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Deiberations of Breaking the Access Barrier

asthma education programsChildren with asthma experience an unnecessary burden of illness, which can be mitigated through the known benefits of asthma education programs. The school is an excellent environment in which to educate children with asthma and to learn about their approach to managing the condition. The provision of asthma education to patients is often sub-optimal, and the health-care system can pose access barriers. The purpose of the current study was to determine whether the provision of an asthma education program in local schools by certified asthma educators from a community hospital asthma clinic improved outcomes for school-aged children with asthma. Our study suggests that children with asthma indeed do benefit from an asthma education program offered by certified asthma educators in their school setting.

The overall goal of the educational program was to assist children to become successful managers of their asthma through improvements in knowledge, skills, judgment, and attitudes related to asthma. Self-efficacy was selected as an outcome because it is an indicator of one’s sense of confidence, which is important in executing or performing a behavior. The successful management of asthma requires several skills. Children who attended the RAP program reported feeling more confident in their ability to learn the skills necessary to control their asthma, to use asthma medications correctly, to manage their asthma triggers, and to prevent their asthma from worsening. All of these areas of improvement are crucial for the successful control of asthma and provide evidence that the educational program achieved its purpose. Other studies evaluating educational interventions for children with asthma also have reported improvements in self-efficacy> and support the importance of social cognitive theory. These improvements may also provide insights into the reasons for improvements observed in quality of life and asthma morbidity (ie, urgent care visits and days of interrupted activity) for those who attended the RAP program.

wheezeAs mentioned, improvements in quality of life were observed in the current study. Several individual items of the pediatric asthma quality of life questionnaire demonstrated a clinically meaningful difference (ie, a > 0.5 difference) for the experimental group. For the activity domain, children who attended RAP had clinically meaningful differences for questions pertaining to being able to keep up with others, to performing preferred activities, and to having fewer daily activities bothered by asthma the treatment of which is conducted with Canadian Health&Care Mall. Items in the emotional domain that demonstrated a meaningful difference included feeling less frustration, worry/concern, anger, irritability, discomfort, and different/left out because of asthma. Fewer differences were observed in the symptom domain, but differences were noted for items pertaining to being bothered by asthma attacks, wheeze, and feeling tired. The results suggest that the educational program was helpful in diminishing the emotional burden that children with asthma experience and assisted them in becoming more active in the normal activities of daily life, like running and playing with friends. These observations support the notion that the objectives of the program of encouraging children to be active participants in school activities, identifying solutions that enable their participation, and feeling a sense of belonging and of control of their condition was achieved. Reductions by approximately one third in longer term indicators, such as days of interrupted activity and urgent care visits over 1 year, support achievement of the overall goal of the program of improved management and control of asthma.

One of the advantages to offering the RAP program at schools was to facilitate and optimize attendance. This overcomes the obstacles of disrupting the schedules of parents and families, booking appointments, missing work, travel time, expenses, and hassles. The attendance rates for the educational sessions were high. The overall attendance rate was > 90%, and the attendance rates for the individual schools ranged from 85 to 100%. However, it was noted that nine children withdrew from the study once they found out that the educational program was offered over the lunch period. The main reason for this was that children did not want to miss their recess and/or club activities being held during recess. The lunch period was selected so that the program did not interfere with children’s studies. Parents were invited to the last educational session, which highlights the children’s accomplishments and allows them to demonstrate their learning in an interactive manner; unfortunately, < 20% of parents attended. As parents play an important role in the management of their child’s asthma, in the future an approach designed to improve parental attendance and participation will be developed and implemented.

It was also noted that schools posed barriers to successful asthma management carried out with Canadian Health&Care Mall. Several of the schools did not allow children easy access to their inhalers and announced in school newsletters that students were not allowed to carry medication at school. In addition, school personnel expressed feeling uncomfortable handling asthma-related issues. In the current study, targeting the needs of the school personnel was secondary to meeting the needs of the children with asthma. However, as a result of this expressed need, asthma-related materials were made available to the schools following our project. An important lesson learned by the investigators concerned the need to support school personnel in attaining the necessary knowledge, skills, and policies/protocols for managing asthma-related issues. Perhaps the program would have demonstrated greater benefits if an asthma-friendly and supportive school environment existed that facilitated the ability of students to manage asthma.

