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ASTHMA EDUCATION FOR THE SCHOOL-AGE CHILD

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Jii] Poimateer

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ASTHMA EDUCATION FOR THE SCHOOL-AGE CHILD

BY
Jill Polmateer

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1998

ABSTRACT
ASTHMA EDUCATION FOR THE SCHOOL-AGE CHILD
BY
Jill Polmateer

Asthma is a major concern for health care providers.
There are approximately 2-5 million children in the United
States with asthma (Ross, 1993). Children with asthma do
not always have a full understanding of their condition and
may be unskilled in their ability to prevent and control
symptoms. The Advanced Practice Nurse's (APN) position
lends itself to patient education. The purpose of this
study was to describe the effect of the Open Airways Program
(GAP), an asthma education program, on emergency room visits
and hospitalizations, school absenteeism, and self-
management skills in children with asthma. The Health
Belief Model served as a conceptual framework to illustrate
the likelihood to make behavioral changes (Becker, 1977).
The results of this study show decreased emergency room
visits and hospitalizations after the CAP. No differences
were observed in the number of school absences or self-
management skills six weeks following the education.
Implications for the APN on the topic of asthma education
are examined. The OAP offers a practical, low-cost approach
to educating children with asthma in the school and warrants
further testing with a larger sample with measurement of the

intervention conducted over a longer period.

ACKNOWLEDGMENTS

This thesis would not have been possible without the
help of many individuals. First, I would like to give my
sincere thanks to Linda Spence, my thesis chair who over the
last year has endured my many phone calls and rewrites. I
also greatly appreciate my children, Jennifer and Julie, who
have offered patience and compassion through my many hours
on the computer and with my nose in the books. Lastly, and
‘ most importantly, I would like to express my gratitude to my
husband, Jon, who is always so supportive and knows just
what to say when times become overwhelming. Thank-you all

for your support.

iii

TABLE OF CONTENTS

List of Tables . . . . . . . . . . . .
List of Figures . . . . . . . . . . . .

CHAPTER I: THE PROBLEM

Introduction . . . . . . . . . . . . .

Statement of the problem . . . . . . .
Purpose . . . . . . . . . . . . .

CHAPTER II: CONCEPTUAL FRAMEWORK

Introduction . . . . . . . . . . . . .

Conceptual Definitions . . . . . . . .
Self-Management Program . . . . .

CHAPTER III: REVIEW OF LITERATURE
Introduction . . . . . . . . . . . . .
Review of Literature . . . . . . . . .
The Health Belief Model . . . . .
Self-Management . . . . . . . . .
Summary . . . . . . . . . . . . . . . .

CHAPTER IV: METHODS
Design . . . . . . . . . . . . . . . .
Hypotheses . . . . . . . . . . . . . .
Operational Definitions . . . . . .
Self-Management . .
Open Airways Program
Sample . . . . . . . . .
Data Collection . . . .
Reliability and Validity . . . . . . .
Data Analysis . . . . . . . . . . .
Protection of Human Subjects . . . . .
Limitations . . . . . . . . . . . . . .

CHAPTER V: RESULTS
Socio-Demographic Characteristics . . .
Hypotheses Results . . . . . . . . . .

iv

btdh'

11
11

13
13
13
15
17

19
19
20
21
21
22
23
25
26
27
28

30
30

TABLE OF CONTENTS (cont.)

CHAPTER VI: DISCUSSION AND
The Health Belief Model . . .

IMPLICATIONS

Hospital and Emergency Room Visits

School Absences . . . .
Self-Management . . . .
Current Literature . . . . .
Implications . . . . . . . .
Implications for Nursing
Implications for Nursing
Implication for Research
Summary . . . . . . . . . . .

LIST OF REFERENCES . . . . .

APPENDICES
UCRIHS approval letter .
Child Interview . . . .
Original Study . . . . .

Research

Education

33
33
34
35
36
37
38
39
4O
43

45
49

50
53

LIST OF TABLES

Page

Table 1. Outline of Open Airways Program . . . . . . . . 22
Table 2. Descriptive Characteristics of Study

Population 0 O I O O O O O O O O O O O O O O O 27
Table 3. Chi-square of hospitalizations and emergency

room visits, school absences, and

self-management skills pre/post-education

with Open Airways . . . . . . . . . . . . . . 32

vi

Figure 1.

Figure 2.

LI ST OF FIGURES

The Health Belief Model . . . . . .

Adaptation of the Health Belief Model

vii

CHAPTER I
THE PROBLEM
Introduction

Asthma is a chronic lung disease afflicting 2-5 million
children in the United States (Ross, 1993). Asthma is
characterized by acute exacerbation of shortness of breath,
wheezing, and coughing due to inflammation and constriction
of the bronchial tubes in the lungs. Prevention of episodes
depends on the early recognition and treatment of
exacerbation. For this purpose individual management goals
and therapeutic regimens are necessary (Laurenzi, 1993).
Asthma is the number one reason for school absenteeism and
hospitalizations in children older than one year of age
(American Lung Association, 1993), accounting for lost
productivity and high cost to families and society at large.
Sleep and family living patterns are interrupted, and the
child's school attendance and performance can be adversely
affected (Laurenzi, 1993).

Sullivan, Elixhauser, Buist, Luce, Eisenberg, and Weiss
(1996) estimated the average annual societal burden of
asthma ranged from $326-$1315 per afflicted person. Asthma
ranks third among causes of hospitalizations for children
less than the age of fifteen (American Lung Association,

1993). According to the data from the American Lung

1

2
Association (1993), "asthma costs Americans $6.2 billion a
year. These costs include $1.1 billion for medicines, $345
million in lost work time, $900 million in lost school
time, and $295 million in emergency room visits."

Recent studies have shown that health education for
childhood asthma delivered to parents and children in health
care settings can improve asthma management skills, thereby
improving school attendance and performance, and reducing
the use of emergency health care services (Clark, Evans,
Feldman, Kaplan, Levin, Levison, Mellins, Rips, &
Wasilewski, 1987). Clinics in four New York City hospitals
developed and implemented the Open Airways asthma education
program (Kaplan, Rips, Clark, Evans, Wasilewski, & Feldman,
1986). The American Lung Association adopted the Open
Airways program for a national program in 1992 to provide
instruction in schools where children can be easily
accessed. The program was developed for children in the
third through the sixth grades to increase children's self-
management skills, self-efficacy, influence parents'
management decisions, reduce school absences and improve
school performance (Clark et al., 1987). Parents are not
expected to attend educational sessions but are sent written
educational materials. The program emphasizes the child's
ability to recognize early symptoms of asthma and take
action to prevent further exacerbation. The educational
program encourages self-management and offers opportunities

to practice new skills. Topics addressed in the program are

3
basic asthma information and feelings, symptoms,
medications, managing asthma episodes, exercise, seeking
medical attention and handling problems related to asthma
and school. The advanced practice nurse's position lends
itself to conducting and organizing Open Airway Programs
within school systems and encouraging clients to attend.

In 1994, the Munson Medical Center Patient Education
Department implemented the Open Airways Program in the
Traverse City, Michigan Area Public School System. In the
1996-97 school year, data were collected from parents and
children before and after the program to evaluate its
effects on asthma management. This thesis will use
secondary data obtained from that study.

The research question to be addressed in this study is:

Does the Open Airways education program decrease emergency
room visits/hospitalizations and school absenteeism and
increase self-management skills among children with asthma?

