Assessment of the
effectiveness of an asthma
education inservice program
for elementary school teachers
/ by Amy E. Pagano.
Thesis Nurs. 2900 P343a
c .2

AN ASSESSMENT OF THE EFFECTIVENESS OF AN ASTHMA EDUCATION
INSERVICE PROGRAM FOR ELEMENTARY SCHOOL TEACHERS

By

Amy E. Pagano BSN, RN

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

Approved by:

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Mith Schilling, CRNP, PhD
Committee Chairperson

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Alice Go.nway, CRNP, PhD)
Committee Member/,

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fyrtpx Geisel, PhD, RN
‘Committee Member

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Date

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Acknowledgements
I would like to acknowledge and give special thanks to Holly Miller of the

American Respiratory Alliance of Northwestern Pennsylvania, for allowing me to
participate in the School Asthma Initiative and conduct this study. Holly’s graciousness
in inviting me to several School Asthma Initiative programs, and her assistance in data

collection, is very much appreciated.
I would also like to thank Dr. Judith Schilling for serving as the chair of my thesis

committee. Dr. Schilling’s advice and comments were prompt, thoughtful, and always
helpful, and I truly appreciate her support. Thank you also to the other members of my

thesis committee, Dr. Alice Conway and Dr. Janet Geisel, for their help.
Finally, thank you to my husband Bill and my daughter Celia. Their patience and

support while writing this thesis made its completion possible.
HighMark of Blue Cross sponsors the School Asthma Initiative.

ii

Abstract

An Assessment of the Effectiveness of an Asthma Education Inservice Program for
Elementary School Teachers
Asthma is the most common chronic childhood illness (Adams & Marano, 1995;

Centers for Disease Control and Prevention, 1995). As children with asthma enter school,
their teachers may become involved in helping them manage their asthma.
Research literature review reveals few studies on teachers’ knowledge of asthma,

or on the effectiveness of asthma education programs. The American Respiratory

Alliance of Western Pennsylvania conducted an asthma education inservice program for
elementary school teachers as part of their School Asthma Initiative. This study was

conducted to assess the effectiveness of this inservice program. Malcolm Knowles’ Adult
Learning Theory was the conceptual framework for this study.

Thirty-six elementary school teachers participated in the study. Teachers’ asthma
knowledge was tested using an identical Asthma IQ pretest and posttest. The teachers had

a significant increase in their scores on the tests taken after the inservice program (p<0
.01).

Responses to a researcher written survey revealed that although at least 60% of

teachers reported having students with asthma, and almost one-half of teachers had
previously had to assist a student with asthma symptoms, only two teachers had ever
attended an asthma education program. Nearly all of the teachers perceived that they

should have some role in assisting students to manage their asthma.
Children with asthma need proper support at school (National Institute of Health,
1997). Recognizing teachers, at least in part, as caregivers of children with asthma, and

iii

asthma, and networking in community based organizations to participate in asthma
education programs, offers the nurse practitioner another opportunity for education.

iv

Table of Contents
Content

Page

Acknowledgements

ii

Abstract

iii

List of Tables

viii

List of Figures

ix

Chapter I: Introduction

1

Background of the Problem

1

Statement of the Problem

3

Theoretical Framework

.4

Statement of Purpose

.7

Assumptions

7

Limitations

7

Definition of Asthma

7

Summary

8
9

Chapter II: Review of Literature

Pathogenesis and Management

9

Teachers Knowledge of Asthma

10

Effectiveness of Asthma Education Programs in Schools

15

Content of a School Asthma Education Program

19

Summary

.20

21

Chapter III: Methodology

Hypothesis

.21

Operational Definitions

21
v

Content

Page

Research Design

.22

Setting and Procedure

.22

Instrumentation

.23

Informed Consent and Protection of Human Rights

.24

Pilot Study

24

Data Analysis

25

Summary

.25

.26

Chapter IV: Research Results

Sample Population

.26

Study Results

.28

Comparison of Individual Pretest Posttest Items

30

True/False Statements

31

Free Text Questions

31
35

Summary

37

Chapter V: Discussion
Findings

36

Importance of the Study

37

Support for Conceptual Framework

38

Study Limitations

38

Recommendations...

39
.40

Summary..

