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LIBRARY ,’
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This is to certify that the

thesis entitled

PHYSICAL EDUCATORS' KNOWLEDGE 0F
EXERClSE-INDUCED ASTHMA

presented by

Laura Kay Kennett

has been accepted towards fulfillment
of the requirements for

M.S. degreejn Kinesiolo y
\ \q

Major professor

Date (Bl/WW
\

0-7639

 

 

\ .__________ _ no.

   

 

PLACE IN RETURN BOX to remove this checkout from your record.
TO AVOID FINES return on or before date due.
MAY BE RECALLED with earlier due date if requested.

DATE DUE DATE DUE DATE DUE

 

6/01 cIClRCIDIIBDuerpBS-p. 15

 

PHYSICAL EDUCATORS’ KNOWLEDGE OF EXERCISE-INDUCED ASTHMA

By

Laura Kay Kennett

A THESIS

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

MASTER OF SCIENCE
Department of Kinesiology

2001

 

 

 

. HI . ..Vy.w.sgulwb .

 

 

 

PHYSICAL EDUCATORS’ KNOWLEDGE OF EXERCISE-INDUCED ASTHMA

By

Laura Kay Kennett

AN ABSTRACT OF A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of
MASTER OF SCIENCE
Department of Kinesiology
2001

Professor Jeanne Foley

 

 

 

 

ABSTRACT

PHYSICAL EDUCATORS’ KNOWLEDGE OF EXERCISE-INDUCED
ASTHMA

By

Laura Kay Kennett

Exercise-induced asthma (EIA) is a topic of concern among school
administrators, educators, and staff. Prevalence rates of EIA as high as 31% have been
reported among particular populations (Larsson et al., 1993). Such a high prevalence of
EIA presents a challenge for school personnel, who oftentimes are called upon to assist
with the management of the disease. The purpose of this research sought to examine the
current level of knowledge of exercise-induced asthma among physical educators. In
addition, the study examined whether or not physical educators are interested in
improving their level of knowledge of EIA and related issues. This research design
utilized a questionnaire, which was chosen because it was the best means to gather data
on physical educators on a large scale. The participants of the study were all physical
education teachers fi'om two Intermediate school districts. Several t-tests were conducted
to see if significant differences existed among sub-groups of participants. There was a
significant difference found in mean knowledge scores among those who have had
training on asthma or EIA and those who have not had training on asthma or EIA. The
knowledge gained from this study may serve as the foundation for future hypothesis

testing and the improvement in future teacher education programs.

 

 

 

 

 

TABLE OF CONTENTS

LIST OF TABLES .................................................................................... v

LIST OF FIGURES ................................................................................. vi
CHAPTER 1

Introduction. ...................................................................................................................... 1

Hypothesis Testing .............................................................................. 2
CHAPTER 2

Literature Review. . ........................................................................................................... 4

Exercise-Induced Asthma ........ '. ............................................................. 4

Definitions and Criteria ..................................................................... 4

Causes of Exercise-Induced Asthma ...................................................... 6

Prevalence of the Disease .................................................................. 8

Medication and Treatment ................................................................ 14

Management of EIA in Schools .............................................................. 15

School-Related Issues ..................................................................... 15

Preventing exercise-induced asthma attacks ................................... 16

Management and treatment of an asthma attack .............................. 17

Medication at school .............................................................. 20

Physical activity ................................................................... 23

Teacher Issues .............................................................................. 25

Current knowledge of educators ................................................ 25

Knowledge deficits among educators .......................................... 26

Confidence of educators ......................................................... 27

Educators’ feelings toward education............................- ............... 28

Training ............................................................................. 28

Conclusions .................................................................................... 30
CHAPTER 3

Methods ............................................................................................................................ 32

Research Design ............................................................................... 32

Participants ..................................................................................... 33

Instrumentation ................................................................................ 34

Survey Development ........................................................................ 35

Validity ...................................................................................... 36

Reliability .................................................................................... 36

Pilot Test Results .............................................................................. 37

Data Collection Procedures .................................................................. 40

Data Analyses .................................................................................. 40

 

 

 

 

CHAPTER 4

 

 

 

 

Results ................................................................................................ 43
Study Results ................................................................................... 43
Descriptive Results ......................................................................... 43
Subgroup Knowledge Comparisons ..................................................... 49
CHAPTER 5
Discussion ............................................................................................ 52
Results of Hypothesis Testing ................................................................ 52
Hypothesis One ............................................................................. 53
Hypothesis Two ............................................................................ 54
Hypothesis Three ........................................................................... 55
Hypothesis Four ............................................................................ 56
Hypothesis Five ............................................................................. 57
Limitations in Teacher Knowledge .......................................................... 58
Implications for School Administrators .................................................... 60
Medication Availability .................................................................. 60
Medication Supervision .................................................................. 61
Teachers’ attitudes concerning their responsibilities .......................... 62
Policy ............................................................................... 62
Need for Training About EIA ............................................................ 63
Recommendations ............................................................................. 63
Tracking EIA Prevalence ................................................................... 64
Resources ................................................................................... 65
Education ................................................................................... 66
Conclusion ...................................................................................... 67
APPENDICES
APPENDIX A: Cover Letter 71
APPENDIX B: Informed Consent . . . . ....73
APPENDIX C: Exercise-Induced Asthma Survey. ....... 75
REFERENCFS 79
GENERAL REFERENCES 22

 

 

 

LIST OF TABLES

Table 1. Summary of Exercise-Induced Asthma Prevalence Studies ........................ 13
Table 2. Pilot Test Results for Paired t-test and Pearson Correlation ....................... 37
Table 3. Sample Descriptives ..................................................................... 43
Table 4. Summary of Knowledge Questions ................................................... 48
Table 5. T-test Results of Subgroup Comparisons on Knowledge Scores .................. 50

 

 

 

 

 

LIST OF FIGURES

Figure 1. Asthma Trends: 1982-1996 ............................................................. 9
Figure 2. Grade Levels Taught ................................................................... 45
Figure 3. Highest Level of Formal Education Earned ......................................... 46
Figure 4. Health Status of Participants .......................................................... 47

Chapter 1
Introduction

Exercise-induced asthma (EIA) is a topic of concern among school
administrators, educators, and staff. They are often called upon to help students manage
their disease. Physical educators in particular must interact with students who have EIA,
often times assisting them with administering their medication. They must also make
decisions on whether the student can participate in physical activity while in school. A
sound understanding and knowledge of EIA is necessary to make appropriate decisions
that affect the health and welfare of students who have EIA.

Asthma accounts for an annual loss of 10 million school days per year in the
United States and more hospitalizations than any other childhood disease. Children with
asthma spend an estimated 7.3 million days per year restricted to bed due to
complications from asthma and EIA. EIA is a disease that affects 12% to 15% of the
United States population (Wilkerson, 1998), and there is currently a lack of data among
US. schoolchildren.

Although the exact prevalence among students between grades one and twelve is
unknown, it has been suggested that the rate could be as high as 29% (Rupp, Guill, &
Brudno, 1992). These reports establish that a considerable number of youth suffer from
EIA. Although the prevalence rates vary, and data on US. youth are scarce, there is still
cause for concern. With so many school-aged children having EIA, the situation calls for
enhanced understanding of the disease in order to help students manage their disease and

live a healthy life.

 

EIA has been shown to limit the activity of school-aged youth. This has serious

implications for the individual’s overall wellness. Lack of physical activity has been
shown to be deleterious to one’s health and increases the risk of obesity, heart disease,
stroke, diabetes, and several other chronic diseases (U .S. Department of Health and
Human Services, 1996).

There has not been a study conducted in the US. that examines educators’
knowledge of EIA specifically. Rather, many of the studies that look at general asthma
knowledge dedicate only a portion of their data collection to EIA and related topics.
Therefore, it is anticipated that the information gathered fiom this research will serve as a
basis for future research and hypothesis testing.

A cross-sectional survey was distributed to gather a snapshot of the current level
of knowledge among the physical educators within the sample chosen. The purpose of
this study was to investigate the current level of knowledge physical educators have of
EIA and determine whether or not physical educators are interested in improving their
level of knowledge of EIA.

Hypothesis Testing

There were two hypotheses tested, and three research questions that were
investigated. Those hypotheses and questions were as follows: (a) Those participants
who are asthmatic (and those who have asthmatic children) will score significantly higher
than those who are not asthmatic (and do not have children with asthma); (b) Those
participants who have had training on asthma and/or exercise-induced asthma will score
significantly higher than those who did not receive training on asthma and/or exercise-

induced asthma; (c) Is there a significant difference between the mean knowledge scores

 

 

 

of those who have taught health education in addition to physical education and those

who have not taught health in addition to physical education; (d) Is there a significant
difference between the mean knowledge scores of those who supervise children when
using their inhalers and those who do not supervise children when using their inhalers;
and (e) Is there a significant difference between the mean knowledge scores of those
who have obtained more formal education (completed a master’s degree, beyond a
master’s degree, or doctoral work) and those who have obtained less formal education

(completed a bachelor’s degree, some master’s work).

 

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Chapter 2

Literature Review

The review of literature on the topic of exercise-induced asthma with respect to
physical educators yielded very little information. To date, there has not been a study
that has systematically researched this topic. Therefore, this literature review seeks to
examine explanations of what exercise-induced asthma is, the prevalence of the disease,
and other research that has been conducted on similar topics in order to serve as a
foundation for the current study.

Exercise-Induced Asthma

Definitions and Criteri_a_

The literature presents several different definitions of exercise-induced asthma
(EIA) and which criteria should be used to determine whether or not someone ins the
disease. EIA is defined by McFadden and Gilbert (1994) as a condition in which
vigorous physical activity triggers acute airway narrowing in people with heightened
airway reactivity. Gibson, Henry, Vimpani, and Halliday (1995) define EIA as having
been diagnosed by a physician, as well as having had an asthma attack in the last 12
months. The definition that offers the most clarity, and is the most widely accepted in the
literature, is presented by Wilkerson (1998). This author states that EIA is a clinical
syndrome characterized by transient airflow obstruction, typically 5 to 15 minutes after
physical activity. This increased airway resistance produces a 15% decrease in the 1
second, forced expiratory volume or peak expiratory flow rate.

To determine if an individual has EIA, forced expiratory volume and peak

expiratory flow rate are both measured after exercise. The most widely used and

 

 

 

accepted exercise test conducted prior to these measures being taken is the fi'ee running
test. This test consists of nmning for six to eight minutes under standardized conditions
at a workload equal to 60 to 80% of the subject’s predicted maximum aerobic power
(Tsanakas, Banniser, Boon, & Milner, 1986).

To better familiarize the reader with the technical measurement terms, a brief
overview shall be presented. Forced expiratory volume (FEV) measures the amount of
gas, in liters, that is expired during a given time interval. This measurement is most
commonly expressed in the amount expired in one second (FEVI), and is typically
measured during a forced vital capacity test. Decreased FEV values are common for
obstructive airway diseases, such as with asthma Overall, FEV values provide an
indication of expiratory power and overall resistance to air movement in the lungs
(McArdle, Katch, & Katch, 1996). Normal values are based upon population studies and
vary according based upon the individual’s age, gender, body height, and race.

Forced vital capacity (FVC) is the maximum volume of air, in liters, exhaled as
rapidly, forcefully, and completely as possible from the point of maximum inhalation.
This measurement is used in conjunction with FEV values to determine whether someone
has EIA. A healthy person can expire approximately 85% of his or her FVC in one
second. The criteria for exercise-induced asthma is a drop in FEV. of 15% or more from
pre-exercise levels.

Peak expiratory flow rate (PEFR) is another method of measuring airway
obstruction. This measurement can also be obtained during a FVC breathing maneuver
and is expressed in liters per second (Monash University, 2000). PEFR can also be

measured using small inexpensive devices called peak flow monitors. These appliances

 

 

 

are used to follow gross changes in airway fimction on an outpatient basis. Their primary
application is used to follow asthmatics who are susceptible to changes in airway
function. Normal values for healthy young people typically exceed 10 liters per second.
However, these values can vary with age, sex, gender, and body height. Both FEV; and
PEFR are the most common measurements physicians use to supplement the history and
physical exam when diagnosing exercised-induced asthma.

