanalyzed, including those with no past asthma educa-tion, no smokers in the home, and at least oneunscheduled physician visit in the previous year.The only departures from the patterns seen in the

Table 1. Comparison of intervention and control groups for demographics and disease

characteristics prior to the intervention.

Characteristics

Intervention (%)

(n¼ 76)

Control (%)

(n¼ 86)

Age

5–7 years 27.6 23.3

8–10 years 61.8 57.0

11–13 years 10.5 19.8

Male gender 55.3 62.8

Regular smoking in the home 32.9 19.8

Cat(s) in the home 18.4 22.1

Caucasian 81.6 74.4

Grade 12 education or less

Mother 41.4 34.6

Father 26.8 36.4

Past asthma educationa 53.3 33.7

Parents’ rating of severity

Mild 62.7 66.7

Moderate 29.3 28.6

Severe 8.0 4.8

Seasonal asthma 84.0 91.8

Number of unscheduled doctor visits

None 30.7 41.9

1–2 visits 44.0 32.6

3–5 visits 18.7 20.9

6 or more 6.7 4.7

Emergency department visits in last year 23.7 14.0

Missed school days in last year

None 22.8 29.5

1–3 28.1 21.3

4–7 21.1 23.0

8–11 19.3 13.1

12 or more 8.8 13.2

ap¼ 0.016.


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overall analysis were seen among the group with nosmoker in the home. Surprisingly, the severity ofcough got worse in both the control (15–29%) andintervention (19–27%) group. The severity of wheezealso became worse, but only for the interventiongroup (8 to 16.2% vs. 12 to 7%). Those participantsin the intervention group that had at least one

unscheduled physician visit (n¼ 48 RAP vs. n¼ 44control) had significant improvements comparedwith the control group in their severity rating ofmoderate to severe (45.8 to 29.2% [ p<.05] vs.41.9 to 30.2 [not significant (NS)]), limitation inkind of play (45.8 to 33.3% [ p<.05] vs. 30.2 to34.9% [NS]), limitation in amount of play (47.9 to

Table 2. Percent of children in the intervention and control groups reporting indicators of control before and after

the intervention.a

Variable

Intervention (%)

(n¼ 65)

Control (%)

(n¼ 71)Deltab

Pre Post Pre Post p

Moderate/severe self-rating 40.0 27.7c 33.3 23.9

Unscheduled doctor visits in last year 76.2 33.8d 60.6 36.6c

Emergency department visits in last year 23.1 12.3e 14.1 9.9

Wake with symptoms >1� in last 2 wk 50.8 44.6 40.8 39.4

Moderate-severe coughing in last 2 wk 30.8 24.6 23.9 28.2

Moderate-severe chest tightness in last 2 wk 14.1 10.9 11.3 11.3

Moderate-severe wheezing in last 2 wk 16.9 15.4 18.3 14.1

Moderate-severe shortness of breath in last 2wk 26.6 15.4c 15.5 11.3

Limited kind of play 41.5 29.2d 29.6 31.0 <0.01

Limited amount of play 47.7 58.5 43.7 57.7

Any missed school days 87.7 38.5d 78.9 46.5d 0.07

aSome percentages differ from those in Table 1 because dropouts were not considered in the pre/post comparisons.bThe degree of change (delta) is calculated as pre-minus post values between groups. ( p value reported if <0.1; otherwise,

p>0.1).cp<0.05.dp<0.01.ep¼ 0.12.

Table 3. Percent of children in the intervention and control groups reporting medication use and management practices

before and after the intervention.a

Intervention (%)

(n¼ 65)

Control (%)

(n¼ 71)Deltab

Variable Pre Post Pre Post p

Appropriate use of preventive medication 31.7 63.1d 28.2 31.9 <0.001

Currently on inhaled steroids 56.9 63.1 54.2 61.1

Appropriate use of reliever medication 68.3 88.9d 52.4 69.8

Currently on inhaled bronchodilators 89.1 89.2 76.5 74.3

Takes steps to avoid triggers 89.1 89.2 76.5 74.3

Uses a peak flow meter 40.0 50.8e 46.5 46.5 0.08

Have an action plan 30.6 49.2c 29.6 26.8 0.1

aSome percentages differ from those in Table 1 because dropouts were not considered in the pre/post comparisons.bThe degree of change (delta) is calculated as pre-minus post values between groups. (p value reported if <0.1; otherwise,

p value >0.1).cp<0.05.dp<0.001.ep<0.1 within groups.