.41

References..

vi

Page

Content
Appendixes

,43

A. Asthma LQ. Test

.43

B. Survey

.44

C. Oral Introduction

.45

vii

List of Tables
Table

Page

1. Years of Teaching Experience

.27

2. Classroom Teachers Report of Students with Asthma

28

3. Teachers Having Assisted a Student Having Asthma Symptoms

.29

4. Teachers Pretest and Posttest Scores

30

5. Name Three Things That Happen to the Lungs During an Asthma Attack.

32

6. Name Three Triggers of Asthma

34

7. Name Two Things You Can Do to Help A Student Having an Asthma Attack..34

viii

List of Figures
Page

Figure
1. Percentage of teachers naming wheeze or

cough as early warning signs of asthma attack

33

2. Teachers mentioning medication, or inhaler

use as means of assisting students with asthma

ix

35

Chapter I

Introduction
This chapter provides an overview of asthma in children including symptomatology,

epidemiology, and the current National Heart, Lung, and Blood Institutes’ (NHLBI)

Expert Panel Report guidelines for asthma management (National Institute of Health

[NIH], 1997). Asthma is a chronic disease, and knowledge about asthma and its
components of care are essential for proper management (NIH, 1997). As children enter
school, teachers in addition to family and health care providers including nurse

practitioners may become involved in the management of asthma and, therefore, may

need education about the disease.
A description of Malcolm Knowles’ Adult Learning Theory, which serves as the
conceptual framework for the study, is provided in this chapter. The definition of terms,
the assumptions and limitations of the study are also included
Background of the Problem
Asthma is a chronic inflammatory disorder of the airways that often begins during

childhood. Asthma is characterized by airway hyperresponsiveness and variable, but
often reversible, airflow obstruction (NIH, 1997). Asthma’s range of symptoms may

include wheeze, cough, shortness of breath, reduced expiratory air flow, exercise
intolerance, and respiratory distress (Szilagyi & Kemper, 1999). When asthma begins in

childhood it is often associated with atopy (NIH, 1997).
Asthma is the most common chronic childhood illness, affecting between 4% and 7%
of children, or approximately 48 million children under the age of 18 in the United States

2

(Adams & Marano, 1995; Center for Disease Control and Prevention [CDC], 1995).

There are more than 5,000 deaths from asthma each year (NIH, 1997). In recent years
asthma has increased in both the number of children affected, and in the severity of

disease in affected children. Asthma occurs more commonly in African-Americans, and

in those living in an inner city environment (Szilagyi & Kemper, 1999).
Approximately one-third of children with asthma have some limitations in their

activities (Newacheck & Taylor, 1992). Asthma is the most common reason for school
absence (Newacheck & Taylor, 1992) and children with asthma have a higher risk of
academic problems when compared to well children (Fowler, Davenport, & Gary, 1992).

The NIH (1997) NHLBI Expert Panel Report 2: Guidelines for the Diagnosis and
Management ofAsthma identifies four components of care necessary for effective asthma
management. These include:
1. Initial assessment and diagnosis of asthma with severity classification to guide
stepwise therapy, followed by periodic assessment and ongoing monitoring to determine

if goals of therapy are being met.

2. Control of factors contributing to asthma severity, including identification of and
reduction of exposure to allergens and irritants.

3. Pharmacologic therapy in a stepwise approach based upon severity, including long
term control medications and quick relief medications used to treat acute symptoms and
exacerbations.

4. Patient education for a partnership in asthma care begun at diagnosis and
incorporated into each step of care.

3

Patient education and knowledge about the disease is an especially necessary component

of asthma care because management of asthma requires that patients and other caregivers
be able to follow complex medication routines, institute environmental control measures,
detect and treat exacerbations, and effectively communicate with health care providers

(NIH, 1997).
Statement of the Problem
The NHLBI National Asthma Education and Prevention Program (NAEP) School

Asthma Education Subcommittee (NIH, 1997) determined that, in order to keep their

asthma under control and to lead fully active lives, children with asthma need proper
support at school. Once children enter school, they spend a large part of their day under
the supervision of their teachers, who may become involved in assisting students in

managing their asthma. Because of this, teachers, in addition to the child’s home

caregiver, need knowledge about asthma and its management. Without training, teachers

may feel reluctant to help students, believing the situation to be a medical issue rather
than an educational issue (Bannon, 1995).

The nurse practitioner uses education as an integral part of practice. A partnership in
care between the health care provider and patients with asthma and their caregivers is
identified as a necessary component for effective asthma management (NIH, 1997).

Recognizing that teachers may be assisting students with asthma, participation by the
nurse practitioner in a community-based asthma education program for teachers such as
the School Asthma Initiative offers a unique method for facilitating this partnership in
care.

4

Theoretical Framework
Malcolm Knowles’ Adult Learning Theory served as the theoretical framework for
this study (Knowles, 1980). Knowles’ theory identified two types of educating:

pedagogy and androgogy. The characteristics of pedagogy and androgogy can be

contrasted by viewing the assumptions of each model in relation to the following
categories: (a) concept of the learner, (b) role of learners’ experience, (c) readiness to

learn, and (d) orientation to learning (Knowles, 1980). Knowles identified both pedagogy
and androgogy as alternative models of assumptions about learners. However, he also
identified the models as most useful when they are not seen as dichotomous, but on a

continuum, with the learner in a given learning situation placed somewhere between two
ends.

