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(Chest. 2005;128:1928-1935.)
© 2005 American College of Chest Physicians

Breaking the Access Barrier*

Evaluating an Asthma Center’s Efforts to Provide Education to Children With Asthma in Schools

Lisa Cicutto, ACNP, PhD; Sue Murphy, RN, CAE; Debbie Coutts, RRT, CAE; Janet O’Rourke, Msci; Gail Lang, RRT; Cori Chapman, MHSci and Pamela Coates, MD

* From the Faculty of Nursing (Dr. Cicutto), University of Toronto, Toronto, ON, Canada; and the Asthma Centre (Mss. Murphy, Coutts, O’Rourke, Lang, and Chapman, and Dr. Coates), Credit Valley Hospital, Mississauga, ON, Canada.

Correspondence to: Lisa Cicutto, PhD, Associate Professor, University of Toronto, 50 St. George St, Toronto, ON, M5S 3H4 Canada; e-mail: lisa.cicutto{at}utoronto.ca


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Objective: To evaluate an asthma education program for children with asthma that is delivered in their school by certified asthma educators from a local hospital-based asthma center.

Study design: Randomized controlled trial.

Setting: Twenty-six elementary schools located in a suburb of Toronto.

Participants: A total of 256 children in grades 2 to 5 with asthma and their parents were randomized to control and experimental groups.

Intervention: Children in the experimental group received the "Roaring Adventures of Puff" asthma education program over the course of six weekly 1-h sessions. Those in the control group continued receiving usual care.

Measurements and results: Data collection involved measuring asthma quality of life, self-efficacy for managing asthma, school absenteeism, days of interrupted activity, health services use, and parental loss of time from work. Quality of life and self-efficacy data were collected from the children at baseline and 2 months. Telephone parental interviews conducted over 1 year were used to collect data on the remaining variables. Unpaired t test, analysis of variance, and {chi}2 test were used to determine whether differences existed between the groups. The results are reported as the mean ± SD. The experimental group demonstrated higher scores than the control group for self-efficacy (3.6 ± 0.7 vs 3.8 ± 0.9, respectively; p < 0.05) and quality of life (5.0 ± 1.4 vs 5.5 ± 1.4, respectively; p < 0.05). At 1 year, the experimental group demonstrated fewer mean urgent health-care visits (2.5 ± 2.5 vs 1.7 ± 1.9 visits per year, respectively; p < 0.01), days of missed school (4.3 ± 5.7 vs 3.0 ± 4.4 days per year, respectively; p > 0.05), and days of interrupted activity (9.1 ± 10.5 vs 6.2 ± 7.3 days per year; p < 0.01) related to asthma than the control group. There were no differences between the groups for parental work absenteeism or scheduled asthma visits.

Conclusion: Providing an asthma education program to children in their school can significantly improve quality of life and reduce the burden of childhood asthma.

Key Words: asthma • asthma education • certified asthma educators • children • controlled-trial • school


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Childhood asthma is the most common chronic childhood disease, affecting 7 to 20% of school-aged children.1234 It is a leading cause of school absenteeism and hospitalizations.4567 A national survey revealed that 60% of individuals with asthma have poorly controlled disease.8 Despite the availability of new and effective pharmacologic therapies, the existing literature suggests that children with asthma unnecessarily experience a reduced quality of life and the health-care system incurs preventable costs.

Some systematic reviews910 have concluded that educational interventions for children and youth with asthma lead to improvements in air flow, school absenteeism, days of restricted activity, and emergency department visits. However, the overwhelming majority of studies were conducted at tertiary hospitals or outpatient centers. It is important to consider the school as a site for asthma education. The school system often poses several obstacles for children in managing their asthma, for instance an inability to access their inhalers, exclusion from physical activities, and the presence of asthma triggers in the classroom. Astonishingly, it is often the school secretary who is designated as the person to manage asthma or control access to medications.11 School systems can have advantages over traditional health-care settings because they provide large-scale centrally organized settings that allow access for all children.

There are some studies in the literature supporting the idea that asthma interventions delivered in the school setting are successful. The types of programs vary from delivering asthma education programs to children with asthma,1213141516 to multimedia educational software programs targeting the whole school body,17 to school-based health centers and case managers.181920

To date, relatively few studies have evaluated the effectiveness of school-based asthma education programs. Some studies1213141621 have suggested that school-based asthma education programs can improve asthma knowledge, peak flowmeter and inhaler techniques, self-efficacy scores, and school grades, and can reduce symptom scores. However, the majority of these studies were conducted in inner-city, low-income schools,1213141718192021 so there is limited experience with school settings outside the inner city, such as the suburbs and rural communities. The limitations of the studies include small sample sizes,13141517181920 nonrandomized controlled study designs,141516181920 significant dropout/loss to follow-up rates,131519 and short-term or very limited long-term data.13141517