Statement of the Problem

The current research reveals the high cost of asthma
and its effect on children and parents. Various asthma
education programs and their role in cost-savings and
management of asthma are described in various studies
(Lawrence, 1995). The literature includes self-management
strategies that improve patient adherence and outcomes
(Make, 1994). Research supports the role of improving self-
efficacy in achieving health behavior change (Strecher,

DeVellis, Becker, & Rosenstock, 1986). There is however, a

4
lack of research that uses the Health Belief Model in
explaining education and self-management in those with
chronic illnesses, such as asthma.
EHIDQSE

The purpose of this study is to evaluate the effect of
the Open Airways education program on emergency room
visits/hospitalizations, school absenteeism, and self-
management skills in children with asthma. The hypotheses
proposed for this study are:

Following school-based, child-centered asthma education
using the Open Airways Program children with asthma will
report a significant:

1. Increase in asthma management skills
2. Decrease in school absenteeism

3. Decrease in emergency visits and hospitalizations

CHAPTER II
THEORETICAL FRAMEWORK
Introduction

This study will use the Health Belief Model to examine
the Open Airways Program. Three factors in the Health
Belief Model have been determined to effect the likelihood
of an individual adopting a behavior (Thomas, 1995). These
are: a) the individual's perception of susceptibility to a
health threat; b) the existence of concern or perceived
susceptibility to the disease and perceived seriousness of
the disease; and c) perceived benefits/barriers to reducing
the perceived threat (1995, p. 248). Rosenstock, Strecher,
and Becker (1988) later added the concept of self-efficacy.
Self-efficacy can be viewed as a benefit or barrier. If
self-efficacy is low, the individual will be less confident
in their ability to complete the task. In this case self-
efficacy is seen as a barrier. If self-efficacy is high,
the individual will feel confident in their ability to
complete the task and self-efficacy is seen as a benefit.
Nurses have used the Health Belief Model to predict the
relationship of health behavior to attitudes and knowledge
and to explain preventative health behaviors (Thomas, 1995).

Research testing the Health Belief Model has typically

been done with adults. This study's sample was children

5

6
ages 8-12 years old. Children of this age are in the stage
of industry vs. isolation (Whaley & Wong, 1982). It
involves an eagerness for building skills and participating
in meaningful and socially useful work. The school-age
child has the ability to classify, to group and sort, and in
the process, is able to hold a concept and make a decision
based on that concept. Children of this age progress from
making judgments based on what is seen to making judgments
based on what is conceptualized. Developmental theory
suggests that children in this age group are able to make
independent decisions based on cues in their environment
(Piaget, 1967).

The Health Belief Model (see Figure 1) offers an
explanation of preventative health behavior. The model
analyzes an individual's motivation to act as a function of
an expectancy of goal attainment in the area of health
behavior (Becker, 1974). The Health Belief Model is
comprised of several constructs: perceived susceptibility,
perceived seriousness, perceived benefits and barriers, and
cues to action. The following paragraphs will describe each
of these constructs.

Becker (1974) defines susceptibility as the subjective
risks of contracting a condition. An individual's perceived
susceptibility is how that person views their likelihood of
actually developing an illness or disease. Using the
example of asthma, this would be the individual's belief

that they will experience an acute asthma episode.

Individual Perceptions

Modifying Factors

 

 

 

Perceived
susceptibility to
disease X

Perceived
seriousness (severity)
of disease X

 

Demographic
variables (age, sex,
race, ethnicity, etc.)

Sociopsychologic
variables

(personality, social .

class, peer and
reference—group
pressure, etc.)
Structural variables
(knowledge about
the disease, prior
contact with the
disease, etc.)

Likelihood of Action

 

 

Perceived beneﬁts of
preventative action

minus

Perceived barriers to
preventative action

 

 

 

l

 

l

 

 

 

Perceived threat of
disease X

 

 

T

 

Likelihood of taking
recommended
preventative health
action

 

 

 

 

 

Cues to action

Mass media
campaigns

Advice from others
Reminder postcard
from physician or

dentist

Illness of family
member or friend

Newspaper or
magazine article

 

 

Figure l. The Health Belief Model. (Becker, Haefner, Kasl, et al., 1977).

 

 

8

Perceived seriousness can be described as the degree of
emotional arousal and kinds of difficulties that the disease
or illness will create. In other words, it is the
individual's perception of clinical or medical consequences.
Again, using the example of asthma, how the asthma will
affect the individual. Will the asthma episode lead to
death or does it cause the individual to cough a little
twice a year? The perceived seriousness and susceptibility
are dependent on education and past experiences of an
individual (Becker, 1974).

The perceived benefits and barriers are also referred
to as the path to action. Becker (1974) describes this as
the belief regarding the relative effectiveness of known
available alternatives in reducing the disease threat. If
taking action is likely to be effective, it relates
subjectively to one's perceived susceptibility or
seriousness of an illness. Beliefs are influenced by the
norms and pressures of society. Barriers include those
motives for avoidance of taking action. Examples of
barriers include expense, inconvenience, time, and
unpleasant, painful, or upsetting interventions.

Cues to action were added to the Health Belief Model.
These are circumstances that set the process in motion.

Cues to action can be internal or external and are dependent
on the perceived susceptibility and seriousness of the
illness. If the perceived susceptibility and seriousness of

the illness are high, less cues to action are needed.

9

Rosenstock, Stretcher, and Becker (1988) discussed the
inclusion of self-efficacy into the Health Belief Model.
When originally formatted, the Health Belief Model was used
to explain and predict simple short-term health behaviors
such as vaccinations. Now, the situation is much different.
Chronic illnesses have mandated the need for long-term
changes. It takes confidence in one's ability to initiate
and continue these lifelong behavioral changes. Thus, for
the change to be implemented as the Health Belief Model
proposes, people must have the incentive to take action,
feel a threat if the change does not occur and perceive a
benefit to taking action; a person must also feel
efficacious to implement that change (1988). In the area of
chronic disease management, it is important to measure
health beliefs and self-efficacy. More emphasis is needed
on the education to enhance self-efficacy in order to effect
change. Rosenstock et al. go on to urge researchers and
practitioners to incorporate self-efficacy into the Health
Belief Model both as an explanatory variable but also as one
that may be manipulated with positive effect (Figure 2).

Most research on the Health Belief Model has focused on
predicting health behavior and not in ways to influence it.
Guided by the Health Belief Model this study will evaluate
the effects of the Open Airways Program on emergency room
visits, hospitalizations, school absenteeism, and self-
management skills. It is evident that education programs

should attend to the attitude and belief dimensions of the

10

Modifying Factors Likelihood of Action

 

 

Demographic variables perceived benefits

_ ,___, minus .
Structural variables

(Prevrous knowledge level) perceived barriers

l l

Perceived threat of asthma Likelihood of taking
‘——> recommended preventative
action

 

 

 

 

 

 

 

 

 

 

 

 

Cues to action Asthma Self-Management

 

 

 

Open Airways Program

 

 

 

Figure 2. Adaptation of the Health Belief Model.

Health Belief Model in addition to other likely influences
on health-related behaviors (Janz & Becker, 1984). Janz and
Becker (1984) point out that few studies indicate any
particular intervention strategy for altering attitudes and

behaviors and that these deserve further investigation.

11

For the purposes of this study, the asthma self-
management will be the likelihood of behavioral change, as
the child and parent report. School absences, ER visits,
and hospitalizations will also be reflected in the
likelihood for behavioral change.

Conceptual Definitions
Selfznanagsment_2r9gnam

Self-management is the ability of the patient and
family to carry out intervention steps to prevent or control
their asthma. A self-management program can improve
patients' ability to manage symptoms and thus, have an
impact on their self-efficacy and symptom levels. Self-
management has the advantage of on-site, early treatment of
asthma symptoms that left untreated may lead to further
distress (Laurenzi, 1993). Self-management is often
evaluated as behaviors of performing care.

