Assessment of the effectiveness of an asthma education inservice program for elementary school teachers / by Amy E. Pagano. Thesis Nurs. 2900 P343a c .2 AN ASSESSMENT OF THE EFFECTIVENESS OF AN ASTHMA EDUCATION INSERVICE PROGRAM FOR ELEMENTARY SCHOOL TEACHERS By Amy E. Pagano BSN, RN Submitted in Partial Fulfillment of the Requirements for the Master of Science in Nursing Degree Edinboro University of Pennsylvania Approved by: z ////^ zDate Mith Schilling, CRNP, PhD Committee Chairperson /hr / Alice Go.nway, CRNP, PhD) Committee Member/, "7 ~~~~ fyrtpx Geisel, PhD, RN ‘Committee Member y / C--Q Date Date 7 2^0 Acknowledgements I would like to acknowledge and give special thanks to Holly Miller of the American Respiratory Alliance of Northwestern Pennsylvania, for allowing me to participate in the School Asthma Initiative and conduct this study. Holly’s graciousness in inviting me to several School Asthma Initiative programs, and her assistance in data collection, is very much appreciated. I would also like to thank Dr. Judith Schilling for serving as the chair of my thesis committee. Dr. Schilling’s advice and comments were prompt, thoughtful, and always helpful, and I truly appreciate her support. Thank you also to the other members of my thesis committee, Dr. Alice Conway and Dr. Janet Geisel, for their help. Finally, thank you to my husband Bill and my daughter Celia. Their patience and support while writing this thesis made its completion possible. HighMark of Blue Cross sponsors the School Asthma Initiative. ii Abstract An Assessment of the Effectiveness of an Asthma Education Inservice Program for Elementary School Teachers Asthma is the most common chronic childhood illness (Adams & Marano, 1995; Centers for Disease Control and Prevention, 1995). As children with asthma enter school, their teachers may become involved in helping them manage their asthma. Research literature review reveals few studies on teachers’ knowledge of asthma, or on the effectiveness of asthma education programs. The American Respiratory Alliance of Western Pennsylvania conducted an asthma education inservice program for elementary school teachers as part of their School Asthma Initiative. This study was conducted to assess the effectiveness of this inservice program. Malcolm Knowles’ Adult Learning Theory was the conceptual framework for this study. Thirty-six elementary school teachers participated in the study. Teachers’ asthma knowledge was tested using an identical Asthma IQ pretest and posttest. The teachers had a significant increase in their scores on the tests taken after the inservice program (p<0 .01). Responses to a researcher written survey revealed that although at least 60% of teachers reported having students with asthma, and almost one-half of teachers had previously had to assist a student with asthma symptoms, only two teachers had ever attended an asthma education program. Nearly all of the teachers perceived that they should have some role in assisting students to manage their asthma. Children with asthma need proper support at school (National Institute of Health, 1997). Recognizing teachers, at least in part, as caregivers of children with asthma, and iii asthma, and networking in community based organizations to participate in asthma education programs, offers the nurse practitioner another opportunity for education. iv Table of Contents Content Page Acknowledgements ii Abstract iii List of Tables viii List of Figures ix Chapter I: Introduction 1 Background of the Problem 1 Statement of the Problem 3 Theoretical Framework .4 Statement of Purpose .7 Assumptions 7 Limitations 7 Definition of Asthma 7 Summary 8 9 Chapter II: Review of Literature Pathogenesis and Management 9 Teachers Knowledge of Asthma 10 Effectiveness of Asthma Education Programs in Schools 15 Content of a School Asthma Education Program 19 Summary .20 21 Chapter III: Methodology Hypothesis .21 Operational Definitions 21 v Content Page Research Design .22 Setting and Procedure .22 Instrumentation .23 Informed Consent and Protection of Human Rights .24 Pilot Study 24 Data Analysis 25 Summary .25 .26 Chapter IV: Research Results Sample Population .26 Study Results .28 Comparison of Individual Pretest Posttest Items 30 True/False Statements 31 Free Text Questions 31 35 Summary 37 Chapter V: Discussion Findings 36 Importance of the Study 37 Support for Conceptual Framework 38 Study Limitations 38 Recommendations... 39 .40 Summary.. .41 References.. vi Page Content Appendixes ,43 A. Asthma LQ. Test .43 B. Survey .44 C. Oral Introduction .45 vii List of Tables Table Page 1. Years of Teaching Experience .27 2. Classroom Teachers Report of Students with Asthma 28 3. Teachers Having Assisted a Student Having Asthma Symptoms .29 4. Teachers Pretest and Posttest Scores 30 5. Name Three Things That Happen to the Lungs During an Asthma Attack. 32 6. Name Three Triggers of Asthma 34 7. Name Two Things You Can Do to Help A Student Having an Asthma Attack..34 viii List of Figures Page Figure 1. Percentage of teachers naming wheeze or cough as early warning signs of asthma attack 33 2. Teachers mentioning medication, or inhaler use as means of assisting students with asthma ix 35 Chapter I Introduction This chapter provides an overview of asthma in children including symptomatology, epidemiology, and the current National Heart, Lung, and Blood Institutes’ (NHLBI) Expert Panel Report guidelines for asthma management (National Institute of Health [NIH], 1997). Asthma is a chronic disease, and knowledge about asthma and its components of care are essential for proper management (NIH, 1997). As children enter school, teachers in addition to family and health care providers including nurse practitioners may become involved in the management of asthma and, therefore, may need education about the disease. A description of Malcolm Knowles’ Adult Learning Theory, which serves as the conceptual framework for the study, is provided in this chapter. The definition of terms, the assumptions and limitations of the study are also included Background of the Problem Asthma is a chronic inflammatory disorder of the airways that often begins during childhood. Asthma is characterized by airway hyperresponsiveness and variable, but often reversible, airflow obstruction (NIH, 1997). Asthma’s range of symptoms may include wheeze, cough, shortness of breath, reduced expiratory air flow, exercise intolerance, and respiratory distress (Szilagyi & Kemper, 1999). When asthma begins in childhood it is often associated with atopy (NIH, 1997). Asthma is the most common chronic childhood illness, affecting between 4% and 7% of children, or approximately 48 million children under the age of 18 in the United States 2 (Adams & Marano, 1995; Center for Disease Control and Prevention [CDC], 1995). There are more than 5,000 deaths from asthma each year (NIH, 1997). In recent