Pedagogy, “the art and science of teaching children” (Knowles, 1980, p. 40), is the
first model of assumptions about learning and characteristics of learners. Pedagogy

evolved over the centuries, and its assumptions were based on the teaching of young

children, with education being the process of transmitting what is known (Knowles,
1980). In pedagogy the learner is dependent and the teacher decides what is to be learned,

how it is to be learned, and how learning is to be evaluated. The role of the learner’s

experience is limited, possibly serving as a beginning point, and the primary teaching
technique is transmittal, with lecture as an example. In pedagogy readiness to learn is

determined by others, such as society or schools. Finally, in pedagogy the learner is

subject-centered in their orientation to learning, and most subject content is understood to
be useful later in life (Knowles).

5

Androgogy is the term used to describe the theory of adult learning that evolved from
research-based knowledge about adult learning derived from educators and other related

disciplines including clinical and developmental psychology, gerontology, sociology, and
anthropology (Knowles, 1980). Knowles (1980) wrote that androgogy, or adult learning,

is premised on four assumptions about the characteristics of learners that are different
from those on which pedagogy is based.
The concept of the learner in androgogy acknowledges that as part of normal
maturation the person moves from dependency to increasing self-directedness. Adult

learners are identified by Knowles (1980) as having “a deep psychological need to be
generally self-directing, although they may be dependent in particular temporary

situations” (p.43).
The role of the learner’s experience in androgogy contrasts to that of pedagogy in that

experiences obtained through growth and development serve as resources for the learner
and others (Knowles, 1980). In androgogy learning gained from experience holds more

meaning than learning gained passively. Educational techniques in andrgogy are,
therefore, based on experiential methods, for instance discussion or problem solving
cases. Readiness to learn in androgogy occurs when a person experiences a need to learn

something in order to manage tasks or problems. The educator helps the student discover

their learning needs (Knowles, 1980).

Finally, the adult learners’ orientation to learning in androgogy is one of immediacy
of application of knowledge (Knowles, 1980). The learner sees education as a means of
developing increased competence to achieve full life potential. Learning shifts from

subject-centeredness to performance-centeredness.

6

Patient education is a foundation of practice for the nurse practitioner, and may be

considered a distinguishing feature of the nurse practitioner as a health care provider.
Positive outcomes of patient education may include earlier detection of disease, better

management and fewer complications from chronic diseases, and fewer hospitalizations

(Glanville, 1999).
Patient education in today’s health care setting has evolved to include a range from

disease-specific teaching to teaching for prevention, health maintenance, and health
promotion. This scope offers nurse practitioners opportunities to use their strengths as

educators in a variety of settings including teaching in the primary care office, teaching in

clinics, facilitating support groups, and teaching in group settings in the community.
Asthma is a common health problem encountered in primary care. Networking within an

existing local organization, such as the American Respiratory Alliance of Western
Pennsylvania, the nurse practitioner can participate in community outreach programs to
help meet asthma education needs.

The nurse practitioner can utilize knowledge of adult learning in an asthma education

inservice program given for teachers. Pretest assessment of asthma knowledge, and
discussion of asthma and its implications, can help teachers identify their own need for

knowledge about asthma and asthma management. A variety of educational techniques
are used in the American Respiratory Alliance of Northwestern Pennsylvania’s asthma

inservice education program. These techniques, including illustrations, discussion,

questions, manipulation of equipment, and use of relevant classroom examples, can help
the teacher obtain the knowledge needed to assist a student in the classroom with their

asthma management.

7

Statement of Purpose

The purpose of this study was to determine the effectiveness of an asthma education
inservice program given for teachers at an elementary school in the Oil City School
District in Venango County, Pennsylvania. A researcher-written survey was done to
determine whether the teachers perceived themselves as having a role in assisting their

students with asthma to manage their disease. It also described the study sample
population.

Assumptions
The assumptions of the study were as follows:

1. There are children in the schools with asthma who may require assistance in their

asthma management from their teachers.

2. School teachers would attend the asthma education inservice program and be able
to read and complete the survey, pretest, and posttest.

Limitations
The limitations of the study were as follows:
1. The study was limited to one school in one county in Pennsylvania, and may not
be generalizable to other school systems or teachers.

2. The study measured pretest and posttest knowledge obtained from an inservice
program, and may not reflect future retention or proper use of the information.
3. The study did not address the effect of the program on asthma morbidity in

children.