Clark (1989), discussed that most asthma self-
management programs operate under three general premises: a)
a partnership of care between patients and the physician
(and the other health care professionals who support the
asthma management plan) must be established; b) medical
management must vary as the symptoms change; and c) patient
compliance is strongly tied to the simplicity of the care
plan and the degree to which its approach is systematic.
Self-management education programs on asthma focus on the
patient and family, at home, school and workplace

environments, and the patient's activities (Laurenzi, 1993).

12
Skill information includes the use of peak flow meters,

medication, and medication administration techniques.

CHAPTER III
REVIEW OF LITERATURE
Introduction

In this section, selected literature relevant to the
Health Belief Model and self-management will be reviewed.
The most common concepts of the model from the literature
were perceived illness and severity, and perceived benefits
and barriers.

Review of Literature

Heallh_ﬂeli££_nnd§l

A study that took place at John Hopkins Hospital looked
at mothers of children with asthma and compliance with drug
regimen. The research focused on explaining and predicting
mothers' compliance with a medical regimen based on general
health motivations, perceived illness threat, and perceived
benefits and barriers to compliant behavior. The findings
indicated that mothers who appropriately administered
medications were significantly more likely to feel that they
generally controlled situations and did things according to
plan (Becker, Radius, Rosenstock, Drachman, Schuberth, &
Teets, 1978).

A study conducted by Szilagyi, Rodewald, Savageau,
Yoos, and Doane (1992) used the Health Belief Model to

evaluate the effects of a reminder letter on obtaining an

13

14
influenza vaccine for children with asthma. Of the
variables investigated, two significantly correlated with
the administration of the vaccine. High levels of parental
worry about asthma (positively correlated: odds ratio=23.3,
P < .01) and high levels of concern about vaccine side
effects (negatively correlated: odds ratio = 0.087, P<
.025). It was concluded that the letters had a positive
influence on increasing the vaccination rate, however, many
still did not respond. Limitations to this study were its
small sample size and most of the children with asthma were
within a high risk population.

Zimmerman, Brown, and Bowman (1996) also used the
Health Belief Model in a study to determine the effects of a
nurse-directed self-management program on dyspnea and self-
efficacy levels in clients with chronic obstructive lung
disease. This study used a single-group quasi-experimental
pre-test/post-test design. The findings for the group
educational approach showed no significant difference in
dyspnea levels, but revealed a significant (p< .001)
increase in the self-efficacy score. The classes were
placed as a cue to action in the Health Belief Model.

Brock and Beazley (1995) used the Health Belief Model
to tie together the concepts of self-efficacy and the
ability to perform a skill. The study found that after the
education program, parents believed that they had the skill
and determination to achieve some degree of success (1995).

The Health Belief Model constructs measured were perceived

15
susceptibility, perceived severity, perceived benefit/
barriers, and perceived self-efficacy with the cues to
action, education being the intervention.
Selfzuanagsment

Many studies support the use of self-management
education programs in the management of asthma. Lawrence
(1995) discussed a full and partial program provided in a
clinic using adults with asthma. When the total of hospital
and emergency room visits were compared pre- and post-
programs, a significant reduction in the requirement for
hospital-based asthma care was found (X2, p < 0.05).
Detwiler, Boston, and Verhulst (1994) conducted an
evaluation of an educational program for children ages 4-8
years and their parents on the "Huff and Puff" program.
Children's and parents' self-management behavior changed
significantly (p < 0.001) in all areas being measured except
"telling an adult" and "communicating with caregiver" about
asthma symptoms (1994). Make (1994) states a preferred term
to self-management should be collaborative self—management.
A key component to self-management is the education of the
patient/family by the health care provider in a manner that
is easily comprehended by the patient and family.

In a study done using primary health care providers;
Mesters, Nunen, Crebolder, and Meertens (1995) showed a
significant change in applied knowledge, attitude, and
self-efficacy and in the report of self-management behaviors

of parents after presented with an asthma education protocol

16
compared to a control group. Self-efficacy can positively
effect health behavior in a number of ways, including an
increased ability to follow a medication and treatment
regimen, increased amount of effort placed on asthma
management, and an increased persistence when a patient is
experiencing difficulties (Wigal, Stout, Brandon, Winder,
McConnaughy, Creer, & Kotses, 1993). Baily, Richards,
Brooks, Windsor, and Manzella (1990) studied the effects of
an educational program with adults demonstrating improved
knowledge and medication skills. Other findings included a
greater adherence to medication regimen, decreased asthma
symptoms, and reductions in ER visits and hospitalizations.
Hindi-Alexander and Cropp (1986) evaluated the effects of a
six week educational program on 147 children with asthma.
Unscheduled health care visits decreased by 51% and school
absences decreased by 48%. Both children and their parents
increased their knowledge. Results were most significant in
those children with severe asthma.

Self-management in children was investigated by Clark,
Feldman, Evans, Wasilewski, and Mellins (1986). The
researchers randomized 310 low-income urban children with
asthma to participate in a self-management or standard
treatment group. The self-management group showed reduced
ER visits and hospitalizations, better grades in school, and
less anxiety about having asthma. A follow-up study was
conducted one year after the Open Airways Program (Clark,

Evans, Feldman, Kaplan, Levin, Levison, Mellins, Rips, &

17

Wasilewski, 1987). The study population consisted of 239
low-income, predominately Hispanic and black children from
12 elementary schools in New York City.. Results of the
study showed higher scores on an index of asthma management
(p < 0.05), greater self-efficacy with respect to asthma
management skills (p < 0.05), more influence on parents'
asthma management decisions (p < 0.05), better grades in
school (p = 0.05), and fewer episodes of asthma (p < 0.01)
and of shorter average duration (p < 0.01).

Summary

Asthma is a chronic illness that can affect a child's
school attendance and performance, cost society billions of
dollars, and effect quality of life. The studies reviewed
suggest that education can foster improved self-efficacy and
self-management in children and parents. The Health Belief
Model can be used to explain how education can act as a cue
to action in improving the management of asthma.

The available research on children with asthma indicate
that collaborative self-management is most effective for
patients with more severe asthma, especially those requiring
emergency room visits or hospitalizations. These studies do
not always reflect quality of life or self-efficacy.
Measures of self-efficacy or quality of life may more
clearly demonstrate how asthma can effect a child on a daily
basis.

Current literature supports the use of education as an

intervention in the management of asthma. The Health Belief

18
Model is a theoretical model that can be used to understand
and show how self-management of health behaviors can be
influenced. However, there is limited research

demonstrating the application of the Health Belief Model to

school-age children.

CHAPTER IV
METHODOLOGY
Design
This study is a secondary analysis of data collected by

the Munson Medical Center Patient Education Department as
part of the implementation and program evaluation of the
Open Airways Program. A quasi-experimental, single-group
pre-test post-test design was used to examine the effects of
the Open Airways Program on children with asthma and their
parents. To assess the impact of the education program,
data were obtained from questionnaires with parents and
structured interviews with children. Data were collected
prior to education at six schools and six weeks post-
education. School absenteeism, ER visits, and
hospitalizations were investigated from the prior year.

Hypothesis

The following hypotheses were tested in this study:

Following school-based, child-centered health education
using the Open Airway Program children with asthma will
have:
1. A significant increase in asthma self-management skills
2. A significant decrease in school absenteeism
3. A significant decrease in emergency visits and

hospitalizations

19

20
Operational Definitions

Multiple outcomes have been used to measure asthma
self-management. These include mortality, morbidity,
medical complications, respiratory symptoms, use of peak
flows, quality of life, health—related behaviors, functional
capacity, utilization of resources and other indirect costs.
Uncontrolled asthma may result in increased
hospitalizations, ER visits, lost time from work and school,
and cost.