years asthma has increased in both the number of children affected, and in the severity of disease in affected children. Asthma occurs more commonly in African-Americans, and in those living in an inner city environment (Szilagyi & Kemper, 1999). Approximately one-third of children with asthma have some limitations in their activities (Newacheck & Taylor, 1992). Asthma is the most common reason for school absence (Newacheck & Taylor, 1992) and children with asthma have a higher risk of academic problems when compared to well children (Fowler, Davenport, & Gary, 1992). The NIH (1997) NHLBI Expert Panel Report 2: Guidelines for the Diagnosis and Management ofAsthma identifies four components of care necessary for effective asthma management. These include: 1. Initial assessment and diagnosis of asthma with severity classification to guide stepwise therapy, followed by periodic assessment and ongoing monitoring to determine if goals of therapy are being met. 2. Control of factors contributing to asthma severity, including identification of and reduction of exposure to allergens and irritants. 3. Pharmacologic therapy in a stepwise approach based upon severity, including long term control medications and quick relief medications used to treat acute symptoms and exacerbations. 4. Patient education for a partnership in asthma care begun at diagnosis and incorporated into each step of care. 3 Patient education and knowledge about the disease is an especially necessary component of asthma care because management of asthma requires that patients and other caregivers be able to follow complex medication routines, institute environmental control measures, detect and treat exacerbations, and effectively communicate with health care providers (NIH, 1997). Statement of the Problem The NHLBI National Asthma Education and Prevention Program (NAEP) School Asthma Education Subcommittee (NIH, 1997) determined that, in order to keep their asthma under control and to lead fully active lives, children with asthma need proper support at school. Once children enter school, they spend a large part of their day under the supervision of their teachers, who may become involved in assisting students in managing their asthma. Because of this, teachers, in addition to the child’s home caregiver, need knowledge about asthma and its management. Without training, teachers may feel reluctant to help students, believing the situation to be a medical issue rather than an educational issue (Bannon, 1995). The nurse practitioner uses education as an integral part of practice. A partnership in care between the health care provider and patients with asthma and their caregivers is identified as a necessary component for effective asthma management (NIH, 1997). Recognizing that teachers may be assisting students with asthma, participation by the nurse practitioner in a community-based asthma education program for teachers such as the School Asthma Initiative offers a unique method for facilitating this partnership in care. 4 Theoretical Framework Malcolm Knowles’ Adult Learning Theory served as the theoretical framework for this study (Knowles, 1980). Knowles’ theory identified two types of educating: pedagogy and androgogy. The characteristics of pedagogy and androgogy can be contrasted by viewing the assumptions of each model in relation to the following categories: (a) concept of the learner, (b) role of learners’ experience, (c) readiness to learn, and (d) orientation to learning (Knowles, 1980). Knowles identified both pedagogy and androgogy as alternative models of assumptions about learners. However, he also identified the models as most useful when they are not seen as dichotomous, but on a continuum, with the learner in a given learning situation placed somewhere between two ends. Pedagogy, “the art and science of teaching children” (Knowles, 1980, p. 40), is the first model of assumptions about learning and characteristics of learners. Pedagogy evolved over the centuries, and its assumptions were based on the teaching of young children, with education being the process of transmitting what is known (Knowles, 1980). In pedagogy the learner is dependent and the teacher decides what is to be learned, how it is to be learned, and how learning is to be evaluated. The role of the learner’s experience is limited, possibly serving as a beginning point, and the primary teaching technique is transmittal, with lecture as an example. In pedagogy readiness to learn is determined by others, such as society or schools. Finally, in pedagogy the learner is subject-centered in their orientation to learning, and most subject content is understood to be useful later in life (Knowles). 5 Androgogy is the term used to describe the theory of adult learning that evolved from research-based knowledge about adult learning derived from educators and other related disciplines including clinical and developmental psychology, gerontology, sociology, and anthropology (Knowles, 1980). Knowles (1980) wrote that androgogy, or adult learning, is premised on four assumptions about the characteristics of learners that are different from those on which pedagogy is based. The concept of the learner in androgogy acknowledges that as part of normal maturation the person moves from dependency to increasing self-directedness. Adult learners are identified by Knowles (1980) as having “a deep psychological need to be generally self-directing, although they may be dependent in particular temporary situations” (p.43). The role of the learner’s experience in androgogy contrasts to that of pedagogy in that experiences obtained through growth and development serve as resources for the learner and others (Knowles, 1980). In androgogy learning gained from experience holds more meaning than learning gained passively. Educational techniques in andrgogy are, therefore, based on experiential methods, for instance discussion or problem solving cases. Readiness to learn in androgogy occurs when a person experiences a need to learn something in order to manage tasks or problems. The educator helps the student discover their learning needs (Knowles, 1980). Finally, the adult learners’ orientation to learning in androgogy is one of immediacy of application of knowledge (Knowles, 1980). The learner sees education as a means of developing increased competence to achieve full life potential. Learning shifts from subject-centeredness to performance-centeredness. 