Volcheck (2000) stresses the fact that complete history and physical examination
should accompany the aforementioned diagnostic tests. Volcheck emphasizes the fact
that oftentimes the aforementioned diagnostic tests are not available in a family
physician’s office, and therefore enhances the need for an accurate history and exam.
EIA is characterized by cough, wheeze, dyspnea, and/or chest tightness during or after
exercise (V olcheck, 2000). However, the author notes that atypical symptoms can occur,
such as fatigue, chest pain, and headache. EIA can occur in individuals who are
otherwise healthy. Typically, symptoms of EIA begin
5 minutes or more after a strenuous exercise has been performed (Volcheck, 2000).
Causes of Exercise-Induced AsthLm

The terms “exercise-induced asthma” and “exercise-induced bronchospasm” are
often times used interchangeably in the literature. Homnick and Marks (1998) state that
pathophysiologically, there may or may not be evidence of airway inflammation or
increased airway hyperresponsiveness, each of which guide two of the most prominent
theories about causes of EIA. (Clarification of technical terms will be presented

elsewhere in this review.) Therefore, terms may or may not be clearly defined or

 

 

differentiated due to the fact that there is still controversy as to the true pathology of the
disease.

Several mechanisms have been hypothesized for the cause of EIA. There will be
two theories presented in this literature review. Although there have been several
theories proposed, these two theories will be presented here because they both stress the
role that the environment and situation plays in the cause and exacerbation of the disease.
The first of the two most prominent theories that guide the research of EIA is the water
loss theory. This theory, as described by Storms and Joyner (1997), contends that water
is lost through the bronchial mucosa by means of the air that is exhaled during the heavy
breathing often associated with exercise. This water loss causes changes in the
epithelium of the airway, which, lead to bronchospasm. These changes include
temperature fluctuation, pH variation, and osmolarity changes. It is believed that any or
all of these physiological variations can trigger the onset of EIA.

The second of the two central theories on EIA is the thermal expenditure theory.
Storms and Joyner (1997) conjecture that it may be heat transfer fiom the pulmomry
vascular beds into the air, either during or after exercise, that results in the onset of EIA.
Rewarming takes place after exercise is complete, and this heat is believed to cause
hyperemia and dilation of the blood vessels within the bronchi. It is the hyperemia which
ultimately leads to EIA.

Several different stimuli have been found to exacerbate the frequency and severity
of EIA. These stimuli include but are not limited to various respiratory illnesses,
excessive physical training, emotional stress, and a variety of pollutants (Wilkerson,

1998). The role of inflammatory mediators in the pathogenesis of EIA is controversial

 

(McFadden & Gilbert, 1994). There have been conflicting results of various studies that

have examined the various compounds in blood and bronchoalveo lar-lavage fluids before
and after exercise.

Other supplemental theories that seek to explain the cause of EIA have been
presented in the literature. It has been reported that the type of exercise, the intensity of
the exercise, the environmental conditions while exercising, and the duration of the
exercise can all contribute to EIA (Wilkerson, 1998). The reasons for this wide range of
factors include differences in the intensity of the exercise, lack of uniformity in the
methods used to detect the response, and the failure to standardize the environmental
variables that control the magnitude of the obstruction (McFadden & Gilbert, 1994).
Therefore, much of the research that is being conducted on the cause of EIA explores the
role these variables play in triggering the onset of an asthma attack.

Prevalence of the Disease

Reported prevalence rates of EIA have varied. However, asthma rates in general
are readily available fiom the National Institute on Health, The Centers for Disease
Control and Prevention, and the American Lung Association. Figure 1 summarizes
recent asthma trends in the United States (American Lung Association, 2001). Each data
point reported is an estimate of the true population value and is subject to sampling

variability.

 

 

 

 

 

 

 

 

 

Rate Per 1,000 Population
U1 O
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3° ‘ Y
20 l l l l T f r 1 l T f l f T
N M V V) \O l\ 00 O\ O '— N M V In \0
oo oo co oo 00 00 00 00 O\ 0‘ a O\ O\ O\ 0‘
ON OK 0\ O\ O\ O\ O\ O\ 0\ OS 0\ O‘ O\ O\
v-l v-Ii ill-l F‘ 0-1 III-I F-d '— v—l I-fl '— '— I-ll I_ I-I‘
Year

 

 

+ <18 years old -I- 18-44 years old + 45-64 years old + 65+ years old

 

 

Eigu_re_l. Asthma Trends: 1982-1996

Prevalence rates of EIA as high as 31% have been reported among particular
populations (Larsson et al., 1993). This rate was reported based on a study of cross-
country athletes belonging to an elite club and exemplifies the fact that most of the
research conducted that examines the rate of EIA involves adults at the elite or Olympic
level of competition. For the scope of this paper, examination of the prevalence rates of
EIA shall be confined to school children in grades 1 through 12.

EIA is a disease that affects a 12% to 15% of the United States population
(Wilkerson, 1998), and there is a lack of data among US. schoolchildren. There have
been few studies that have examined the occurrence of this disease among school-aged
youth. Although the exact prevalence among students between grades one and twelve is
unknown, it has been estimated that the rate could be as high as 29% (Rupp, Guill, &

Brudno, 1992).

 

 

 

 

Bransford, McNutt, and Fink (1991) conducted a study in a population of 12 to
13 year old schoolchildren in the context of their regular gym class using the fiee running
test as their method of screening. The researchers found that 9% of the 201 children they
tested had at least a 15% decrease in their peak expiratory flow rate, thus meeting their
diagnostic criterion for EIA.

Croft and Lloyd (1989) interviewed 100 asthmatic children. They found that 62
out of the 69 asthmatic students aged 8-15 experienced EIA. Further, 41 indicated that
their participation in circumscribed games was avoided or seriously disrupted. An
additional 38 noted they suffered from mild EIA and that games were not seriously
affected.

Secondary school adolescents were questioned about their asthrm knowledge,
attitudes, and quafity of life by Gibson, Henry, Vimpani, and Halliday in 1995. The
findings of this study pertaining to quality of life indicated that 23% of students had
experienced mild to moderate quality of life impairment, particularly regarding strenuous
exercise (Gibson, Henry, Vimpani, & Halliday, 1995).

A study conducted by Kukaflta et a1. (1998) examined the prevalence of EIA
among high school athletes who had no reported history or diagnosis of asthnn. They
discovered that 18% of those athletes who participated had at least a 15% decrease in
their peak expiratory flow rate, and thus met the study criteria for EIA. The authors
argued that the substantial rate of unrecognized EIA does exist in high school athletes,
and suggested that screening is required to help those individuals properly manage their

disease (Kukaflta et. a1, 1998).

10

 

 

 

As noted earlier, there is little data on the prevalence of EIA in the United States.
A study conducted in Jamaica focused on the prevalence among primary and secondary
schoolchildren to identify those students who unknowingly suffer from the disease.
There were originally 214 students that were surveyed. From this group, 84 children
were subjected to stress testing based on their questionnaire results, which indicated they
might be at risk. Of the 84 who were subjected to the stress testing, 21% met the study
criterion for EIA (Nichols & Longsworth, 1995).

Four hundred and thirty adolescents aged 14-17 in Vancouver, British Columbia,
participated in a study to determine if increased air pollution or lifestyle changes were
associated with EIA. A second group of 219 adolescents aged 14-17 from Prague, Czech
Republic, also participated in the study. The fiee running asthma screening test was
performed and a post running peak expiratory flow rate was measured. A positive
response for EIA was considered to be a 15% decrease in peak expiratory flow rate.
The study reported a prevalence of 12% among the high school students (Vacek, 1999).

Perhaps the most comprehensive study of school-aged youth conducted in the
United States was done by Rupp, Guill, and Brudno (1992). Their study examined 1,241
middle and high school students in Richmond County, Georgia. The researchers’ main
purpose was to look for risk factors, signs, and symptoms of unrecognized EIA. The
subjects who, based on a questionniare and interview, were found to be at risk for EIA
underwent exercise challenge tests to determine if they met the criteria to be considered
an exercise-induced asthmatic. There were 348 students who were determined to be at
risk, however only 232 completed the exercise challenge testing. Of the 232 who

completed the exercise testing, 66 athletes met the criteria for EIA, resulting in a

ll

 

 

 

prevalence rate of 28%, and an overall risk percentage of 5%. A follow-up study
conducted by Rupp, Brudno, and Guill (1993) found an unrecognized EIA rate of 13%
among middle school and high school athletes.

Table 1 summarizes results from various studies that have investigated EIA
prevalence rates. Each of the studies previously discussed is listed in ascending order by
the year in which the author conducted the study. The column entitled “location” refers
to the country in which the study was conducted. The next two columns note the gender
of the sample, as well as the age range of the participants of each of the studies. The
column entitled “other” gives a brief description of other identifying factors of each study
sample. Lastly, an EIA prevalence rate is reported in terms of the percentage of the
sample population who was found to have EIA.

These reports establish that there is a considerable number of youth who suffer
from EIA. Although the prevalence rates vary, and data on US. youth are scarce, there is
still cause for concern. With so many school aged children having BIA, the situation
calls for enhanced understanding of the disease so teachers can help students manage

their disease and live a healthy life.

12

4..- 'vau-

 

 

 

 

 

Table 1. Summary of Exercise-Induced Asthma Prevalence Studies

 

 

Author(s) Location Age Other Criteria for Prev-
Year determining alence
EIA among
sample
Croft and Eng- 5 to 15 Asthmatic FEVl 90%
Lloyd land years Students measures
1989
Bransford, United 12 to Adolescent 15% or more 9%
McNutt, States 13 gym class decrease in
and Fink years students at a PEFR
1991 middle measures
school following the
fiee running
test

Rupp, United 10 to Students 15% or more 29%
Guill, and States 16 taking a pre- decrease in

Brudno years season FEV]
1992 sports measures after
physical an exercise
challenge
Larsson et Sweden 16 to Elite cross- 15% or 31%
a1. 50 country greater
1993 years skiers decrease in
FEVI values
after exercise
Rupp, United 12 to Volunteer 15% or 13%
Guill, & States 18 students in greater
Brudno years sports decrease in
1993 FEVl
measures after
exercise
Nichols Jamaica 8 to 15 Primary and Question- 21%
and years secondary naire and
Longs- school aged stress testing
worth children
1995

 

13

 

 

 

 

 

Table 1 (cont’d).

 

 

Author(s) Location Age Other Criteria for Prev-
Year Range determining alence
EIA among
sample
Vacek BC. and 14 to Students 15% or 12%
1999 Czech. l 7 with greater
years unrecog- decrease in

nized EIA PEFR

 

Medication and Treatment

A brief overview of the medications used to treat EIA will serve to introduce the
reader to the different types, as well as the role they play in managing the disease. The
medications of choice for treating EIA are known as betaz-agonists. These drugs are
otherwise known as albuterol (V entolin, Proventil), terbutaline (Brethaire), pributerol
acetate (Maxair), mesylate (Tomalate), and salmeterol sinafoate (Serevent). These beta-
adrenergic agents serve to relieve acute symptoms of EIA by relaxing the smooth muscle
surrounding the airway thus keeping them from constricting (Rau, 1994). They are
typically administered with the use of a meter-dosed inhaler; however, they can be
administered orally.

Albuterol, terbutaline sulfate, pributerol acetate, and bitolterol mesylate usually
last 4 to 6 hours. Metaporteremol only lasts approximately 2 to 4 hours. Albuterol,
terbutaline, pirbuterol, and bitolterol are administered 5 to 30 minutes before exercise.
Salmeterol needs to be administered at least 30 to 60 minutes prior to activity. Onset of
action for all of these Bz—agonists (other than salmetrerol) is 5 minutes, with peak
bronchodilation in 15 to 60 minutes (Wilkerson, 1998).

Cromolyn sodium (Intal) and nedocromil sodium (Tilade) are alternatives to the

Bz-agonists. Both are administered via a meter-dosed inhaler and should be taken 15 to

14

 

 

 

 

 

 

 

30 minutes prior to exercise. They serve as a preventative medication, however, they are
not as effective in reversing an acute asthma episode. Their mechanism of action is not
as completely understood as the Bz-agonists. Proposed theories suggest several difi‘erent
methods of action. This class of drugs does, however, serve as an effective preventative
alternative medication to Bz-agonists (Wilkerson, 1998).

Although it carmot be expected that teachers know every drug that is used by
every asthmatic student, it is important that they have a general idea of which drugs
should be used in certain situations. This lack of knowledge of asthma medication is
indicative that children may not be receiving adequate medication while at school. It also
seems to be contradictory that such a low level of knowledge is being reported, yet there
is a high rate of teachers who are supervising medication. This could have an overall
harmful effect on the students’ asthma management.

Ma_n_agement of EIA in Schools
School-Relimd Issues

Several studies have sought to investigate the amount of school absenteeism due
to asthma-related health complications. Although there are no statistics for EIA
specifically, according to the Asthma and Allergy Foundation of America (2001),
asthma-related illness is the leading cause of school absences. In the United States,
asthma accounts for an annual loss of 10 million school days per year and more
hospitalizations than any other childhood disease. Children spend an estimated 7.3
million days per year restricted to bed due to complications from asthma and EIA

(Asthma and Allergy Foundation of American, 2001).