The dependent variables chosen for this study are
asthma self-management, number of days absent, number of ER
visits and number of hospitalizations. Parents reported the
number of school absences, emergency room visits, and
hospitalizations on a mailed questionnaire. The independent
variable identified is participation in the Open Airways
Education program.

School attendance was measured by using the total
number of days missed in the school year. Emergency room
visits and hospitalizations were those reported within the
last year. This information was obtained from mailed
questionnaires filled out by the parents.

Changes in children's behaviors and feelings were
measured through indices derived from the interviews.
Demographic data was gathered from the parent
questionnaires. An index of 43 self-management activities
(question #‘s 1, 2, 4-7, 9-17) performed by children to

prevent the occurrence of symptoms, communicate health

21

concerns to their parents, and to manage asthma symptoms at
home and school will measure self-management.
Selfznanagement

Self-management is the ability of the patient and
family to carry out management steps to prevent or control
their asthma. This information included utilization of
health care services, school attendance and occurrence of
symptoms. Self-management was operationalized using
questions in child interviews. Questions # 1,2,4-7,9-17
were the items operationalizing self-management in the
interview with children.
WW

Open Airways is a parent-child health education program
for children with asthma to be taught in elementary schools.
The program consists of six separate 40 minute sessions
which incorporate self-management skills and solutions to
common obstacles encountered by children with asthma (See
Table 1). Children attend classes as part of their school
day. Written material is sent home to parents following
each session. Parents are invited to attend the last
session. Students must have attended at least 66% of the
program sessions for the family participating to be included
in this study. Missing classes may alter the results of the

study.

22

 

 

Table 1.
: 11' E : E' E
Session Topic
1 Information about asthma/Feelings about asthma
2 Recognizing and managing asthma symptoms
3 Solving problems with medicines/Deciding how bad
4 Finding and controlling asthma triggers
5 Keeping your battery charged
6 Doing well at school

 

Sample

Six of eighteen elementary schools in the Traverse City
Public Schools were used for this study. The schools were
chosen by a voluntary method in cooperation with the school
nurses. A presentation of the Open Airways Program was
presented to school nurses and principals four years ago.
Principals were then asked who would like to participate.
Eventually all wanted to offer the program. The schools
chosen the first year were the first two schools to respond.
These schools may represent the more motivated parents, but
more likely the more motivated school administrators. The
order of the schools thus was not randomly chosen and could
possibly alter the results of the study.

The sample was a convenience sample of second through

sixth grade children. Children had been diagnosed with

23
asthma but did not need to be on any prescribed medication.
Students were identified by school nurses based on their
health history. In addition, the program was advertised
through the school newsletter. A letter was sent to the
parents of the children for permission to participate in the
educational program. A description of the program was sent
with the permission form. The sample consisted of those who
consented to participation. A convenience sample was used
due to availability, cost, and travel.

The Traverse City Public School District has eighteen
elementary schools. The study includes aggregate
demographic data on all of these schools. Background
characteristics that may have an impact on the study were
examined. Asthma prevalence in the United States was 4% in
1990 according to the National Heart, Lung, and Blood
Institute (1994). This figure was compared to the number of
students participating in the study. The characteristics
examined were socio-economic status, parent marital status,
and absenteeism of students. These were examined
statistically to measure their impact on the outcome at the
school level. The study includes aggregate demographic data
on all of these schools.

Data Collection

Structured interviews with children were conducted at

the schools by three registered nurses in Munson Medical

Center's Patient Education Department pre—education and 6

24
weeks post-education. The Open Airways Parent Questionnaire
and informed consent was sent to parents.

A structured interview format was used to measure self-
management of asthma (Appendix B). The questionnaire was
developed by a Columbia research team supported by Grant
R18-HL-28907 from the Division of Lung Diseases, National
Heart, Lung and Blood Institute. For purposes of this
study, it was shortened using input from David Evan,
Ph.D.(personal communication, March 1996), a Columbia
research team member, using mainly self-management
questions. The questionnaire is composed of closed ended
questions with room for additional comments. The parent
questionnaire includes demographic data.

The questionnaires were administered by three
interviewers. This lessened the bias of the researcher.
There may be bias of the interviewer on how much prompting
the interviewer does to receive answers. The parents
questionnaires were mailed. This provided for greater
accessibility for the interviewer and parents. This was
also more cost effective and saved on travel time and
expense. Children were interviewed at school, again for
easier access. Children were more likely to understand the
questions in person. By offering a personal interview to
children versus a mailed questionnaire, response rate was
increased.

The parent questionnaire asked for recall data on

missed school days, ER visits, and hospitalizations. School

25
attendance was measured by the total number of days missed
from school in the year. ER visits and hospitalizations
were those within the last year. The parent questionnaire
includes demographic data.

To assess the effect of education on the number of
asthma episodes, parents were asked to report the number of
episodes they treated at home and the number requiring a
visit to the physician. This data may not be as accurate
due to parental recall especially if there is a high number
of episodes, but many students with asthma have a history of
mild asthma and a low number of emergency visits and
hospitalizations. Multiplication of the annual number of
episodes of asthma by the average duration of the episodes
provided an index of the annual frequency of days with
symptoms of asthma.

Reliability and Validity

Reliability and validity of the questionnaire were not
addressed in the Evans article (Clark, Evans, Feldman,
Kaplan, Leven, Levison, Mellins, Rips, & Wasilewski, 1987),
nor in the interview information sent by David Evans.
Reliability was run on the study data. The internal
consistency using Cronbach's alpha measured 0.5053 on the
self-management index of the child interview. When question
15a was deleted, Cronbach's alpha was increased to 0.7221.
This question relates to suggesting to the teacher a need to
leave class early due to asthma symptoms. This child

interview tool was chosen because it most closely reflects

26
the educational program the Patient Education Department
administered. It is important to evaluate the program with
consistent tools. This is even more important because the
Open Airways Program is a national program, and this
information may be helpful to other educators. The more
evidence that can be gathered confirming that an instrument
is measuring what it is suppose to be measuring, the more
confidence researchers will have in its validity (Hungler &
Polit, 1995). Validity, other than content validity takes
more than one study to establish.
Data Analysis

Data analysis was completed using similar testing as
the Zimmerman, Brown, and Bowman (1996) which is very
similar to this study in pre-test/post-test design.
Chi-squared was run on the data to measure self-management
before and after the program. Descriptive statistics were
completed on the demographics of socio-economic status,
child's age, age of asthma diagnosis, child's grade level,
and medical insurance to determine their relationship to any
changes in the level of self-management. This data is
displayed in table form (Table 2). In order to show the
relationship before and after education, chi-square was
carried out on the variables of hospitalizations, emergency
room visits, school absences, and self-management. The
outcome of this data analysis is presented in table format

for ease of interpretation.

27

 

 

Table 2.

u-: o - .. . - - : o‘ . -.. - .. (3

Demographic variable Range Sample
Mean/Percentage

Age 7-12 8.74 +/-2.05 SD

Male 50%

Age diagnosis 4mo-11yr 5.19 +/-3.53 SD

Grade 2-6 3.58 +/-1.74 SD

Income mean $20,000- $40,000-49,999

>$50,000
Insurance 87.5%
Prescriptive coverage 87.5%

 

Note; Values represent means +/- standard deviation or
percent frequency. NS= not significant.