6 Patient education is a foundation of practice for the nurse practitioner, and may be considered a distinguishing feature of the nurse practitioner as a health care provider. Positive outcomes of patient education may include earlier detection of disease, better management and fewer complications from chronic diseases, and fewer hospitalizations (Glanville, 1999). Patient education in today’s health care setting has evolved to include a range from disease-specific teaching to teaching for prevention, health maintenance, and health promotion. This scope offers nurse practitioners opportunities to use their strengths as educators in a variety of settings including teaching in the primary care office, teaching in clinics, facilitating support groups, and teaching in group settings in the community. Asthma is a common health problem encountered in primary care. Networking within an existing local organization, such as the American Respiratory Alliance of Western Pennsylvania, the nurse practitioner can participate in community outreach programs to help meet asthma education needs. The nurse practitioner can utilize knowledge of adult learning in an asthma education inservice program given for teachers. Pretest assessment of asthma knowledge, and discussion of asthma and its implications, can help teachers identify their own need for knowledge about asthma and asthma management. A variety of educational techniques are used in the American Respiratory Alliance of Northwestern Pennsylvania’s asthma inservice education program. These techniques, including illustrations, discussion, questions, manipulation of equipment, and use of relevant classroom examples, can help the teacher obtain the knowledge needed to assist a student in the classroom with their asthma management. 7 Statement of Purpose The purpose of this study was to determine the effectiveness of an asthma education inservice program given for teachers at an elementary school in the Oil City School District in Venango County, Pennsylvania. A researcher-written survey was done to determine whether the teachers perceived themselves as having a role in assisting their students with asthma to manage their disease. It also described the study sample population. Assumptions The assumptions of the study were as follows: 1. There are children in the schools with asthma who may require assistance in their asthma management from their teachers. 2. School teachers would attend the asthma education inservice program and be able to read and complete the survey, pretest, and posttest. Limitations The limitations of the study were as follows: 1. The study was limited to one school in one county in Pennsylvania, and may not be generalizable to other school systems or teachers. 2. The study measured pretest and posttest knowledge obtained from an inservice program, and may not reflect future retention or proper use of the information. 3. The study did not address the effect of the program on asthma morbidity in children. Definition of Asthma The following term is defined as it was used in the study: 8 Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, neutrophils, and epithelial cells. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli (NIH, 1997, p. 1). Summary Asthma is a chronic inflammatory disease, and is the most common childhood chronic illness (Adams & Marano, 1995). Caring for asthma requires that children with asthma, and those involved in their care, are knowledgeable about the disease and its components of care. As children enter school, their teachers may become involved in their asthma care and, therefore, need knowledge about the disease and its management. Malcolm Knowles Theory of Adult Learning was the framework this study used to assess the effectiveness of an asthma education inservice for teachers conducted at an elementary school district in Oil City inVenango County, Pennsylvania. The definition of asthma, and assumptions and limitations of the study, were included in this chapter. 9 Chapter II Review of Literature The purpose of this study was to assess the effectiveness of an asthma education inservice program for elementary school teachers. This chapter describes the pathogenesis of asthma and components of asthma management. Research literature on teachers’ knowledge of asthma, and on the effectiveness of asthma education programs for teachers, is reviewed. This chapter also includes a description of the National Asthma Education and Prevention (NAEP) program guidelines for managing asthma at school. Pathogenesis and Management Asthma is a chronic inflammatory disorder of the airways at all levels of severity (NIH, 1997). The airway inflammation that occurs in asthma results from complex interactions among inflammatory cells, mediators, and other cells and tissues of the airways. Features of asthma in relation to lung function include airway hyperresponsiveness and airflow obstruction. An exaggerated bronchoconstriction response with bronchi narrowing too easily, and too much to a variety of stimuli, occurs in asthma, and airway inflammation contributes to the airway hyperresponsiveness. Airway hyperresponsiveness can lead to the clinical symptoms of wheezing and dyspnea after exposure to triggers such as allergens, environmental irritants, viral infections, cold air, and exercise. Airway limitation or obstruction that occurs in asthma is recurrent, and caused by a variety of changes in the airway including acute bronchoconstnction, airway edema, chronic mucus plug formation, and airway remodeling. 10 Asthma severity is classified as mild intermittent, mild persistent, moderate persistent, and severe persistent (NIH, 1997). However, a mild, moderate, or severe exacerbation of asthma can occur at any level of asthma severity. Components of asthma care include initial assessment and diagnosis followed by periodic assessment and monitoring, control of factors contributing to asthma severity, pharmacologic therapy, and education (NIH, 1997). Goals of asthma therapy are symptom prevention, maintenance of normal pulmonary function, maintenance of normal activity level, prevention of exacerbation, provision of optimal pharmacotherapy, and satisfactorily meeting patient and families expectations of care. Asthma medications are categorized into long-term control medications directed toward long-term suppression of inflammation, and quick-relief medication for treating symptoms and exacerbations (NIH, 1997). Asthma pharmacotherapy should be instituted along with environmental control measures. Patient education should begin at diagnosis and be ongoing (NIH, 1997). Key educational messages include basic facts about asthma, roles of medications, skills such as inhaler and peak flow meter use, environmental control measures, and when and how to take rescue action. A daily self-management plan should be written. A self­ management plan should also be written to help school personnel manage a child s asthma. Teachers’ Knowledge of Asthma A study conducted in Holon, Israel (Brook, 1990) evaluated teachers’ knowledge and information about asthma, and determined teachers’ awareness about asthmatic students in their class. The study also compared general classroom teachers to single subject 11 teachers. Two of six high schools were randomly chosen, representing 113 teachers