15

 

 

 

 

 

Gibson et a1. (1995) found that the mean days missed among asthmatic
adolescents per school year due to asthma-related problems was five days. Additionally,
almost half of the participants experienced an asthma attack while at school. However,
the study did find that the school environment of the study participants was quite
supportive of the issues regarding asthnm management at school (Gibson et al., 1995).

The data from the 1988 US. National Health Interview Study was used in a study
conducted by Fowler, Davenport, and Garg (1992) to examine asthma-related issues and
school performance. While the authors considered several different research questions,
their most remarkable finding involved the amount of school missed by asthmatic
children versus well children. Ten percent of children with asthma were reported to have
missed 11 through 15 days and 11% missed 16 or more days in the previous year (Fowler
et al., 1992). The well children had a rate of 1% missing 11 to 15 days and 2% missing
16 or more days.

Preventhgxercfiise-induced asthma attacks. EIA attacks are prevented with the
use of pharmacological and non-pharrmcological treatment. Non-pharmacological
treatment includes physical conditioning, and proper warm-up prior to physical activity.
If the athlete is in poor physical condition, an exercise regimen performed in the proper
environmental conditions is one of the first steps in treatment and management of EIA
(Wilkerson, 1998).

Proper warm-up has been shown to reduce EIA in children (deBisschop, Guenard,
Desnot, & Vergeret, 1999). The researchers conducted two studies to look at the effect of
a warm-up schedule on EIA. Their first study included only 16 asthmatic children. The

participants had their peak flow measured during and after three short, repeated warm-up

l6

 

 

schedules. Each of the warm-up sessions was identical in form but varied in the level of
intensity. The second study took the best three warm-up schedules and applied them to a
new group of 30 asthmatic children. Overall, the researchers found that a short, repeated
warm-up session lessened the drop of peak flow for 24 of the 30 children (deBisschop,
Guenard, Desnot, & Vergeret, 1999).

The preferred pharmacological treatment before exercise is an inhaled quick-
acting beta-agonist (Storms, 1999; Wilkerson, 1998). If this treatment is not adequate,
cromolyn or nedocromil can be added to this pretreatment. As discussed earlier, these
cromolyn and nedocromil are good in terms of prevention, however, they are not as
effective in relieving acute symptoms. Both of these can also be administered with a
meter-dosed inhaler (Wilkerson, 1998). The long acting beta-agonist Theophylline can
also be given several hours before exercise (Storms, 1999).

It should be noted that although symptoms of EIA can be reduced, they cannot
always be eliminated (Smith & LaBotz, 1998). In addition, the efficacy of the
medication may vary depending on the environment in which it is used. In order to
enhance the pharmacological regimen, patients must be educated on the factors that may
vary the response, which could prove to optimize their use of the prescribed medication
(Smith & LaBotz, 1998).

Mmement and treatment of an asthma attack. Individuals who have EIA
and are prescribed medication will oftentimes require their medication if or when they
begin to experience bronchospasm or an asthma attack. As stated earlier, medication is

ideally meant to be used prior to physical activity in order to prevent an attack. However,

17

 

 

if a student should begin to experience an asthma attack, proper planning should ensure
that proper steps are taken and appropriate medical personnel are called upon.

As explained earlier, educators and stafl at schools are fiequently unaware of a
protocol or policy that they are to follow in the event of an asthma attack. The American
Lung Association (2001) recommends that all affected students provide their school with
an asthma action plan, so that all staff will know what medication the student needs and
who to contact in the event of an emergency. Unfortunately, many students do not
provide their school with an asthma action plan, and many schools do not require that
students provide such information.

According to the American Medical Association (2001), there are varied levels of
severity of an asthma attack. The levels include mild, moderate, and severe.
Recommended initial treatment of an asthma attack includes inhaled, short acting beta;-
agonist drugs. If symptoms are not subsiding after initial medication administration,
continued betaz-agonists should be given every 3 to 4 hours and a physician should be
contacted.

If after the first administration of medication the symptoms decrease, but return
within 3 hours, corticosteroids are recommended in addition to the betaz-agonist. Urgent
contact should be made with student’s physician. If the initial dose of the medication
does not help, or if symptoms worsen, immediate transport to the hospital is necessary
(American Medical Association, 2001).

The National Heart, Lung, and Blood Institute (2000) has developed a guide for
educators to learn more about asthma. They have created this guide to help educators

assist students control their asthma. The guide also includes a list of asthma triggers,

18

 

 

 

 

 

 

 

instruction on how to follow an asthma management plan, and actions to consider in

order to help the student take control of their disease. An emergency action plan is also
included if a physical educator should need it to use as a guideline.

Shah, Gibson, and Wachinger (1994) conducted a community seminar to educate
parents and school stafi‘ on the problems with emergency management of asthma at
school, and their plans for addressing the problem. They developed a pilot emergency
management plan for asthma and implemented it into 12 schools. Their comprehensive
plan included each school having an asthma first aid kit, as well as workshops to educate
school staff. In addition, all students had to fill out an asthma-screening questionnaire.
The final component of their program was a school crisis plan. This crisis plan was
completed by the asthmatic student’s physician, and stored at school. Upon completion
of the evaluation portion of the pilot program, the results revealed that one in 10 students
who had crisis plans at school required emergency treatment.

Mellis et al. (1994) authored a position paper on a national policy for Australia on
asthma management for schools. In it, the authors explain the elements of their proposed
policy, which includes a school “first aid kit” for asthma. It also includes an emergency
treatment plan, as well as an explanation to assess the severity of an attack fi'om asthma
and treatment during an attack. Their recommendations for prevention and management
of an attack go one step further than those presented by the American Medical
Association (2001), The National Heart, Lung, and Blood Institute (2000), and American
Lung Association (2001). Their recommendations include: (a) improved asthma training
for teachers at the undergraduate and postgraduate levels; (b) improved recognition from

schools of those students who have asthma; (c) schools should encourage exercise for all

 

 

students with asthma; (d) medications should be readily available to all students who

have asthma; and (e) early introduction of “lung health” education should be encouraged
(Mellis et al., 1994).

It is clear that in the event of an asthma attack, it is essential for a school staff
member to know what action to take. A student’s life could depend on whether
appropriate steps are taken to manage the situation. However, it is clear that some
educators feel they need to be educated on the topic.

Medication at school. Another school related issue that students with asthma
have to be concerned about is the availability of their medication. The State of Michigan
has passed Public Act Number 10 (2000), which allows school children to possess and
use their meter-dosed inhaler with proper authorization from their health care provider
and parent. The Bill states that the pupil may use the inhaler to alleviate asthmatic
symptoms or before exercise to prevent the onset of asthmatic symptoms. He or she may
also use his/her inhaler at school, on school-sponsored transportation, or any activity,
event, or program sponsored by or in which the pupil’s school is participating (Public Act
10, 2000). The Bill also states that the principal or other chief administrator who is aware
that a pupil is in possession of an inhaler should notify each of the pupil’s classroom
teachers.

The State of Michigan also passed Public Act 9 in March of 2000, which
addresses the issue of liability for school teachers and administrators. The Bill states that
a school administrator, teacher, or other school employee designated by the school
administrator, who in good faith administers medication to a pupil in the presence of

another adult or in an emergency that threatens the life or health of the pupil, is not liable

20

 

 

 

 

 

 

 

 

 

 

in a criminal action or for civil damages as a result of an act or omission in the

administration of the medication, except for an act or omission amounting to gross
negligence or willfirl and wanton misconduct (Public Act 9, 2000). The legislature in
Michigan has taken an important step by recognizing the importance of medication
availability for students who have asthma. However, it is not known whether or not all
schools are supporting this act, and not all states have passed an act like this.

The results of several different studies that examined the handling and
administration of medication for asthmatic children revealed very different results based
on the policy of the school being examined. Several of the schools that have had teachers
surveyed indicated that their school did not even have a policy concerning medication
handling and administration (Atchison & Cuskelly, 1994; Bevis & Taylor, 1990; French
& Carroll, 1997; Henry, Hazell, & Halliday, 1994; Hussey, Cahill, Henry, King, &
Gorrnley, 1999).

Due to the fact that most of the studies that are cited within this review were not
conducted in the United States, it may be argued that the statistics reported here may not
be accurate or applicable for the US. school population. However, it must be noted
again, there are few data available on this topic in the United States. Therefore,
discussion on the varying school or national policies will be presented with the various
study results.

In London, a group of teachers was surveyed on several different issues related to
asthma and EIA (Bevis & Taylor, 1990). The researchers distributed their questionnaire
to 98 primary school teachers fiom eight schools. Their results concerning asthma

medication and handling revealed that 39% of teachers did not allow children to keep

21

 

 

their inhalers with them, and 68% said they supervise children when they are using their
inhalers. However, the group’s overall knowledge of medication was very poor. When
asked about the use of antrhiotics, 67% did not know if they were the right type of
medication used to treat asthma.

Bevis and Taylor (1990) also found that school policy varied. The article cited
that most of the teachers were unaware of their school policy; however, it did not provide
an exact number or percentage. One of the schools forbade the use of medication at
school and in the event of illness the student was sent home or a parent had to bring his or
her medication to school. Other schools had a designated teacher who was responsible
for keeping medications.

Evidence of the lack of availability of inhalers to school children was presented
by Hill, Britton, and Tattersfield (1987). They examined 29 schools in Nottingham,
England. They found that the responsibility of supervising pupils who were asthmatic lay
almost entirely with the primary school teacher. School policy varied, with 65% of the
primary schools reporting that the students were required to hand in their inhaler to a
school staff member. Unfortunately, 40% of all the teachers surveyed reported they were
worried that they were not prepared to deal with a student experiencing an asthma attack
and were concerned about the extra time it would take to ensure the child received their
medication.

Based on the findings of Hill, Britton, and Tattersfield (1987), asthma
management and medication handling were examined in British school children by Croft
and Lloyd (1989). Their study proposed to explore whether or not inhalers are available

to children with EIA prior to physical activity. Of the 100 children they surveyed, 56

22

 

 

said they had to hand their inhaler over to a school staff member, and any delay in getting
medication when needed was caused by the inability to find the person in charge of their
inhaler. Eighteen students surveyed were not allowed to use their inhaler while at school.
Out of the 62 children that indicated they had EIA, 48 took bronchodilators before
exercising. However, half reported they had to leave the game to go find the staff
member who was responsible for their inhaler.

One hundred sixty-four primary school teachers from Perth, Australia, were
surveyed on their knowledge of asthma. Forty-five percent indicated they did not know
what medications are given to children with EIA prior to exercise. Over 95% of the
teachers questioned said they allow children to keep their medicine with them in school.
Seventy-six percent have to remind children to take their medication. Despite the fact
that 150 of the 164 teachers felt they did not know enough about asthma, 63% supervise
asthmatic children when taking their medication.

School teachers in Dublin, Ireland, were questioned about their knowledge of
asthma and its management (Hussey et al., 1999). Data were collected based on the
responses of 147 teachers fiom the primary and secondary school level. Eighty-four
percent of the teachers reported that their school did not have a specific policy or protocol
in the event of an asthma attack. When asked about their confidence in dealing with an
attack, 88% said they were not confident. Although 70% of the total population surveyed
said they are responsible for supervising medication administration for asthmatic
students, 49% said they are not familiar with the correct technique for use of inhalers.

Physical activity. EIA has been shown to limit the activity of school-aged youth.

Croft and Lloyd (1989) performed a study including children in London and found that

23

 

41% of the student p0pulation they surveyed had their physical activity seriously

disrupted or prohrhited completely due to EIA. This has serious implications for the
individual’s overall wellness. Lack of physical activity has been shown to be deleterious
to one’s health and increases the risk of obesity, heart disease, stroke, diabetes, and
several other chronic diseases (US. Department of Health and Human Services, 1996).

A study performed by Thio, Nagelkerke, Ketel, vanKeeken, and Dankert-Roelse
(1996) was conducted to determine whether or not cardiovascular fitness could be
beneficial for the prevention of EIA. Their findings revealed that children with severe
EIA can attain normal cardiovascular fitness. In addition, they were able to demonstrate
that normal cardiovascular fitness in itself does not prevent severe EIA (Thio, et al.,
1996).

Gibson, et al. (1995) examined asthma knowledge, attitudes, and quality of life in
adolescents from 32 Catholic secondary schools in New South Wales, Australia They
found that asthma had limited the activities of 35% of the 796 asthmatic students they
surveyed. Further, the most frequently limited activity due to asthma was participation in
sport.