Protection of Human Subjects

The protection of human subjects is insured by several
measures. Prior to the data collection, the original
proposal was presented to the Munson Medical Center
Institutional Review Board for approval. This proposal for
secondary analysis was also reviewed by the Munson Medical
Center Institutional Review Board. In addition, this
proposal was submitted to the Traverse City Area Public
Schools for approval. It was reviewed by the school nurses,
Assistant Superintendent for Curriculum and Instruction, and
Superintendent of the Traverse City Area Public School

System. Next, the interviewers coded all identifying

28
information so that identities of the subjects are unknown
while carrying out secondary data analysis. Finally, this
study proposal was presented to Michigan State University
Committee on Research Involving Human Subjects (UCRIHS) for
approval (IRBI98-048).
Limitations

Several limitations were cited in this study. There
was a small sample size of only 18 families. The data was
collected at six weeks post education not allowing a
sufficient time for the integration of new asthma management
skills. A previous study done with the New York City
schools was unable to use ER visits or hospitalizations as a
variable due to the low number of these services pre-
education (Clark, Evans, Feldman, Kaplan, Levin, Levison,
Mellins, Rips, & Wasilewski, 1987). This was also a problem
for this study. Not only was there a small number of
emergency room visits and hospitalizations, but also a
minimal number of school absences. Regardless, these were
measured with the advent of managed care and the concern to
save health care dollars.

Interviews are not the most reliable source of
information, but may be one of the only ways to measure the
effect of self-management skills if ER visits and
hospitalizations are low prior to education. An identified
limitation was the potential for the bias of the
interviewers. There was not one consistent interviewer and

more prompting may have been given by one versus another.

29
The interviewers also taught the Open Airways Program
lending itself to interviewer bias.

Some of the limitations of the study also included a
small convenience sample and the study's restriction to one
geographic area. A final limitation was the utilization of
volunteers. The use of a convenience sample tends to result
in a motivated group that is more likely to make behavioral
changes.

Threats to internal validity consist of history,
differential selection, and attrition (participants no
longer living in the area and unable to be contacted).
Threats to the external validity in this study are the
interaction of selection bias and effect of external

stimulus.

CHAPTER V
RESULTS

The results reported in this section are the product of
the questionnaires and interviews completed by 18 families
in the original study. Tables showing socio-demographic
characteristics of the sample and results of hypotheses
testing are included. Chi-square was used to determine if
there was a significant difference pre- and post-education
between variables.

Socio-Demographic Characteristics

A number of socio-demographic and illness-related
variables were included in the data. These variables
included the age and gender of the child, insurance status,
prescriptive coverage, age of asthma diagnosis, grade and
income. Table 2 reflects the descriptive characteristics of
the study sample. The total sample consisted of 18 families
of children with asthma in the second through sixth grades.
Data describing the sample are represented either as the
mean +/- standard deviation (SD) or as a percentage of
responses. This population is representative of medically
insured mid-income families of school-age children with mild
to moderate asthma. The demographic data was collected from

self-reported parent questionnaires.

30

31
Hypotheses Results

Chi-square was calculated on the variables of
hospitalizations, emergency room visits, school absences,
and self-management skills before and after education to
test all three hypothesis. The results of the chi-square
are discussed in detail below and are summarized in Table 3.
Each of the hypotheses are addressed separately.
Significance for the purpose of this study was established
to be p g 0.05.

The first hypothesis--that following school-based,
child-centered asthma education using the Open Airways
Program children will report a significant increase in
asthma management skills was not supported. The self-
management indices scale was scored higher (M= 73.4, sd=
4.00) following the Open Airways Program than prior to
education (M=66.07, sd=7.05). However, Chi-square revealed
that the difference between these scores were not
significant (X2= 90.41, p > 0.05).

The second hypothesis--that following school-based,
child-centered asthma education using the Open Airways
Program children with asthma will report a significant
decrease in school absences was rejected. The mean school
absences prior to education were low at 1.9. Six weeks
after the education, the mean annual school absences were
1.39, a slight decrease. Chi-square was not significant

(X2= 9.5, p > 0.05).

32

 

 

Table 3.
:1 O - E l O l J O l O O O l
W

i | . OI] : E. E .
Variable Pro-education Post-education x2 value . df p

Mean Mean

Hosp/ ER 0.50 0.30 20.00 4 0.001*
School absences 1.92 1.39 9.50 9 0.39
Self-management 66.07 73.40 90.41 81 0.22

 

Mote. * 8 significant finding

The final hypothesis--that following school-based,
child-centered asthma education using the Open Airways
Program children with asthma will report a significant
decrease in emergency visits and hospitalizations was
supported. A chi-square test revealed that following the
Open Airways Program, children with asthma were
significantly less likely to have emergency room visits or
hospitalizations (x2= 20.00, p< 0.05).

The results of this study have been presented as they
apply to the three hypothesis. Two of these hypothesis were
not supported, school absenteeism and self-management
skills. The hypothesis dealing with health care utilization
was supported. An interpretation of these findings will
follow in the next section. A discussion will pursue to the
pertinence of these findings to the conceptual model,

methods, and current literature.

CHAPTER VI
DISCUSSION AND IMPLICATIONS
The Health Belief Model

The Health Belief Model was used to describe the effect
of the Open Airways Program. The Open Airways Program
served as a cue to action. The findings illustrate that the
Health Belief Model may be limited in helping to understand
asthma education for the school-age child. The Health
Belief Model does not allow for the fluctuating
exacerbations of asthma. It is also not specific to the age
group being studied. Despite its limited usefulness, the
Health Belief Model did provide a conceptual framework for
evaluating the effectiveness of this intervention. Adding
the variable of self-efficacy may demonstrate more
significant findings. Also a better measurement of pre- and
post- perceived seriousness and severity, such as a
pictorial visual analog scale (Fritz, Spirito, Yeung, Klein,
& Freedman, 1994) may have linked a difference before and
after the cue to action.

'I J i . 'l

Following school-based, child-centered asthma education
using the Open Airways Program, children with asthma will
have a significant decrease in emergency room visits and

hospitalizations. The results of this study did find a

33

34
significant difference in this variable following education.
These variables served as the likelihood of behavioral
change. This sample group had seven emergency room visits
and only 1 admission prior to the educational program making
it difficult to measure a change. With mild and moderate
asthma, emergency room visits and hospitalizations are
typically low. These variables are more useful when working
with severe asthmatics.

The results in this study support the conceptual model
in that the intervention had a significant effect on the
emergency room/hospital visits. This has a major impact on
the cost of asthma care. Health care utilization has been
suggested as an important proxy measure of disease morbidity
and as an independent measure of asthma outcome. Of the
$3.64 billion spent on direct expenses for asthma in 1990,
approximately 56% was for inpatient hospital stays,
outpatient hospital visits, and emergency room visits
(Sullivan, Elixhauser, Buist, Luce, Eisenberg, & Weiss,
1996). The results in this study are similar to those of
previous studies, such as those reported by Mesters, Nunen,
Creebolder, and Meertens (1994) which showed significant
support for the hypothesis that child-centered asthma
education results in decreased emergency room/hospital
visits leading to decreased costs.

W
The results did not support the hypotheses that a

school-based, child-centered education program for second

35

through sixth grade students with asthma can increase school
attendance. Following school-based, child-centered asthma
education using the Open Airways Program, children with
asthma will have a significant decrease in school
absenteeism. Again, this study did not demonstrate a
significant relationship. Current literature has mixed
findings on this outcome. This in part could be because of
multiple reasons for school absenteeism including the common
colds and flu often a problem in school-aged children.

The sample pre-education had a school absence mean of
1.92 making it very difficult to show a difference following
intervention. This is suggestive of children with mild and
moderate asthma. Children with severe asthma and more
school absences initially would result in a greater
likelihood for change.
Selfzmanagemsnt

Following school-based, child-centered asthma education
using the Open Airways Program, children with asthma will
have a significant increase in asthma management skills.
The results showed no significant change in the asthma self-
management indices following education with the Open Airways
Program. Although this study did not demonstrate a
significant change, the current research supports the
utilization of asthma education to improve asthma
management. The findings in this study do not strongly
support the conceptual model in that the Open Airways

Program, the expressed cue to action, did not have a

36
significant effect on the self-management skills of
children.

