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USE OF A SYMBOLIC LABEL TO ENHANCE LEARNING
ABOUT ASTHMA MEDICATIONS FOR ELEMENTARY SCHOOL CHILDREN

By
Debra L. Feeney, RN, BSN

Submitted in Partial Fulfillment of the Requirements for the
Master of Science in Nursing Degree

Edinboro University of Pennsylvania

Use of a symboIic IabeI to
enhance
I earn i ng about as thma
med i cat i ons
for elementary school children
/ by. . .
Thes i s Nurs. 1999 F295u
c .2

Approved by:
/ 0/-^/ Alice Conway, RN, PhD //
Committee Chairperson

Date

'J/n 197
Judil Schilling, CRNP, PhD
Cofr littee Member

Date

Rita Schmitt, RN, MSN
Committee Member
School District of the City of Erie

Date

•7
-

Abstract

Use of a Symbolic Label to Enhance Learning
About Asthma Medications for Elementary

School Children
Asthma is the most common serious chronic illness in children (Centers for

Disease Control and Prevention, 1996). Asthma education has been found to increase the
ability of children and their parents to effectively manage their asthma and decrease their
morbidity (Evans et al., 1997). Asthma medications are not marked in any way to

distinguish between inhalers for control and inhalers for acute symptoms, and are labelled

with their generic name, brand name, or both. The names are often long and confusing.
The control inhaler will not help to open the airways in an asthma attack. Children need

to know which inhaler will help them when they have trouble breathing.
The purpose of this study was to determine if the addition of a symbolic label to

bronchodilator inhalers facilitated learning about which inhaler to use for asthma attacks

in an elementary school-based asthma education program. The method included a pretest­
posttest design involving two groups of inner-city children with asthma in Erie, PA. Both
the control and the experimental group received asthma education at school using the A+
Asthma Club curriculum, including oral instructions about their asthma medications. This

curriculum is designed to be culturally sensitive for inner-city children. The experimental
group added a star sticker to the bronchodilator inhaler to remind them to use this inhaler

when they have trouble breathing. Children identified their inhaler more often by the star,
the color, or the look of the inhaler than by the name, even after individual instruction.
ii

Acknowledgments

Thank you to the School District of the City of Erie for permitting this research.

Thank you to the faculty and staff at McKinley School for providing the space and the

time for this research. Thank you to the students who participated in this study. Their
enthusiasm for learning and their candid responses made this project enjoyable. Thank

you to the thesis committee for all their support and encouragement. Thank you to Rita
Schmitt for conducting the pretest and posttest. Thank you to Dr. Judith Schilling for her
sage advice. Thank you to Dr. Janet Geisel for helping to get this project started. Thank

you to Dr. Alice Conway for her insight and encouragement. Thank you to my husband
and son for all the help and support.
Thank you to God for inspiring me to do my best to help others.

iii

Table of Contents

Content

Page

Abstract

ii

Acknowledgements

iii

Table of Contents

iv

List of Tables

viii

Chapter I - Introduction

1

3

Background of the Problem

Prevalence

3

Cost

4

School Absenteeism

.4

Medications in Inhaler Cannisters

.4

Labeling

5

Theoretical Framework

5

Problem Statement

6

Definition of Terms

6

Assumptions

.7

Limitations

7

Summary

7

Chapter II - Review of Literature

9

Asthma Prevalence

10

National Institutes of Health Guidelines

12

Asthma Education Programs

12
iv

Open Airways for Schools

13

A+ Asthma Club

15

Other Programs

17

Summary

20

Chapter III - Research Methodology

21

Research Question

21

Hypothesis

21

Operational Definitions

21

Design

22

Instrumentation

22

Pilot Study

22

Sample, Setting, Procedure

23

Protection of Human Rights

26

Data Analysis

26

Summary

26

Chapter IV - Research Results

28

Description of Sample

28

Knowledge of Medications

33

Needing to Know

38

Identifying Inhalers

.40

Are You Confused?

.41

Summary

.42

Chapter V - Discussion

.43
V

Conclusion

44

Recommendations

49

References

51

Appendixes

55

A. Medicine Knowledge Survey

55

B. Saint Christopher’s Hospital for Children Poster Inhaler Alert

57

C. Saint Christopher’s Hospital for Children Permission Form

58

D. Parental Consent Form for Children Previously Identified as Asthmatic..59
E. Parental Consent Form for All Children

60

F. School District of the City of Erie Permission

61

G. Edinboro University Permission

62

H. Medicine Knowledge Pretest Experimental (X)

63

I. Medicine Knowledge Pretest Control (C)

64

J. Medicine Knowledge Posttest Experimental (X)

65

K. Medicine Knowledge Posttest Control (C)

66

L. How Do You Know? Pretest Experimental (X)

67

M. How Do You Know? Pretest Control (C)

68

N. How Do You Know Posttest? Experimental (X)

69

O. How Do You Know Posttest Control (C)

.70

P. Who Gives Inhalers? Pretest Experimental (X)

71

Q. Who Gives Inhalers? Pretest Control (C)

72

R. Who Gives Inhalers? Posttest Experimental (X)

73

S. Who Give Inhalers? Posttest Control (C)

74

vi

T. Child Alone Inhaler Identification Pretest Experimental (X)

,75

U. Child Alone Inhaler Identification Pretest Control (C)

,76

V. Child Alone Inhaler Identification Posttest Experimental (X)

77

W. Child Alone Inhaler Identification Posttest Control (C)

,78

X. Identifying Inhalers Pretest Experimental (X)

79

Y. Identifying Inhalers Pretest Control (C)

80

Z. Identifying Inhalers Posttest Experimental (X)

81

AA. Identifying Inhalers Posttest Control (C)

82

AB. Are You Confused? Pretest Experimental (X)

83

AC. Are You Confused? Pretest Control (C)

84

AD. Are You Confused? Posttest Experimental (X)

85

AE. Are You Confused? Posttest Control (C)

86

vii

List Of Tables
Table

Page

1. Sample Composition

29

2. Inhaler Instruction

31

3. Knowledge of Medications

33

4. Identification of Medications Pretest Results

34

5. Identification of Medications Pretest Results Regarding Color

35

6. Identification of Inhalers Posttest Results

36

7. Identification of Medications Posttest Results Regarding Color

37

viii

1

Chapter I

Introduction
Asthma is the most common serious chronic illness in children (Centers for
Disease Control and Prevention [CDC], 1996). Inner city minority children are at greater

risk for asthma and may receive episodic care for asthma rather than continuing primary
care for the prevention of exacerbations (Evans et al., 1997). Asthma education has been

found to increase the ability of children and their parents to effectively manage asthma

and decrease morbidity.
Children with mild persistent, moderate persistent, and severe persistent asthma

should be prescribed two inhaler medications according to the National Institutes of
Health (NIH) 1997 guidelines. One inhaler medication is used to decrease inflammation

in the airway to prevent exacerbations of asthma. This is often referred to as the anti­
inflammatory or controller inhaler medication. The other medication is a short-acting

bronchodilator inhaler that is used to open the airway when bronchospasm, tightening of
the airway, has begun. Because this inhaler can stop an asthma attack, it is often referred
to as the rescue inhaler. The names of the inhaler medications are confusing and long.

Medications are identified either by the brand name, the generic name, or both. The
cannisters of the inhaler medications are not standardized in color, design, or label to

indicate which inhaler is to be used for inflammation control and which is to be used for

rescue to stop an asthma attack. An anti-inflammatory inhaler will not alleviate symptoms
or open an airway that is in bronchospasm. For a child who is having an asthma attack

2

and cannot breathe well due to bronchospasm, using the wrong inhaler can be frightening
and dangerous.
The National Co-operative Inner-City Asthma Study (NCICAS) found that inner-

city children often have multiple asthma caregivers; most had two additional caregivers,
beside a parent (Wade et al., 1997). Multiple caregivers may be advantageous for single

parent families in providing support. But there is a risk that medical instructions and

medication regimens may have been inaccurately transmitted from one caregiver to
another. The NCICAS psychosocial protocol researchers suggested that the existence of

multiple caregivers raises the issue of how to design interventions to target these several

individuals. Families of children with asthma were found to have limited asthma problem
solving skills, child and adult adjustment problems, and high levels of stress. Caretakers
reported experiencing an average of eight undesirable life events in the previous 12-

month period on the Psychiatric Epidemiology Research Interview Life Events Scale.
Caretakers also reported having a high level of available support to help with the high

levels of stress related to these events.

Adult caretakers reported a high level of responsibility for asthma management
regardless of the child’s age. Children perceived that they were more responsible for selfcare than was indicated by the parents. Researchers reported that this discrepancy might

result from the child’s overestimation of his or her role or the parent’s lack of awareness
of the degree of the self-care the child is actually engaging in (Wade et al., 1997). The

names of the inhaler medications may be difficult to read and remember for supplemental
caregivers, and for children who assume responsibility for their own self-care.

3

Asthma is the leading cause of school absenteeism due to a chronic condition

(Flaum, Lung, & Tinkleman, 1997). Attendance in school is a primary factor in school
success. Achievement and test scores, which are often low in poor urban areas, could be

improved by increased attendance. This chapter provides an overview of the problems of

inner city asthmatic children’s knowledge of asthma. Dorothea Orem’s (1995) self-care
deficit nursing theory provided the theoretical framework for this study. Nurse

practitioners focus on the whole patient and educate their patients to promote self care for
improved health and are in a great position to assist children and their families in learning
about asthma and asthma medications. Nurse practitioners provide health education

directed at the needs and abilities of the learner with asthma. A symbolic label may help
children to identify the correct inhaler to use during an asthma attack. This could be a

valuable tool for nurse practitioners and other health care providers to use in teaching
children and their families. The research purpose, assumptions, limitations, and definition
of terms complete the chapter.

Background of the problem
The background of the problem of asthma involves its prevalence, cost,

absenteeism, different medications in similar inhaler cannisters, and lack of standardized

labeling. These concepts are outlined in this chapter.
Prevalence. Asthma is the leading serious chronic illness among children effecting

an estimated 4.8 million children under the age 18 (CDC, 1996). Minority children are
affected proportionately higher than the general population (Evans et al., 1997). Effective

preventive care for the control of asthma is available but many inner city minority
children continue to receive periodic episodic care with little focus on follow-up,

4

prevention of exacerbations, and education (Evans et al., 1997). Patient education has

proven to be effective in improving asthma management skills, reducing morbidity,
hospitalization, use of emergency care services, and improving quality of life (Evans et

al., 1997).
Cost. The annual cost for asthma care is estimated at $6.2 billion or 1% of all U.S.

health care costs, including medical care and lost time from school and work (O’Neill,
1996). Asthma is the leading cause of pediatric hospitalization (Flaum et al., 1997).

Preventive care aimed at improving the control of asthma and decreasing the need for

hospitalization could impact the rising cost of health care significantly.

School Absenteeism. Asthma is the leading cause of school absenteeism due to a
chronic condition (Flaum et al., 1997). Attendance in school is a primary factor in school

success. Achievement and test scores, which are often low in poor urban areas, could be
improved by increased attendance.

Medications in Inhaler Cannisters. Asthmatic children who have mild persistent,

moderate persistent, or severe persistent asthma should be prescribed both an anti­
inflammatory and a bronchodilator inhaler medication (NIH, 1997). These inhalers are

not standardized for color, shape, or identifying markers. The child may receive a brand
name bronchodilator from the health care professional as a free sample and a generic

bronchodilator from the pharmacist. They may look entirely different, have different
names, and yet are the same medications. Short-acting bronchodilator multidose inhalers

(MDI) currently can be white, yellow, gray, white with a green stripe, or blue. White
inhalers can contain short-acting bronchodilators, steroidal anti-inflammatory,
nonsteroidal anti-inflammatory or anticholinergic medication. Gray inhalers can be short-

5

acting bronchodilators or steroidal anti-inflammatory inhalers. With all the possibilities,
even the experienced health care professional has difficulty identifying which medication

a patient is using.
Labeling. Symbolic labels are prevalent in our society. The Nike swoosh, the

McDonald’s Golden Arches, the Mr. Yuk symbol, and the Red Cross serve to identify a
product without the use of language. In a multicultural world, labels identify a product in
a universal way that is not subject to translation or loss of information in translation. The

addition of a symbol may facilitate the learning process for all asthmatics. Children may
be assisted to identify the correct inhaler medication even if they cannot read the name of
the medications. An identifying label may help to eliminate confusion and enhance

memory for asthmatic patients and their health care providers.
Theoretical Framework

Dorthea Orem’s (1995) self-care deficit nursing theory states that parents provide
dependent-care for the child with a self-care deficit. Dependent-care is that care which

responsible mature persons perform on behalf of socially dependent persons in order to
maintain their lives and contribute to their well being. Children are often provided
dependent care by their parents until they grow and develop to the age at which they can

care for themselves. The child provides for his/her own self-care within the child’s

ability.
The nurse practitioner provides primary care to patients including diagnosing,

treating, and educating the patient and family. Orem (1995) described the nurse
practitioner role as supportive-educative in educating the parents to enable them to
provide dependent-care and the child to provide self-care within his/her ability. The nurse

6

practitioner identifies health education needs, as well as strengths and limitations of the
leamei that effect his/her learning abilities, and individualizes the educational program to

meet those needs.
In asthma education, the children may have limited ability to read the names on

their inhaler medications. And yet the children have a need to know which inhaler to use

for control and which to use for rescue. To address this limitation and meet their
educational needs, the researcher in this study proposed that a label, added to the
bronchodilator inhaler, might enable patients and families to learn and remember which

inhaler to use for “rescue” from symptoms. The patients and families may be better able

to distinguish between bronchodilator inhalers and anti-inflammatory inhalers which
would enhance the child’s self-care capabilities and the parents’ dependent-care agency.