teaching 1,422 students. A three part 40-item questionnaire asked about experience in teaching, asthmatic pupils in the classroom, and teachers’ general knowledge and information about asthma. General knowledge questions were checked by a single physician and rated as correct, absence of knowledge, or incorrect. The teachers answered 50/o of the asthma questions correctly, and there was no significant difference between general and single subject teachers. With the exception of physical education teachers, who received medical information concerning students, general subject teachers were more able than single subject teachers to identify asthmatic pupils, and were more able to estimate severity of symptoms. The study revealed that 65% of the teachers’ knowledge of asthma came from reading articles in journals or health periodicals, and by reading health books (Brook, 1990). In addition, 46% of the teachers also acquired asthma information by talking with nurses and physicians. Other sources of asthma knowledge included previous studies, asthmatic friends, acquaintance with parents of children with asthma, and television programs. Eighty-seven percent of the teachers responded positively to the suggestion of learning more at school about asthma. Bevis and Taylor (1990) surveyed 98 teachers in eight primary schools in London to assess the asthma knowledge among primary teachers, and to identify specific areas of lack of understanding. The study was also done to investigate how teachers felt about managing asthmatic children in school, and policies for giving treatment. A questionnaire comprised of 33 statements about asthma, to be marked ■true” “ false,” or “don’t know” was used. There were 17 additional questions on the teachers’ views and opinions about 12 asthmatic students, about their experience with children with asthma, and about their views on policy for giving medications. Although 69% of the teachers had taught asthmatic children, only 5% thought that they knew enough about asthmatic children, and only 4 /o reported that they received any asthma training or teaching. Correct responses to statements about asthma varied widely, and most teachers answered “don’t know” or incorrectly responded to all statements about medications except Ventolin. Teachers’ understanding of the relationship between exercise and asthma was also limited, and although 79% of teachers thought that asthmatic students should be encouraged to participate in exercise and sports at school, only 27% recognized cold air as a trigger and only 33% knew that premedication before exercise could prevent symptoms. The schools’ policies on asthma medication varied. Some of the teachers reported being unaware of a policy, and only one-half of the teachers allowed students to keep their inhalers with them. Noting that asthma in New Zealand is a major child health problem, Seto, Wong, and Mitchell (1992) conducted a survey in South Auckland to examine management of asthma in the primary schools, and the teachers’ knowledge, confidence, and attitude in managing students with asthma. Forty-two primary schools were randomly chosen to participate. School principals were given a questionnaire asking the number of students in the school, the number of students with asthma, the method of notifying the school of students with asthma, who was responsible for management of asthma in children and supervision of medication administration, and use of a nebulizer for medication administration. 13 Questionnaires were also given to 253 randomly selected teachers Iron, these schools asking age and length of teaching experience, experience with students with asthma, and their personal experience with asthma (Seto et al. 1992). Questions were also asked to test the teachers’ asthma knowledge, their confidence in the administration of inhaled medication, and to ascertain their sources of information about asthma in children. The questionnaire (Seto et al. 1992) was completed by 76% of the school principals and 66% of the schoolteachers selected. The mean percentage of students reported as having asthma by principals was less than previously reported in the literature for this area. Students were identified as having asthma by entrance questionnaire, parent report, and previous school records. In 51% of the schools, the class teacher was the person primarily responsible for supervising the needs and treatment of students with asthma. Sixty percent of the schools allowed either the teacher or the student to keep the inhaler medication. Although all teachers had a book on asthma management at school, only 37% reported having used it. Ninety-seven percent of the teachers reported having taught students with asthma, and 76% had witnessed an asthma attack. Teachers were considered to have good asthma knowledge, with the exception of knowledge about asthma medications, with 66% recognizing Ventolin as being a symptom reliever, and less than 50% recognizing preventive medications. Also, 52% of the teachers had the misconception that overuse of asthma medication would result in diminished effect, meaning that they might be reluctant to repeat treatment with a bronchodilator medication. Teacher education, especially on practical aspects of asthma management, was recommended based on the study. 14 Capers. Ebbutt, and Ba™ (1995) conducte(i a schools in Wes. Gloucestershire. England determine their level oflomwledge about asthma, and whether increased knowledge of asthma was associated with increased ability to help children manage asthma. TTte survey was conducted in suburban, rural, and innerwity- areas. Sixty-one percent of schools responded to the survey, representing 235 teachers in 48 schools. The survey included background questions about the number of students in the classroom with asthma, exposure to asthma training, experience of direct contact with asthma, and knowledge of asthma treatment plans and location of asthma medications in the school. There were also questions to assess general knowledge about asthma. A trained asthma nurse coded the survey. Teachers were placed in subgroups based on exposure to asthma training and direct contact with persons with asthma. Sixty- one percent of the teachers had no asthma training, and no asthma knowledge related to direct contact with asthma. Comparison for differences between these subgroups was done using a chi-square test, with significance level at .05. The study found limited knowledge of asthma among the teachers. All teachers recognized asthma as a respiratory problem, but only 32% mentioned airway constriction, and even fewer were aware of allergic and inflammatory changes. Teachers with both asthma training and direct contact with asthmatics were more knowledgeable than those with neither. These teachers more able to correctly identify airway characteristics of asthma, with 41 /o knowing airway