As noted earlier, the study failed to show any
significant change in self-management skills or school
attendance. The findings may be attributed to the small
sample size, to the chronicity of the disease, or data-
collection only six weeks post-education. Unfortunately,
the short duration of data collection post-education and the
small sample size limited the ability to show significant
outcomes in some of the areas measured. Replication with a
larger sample and one year post-education should be
considered.

Current Literature

The current literature supports the effect of the Open
Airways on decreased emergency room visits and
hospitalizations, increased school performance and increased
self-management skills. This study on secondary data was
chosen to repeat a previous study done in the New York City
school system (Clark, Feldman, Rips, Kaplan, Levison,
Wasilewski, & Mellins, 1987), a highly populated urban area,
in this rural geographic area. The current self-management
literature suggests that asthma education in multiple
settings has a positive impact on the self-management skills
of children and their parents, health care utilization, cost
of health care, and school attendance and performance
(Sullivan, Elixhauser, Buist, Luce, Eisenberg, & Weiss,

1996).

37

Similar to the Evans, Clark, Feldman, Rips, Kaplan,
Levison, Wasilewski, Levin, and Mellins (1987) study, school
attendance was not significantly changed. This finding may
be suggestive of the sample containing children with mild
and moderate asthma who are less likely to have poor
attendance. With the small sample and limited number of
absences a significant change would be difficult.

Implications

The results of this study found significant differences
between pre- and post- education for the variables of
emergency room visits and hospitalizations. A decreased
number of emergency room and hospital visits was associated
with the Open Airways Program.

Because of the symptoms associated with asthma, many
children with this chronic illness exhibit decreased levels
of self-efficacy that results in a failure to attempt many
activities, such as running and team sports. People tend to
avoid activities that they think will exceed their capacity.
Assessing and researching self-efficacy integrated into the
Health Belief Model may provide the Advanced Practice Nurse
with insight as to the best way to format education. Future
research should address the integration of self-efficacy as
a variable to measure both perceived benefits/barriers and
likelihood of taking action.

The implications for Advanced Practice Nursing, nursing

education and research are discussed in the following

38
sections. A general summary as it relates to these findings
and implications for primary care will conclude this study.
I J’ l' E H .

The implications for Advanced Practice Nursing are
discussed in this section as they relate to the hypotheses.
Recommendations and implications for future research and
practice will follow.

The NHLBI Guidelines for the Diagnosis and Management
of Asthma (NAEP, 1997) serve as a guideline in the treatment
of asthma for practitioners in primary care.. The guidelines
discuss four components to asthma management: objective
monitoring, environmental control, pharmacological
management, and patient education. The Open Airways Program
concentrates on one of these components, patient education.

The Advanced Practice Nurse's characteristics include
that of patient educator. The Open Airways Program is a
tool for the Advanced Practice Nurse to provide education to
children with asthma in an environment that improves access
and convenience for students and their families. The
implications for nursing include the use of small group to
teach self-management skills. Using small groups provides
an environment conductive to learning and social support.
Participation in a self-management group can increase self-
management skills, although not identified by this study.
Numerous studies (Zimmerman, Brown, & Bowman, 1996; Clark,
1989; Clark, Feldman, Kaplan, Levin, Levison, Mellins, Rips,

& Wasilewski, 1987; Detwiler, Boston, & Verhulst, 1994) have

39
demonstrated increased self-management skills. The Advanced
Practice Nurse can effectively foster clients and their
families in asthma management by using these strategies.

The school provides an excellent setting to educate
school-age children with asthma. Americans today have a
very busy schedule for affording time for health education.
Working couples are commonplace and children are active in a
multitude of after-school activities. The Advanced Practice
Nurse can help break this barrier by providing education in
the school setting where children already spend a great deal
of time.

Advanced Practice Nurses might further improve the
management of asthma by emphasizing the value of asthma
education and preventative treatment of asthma.
Clarification of correct medication use and potential side
effects are also important pieces of education. Utilizing
an existing program, such as Open Airways, can save
duplication of effort and save on the costs of materials.

I 1' I' E H . El l'

The Advanced Practice Nurse needs to be prepared to
institute collaborative self-management with all school-aged
children with asthma. Teaching asthma self-management
skills requires a basic knowledge of the signs, symptoms,
and treatment of the disease and may be augmented by the
Open Airways Program. The National Heart, Lung, and Blood
Institute Guidelines for the Diagnosis and Management of

Asthma provide the material for the Advanced Practice Nurse

40
to gather this information. This body of knowledge should
also be incorporated into college curricula.

A key point in asthma management is correct care by the
primary care provider. Reliance on episodic care alone puts
the child at risk for severe episodes and limits their daily
lifestyle. The Advanced Practice Nurse in primary care must
stay abreast on the most current asthma management. This
can be accomplished by attending educational conferences,
reading current research and journals, and following the
most current NHLBI Guidelines for the Diagnosis and
Treatment of Asthma. The Advanced Practice Nurse should
also educate other primary care providers and patients in
the most up to date treatment.

The Health Belief Model continues to lend itself to the
advance practice nurse curriculum. The advanced practice
nurse focuses on preventative health and health promotion
which can be easily applied to the Health Belief Model. The
Health Belief Model has a multitude of studies that give
examples for future research. Education of nursing theories
must include examples of practical application so that
nursing theories will be chosen for future research.
Educators must foster this transition to make nursing
theories more useful.

W
Research should focus on follow-up one to five years

after education with the Open Airways Program. Asthma costs

41
should be included in the data collection as managed care
focuses on providing cost-effective quality care.

Lawrence (1995) states future research must address the
need for a standardized method to measure asthma outcomes
that will not only demonstrate decreased cost of care after
intervention, but also serve to quantify the emotional cost
of uncontrolled asthma that must be recognized and addressed
by policy-makers and those who are paying for asthma care.

A socio-demographic characteristic to be considered in this
equation is working versus non-working parents and the
likelihood of attending an asthma education program.
Economic evaluation of the intervention of asthma education
focusing on direct and indirect costs will be necessary with
the managed care environment. The National Asthma Education
and Prevention Program Working Group Report on the Cost
Effectiveness of Asthma Care (Sullivan, Elixhauser, Buist,
Luce, Eisenberg, & Weiss, 1994) recommend correlating asthma
severity, who educated, amount of education, and how long
the effects of education last.

Several factors limit the ability to generalize the
results of this study. The first factor is the voluntary
participation of the sample population. Voluntary
participants tend to be highly motivated and more likely to
take action in self-management skills. Another factor is
the lack of a control group. A control group would have
been useful in quantifying and testing the effects of the

Open Airways Program. Asthma symptoms and management often

42
change with the seasons and weather and would be reflected
in the control group. Lastly, a more long-term evaluation
needs to be completed to investigate the intervention over
time. Asthma is a chronic illness often affected by seasons
and weather changes that are better measured as a full year
to reflect these changes.

Another area of research needed is self-efficacy.
Although difficult to measure, self-efficacy can be
manipulated through education and provides more than just
knowledge in integrating health care behaviors. Self-
efficacy has been shown to have a positive effect on
multiple behavior changes including smoking cessation,
weight management, use of contraception, alcohol use,
exercise, and nutrition (O'Leary, 1985; Strecher, 1986;
Bandura, 1977, 1982; Yalow & Collins, 1989). Rosenstock,
Stretcher, and Becker (1988) encouraged researchers to use
the Health Belief Model incorporating self-efficacy as an
explanatory variable and as one that may be manipulated in
good effect. Perceived severity and seriousness should be
evaluated to measure these variables effects. The severity
of asthma impacts the number of asthma episodes and how the
disease impacts lifestyle. In addition to perceived
severity, an actual diagnosis of severity should be
included.