Hussey et a1. (1999) asked teachers how many of their students used or required
medication in order to participate in physical activity or physical education class. They
found that 5% of the teachers’ students required medication prior to activity. An
additional 3% of their students required medication during class. Further, an added 13%
of their students required medication after physical education class. Thus, a total of 21%
of their students required medication either before, during, or after physical education

class.

24

 

 

Students who suffer fi'om EIA should not have to refrain fiom physical activity.
With the proper education and management plan, anyone with EIA should be able to
participate with little interference in their desired sport or activity. However, a
comprehensive approach to managing EIA is necessary to minimize any health related
problems. This comprehensive approach requires guidance from a physician, education,
proper medication, and avoiding potential triggers. The components of comprehensive
EIA management shall now be discussed.

Teacher Issues

Current knowledge of educators. Virtually all of the research that has
investigated teachers’ knowledge of asthma has been conducted outside of the United
States (Atchison & Cuskelly, 1994; Bevis & Taylor, 1990; French & Carroll, 1997;
Henry, Hazel], & Halliday, 1994; Hussey et al., 1999). Further, there has not been a
study that examines educators’ knowledge of EIA specifically. Rather, many of the
studies that look at general asthma knowledge dedicate a portion of their data collection
to EIA and related topics. Therefore, it is the information offered fi'om segments of
questionnaires and surveys, which will serve as the basis for the current level of
knowledge of educators with respect to EIA.

Bevis and Taylor (1990) conducted a study in the Paddington area of London with
the purpose of finding out what teachers know about asthma Within their questionnaire,
they were able to gather some information on EIA and related issues. Over 60% of the
teachers knew that swimming was the best sport for asthmatics, and 79% felt asthmatic

children should be encouraged to participate in sport.

25

 

 

 

 

 

 

French and Carroll (1997) issued a questionnaire which tested primary teachers’

knowledge of asthma. It included only a few questions that were devoted to EIA. They
found that 97% of the teachers surveyed knew that children with asthma should be
encouraged to participate in games and sport. In addition, 89% knew that swimming is
the best sport for asthmatic youth.

Knowledge deficits among educators. The results of several studies which questioned
teachers on their knowledge of asthma consistently reported that teachers’ knowledge in
the area of EIA is lacking moreso than any other aspect that was surveyed (Bevis &
Taylor, 1990; French & Carroll, 1997; Gibson et al. 1995; Hussey et al., 1999). Various
topics surrounding EIA that have been explored include sport participation, prevention,
and medication.

Shah, et al. (1994) developed an asthma crisis plan to be implemented into
schools. One component of their plan involved workshops to help educate teachers.
During the 12 workshops they conducted, they were able to gather some inforrmtion on
the current level of knowledge of the teachers. While the authors’ workshop was able to
significantly improve overall knowledge, a deficit still remained. At completion of the
workshops, 54% of the teachers still were unable to identify ways of preventing EIA.

Bevis and Taylor (1990) found that only 33% of the teachers they surveyed knew
that pre-medication before physical activity should prevent EIA, and 47% were not sure
if it would harm or help the student. Nearly half of those surveyed did not know if
children with asthma were more competent or less competent in physical sports than
students who did not suffer fiom asthma or EIA. Over 60% did not know that wheezing

after exercise suggests asthma (Bevis & Taylor, 1990).

26

 

 

 

French and Carroll (1997) found that 42% of the teachers they surveyed felt it is

not the responsibility of the teacher to ensure that necessary drugs should be taken before
physical exercise. In addition, 45% of their participants did not know that asthma
medication prior to physical activity should prevent an asthma attack. Playing games in
the wind or cold wind increases the likelihood of an asthma attack, which 63% of the
teachers did not know (French & Carroll, 1997).

Teachers surveyed by Hussey et al. (1999) indicated that 80% were aware that
asthma has an exercise-induced component. However, few take appropriate measures for
their students prior to physical activity. Although symptoms of EIA may be prevented if
a child takes a relieve bronchodilator before beginning exercise, only 17% of the subjects
knew this when asked (Hussey et al., 1999).

Confidence of educators. Several teachers in Bevis and Taylor’s (1990) study
commented on their lack of confidence when an asthmatic child became ill and when
there is no other help available, resulting in anxiety for the teacher and student. The
authors of this study argued that, with proper education, teachers will be more likely to
feel confident and be able to distinguish when a child is becoming unwell, and what
actions must be taken. Hussey et al. (1999) found that 70% of the teachers in their survey
administered medication during school hours, yet only 39% felt they knew the proper
technique to administer the mediation. Further, only 19% felt they were or would be,
confident in managing an asthma attack while 80% felt they were not or would not be
confident. The authors also indicated that teachers who are uninformed felt their

intervention could jeopardize the child’s health, rather than help it (Hussey et al. 1999).

27

 

Accurate knowledge about proper medication and its effects could prove to save a

child’s life. A well-informed teacher who is confident in his or her knowledge and
actions can ensure that a child is self-medicating correctly and proper management is
taking place. A discussion on training educators shall be explored as the final issue in
this literature review.

Educators’ feelr_n' gs toward education. While education may by needed, it is also
important to determine if educators feel as though they need it, or if they would take
advantage of it if it were ofl'ered to them. This has been examined by several researchers,
with a consensus that teachers feel as though they need more education on asthma, and
need more information to help improve their level of understanding of the disease (Bevis
& Taylor, 1990; French & Carroll, 1997; Henry et al., 1994; Hussey et al., 1999). French
and Carroll (1997) reported that 91% of the teachers surveyed did not feel they knew
enough about asthma. Hussey et al.’s (1999) results on this were similar, noting that 88%
were not satisfied with their current knowledge of asthma.

Timing Widescale attempts to educate teachers about EIA specifically have not
been made. Studies that have been conducted on asthma knowledge in general have been
able to gather some data on approaches that may serve to educate teachers on EIA and
related issues (Bevis & Taylor, 1990; French & Carroll, 1997; Gibson et. al 1995;
Hussey, et al., 1999). As stated earlier, it is the information offered fi'om segments of
questionnaires and surveys on asthma in general, which will serve as the basis for the
current level of knowledge of educators with respect to EIA.

There are several aspects that must be considered when attempting to educate

teachers about asthma Atchison and Cuskelly (1994) intended to explore a method of

28

 

 

educating teachers on asthma. They prefaced their study with the presentation of the

areas that must be addressed in designing an educational program. They emphasized the
need for teachers to understand asthma, know how and when to give medication to an
asthmatic, when to seek assistance from parents or medication professionals, and when to
call an ambulance (Atchison & Cuskelly, 1994). In addition, educating teachers about
triggers and prevention are key to minimizing asthma attacks. Each of these subjects
shall be discussed in order to realize the need for education on this disease.

Atchison and Cuskelly (1994) sought to determine whether an informational
session on asthma in conjunction with providing teachers with material on asthma
symptoms and management would produce a significant change in their level of
knowledge of asthma. They issued a questionnaire with five subscales addressing the
topics of medication, preventing asthma attacks, when to call an ambulance, and general
facts. The last subscale included questions about the relationship of stress and asthma,
causes of asthma, mortality, and morbidity. Their study separated participants into an
experimental group and a control group. The experimental group received an
information session, while the control group did not. The information session consisted
of a lecture on asthma and an exhibition of the different types of asthma medication and
devices used to treat asthma (Atchison & Cuskelly, 1994). The medications included
Ventolin, Becotide, Becloforte, and Intal. The devices demonstrated included pufi’ers,
spacers, and peak flow monitors. Brochures were also given out, and included “Asthma
First Aid for Schools” and “What Teachers Should Know About Asthma.”

Each group was given a pre-test and post-test to see if the session improved the

level of knowledge of those who attended. The results revealed that teachers in both

29

 

 

 

groups had very little knowledge, particularly in the area of prevention. This method of

educating teachers failed to produce any significant change in teachers’ knowledge of
asthma. The authors go on to criticize this method of education and the regular use of
this approach to disseminate information.

In opposition, Henry, et al., (1994) were able to demonstrate that a two-hour
seminar was able to produce significant difl'erences in asthma knowledge among school
staff. The researchers were able to gather baseline data on the participants prior to
attending the seminar. The results of the baseline data indicated that the level of
knowledge was insuflicient for proper disease management (Henry, et al., 1994). Only
one school staff person was able to name two ways to prevent EIA before this seminar.
This number increased to 20 (29%) after attending the seminar.

Bevis and Taylor ( 1990) found that only 4% of the teachers they surveyed had
ever been educated on the topic of asthma. French and Carroll (1997) found that only
10% of the teachers they surveyed had ever had any education on asthma topics. Only
12% of those surveyed by Hussey et al. (1999) felt confident in their current level of
knowledge on asthma.

mm

It has been clearly demonstrated that EIA is a health concern for students.
Management of the disease is a challenge for all who have it. It has also been illustrated
that while educators desire more training on asthma, they continue to play an important
role in helping school children manage their disease.

Because EIA is triggered specifically by physical activity, it is assumed that

physical educators could play a crucial role in preventing unnecessary complications

30

 

 

caused by this disease. Therefore, it would serve to be beneficial for school
administrators to find out what physical educators know about the disease, and whether
they are equipped to handle emergency situations. In addition, it would be usefirl to
know if physical education teachers would take advantage of educational opportunities if
they were to be nude available for them.

Physical educators have access to a large population of school aged children who
participate in physical activity. Improving their knowledge would only serve to improve
the health and welfare of their students. There is no question that a comprehensive
program to educate teachers on this topic is necessary. Future programs using the
appropriate method of instruction could serve to better prepare physical educators. The
better prepared our teachers are, the better the choices they can make concerning their

students.

31

 

 

 

 

 

 

 

Chapter 3

Methods

The basic design that was used in this investigation was a descriptive research
design The purpose of choosing this design was to gather basic information on the
current level of knowledge among physical educators on the topic of exercise-induced
asthma (EIA). There were two research questions explored: (a) what is the current level
of knowledge of exercise-induced asthma among physical educators?, and (b) are
physical educators interested in improving their level of knowledge of EIA and related
issues?

Research Design

This research design was used because it has been demonstrated to be an effective
means to gather information on asthnm knowledge among educators (Atchison &
Cuskelly, 1994; Bevis & Taylor, 1990; French & Carroll, 1997; Henry, et al., 1994;
Hussey et al., 1999). It also allowed for the examination of some demographic variables
and their relationship to the level of knowledge among physical educators. As shown in
the previous chapter, research of this kind has not been conducted in the United States.
Therefore, the information gathered from this research will serve as a basis for future
research and hypothesis testing.

A cross-sectional survey (see Appendix C), which is a survey conducted at one
point in time, was distributed to gather a snapshot of the current level of knowledge
among the physical educators within the sample chosen. This method was utilized
because it is the quickest and least expensive method of gathering information on

multiple variables. It also allowed for anonymity of those who participated.

32

 

While this method does not allow for cause and effect relationships to be

determined, it served to gather unique baseline data. Because this topic of research is
new to the United States, advancing the current level of knowledge must start with some
basic information on the population of interest. This design does not allow for a
historical perspective or maturation analysis on this issue; however, an efl'ort to decrease
these potential threats was made by randomly selecting a sample of teachers fi'om two
intermediate school districts. This procedure was done in order to attempt to get a
representative sample of the entire population of teachers in the two school districts while
minimizing the potential of any historical event that may affect the potential outcomes of
the measurements taken.

The criteria for inclusion were none other than being a physical education teacher
on staff at a school that was chosen. Informed consent was received fi'om all study
participants and will be discussed in more detail in the data collection portion of the
methods section. The potential sample of physical education teachers were those
physical education teachers who worked within two intermediate school districts that was
comprising 340 schools. There were 170 elementary schools, 90 middle schools, and 80
high schools within the two intermediate school districts. A total of 300 physical
education teachers worked at these schools; some physical education teachers serve more
than one school.

Participants

The population examined in this study included physical education school-
teachers who taught physical education in at least one public school within the two
intermediate school districts. The elementary schools out numbered the middle and high

schools by a ratio of approximately 2:1. In order to get a representative sample fiom

33

 

 

each level, approximately 65% to 70% of the schools at each level were sent surveys.
Therefore, survey packets inviting physical education teachers to participate were sent 65
middle schools, 55 high schools, and 118 elementary schools.

A total of 238 questionnaires addressed to the physical education teacher were
sent out to randomly selected schools in the two chosen districts. There were 72
completed surveys returned. This is the equivalent to a response rate of at least 30%. It
must be noted that because some of the teachers represent more than one school, the
response rate could actually be higher.