constriction (p<0.001), and 14 % more knowing airway inflammati (B They were also more knowledgeable about triggers of asthma symptoms, 31% more mentioned allergies (p-0.001), and 26 % more mentioned upper respiratory infeelions (rO.OOl). Knowledge of what to do if a child has an asthma attack was aiso limited in 15 that only 41% of all teachers mentioned administering an inhaler medication. Teachers with asthma training or direct contact with persons with asthma were 48% more likely to call parents (p<0.001), and 25% more likely to get medical help (p<0.001). Teachers with asthma training were most likely to mention inhaler use (difference 40%, p=0.007). Seventy percent of children were not permitted to keep their inhalers with them. In parallel with this survey, a group of teachers was formed in conjunction with the Asthma Training Centre to design educational material for use in schools. Recommendations of the study were for education of school personnel about asthma, and formation of a national policy on asthma management in schools. Bowen (1996) conducted a study in England to determine whether teachers had received education in their basic teacher training, or inservice training, for dealing with emergency situations in children with asthma, epilepsy, and diabetes. Surveys were given to 36 teachers with varying levels of experience in five schools, and 83% were returned. The knowledge of teachers was not tested. All of the teachers reported having students in their class with asthma. Seventy percent of the teachers reported having received instruction on children’s medical conditions in their teacher training, and 50% stated they had had updates since. However, only 43% of the teachers reported feeling competent to cope with a child having an asthma attack, and 83% of the teachers requested further training. Subsequent to the study, a training session on each of the three conditions surveyed was arranged. Effectiveness of Asthma Education Programs in Schools In conjunction with the American Lung Association of Oregon, Eisenberg, Moe and Stillger (1993) developed an asthma education program for medical and nonmedical 16 personnel in schools. The program was conducted statewide in Oregon, with data reported from four programs. School personnel attendance was voluntary, with the exception of some school districts requiring school nurses to attend. An assessment tool was mailed to participants prior to the program. The tool consisted of 24 statements about asthma with true, false, or don t know” as possible responses. There were seven additional questions asking about participants’ role at school, medication policy and responsibility for asthma management, attitude regarding medication administration at school, and personal experience with asthmatic children. A second assessment tool was mailed to participants 4 weeks after program attendance. Ninety participants completed pretest tools, and of those, 37 or 46 % completed posttest tools. On the initial assessment tool nurses scored higher than nonmedical personnel. For each question the percentage of correct answers increased from pretest to posttest, and there was a decreased number of “don’t know” responses for each question. For the entire group there was a statistically significant increase from pretest to posttest scores (p<0.001), with correct responses to 24 knowledge statements about asthma increasing from 15.9 to 20.2. Posttest scores for nonmedical staff were nearly identical to the nurses. Although the low number of post class assessment tools returned was identified as a possible bias of the data, as nonresponders may have been less knowledgeable, the data indicated that nonmedical personnel can demonstrate an increase in their level of understanding about asthma .her attending an educational session. Hazel, Henry, Frances, and Halliday (1995) initiated a study in New South Wales. Australia to assess whether information about asthma acquired by individual teachers at an asthma inservice seminar would be disseminated to other schoolteachers and staff, and 17 whether the information would lead to schools developing policies about asthma management. A 2-hour asthma education inservice seminar for school staff was presented by an asthma educator in each school district in the region, with at least one representative from each school attending. Fifty schools were randomly chosen for a telephone survey from the 149 primary schools that participated in the seminars, and personnel at 48 of these 50 schools completed the telephone survey. The asthma educator who presented the inservice program did the telephone survey. The survey was a 30- minute interview that documented each school’s policy and procedure for management of asthma before and after the seminar. The survey also asked questions about the feedback given by the teacher who had attended the inservice program to other teachers and personnel at the home school. In all 48 schools feedback was given to the teachers by the person attending the inservice and all, or most, of the staff were reached in 46 of the schools (Hazel et al. 1995). Presentation of the information obtained at the asthma inservice seminar was most commonly done at a staff meeting, and for more then 80% of the schools the content of the feedback included information on asthma symptoms, medications, asthma equipment for the first aid kit, guidelines for the treatment of an asthma attack, and the issue of having a school policy. After the seminar the number of schools with an asthma policy increased from one to 20 (p<0.001), and the number of schools requesting written instructions from parents about management of their child’s asthma increased from 18 to 44 (p<0.001). Prior to the seminar only four of the teachers felt that the staff at their school knew how to recognize an asthma attack. At the time of the follow-up survey this number had increased to 22 (£<0.001). Because the asthma educator conducted the 18 interviews, and because those interviewed were the persons attending the original seminar, the researchers acknowledged the possibility of observer bias in the study. However, they concluded that inservice education is an efficient means of communicating asthma education, and resulted in improved knowledge of staff about asthma, with an increased number of schools developing appropriate policies and procedures for asthma management. Kaiser Permanente Medical Center implemented and studied Peak Performance USA, an asthma education training program developed by the American Association of Respiratory Care, at two of six school districts in San Jose, California, reaching 180 school personnel (Powell, 1998). After contacting principals, nurses in the six school districts of the medical center’s service area were asked to attend an initial planning meeting. Training sessions were set up in the two school districts