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Effect of Education on School-Age Children's and Parents' Asthma Management

Posted on: Saturday, 30 October 2004, 03:00 CDT

ISSUES AND PURPOSE. Asthma affects 7.4% of school-age children, with poor children or members of ethnic minorities disproportionately affected.

DESIGN AND METHODS. A quasiexperimental, year-long pilot study tested the effectiveness of an intervention that included school- based small-group education for children with home-based education for parents. Pretest and two posttest measures were collected.

RESULTS. Forty-four families completed the study (41% African American, 36% European American, 23% Mexican American), with 46% coming from poor or working-class families. Asthma management in the treatment group was lower than the comparison group at baseline, but improved significantly at 6 months and stabilized at 12 months, a trend that was most pronounced among the poorer children.

PRACTICE IMPLICATIONS. Improvements in asthma management point to the need for ongoing asthma education to address learning needs of the children and families.

Search terms: Asthma, health education, school age, self- management

Accepted for publication March 2, 2004.

Asthma, the most common chronic illness of childhood, is an inflammatory disease characterized by hyperresponsiveness of the airways to stimuli and reversible airway obstruction Qanson, 1998). Epidemiological data indicate that 7.4% of school-age children report having asthma symptoms annually, and 2.8 million children between 5 and 14 years of age have a diagnosis of asthma (Centers for Disease Control and Prevention [CDC], 1998). School absenteeism is two to three times higher for children with asthma than for their healthy peers (Hanson, Lapidus, Zumga, & Murphy, 2000). Office and emergency department (ED) visits and hospitalizations for asthma are increasing substantially, even though patient education could prevent most episodes of poorly controlled asthma (American Academy of Allergy, Asthma, and Immunology [AAAAI], 1999; CDC, 2002). The purpose of this pilot study was to test an intervention that combines school-based small-group education for children with home- based education for parents to improve family asthma care.

Background

An asthma health education model was used in planning this study (Bruhn, 1983). This model indicates that personal and familial factors influence the asthma management behaviors enacted by children and their parents and subsequently affect health outcomes. Personal factors include modifiable variables such as asthma knowledge and the child's asthma severity, as well as nonmodifiable factors of ethnicity, age, and gender. Familial factors address the contextual aspects of home asthma management such as the parents' marital status, educational levels, and socioeconomic status. Asthma management is a repertoire of behaviors enacted by children and parents to prevent symptoms, reduce contact with stimuli, and treat active asthma symptoms (AAAAI, 1999). Health outcomes that can be influenced by asthma management include Healthcare resource utilization and school absenteeism (CDC, 1998).

Asthma severity clearly influences asthma management. More severe asthma requires greater medication consumption, reduces quality of life, limits daily activities, and increases the burden of care for the family (AAAAI, 1999; Persky et al., 1998). However, asthma severity (frequency and magnitude of symptoms) is modifiable by implementing an asthma management plan that includes medication therapy and environmental management (AAAAI). Knowledge of asthma provides the foundation for parents and children to make decisions in response to changing conditions such as climate changes, allergen levels, and activity levels (AAAAI; Clark et al., 1997). Knowledge alone is not sufficient to ensure good asthma management. Families need the necessary resources for carrying out the asthma management plan (Leickly et al., 1998).

In terms of intrinsic personal factors such as ethnicity, age, and gender, the effect on asthma management is not as direct. While it is known that more African Americans have asthma than other ethnic groups, and more boys than girls (2:1) have asthma, these trends represent health disparities for these groups. However, there are few data on the influence of gender and ethnicity on family asthma management (Grant, Wagner, & Weiss, 1999). In a study comparing asthma severity between boys and girls, more girls were found to have moderate to severe asthma, while more of the boys had milder asthma (Halterman, Aligne, & Auinger, 2000). One might conclude that there is a need for more family asthma management when the child with asthma is a girl.

This question of ethnicity and gender was explored in an analysis of baseline data for the present study (Horner, Surratt, & Smith, 2002). Findings revealed girls engaged in more asthma management than boys (m = 64.24 v. m = 62.07, on a scale of 17-85). Among their parents, Mexican Americans enacted more home-management strategies (42.6) than did European Americans (36.11) or African Americans (35.25, on a possible scale of 0-64). However, parents reported enacting more home-management strategies for their boys (38.00) than for their girls (36.18).