Problem Statement
Inhalers are not marked in any way to distinguish between bronchodilators and

anti-inflammatory inhalers. The names of these medications are often confusing and long.
Statement of Purpose
The purpose of this study was to determine if the addition of a symbolic label to

bronchodilator inhalers facilitated learning about the correct use of bronchodilator
inhalers in a school-based asthma education program for inner-city school-age children in

Erie, PA.
Definition of Terms
The terms used in this study were defined as follows:

1. Symbolic label is an emblem or sign that identifies a product without the use of

words.

7

2. Innei-city children are elementary school children in grades 1 through 6 within
an economically disadvantaged region of an urban area.

Assumptions
The assumptions of this study were as follows:

1. Participants were English-speaking and answered questions honestly and to the
best of their ability.
2. Education is necessary in order for those children who have asthma to

understand what happens in their lungs and how to prevent/treat an asthma attack.

3. Children are confused by the names of medications.
Limitations
The limitations of this study were as follows:
1. The study group was limited to a convenience sample of elementary school

students previously diagnosed with asthma in an inner-city school in northwestern

Pennsylvania.
2. Students had varied experience with previous asthma education.

Summary
This chapter focused on the addition of a symbolic label to the bronchodilator

medication within an elementary school-based asthma education program. Inner city
children may receive fragmented episodic care for their asthma, which does not
adequately address their educational needs regarding self-care (Evans et al., 1997).

Dorothea Orem’s self-care deficit theory (1995) provided the theoretical framework for
this study. Orem wrote that the nurse provides supportive-educative care to assist the
patient’s family to provide dependent care for the child and to assist the child to develop

8

self-care ability. The purpose of the study was to determine if a symbolic label added to
the bronchodilator inhaler increased childrens’ ability to differentiate between a
bronchodilator and a controller inhaler. This chapter included definition of terms,

assumptions, and limitations of the study.

9

Chapter II
Review of the Literature
This chapter reviews the literature pertaining to asthma prevalence, the National
Cooperative Inner-City Asthma Study, the National Institutes of Health Guidelines,

asthma education programs, Open Airways for Schools, the A+ Asthma Club, and other

programs. Literature was reviewed to determine how asthma education programs were

implemented and how the issue of different inhaler medications was taught. Literature

was also reviewed to determine if a label or other symbol had been used to differentiate
between bronchodilator and anti-inflammatory medication inhalers. This study addressed
concerns about confusion between asthma inhaler medications by placing a symbolic
label on the bronchodilator inhaler to distinguish it from the controller inhaler

medication. The goal was to facilitate teaching and learning about inhalers.
Asthma research has been directed at many factors associated with morbidity,
hospitalization rates, and mortality. Inner-city minority and poor children are at an

increased risk (Mitchell et al., 1997). The annual death rate for persons aged 5 to 34 years
increased 42% from 1982 to 1991 (CDC, 1995). The National Institutes of Health (NIH,

1997) released guidelines to direct the management of asthma care. Asthma education
programs have been formulated and conducted to address the modifiable factors
associated with asthma morbidity (Lurie, Straub, Goodman, & Bauer, 1998). Open

Airways for Schools is a validated program, endorsed by the NIH for the education of
school children. Education programs have had varying success in reducing hospitalization

rates, and increasing compliance with asthma care (Evans et al., 1997; Schneider et al.,
1997).

10

Asthma Prevalence
Recent statistics indicate an increase in asthma prevalence, hospitalization, and

death rates nationally (Mannino et al., 1998). Low socioeconomic level has been
associated with increased asthma rates and increased severity of asthma symptoms (Butz

et al., 1994). Access to and quality of health care have been problematic for poor minority

children (Lewis, Lewis, Leake, Monohan, & Rachelefsky, 1996). Asthma is the leading
cause of pediatric hospitalization (Flaum et al., 1997).

Goodman, Stukel, and Chang (1998) studied the state hospital discharge records
of children under age 18 residing in Maine, New York, New Hampshire, and Vermont

during the period 1985 to 1994. Hospitalization rates due to asthma were 3.6 times higher

for children living in the low-income zip code areas than high-income zip code areas.
(Goodman et al., 1998). Metropolitan children were hospitalized at more than twice the

rate of nonmetropolitan children. Hospitalization rates for black children were more than
six times, and rates for Hispanic children were five times, the rate for white non-Hispanic

children (Goodman et al., 1998). This is despite the fact that the proportion of blacks with
asthma was 4.4 % compared to 4 % for whites (U.S. Department of Health and Human

Services [DHHS], 1991). The frequency of pediatric hospitalization for nonasthma causes

fell substantially. Therefore, the proportion of hospital days attributable to asthma has
increased in all population groups (Goodman et al., 1998). The goals of Healthy People

2000 included reduction of asthma hospitalizations to no more than 160 per 100,000
people and to reduce to no more than 10 % the proportion of people who experience
activity limitation related to their asthma (DHHS, 1991).

11

The National Cooperative Inner-City Asthma Study was a multiphase

epidemiological study that focused on factors associated with high levels of asthma

morbidity among 1,528 inner-city children (Mitchell et al., 1997). Eight research centers
enrolled children aged 4 to 9 years from English-speaking or Spanish-speaking families

who resided in eight major metropolitan inner-city areas. Study methods included
interviews, urine for cotinine assessment as an indicator of recent exposure to cigarette

smoke, allergy skin testing, dust sample collection, observation of home environment,

and peak expiration flow diaries. Researchers followed study subjects through telephone
calls at 3, 6, and 9 months to assess morbidity and utilization of health care including

unscheduled doctor visits, emergency department visits, and hospitalizations. Phase I of

the study identified characteristics of inner city children that related to increased
morbidity (Mitchell et al., 1997). Factors were divided into modifiable and nonmodifiable factors. The non-modifiable background factors included genetics, atopy,

prematurity, other health conditions, child health history, family history, race/ethnicity,
gender, socioeconomic status, neighborhood, and season. The modifiable factors included

home condition, dust antigens, smoking, asthma attitudes and beliefs, asthma knowledge,
asthma problem solving, and responsibility for asthma management. Additional
modifiable factors were alcoholism, behavioral problems of the child, family
environment, parenting practices, psychological symptoms, self-competence, social

support, stressful life events, adherence to an asthma emergency plan and preventive care,
and health care including acute care, preventive care, and access, quality, and continuity
of care. The aim of Phase I was to provide sufficient information about factors associated

12

with asthma morbidity to design and implement a Phase II project to intervene in those
factors.
National Institutes of Health Guidelines
In 1991, and again in 1997, the National Institutes of Health published guidelines

for effective control of asthma including the use of long-term control medications to
suppress inflammation, and quick-relief medications to treat symptoms and
exacerbations. Patient and family education were described as essential to successful
asthma management in assisting patients to assume the role of active partner in asthma

care. The NIH guidelines stressed that asthma education should be ongoing from the time

of diagnosis, and include a written daily self-management plan and an action plan for
exacerbations. Education should be tailored to the needs of the individual and modified to
address the cultural or ethnic beliefs of the individual patient. Simple, brief written
instructions should be provided to reinforce the recommended actions and skills taught.
Patient education should be provided in the emergency department and during inpatient

hospitalizations as well as during follow-up appointments in the clinic or office.
Asthma Education Programs
Programs to influence behavior and improve self-management of asthma have
improved asthma control and reduced related morbidity (Flaum et al., 1997). Because

access to health care is problematic, inner city children may not be receiving asthma
education as frequently as others (Evans et al., 1997).
In a focus group study of eight emergency room care recipients in East St. Louis,

Illinois, patients did not mention health education at all in response to the question “How

did you learn to take care of your asthma?” Responses indicated self-teaching or learning

13

with a philosophy of survival-by-your-own-wits (Munro, Haire-Joshu, Fisher, & Wedner,
1996). Patients expressed a perception of the health care system as frequently insensitive

to their needs and felt that health care providers assumed they lacked knowledge

concerning their own care. Participants’ comments indicated that asthma education or
support measures did not play a significant role in learning to care for themselves.

Open Airways for Schools, Asthma education programs have been offered in
public health clinics, hospitals, and schools. In 1986, Columbia University researchers

studied the transition of a clinic-based asthma education program, in which parents and
children attended sessions separately, to a school-based child-centered program that

parents did not attend. Open Airways was clinic-based and focused on the parent’s role in
managing the child’s asthma. The goal was to help parents and children work together to
overcome common obstacles in managing the child’s asthma. Researchers conducted six

sessions of asthma education in each of three phases: a clinic based program, a pilot study

in schools, and a larger school study, that was called the School Study II. Researchers
reported that 99% of the children had perfect attendance in the school-based asthma
education program School Study II, with make-up sessions. Only 5% of the children in

the clinic-based program attended all sessions (Kaplan et al., 1986).
The clinic program included 269 inner-city low-income minority children. The

study compared program and control group families. Families in the clinic program

attended an average of 3.3 of the six classes offered, with 18% of the families attending
none of the classes. Only 25% of the parents attended four or more of the classes. The
program significantly and positively impacted self-management skills, school grades,
emergency room visits, and hospitalizations due to asthma. Researchers reported that the

14

program might have been more effective if attendance had been better. Financial barriers

due to the cost of a clinic visit and scheduling conflicts were cited as possible reasons for

the poor attendance (Kaplan et al.,1986).
The pilot school program, School Study I, included a total of 67 inner-city low

income children (Kaplan et al., 1986). In an experimental research design, schools were
assigned randomly to program and control groups. Children in the control schools
received the program following the completion of research. Parent attendance was poor in

the pilot school sessions with only 33% of the parents attending four or more sessions.
One-third of the parents attended four sessions or more, one-third attended between one
and three sessions, and one-third attended no sessions. No parents attended all six
sessions in the school pilot study. Only 3% attended all six sessions in the clinic program.
Employment and having preschool children at home were cited as explanations for low

parental attendance. Children in the pilot school study whose parents did not attend were

embarrassed that their parents were not there. Language barriers with some parents who

did attend interrupted the flow of teaching. Therefore, parent participation was
discontinued in the school-based program when the second phase, School Study n, was

implemented.

School Study II included 239 inner-city low-income children. School Study II was

implemented in 12 elementary schools in upper Manhattan and Bronx, NY (Kaplan et al.,
1986). Six schools received the program and six schools served as controls. School Study
II reached children who lacked routine follow-up care for asthma. Families reported no

source of care other than the emergency room for 18.6% of the children in School Study
II. The parent sessions and child-parent interaction activities were eliminated from the

15

program prior to the beginning of School Study n, as noted above. Researchers provided
make-up sessions for child sessions, which increased the children’s attendance at all

sessions to 99%. Five percent of the children in the clinic setting and 47% of the children

in the pilot school study had attended all six classes. The researchers modified the
educational program to become child-centered. It focused on the child’s central role in
disease management and addressed tasks the children could undertake themselves. The
experimental group showed improvements in academic performance and asthma
management skills. This program then became the Open Airways for Schools program

(Kaplan et al., 1986).
Researchers at Columbia University College of Physicians and Surgeons designed
the Open Airways for Schools program and recruited the American Lung Association

(ALA) to implement the plan nationwide. The ALA goal was to establish the program in
every elementary school in the United States with help from the National Heart, Lung,

and Blood Institute (NHLBI), the U.S. Environmental Protection Agency, Fisons
Pharmaceuticals, Inc., and the Zeta Phi Beta Sorority, Inc., an organization of

professional African-American women (O’Neill, 1996). It was noted that children are the
most effected by asthma, and that schools are the ideal place to reach children (O’Neill,

1996). The children recognized the warning signs of an asthma episode with increased

confidence after participating in the program (Evans et al., 1987).
The A+ Asthma Club. The A+ Asthma Club was designed in 1991 through
a collaborative effort of researchers from Georgetown University, Howard University,

and Johns Hopkins University. The program was specifically designed for inner-city
children with asthma and combined a child-centered school program with a parent­

16

centered lay home visitor program (Schneider et al., 1997). The researchers hoped that a
combination of the two approaches would achieve the most effective control of asthma.
The research project that targeted children was called “Community Interventions for

Minority Children with Asthma.”
The study’s purpose was to test the effectiveness of a school-based asthma

program with 392 first through sixth grade children in Baltimore, Maryland and

Washington, D.C. The sample was 98% African-American children with 44 % on
medical assistance and 55 % with moderate to severe asthma. The study randomized

schools into four groups: the school-based program, the home visitor program, both

programs, and neither program (control schools). Of the 221 children who were to

receive the home visitor program, only 140 (63%) completed an initial home-visit
questionnaire. The home visitors encountered difficulties in visiting some families due to

disconnected or unworkable phones, relocated or inaccurate addresses, and parental or
child refusals. Researchers concluded, nevertheless, that the lay visitor program was

effective in obtaining useful medical information and providing basic asthma education to
inner-city children with asthma (Butz et al., 1994).