that agreed to participate, representing 65 schools. Schools were given a package of written material on asthma management training, and peak flow meters and aero chambers (spacers) were given to physical education teachers. All teachers were given Peak Performance USA asthma management guide handouts. Either a 2-hour or a 3-hour class was also presented and attended by 180 school personnel, including at least one person from each of the 65 participant schools. A preprogram questionnaire was administered before the class session, and a post­ program questionnaire was administered by mail 6 months afterward (Powell, 1998). Chi-square testing was used to compare preprogram and postprogram results for increased knowledge and confidence, and statistical significance was p<0.05. Of the 180 persons attending, 47 completed both the pre and posttes. questionnaires used for data 19 analysis, although some preprogram data were missing and not all items were answered by every participant. Preprogram, 42% of 19 respondents stated they were “not at all” confident in their ability to help a school child with asthma management, while none responded “not at all” in matched analysis of the postprogram question (p=0.003). Of 20 personnel responding to the question about two things a child can do to manage asthma symptoms, 65% answered correctly preprogram, and 100% answered correctly postprogram (p=0.008). Preprogram, 86% of responders knew that children with asthma should not avoid exercise; this increased to 100% postprogram(p=0.007). The chief limitation of the study was identified as the low response rate. As a result of the program, an additional school district requested the training, and a participating district requested a review of the training a year later. Content of a School Asthma Education Program The NHLBI encourages a partnership between students with asthma and their families and health care providers and school personnel in managing and controlling asthma (NIH, 1991). Comprehensive school asthma education for school personnel should focus on encouraging recognition of asthma as a disease requiring ongoing care, with the understanding that proper asthma treatment and education will improve the school performance of students with asthma. Effective management of asthma at school encourages a supportive learning environment for students with asthma, decreases number of absences, decreases classroom disruption, and provides necessary support for emergency asthma situations (NIH, 1991). 20 Managing Asthma: A Guide for Schools (NIH, 1991) was developed as a collaborative project between several government agencies, including the NHLBI and NAEP, and was designed to help schools develop and maintain an asthma management program that provides school personnel with practical ways to assist students with asthma. The informational content of the guide includes a definition of asthma and description of asthma symptoms. Also included are measures for effectively managing asthma, such as recognition of early warning signs of an asthma episode, identification and avoidance or control of common asthma triggers, use of anti-inflammatory and bronchodilator medications, and monitoring asthma with a peak flow meter. According to the guide (NIH, 1991) schools are encouraged to help students manage their asthma by providing support through the development of an asthma management program. The asthma management program should include school policies and procedures for medication administration, specific actions for staff members to perform in asthma management, and an action plan for student asthma episodes. The action plan is specific to each individual student, is completed by the parent and physician, and is kept on file at the school. Summary This chapter reviewed the pathogenesis of asthma and current recommendations for asthma management. A review of recent research studies done to assess teachers knowledge of asthma, and to assess the effectiveness of asthma education programs for to school personnel, is included in this chapter. This chapter also reviewed NHLBI, NAEP (NIH, 1991) recommendations for content of asthma education for school personnel. 21 Chapter III Methodology This chapter describes the research methodology used for this study. The American Respiratory Alliance of Western Pennsylvania conducted a school asthma initiative in public schools in several counties in Pennsylvania. This program included asthma education for school nurses, teachers, and students with asthma at the elementary and middle school grade levels, and peers of students with asthma at the middle school grade level. The curriculum for each group contained key educational messages identified by the NHLBI National Asthma Education Program (NAEP) (NIH, 1991). This study was done to determine the effectiveness of the asthma education program given for teachers by the American Respiratory Alliance, as part of the schools’ asthma initiative. Included in this chapter are the research hypothesis, operational definitions, and method of informed consent. A description of the research design, instrumentation, procedure for data collection, and data analysis is also included. Hypothesis The hypothesis of this study was that the teachers would have a statistically significant improvement in their scores on the Asthma I.Q. test taken after the inservice program. Operational Definitions The operational definitions of the study were as follows: 1. Elementary school teachers were teachers teaching students in grades kindergarten through six in a public school in Pennsylvania who attended the asthma education inservice program. 22 2. Asthma education inservice program was an education program about asthma and asthma management for teachers designed and given by the American Respiratory Alliance of Western Pennsylvania. The inservice program was presented to the teachers, as a group, in an inservice education setting. 