In summary, it is recommended that further research be
conducted using a quasi-experimental design that includes a

control group to more clearly understand the correlation

43

between variables. A likert scale could be used to measure
self-management allowing parametric testing. A larger
sample studied over a longer duration of at least one year
post-education is suggested. Another recommendation for
research is the inclusion of self-efficacy into the Health
Belief Model. It would be beneficial to assess perceived
severity and seriousness pre- and post-education. Again,
cost should must also be collected to evaluate the cost
effectiveness of asthma education.

Summary

In summary, by seeking knowledge directed towards
asthma education, communication skills, asthma management,
and working with small groups, the nurse can understand the
proper nursing care of patients and families with the
chronic disease of asthma. It is imperative that the
Advanced Practice Nurse become educated in patient education
in the topic of asthma.

The Health Belief Model has been useful in identifying
health-related risk behaviors and predicting the frequency
at which health behaviors are practiced. Advanced Practice
Nurses can link the key concepts of the Health Belief Model
to their actions to administer the Open Airways Program.
The Advanced Practice Nurse can also demonstrate these>
actions to their fellow practitioners in primary care.

Although this study only demonstrated one significant
finding, it provides a launching point for the.Advanced

Practice Nurse to conduct future research on this subject

44
with a control group using a larger population. The
outcomes and cost-effectiveness should be demonstrated over
time. The Advanced Practice Nurse can play a key role as
educator, practitioner, and researcher to have a significant

impact on the asthma self-management of children with this

chronic illness.

LIST OF REFERENCES

LIST OF REFERENCES

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achieving health behavior change. Health_£dnga§1gn
Quarterlxl 72- 91.

Sullivan, S., Elixhauser, A., Buist, S., Luce, B.R.,
Eisenberg, J., & Weiss, K. B. (1996). National asthma
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WW 584- 595-

Szilagyi, P.G., Rodewald, L.E., Savageau, J., Yoos, L.,
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48

Wigal, J.K., Stout, C., Brandon, M., Winder, J.A.,
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£h£§£1_1ﬂﬁ+ 1144-1143-

Yalow, E. S. 8 Collins, J. L. (1987). Self-efficacy in
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89W. 253- 257.

Appendix A

 

OFFlCE OF
RESEARCH
AND
GRADUATE
STUDHHS

Ushers!" Committee 0
lhunnthhMg
Human Subjects
(UCRIHS)
MkanQmeWMevw
246 mmstmm Budding
ESUngMowm
4&thw

SWISS-21$)
FAX' 517/432-1171

mwmm
woman»:
Warm

WBUW

49

 

AAppcndbtA.
MICHIGAN STATE
U f9 | \l E I! S I 1' Y
February 19, 1993
TO: kéggabigtnggiences
RE: éggﬁg, ASTEA: EDUCATION son THE SCHOOL-AGE CHILD
REVISION REQUESTED: N/A
CATEGORY: l-C
APPROVAL oars: 02/17/98

The University Committee on Research Involving Human Subjects'lUCRIHS)
review of this roject is complete. I am pleased to adv1se that the
rights and wel are of the human subjects appear to be adequately
rotected and methods to obtain informed consent are appropriate.
herefore, the UCRIHS approved this project and any rev1sions listed
above.

RINIWAL: UCRIES a roval is valid for one calendar ar, inning with
the apprggal data shown above. Investigatggs plizging to~
continue a project be nd one year must use the green renewal
form (enclosed with e original a roval letter or when a
project is renewed) to seek t certification. There is a
maximum of four such expedit renewals ssible. Investigators
wishing to continue a project beyond tha time need to submit it
again or complete review.

REVISIONS: OCRIHS must review any changes in rocedures involving human
subjects, rior to initiation of change. If this is done at
the time o renewal, please use the sen renewal formq To
revise an approved protocol at an 0 er time during the year,
send your written request to the. IRS Chair, requesting revised
approval and referenc the preject's IRB S and title. Include
in ur request a descr ption of the change and any revised
ins ruments, consent forms or advertisements that are applicable.

anosnsxs/

CHANGES: Shcu1d_either of the foil _ arise during the course of the
work. investigators must not1 OCRIHS promptly: (1) roblems
(unexpected side effects comp aints, e c.)
subjects'or (2).changes in the research environment or new
information indicating greater risk to the human sub ects than
existed when the protocol was previously reviewed an approved.

involving uman

If we can be of any future help, lease do not hesitate to contact us
at (517)355-2180 or FAX (517)4 2- 171.

Sincerely,

 
   
 
  

1d E. Wright, Pb.
CRIHS Chair

DEW:bed

CC: Jill Polmateer

 

Appendix B

50

Appendix B

OPEN AIRWAYS
CHILD QUESTIONNAIRE (INTERVIEW)

1. How often do you cough or wheeze ﬁ'om your asthma?
(4) 1-2 times per day (3)1-2 times per week
(2) 1-2 times per month . (1) 1-2 times per year“
2. Can you ever tell if you are going to wheeze or cough before you start? Yes (2) N00)
3. (If yes) How do you know that you are going to wheeze or cough? RECORD SIGNS
4. Do you remember the last time you wheezed or coughed from asthma? When was that?
(4) Today (3) In the last week (2) In the last month

(1) In the last year
5. Now; I'd like you to think about the last time you wheezed or coughed. Do you do any of the
following things to take care of your asthma?

Circle all that apply.(Code 2=yes, l=no)

Stop playing/rest

Tell mother/other adult

Take asthma medicine

Drink some water or juice

Relax (massage, meditate, relaxation exercise)

Cough to clear mucus or phlegm ﬁ'orn lungs

Go to doctor or hospital

Are there other actions not listed? List
6. DO you ever tell your mother or caretaker things about how you feel so that she will know
what to do for your wheezing?

(2) Yes (1) No
7. Do you ever ask your mother or other caretaker to do things to help stop the wheezing or
coughing? (2) Yes (1) No
8. (If yes) What do you ask them to do? List

 

 

9. Who decides when to give you your medicine?
(list all that apply)(Code 2=yes, 1=no)
Mother Father Self Other __
10. Have you ever told your parents that you needed to go to the doctor, hospital, or emergency
room for your asthma?
(2) Yes (1) NO
11. When you are wheezing or coughing, do you tell your mother or other caregiver whether you
think you should go to school or not?
If so, do you do this (3)Most of the time,(2) some of the time, or (1) hardly ever?

51

12. DO you do the following things on your own,without the help of your parents, to keep your-
self from starting to wheeze? (Circle all that apply)
Take medicine regularly (Code 2=yes, l=no)
Take medicine to avoid wheezing
Practice breathing! relaxation exercise
Keep ﬁom getting too tired
Keep from getting out of breath
Get rid of wheezing triggers! avoid triggers
Clean house/room/desk to control triggers
Cough out phlegm to clear lungs
Keep relaxed in stressﬁtl situations
Other things not mentioned ,, , ﬂ 0
13. Do you remember the last time you had wheezing or coughing in school?! When was that?
(3)In last week (2) In lat month (1) In last year
14. Did you do any of the following things? Circle all that apply. (Code 2=yes,l-no)
Stop playing/rest
Told teacher/staff
Took/asked for medicine
Drank water orjuice
Relaxed
Coughed to clear mucus
Went home
Went to doctor or hospital
Other
15. Have you ever suggested to your teacher or someone else at school that you should:
Leave class early because of asthma
(2) Yes (l)No
Stay in class and see if wheezing steps
(2) Yes (1) No
Take your medicine
(2) Yes (1) No
Call you mother or care taker or go home
(2) Yes (1) No
Go to the doctor or emergency room
(2) Yes (1)No
16. Do you ever ask your teacher about making up schoolwork you missed because of asthma?
(2) Yes (1)No
17. Do you ever choose not to play games in gym or outdoors because of asthma?
(2) Yes (1)NO
If yes, in what situations?
18. Now I'd like to ask you to tell me ifyou can do these things.
(-3)ICANDOIT(2)IMIGI-ITBEABLETODOIT
(l) I CANNOT DO IT
a. Tell how much medicine to take
b. Choose (decide) when to take your medicine (the as needed medications)

lllllllllll

52

c. Tell ahead of time that you are going to start wheezing or coughing

d. Tell your mother or care taker how bad your wheezing or coughing is
e. Cough to clear phlegm from your lungs

f. Relax and keep calm when you are wheezing

g. Remember what you are suppose to do when you start wheezing

h. Stop playing a game with other children and sit down to rest when wheezing starts
i. Talk to your teacher about asthma

j. Know if you should go to school or not when wheezing in the morning
k. .T ell your parents why you should or should not go to school