Access to specialty asthma clinics/centers can be a problem for children and families affected by asthma due to the restricted hours of operation (ie, daytime hours Monday through Friday), transportation and parking costs, and, in Canada, the need for a referral from a primary care physician. As a possible solution for overcoming the access barrier to formal asthma education for children, it was decided that the suburban hospital-based asthma center would provide an asthma education program similar to what would be offered in the asthma clinic to children with asthma in their schools. We hypothesized that a school-based asthma education program delivered by certified asthma educators from the local asthma center would be an effective way to improve children’s quality of life and confidence in their ability to manage their asthma and, thereby, to reduce asthma-related morbidity, such as school absenteeism, days of interrupted activity, and use of urgent medical care visits.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
A randomized controlled trial of an elementary school-based asthma education program was conducted with children with asthma in a large suburb of Toronto. Approval for conducting the study was received by the participating school board and the Ethics Review Committee of the Credit Valley Hospital (Mississauga, ON, Canada). Parents and children provided informed consent and assent, respectively. Children were eligible for inclusion if they were enrolled in grades 2 through 5 in a participating elementary school, were able to speak English, had provided assent/consent, and, in addition, had a parental report of physician-diagnosed asthma, asthma medication use, and had experienced asthma symptoms three or more times in the past year. Children were excluded from the study for the presence of a second major chronic illness with a pulmonary component (eg, cystic fibrosis).

Study Protocol
Forty elementary schools were randomly selected from a potential pool of 147 elementary schools. A letter was sent home to all parents of children in the selected schools to advertise and explain the study. Parents and children interested in participating in the study were asked to return a form indicating whether or not their child had physician-diagnosed asthma, used an asthma medication (ie, bronchodilator and/or anti-inflammatory agents) for breathing difficulties, and had experienced asthma symptoms three or more times in the past year. In order to be eligible for study inclusion, the parent/guardian must have reported that their child met all three criteria. Based on the returned eligibility forms, 26 schools had a sufficient number of eligible children (ie, more than seven children per school) to provide the intervention. Of the 297 returned forms with eligible children, 256 children with asthma and their parents were enrolled into the study from the 26 schools. In order to prevent contamination, the unit of randomization was the school. There were 132 children who attended schools that were randomized to receive the intervention, and 124 children who attended the control schools. Randomization was centrally controlled with the use of a computerized randomization program. Children randomized to control schools received their usual asthma care, and those randomized to experimental schools received a school-based asthma education program in addition to their usual asthma care. The program was offered to control schools subsequent to final data collection.

Intervention
Children attending schools that were randomized to the experimental group received a school-based asthma education program called the "Roaring Adventures of Puff"(RAP).22 The program is based on asthma practice guidelines23 and the theoretical principles of social cognitive theory24 and self-regulation theory.25

RAP consists of six sessions 50 to 60 min in length that are held once a week over six consecutive weeks with children with asthma. Parents are invited to the last session of RAP, which showcases the children’s learning and skill development. The sessions include the following: (1) getting to know each other, goal setting, use of a peak flowmeter, and diary monitoring; (2) trigger identification, control, and avoidance, and basic pathophysiology; (3) medications and the proper use of inhalers; (4) symptom recognition and action plan use; (5) lifestyle, exercise, and managing an asthma episode; and (6) sharing asthma information with teachers and parents. Teaching strategies include puppetry, games, role playing, model building, discussions, and asthma diary recordings. Parental involvement is encouraged through the use of asthma-related homework activities for the family during the weekly intervals. Prior to delivering the intervention, all RAP instructors who were certified asthma educators attended a 2-day workshop provided by the developer of RAP.22 In Canada, certified asthma educators are professionals who have completed an asthma educator program (of approximately 6 months duration) and have successfully passed a national written examination.

Data Collection
To assess the impact of our school-based initiative, data were collected from questionnaires and interviews with children and their parents. The two main outcomes of interest were the total number of emergency department visits and office visits for acute asthma episodes at the end of the 1-year follow-up period and quality of life. Secondary outcome measures were self-efficacy, the number of days absent from school, the number of days of interrupted activity, and parental absenteeism from work. Data collection for children with asthma occurred at baseline and 2 months. Children were interviewed in the school at these time points using the Juniper Pediatric Asthma Quality of Life Questionnaire252627 and the Child Asthma Self Efficacy questionnaire.28 The Juniper Pediatric Asthma Quality of Life Questionnaire consists of three domains (activity, symptoms, and emotion) and uses a 7-point Likert scale, with a higher score reflecting a higher quality of life. A change in score of 0.5 is the minimal important difference for both overall quality of life and individual domains.25 The child asthma self efficacy questionnaire reflects skills involved in asthma attack identification, prevention, and management, and uses a 5-point Likert scale in which 1 represents no confidence and 5 represents complete confidence in one’s ability.