The researchers interviewed principals, school nurses, secretaries, children,

parents, and teachers for recommendations and ideas in developing the A+ Asthma Club

program (Schneider et al., 1997). Children wanted an interactive club with small groups

so that they could talk and participate in role-playing and games rather than more
structured school lessons. The students in the pilot program helped to choose the
materials and logo. Students were shown materials from several asthma education

programs. They preferred the You Can Control Asthma (1991) materials, which was

17

developed by the Center for Interdisciplinary Research on Immunologic Diseases and the

Division of Children s Health Promotion of Georgetown University (Schneider et al.,

1997). Schneider, Richardson, and Clark (1991) wrote the A+ Asthma Club program,
incorporating portions of the You Can Control Asthma materials and Getting Started in

Asthma Education: A Guide for Physicians and Nurses. Materials from Open Airways

(1984) and Children with Asthma: A Manual for Parents (1988) by Thomas Plaut, M.D.
were included as well (Schneider, Richard, & Clark, 1991).
The traditional asthma education jargon was replaced with vocabulary that was

culturally sensitive to the inner-city child. Words or expressions that made an assumption

about the child’s living situation were avoided. Thus, “at home” was substituted for “at

your house” and “the room where you sleep” was substituted for “your bedroom.” “Your

parents” or “your mother and father” were replaced by “the people in your family.” The
acronym “STAR” was used to reinforce problem-solving approaches. “S” reminds
children to “Stop and figure out the problem.” “T” is for “Think about your choices. ,, «A„

reminds them to “Ask yourself what would happen with each choice.” And “R” means

“Respond and test it out.” Incentives such as stickers, pencils, erasers, club I.D. badges,
and certificates of club participation were given when children attended the sessions. T-

shirts and mattress covers were also given for participation (Schneider et al., 1997).
Other Programs. In 1990, O’Neill (1996) found that 19 self-management
programs for asthma were in existence. Programs had been developed or modified to

reach target populations such as Hispanic, African-American, preschool or school age
children, adolescents, and adults. Programs had been presented in camp settings, schools,

clinics, and in homes. Target audiences included the asthmatic person alone, the family

18

caregiver, the entire school classroom, and the community. This variety of programs

i effects attempts to meet the educational needs of the differing groups within
environmental and time constraints, and to accommodate changing health care delivery

and financing (Yoos et al., 1997). School-based programs have reduced hospitalizations

and emergency room visits, increased school performance, decreased school absence, and
improved asthma management skills to varying degrees dependent upon the severity of

asthma in the group studied (Christiansen et al., 1997).
A summer asthma camp study identified a cost savings of $88,000 for health care
utilization in the first year after camp attendance for 40 participants, or a savings of over

$2,000 per child (Kelly et al., 1998). The study followed 40 children between the ages of
8 and 13 who participated in Camp Wheeze-B-Gon in 1994. The camp included athletic,

social, and educational activities. Questionnaires identified participants’ emergency room
visits, hospitalization, and absenteeism rates prior to camp and in the year following

camp. The camp study identified a decrease in total school absenteeism from 266 to 188
days for the 40 participants in the school year following camp attendance (Kelly et al.,
1998).

The San Diego City Schools and Scripps Clinic and Research Foundation

developed an education program for economically disadvantaged children who were

primarily Mexican-Americans (Christiansen et al., 1997). The five sessions lasted 20
minutes each and reflected the guidelines for asthma care published by the National
Institutes of Health. The sessions included.
(1) Basic information about asthma; (2) identification of asthma warning signs,

reduction of asthma triggers, and use of an inhaler; (3) asthma medications

19

(bronchodilators); (4) asthma medications (antiinflammatory [sic] agents); and
(5) use of a peak flow meter, development of an action plan, and development of
an emergency plan for asthma (p. 614.)

The San Diego study found that asthma knowledge, peak flow meter technique,

and inhaler technique all improved in the educated group and asthma knowledge and

inhaler technique deteriorated in the control group. Peak flow meter technique improved

slightly in the control group, but it was not significant. The researchers found that it was
feasible to offer asthma education in school. Asthma severity was decreased in the

educated group compared to the control group.
The NIH (1997) guidelines stated that a formal asthma education program that has

been evaluated and reported in the literature may be beneficial to all asthma patients but

that it should be used only to enhance clinician-provided education, not to replace it. The

Open Airways for Schools educational program is one of the programs listed by the NIH
as a valid educational program because it has been reported and evaluated in the
literature. The NIH guidelines cautioned that the program should be followed in its

entirety to avoid loss of validity and effectiveness. The use of videos or computer
programs may enhance the learning as well.

This researcher found no studies that concerned the lack of standardization in
packaging inhaler medications. No studies were found that suggested utilizing a label to

assist the asthmatic child to learn about medications. No studies identified the names of
medications as being above the reading level for the average school-age child. Studies did

not indicate how the children identified the medications in their inhalers: by name, by
appearance, by color, by applying identifying marks, or by any other means. Many studies

20

utilized a child-based education program at school but none addressed the readability of

inhaler names.
Summary
This chapter has reviewed literature regarding asthma education programs.
Review of the literature indicated an increase in asthma prevalence, morbidity,
hospitalization, and mortality especially among inner-city children. NIH (1991 & 1997)

guidelines were developed to address the need for preventive care in asthma. Education

programs have been developed and utilized with varying success to increase asthma
knowledge and compliance, and decrease morbidity and mortality. Open Airways for
Schools is one such program, which is deemed to be validated by the NIH. The A+
Asthma club is specifically designed for the inner-city minority children. This review of

the literature found no use of labels for inhaler medications in asthma education

programs. This study was designed to determine if the addition of a symbolic label on the
bronchodilator inhaler facilitated learning about the difference and use of bronchodilator
and anti-inflammatory inhalers.

21

Chapter IH

Research Methodology
This chapter focuses on the methods used in this study. The hypothesis,

operational definitions, design, sampling techniques, informed consent/ review board,
instrumentation, and data analysis are presented.

Research Question
This study researched the addition of a symbolic label to the bronchodilator
inhaler cannister, and childrens’ learning response to it. Is the elementary school-aged

asthmatic child more likely to identify the bronchodilator inhaler correctly with the

addition of a symbolic label to the bronchodilator inhaler cannister?

Hypothesis
The addition of a symbolic label to the bronchodilator inhaler medication

cannister will result in increased ability of the inner city school-age children with asthma
to choose the correct inhaler.

Operational Definitions

1. Symbolic label is an emblem or sign that identifies a product without the use of
words. For this study the label was a multi-colored star sticker.
2. Bronchodilator is an agent that causes expansion of the lumina of the air

passages of the lungs. (Dorland’s Illustrated Medical Dictionary, 1988).
3. Inner-city children are elementary age (grades 1-6) school children within an

economically disadvantaged region of an urban area in Erie, PA.

22

Design
The study design is a descriptive design consisting of two educational groups.

Students with asthma were randomly selected to either the control or experimental group

by drawing their names from a hat. Students in both groups were taught about their

asthma using the A+ Asthma Club curriculum, which is designed for use with inner-city
minority children. A parent handout was given for students to take home, but the lay

home visitor portion of the study that produced the A+ Asthma Club was not included
due to lack of personnel, time, and resources.

Instrumentation
The investigator-developed tool (Appendix A) is a 20 question open-ended

survey, which was read to the students individually prior to the first class. Their answers

were written down. The St. Christopher’s Hospital for Children poster (1996) (Appendix

B), entitled Inhaler Alert, was available for children who could not recall the name or
color of their inhalers. The same survey was read to students individually after the final
educational session as a posttest and those answers were also written down. A volunteer

elementary school nurse read the surveys to the participants and wrote down their
answers.
Pilot Study. A pilot study was done to determine how long the survey took and the
clarity of the questions. A group of 17 first-grade students listened to the questions to

determine if any were difficult to understand. Question number 15, about which
medication to use for prevention, was changed. The word “prevention” was replaced

because the children did not understand it. Question 15 was rewritten to read, “Which

23

inhalei do you use so you won t have an asthma attack?” The entire questionnaire took 10

minutes to complete.

Sample, Setting, Procedure
The research sample consisted of those elementary students whose parents had

signed and returned the permission forms. Participants were randomly assigned to the
control or the experimental group. Thirteen students were in the experimental group.

Fourteen students were in the control group. The setting for the study was an elementary

school music room or art room, whichever was available on the day of the class.
The school nurse sent home permission forms (Appendix C) to the parents of

those students who had previously been identified as having asthma. Due to a small
response, a second permission form (Appendix D) was sent home with every first through
sixth grade student in the school. Additional students were identified as having asthma

and were given permission to attend by their parents. Parents of two students asked if they
could attend the sessions due to a strong family history of asthma and a perceived need to

know about asthma due to close family members with asthma. These two students were
included in the classes due to the possibility that the knowledge may help them in the care

of their family members. After permission was granted, the initial survey was conducted.
The St. Christopher’s Hospital poster (Appendix B) entitled Inhaler Alert (1996) was

available for those students who could not remember the name or color of their inhaler(s).
The educational sessions were held during lunchtime, after students had finished eating,

so that less class time was missed. The school has three lunch periods daily. Because the
study groups were randomly selected, some students were scheduled for class and others
were scheduled for lunch at their designated time. Classes were held at 11:30 and 12:15,

24

2 days a week for 3 weeks. The 11:30 class was the experimental group who received star
stickeis on their inhalers to identify the bronchodilator inhaler. The 12:15 group was the
control group who received the same instructions about the differences in the medicines,

but who did not receive the star sticker in the inhaler. The A+ Asthma Club curriculum

includes six meetings: So You Have Asthma Too, What is Asthma, How to Keep Asthma
Attacks from Starting, Asthma Medicines, Making Decisions and Choices, and Running,

Playing and Sports/ Review. Make-up sessions were conducted individually or in small
groups. This study took place in May and June, 1999.
As part of the fourth session of the program, the control group members were

asked to bring their inhalers to the program and were taught the differences between the

anti-inflammatory and the bronchodilator inhaler medications. The experimental group
members were asked to bring in their inhalers and were taught the differences between
the anti-inflammatory and the bronchodilator inhaler as well. During the class on
medications, the researcher took each subject’s inhalers in hand and identified the
inhalers by name and indicated if the inhaler was to prevent swelling (anti-inflammatory)

or to open up the airways (bronchodilator). The researcher showed the students the St.

Christopher’s Hospital for Children (1996) (Appendix B) poster entitled Inhaler Alert to
explain that different medications may be contained in inhalers with similar colors and

that the same medication may be contained in different color inhalers depending on which

company made the medicine. An explanation compared Nike and Adidas sneakers to

Albuterol, Proventil, and Ventolin to indicate that different companies make the same
product, but their products do not look the same. A sticker with a symbol was added to
the bronchodilator inhaler for the experimental group. The symbol was a star so that it

25

would be easy for students to identify, a multi-color star sticker was chosen to avoid

problems due to colorblindness.
The worksheets from the A+ Asthma Club workbook were used during the

education program to assess the children’s understanding of basic concepts. Incentives
such as stickers, novelty pencils, and erasers were given to children who attended

meetings and who remembered their folders and inhalers. This incentive program was
part of the A+ Asthma Club plan. Children were included in the statistical analysis for the
study if they had attended at least four of the six sessions and if one of those sessions was

the fourth session entitled Asthma Medicines. Make-up sessions were conducted for
students who missed sessions.

All students in the sample attended either the scheduled class session or the make­
up session for each of the six sessions. Therefore, attendance was 100%. One student was

not available during the pretesting period, but attended four sessions and two make-up
sessions. Posttest results for this student were included in the study data. One student

asked the researcher to join the classes after the fourth class. After parental permission

was obtained, the student was permitted to attend the fifth and sixth session and make-up
sessions for the first four sessions. This student was not available for posttesting and was

not included in the study data.

Due to the timing of the study at the end of the school year, several students
missed scheduled sessions due to field trips. If children missed more than two sessions,

they were encouraged to continue to participate in the remaining sessions, but the data
from their surveys were not included in the study. After the sixth session, students were
read the posttest survey (Appendix A) individually and their answers were recorded. The

26

same volunteer school nurse administered the pretest and the posttest. After the posttest,

the control subjects placed the multicolored star sticker on their bronchodilator inhaler

with an explanation that it is the inhaler to use when they are having breathing problems
and before gym, recess, and exercise.