Randomization was done with the schools rather than teachers because there are
more schools than physical education teachers, and addresses of the physical education
teachers were not available. Based on the findings of the literature review that was
conducted on this topic, a response rate of approximately 30% was expected (Atchison &
Cuskelly, 1994; Bevis & Taylor, 1990; French & Carroll, 1997; Henry, et al., 1994;
Hussey et al., 1999). In order to generalize the findings of this study to the 300 physical
educators in the two districts, 162 completed surveys were needed (Krejcie & Morgan,
1970). There were only 72 completed surveys returned, thus the findings of this study
cannot be generalized to the two districts’ entire cohort of physical education teachers.

Instrumentation

The research conducted within this study sought to explore two basic questions.
These questions were examined using a survey comprised of several sections (see
Appendix C). The first question addressed the current level of knowledge that physical
educators have of EIA. The first section of the survey consisted of a series of multiple
choice questions to test participants’ fundamental knowledge of exercise-induced asthma.

The knowledge portion of the instrument served as a means to determine the number of

34

 

 

 

 

 

 

 

 

 

 

 

correct and incorrect answers submitted by the participants. The answers were tallied and

are presented in aggregate form as an objective index of the current level of knowledge of
the participants of this study.

The second research question posed in this study addressed whether or not
physical educators would like more education on this topic. This information was
gathered using additional survey questions, as well as statements that allowed the
participants to express their opinions on topics related to EIA using a Likert scale. This
section also allowed them to indicate whether they feel they know enough about EIA, and
if they would take advantage of continuing education on the topic if it were offered.
Demographic information on gender, years of teaching experience, age, health status (i.e.,
asthmatic or non-asthmatic), and level of education were also collected in the third
section of the survey.

Survey Development

Virtually all of the research that has investigated teachers’ knowledge of asthma
has been conducted outside of the United States (Atchison & Cuskelly, 1994; Bevis &
Taylor, 1990; French & Carroll, 1997; Henry, et al., 1994; Hussey et al., 1999). The
international literature has demonstrated the need for education in the area of exercise-
induced asthma However, little is known about the current state of EIA knowledge of
US. physical educators specifically. Therefore, before research and education in this
area can advance, an assessment of the individuals in question must first be conducted.

There are several general asthma questionnaires that have been designed and used
on educators; however, these questionnaires only have small sub-categories with a few

questions on the topic of exercise-induced asthma. The survey instrument used in this

35

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

study includes questions in seven categories (see Appendix C). Those categories include

(a) general knowledge of EIA; (b) prevention of EIA; (c) medications used for EIA: ((1)
school policy on EIA; (e) emergency management of an asthma attack; (t) feelings on
education in the area of EIA; and (g) demographic information. The survey consisted of
37 questions in all.

The questions for this survey were adapted fi'om other asthma surveys that had
sub-categories that included questions relevant to exercise-induced asthma. The survey
used in this study contained 14 knowledge questions having only one correct answer.
The remaining questions were either demographic questions or asked the participants
about their feelings on various issues related to EIA.

M

This survey instrument has never been used before, and it was developed and
validated in stages. The first drafi was submitted to the primary investigator’s thesis
committee to assess content validity and to get feedback on potential changes that needed
to be made. The survey was then issued to graduate level kinesiology students at
Michigan State University who were enrolled during the spring semester, 2001. After
discussion to gather feedback on various items within the survey, an item analysis was
conducted and the survey was finalized for a pilot test.

Reliame

Permission from the University Committee on the Research of Human Subjects

(UCRIHS) was obtained prior to the pilot testing of the instrument. Because this tool

does not have a criterion with which it can be compared, the survey was piloted to senior

36

 

 

 

physical education students at Grand Valley State University during the spring semester,

2001, to measure reliability.

The participants in the pilot test were issued the survey during a 400 level
capstone class. The survey was issued the first week of class and then exactly two weeks
later at the same time of day, in the same classroom, and on the same day of the week.
There were 30 completed pre- and post-tests collected. A paired t-test was conducted on
the data to determine a correlation coeflicient for the reliability of the applicable items in
the survey.

Pilot Test Results

In order to assess reliability of the survey, the instrument was pilot tested with
senior physical education students. A paired t-test was conducted on each item of the
survey to measure individual differences. The significance level and Pearson correlation
coeflicient for each answered item in the survey can be seen in Table 2. Some of the
questions were not applicable to the senior students, as they had to do with years of
experience and other questions that could not be answered. These questions (items E1,
Tl-4, Bl, B4, B5) are therefore not included in the analysis (Table 2).

Table 2. Pilot Test Results for Paired t-test and Pearson Correlation

 

 

Question p value Correlation

coefficient
What is exercise-induced asthma? .18 .82
Swimming is the only exercise that is suitable for .50 .89

individuals with asthma of exercise-induced asthma.

Full participation in sport should not be encouraged to .16 .87
individuals with asthma or exercise-induced asthma.

 

37

 

 

 

 

 

 

 

 

 

 

 

Table 2 (cont’d).

 

 

Question p value Correlation
coefficient
Teachers of elementary aged children should be .78 .87

responsible for ensuring that proper medications are
taken by their students with asthma prior to engaging in

physical activity.

Which of the following is most likely to inflame an .23 .93
asthma attack in an asthmatic child?

Which of the following activities should not be .50 .65
undertaken by children with controlled, mild asthma?

Which is the most likely to bring about an asthma attack .80 .64
in children with controlled asthma?

Wheezing after exercise suggest that a person has .16 .88
asthma.

Asthmatic students are generally less competent at .35 .81
sports.

What factor(s) indicate that a child is experiencing a bad .35 .80
attack of asthma?

What is the most obvious feature associated with .66 .90
asthma?

Antibiotics are the most important part of treatment for 1.00 .94
most children with asthma.

Taking medication for EIA as prescribed before physical .26 .85
activity/ games should reduce the likelihood of an asthma

attack.

Prior to physical activity, beta-adrenergic medications .16 .86

are the most effective type of medications used by
individuals with exercise-induced asthma.

Do you supervise asthmatic children when they use their .54 .72
inhalers?
Which of the following medications is the most effective .08 .96

at preventing an exercise-induced asthma attack?

 

38

 

 

Table 2 (cont’d).

 

 

Question p Correlation
value coefficient
When should an ambulance be called for an asthmatic .33 .93
child?
When a child has a sever attack of asthma and the asthma .31 .75

has not improved after several doses of medication, which
is the most crucial procedure that needs to be

implemented?

Do you have an asthmatic child? 1.00 1.00
Are you currently CPR certified? 1.00 1.00
What is your gender? 1.00 1.00
Are you aware of Public Act 9 in the state of Michigan? .08 .47
A school administrator, teacher or other school employee .57 .79

designated by the school administrator, who in good faith
administers medication to a pupil in the presence of
another adult or in an emergency that threatens the
life/health of the pupil is not liable in a criminal action.

In order to assess within-group differences, a significance level of p = .05 was
used to predict the probability of a Type I error. There were no reported p-values less
than .05, which resulted in the failure to reject the null hypothesis in all cases. Therefore,
there were no detectable differences in the answers given from the pre-test to the post-
test. A correlation coefiicient was also calculated to determine the mathematical
relationship between the two variables. The correlation between items ranged fi‘om
moderate to very high, except in one case. Item B8 (Are you aware of Public Act 9 in the
state of Michigan?) had what would be considered to be a low correlation (Munro, 1997).
In summary, there was no significant difference within the groups on the measured
survey items. Given these results, there were no changes made to the questionnaire, and

it was distributed to the study population.

39

 

 

 

 

Data Collection Procedures

Surveys were mailed out on May 2nd, 2001, after UCRIHS approval was granted.
The surveys were sent to the schools addressed to the attention of the physical educator.
An addressed, stamped return-envelope was included in order to improve response rate.
Participants were instructed to place the completed survey in the provided envelope and
place it in the mail no later than May 31, 2001. A cover letter (see Appendix A) was sent
with the survey to explain the nature of the study. Directions for the instrument can be
found at the top of survey itself (see Appendix C).

A separate informed consent form (see Appendix B) was included and was
necessary only if individuals wanted to send in their name and contact information so as
to receive information on the study results, or be included in a prize drawing. Informed
consent was implied if the participant sent in a completed questionnaire without an
accompanying informed consent. The participants were assured that their informed
consent form would be immediately separated from their survey responses so as to
maintain anonymity.

The drawing was done at the completion of the study. The names of all
participants who sent in their contact information were put together in a bowl and one
name was randomly drawn. The prize for the individual whose name was drawn was a
$50.00 gift certificate to a sporting goods store.

Data Analyses

Each question posed in the survey was first analyzed individually. Demographic
data were reported in terms of frequencies and percentages. The demographic questions
involving age and years teaching were reported in terms of mean age, mean years the

participants have taught physical education, and the range of responses.

40

p

we KL...“ -

... :r-c r: s

 

There were 14 questions presented in the survey that were used to measure the
overall knowledge each participant had of EIA. They were of nominal level and carry a
value of one point when a correct answer is given. A mean score for all participants was
calculated.

Knowledge means for various subgroups of participants were compared using t-
tests as described below. One-tailed tests were used for those comparisons for which a
directional difference could be hypothesized. A statistical significance level of p = .05
was used to predict the probability of a Type I error for all tests conducted in this study.

A one tailed t-test was performed to investigate whether or not there was a
difference in the mean knowledge scores of those individuals who have asthma and/or an
asthmatic child versus those who do not have asthma and/or an asthmatic child. It was
hypothesized that the mean knowledge score for those who have asthma and/or children
with asthma would be significantly higher than those who do not have asthma and/or
children with asthma.

A two tailed t-test was conducted to explore if a difference in the mean
knowledge scores exist for those who have taught health education (in addition to
physical education) versus those who have not taught health education (in addition to
physical education). A one tailed t-test was also run to see if a difference exists between
the mean knowledge scores of those who have had training on the topic versus those who
have not had training on the topic. It was hypothesized that the mean scores for those
who have had training would be higher for those who have not had training.

A two tailed t-test was conducted to examine whether a difference exists in the

mean knowledge scores of those who supervise children using their inhalers and those

41

 

 

 

who do not supervise children using their inhalers. Lastly, a two-tailed t-test was used to
determine if there was a difference in the mean knowledge score of those who have
obtained more formal education (a master’s degree, beyond a master’s degree, or doctoral

work) versus those who have obtained less formal education (a bachelor’s degree or some

master’s work).

42

 

 

 

Chapter 4

Results

Study Results

Descriptive Results

There were 238 surveys sent out, and 72 surveys were returned, resulting in a
30% response rate. There were three surveys that did not have a response to item B8,
which asked participants if they were aware of Public Act 9. There was one survey
respondent who did not indicate his/her age in response to item B12.

The data collected revealed that there were 41 (57%) male respondents and 31
(43%) female respondents. The descriptive statistics for the age of the participants can be
found in Table 3. The mean age for the participants was 41 years. The survey
participants spanned a wide range of teaching experience (Table 3). There was a 39-year
range of experience, with a l3-year mean of teaching physical education.

Table 3. Sample Descriptives

 

 

Variable Response
Gender
Male 57%
Female 43%
Age 41 .2i9.7 years
Highest Level of Education Completed
Bachelors from a 4-year college 18%
Some graduate work 10%
Master’s degree 26%
Beyond Master’s degree 44%
Doctoral work 1%
Years of Physical Education Teaching Experience 13.1i10.3years

 

43

 

 

 

Table 3 (cont’d).

 

 

Variable Response

Those Who Have Taught Health Classes 34%
Grades Taught

Grades K-6 49%

Grades 7-8 15%

Grades 9-12 19%

Combination Assignments 17%
CPR Certified 58%
Personal Involvement with EIA

Teacher with EIA 6%

Teacher who has child with EIA 13%

Teacher has no personal involvement with EIA 81%
Experience with EIA in Schools

Teacher has/had asthmatic child in class 100%

Teacher allows children to keep inhalers with them 81%

Teacher supervises children when they use their 42%

inhalers

School has policy on how to handle an asthma attack 71%
Knowledge about EIA

Teacher is satisfied with knowledge of EIA 12%

Teacher has received training on asthma or EIA 31%

Aware of Public Act 9 in the State of Michigan 32%

Would attend training on this topic if it were offered 91%
Total Correct on Knowledge Questions (out of 14) 8.79i2.87

 

The participants included teachers who teach physical education at levels ranging

from kindergarten to twelfth grade (Figure 2). Most respondents replied with a range of

grades that they teach and therefore needed to be placed into categories. The categories

were as follows: (a) grades K-6; (b) grades 7-8; (c) grades 9-12; and (d) grades that span

two or more of the groups. There were 35 participants who taught K-6, 11 who taught

 

grades 7—8, 14 who taught grades 9-12, and 12 who taught some combination of two or

more of the categories.