Familial factors reflect the resources available for the family to manage children's asthma. Socioeconomic status (SES) is consistently reported as influencing health status, access to health care, and self-management (Crago, Coors, Lapidus, Sapien, & Murphy, 1998; Newacheck, 1994). There is a higher prevalence of asthma among poorer children, and they have fewer contacts with healthcare providers (Grant et al., 1999; Newacheck). Marital status affects family management in terms of human and economic resources. Two- parent families can share the responsibility for caring for their children and even provide respite time for the primary caregiver. In single-parent families, the financial and emotional responsibility for the family's well-being rests heavily on one parent. Depending on employee healthcare benefits, families may experience a loss of income when they must miss work to care for children (Lara et al., 2001). Poorly controlled asthma is disruptive to family routines and drains family resources. More seriously, while mortality due to asthma is low, the death rate for children ages 5 to 14 years doubled in the past 20 years from 1.5 to 3.7 deaths per million (U.S. Department of Health and Human Services, 2000).

Parents and children must demonstrate vigilance in order to reduce the severity and frequency of asthma episodes. Good home asthma management requires that the family become aware of stimuli that can trigger asthma symptoms and take steps to avoid triggers, reduce contact with triggers, or take medications preventively to lessen the airway hyperresponsiveness and bronchoconstriction (AAAAI, 1999). Triggers such as scented household cleaners and potpourri can be removed from the home. The child can wear a scarf over the nose when the temperature is cold or wind is gusting to lessen contact with triggers. Regular housekeeping activities can reduce dust-mite and mold levels in the home. Preventive medications can be taken before engaging in vigorous physical activity, or before the child leaves the house to catch the school bus during the child's allergy season (AAAAI; Platts-Mills, 2004).

Good home asthma management contributes to control of asthma symptoms and, therefore, to improved health outcomes. When symptoms are controlled, unplanned visits to physicians, ED, and hospitalizations are reduced or even eliminated (AAAAI, 1999). These unexpected visits are costly for the family in terms of noncovered healthcare expenses, travel, child care for well children, disrupted plans, and the added stress experienced by parents and child (Lara et al., 2001). Family education for asthma management has had some effects on improving school attendance and decreasing ED visits and hospitalizations, but the impact of education on health outcomes has not been consistent across studies (Alexander, Younger, & Cohen, 1988; Kaplan et al., 1986; Parcel, Nader, & Tiernan, 1980; Taggart et al., 1991).

Methods

A pilot intervention study was conducted with a sample of Mexican- American, African-American, and European-American families with school-age children in third to fifth grades who had a diagnosis of asthma. The research design was quasiexperimental, with treatment and comparison groups randomized at the level of the school. The educational intervention was provided to the treatment group after baseline data were collected, then posttest data were collected at 6 and 12 months following the intervention. The research question guiding this analysis is: "What is the effect of participation in a health education program on parents' and children's management of asthma?" Analysis of baseline data revealed no significant differences between children in the treatment and comparison group when compared on personal factors, including SES, family composition (single- vs. two-parent family), and child's gender, age, ethnicity, or asthma severity. Asthma classes were provided to the comparison group after the final round of data were collected. Data were analyzed to evaluate changes in parents' and children's management behaviors after being provided with the intervention.

Procedures

The study was reviewed and approved by the university's Institutional Review Board for Protection of Human Subjects. All written materi\als were translated into regional Spanish, back translated to check accuracy, and field-tested with bilingual community members to verify equivalence between English and Spanish forms. To maintain confidentiality of participant information, the school nurses identified potential participants from the school medical records. Recruitment letters that explained the study and a stamped return postcard, addressed to the school, were mailed by the school nurses to children's parents. Parents could indicate on the return postcard their willingness to be contacted by the researcher to discuss the study further. The research team then contacted those parents who had given permission to do so.

School nurses were compensated for time spent reviewing medical records and identifying children who had a history of asthma. Inclusion criteria were (a) a diagnosis of asthma made by a healthcare provider; (b) able to speak English or Spanish; (c) child's age between 8 and 12 years; and (d) no significant co- morbidity that would preclude class participation. Sixty families with children who had experienced asthma symptoms in the past 12 months agreed to participate in the study. A home visit was arranged to obtain informed consent from parents and assents from children, and to collect the baseline data.

Variables

Demographic data, asthma severity, asthma management, and school absenteeism data were collected. Demographic data included child's age, gender, ethnicity, grade level, and parents' age, ethnicity, education level, occupation, and marital status. Data on parents' educational levels and occupations were used to compute the family SES (Hollingshead, 1983).