Parents/guardians of children with asthma were interviewed over the telephone at five time points. At baseline, parents were interviewed to collect demographic and asthma-related characteristics. Data collection also occurred at 3, 6, 9, and 12 months. At these later time points, parents provided information regarding health services use, absenteeism, and number of days of interrupted activity related to asthma. Tracking sheets were developed and given to parents to assist with data collection and telephone interviews. A tracking sheet was provided for each 3-month period, and was used to record health services use (eg, emergency department, walk-in clinics, office visits, and hospitalization) for both urgent care visits related to exacerbations and for regular/follow-up visits for asthma; days missed from school; days of interrupted activity because of the child’s asthma; and parental work loss as a result of their child’s asthma. A day of interrupted activity was defined as missing a usual activity because of asthma symptoms, such as missing a day of camp or a party, or skipping a sport’s practice/game. Individuals who were blinded to group status performed data entry and collection. At each call and before each new 3-month interval, parents/guardians were reminded and encouraged to use the tracking sheet to record the various events and disruptions related to asthma.

Statistical Analysis
The number of urgent care visits, scheduled follow-up visits, days of interrupted activity, school days absent, and parental days of work missed were calculated for the 1-year follow-up period. Scores for self-efficacy and quality-of-life instruments were calculated according to the instructions of the developer. For each outcome of quality of life and self-efficacy, an overall average score was computed. In order to determine whether the participating schools or sites varied, an analysis of variance (ANOVA) was used with the school serving as the independent variable. There were no significant differences among the schools for the key variables, and thus the data were combined into one large data set.

An intention-to-treat approach was used for the analysis; that is, the analysis included all participants randomized to the group to which they had been allocated.29 The primary analysis compared postintervention outcomes for children with asthma receiving the education program and for those who did not receive the program at the 1-year follow-up period. An ANOVA was used to compare the two study groups for the variables of health services use related to asthma, school absenteeism related to asthma, days of interrupted activity related to asthma, and parental days of work missed that were related to the child’s asthma. To further understand the use of health services, a follow-up ANOVA was calculated on the unscheduled/urgent and follow-up health services visits. Unpaired t tests were used to determine whether differences existed between the groups for overall scores of quality of life and self-efficacy. Subsequent to this analysis, ANOVA was performed on the three domain scores for quality of life and on the individual self-efficacy items.

Since scores for self-efficacy and quality of life are based on 5-point and 7-point Likert scales, both parametric and nonparametric statistical tests were used to determine the differences between the experimental and control groups. The results of the parametric and nonparametric tests were consistent. In addition, 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. Baseline outcomes were compared to see whether the two study arms (ie, control and experimental) were similar or were balanced before the intervention and there were no significant differences observed between the two groups. Differences were considered statistically significant at the 0.05 level (two-sided test). The data were analyzed using a statistical software package (Statview; Abacus Concepts; Berkeley, CA).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
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.30 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 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).


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  		Table 1. Baseline Characteristics of Children According to Study Group*

 
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 < 0.001).


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  		Table 2. Comparison of Self-Efficacy and Quality of Life at 2 mo*

 
Children who attended RAP also reported a higher quality of life compared to children who did not attend the program, which was statistically significant. This trend was observed in all three domains and in the overall score of the pediatric asthma quality of life questionnaire (Table 2). The activity and emotional domains of the questionnaire demonstrated the greatest difference between the experimental and control groups. The difference between the two study groups at 2 months was clinically meaningful (ie, demonstrated a difference of ≥ 0.5)27 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 health-care 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. 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.


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  		Table 3. Comparison of Study Outcomes at 1 yr of Follow-up*

 
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.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
Children 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 suboptimal, 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.24 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-efficacy910 and support the importance of social cognitive theory.24 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.

As 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.27 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. 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. 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.

At 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.21 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 al21 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,21 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 program30 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,31 self-efficacy,12 knowledge,1213 use of self-management actions,12 device technique,13 asthma symptoms,122129 symptom-free days,12 school absences,12213132 positive feelings about school,12 and school grades.1221 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, 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 al33 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.33

Our study has some limitations. A shortcoming of the current study was that quality of life and self-efficacy 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
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
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.


   Footnotes
 
Abbreviations: ANOVA = analysis of variance; RAP = Roaring Adventures of Puff

Partnership funding was received from The Change Foundation, Credit Valley Hospital, Asthma Society, University of Toronto, and the Ontario Lung Association. Dr. Lisa Cicutto was supported by a Career Scientist Award from the Ontario Ministry of Health and Long Term Care.

The results and conclusions of this research are those of the authors; no official endorsement by the Ministry is intended or should be inferred.

Received for publication January 15, 2005. Accepted for publication April 9, 2005.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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