Protection of Human Rights
The School District of Erie reviewed the study proposal and gave permission for
implementation (Appendix E). The Edinboro University of Pennsylvania Review Board

or its designate reviewed and approved the proposal for suitablity (Appendix F). The
pretest and posttest surveys were kept confidential in a locked drawer only available to

the investigator. Student surveys were identified by their initials and grade.

Data Analysis
Data were analyzed to interpret the responses to the educational program and the

addition of the symbolic label. Due to an expected small sample size, descriptive statistics
were used to analyze the pretest and posttest data. The pretest score was compared to the
posttest score for all children. The posttest answers were evaluated to determine if
children had learned the names, colors, and correct use of their inhalers as a result of the

educational program. The posttests for the control group were compared to the posttests

of the experimental group to determine if the addition of the symbolic label assisted

children in learning and remembering the differences between their inhalers.
Summary

This chapter discussed the research methodology, hypothesis, operational
definitions, sample, informed consent, review board, instrumentation, data analysis, and

27

pilot study for this research. The study involved the use of a multicolored star as a

symbolic label to differentiate between the bronchodilator inhaler and the
anti-inflammatory inhaler for a group of inner-city elementary school children in Erie,
Pennsylvania.

28

Chapter IV

Research Results
This descriptive study was conducted in an elementary school in inner-city Erie,

PA with a convenience sample of 27 students from first through fifth grade. The original
design for the research was to be quasi-experimental, but due to a small sample size and
an even smaller number of children possessing both anti-inflammatory and
bronchodilator inhalers, the results were interpreted in a descriptive manner. A
permission form (Appendixes C and D) was obtained from each participant’s parents
prior to inclusion in the study. Students were randomly selected by drawing their name

from a hat to place the child into either the control or the experimental group. A pretest
and postest (Appendix A) were read to the students and their answers were recorded by a

volunteer school nurse. The same school nurse performed all the pretests and posttests.
The A+ Asthma Club program was presented to the students at two different
times. The 11:00 class was the experimental group who received stickers on their inhalers
to identify the bronchodilator inhaler. The 12:15 group was the control group who

received the same instructions about the differences in the medications, but who did not
receive the star sticker on the inhaler. Two class sessions per week for 3 weeks were

conducted to complete the six-session A+ Asthma Club program. Make-up sessions were
conducted individually or in small groups. This study took place in May and June, 1999.
Description of Sample

The sample included 27 students from grade one through grade five. No sixth

grade students responded although they were eligible to participate. Students were
included in the study regardless of their educational status: regular, learning support, and

29

life skills students were all included in the study. No attempt was made to determine the
reading level of individual students. Niine first grade students (33.3%) participated. Four

second grade students (14.8%), no third grade students (0%), six fourth grade students
(22.2%), and four fifth grade students (14.8%) participated. Four students (14.8%),

because of their special education status, are not listed at grade levels. Fourteen girls

(51.8%) and thirteen boys (48.1%) were included in the study sample (Table 1).

Table 1

Sample Composition

Control

Experimental

Entire Study

Grade 1

4

5

9

Grade 2

2

2

4

Grade 3

0

0

0

Grade 4

4

2

6

Grade 5

2

2

4

Grade 6

0

0

0

Special Education

2

2

4

Total

14

13

27

30

The experimental group consisted of five first grade students (38.5 %), two

second grade students (15.4 %), two fourth grade students (15.4 %), two fifth grade
students (15.4 %), and two special education students (15.4 %). Five girls (38.5 %) and
eight boys (61.5 %) comprised the experimental group. The control group included four

first grade students (28.6%), two second grade students (14.3%), four fourth grade
students (28.6%), two fifth grade students (14.3%), and two special education students
(14.3%). Nine girls (64.3%) and five boys (35.7%) comprised the control group.

The experimental group had eight students (61.5%) who attended all six
scheduled sessions. Three students (23.1%) missed one regularly scheduled session and

attended one make-up session. Two students (15.4%) missed two regularly scheduled

sessions and attended two make-up sessions. All participants attended either a scheduled
session or a make-up session. Attendance was 100% for the experimental group.

The control group had 10 students (71.4%) who attended all six regularly
scheduled sessions. Two students (14.3%) attended one make-up session, and two
students (14.3%) attended two make-up sessions due to absence at the regularly

scheduled session. The control group had 100% attendance at either a regular session or a

make-up session.

Two students who participated in the study did not have asthma but were family
members of persons with asthma. Both of these students were randomly selected to the

experimental group.
During the fourth session, students from both the experimental group and the
control group were asked to bring in their inhalers to learn about the different medicines
and which medication to use for asthma symptoms. In the experimental group, six

31

students (46.2%) brought in inhalers and star stickers were applied to the bronchodilator
inhaler to indicate that this inhaler was to be used for symptoms. Four of these students

(30.8%) had an anti-inflammatory inhaler as well. Two students (15.4%) had only a

bronchodilator inhaler. One student (7.6%) used only a nebulizer machine at home for

asthma. This student’s parent has to bring in the nebulizer machine to school when the
child suffers an asthma episode at school. Two students (15.4%) were not asthmatic so

they did not have inhalers. The remaining four students (30.8%) had no inhalers although
they had been identified as having asthma (Table 2).

Table 2

Inhaler Instruction

Entire Study

Control

Experimental

One inhaler

4

2

6 (22.2%)

Two inhalers

4

4

8 (29.6%)

No inhalers

6

4

10 (37.0%)

Not asthmatic

0

2

2 (7.4%)

Had machine only

0

1

1 (3.7%)

Total

14

13

Inhaler

27

32

The control group included eight children (57.1%) who brought their inhalers to

school. Four of these students (28.6%) had an anti-inflammatory inhaler as well as as
bionchodilator inhaler. One student (7.1%) brought only an anti-inflammatory inhaler to

school although he said that he had a whole bag of inhalers at home for himself and his
mother. Three students (21.4%) had only a bronchodilator inhaler. Six students (42.9%)

had no inhaler although they had been identified as having asthma.
The researcher questioned students who did not bring an inhaler to school as to

whether they had an inhaler at home that they had forgotten. The students who did not

bring an inhaler to school replied that they did not have one at home. Students offered
reasons such as: they ran out of medicine, they lost the inhaler, and they had not had an
asthma problem for a while so they hadn’t seen a doctor lately for asthma. Students who

did not bring an inhaler still received a sticker if they brought their folder to class and a
novelty pencil for attending the class. Students who brought inhalers received the same
incentives plus an additional novelty pencil for bringing their inhalers. No penalty was

given to students who did not have an inhaler.
The questions on the pretest and posttest (Appendix A) were designed to find out
what the students knew about their medicines. The researcher was interested in how

often, if ever, they were required to select an inhaler to use and if they had any difficulty
in remembering when to use each medicine. Questions about the name, color, and look of

their inhalers were intended to explore how the child identified the inhaler and if there

was any confusion due to similar cannisters with different medications and different
cannisters containing the same medication. Open-ended question were used to avoid

leading the child toward a particular answer. For some students, the open-ended question

33

was difficult to answer and “I don’t know” was a frequent response. Some children gave
no answer to some questions. Individual responses can be found in the Appendixes G
AD.
Knowledge of Medications
The pretest indicated that nine of the 13 experimental subjects (69.2%) were

taking medicine for asthma (Table 3). Four subjects (30.7%) did not have medicine for

asthma. Two of those students (15.4%) were family members of asthma patients. And

two (15.4%) were identified as having asthma, but did not have medication.

Table 3
Knowledge of Medications

Control

Experimental

Entire Study

Taking medications

10

9

19

No medication

3

2

5

Not asthmatic

0

2

2

No pretest

1

0

1

Ten of the 14 control subjects (71.4%) available for the pretest took medication

for asthma. Three students (21.4%) had no medication. One student (7.1%) was not

available for the pretest but was
medicine.

included in the posttest. This student did take asthma

34

Of the 19 students who took medicatron for asthma, 15 (78.9%) replied “no” to

question 4 regarding whether they knew the name of their medication. Three students
(15.8%) knew the names of their asthma medicines. One student (5.3%) knew one name
but not the name of the other medicine (Table 4).

Table 4

Identification of Medications Pretest Results

Control

Experimental

Entire Study

Knew the name(s)

1

2

3

Knew one name

1

0

1

Did not know name

8

7

15

No medications

3

2

5

Not asthmatic

0

2

2

No pretest

1

0

1

Total

14

13

27

Five students who were identified as having asthma did not have inhalers for their

asthma. Two students had only

nebulizer machines for their asthma. Two students were

not asthmatic and therefore had no inhalers. One student was no. pretested, but was
known to have inhalers.

35

Question 3 asked if students knew the names of the medicines. Question 4 asked
what were the names of their medicines. Oft<:en the student was unable to reply to

Question 6, “What do your inhalers look like?” The poster (Appendix B) entitled Inhaler

Aleit (St. Christopher s Hospital, 1996) was used to give the students a number of
inhaleis from which to choose. Students were able to point to the picture of their inhaler

with no prompting. The results were recorded as the color they mentioned and to which
inhaler the subject pointed (Table 5)(Appendixes G, H, I, and J).

Table 5
Identification of Medications Pretest Results Regarding Color

Knew the Color

10

9

19

No medications

3

2

5

Not asthmatic

0

2

2

No pretest

1

0

1

Total

14

13

27

After the educational program, the posttest results for knowledge about medicines

indicated that eight subjects of the 19 who had medication (42.1%) were able to state the
name of their medication (Table 6 and 7). Eleven students (57.8%) still did not know the
name of their medicine after the teaching program. One of the 11 students could

remember that the name began with an A. Two of the 11 students remembered that the

36

nurse had told them the names of their medications but could not remember the name.

During the class on medications, the researcher had taken each subject’s inhalers in hand

and identified the inhalers by name as well as indicating if the inhaler was to prevent
swelling (anti-inflammatory) or to open up the airways (bronchodilator).

Table 6

Identification of Inhalers Posttest Results

Entire Study

Experimental

Control

Knew name(s)

8

3

5

Knew began "A"

1

0

1

Did not know name

10

5

5

No medications

6

3

3

Not asthmatic

2

2

0

Total

14

13

27

37

Table 7

Identification of Medications Posttest Results Regarding Color

Control

Experimental

Entire Study

Knew the Color

11

6

17

No medications

3

3

6

Not asthmatic

0

2

2

Used machine only

0

2

2

Total

14

13

27

Question 8 asked how a subject knew which medicines to take. Responses from
the experimental and control subjects are contained in Appendixes K and L. On the

pretest, 10 subjects answered that a parent gives them the medicine. Five subjects
answered that they did not have medication. Two subjects indicated that they did not

know. Nine subjects attempted to explain how they could tell which medicine to take.

One subject was not available to pretest.
Of the nine students who attempted to explain their decision concerning which

medication to take, two stated that they could tell by the color of the inhaler. One student

only had one inhaler. One student only had the machine. One said the doctor told him/her

38

which one to take. One indicated that one medicine was for running and trouble

breathing, and one was for feeling sick. One student just took both inhalers every time.
Two students indicated that they looked at the name on the bottle.

On question 8 in the posttest, eight students (29.6%) indicated that a parent gave
them the medicine (Appendixes M and N). Two students (7.4%) said that they did not

know. Six students (22.2%) did not have medication, including one student who did not

have asthma. One student who did not have asthma answered that her mother gives it to

her. This may indicate that the question was not clear as to whether it referred to
asthmatic medicine or any other medicine. One student (3.7%) stated the name Albuterol

as the medicine he/she usually takes. Three students (11.1%) referred to symptoms of
coughing or breathing trouble as how they knew when to take the medicine. One subject
(3.7%) replied that he/she knew the medicines by heart. Only one student (3.7%) referred
to the star on the inhaler as a way to know which medication to take.

Needing to Know
Questions 9, 10 and 11 were designed to assess how many people take
responsibility for the child’s medication administration and if the child has to choose and
administer his/her own medication at any time (Appendixes O and P). Subjects indicated

that between one and four people gave them their medication. On the pretest, eight
students (29.6%) indicated that only one person gave them their medication. Seven
students (25.9%) had two medication administrators. Three students (11.1%) had three

people who gave them medication. Two students (7.4%) had four people who gave them

medications. Six students (22.2%) had no medication. One student (3.7%) did not pretest.

39

All students listed family members and the school nurse as the medication
administrators. No subject listed a day care teacher or babysitter as someone who needed

to give medications. Eleven subjects (40.7%) replied that someone always gave them
their inhaler. Eight subjects (29.6%) indicated that they self-administered their
medication without assistance some of the time. Seven subjects (25.9%) did not have an
inhaler. One subject (3.7%) did not pretest.

On the posttest, eight students (29.6%) replied that someone always gave them
their inhaler (Appendixes Q and R). Ten students (37.0%) indicated that they self­
administer their medicine sometimes. And nine students (33.3%) either did not have an

inhaler or were not asthmatic.