3. Asthma knowledge was evidenced by an asthma I.Q. test, a test about asthma and asthma management developed by the American Respiratory Alliance of Western Pennsylvania (Appendix A). Research Design A preexperimental design using a pretest posttest was used for the study. A researcher-written survey was also administered immediately prior to the inservice program (Appendix B). Setting and Procedure This study was part of an education inservice program about asthma and asthma management developed for teachers by the American Respiratory Alliance of Western Pennsylvania. The inservice content included a 15-minute videotape about asthma management in the school. The videotape was made by the NHLBI National Asthma Education Program (NIH, 1995). Basic anatomy and physiology of the respiratory system was presented and reviewed, followed by a description of the pathophysiology of asthma and asthma symptoms. In addition, overhead illustrations were used throughout the program to present information about triggers of asthma symptoms, early warning signs of an asthma attack, the use of individualized school action plans for students with asthma, and school personnel procedures. Peak flow meter use and its significance in 23 asthma management was discussed, as was the use of anti-inflammatory and bronchodilator drugs administered via metered dose inhalers with spacers. A period of time was allotted for questions and discussion, and questions were encouraged throughout the program. Examination and manipulation of peak flow meters, and metered dose inhalers and spacers, was allowed. Teachers were given a folder with written information reflecting the content of the program to keep for future reference. The inservice program was given for elementary school teachers from the Oil City school district in Venango County in Pennsylvania. An asthma educator trained by the American Respiratory Alliance of Western Pennsylvania conducted the inservice. The inservice was mandatory, and was conducted in a group setting on a planned teacher inservice day. Instrumentation An asthma I.Q. test developed by the American Respiratory Alliance of Western Pennsylvania was administered prior to and at the completion of the inservice program. The test was graded and scored by the researcher. The test consisted of six true/false questions, and four free-text questions about asthma and asthma management. The pretest questions were identical to the posttest questions. Each true/false question was marked correct, or incorrect, and was given one point. Each of the 4 free-text questions asked the participant to name either two or three things. One point was given for each thing correctly named and were, thus, worth either two or three points. There were 16 possible points on the test. A researcher-written survey (Appendix B) of the inservice participants was conducted prior to the inservice program. This survey consisted of eight questions to determine the 24 presence of students with asthma in each teacher’s classrooms, their perceptions of their role in assisting students to manage their asthma, previous experience assisting a student with asthma, previous personal experiences with asthma, previous experience in attending an asthma education program, their number of years of teaching experience, and the grade level taught. Informed Consent and Protection of Human Rights An oral introduction was given by the asthma educator to convey the importance of the problem and the purpose of the study (Appendix C). Submission of the completed survey constituted consent to participate in the study. Only grouped data are reported, and no names were placed on the pretests, posttests, or surveys. The study was eligible for expedited review for protection of human rights by the Edinboro University of Pennsylvania review board. Pilot Study A pilot study of the researcher-written survey was conducted at an inservice education day for high school teachers in Cranberry Township in Venango County, Pennsylvania. There were 47 participants. A survey question regarding teachers’ perception of their role in assisting students to manage their asthma was added. This was done because no literature was found examining teachers concerns regarding asthma management. If teachers do not feel they should have a role in assisting students to manage their asthma the inservice education program may be moot. A question regarding personal experiences with asthma was added because the literature review revealed that personal experiences of persons with asthma may affect knowledge of asthma and may be useful in making comparison. 25 Data Analysis Descriptive statistics were applied to the study survey, and the pretest and posttest results. The survey data were analyzed by counting the frequency of responses to the dichotomous questions. These were placed in frequency distribution and percentage tables. Years of teaching experience was placed in a frequency distribution, and then grouped by 5-year intervals. Numbers of students in the classroom with asthma, and the total number of students in the classroom, were placed in a frequency distribution table. Measures of central tendency were used to describe the survey results and sample population. Similarly, the pretest and posttest item results, identified as correct or incorrect, were scored and were placed in frequency distribution and percentage tables. Pretest and posttest results were placed in percentage tables for comparison. Pretest and posttest score ranges and means were determined. A paired t-test was used to test the research hypothesis. Summary The purpose of this study was to determine the effectiveness of an asthma education inservice program given for elementary school teachers. A pretest-posttest design was used. A researcher-designed survey was also given. A description of the research design and instrumentation, method of informed consent, a pilot study, and data analysis were included in this chapter 26 Chapter IV Research Results This chapter presents the results of the Asthma IQ test given to elementary school teachers prior to and following an asthma education inservice program. Thirty-six elementary school teachers in the Oil City school district in Venango County Pennsylvania completed a survey, and Asthma IQ pretest and posttest, and were included in the study. Data on the sample population, teacher survey, and individual test item comparison are also included in this chapter. Sample Population Forty-six elementary teachers completed the survey and were eligible for the study. Of these, 36 teachers completed both the pretest and the posttest, and their data were used for the study. There were 26 regular classroom teachers grades kindergarten through five. The remaining ten teachers included two reading teachers, two physical education teachers, two learning support teachers, one special education teacher, and one school librarian. The teachers’ number of years of teaching experience ranged from 1 to 35 years, with more than one-half of the participants having taught for more than 15 years (Table 1). Three teachers reported having taught for 35 years. Classroom teachers of kindergarten through fifth grade reported a range in classroom size from 16 to 30 students. The average class size was 23 students. Of all the teachers, 66% reported having students in their classrooms with asthma. Eighteen of the 26 regular classroom teachers reported having students with asthma, and eight reported having none. The reported number of students in the classroom with 27 asthma ranged from one student to five students, with one or two students being reported most often (Table 2). The teacher who reported five students in her classroom with asthma commented that in the last few years there had been one student per year with asthma. Table 1 Years of