Asthma severity. The 4-item scale "How Bad is the Asthma?" (HBA) addresses wheeze frequency, medication usage, and sleep and activity limitations (Kieckhefer, 1987). The HBA uses a response scale of 0 for mildest response to 2 for most severe response, and responses are summed to yield a total asthma severity score (possible range 0- 8). For example, the response options for wheezing are 0: "wheeze only when exposed to things that cause asthma"; 1: "wheezing more than once a week"; and 2: "wheezing almost every day." The HBA has good internal consistency and validity and is supported through significant correlations with acute medical visits (-0.34), ED visits (0.28), and hospitalizations (0.26) (Kieckhefer). Internal consistency in the present study was good, with alpha of .68.

Asthma management. Parents' asthma management was assessed with the 16-item "Management Behavior Survey" (MBS) that has a 5-point Likert scale with O for never, to 4 for always (possible range 0- 64). The tool demonstrated good internal consistency (α = .92) and improved parental asthma management after participating in an asthma health education program (t = -4.00, p<.001) (Mesters, Meertens, Crebolder, & Parcel, 1993). Internal consistency in the present study with a more diverse sample of parents was good (α = .81).

Children's asthma management was assessed by self-report and parent report. Children completed the "Asthma Inventory for Children" (AI-C), an 18-item questionnaire with a 5-point Likert scale with 1 for never, to 5 for always. Responses were summed and then divided by 18. The tool had good internal consistency in a sample of 71 school-age children (α = .71) (Kieckhefer, 1987). To help children understand the Likert response format, the first item was read to the child five tunes, each time using one of the response options. For example, I never stay away from things that cause breathing problems; I stay away . . . once in a while; I stay away . . . about half the time; I stay away . . . most of the time; and I always stay away from things that cause breathing problems. After this demonstration, the children had little difficulty selecting their response to items. Internal consistency for the present study was adequate (α = .63).

Parents rated their child's asthma management by indicating how often their child performed observable asthma management behaviors. The parents' form (AIP) consisted of 16 items revised to read "my child" instead of "I" and used the same 5-point Likert scale. The items were summed and divided by 16. Internal consistency was good (α = .83).

School absenteeism. The consent form included permission for the school to release attendance data to the researcher. The number of days enrolled and days absent were obtained at baseline for the previous school year and again at the end of the intervention year. An absence rate was calculated for each child by dividing absences by days enrolled to account for students who moved out of the school district.

Educational Intervention

The school-based group education for children consisted of nine 15-minute, biweekly sessions covering asthma physiology and symptoms, asthma triggers, steps in managing asthma, and decision making in common school activity and play situations. The short class sessions were an accommodation to academic schedules that must adhere to increasingly restrictive or directive mandates from legislators and school boards regarding the use of class time. The 15-minute sessions were conducted during lunchtime in an empty classroom. The classes were provided twice a week so that content could be reinforced regularly with short time lags between sessions. Short stories, games, posters, and peak flow meters (PFMs) were used to illustrate content and provide mastery learning.

Parents received a bound educational booklet that addressed core content of asthma pathophysiology, symptoms, triggers, environmental management, medication management, and use of metered dose inhalers, spacers, and PFM. Additional content included an asthma management plan to be completed by the physician for home use, a guide for talking with physicians about concerns, and guidelines for safely increasing children's participation in activities (AAAAI, 1999; Kaplan et al., 1986). The booklet included many illustrations, was written at fifth-grade reading level, and translated into regional Spanish. The booklet was field-tested with bilingual community members to ensure accuracy and relevancy of the translations (Horner, Surratt, & Juliusson, 2000). At the 6-month follow-up visit, parents in the treatment group were asked if they had any questions and to give feedback on the educational booklet.

Results

Sixty children were enrolled in the study, but two families had incomplete questionnaires. There were 58 children with complete data enrolled in the study, and 52 children continued in the study after the 6-month posttest. At 12 months, 44 children completed the entire study. Attrition was due to moves out of town (8), no response to voice mail (2), or failure to return completed questionnaires (4). The findings represent the 44 families who completed the study. Table 1 presents the frequencies for the personal and familial factors. Table 2 presents the descriptive statistics for the pre- and posttest measures for the treatment and comparison groups. More third-grade children (40%) participated in this study than older children. A small majority (54%) of the sample was in the three highest SES categories, and 46% were poor and working class families. An alpha of 0.05 was considered to be significant in this exploratory study. Bonferroni correction for multiple comparisons with t-tests and ANOVA was applied so that findings were deemed to be significant when p ≤ 0.0125 (Munro, 2001).