1. Know when you have to go to the doctor or hospital for help

m. Tell your parents why you need to go to the doctor or hospital

Appendix C

Original Study

53

Appendix C
Original Study

INFORMED CONSENT
OPEN AIRWAYS EVALUATION

In signing this document, I am giving my consent for myself and child (Open Air-
ways participant) to be interviewed by an employee of Munson Medical Center’s
Patient Education Department of Traverse City, MI. I understand-that my child
and I will be part of a research study that will focus on asthma education and its
effect on asthma management.

I understand that my child and I will be interviewed by mail or at an agreed upon
location at a time convenient to me. I will be asked questions regarding how my
child and I manage the participant's asthma, conﬁdence in our ability to do so, and
seeking of health care services. The interview will take 1/4 - 1 hour to complete.

I understand that my family has been selected to participate in this study because
was child was involved or will be involved in Open Airways, and asthma educa-
tion program within the last 3 years.

This interview was granted freely. I have been informed that the interview is en-
tirely voluntary, and that even after the interview begins, I may reﬁrse to answer
any question or decide to terminate the interview process. I have been told that
my answers to questions will not be given to anyone else and no reports of this
study will identify my child or I in any way. I have also been informed that my
participation or non-participation or my refusal to answer any questions will have
no eﬂ'ect on services that I or any member of my family may receive from health
or school providers.

I understand that the results of this research will be given to me if I ask for them
and that Jill Polmateer, RN ,C, BSN is the person to contact if I have any questions
about the study. Jill Polmateer can be reached at (616) 93 5-8208.

UCRlHS APPROVAL FOR
THlS project EXPIRES:

FFB L7 1999

 

Date Respondent's Signature
soar-arr nevewmmmrcanon
one MONTH FRtOR TO
ABOVE DATE TO CONTINUE

 

Interviewers Signature

54

'l'! ~.
MUNSON
MEDICAL
CENTER

9 “5m NWTHCKRE FItClLITNt

October 15. 1996

Jill Polmateer, RN. BSN.
Patient Education Department
Munson Medical Center

1105 Sixth Street

Traverse City. Michigan 49684

Dear Jill:

This letter is to formally conﬁrm for you that the Munson Medical Center Institutional Review
Board has approved the study which you presented to the Committee in conjunction with the
Patient Education Department. It is our understanding that your study pertains to the analysis
of the 'open airways” program, which is an effort to edumte pediatric patients and their families

in self-help techniques to avoid complications of asthma.

We wish you success in your research project.

Sincerely,

~My¢

Ralph J. Cemy
President

RJC/sb

 

1105 Sixth Street
Traverse City, Michigan 49684-2386
I616l935-5000

55

TRAVERSE CITY AREA PUBLIC SCHOOLS

Jayne H. Mohr, Ed.D.

Assistant Superintendent for Curriculum 8 Instruction

PO. Box 32
Traverse City, Michigan 49685-0032

.‘r-c:zxg.1is A! g!» is c A

”Cool:
“A.”

Telephone (616) 922-6453
FAX (616) 922-6420

o rt 2.1. E sxca L: :1. as. an cf -,r-:-

 

November 6. 1996

Ms. Jill Polmateer, R.N.
Munson Medical Center

1105 Sixth Street

Traverse City, MI 49684—2386

Dear Ms. Polmateer:

Thank you for your summary of the Patient Edueation's Research Proposal. The
nurses and I have reviewed the materials and have shared our recommendation with
the superintendent. He supports this proposal and we expect written documentation
of the results upon completion.

Thank you for your interest in following up with our students who have
participated in the Open Airways Program. Please feel free to contact me ifl may offer
further assistance. Renee Dean (922-6472) is also available.to provide add'rtional
information if necessary.

Sincerely.

WM 77%

Jayne H. Mohr, Ed.D.
Assistant Superintendent

JHM:jkc
PC: Peter Wharton
Renee Dean

7’

I
(3
I x i

l

“t
b
Ci

10.

ll.

12

56

OPEN AIRWAYS

PARENT QUESTIONNAIRE
Age of child
Sex of child (circle) M F
Current grade of child
Age of asthma diagnosis___
Parent's marital status: _ Married _ Single
Family income before taxes (circle)

3 0-9,999 810,000-19399 320,000-29399
830,000-239,999 $40,000-49,999 $50,000 & up

Does your child have medical insurance covering ofﬁce visits? Yes No

Does your child have prescription coverage for his/her medications?
Yes No

How many hospital admissions has your child had in the last year for asthma
related illnesses (i.e. asthma, bronchitis, pneumonia, asthmatic-bronchitis)?

 

How many emergency room or walk-in clinic visits has your child had in
the last year due to asthma related illness?

How many physician visits has your child had in the last year for asthma
related illnesses?

When your child wheezes or has other symptoms of asthma, what do you
usually do?

 

 

13.

14.

15.

16.

I7.

18.

19.

57

Does your child do anything to stop the wheezing or symptoms by
his/herself? Yes No

What medications does your child currently take?
Name___D9ss__Iimes.psr_Dax

 

 

 

9:59.“?

 

Does your child take medications as prescribed?
Yes No

Does your child use a spacer with inhalers?
Yes No

Does you child use a peak ﬂow meter?

Yes No
Ifyes, what is their target?

How many days has your child missed from school in the past year?
0 1-3 4~6 7-9 10-12 >12

How often does your child experience symptoms from asthma?
_ 1-2 u'mes per day _ 1-2 times per week
_ 1-2 times per month __ 1-2 times per year

58

 

 

A; ‘

MUNSON

MEDICAL

C EN l ER

" " Dar Pmats ofOpen Airway Participants;
Thank-you for participating in the Open Airways program and research study. I hope that you
enjoyed the classes and written material. It has been a pleasure to work with your children.
Asthmaeducationisavitalpieceto itsmanagement.
You will ﬁnd included a questionnaire. This isthe same as previously. We will be measuring
the diﬁerence beforeandaﬁertheclases. Wewillbeinterviewing yourchildrenonelasttime
also. Please ﬁll out the questionnaire and return it in the self-addressed stamped envelop by
April 30, 1997.
It is critical to the study to receive follow-up data. Thank-you for your response. For any
questions about asthma or this program, please call Jill Polmateer, RN, C, BSN at
(616) 935-8208.
Sincerely;
va ﬁrm/90,9350 was safe A... .97 , a), M
Jill Polmateer, RN,C, BSN Debbie Gray, RN Tina Soyring, RN, BSN
HOS Sixth Street

 

Traverse City, Michigan J'Jbbddltﬂr

«sun 945.5000

MICHIGAN STATE UNIV. LIBRARIES
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