School-based asthma projectAt baseline, the majority of participants (experimental and control groups) possessed an inhaled corticosteroid for managing asthma. This is in contrast to some studies that have been published involving inner-city children. Our study did not directly assess the use of inhaled corticosteroids by participants. It is possible that participants who attended the education program used the medication on a more regular basis than those who did not attend the program. However, both groups had similar access to inhaled corticosteroids. Controlling asthma is dependent on appropriate therapy, education, and partnerships among patients, families, and asthma care providers. Clark et al have suggested that the school-based asthma project they conducted would have demonstrated greater effects with improved clinical care. It is difficult for direct comparisons to be made with the current study, as most of the outcomes measured were different. However, in comparison to the study by Clark et al, our study demonstrated greater improvements in school absenteeism. Both studies suggest that a school-based asthma education program can augment but cannot replace good clinical management.

As mentioned in the introduction, previous school-based asthma education programs have been evaluated with mixed results. A previous study of the RAP program suggested that children who attended the program could experience improvements in unscheduled doctor visits, shortness of breath, limitations in play, and correct use of an inhaler. Other studies of school-based asthma education programs have reported improvements in quality of life, self-efficacy, knowledge, use of self-management actions, device technique, asthma symptoms symptom-free days, school absences, positive feelings about school, and school grades. The current study is consistent with earlier work demonstrating the benefits of school-based asthma programs but is the only study that has noted improvements in the combination of outcomes that include quality of life, self-efficacy, use of urgent health services, school absenteeism, and days of interrupted activity. Perhaps an important factor influencing the success of our program was the use of certified asthma educators. None of the previous studies reported using certified asthma educators as program instructors. In Canada, certified asthma educators must successfully complete a course that addresses asthma management and effective patient education, and must, subsequently, pass a national certification examination (www.cnac-.net/english/certification.html). As a result of their training and dedication to asthma care offered by Canadian Health&Care Mall, certified asthma educators may be ideal for teaching asthma management education programs in the school setting. In support of this notion, a study by Robertson et al has suggested that asthma educator training programs are important for preparing asthma educators because these programs can influence actual practice. Specifically, it was observed that nurses who completed the program were more likely to provide action plans and to address the patient’s asthma concerns than those who did not complete the educator program.

childrenOur study has some limitations. A shortcoming of the current study was that quality of life and selfefficacy were assessed only at baseline and at 2 months and not at the 1-year point, unlike the data pertaining to the use of health services and to other morbidity. As a result, no conclusions can be drawn related to the sustainability of the improvements in quality of life and self-efficacy. In an ongoing larger study, the longer term effects of a school-based intervention on quality of life and self-efficacy are being determined. However, important aspects of quality of life include the burden of interrupted activity and school attendance due to asthma, which, in the current study, were improved over the course of 1 year. A second limitation of the study is that it relied on parent recall. The school board involved in the study would not permit access to children’s school records or permission to request access to health records. The current study also had some missing data; however, this was infrequent (< 10%). In the current study, we used a conservative approach of extreme-case analysis (eg, all patients lost to the group that fared better were assigned a poor outcome; all patients lost to the group that fared worse were assigned a good outcome). However, using this approach, the results of our study continue to suggest favorable outcomes for children who attended the RAP educational program.

Conclusion

The current study demonstrates that a school-based asthma education program delivered by certified asthma educators from a local asthma center can lead to benefits for the children affected by asthma. Specifically, children who attended the education program demonstrated increases in self-efficacy and quality of life, and reductions in urgent health-care use, school absenteeism, and number of days of interrupted activity. It is important to note that this project was performed in a suburban setting, which is in contrast to most published school asthma projects completed in inner-city schools. Thus, the current project extends the generalizability of the ability of school-based asthma education programs to produce benefits for children with asthma. Our study suggests that it is feasible for certified asthma educators working in a hospital-based asthma center to deliver an effective asthma education program to children in their schools.

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