49%

19%

 

17%

 

I Grades K-6 El Grades 7 & 8 E1 Grades 9 - 12 El One or more categories

 

 

 

figuLeg. Grade Levels Taught

All of those surveyed were physical education teachers. Of those, 34 (47%) have
also taught health classes in addition to physical education. There were also 42
participants who indicated they were certified in cardio-pulmonary resuscitation, making
up 58% of the sample. All participants had a minimum of a bachelor’s degree from a
four-year college. The formal educational level of the participants ranged from

bachelor’s degree only to having some doctoral work (Figure 3).

45

1%

 

E1 Bachelor’s Degree

I Some Graduate Work

0
45% 10 A) I Master's Degree

I Beyond Master's
Degree

121 Doctoral Work

 

 

 

 

F_igu_re_3. Highest Level of Formal Education Earned

When asked if they had ever had an asthmatic child in their class, 71 responded
that they had an asthmatic child in their class at some point during their teaching career.
The remaining respondent did not reply to the question. Therefore, 100% of those who
responded to the question have had an asthmatic child in their class at some point.

Almost half of the participants (42%) supervise children when they use their
inhalers, yet 5 7% of all of the participants could not identify the most effective
medication for preventing an exercise-induced asthma (EIA) attack. A total of 29% of
the respondents said that their school did not have a policy for handling an asthma attack.
An additional 22% replied that they did not know if their school had a policy or not.

When asked about their knowledge of Public Act 9 (which concerns the
administration of medication to students), 68% indicated that they were not even aware of

such an Act. The survey that was used in this study included a question presenting

46

 

 

 

 

3
Wm.
fin:
—-—m' l

 

 

 

participants with a statement taken directly from the Act. Twenty-one percent of the

participants labeled the statement as false.

Only 14 of the respondents either had exercise-induced asthma or parented a child
who had exercise-induced asthma; therefore 19% of the survey sample have had some
personal involvement with the disease. Figure 4 gives a summary of the number of

participants who had asthma or a child with asthma, and those who did not have asthma

 

or a child with asthma.
6%
14%

I Athmatic

El Have Asthmatic Child

E1 Non-Asthmatic & No
Children With Asthma

80%

 

 

 

figufl. Health Status of Participants

Of all of the study participants, 31% had some type of training on the topic. The
data revealed that 88% (63 people) indicated that they were not satisfied with their
current level of knowledge of exercise-induced asthma. Furthermore, 90% said that they
would attend training on the topic if it were offered.

There were 14 questions posed in the survey that tested the participants’
knowledge of exercise—induced asthma Table 4 presented below summarizes the results

of the responses given to each of those 14 questions. The mean for the total number

47

 

with a sample variance of 8.25.

Table 4. SummarLofKnowledge Question

correct out of 14 was 8.79, or 62%. The standard deviation for the mean score was 2.87

 

 

Question % Who % Who % Who
answered didn’t answered
correctly know incorrectly

What is exercise-induced asthma? 54% 12% 34%
Playing games/physical activity in the 60% 22% 18%
cold wind increases the likelihood of an

asthmatic having an asthma attack. (T/F)

Which of the following is MOST likely to 69% 24% 7%
inflame an asthma attack in an asthmatic

child?

Which of the following activities should 93% 4% 3%
not be undertaken by children with

controlled, mild asthma?

Which is the most likely to bring about an 46% 13% 41%
asthma attack in children with controlled

asthma?

What factor(s) indicates that a child is 72% 2% 26%
experiencing a bad attack of asthma?

What is the most obvious feature 61% 2% 37%
associated with asthma?

Antibiotics are the most important part of 68% 18% 4%
treatment for most children with asthma?

Taking medication for exercise-induced 90% 7% 3%

asthma as prescribed before physical
activity/games should reduce the
likelihood of an asthma attack. (T/F)

 

4s

 

 

._ -
x.

 

 

 

Table 4 (cont’d).

 

 

Question % Who % Who % Who
answered didn’t answered
correctly know incorrectly

Prior to physical activity, beta-adrenergic 26% 68% 6%

medications are the most effective type of
medications used by individuals with
exercise-induced asthma. (T/F)

Which of the following medications is 40% 57% 3%
most effective at preventing an exercise-

induced asthma attack?

When should an ambulance be called for 72% 18% 10%
an asthmatic child?

When a child has a sever attack of asthma 54% 8% 38%

and the asthma ha not improved after
several doses of medication, which is the
MOST crucial procedure that needs to be
implemented. (T/F)

A school administrator, teacher, or other 75% 0% 25%
school employee designated by the school

administrator, who in good faith

administers medication to a pupil in the

presence of another adult or in an

emergency that threatens the life/health of

the pupil is not liable in a criminal action.

 

Su ou Knowled eCom arisons

A one tailed t-test was used to compare the mean knowledge scores of those
participants who have asthma and/or have an asthmatic child and the mean scores of
those who do not have asthma and/or an asthmatic child. It was hypothesized that
asthmatics and/or those with asthmatic children would score significantly higher than
those without asthma and/or without asthmatic children. Asthmatics and/or those who
have children with asthma and those who do not have asthma and/or children with asthma

did not differ significantly on their mean knowledge scores. See Table 5 for the results.

49

 

 

 

 

 

 

Table 5. T-test Results for Subgroup Comparisons on Knowledge Scores

 

 

 

 

 

 

 

 

 

 

 

 

Subgroup N Mean (SD) t Df p
Comparison
Asthmatic 13 8.34 (3.18) 0.56 71 0.29
Non-asthmatic 59 8.88 (2.82) (one-tailed)
Health Teacher 34 8.79 (3.00) -1.46 71 0.15
Non-Health 38 8.79 (2.79) (two-tailed)
Teacher
Trained 22 9.68 (2.80) 1.77 71 0.04*
Untrained 50 8.40 (2.84) (one-tailed)
Supervise 30 8.83 (2.53) 0.10 71 0.92
Do Not Supervise 42 8.76 (3.12) (two-tailed)
More Educated 45 8.42 (2.87) 1.303 71 0.20
Less Educated 27 9.35 (2.88) (two-tailed)
*Statistically significant at the .05 level

A two tailed t-test was conducted to compare those survey participants who have
taught health classes (in addition to physical education) and those who have not taught
health classes (in addition to physical education) on knowledge scores. Health teachers
and non-health teachers did not differ significantly on knowledge scores. See Table 5 for
results.

A one tailed t-test was also used to compare mean knowledge scores of those
survey participants who have received training on exercise-induced asthma and those
who have not received training on EIA. It was hypothesized that those who have
received training would score significantly higher than those who have not received
training. Those who had been trained and those who had not been trained differed

significantly on their knowledge scores, with trained individuals scoring significantly

50

 

 

 

 

 

higher than those who had never attended training. The null hypothesis was thus

rejected. See Table 5 for results.

A two tailed t-test was conducted to compare mean knowledge scores of those
who supervise children when they use their inhalers and those who do not supervise
children while they use their inhalers. Those who supervise children while they use their
inhalers and those who do not supervise children while they use their inhalers did not
differ significantly on their knowledge scores. See Table 5 for results.

Lastly, a two-tailed t—test was used to determine if there was a difference in the
mean knowledge score of those who have obtained more formal education (a master’s
degree, beyond a master’s degree, or doctoral work) versus those who have obtained less
formal education (a bachelor’s degree or some master’s work). Those who are more
educated and those who were less educated did not differ significantly on their
knowledge scores. Although no statistically significant difference was detected, the mean
score for the less educated was 9.4 versus 8.4 for the more educated. See Table 5 for

results.

51

 

 

Chapter 5
Discussion

This study sought to investigate the knowledge that physical education teachers
have of exercise-induced asthma (EIA). This small-scale study provided some baseline
information on an issue never before systematically examined in the United States.
While the sample size was not quite large enough to generalize to all of physical
education teachers in the two sampled school districts, it did present useful data and
provided information to substantiate a rationale for future investigation in this area

The response rate for this study was 30%, which is similar to the average of 30%
response rate found in other studies that have questioned teachers on asthma (Atchison &
Cuskelly, 1994; Bevis & Taylor, 1990; French & Carroll, 1997; Henry, et al., 1994;
Hussey et al., 1999). This could be due to the fact that the respondents were provided
with a stamped return envelope and/or because they had the opportunity to enter a
drawing. This response rate could also have been due to the fact that the participants had
a vested interest in the topic (80% of the survey participants indicated they wanted results
from the study).

Results of Hypothesis Testing

Several t-tests were conducted to see if a mean difference existed between groups.
The only groups found significantly different on mean knowledge scores were those
individuals who have had some training on the topic and those who have not had training
on the topic. The remaining t-tests did not find significant differences between the
following groups: (a) those teachers who have taught health classes other than physical

education and those who have not taught health classes other than physical education; (b)

52

 

 

those individuals who supervise children while using their inhalers and those who do not
supervise children while using their inhalers; those who supervise students when they are
using their inhalers and those who don not supervise students when they are using their
inhalers (c); and ((1) those who have obtained more formal education (master’s degree,
beyond master’s degree, some doctoral work) versus those who have obtained less formal
education (bachelor’s degree, some master’s work).

Hymthesis One

There were no significant differences found in asthmatics and/or parents of
asthmatics versus non-asthmatics and/or those without asthmatic children. It was
hypothesized that asthmatics would score significantly higher. It should be noted that the
sample size for the asthmatics was disproportionately smaller (n=l3) than the group who
was non-asthmatics (n=59). This falls within the estimated percentage 12%-30% of the
world’s population, as cited in the literature review of this study. It should be noted that
there is a large standard deviation among the asthmatic group, which may have affected
the ability to detect a difference if it did in fact exist.

The literature review conducted for this study did reveal that significant
differences in knowledge of asthma have been found between asthmatics and non-
asthmatics in some studies (Atchison & Cuskelly, 1994). Bevis and Taylor (1990) did
not find significant differences in knowledge of asthma between those who lmve had
exposure (personal, relative, or having had a student) and those who have not had
exposure. The findings in this study may have uncovered another problem, in that it may
suggest that those individuals who have asthma and or a child with asthma may not be

very knowledgeable about their disease. In turn, they may not have a sound

53

 

 

understanding of precautions that need to be taken when modifying students’ physical
education activities. Educating these individuals could also allow them to make better
decisions concerning their own personal asthma management.
Hypothesis Two

There are some potential explanations for the findings from the comparison
among the teachers who have taught health education in addition to physical education
and those who have not. Many physical education teachers are forced to teach health
education classes with minimal or no other training than their physical education
curriculum they studied in college. In addition, the Michigan Model for Comprehensive
School Health Education does not call for expertise of physical education teachers in the
area of asthma and exercise-induced asthma

These findings are noteworthy because they suggest that asthma and exercise-
induced asthma may not be looked at as a serious health issue in the schools where these
physical education teachers are working. If those individuals who are teaching health
education are no more knowledgeable about the topic than those who are not teaching
health classes, it raises a question as to whether there is an awareness about issues such as
asthma and exercise-induced asthma. Lastly, it suggests that there may be a lack of
knowledge of the ways in which asthma and exercise-induced asthma is affecting the
health and welfare of students who are living with the disease. In other words: Are
teachers who are teaching health education aware of the absences and quality of life

issues caused by the disease? These are health issues that arguably could belong in

education curriculum to address the needs of students.

54

 

 

 

 

 

 

Future hypothesis testing is needed to determine whether students are getting
information on childhood diseases that are affecting them. Also, examining the training
of those individuals who are teaching health education is schools would answer some of
the questions that have been raised. Assessing the training and qualifications of teachers
who are teaching health education would be the first step in deciding whether they should
or could teach students about diseases that are affecting them on such a wide scale.
Lastly, health education teachers may prove to be an untapped resource in teaching
students about disease management and recognizing when a child needs to seek medical
attention when experiencing symptoms of an illness such as asthma or exercise-induced
asthma.

Hypothesis Three

The third t-test conducted compared mean knowledge scores between those who
have been trained on this topic and those who have not been trained on this topic. It was
hypothesized that those who have had training on the topic would score significantly
higher than those who have not had training. This hypothesis was supported. The trained
group scored significantly higher than the untrained group.

The literature review supported the findings of this study. Henry, et al. (1994)
were able to demonstrate improved knowledge in asthma scores in all areas tested except
nunagement and medication following a two-hour seminar. The significance of these
findings is that they have demonstrated that training can improve knowledge in particular
topics related to asthma and exercise-induced asthma. This demonstrated success also

provides a rationale for future research in this area.

55

 

 

 

 

Hymthesis Four

Another comparison that was examined was the difference in mean knowledge
scores between those who supervise children while they use their inhalers and those who
do not. The results of the two-tailed t-test revealed that there was no significant
difference in mean knowledge scores of the two groups. These findings may have been
impacted by the law in Michigan This law allows children to handle their own
medication if given permission to do so by a parent or health care provider.