Questions 12 and 13 were designed to indicate how often a subject felt
responsible for self-medication and to validate the information in the previous three

questions (Appendixes S and T). Seven subjects (25.9%) answered that they do have to
figure out which inhalers to use sometimes. Two students (7.4%) indicated that they only

had one inhaler to take. One student (3.7%) replied that he/she takes both inhalers every

time. Nine students (33.3%) replied that they did not have to figure out which inhaler to
use on their own. Seven (25.9%) did not have inhalers to take. One (3.7%) did not pretest.

Of those seven students who reported choosing their own medication, three replied “once
in a while”, two replied “sometimes”, and two did not indicate how often they choose

their own medication.
On the posttest, five subjects (18.5%) repotted choosing their own inhalers

(Appendixes U and V). Two subjects (7.4%) reported that they only had one medication,
but that they choose when to take it. Two subjects (7.4%) always took both inhalers. One

40

subject (3.7%) reported taking whichever inhaler he/she found first. Seven subjects

(25.9%) had no inhalers. Ten subjects (37.0%) reported they did not have to figure out
which inhaler to take because they always had help choosing their inhaler.

Two of the subjects responded that they had to figure out when and/or which
medications to take once in a while. Two subjects replied sometimes. Three students
replied always. And two subjects did not answer.

Although subjects sometimes changed answers, there were indications that, at

least from their perspective, some of these elementary students (18.5 % to 29.6%)

determined if they should take their medication and which medication to take at least

some of the time. Most students were not able to read or remember the names of their
medications. Subjects relied on the color or the look of the inhaler by pointing to the
poster to identify the medicine to the questioner.

Identifying Inhalers
Questions 14, 15, 16, and 17 were designed to assess how the child identified the

correct inhaler to use. In the pretest, three students (11.1%) in the experimental group
mentioned their medications by name (Appendixes W and X). No students in the control
group mentioned a medication by name. Nine students (33.3%) named the color of their

inhaler. Three of those students (11.1%) were in the experimental group and six (22.2%)
were in the control group. Six students (22.2%) did not have inhalers. One student (3.7%)

did not answer. Four students (14.8%) answered that they use a breathing machine. Two
students (7.4%) did not describe their inhalers vocally, but were able to point to a picture

on the chart. One student (3.7%)

pretested.

responded I don’t know. One child (3.7%) was not

41

In the posttest, thiee students (11.1%) in each group could name their medicine
for a total of six students (22.2%) (Appendixes Y and Z). Five students (18.5%) named a
color to identify the inhaler, one in the experimental group and the remaining four in the

control group. Two students in each group pointed to the chart. Five students did not

answer. Four of these students were in the experimental group and one was in the control
group. One student admitted, I forgot.” Four students used the machine only. And two

subjects in the experimental group named the star on the inhaler.
Are you confused?
The remaining two questions, 18 and 19, assessed the subjects’ confusion about

the medications (Appendixes A A and AB). Question 18 reads “Are you sometimes
confused about which inhaler to take?” Question 19 asked if it was easy or hard to
remember which inhaler to use. Twelve students (44.4%) responded no, giving reasons

such as “it is easy because my mom tells me,” “I only have one type,” and “I always take

both medicines.” Nine subjects (33.3%) did not answer question 18. Five students

(18.5%) said yes, it is confusing. One subject did not pretest. Students who reported that
it is hard to remember which inhaler to use gave reasons such as it is difficult to find and
if you have an asthma attack, it is hard to remember.

In the posttest, 13 subjects (48.1%) answered no and gave similar answers as to

why it was easy to remember which inhaler to use (Appendixes AC and AD). Two

subjects of 13 (15.3%) in the

experimental group mentioned the star. Seven subjects

(25.9%) answered yes they are sometimes

confused. Seven students (25.9%) did not

answer question IS. On question 19. five of the 14 subjecu (35.7%) in the oonttol group
reported that it is hard to renentber (Appends X). Two subjects (15.3%) in the

42

experimental group reported that it is hard to remember. Students gave reasons such as it

is difficult to find, and when you have an asthma attack it is hard to remember even if you
know it by heart. One student replied, “It is hard to remember which inhaler to use

because when you have an asthma attack, you can’t think good.”
Summary

This study explored the ways children identify which inhaler to use during an

acute exacerbation of asthma and the use of a symbolic label added to the bronchodilator
inhaler to differentiate it from the anti-inflammatory inhaler. This symbolic label was
intended to make it easier for children to identify which inhaler to use during an asthma

attack.

Many children in this study did not have inhalers or only had one inhaler. The
small sample size was further reduced because 14 children (51.8%) did not have two
inhalers to use. Because the sample was so small, this was a descriptive study. There were

not enough children with two inhalers to assess their learning response to the star label.
Some children expressed a need to identify their inhalers and self-medicate at times.

43

Chapter V
Discussion

Twenty-seven inner-city elementary school children in Erie, Pennsylvania
participated in this study with their parent’s permission. This study researched the

addition of a symbolic label to the bronchodilator inhaler and the learning response to
such a label. Is the asthmatic child more likely to identify the bronchodilator inhaler

correctly with the addition of a symbolic label to the bronchodilator? The design included
random sampling, a pretest, the educational A+ Asthma Club program, and a posttest.

Results were reported in a descriptive manner due to a small sample size and the fact that
many children did not have two inhalers. Twenty-seven elementary age students in an

urban school participated with their parents’ permission. All students attended either the
scheduled session or a make-up session for each of the six lessons in the A+ Asthma Club

program.
The review of literature covered the prevalence of asthma, National Institutes of

Health Guidelines, asthma education programs, Open Airways for Schools, and the A+
Asthma Club. No studies were found that researched the lack of standardization in
inhalers.

Students identified their inhalers by the color or the look of them much more often

than by name. Students expressed being responsible to choose and administer their own
inhalers some of the time. Even after the educational program in which each student was
told the name of each medication individually, most students still identified their inhaler

by the color or by pointing to its picture. Two students said that they remembered that the
researcher had told them the name, but they did not remember the name. Five of the 27

44

subjects reported being confused about which i„haler to take. This number was
unchanged even after the educational program. Two subjects mentioned the star as

helping to identify the correct inhaler.

This study was a pilot study. Future studies could be planned to determine if the
concept of a universal symbol, added to the bronchodilator inhaler, would be beneficial to
a larger group. The National Cooperative Inner-City Asthma Study (NCICAS) Phase II

intervenes in those factors that were found to impact asthma morbidity during phase I. It
is this researcher’s intention to approach those involved in the NCICAS study to offer this
concept as one small part in the intervention process. Perhaps it can simplify one aspect

of asthma management, which is often complex and confusing. With enough data to

support the concept, the Food and Drug Administration may wish to require
pharmaceutical companies to standardize the rescue inhalers in this way.
Conclusion

The subjects in this study had some confusion and felt that it was hard to

remember which medication to take when they were having an asthma attack. The
children had a variety of situations such as having only one inhaler, a nebulizer machine

for asthma attacks, two inhalers or more, no inhalers, or having a family member with
asthma rather than having asthma themselves. Two of the thirteen subjects who were
introduced to the concept mentioned the star sticker as helping to identify the correct

inhaler. Because so many children did not have medications or did not have two types of

medications, the results may be skewed to indicate the star sticker was not helpful. If
those students had had two inhalers, they may have found it more helpful.

45

Two assumptions were not delineated in the study design. The researcher had

assumed that the students who were diagnosed with asthma would have medication to

treat asthma. It was further assumed that more children would have two inhalers, both a
bronchodilator to relieve bronchospasm and an anti-inflammatory inhaler to reduce

swelling. The NIH guidelines (1997) suggest an anti-inflammatory inhaler for all people
with asthma who have symptoms three or more times per week. Those who have
symptoms two times a week or less are classified as mild intermittent and the preferred

treatment is one bronchodilator inhaler to be used as needed for symptoms.
In the researcher’s previous experience, caring for several students who had

severe asthma attacks at school, the researcher has witnessed children using the

anti-inflammatory inhaler for symptoms because they did not know there was a difference

between their medicines. The researcher has cared for students with severe asthma attacks
who had not seen a doctor for follow-up and had had no medication for an extended

period. Parents have told the researcher that they know that asthma is serious, so they
only take their child to the emergency room for care, not to any doctor between these

emergency room visits. Children and their parents have brought in both a Proventil and an

Albuterol inhaler and thought that the child was to take two puffs of each one. This could
be dangerous because they are the same medication and can raise the child’s heart rate
and blood pressure.

Clearly, education is needed for children and their parents. This study suggests
that children may not be able to read and remember the names of inhalers. Even after the
educational program, the children still did not remember names. The present system for

identifying asthma medications may be inadequate to meet the needs of the children and

46

their parents. Most children in this study did not identify the names of their medications.

The look and color of the medication cannister was the primary way the children
identified their medication when they have had to do so. Children and caregivers may
become confused when the cannister is different due to a pharmacy or clinic dispensing a

different company’s version of the same bronchodilator. This could lead to over

medication if both are taken. Or, it may lead to confusion during an acute asthma attack

when the person is least able to remember which medication to use. Even a well-meaning
parent may not compare the generic names on the cannisters. The system can be difficult

for people to use.
The children in this study indicated that between one and four caregivers gave

them their medication. All students listed family members and the school nurse as their
only medication administrators. No subject listed a day care teacher or babysitter as

someone who needed to give them their medications. The researcher proposed that the
more people who have marginal responsibilty for the child’s care, the greater the chance

of confusion and incorrect administration of medication.
The children in this study were able to learn many things about asthma, including

the need for follow-up care, the need to control those factors in their environment that can

be controlled, and that there is a difference between the types of medication used for

asthma. Children verbally responded that their parents were going to take them to the
doctor for follow-up care. Children admitted that they need to do the things suggested in
the A+ Asthma Club program to control their exposure to environmental asthma triggers.

Many children in this study were capable of learning much about asthma and
their own care. Students were amazed at the number of different bronchodilator or rescue

47

medicines. The experimental group liked the idea of a sticker to label the rescue

medicine. Aftei the posttest, the control group subjects were each given a sticker to place
on their inhalers as well. These children seemed to appreciate the easy identification.

Another interpretation would be that these children just liked to get any kind of sticker.

The researcher attended a continuing education program given by the American
Lung Association regarding asthma education in the schools (May 26,1999). The
presenter explained that when she discusses medications with the children, she draws a

red cross on the inhaler that is their rescue (bronchodilator) medicine. The presenter
explained that the children are used to seeing a red cross for emergencies and could

remember it that way. The presenter marked the bronchodilator inhaler in this way to
prevent confusion for children during an asthma attack.
In the A+ Asthma Club program, the children, as a group, listed what they knew
about asthma and discussed how they felt about having asthma. Children expressed
feeling that sometimes they could not do what they wanted to do because of asthma. They
expressed that they could not run and play the way they wanted because of asthma

problems. In the last session, the children played charades, acting out sports that were
written on cards. The children were happy to hear that people with controlled asthma can,

and do, play all of these sports. The A+ Asthma Club program encourages children to talk
to their health care provider and parents about medicine they can use to avoid wheezing.
The children said that they would talk to their parents and health care provider about

making the changes that were suggested in the program to control their asthma.

Asthma is prevalent and costly. Hospitalization rates for asthma were twice as

high for metropolitan children when compared to nonmetropolitan children (Goodman, et

48

al., 1998). Research has focused on factors associated with high levels of asthma

morbidity (Mitchell et al., 1997). An asthma education program that was offered in

school with make-up sessions was successful in improving attendance at all sessions to
99%. Only 5% of the children attended all sessions of the same program in a clinic-based

setting (Kaplan et al., 1986).
Asthma is a growing problem. This study has shown that children as young as age

7 who have asthma are sometimes responsible for their own care. The children do not
remember the names of their medications as frequently as they remember the color or

how the inhaler looks. Some children admit to being confused about which inhaler to use
when they have an asthma attack. Educational programs are important, but educational

programs alone may not be enough to assist children in correctly identifying their
inhalers.

Asthma education that is offered in the school with make-up sessions increases
the child’s attendance at asthma education sessions. The attendance was 100% in this

study. Although education was helpful and children learned more about asthma, 11 of the
19 children (57.9%) who had medicine still did not know their medication names.

This research showed that children may benefit from a symbolic label added to
their inhaler. They did not remember their medication names even after individual

instructions related to their inhaler names and which ones to use for control or asthma
attacks. Children were sometimes in a position to provide for self-care and they were not

able to remember the name of their medication, only the color or look of the cannister.

Therefore, a symbol on the rescue inhaler would be a valuable tool for the nurse

practitioner to use to assist children

and their families to identify the correct inhaler to use

49

during an asthma attack. Orem’s (1995) theory was only partially supported by the results

of this study. Orem (1995) stated that the parent provides dependent care for the child

with a self-care deficit, and the child provides self-care within the child’s ability. The
children in this study provided self-care for their asthma at least some of the time. Their

ability did not include remembering the names of their medications. Therefore, the nurse
practitioner would provide a supportive-educative role in labeling the rescue inhaler to

support children in their self-care despite their inability to remember the inhaler

medication names.

