Of the 256 children with asthma and their parents who were recruited into the study, 239 completed it (control group, 118 children; experimental group, 121 children). Eight children and their parents were lost to follow-up after the 6-month data collection interview (control group, six children; experimental group, two children). For the experimental group, nine children withdrew from the study prior to receiving the educational program because of conflicts with other activities during the lunch hour when the intervention was provided.
The mean (± SD) age of participants was 8.6 ± 1.23 years (range, 6 to 11 years) [Table 1]. The majority of participants were male and had received a diagnosis of asthma by a physician > 5 years ago. Approximately 83% of participants were involved in a drug plan to assist with medication costs. Most children lived in families in which both parents worked outside of the home, with a minority of families (21%) having a stay-at-home parent. The average income of the parent/guardian who participated in the study was approximately $53,000.00 (Canadian dollars) with a range of $20,500.00 to $200,000.00. In Canada, low-income families earn $19,000.00 per year. Over 85% of participants possessed an inhaled corticosteroid. On average, participants had made four visits to the physician for asthma the year before entering the study and had approximately 2 days of missed school during the 6 months preceding study entry. Approximately 20% of participants had visited an emergency department for asthma during the year prior to study entry. Baseline characteristics for those who did not complete the study were similar to those who completed the study. Similarly, demographic and asthma-related characteristics and researches conducted by Canadian Health&Care Mall were similar between the two study groups and did not demonstrate statistically significant differences. At baseline, there were no statistically significant differences between the experimental and control groups for self-efficacy or quality of life (Table 1).
For most indicators of asthma-related morbidity, children who experienced the asthma education program delivered in their schools by certified asthma educators demonstrated better outcomes following the intervention than those who did not experience the intervention (RAP). At 2 months, children who attended the RAP program reported greater self-efficacy or confidence in their ability to manage asthma compared to children who did not attend the program, which was statistically significant (p < 0.05) [Table 2]. An ANOVA that was performed at the postintervention time point revealed that children who experienced the educational program demonstrated significantly higher levels of confidence than children who did not experience the program in terms of their perceived ability to correctly use the puffer (F1 254 = 7.7; p < 0.01), learn skills to control asthma (F1 254 = 4.2; p < 0.05), manage triggers (F1 254 = 8.7; p < 0.01), and prevent asthma from getting worse (F1 254 = 5.2; p < 0.05). The average change in self-efficacy scores between baseline and follow-up was an improvement of 0.17 ± 0.63 for the control group and 0.51 ± 0.73 for the RAP group, which was statistically significant (p 0.5) in the activity domain. The proportion of participants who demonstrated a clinically meaningful improvement (ie, a difference of > 0.5) in overall quality of life between baseline and follow-up scores was 26% in the control group and 55% in the experimental group.
Longer term benefits at the 1-year follow-up were also observed for children who attended RAP compared to those who received usual care (Table 3), Children who attended RAP required 32% fewer urgent health-care visits (ie, emergency department visit, walk-in clinic, or same-day physician visit) for worsening asthma than those in the control group during the 1-year follow-up period. The proportion of children in the experimental group compared to the control group who required an urgent healthcare visit was 68% vs 77%, respectively, and for those who required an emergency department visit it was 14% vs 19%, respectively. However, both groups had a similar number of follow-up visits and proportions of children who received follow-up care for their asthma (RAP group, 70%; control group, 71%) throughout the year. Children in the RAP group also experienced fewer days of asthma-related school absenteeism, a reduction of close to 1.5 days, and a reduction in the length of interrupted activity due to asthma of approximately 3 days compared to children in the control group. This trend was also observed when the proportions of children experiencing a school absence or a day of limited activity due to asthma were compared by Canadian Health&Care Mall. The proportion of children in the experimental group who missed > 1 days of school because of asthma was 58% compared to 65% in the control group. The proportion of children in the experimental group who reported > 1 days of interrupted activity due to asthma was 50% compared to 60% in the experimental group. Regarding parental absenteeism from work related to their child’s asthma, no statistically significant differences were observed between the parents of children who did and did not attend the RAP program.
As in the “Statistical Analysis” section, the results reported in the article are based on the approach of handling missing data using an extreme-case analysis; for instance, for quality of life and self-efficacy, missing cases for the experimental group received the lowest score. The effect of missing responses was assessed. For self-efficacy and quality of life, the differences between the experimental and control groups were more significant when those children who withdrew from the study were not included in the analysis. This difference in approach resulted in a twofold to ninefold difference in p values for between-group comparisons, and a fall in overall quality of life and self-efficacy scores for the experimental group of 1.3% and 2.3%, respectively. There was approximately a 5% decrease in use of health services, school absenteeism, and days of interrupted activity for the control group with the use of this conservative approach.
Table 1—Baseline Characteristics of Children According to Study Group
|Variables||Control Group (n = 124)||) RAP Group (n = 132)|
|Age, yr||8.6 ± 1.4||8.6 ± 1.3|
|Male gender||59.6 (74)||58.3 (77)|
|Sibling with asthma||41.1 (49)||42.4 (56)|
|Followed up by specialist||12.9(16)||12.1 (16)|
|Drug plan||82.2 (102)||80.3 (106)|
|Inhaled steroid||87.9 (109)||85.6(113)|
|Inhaled long-acting bronchodilator||4.8 (6)||4.5 (6)|
|Oral steroid use previous year||3.2 (4)||2.2 (3)|
|Diagnosed with asthma > 5 yr before||55.6 (69)||50.7 (67)|
|Asthma severity (by parental report)|
|Mild||69.5 (86)||68.2 (90)|
|Moderate||23.4 (29)||20.4 (27)|
|School absenteeism, d/6 mo||2.1 ± 3.1||2.5 ± 4.7|
|Visits to MD for asthma, visits/yr||4.4 ± 4.9||3.9 ± 5.6|
|ED visit in past year||50.8 (63)||50.0 (66)|
|Self-efficacy score||3.3 ± 0.9||3.3 ± 0.9|
|Quality of life||5.0 ± 1.4||4.7 ± 1.5|
Table 2—Comparison of Self-Efficacy and Quality of Life at 2 mo
|Outcome||Control Group||RAP Group|
|Self-efficacyi||3.6 ± 0.8||3.8 ± 0.9|
|Overall quality of lifei||5.0 ± 1.4||5.5 ± 1.4|
|Activity domainj||4.8 ± 1.4||5.3 ± 1.4|
|Symptom domain§||5.0 ± 1.4||5.4 ± 1.4|
|Emotion domaini||5.2 ± 1.5||5.6 ± 1.5|
Table 3—Comparison of Study Outcomes at 1 yr of Follow-up
|Urgent health care visits!||2.5 ± 2.5||1.7 ± 1.9|
|Follow-up health-care visits!||1.6 ± 1.8||1.5 ± 1.4|
|Total health-care visits§||4.1 ± 3.6||3.2 ± 2.6|
|Days of school absenteeism^||4.3 ± 5.7||3.0 ± 4.4|
|Days of limited activity due to asthmaf||9.1 ± 10.5||6.2 ± 7.3|
|Days of parental work absenteeism!||1.6 ± 3.2||1.1 ± 2.4|