Comparison-group parents reported more home management than the treatment group (38.86 vs. 34.70) at baseline, but the two groups were comparable at 6 and 12 months. The improvement in the treatment group's home management from baseline to 12 months posttest (t = - 3.30, p = .003) was significant.

Table 1. Frequencies of Personal and Familial Factors

Table 2. Descriptive Statistics for Treatment and Comparison Groups

Children's self-reported asthma-management behaviors were significantly increased from baseline to 12 months postintervention for both treatment- and comparison-group children (t = -3.74, p = .001); but the increase was not significantly different between the two groups. The treatment group parents' ratings of their children's management behaviors also significantly increased over the course of the study from baseline to 12 months (t = -3.10, p = .003). Absenteeism remained the same or decreased slightly (equal to one school day) by 12 months.

While parents' and children's reported asthma management in the treatment group improved significantly, the increased scores among the comparison group led to a search for other influencing factors. Post hoc analyses were run to determine whether personal or familial factors contributed to family asthma management. Family SES contributed significantly to children's self-management in that children from poorer homes increased their self management significantly at 6 months (F = 5.484, p = .024) and maintained this improvement at 12 months.

Discussion

The findings are limited by the small sample size, by participant attrition over the course of a year, and by the finding of improved scores in both groups of children. The fact that both the treatment and comparison groups improved by 12 months could be due to individual learning as the children answered questionnaire items that address specific behaviors and concepts about asthma - a type of Hawthorne effect. However, other external factors that could potentially influence the comparison group scores were identified serendipitously over the study year. Two comparison children were started on allergy immunotherapy and allergists provided families with focused information on asthma care. In addition, two children in the comparison group were hospitalized for asthma - one to the pediatric intensive care unit. These events may have sensitized other children with asthma who attended the same schoolsas to the importance of asthma management.

It is important to note that SES did not limit the children's ability to implement the behaviors taught in the program. Because of asthma health disparities reported nationally among poorer families, these families may have a greater need for learning asthma management. The improvements in asthma self-management among the children from poorer families in this study is very encouraging.

While the educative booklet was reviewed favorably by the treatment group parents, it did not address all their concerns. For example, parents in rural areas live on dirt roads or near fields that are plowed and left fallow for a season. This results in fine dust clouds whenever a car drives on the roads or when the wind is more forceful, and these clouds are a hazard for children when they play outside or walk from the school bus to their homes. The length of time the children ride the school buses during hot weather contributes to increasing frequency of asthma episodes after school. Future directions for research include refining parent education materials, increasing children's skill mastery, and teaching parents how to supervise their children's asthma management. A larger sample size would improve the generalizability of the findings, but more importantly, the inclusion of Mexican-American families will allow for comparisons across ethnic groups and to begin filling gaps in the healthcare and nursing literature.

How Do I Apply These Findings to Nursing Practice?

Ongoing work is needed to refine further the home education component for parents. Parents reported they received very little information about asthma care prior to the intervention. The brief encounters that families have with healthcare providers limits the information that may be given (Clark et al., 1997; Leickly et al., 1998). However, parents do not participate in organized educational offerings with any regularity. Kaplan et al. (1986) found that only one-third of parents attended all the parent sessions for the Open Airways program, one-third attended about half the sessions, and the remaining third did not attend. This points to a need for nurses who care for children to provide education to fill this gap for parents and children. Nurses who work in specialty clinics can provide individualized instruction to families. School nurses have extensive contact with children and parents and could implement projects to support child and family asthma management. For instance, small group sessions with children can improve self-care. Parents need information as well, but the education sessions must be structured to fit their busy schedules. Individual sessions work well for parents is time can be scheduled for this purpose, but alternative information resources can be used to fill gaps in knowlledge as well (see box for Web-based resources). Information can be given to parents through school newsletters, clinic newsletters, booklets sent to the home, and presentations at parent-teacher nights; or even offering an early evening class for children and parents at the school, local community center, or church, may be a way to boost parental knowledge and confidence in managing childhood asthma.

Acknowledgment. This study was supported with an AREA grant from the National Institute of Nursing Research, NR04775.

Additional Web-Based Asthma Resources for Children and Parents

Good home asthma management contributes to control of asthma symptoms and, therefore, to improved health outcomes.

References

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Sharon D. Horner, PhD, RN, is, Associate Professor, University of Texas at Austin, Austin, TX.

Author contact: s.horner@mail.utexas.edu, with a copy to the Editor: roxie.foster@uchsc.edu

Copyright Nursecom, Inc. Jul-Sep 2004

Source: Journal for Specialists in Pediatric Nursing

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