Recommendations
Further research needs to be done to determine if a symbol on the bronchodilator

could assist children, and others with asthma, in choosing the correct inhaler to use when
having an asthma attack. A study including only subjects who have both a

bronchodilator and an anti-inflammatory inhaler may result in clearer findings. This study
included children in grades one to five with a wide variety of abilities. A future study
could include children of a narrower age and ability range. The open-ended questions

were cumbersome and difficult to administer and evaluate. The open-ended question
format was chosen because the researcher did not know how children identify their

inhalers. A checklist could be developed to indicate whether the child could identify the

inhaler by the name, color, picture, or other means, such as the star.
Asthma education should be directed at both parents and the children to
ensure safe and effective care. Children with asthma should have medication available to

them and follow-up care. Six of the 25 children (24%) in this study who had asthma had
no medication. Asthma is a chronic problem that can be controlled (NIH, 1997). Parents

50

and children need to be made aware of this. Children expressed that they could not do

what they wanted to do because of asthma. During the class having to do with exercise
and sports, the children were very happy to find out that many athletes have asthma and
control it with medication.
This research program was conducted at the end of the school year, during the

time that the children would have been outside for recess. Perhaps, an educational
program that was offered during the winter months, and at some other time, would be
more convenient and better accepted by the students and teachers. Future classes should
include peak flow monitoring to a larger extent than was in the A+ Asthma Club

program. The A+ Asthma Club introduced the idea, but there was no time in the program

for children to receive a peak flow meter and practice using it. In an attempt to follow the
program in its entirety, and due to lack of time, peak flow meters were discusssed and

demonstrated, but no peak flow meters were given to the children participating in this

research.

The field of asthma care, with peak flow meters, environmental controls, follow­
up care, inhalers, nebulizers, and medications is complex. There is so much to learn

and to remember for the person who has asthma, as well as for family members. During
an asthma attack, the person who has asthma and those who are assisting are stressed. A
label to indicate the correct medicine to use to relieve the symptoms could simplify their

choice and perhaps save lives.

51

References

Butz, A., Malveaux, F., Eggleston, P., Thompson, L., Schneider, S., Weeks, K.,
Huss, K., Murigande, C., & Rand, C. (1994). Use of community health workers with

inner-city children who have asthma. Clinical Pediatrics, 33(3), 135-141.
Centers for Disease Control and Prevention (1995). Asthma-United States, 1989-

1992. MMWR, 43, 952-955.
Centers for Disease Control and Prevention (1996). Asthma mortality and
hospitalization among children and young adults-United States, 1980-1993. MMWR,45
(17), 350-353.

Christiansen, S., Martin, S., Scheicher, B. A., Koziol, J., Mathews, K., & Zuraw,

B. (1997). Evaluation of a school-based asthma education program for inner-city children.

Journal of Allergy and Clinical Immunology, 100, 613-617.
Dorland's Illustrated Medical Dictionary (1988). Philadelphia: W.B. Saunders

Company.
Evans, D., Clark, N. M., Feldman, C. H., Kaplan, D., Levison, M. J., Wasilweski,

Y., Levin, B., & Mellins, R. B. (1987). A school health education program for children
with asthma. Health Education Quarterly, 14(3), 267-279.
Evans, D., Mellins, R., Lobach, K., Ramos-Bonoan, C., Pinkett-Heller, M.,
Wiesemann, S., Klein, I., Donahue, C., Burke, D., Levison, M., Levin, B., Zimmerman,

B., & Clark, N. (1997). Improving care for minority children with asthma: Professional

education in public health clinics. Pediatrics,99, 157-164.

52

Flaum. M„ Lung, C„ & Tinkelman, D. (1997). Take control of high-cost asthma.

Journal of Asthma, 34(1), 5-14.

Goodman, D., Stukel, T., & Chang, C. (1998). Trends in pediatric asthma
hospitalization rate: Regional and socioeconomic differences. Pediatrics, 101(2), 208-

213.
Kaplan, D., Rips, J., Clark, N., Evans, D„ Wasilewski, Y., & Feldman, C. (1986).
Transferring a clinic-based health educatioin program for children with asthma to a

school setting. Journal of School Health,56(7), 267-271.
Kelly, C., Shiled, S., Gowen, M., Jaganjac, N., Andersen, C., & Strope, G. (1998).
Outcomes analysis of a summer asthma camp. Journal of Asthma, 35(2), 165-171.

Lewis, M.A., Lewis, C., Leake, B., Monahan, G., & Rachelefsky, G. (1996).
Organizing the community to target poor Latino children with asthma. Journal of Asthma,
33(5), 289-297.

Lurie, N., Straub, M. J., Goodman, N., & Bauer, E. J. (1998). Incorproating

asthma education into a traditional school curriculum. American Journal of Public Health,
88(5), 822-823.

Mannino, D., Homa, D., Pertowski, C., Ashizawa, A., Nixon, L., Johnson, C.,

Ball, L., Jack, E., & Kang, D. Surveillance for asthma-United States, 1960-1995.

MMWR, 47(SS-1). 1-27.
Mitchell, H„ Senturia, Y., Gergen, P., Baker, D., Joseph, C„ McNiff-Mortimer,
K., Wedner, H.J., Crain, E., Eggleston, P.» Evans, R., Katten, M., Kercsmar, C., Leickly,
F„ Malveaux, F„ Smartt, E„ Weiss, K. (1997). Design and methods of the national

cooperative inner-city asthma study. Pediatric Pulmonology .24, 237-252.

53

Munro, J., Haire-Joshu, D., Fisher, E., & Wedner, H. J. (1996). Articulation of

asthma and its care among low-income emergency care recipients. Journal of Asthma, 33
(5), 313-325.

National Institutes of Health. (1991). Expert Panel Report: Guidelines for the

Diagnosis and Management of Asthma(NIH Publication No. 91). Washington, DC: U.S.
Department of Health and Human Services.
National Institutes of Health. (1997). Expert Panel Report 2: Guidelines for the

Diagnosis and Management of Asthma, (NIH Publication No. 97-4051). Washington,
DC: U.S. Department of Health and Human Services.

O’Neill, M. (1996). Helping schoolchildren with asthma breathe easier:

Partnerships in community-based environmental health education. Environmental Health

Perspectives, 104(5), 464-466.
Orem, D. (1995). Nursing Concepts of Practice (5th ed.). St Louis: Mosby.
Schneider, S., Richard, M., Clark, K. (1991). A+ Asthma Club. Washington, D.C.
Schneider, S., Richard, M., Huss, K., Huss, R., Thompson, L., Butz, A.,
Eggleston, P., Kolodner, K., Rand, C., Malveaux, F. (1997). Moving health care

education into the community. Nursing Management, 2.8(9), 40-43.
St. Christopher’s Hospital for Children. (1996). Inhaler Alert, [brochure].

Philadelphia: Author.

U.S. Department of Health and Human Services, Public Health Service (1991).

Healthy people 2000, National health promotion and disease prevention objectives.
Washington, DC: U.S. Government Printing Office.

54

Wade, S., Weil, C., Holden, G., Mitchell, H., Evans, R., Kruszon-Moran, D.,
Bauman, L., Crain, E., Eggleston, P„ Kattan, M„ Kercsmar, C„ Leickly, F„ Malveaux, F.,

Wedner, H. J. (1997). Psychosocial characteristics of inner-city children with asthma: A

description of the NCICAS psychosocial protocol. Pediatric Pulmonology, 24, 263-276.
Yoos, H. L., McMullen, A., Bezek, S., Hondorf, C., Berry, S., Herendeen, N.,

MacMaster, K., Schwartzberg, M. L. (1997). An asthma management program for urban
minority children. Journal of Pediatric Health Care, 11(2), 66-74.

55

Appendix A

Medicine Knowledge Survey

Initials

Grade

1. Do you take medicine for your asthma?

2. How many different medicines do you take?

3. Do you know the names of your medicines?

4. If yes, what are they?

5. Do you take inhaler medicines?

6. What do your inhaler medicines look like?

7. What color are your inhalers?

8. How do you know which medicines to use?

9. Who gives you your inhaler?

56

10.

Does someone always give you your inhaler?

11.

How many people help you to take your asthma medicine?

12. Do you sometimes have to figure out which inhaler to use by
yourself?

13.

If yes, how often? Always sometimes once in a while

14. When you have to give yourself your medicine, how do you
know which medicine to take?

15. Which inhaler do you use so you won’t have an asthma
attack?

16.

Which inhaler do you take for breathing trouble?

17.

Which inhaler do you take before gym, recess, or exercise?

18.

Are you sometimes confused about which inhaler to take?

19. Is is easy or hard to remember which inhaler to use when you
have trouble breathing?

57

APPENDIX B

SI CHRISTOPHER’S

W HOSPITAL FOR CHILDREN

Erie Avenue at Front Street, Philadelphia, PA 19134-1095 (215) 427-5000

INHALER ALERT
For Those Using Inhalers: These metered dose inhalers are used by patients with asthma.
Please note: different medications may be contained in inhalers with similar colors. It is important that you
take the correct medication. If you are unsure about when and how to take your medication, please ask your
doctor. Don’t guess...your health counts on this!

BRONCHODILATORS

fI

IMI

I
ALUPENT®
(metaproterenol sulfate)
[Boehringer]

ALBUTERGL
(albuterol sulfate)
[Warrick]

ATROVENT®
(ipratropium bromide)
[Boehringer]

MAXAIR®
(pirbuterol acetate)
[3M]

ALBUTEROL
(albuterol sulfate)
[Zenith]

VENTOLIN®
(albuterol sulfate)
[Allen & Hanburys]

SEREVENT®
(salmeterol xinafoate)
[Allen & Hanburys]

PROVENTIL®
(albuterol sulfate)
[Schering]

1
<5 -I

ANTI-INFLAMMATORIES

AEROBID®
(flunisolide)
[Forest]

AZMACORT®
(triamcinolone)
[Rhone-Poulenc-Rorer]

AER0BID®-M
(flunisolide)
[Forest]

BECLOVENT®
(beclomethasone dipropionate)
[Allen & Hanburys]

/"■ .4-

nsoxs

INTAL®
(cromolyn sodium)
[Rhone-Poulenc-Rorer]

TILADE®
(nedocromil sodium)
(Rhone-Poulenc-Rorer]

VANCERIL®
(beclomethasone dipropionate)
[Schering]

9/36

00/15/99

WED 22:47 FAX 2154274643

SCHC PROGRAMDEVELOPMENT


@001

APPENDIX C

St. Christopher’s
Hospital for Children
Erie Avenue at Front Street
Philadelphia, Pennsylvania 19134-1095

tel: 215.427-5000
fax:2i5.427.53oo

September 16, 1999

Kinko's

To Whom It May Concern:
Please consider this permission for Debbie Feeney to have 8 copies made of
our asthma inhaler poster for her thesis.

If you have any questions, please call me at 215-427-5396.
Sincerely,

Linda Van Winkle
Administrative Coordinator
Public Relations
/Ivw

rener

58

1

Appendix D

School Nurse
Debbie Feeney, R.N.jp

McKinley School
Parent of

Dear Parent:
I will be teaching an Asthma education program, called the A+ Asthma Club, as part
of my Master s Degree program for Edinboro University. The children participating
in this program will meet for 45 minutes twice a week for six sessions during the
school day. The program sessions are:
Meeting 1- SoYou Have Asthma Too!
Meeting 2- What is Asthma?
Meeting 3- How to Keep Asthma Attacks from Starting
Meeting 4- Asthma Medicines

Meeting 5- Making Decisions and Choices
Meeting 6- Running, Playing and Sports/ Review

A pre-test and posttest about asthma will be given to all participating students. This test will
not affect their school grades and will be confidential. Some students will receive a sticker on
their inhaler during Meeting 4. The rest of the students will receive a sticker on their inhaler
at the end of the program. If you have any questions or concerns about the program, you may
call me at McKinley School 871-6524. Please sign below if you permit your child to
participate and return this form to school.
I permit my child to participate in the A+ Asthma Club.

Parent Signature.
Sincerely,

Debra Feeney, RN
School Nurse

Appendix E

School Nurse
Debbie Feeney, R.N.

McKinley School
Parent of
Dear Parent:

I will be teaching an Asthma education program, called the A+ Asthma Club, as part
of my Master’s Degree program for Edinboro University. The children participating
in this program will meet for 45 minutes twice a week for six sessions during the
school day. The program sessions are:
Meeting 1- So You Have Asthma Too!
Meeting 2- What is Asthma?
Meeting 3- How to Keep Asthma Attacks from Starting
Meeting 4- Asthma Medicines
Meeting 5- Making Decisions and Choices

Meeting 6- Running, Playing and Sports/ Review
If your child has asthma and you would like for your child to participate in this
program, please sign below. If you have any questions, please call me at 871-6524.

I permit my child to participate in the A+ Asthma Club.