Teachers may feel differently about the necessity of supervising elementary aged
students versus high school aged students. In other words, teachers supervising older
children may not feel as great a need for such knowledge, or have the expectations that
these students are mature and responsible enough to take the medication regardless of
whether or not they are being supervised. Another possible explanation for these findings
can be found in the response given to question P2 of the survey which asked whether or
not elementary teachers should be responsible for ensuring that proper medications be
taken by their asthmatic students prior to engaging in physical activity. The entire survey
group average for this question was 3, or “not sure”. Hussey, et al. (1999) found that
school-teachers in England were concerned that their intervention or handling of
medication could jeopardize the child’s health rather than help it. Bevis and Taylor
(1990) found that the teachers that they surveyed had concerns over the supervision of
children when using their inhalers due to overdoses, loss of the inhaler, or the children
having an unhealthy attachment to it.

These findings could have important implications. They suggest that those who

are supervising and handling medications are not knowledgeable about them, and thus

56

 

 

 

could potentially make uneducated deciSions. As the findings of the literature review

reveal, some teachers feel as though their lack of knowledge could actually jeopardize the
child, rather than help. Further, a physical education teacher who is supervising a student
who is not using their medication properly needs to be aware of the fact that the student is
not using the medication the way it was intended to be used. This could potentially cause
liability issues, and thus reinforces the need for knowledge in this area, as well as
standardized policies for handling asthma and other health related issues.

Hyp_othesis Five

The last comparison made was a two tailed t-test between those who have
obtained more formal education and those who have obtained less formal education.
There was no significant difference in mean knowledge scores between the two groups.
A potential explanation in this finding could be the difference in the education that older
teachers received. For example, exercise physiology has evolved over time. The
research findings and knowledge on illnesses like exercise-induced asthma progress over
time. Therefore, those participants who have been teaching for a longer period of time
may not have had the same information made available to them as more recent graduates
did.

Another possibility that needs to be considered is what type of education those in
the more educated group have obtained. Even though they have completed a master’s
degree or beyond, it doesn’t necessarily mean that the advanced study is in the physical
education realm. Bevis and Taylor (1990) conducted a similar comparison and found no
significant difference between groups of teachers who had obtained more formal

education and those who had obtained less formal education. These findings are

57

 

9’. 4' :7 ‘2‘”

 

 

 

 

significant in that it exemplifies the need for teachers of all educational levels and
experience to be educated on the topic of exercise-induced asthnm.

In summary, the only variable examined in this study that seems to make a
difference in terms of mean knowledge scores is the training, supporting the rationale that
training and formal education on the topic can help a teacher to better understand
prevention, management, medication, and emergency action with respect to the disease.
It should be noted that the individuals who chose to return their surveys are more likely to
find this topic to be worthy and important than those who failed to participate in the
study. Every person who responded indicated that they had had a student with EIA or
asthma. Therefore these respondents may have an interest in the topic versus those who
may never have had a student with EIA or asthma

Limitations in Teacher Knowledge

The results of the questions that made up the medication sub-topic of the survey
highlighted the greatest knowledge deficit of participants. The literature review
summarizes results from many surveys that cover asthma in general. Responses to these
surveys typically showed that EIA was the sub-topic area where knowledge was most
lacking (Bevis and Taylor, 1990; French & Carroll, 1997; Gibson et al., 1995; Hussey et
al., 1999). The current study revealed while 42% of the participants supervise children
while they use their inhaler, 60% could not identify the name of the most effective
medication for preventing an exercise-induced asthma attack. Further, 74% did not know
that beta-adrenergic medications are the most effective type of medications used by
individuals with EIA. These results are of interest as they indicate that the teachers

involved in this study are supervising children while they are using medication, yet they

58

 

 

 

 

 

 

 

 

 

 

 

may not be very knowledgeable about the medication or method of administration. If

physical education teachers are being left to supervise students and their medication, they
need to have the resources and training so they can help children manage their disease
and not inadvertently cause problems that could have been prevented.

The literature review conducted for this study presents the two more prominent
theories on mechanisms and triggers of EIA. The type of exercise, the intensity of the
exercise, the environmental conditions while exercising, and the duration of the exercise
can all contribute to EIA (Wilkerson, 1998). However, the results of the survey issued in
this study indicate that 53% of the respondents did not know that exercise is the most
likely trigger of an asthma attack in children with controlled asthma. Another question in
the survey asked whether or not participating in physical activities in the cold wind would
increase the likelihood of an asthmatic having an asthma attack. While the correct
answer to this question is yes, 40% of the teachers who answered this survey did not
know that fact. This has potential repercussions in that teachers make decisions on gym
class activities on a daily basis. If they are not aware that holding physical education
classes outside on a cool day could be very dangerous for an asthmatic student, it could
potentially cause otherwise preventable problems for the student.

The medical criteria for EIA were also discussed in the review of literature.
Those criteria included clinical measures for determining whether or not someone has
asthma. However, the literature also emphasized the need for field practitioners to have
an understanding of signs and symptoms of asthma because oftentimes diagnostic tests
are not available and undiagnosed asthmatics may be among the student population. The

participants of this study were asked if they knew what factors indicate that a child is

59

 

 

 

 

 

experiencing a bad attack of asthma. The responses for this question indicated that 28%
could not recognize the symptoms of an asthma attack. Further, 39% could not determine
what were the most obvious features associated with asthnm. These findings could also
be considered alarming in that teachers may not even be able to recognize when a student
is in distress or experiencing an asthma attack.

The overall knowledge of the participants was measured in terms of a mean score
on the core 14 questions, each of which had only one correct answer. On average,
respondents answered less than two-thirds of the questions correctly. There is not a
criterion measure with which to compare this score; however, it certainly indicates a
relatively low overall knowledge level of this study sample. As mentioned before, these
results cannot be generalized to all teachers; however these data could serve as part of the
rationale for conducting a similar study on a larger scale. This low level of knowledge is
disturbing because these teachers must make decisions on the type of physical activities
in which children with asthma and exercise-induced asthma must participate. Making
decisions without the proper knowledge of the disease may cause otherwise preventable
problems for students with EIA.

WWW
Medication Availability

There are many school-related issues concerning students with asthma or EIA.
During the school year, youth spend a large percentage of their time at school, thus
increasing the likelihood of experiencing an asthma-related emergency while at school.
One topic of concern for students with respect to school is the availability of their inhaler.

When asked if they allow asthmatic children to keep their inhalers with them, 81% of the

60

 

 

.,._

 

participants indicated that they did allow children to do so. However, 20% indicated that
they did not allow children to keep their inhaler with them. This rate is lower than the
rate found in the literature review, which cited that 39% of the teachers surveyed in
London did not allow children to keep their inhalers with them (Bevis & Taylor, 1990).
Another study conducted in England found that 65% of the 29 schools reporting said that
students were required to hand in their inhaler to a school staff member (Hill et al., 1987).
The disparity in rates could be due to the fact that Michigan has passed Public Act 10,
which allows school children to possess and use their meter-dosed inhaler with proper
authorization from their health care provider and parent. Although only 20% did not
allow children to keep their medication, it is not known if the parent chose that option or
if the teacher decided to hold the medication. In this case, teachers need to be aware of
the law as well as make sure that the medication is available or that there is no delay in
the student accessing the medication if a situation should arise where the student needs it.
Medication Supervision

Another issue relevant to school is the supervision of the youth when using their
medication. The literature reviewed for this study found varying rates. Of the 147
schoolteachers in Ireland who were surveyed on this topic, 70% indicated that they were
responsible for supervising medication administration (Hussey et al., 1999). In addition,
63% of the 164 teachers surveyed in Australia supervised asthmatic children when taking
their medication. Only 42% of the respondents of the current study indicated that they
supervise children while using their inhaler. This, too, may be attnhuted to the passing of

Public Act 10, thus leaving the responsibility with the student rather than the teacher.

61

 

 

 

 

 

Teachers’ attitudes concerning their responsibilities. The survey participants were
also asked their feelings on the whether or not elementary teachers should be responsrhle
for ensuring that proper medications are taken by their students prior to engaging in
physical activity. The response rate illustrates that 50% either disagree or strongly
disagree with that statement, thus indicating that halfof the teachers do not feel as though
they should be responsible for supervising students’ medication. The literature review on
this topic found that 42% of the teachers surveyed in Australia by French and Carroll
(1997) also felt that it is not the responsibility of the teacher to ensure that the necessary
drugs be taken prior to physical exercise. This is notable because it suggests that teachers
may not feel as though this type of responsibility should be left to them. This raises an
interesting question for future policy research: Should this type of responsibility be left
to teachers?

fio_lic1. Michigan Public Act 9 concerns liability of school personnel and
administration of medication. This Act states that a school administrator, teacher, or
other school employee designated by the school administrator, who in good faith
administers medication to a pupil in the presence of another adult or in an emergency that
threatens the life/health of the pupil, is not liable in a criminal action. When asked about
this Public Act, 22% did not answer correctly and 32% were not even aware of the Act.
This, too, is of concern in that some of the participants in this study were not even aware
of the law concerning the issue, or were incorrect in their understanding of it.

In addition to the law concerning the administration of medication, school policy
is another standard that teachers need to be more aware of in order to properly administer

medication and handle asthma related emergencies. The literature review for this study

62

 

 

 

 

 

 

 

 

revealed that many schools surveyed (which were located in other countries) did not even
have a policy concerning medication handling and administration or emergency protocol
(Atchison & Cuskelly, 1994; Bevis & Taylor, 1990; French & Carroll, 1997; Henry et al.,
1994; Hussey et al., 1999). The respondents to this study indicated that 49% worked at a
school that had a policy for handling an asthma attack. Therefore, 51% either did not
have a policy or were unaware of whether a policy existed or not. A standard of care
must be established to ensure the proper steps are taken in handling medication or an
asthma emergency. Without a school policy, a teacher is left to make decisions without
having an established plan to best help the student.
Need for Training About EIA

While the results of this survey indicate that more education may be needed, a
question was also presented in the survey to see if teachers would take advantage of the
education if it were available. The literature has indicated that teachers feel as though
they need more education on asthma in general, but there is not literature that has looked
at EIA specifically. However, this study did ask that question, and 88% of respondents
reported that they are not satisfied with their current level of knowledge on the topic.
Thirty one percent of the participants had received some training on the topic; however,
91 % said they would attend training on the topic if it were offered. These results are
consistent with those of French and Carroll (1997) who found that 91% of the Australian
school-teachers they surveyed did not feel they knew enough about asthma. Hussey et al.
(1999) found similar results, noting that 88% of the teachers they surveyed in Ireland

were not satisfied with their knowledge of asthma.

63

 

 

The fact that the survey was returned indicates that the study participants may
have a higher level of interest in the topic compared to nonrespondants. However, with
such a large percentage indicating that they were not satisfied with their current
knowledge, combined with their willingness to attend training, the result firrther supports
the rationale for developing some type of training for physical education teachers.
Furthermore, if the respondents represent the more interested portion of the targeted
survey population, one might speculate that the knowledge level of the non-responding
teachers was even lower than that measured in the respondents.

Recommendations
Tracking EIA Prevalence

The literature review conducted for this study also exposed a great need for better
tracking of EIA, especially among school aged youth. Statistics on asthma in general are
readily available fi'om the American Lung Association, the National Heart, Lung, and
Blood Institute, the Centers for Disease Control and Prevention, and the Michigan
Department of Community Health. However, there was little information on specific
EIA prevalence rates among school children. Unfortunately, this study was not able to
address this need due to the small sample size and the type of participants involved.
However, the fact that every participant indicated that he or she has had an asthmatic
student at some point in their teaching career reinforces the fact that the prevalence rates
for EIA need to be measured due to the fact that reported rates for this disease have
varied widely (Wilkerson, 1998; Bransford, et al. 1991; Kukaflta et al., 1998; Nichols &

Longsworth, 1995; Vacek, 1999; Rupp, et a1. 1992)-

64

 

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._. ..
‘I'w-‘e‘ ‘1'" 4‘.’

 

The lack of data on this topic is very evident. A better method of tracking and
surveillance of EIA is necessary. The Michigan Department of Community Health
(MDCH) has begun work on the improvement of statewide surveillance and monitoring
of asthma control. MCDH has also started work on a centralized database of asthma
information, which will also serve as a resource to schools and teachers. Further, the
MDCH is in the infancy stages of work to explore the feasibility, benefits, risks, and cost
of a screening system capable of identifying uncontrolled and unrecognized asthma in
school aged children. It is recommended by this study investigator that this system
should include the tracking of EIA and its role in causing or triggering asthma, as well as
emergency room visits due to EIA triggered asthma attacks.