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66.7% [ p<.05] vs. 44.2 to 62.8% [NS]), correct use of

preventer medication (34.8 to 71.7% [ p<.01] vs. 30.2

to 34.9 [NS]), and use of peak flow meter (47.9 to

60.4% [ p<.01] vs. 48.8 to 48.8% [NS]).

DISCUSSION

The RAP program had a positive effect on chil-

dren with asthma. Overall, most outcomes improved

in the intervention group. Outcomes that could

be attributed to RAP included improvements in

shortness of breath, limitation in the kind of play,

appropriate use of medication, and improved

parent-rated understanding, control, and coping

ability. The results are comparable to the reduction

in symptoms that limit activity and improvement in

self-care behaviors that other studies of educational

interventions for asthma have found (14,22,25).

Subanalysis was applied to individuals with

specific characteristics including no past asthma edu-

cation, no smoke in the home, and at least one

unscheduled physician visit in the last year. No past

asthma education (n¼ 76) was selected as a subgroup

because it was a characteristic that was different

between the RAP and control group. We also

wondered if those with past asthma education

might show a plateau effect and thus their behavior

change might not be as meaningful as someone who

heard the information for the first time. Nonsmokers

(n¼ 78) were also chosen as a subgroup, given the

notion that families that smoke may have more

asthma problems and may not be entirely controlla-

ble by behavioral changes. Unscheduled doctor visits

(n¼ 52) was also selected as one indicator of severity.

Some researchers have suggested that education

should only target participants with higher severity,

because those with lower severity and fewer asthma

problems are less likely to exhibit improvement. The

same trend seen with the group overall was compar-

able in all subgroups for both the intervention and

control group except for some variables in the non-

smoking families. Surprisingly, the severity of cough

and wheeze got worse. The reason for this variation is

unclear, although our power was weak and, there-

fore, it was difficult to make any conclusions.

This subanalysis adds an important context to

the data given, increasing debate that children with

mild asthma are less likely to benefit from asthma

education and asthma management tools such as

action plans. However, if this is true, we should

have seen a greater impact with those children that

0

10

20

30

40

50

60

70

80

Improved understanding ofasthma

Improved control of asthma Improved ability to cope withasthma

%

Intervention

Control

**

*

**

Figure 1. Percent of children in the intervention and control groups reporting global changes after the intervention.

*p<0.01; **p<0.001.


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had one or more unscheduled physician visits fortheir asthma. However, the power of this analysismay have limited our ability to make a definitiveclaim. Other studies have found that community-based interventions asthma management programsthat include children with mild asthma have shownpositive outcomes (14).

Empowerment has been defined as a process bywhich individuals, communities, and organizationsgain knowledge and skills that increase ability tomake their own decisions that affect one’s life(47,48). This concept is similar to self-regulationdescribed by Bandura (38). Given the strong empha-sis on these concepts in the design of RAP, it was notsurprising that parents rated their understanding andcontrol of asthma and ability to cope with asthmasignificantly higher than the control group. In addi-tion, we received feedback from parents and teachersabout increased level of confidence and responsibilitythe participant had toward managing asthma.Although a few researchers have measured and iden-tified enhanced self-regulation using qualitative mea-sures (49), measurement of that outcome was beyondthe scope of this study. Further investigation isrequired into efficient and effective means of measur-ing empowerment and self-regulation and how theyaffect health outcomes.

Providing the education at the child’s schooloffered the opportunity to help build school staffcompetence in asthma management and influencethe child’s social and physical environment.Targeting school staff and teachers was secondarybut critical to ensuring support of the child in theschool. Teacher sessions, information packages(including booklets and a video), school asthmaguidelines, and school curriculum materials wereoffered as part of the intervention. Feedback fromparents suggested that some schools implementedchanges to improve access to asthma medicationsand improve the classroom environment. However,a standardized measurement of school competenceand asthma-related changes was beyond the scopeand budget of the study. Because the school playsa caregiving role for the child, and can also influenceand implement necessary changes in the school,it makes sense for asthma education programsto target the school and to measure the results.Similar studies have reported favorable results usinga comprehensive, multilevel school-based interven-tion (30,31).