Parent Signature.
Sincerely,

Debra Feeney, RN
School Nurse

I

THE SCHOOL DISTRICT OF THE CITY OF ERIE
RESEARCH REQUEST ------

PENNA.

61

APPENDIX F
I

MAME

Pfy? br3____________

( Last )/

I

ADDRESS

Fir3C )

( Middle )

( Malden )

fib /

Arps

7^

Par

TELEPHONE

I

NAME OF COLLEGE / AGENCY

I

I request permission to conduct a iresearch project involving pupil records and/or pupils
in the School District of the City of Erie
|
(Name o School / Department)

k

for the purpose of

£ C'l

C

If granted permission to do this research, I agree to abide by all the regulations concern­
ing confidentiality of records. I will supply written parent/student consent as required.
' I will supply a copy of the completed research to the Erie School District for its file
and use. Before I publish any results from the research, I agree that the School District
committee will validate my research technique.

for research to be done in the months of

Presented by August 1,

(Year)
I request an exception to August 1 deadline for the following reasons.

Building principals, department heads, coordinator
Before approval is granted.

Date



will be consulted by the superintendent

approved
rejected

___________________________________________________________________________________________________________ ■

Building Pr dclpal/’Department Head/

Date

_ «£___

approved
Coordinator/
rej ected
7

Superintendent of Schools

approved
rej ected

Date

Board of Edx^ation

F0RN:

132-CSD-4-75

-29-

APPENDIX G

62

EDINBORO UNIVERSITY
OF

PENNSYLVANIA

Department of Special Education and
School Psychology
Edinboro, PA 16444
(814) 732-2200

Date: April 14,1999
To: Debra Feeney
Dr. Alice Conway
From: Dr. Dastoli, Chairperson
Human Subjects Review Board
Re: Use of a symbolic Label to Enhance Learning About Asthma medications.

I have reviewed the human subjects application for the above captioned study. It
has been found to be in compliance with the standards of Edinboro University of
Pennsylvania's Human Subjects Review Board and is therefore approved.

CC:

Dr.
Dr.
Dr.
Dr.

Culbertson
Demiral
Kerstetter
Baker

r.

A member of the State System of Higher Education

63

Appendix H

Medicine Knowledge Pretest Experimental (X)
Survey Questions
1 Do you take medicine for your asthma?
2 How many different medicines do you take?
3 Do you know the names of your medicines?
4 If yes, what are they?
5 Do you take inhaler medicines?
6 What do your inhaler medicines look like?
7 What color are your inhalers?

Survey Question Numbers
Subject # 1 Medicine 2 # Medicines 3/4 Names?
IX
2X
3X
4X
5X
6X
7X

8X
9X
10X
11X
12X
13X

No (family)
0
No
1
Yes
1
2
Yes
No (family) 0, Mom does
Machine
1
2
Yes

NA
No
No
No
No
No
Yes Albuterol
Intal
2 Bottle/Tube No
Yes
Yes Albuterol
2
Yes
Intal
Machine
No
2
Yes
No, Ritalin Ritalin only NA
No
3
Yes
No
2
Yes

5 Inhalers 6/7 Looks/color

NA
Blue/ Ventolin
Brown/Lt Brown
Don't know
White
NA
White/ Blue &
white
Yes
White/Albuterol
Sometime White/blue &
white
White/Albuterol
No
NA
No
White/pink
Yes
Pink/blue
Yes
V anceri 1/Albuterol

NA
Yes
Yes
No
Mom
No
Yes

64

Appendix I
Medicine Knowledge Pretest Control (C)

Survey Question Numbers
Subject# 1 Medicine 2 # Medicines 3/4 Names?
14C

15C
16C
17C

18C

19C
20C
21C
22C

23C

24C
25C
26C
27C

Yes

Don’t know

5 Inhalers 6/7 Looks/color

Yes/need White/Albuterol
one
Yes
1
No
Yellow
Yes
2
Yes
Yes
No
White
Albuterol/Tilade
Yes
2
Yes Vanceril & ? Yes
White/pink
Albuterol/Vanceri 1
Yes
Had 2 before No
Yes
White & pink
white & blue
none now
Albuterol/Intal
Yes
Yes
On spoon No
Yellow/Proventil
or pills
No
Yes
White/Albuterol
1
Yes
White/pink
Yes
2
No
Yes
Albuterol/Vanceril
Yes Albuterol
White
6(2 for
Yes
Yes
asthma)
Azmacort
Albuterol/Azmacort
"Mom says she'll
NA
No
No
0
get some."
NA
No
NA
NA
No
NA
No
NA
0
No
White/pink
2
No
Yes
Yes
Albuterol/V anceril
Not available for pretesting
No

65

Appendix J

Medicine Knowledge Posttest Experimental (X)
Survey Questions
1 Do you take medicine for your asthma?
2 How many different medicines do you take?
3 Do you know the names of your medicines?
4 If yes, what are they?
5 Do you take inhaler medicines?
6 What do your inhaler medicines look like?
7 What color are your inhalers?
Survey Question Numbers
Subject# IMedicine 2#Medicines
3/4 Names
IX

0

NA

NA

NA

0 Dad said he
will get some
2

NA

No

NA

No "inhalers"

Yes

3
0

No
NA

No
NA

White/orange &
brown, Albuterol
NA
NA

0
2

NA
Yes

No
Yes

Yes
Yes

2
Machine & 2

Albuterol/Intal
No
Albuterol/Intal

Yes
Yes

Yes
No
Ritalin
Machine
Yes

1
Ritalin only

No
Yes

Yes
No

Don't know
2

No
Albuterol
Vanceril

No
Yes

2X

No
(family)
No

3X

Yes

4X
5X

No
No
(family)
Machine
Yes

6X
7X

8X
9X

10X
11X

12X
13X

5 Inhalers 6/7 Looks/color

NA
White
Blue & white
Albuterol/Intal
White/Albuterol
white/blue&
white
Albuterol/Intal
White
NA
NA
Purple/blue
Vanceril
Albuterol

66

Appendix K

Medicine Knowledge Posttest Control (C)

Survey Question Numbers
Subject#
1 Med. 2 # Medicines

14C

Yes

15C
16C

Yes
Yes

17C

Yes

18C

Yes

19C

Yes

20C
21C

Yes
Yes

22C

Yes

23C
24C
25C
26C

No
No
(family)
No
Yes

27C

Yes

3/4 Names

5 Inhalers 6/7 Looks/Color

Machine & 1

No, but the
Yes
White/Albuterol
nurse told me.
1
Yes
Proven til Yellow/Proventil
No
Yes
No
White/white&
blue
Albuterol/Tilade
2
Albuterol
Yes
Pink/white
Vanceril
Albuterol
Vanceril
2
No, I forgot. Yes
White & pink
Grey & pink
Intal
Albuterol
Whole bag full
No
Yes
All kinds of
Mom has bad
colors.
asthma.
Albuterol/Proventil/Azmacort
White/Albuterol
Yes Albuterol Yes
1
White/pink &
1 starts with an A Yes
2
purple, Albuterol
Vanceril
White
Yes
Proventil
Machine & 2
Intal
Azmacort
NA
No
NA
0
NA
No
NA
0
0
Machine & 2

NA
No

No
Yes

5

No

Yes

NA
White/pink &
purple, Albuterol
Vanceril
White/green
Albuterol
Serevent

67

Appendix L
How Do You Know? Pretest Experimental (X)
Subject #

IX
2X
3X
4X
5X
6X
7X
8X
9X
10X
11X
12X
13X

Survey Question Number 8 How do you know which medicines to use?

My mom gives it to me.
Mom gives me the medicine.
Grandma tells me then I tell my mom.
Don’t know (shrug)
NA (family)
My mom tells me.
Because Dad used to be an EMT and he tells me.
I have trouble breathing so I take the machine.
Mom tells me and in the morning I make my own medicine.
My mom gives it to me.
NA (no medicine)
If I cough a lot my Dad says to take a treatment.
My mom tells me.

68

Appendix M
How Do You Know? Pretest Control (C)

Subject # Survey Question Number 8 How do you know which medicines to use?

14C
15C
16C
17C
18C
19C
20C
21C

22C
23C
24C
25C
26C
27C

My mom gives me the machine if I cough or have trouble breathing.
It’s the only one I have.
One is for running and if I have trouble breathing or feel sick I take the other
one.
Doctor told me.
I just used both.
I don't know.
I look at the name that I can see over the plastic.
When I am playing too hard I take the white one. I take the pink one in case I
need it.
It says on the bottle.
No medicine
No medicine
No medicine
Pink one if I'm not too bad and the white one if I'm bad.
Not available for pretest.

69

Appendix N
How Do You Know Posttest? Experimental (X)

Subject #

IX
2X

3X
4X
5X
6X
7X
8X
9X
10X
11X
12X
13X

Survey Question Number 8. How do you know which medicines to use?

My mom gives it to me.
My Dad said if I do my homework he will take me to the doctor to get one of those
(inhalers.)
I don't know.
Don't know (shrug)
NA (family) It's the only medicine mom has.
My mom tells me.
Because Dad used to be an EMT and he tells me.
I have trouble breathing so I take the machine.This one sprays (albuterol inhaler).
I usually use albuterol.
My mom tells me.
NA (no medicine)
If I cough a lot, my Dad says to take a treatment.
Because Mrs. Feeney put a star on one and told us which ones to use.

70

Appendix O

How Do You Know? Posttest Control (C)

Subject # Survey Question Number 8. How do you know which medicines to use?

14C
15C
16C
17C
18C
19C
20C
21C
22C
23C
24C
25C
26C
27C

If my chest hurts or if I am coughing I use the machine but if it is just starting I use
the puffer.
Only one I have and I use it when I cough.
My mom tells me or leaves me a note after school.
The Doctor told me.
One is for a sore throat and one is if I have trouble breathing.
My mom tells me.
Because I only have one and my sister's are in a separate bag.
If I am coughing my mom tells me to take the white one or the pink and purple one.
Cause I know them by heart.
No medicine
No medicine
No medicine
I use the white one if I need it and the pink one if I don't need it.
I take the puffers when I get home.

71

Appendix P
Who Give Inhalers? Pretest Experimental (X)
Survey Questions
9 Who gives you your inhaler?
10 Does someone always give you your inhaler?
11 How many people help you to take your asthma medicine?

Survey Question Numbers
Subject # 9 Who gives? 10 Does someone always give inhaler? 11 How many people?
IX
2X
3X
4X
5X
6X
7X
8X
9X
10X

11X
12X
13X

NA (family)
Mom, Dad
Mom, Gram
Mom
NA (family)
Machine
Dad
Mom, Dad
Mom, sister
Mom
Grandfather
NA
Dad
Myself

NA
Yes
No, sometimes its me.
Didn't answer
NA
Mom and Step-mom
No, sometimes its me
Yes Aunt, Grandma
Yes Grandma
No, sometimes its me.

NA
2
2
1
NA
2
2
4
3
2

NA
No, sometimes it's me.
No

NA
1
3 Mom Dad sister

72

Appendix Q

Who Gives Inhalers? Pretest Control (C)

Survey Questions
9 Who gives you your inhaler?
10 Does someone always give you your inhaler?
11 How many people help you to take your asthma medicine?

Survey Question Numbers
Subject # 9 Who Gives?
10 Does someone always give inhaler? 11 How many people?
14C
15C
16C
17C
18C
19C
20C
21C
22C
23C
24C
25C
26C
27C

Me
Mom
Mom, Dad
Mom, me
Mom me
Mom, me
Mom, nurse
Mom, Grandma
Nurse Feeney
NA
NA, (family)
NA
Mom, Nurse
Not available for pretest

No, I do.
Yes
Yes
No, sometimes its me.
No, sometimes its me.
Yes
Yes
Yes
Yes
NA
NA
NA
Yes

1, only Mom.
1
4, Grandpa,Sister
1
1
1
2
2
1, only Nurse Feeney
NA
NA
NA
3 Dad

73

Appendix R

Who Gives Inhalers? Posttest Experimental (X)
Survey Questions
9 Who gives you your inhaler?
10 Does someone always give you your inhalers?
11 How many people help you to take your asthma medicine?

Survey Question Numbers
Subject # 9 Who gives? 10 Does someone always give inhaler? 11 How many people?

4X
5X
6X
7X
8X

NA (family)
NA
Mom, Dad,
Gram
NA
NA (family)
NA machine
Me, Mom, Dad
I do at school.

9X
10X
11X
12X
13X

Ido
Mom
NA
Machine
Myself

IX
2X
3X

NA
NA
Yes

NA
NA
4 brother

NA
NA Mom takes it by herself.
NA
No, sometimes it's me.
No. It's in my bookbag.

NA
NA
NA
2
4 Mom Dad Aunt
Grandma
1 Mom
2 Nurse Debbie, Mom
NA
3
3 Mom, Dad, sister

No, sometimes it's me.
Yes
NA
Yes, Dad, Brother, Sister
No, sometimes it's me.