Teachine; Experience (N=36) Years of Teaching 2 1 to 5 7 6 to 10 6 11 to 15 1 16 to 20 4 21 to 25 4 26 to 30 11 31 to 35 3 Six of the ten teachers who did not have a regular classroom reported having students with asthma. One of the physical education teachers estimated that of 700 total students, 30 have asthma, and the other physical education teacher reported having lots of students with asthma. Both music teachers, who see children grades kindergarten through fifth, reported having students with asthma: one had ten students, the other wrote that she had “many.” A reading teacher who sees 60 students reported three students with asthma, and a learning support teacher reported two. 28 Table 2 Classroom Teachers Report of Students with Asthma (N=26) Students n 0 8 1 7 2 7 3 3 4 0 5 1 Nine of the teachers, or one-quarter of participants, reported having personal experience with asthma. Only two of all 36 teachers had ever attended any other asthma education program. In response to the survey question “Have you ever had to assist a student who was having asthma symptoms?” 17 teachers, or 47%, reported they had, and 19, or 53%, reported they had not (Table 3). Thirty-three of 36 teachers responded to the question “What role should elementary teachers have in assisting students to manage their asthma?” No teacher responded that they should have no role. Study Results The hypothesis of this study was that the teachers would have a statistically significant improvement in their scores on the Asthma LQ. test taken after the inservice program. 29 Table 3 Teachers Having Assisted a Student Having Asthma Symptoms (N=36) Had to Assist a Student Regular Classroom Teachers Other Teachers Yes 11 6 No 15 4 The pretest and posttests were graded by the researcher. One point apiece was assigned to each correct true/false question. One point was given for each part of each free-text question answered correctly. A total of 16 points were possible on the test. When calculating percentages, values were calculated to the nearest whole percentage point. The range of scores on the pretest was 7 points (44%) to 16 points (100%)(Table 4). The mean score was 11.7, and the SD was 3.19. The range of scores on the posttest was 12 points (75%) to 16 points (100%). The mean score on the posttest was 14.5, or 91%, and the SD 1.13. Data were analyzed using a one-tailed paired t -test. Pretest scores were subtracted from posttest scores. The difference in scores was squared and the mean difference between scores was calculated. A t-test score of 7.10 at 35 degrees of freedom was compared to a list of critical values to test the hypothesis (Pagano, 1998, p. 527). Smce the t-score of 7.10 was greater than the table value of 2.42 (p <0.01) the research hypothesis was accepted. Thus, this study revealed that asthma knowledge, as tested by the Asthma I.Q. test, was significantly higher after the inservice program. 30 Table 4 Teachers Pretest and Posttest Scores (N=36) Teachers Score Pretest Posttest 7 (44%) 1 0 8 (50%) 3 0 9 (56%) 5 0 10 (63%) 2 0 11 (69%) 6 0 12 (75%) 4 1 13 (81%) 5 7 14 (88%) 3 7 15 (94%) 5 13 16(100%) 2 8 Comparison of Individual Pretest and Posttest Items True false statements There were six true-false statements regarding asthma. These were marked correct or incorrect, and were scored one point apiece. A comparison of pretest and posttest results by statement follows. Before the inservice program thirty-two teachers, or 89% of participants, correctly responded “true” to the statement “Asthma is a lung disease that makes it difficult to breathe.” After the program all but one participant responded correctly to the statement. 31 On the pretest all of the teachers correctly responded “true” to the statement “You can be having an asthma attack without wheezing.” However, two teachers incorrectly marked the statement as false after the program. Before the inservice program 32 teachers, or 89%, correctly responded “false” to the statement “Asthma is an emotional problem.” This number increased to 34 teachers, or 94 %, after the program. One of the teachers failed to answer the question and put a question mark after it. Two teachers who responded correctly wrote comments next to the statement including “it can be,” and “emotions can make the attack more difficult.” All teachers recognized as false the statement “You cannot get asthma from someone else” before and after the program. Before the inservice program 94%, or all but two teachers, knew that asthma rescue medications can start to work in 3 to 5 minutes. On the posttest there was no difference in the number of teachers correctly responding to the statement. However, the two post­ program teachers who were incorrect failed to answer the question, rather than marking the statement as false. Free text questions In each of the four free-text questions the teachers were asked to name either two or three things in relation to asthma. The questions were scored by being given 1 point for each thing named correctly. Following is a comparison of the results of the pretest posttest free-text questions. Prior to the inservice program 17 teachers, or 47 % of participants, were unable to name anything that happens to the lungs during an asthma attack (Table 5). After the program there were no teachers who were unable to do so. The number of teachers able 32 to name three things that happen to the lungs during an asthma attack rose from four, or 11 % on the pretest, to 18 or 50 % of teachers on the posttest. Although the second free-text question “name two early warning signs of an asthma attack” asked for signs, subjective symptoms such as tightness in chest or shortness of breath were marked as correct. Prior to the inservice program seven teachers or 19 % were unable to name any early warning signs of an asthma attack, and 21 teachers or 59% were able to name two. On the posttest all participant were able to name two. Table 5 Name Three Things that Happen to Lungs During an Asthma Attack (N=36) Pretest Posttest Comparison Pretest Posttest Able to name none 17 0 Able to name one 6 6 Able to name two 9 12 Able to name three 4 18 Prior to the inservice program wheezing was named as an early warning sign of asthma by 15 teachers (41%), and cough was named by 7 teachers (19%) (Figure 1). On the posttest 28 teachers (77%) wrote wheezing, and 31 teachers (86%) wrote cough as early warning signs. Prior to the inservice program 22 teachers, or 61% of participants, were able to name three triggers of an asthma attack; after the program 34 teachers, or 94% of participants, were able (Table 6). The remaining two teachers correctly identified two triggers of asthma. Included in some of the responses to identify triggers of asthma were smoke, 33 allergens, pollens, dust, molds, irritants, pollution, cold air, colds, exercise, infections, chemicals, and animal dander. 100 86 90 - 80 1 70 c