Another advantage of offering the program atschools is that it optimized child attendance rate tothe RAP sessions. Parents’ schedules were not dis-

rupted because they were not asked to attend thechild sessions and did not need to transport theirchild. As a result, we achieved a high attendancerate for the child sessions (85–100%). This reinforcesthe claim that a large, captive population can bereached at an early age in the schools (29,50).However, attendance at the parent sessions variedamong schools. Parent and teacher attendanceranged from 10% to 80%. Because the caregiversinfluence the management of the child’s asthma, anapproach to address or improve parental attendanceneeds to be implemented in the future. Many studieshave reported difficulty with attendance at educa-tional sessions (13,27,51–53). Attendance has variedfrom 31% in a hospital-based program (53) to 67%in a clinic-based program (52). To effectively test aneducation program, attendance of the participantsshould be high. Understanding more about the char-acteristics and circumstances of nonattendees wouldhelp educators to better understand how to reachparents who are less likely to participate.

Although the study produced several positiveoutcomes, the study had a number of limitationsthat may have hindered our ability to show maximumimpact of RAP, potentially resulting in some type IIerrors. The limitations help define future areas ofresearch. Others have indicated similar challengeswith such studies, including differences between par-ticipant and dropout characteristics (52–54), respon-siveness of the health care team, and instructorcharacteristics and qualifications (54). Given thatthe participants volunteered in response to a schoolmail-out, the exact response rate of children withasthma was not measurable. Although we estimateda response rate of 29%, it is difficult to know howgeneralizable our population is. In addition, most ofthe participants reported that their asthma severitywas mild, making it more difficult to see improve-ments. Clear, written directions from the primaryphysician was a critical component to providing thechild with specific asthma management education.Very few written action plans were provided to theinstructors. Finally, because of budget constraints,we used students as RAP instructors, and they hadvarying qualifications and interests in teachingchildren with asthma.

Although some studies limit enrollment to chil-dren with moderate-to-severe asthma, we includedchildren with mild asthma. This probably weakenedthe power of our study because children with mildasthma are less likely to show improvements.However, researchers should investigate if educationof families with mild asthma may prevent asthma

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from worsening and reduce the long-term need for

medical attention.

Unfortunately, few physicians provided action

plans for the children in RAP, although this was a

requirement of the study. Many parents stated that

their physician would not complete it or would

charge an additional fee. More children in the

intervention group received an action plan, but this

was still only 47% of the total group. Future research

should examine strategies that would enhance physi-

cian compliance in providing action plans.

Although we provided a 2-day workshop for

instructors, a comprehensive manual, and ongoing

guidance from the Alberta Asthma Centre, the

RAP instructors were relatively inexperienced nur-

sing students. The intervention phase of the study

was carried out by 12 pairs of nursing students

under the supervision of community health nurses

responsible for the school. Instructors submitted a

checklist of class activities, but by virtue of their vary-

ing experiences and limited exposure to the health

field, the nature of the intervention probably varied

among the schools because the instructors attempted

to influence several complex factors. Their task was

challenging and required a diversity of skills beyond

the teaching process, including collaboration, com-

munication, negotiation, and organization. We

concur that the instructor should ideally be an

‘‘expert’’ (54) and have skills that help the family

gain confidence, provide a consistent message, and

present information in a variety of formats (17).

Future research should explore how the characteris-

tics, skills, and experience of instructors affect the

results. Because of the limitations outlined here we

have undertaken a larger and improved study of the

impact of RAP for children with asthma.

CONCLUSIONS

A study of an asthma education program (RAP)

used randomly assigned schools and demonstrated

several positive outcomes for the intervention

group. Improvements occurred in severity of short-

ness of breath, limitations in the kind of play, and

appropriate use of reliever and preventer medication.

Factors that may have influenced the results include

dropout and participant characteristics, physician

participation, and instructor qualifications. These

variables need further investigation and should be

considered in the research design of future asthma

education intervention studies.

ACKNOWLEDGMENTS

We would like to acknowledge the AlbertaAsthma Network and Alberta Lung Association forfinancial support; Tania Stafinski for her insight andassistance with the data analysis; faculty of the grad-uate program in the Faculty of Nursing for reviewingthe proposal; faculties of Nursing and Pharma-ceutical Sciences for allowing their students to parti-cipate in this project; students who provided the edu-cation to the study participants; community healthnurses and pharmacists who supervised the students;Capital Health Authority for assisting in the study;the Edmonton Public and Catholic School Boards forfacilitating access to the schools; and participatingschools, parents, and children.

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evaluation of an education program for elementary school children with asthma

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