Resources

Michigan has several local asthma coalitions which bring public and private
stakeholders together on a volunteer basis to work on a variety of asthma control and
education efforts, including school-based interventions. This is a good resource for
schools and educators to tap for expert advice and/or potential speakers for in-service
programs to educate teaching stafl‘. It is imperative that individuals who are providing
asthma education services provide core competencies and possess adequate
qualifications. These coalitions are a great place to find that expertise, and oftentimes
these organizations have grant monies available for projects like teacher education.
These coalitions would serve as a good resource for schools that have limited time and
resources to develop and/or conduct training.

Well-designed, comprehensive, and easily accessible learning opportunities and

informal resources are needed to assist physical education teachers. The National Heart,

65

 

 

 

Lung, and Blood Institute has developed a handbook for teachers and coaches who want
to help students with asthma participate in sports and physical activities. It covers the
causes of asthma, symptoms of an asthma attack, how to avoid and control asthma
triggers, how to help students who take medications, and how to modify activities to
match children's current asthma status. The handbook comes with a video and a
reproducible student asthma action card. This handbook provides national guidelines set
forth by the National Institute on Health, and could easily be distributed to physical
education teachers at schools with minimal to no cost to the school. This option would
be a good resource for those schools that have limited time and resources to formally
train their staff.
Education

Wide scale attempts to educate physical education teachers about EIA specifically
have not been made. The literature has not demonstrated what is the best method to
educate teachers on the topic of asthma. Henry, et al. (1994) demonstrated that a two-
hour seminar produced significant differences in asthma knowledge among school staff.
However, Atchison and Cuskelly (1994) conducted a study with a similar design to
Henry, et al. (1994) and failed to produce significant results based on pre and post-test
scores.

In terms of the development of staff in-service training, it is recommended that
this be done on more than one occasion during the school year, as it has been
demonstrated that a one-time iii-service is not always efi‘ective (Atchison & Cully, 1994).

In addition, it is recommended that the iii-service should adopt and provide written

66

 

 

 

 

materials that are consistent with accepted guidelines and standards, such as those

provided by the National Heart, Lung, and Blood Institute.

Information provided in an in-service for staff should include the following
topics: (a) overview of what exercise-induced asthma is and simple physiology of the
disease; (b) prevention; (c) signs and symptoms; ((1) triggers; (e) medications and the
administration of them; (f) the law in Michigan as it pertains to access to and
administration of meter-dosed inhalers; (g) emergency action plans; (h) activity
modifications; and (i) further resources on the topic. There are many components
necessary to provide physical education teachers with the knowledge they need.
Therefore, it is recommended that this information be shared in two or three l-hour
sessions.

There are also several organizations in Michigan which provide access to physical
education teachers and other professionals who could benefit from this type of education
or in-service. The Michigan High School Athletic Association would be one such
organization. Another organization that could be approached with this type of
educational opportunity would be the Youth Sports Institute at Michigan State
University. Lastly, the American Lung Association of Michigan, which already Ins
school-based asthma programs, could be a potential partner or granting agency to develop
this type of program and evaluate its effectiveness.

Conclusion

It is the plan of the researcher that this study will serve as a foundation to conduct

future testing in this area, as well as to develop educational materials and programs for

physical education teachers and other professionals that work with youth who have

67

 

asthma and EIA. This study has demonstrated on a small scale that education in this area
is needed and would be utilized if provided. It is the intent of the researcher to secure
grant firnding fiom one of the agencies discussed to develop education opportunities for
physical education teachers in Michigan. Physical educators have access to a large
population of school-aged children who participate in physical activity. Improving their
knowledge on this topic would serve to improve their decision-making capabilities

concerning the health and welfare of their students.

68

 

 

 

APPENDICES

69

 

 

APPENDIX A

Cover Letter

 

70

 

Laura Kennett

 

April, 2001

Dear Physical Educator,

I am a graduate student at Michigan State University and I am currently gathering
information that is vital to my thesis and that I hope will result in benefits to children
with exercise-induced asthma. As a physical educator, you play a critical role in
encouraging healthy attitudes and exercise habits in young children. Your response to
this ten minute survey will help me and my colleagues develop improved methods of
informing teachers and coaches about prevention and treatment of exercise-induced
asthma.

This short questionnaire is completely confidential. You do not need to provide
your name or identify yourself in any way, nor is there any identifying mark or code on
your survey. However, as a small compensation for your time, you may chose to be
entered in a drawing for a $50.00 gift certificate to MC Sports by completing and
returning the enclosed information sheet. If you decide to do this, I will maintain your
anonymity by separating your contact information from your survey before I look at your
responses. You can also use the infomiation sheet to request a summary of the study. I
have also provided my contact information in case you want to ask me any questions at
any time during or after the study.

I realize that teachers have hectic schedules and that you have a very long “to-do”
list. However, the information you provide may some day serve to help a child. It will
also help me complete my thesis, and graduate. Please return your completed survey no
later than May 31, 2001. Thank you very much for considering helping me out. Your
assistance to me would be appreciated more than you know.

Sincerely,

Laura Kennett

Graduate Student
Michigan State University
Department of Kinesiology

71

 

APPENDIX B

Informed Consent

72

 

 

Informed Consent

I am a graduate student at Michigan State University. As part of my thesis, I am
administering this survey on Exercise Induced Asthma (EIA). Participation is voluntary.
You indicate your voluntary agreement to participate by completing and rettu'ning the
survey. You may choose not to participate at all, may refuse to answer certain questions,
or any discontinue your participation at any time without penalty. Responses will be
kept confidential to the maximum extent allowable by law. Please DO NOT put your
name on the survey. Results will be reported in aggregate form in my completed thesis
and possibly in professional journals or at professional meetings. There are no known
risks with participation in this study. Participation will require approximately 10 minutes
of your time. If you have any questions, I can be reached at (616) 447-0682 or at
laurakennett@netscape.net. If you have any questions concerning your role and rights as
a participant of human research, you may contact Dr. David E. Wright, Chair of the
University Committee on Research Involving Human Subjects at (517) 355-2180.

Filling out the bottom portion of this form is only necessary if you would like to be
entered into a drawing, or would like to get survey result information. In order to
compensate you for returning your completed survey, you may fill out the form below to
be included in the drawing for a $50.00 gift certificate to MC Sports. When I receive this
informed consent with your survey, I will immediately separate the two so as to maintain
your anonymity. Again, you may choose not to fill out this form when you return it with
your survey.

Name: Date:

 

 

Address:

 

City, Zip Code:

 

Phone:

 

Email Address:

 

Yes, I would like to be included in the drawing

Yes, I would like information on the results of this survey

73

 

APPENDIX C

Exercise-Induced Asthma Survey

 

74

 

 

Exercise-Induced Asthma Survey
Directions: Please circle the ONE item
you feel is the correct response.

We:
K1) What is exercise-induced asthma?
1) mucus production in the airways
caused by physical activity
2) a psychological disorder that
causes panic and inability to breath
during physical activity
3) acute, reversible airway
obstruction triggered by physical
activity
4) I don’t know

K2) Swimming is the only exercise that
is suitable for individuals with asthma or
exercise-induced asthma

1) Strongly Agree

2) Agree

3) Not sure

4) Disagree

5) Strongly Disagree

K3) Full participation in sport should
NOT be encouraged to individuals with
asthma or exercise-induced asthma

l) Strongly Agree

2) Agree

3) Not sure

4) Disagree

5) Strongly Disagree

mm
P1) Playing games/physical activities in
the cold wind increases the likelihood of
an asthmatic having an asthma attack.

1) True

2) False

3) Don’t know

 

P2) Teachers of elementary aged
children should be responsible for
ensuring that proper medications are
taken by their students with asthma prior
to engaging in physical activity.

1) Strongly Disagree

2) Disagree

3) Not sure

4) Agree

5) Strongly Agree

P3) Which of the following is MOST
likely to inflame an asthma attack in an
asthmatic child?

1) sudden changes in temperature

2) teacher punishment

3) parental anxiety about child’s
health

4) too much rmdication

5) I don’t know

P4) Which of the following activities
should NOT be undertaken by children
with controlled, mild asthma?

1) swimming

2) running

3) hockey

4) all of the above can be done safely

5) I don’t know

P5) Which is the MOST likely to bring
about an asthma attack in children with
controlled asthma?

1) fear

2) anxiety

3) exercise

4) I don’t know

 

 

 

 

Sigg and Symptoms
Sl) Wheezing after exercise suggests

that a person has asthma
1) Strongly Disagree
2) Disagree
3) Not sure
4) Agree
5) Strongly Agree
82) Asthmatic students are generally
less competent at sports
1) Strongly Agree
2) Agree
3) Not sure
4) Disagree
5) Strongly Disagree

 

S3) What factor indicate that a child is
experiencing a bad attack of asthma?

l) inability to talk

2) presence of wheeze in a distressed

child

3) development of vomiting

4) preoccupation with breathing

5) all of the above

6) I don’t know

S4) What is the most obvious feature
associated with asthma?
1) bouts of coughing
2) wheezing
3) breathlessness / gasping for air
4) all of the above
5) I don’t know

Medication
M1) Antibiotics are the most important
part of treatment for most children with
asthma

1) True

2) False

3) Don’t know

 

 

76

M2) Taking medication for exercise-
induced asthrm as prescrrhed before
physical activity/ games should reduce
the likelihood of an asthma attack.

1) True

2) False

3) Don’t know

M3) Prior to physical activity, beta-
adrenergic medications are the most
effective type of medications used by
individuals with exercise-induced
asthma

1) True

2) False

3) Don’t know

M4) Do you supervise asthmatic
children when they use their inhalers?
1) Yes
2) No

M5) Which of the following
medications is most efi‘ective at
preventing an exercise-induced asthma
attack?

1) Claritin

2) Penicillin

3) Ventolin

4) I’m not sure

Emeggency Action
El) Does your school have a policy on
how to handle an asthma attack?

1) Yes

2) No

3) I don’t know

 

   

 

 

E2) When should an ambulance be
called for an asthmatic child?

1) when the child coughs regularly
2) when the child complains of
wheezing
3) when the child is wheezing
slightly and irritable
4) when the child has had two puffs
of their quick acting asthma
medication within 6 hours
5) none of the above
6) I don’t know

E3) When a child has a severe attack of
asthma and the asthma has not improved
after several doses of medication, which
is the MOST crucial procedure that
needs to be implemented

1) keep the child in the sick bay or

with the school nurse
2) contact a parent or guardian
3) administer prescribed inhaler
every 3 hours
4) call an ambulance
5) I don’t know

mug
T1) Do you feel that you know enough
about exercise-induced asthma?
1) Yes, I am completely satisfied
with my knowledge
2) No, I am not completely satisfied
with my knowledge

T2) Would you attend training on this
topic if it were offered?

1) Yes

2) No

T3) Have you ever had any training on
asthma or exercise-induced asthma?

1) Yes

2) No

 

77

T4) If yes to the previous question,
where did you obtain the education?
I) in-service or seminar
2) college or university
3) community organization
4) local health care agency / hospital
5) Other:

 

Backgiound Information
B1) Do you allow asthmatic children to
keep their inhaler with them?

1) Yes

2) No

B2) Do you currently have, or have you
ever had exercise-induced asthma?

1) Yes

2) No

B3) Do you have an asthmatic child?
1) Yes
2) No

B4) Do you currently, or have you ever
had, an asthmatic child in your class?

1) Yes

2) No

BS) Do you currently, or have you ever
taught health classes other than physical
education?

1) Yes

2) No

B6) Are you currently CPR certified?
1) Yes
2) No

B7) What is your gender?
1) Male
2) Female

B8) Are you aware of Public Act 9 in
the state of Michigan?

1) Yes

2) No

B9) A school administrator, teacher, or
other school employee designated by the
school administrator, who in good faith
administers medication to a pupil in the
presence of another adult or in an
emergency that threatens the life/health
of the pupil is not liable in a criminal
action

1) True

2) False

B10) How many years have you been
teaching physical education?

B11) What grades do you teach?

B12) How old are you?

 

B13) What is the highest level of
education you have completed?

1) Associates degree from a 2 year
college

2) Some undergraduate work

3) A Bachelor degree fiom a 4 year
college

4) Some graduate work (Ph.D or
Masters)

5) a Masters degree

6) Beyond Master’s degree

7) Other:

 

Please return your completed survey on/before May 31Q001 A stamped envelope has been
provided. Mail to: Laura Kennett

78

 

 

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[Warm-ra- Ayn-

c.._ .....

a

75;...

 

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