74

Appendix S

Who Gives Inhalers? Posttest Control (C)
Survey Questions
9 Who gives you your inhaler?
10 Does someone always give you your inhaler?
11 How many people help you to take your asthma medicine?

Survey Question Numbers
Subject # 9 Who gives?
10 Does someone always give inhaler? 11 How many people?

14C
15C
16C
17C
18C
19C
20C
21C
22C
23C
24C
25C
26C
27C

Myself
Myself
Mom, sister
Me, Mom
Me, Mom
Myself
Mom, Uncle
Mom, me
Mom, Nurse
NA
NA (family)
NA
Mom
Dad

No, sometimes it’s me.
No, sometimes it's me.
Yes
No, sometimes it's me.
No, just me.
No, myself.
Yes
Yes
Yes
NA
NA
NA
No, sometimes it's me.
Always

Mom gives machine.
2 Mom and me
5 Grandpa, Dad, Aunt
2 Me and Mom
Me
1 Mom
3 Dad
2 mom and Grandma
3 Dad
NA
NA
NA
4 Dad and 2 sisters
3 Dad, Mom, aunt

75

Appendix T
Child Alone Inhaler Identification Pretest Experimental (X)

Survey Question Numbers
Subject # 12 Do you sometimes have to figure out which inhaler to use by
yourself?
IX
2X
3X
4X
5X
6X
7X
8X
9X
I0X
11X
12X
13X

NA (family)
If I am coughing I take the puffer.
No, someone tells me.
No
NA (family)
No inhalers
Yes
No
No
I only have one
NA
No
No, I always take both.

13 How often?

NA
No answer
NA
NA
NA
NA
Once in a while
NA
NA
No answer
NA
NA
NA

76

Appendix U
Child Alone Inhaler Identification Pretest Control (C)

Survey Question Numbers
Subject # 12 Do you sometimes have to figure out which inhaler to use by
yourself?

14C
15C
16C
17C
18C
19C
20C
21C
22C
23C
24C
25C
26C
27C

No, I only have one puffer.
No, Only my mother gives it to me.
No
Yes
Yes
No
No
Yes
Yes
No inhalers
No inhalers
No (Family)
Yes
Not available for pretest

13 How often?

NA
NA
NA
Sometimes
No answer
NA
NA
Sometimes
Once in a while
NA
NA
NA
Once in a while

77
Appendix V

Child Alone Inhaler Identification Posttest Experimental (X)

Survey Question Numbers
Subject # 12 Do you sometimes have to figure out which inhaler to use by
yourself?

IX
2X
3X
4X
5X
6X
7X
8X
9X
10X
11X
12X
13X

NA (family)
If I am coughing I take the puffer.
No, someone tells me.
No
NA (family)
No inhalers
Yes
No
Yes
I only have one
NA
No
No, I always take both.

13 How often?

NA
No answer
NA
NA
NA
NA
Once in a while
NA
Always
No answer
NA
NA
NA

78

Appendix W
Chijd Alone Inhaler Identification Posttest Control (C)

Survey Question Numbers
Subject # 12 Do you sometimes have to figure out which inhaler to use by
yourself?

14C
15C
16C
17C
18C
19C
20C
21C
22C
23C
24C
25C
26C
27C

I have to decide when to take my inhaler (I have one.)
No, Only my mother gives it to me.
No
Yes
No, I have to take both everyday two times.
No, I take whichever one I find first.
No
No
No
No inhalers
No inhalers
No (Family)
Yes
No
*

13 How often?

Always
NA
NA
Once in a while
Always
Sometimes
NA
NA
NA
NA
NA
NA
Sometimes
NA

79

Appendix X

Identifying Inhalers Pretest Experimental (X)

Survey Questions
14 When you have to give yourself your medicine, how do you know which medicine to
take?
15 Which inhaler do you use so you won’t have an asthma attack?
16 Which inhaler do you take for breathing trouble?
17 Which inhaler do you take before gym, recess, or exercise?

Sub# Question 14

IX
2X
3X

NA
No answer
No answer

Question 15

Question 16

Question 17

NA
Only have one
At home dark
blue
light blue
No answer
NA
None
Albuterol

NA
Blue
White, at school

NA
No
None

No answer
NA
Machine
Both

No answer
NA
None
Albuterol

Machine
Machine

None
Only if having trouble.

Mom puts it in the
machine.
NA
Take a treatment and
lay down.
Pink

White one

No answer
NA
Mom tells me.
Colors and Dad
teaches me
None
8X Mom helps me.
White 1st then white/ Both
9X
blue
I used to have
10X I don’t know
Vanceril.
NA
11X NA
Albuterol
12X No answer

4X
5X
6X
7X

13X Both

Blue

NA
None
Blue

80

Appendix Y

Identifying Inhalers Pretest Control (C)

Survey Questions
14 When you have to give yourself your medicine, how do you know which medicine to
take?
15 Which inhaler do you use so you won’t have an asthma attack?
16 Which inhaler do you take for breathing trouble?
17 Which inhaler do you take before gym, recess, or exercise?

Sub # Question 14

Question 15

14C Puffer or
machine(bad)
15C I never have to.
16C Mom leaves me a
note.
17C Pink first then white
I8C Both always
19C No answer
20C Mine is in its own bag.
21C I take the pink.

I don't know

22C
23C
24C

25C
26C
27C

Question 16

White if it had
medicine
I only have one. Yellow
Pointed to Tilade Pointed to albuterol.

Pink one
I don't know.
I don't know.
White
Pointed to
Albuterol.
Both
No answer

My Dad tells me.
No answer
(no inhalers)
No answer
No answer
(no inhalers)
No answer
No answer
(no inhalers)
White
White if it's bad.
Pink if it's not bad.
Not availaible for pretest.

Question 17

I don't take one.
I don't take one.
Pointed to albuterol.

Both, pink then white
I don't know.
Orange one
Same one (white)
Pointed to pink.

Pink one 2 puffs
Both
No
White one
Pointed to white

Breathing machine
No answer

Pointed to Albuterol
No answer

No answer

No answer

No answer

No answer

White

Pink

81

Appendix Z
Identifying Inhalers Posttest Experimental (X)
Survey Questions
14 When you have to give yourself your medicine, how do you know which medicine to
take?
15 Which inhaler do you use so you won’t have an asthma attack?
16 Which inhaler do you take for breathing trouble?
17 Which inhaler do you take before gym, recess, or exercise?

Sub#

Question 14

IX

No answer

2X

No answer

3X
4X
5X

The one with star.
No answer
NA Mom has only
one.
Mom tells me.
Dad and Nurse
Debbie taught me.
If it’s bad/machine.
If it's not bad/ puffer.
Eenie meenie
minie mo
What Mom tells me
NA
No answer
Nurse and Mom tell
me.

6X
7X

8X

9X
10X
11X
12X
13X

Question 15

Question 16

Question 17

Pointed to

Inhaler with star

No answer
Intal

Machine
Albuterol then Intal

None
Intal

Pointed to
Albuterol
Albuterol

Machine

My puffer is empty.

Albuterol and Intal

Both

Shook head no
NA
No answer
Albuterol with
star

Mom put in machine
NA
No answer
Albuterol & Vanceril
Changed mind twice.

White one
NA
No answer
Albuterol

Albuterol and
Pro ven til
Proventil
are the same.
Pointed to
Pointed to
Pointed to
Albuterol
Albuterol
Albuterol
Orange and brown one None
I don't know
No answer
No answer
No answer
NA
NA Mom has one. NA

82

Appendix A A
Identifying Inhalers Posttest Control (C)

Survey Questions
14 When you have to give yourself your medicine, how do you know which medicine to
take?
15 Which inhaler do you use so you won’t have an asthma attack?
16 Which inhaler do you take for breathing trouble?
17 Which inhaler do you take before gym, recess, or exercise?

Survey Question Numbers
Sub# Question 14
Question 15
Puffer or machine,
when it's bad.
15C No answer
16C Mom leaves it out.
17C Mom tells me.

14C

Question 16

White if it had
medicine.
I only have one. Proventil
White/ blue one Plain white
Vanceril The nurse
Albuterol The
told me.
nurse told me.
Albuterol
Albuterol
Pointed to
Pointed to
Proventil
Azmacort
Same one (white)
White
White The nurse Pink and purple
told me.
Breathing machine
I don't know
If I have trouble
No answer
I go to the doctor.
No answer
I forgot
Machine

18C
19C

I don't know
I learned them on own.

20C
21C

Mine is in its own bag.
I never have to give it.

22C
23C

I never have to give it.
No answer
(no inhalers)
No answer
(no inhalers)
Pointed to Tilade Pointed to Albuterol
(no inhalers)
Breathing machine
White
Pink
Pointed to Albuterol
Pills?
No answer

24C

25C
26C
27C

Question 17

I don't take one.
I don't take one.
Plain white
Albuterol

Both
None

White one
White one

Pointed to Albuterol
No answer
No answer
No answer
Pink
None

83

Appendix AB
Are You Confused? Pretest Experimental (X)

Survey Questions
18 Are you sometimes confused about which inhaler to take?
19 Is it easy or hard to remember which inhaler to use when you have trouble breathing?

Survey Question Numbers
Sub # 18 Are you confused?
IX
2X
3X
4X
5X
6X
7X
8X
9X
10X
11X
12X
13X

No answer
No answer
No
No answer
No answer
No answer
A little
No
No
Yes
No answer
Kind of
No

19 Is it easy or hard to remember which inhaler to use?

No answer
I take my puffer when my mom says.
Easy
I have a machine at home.
No answer
Easy, because I only have one kind of medicine.
Not very easy, because I get weak and have trouble deciding.
Easy
Easy, because I have a big brain.
Easy, because I only have one.
No answer
Hard
Easy, because I know which ones to take.

84

Appendix AC
Are You Confused? Pretest Control (C)

Survey Questions
18 Are you sometimes confused about which inhaler to take?
19 Is it easy or hard to remember which inhaler to use when you have trouble breathing?

Survey Question Numbers
Sub # 18 Are you confused?

14C
15C
16C
17C
18C
19C
20C
21C
22C

No, I only have one.
No
No
No
No, I take both.
No
No
Yes
No

23C
24C
25C

No answer
No answer
No answer

26C
27C

Yes
Not available for pretest.

19 Is it easy or hard to remember which inhaler to use?

Sometimes it's difficult because I don't know which one I need.
Easy, I only have one.
Easy. My mom leaves it out for me.
Easy
Easy, I take both.
Hard, because I can't find it.
Easy
Sometimes easy, sometimes hard.
Easy, because I always take my machine when I have trouble
breathing.
I have trouble breathing in the morning a lot.
No answer
If I run a lot my chest starts to hurt and my throat gets really dry.
I don't take asthma medicine.
Hard, because if you have an asthma attack you forget stuff.

85

Appendix AD
Are You Confused? Posttest Experimental (X)
Survey Questions
18 Are you sometimes confused about which inhaler to take?
19 Is it easy or hard to remember which inhaler to use when you have trouble breathing?

Survey Question Numbers
Sub # 18 Are you confused?
IX
2X
3X

No
No
No

4X
5X
6X
7X

No answer
No answer
No answer
Sometimes

8X

No

9X
10X
11X
12X
13X

No
No, Mom tells me.
No answer
No answer
No

19 Is it easy or hard to remember which inhaler to use?

Easy, because if you took this class you use the one with the star!
My uncle has a breathing machine and sometimes I use it.
Easy, because at home I only have the orange and brown and at
school I have a white one.
No answer
Hard, because you have to look through things to find it.
I don't use inhalers . I think it would be hard.
Both. It's easy because I know by memory, but it's hard because
when I have an asthma attack I get weak and forget.
Easy, because if it is a little one we use the puffer and if it is a really
hard one we use the machine.
A little easy, because I am really smart.
Easy, because Mom tells me.
I have never had to take inhaler medicine.
No answer
Easy, because I know which ones to take.

86

Appendix AE

Are You Confused? Posttest Control (C)

Survey Questions
18 Are you sometimes confused about which inhaler to take?
19 Is it easy or hard to remember which inhaler to use when you have trouble breathing?

Survey Question Numbers
Sub# 18 Are you confused?

14C Sometimes
15C No
16C No, My Mom leaves it
out.
17C Yes
18C No, I take both.
19C No, Mom taught me.
20C No
21C Yes
22C
23C
24C
25C

No
No answer
No answer
Yes

26C
27C

Yes
Yes

19 Is it easy or hard to remember which inhaler to use?

Hard, because when it is starting you don't know if it will get bad.
Easy, I have the same kind at school and at home.
Easy, because I always have the one I need with me.

Easy, because my Mom tells me.
Easy, by the colors.
Easy, because Mom showed me and telled me how to take it.
Easy, 'cause I only have one and it has my name on it.
It's not easy. It's hard because when I have an asthma attack it's hard
to breathe.
Easy, because my Mom gives it to me.
I think it would be hard.
No answer
Hard cause when you have lots of inhalers you wouldn't know which
one to use.
Hard because if you have an asthma attack you can't think good.
Hard