Definition of Asthma
The following term is defined as it was used in the study:

8

Asthma is a chronic inflammatory disorder of the airways in which many cells

and cellular elements play a role, in particular, mast cells, eosinophils,

neutrophils, and epithelial cells. In susceptible individuals, this inflammation
causes recurrent episodes of wheezing, breathlessness, chest tightness, and

coughing, particularly at night or in the early morning. These episodes are usually
associated with widespread but variable airflow obstruction that is often reversible

either spontaneously or with treatment. The inflammation also causes an
associated increase in the existing bronchial hyperresponsiveness to a variety of
stimuli (NIH, 1997, p. 1).
Summary

Asthma is a chronic inflammatory disease, and is the most common childhood

chronic illness (Adams & Marano, 1995). Caring for asthma requires that children with

asthma, and those involved in their care, are knowledgeable about the disease and its

components of care. As children enter school, their teachers may become involved in
their asthma care and, therefore, need knowledge about the disease and its management.
Malcolm Knowles Theory of Adult Learning was the framework this study used to assess

the effectiveness of an asthma education inservice for teachers conducted at an
elementary school district in Oil City inVenango County, Pennsylvania. The definition of

asthma, and assumptions and limitations of the study, were included in this chapter.

9

Chapter II

Review of Literature
The purpose of this study was to assess the effectiveness of an asthma education

inservice program for elementary school teachers. This chapter describes the
pathogenesis of asthma and components of asthma management. Research literature on
teachers’ knowledge of asthma, and on the effectiveness of asthma education programs

for teachers, is reviewed. This chapter also includes a description of the National Asthma
Education and Prevention (NAEP) program guidelines for managing asthma at school.
Pathogenesis and Management

Asthma is a chronic inflammatory disorder of the airways at all levels of severity
(NIH, 1997). The airway inflammation that occurs in asthma results from complex

interactions among inflammatory cells, mediators, and other cells and tissues of the
airways. Features of asthma in relation to lung function include airway
hyperresponsiveness and airflow obstruction. An exaggerated bronchoconstriction

response with bronchi narrowing too easily, and too much to a variety of stimuli, occurs
in asthma, and airway inflammation contributes to the airway hyperresponsiveness.

Airway hyperresponsiveness can lead to the clinical symptoms of wheezing and dyspnea
after exposure to triggers such as allergens, environmental irritants, viral infections, cold

air, and exercise. Airway limitation or obstruction that occurs in asthma is recurrent, and
caused by a variety of changes in the airway including acute bronchoconstnction, airway
edema, chronic mucus plug formation, and airway remodeling.

10

Asthma severity is classified as mild intermittent, mild persistent, moderate

persistent, and severe persistent (NIH, 1997). However, a mild, moderate, or severe

exacerbation of asthma can occur at any level of asthma severity.

Components of asthma care include initial assessment and diagnosis followed by

periodic assessment and monitoring, control of factors contributing to asthma severity,
pharmacologic therapy, and education (NIH, 1997). Goals of asthma therapy are
symptom prevention, maintenance of normal pulmonary function, maintenance of normal
activity level, prevention of exacerbation, provision of optimal pharmacotherapy, and

satisfactorily meeting patient and families expectations of care.
Asthma medications are categorized into long-term control medications directed

toward long-term suppression of inflammation, and quick-relief medication for treating
symptoms and exacerbations (NIH, 1997). Asthma pharmacotherapy should be instituted

along with environmental control measures.

Patient education should begin at diagnosis and be ongoing (NIH, 1997). Key
educational messages include basic facts about asthma, roles of medications, skills such

as inhaler and peak flow meter use, environmental control measures, and when and how

to take rescue action. A daily self-management plan should be written. A self­

management plan should also be written to help school personnel manage a child s
asthma.

Teachers’ Knowledge of Asthma
A study conducted in Holon, Israel (Brook, 1990) evaluated teachers’ knowledge and
information about asthma, and determined teachers’ awareness about asthmatic students
in their class. The study also compared general classroom teachers to single subject

11

teachers. Two of six high schools were randomly chosen, representing 113 teachers
teaching 1,422 students. A three part 40-item questionnaire asked about experience in

teaching, asthmatic pupils in the classroom, and teachers’ general knowledge and
information about asthma. General knowledge questions were checked by a single

physician and rated as correct, absence of knowledge, or incorrect. The teachers
answered 50/o of the asthma questions correctly, and there was no significant difference
between general and single subject teachers. With the exception of physical education

teachers, who received medical information concerning students, general subject teachers

were more able than single subject teachers to identify asthmatic pupils, and were more
able to estimate severity of symptoms.
The study revealed that 65% of the teachers’ knowledge of asthma came from reading

articles in journals or health periodicals, and by reading health books (Brook, 1990). In

addition, 46% of the teachers also acquired asthma information by talking with nurses
and physicians. Other sources of asthma knowledge included previous studies, asthmatic

friends, acquaintance with parents of children with asthma, and television programs.
Eighty-seven percent of the teachers responded positively to the suggestion of learning

more at school about asthma.
Bevis and Taylor (1990) surveyed 98 teachers in eight primary schools in London to

assess the asthma knowledge among primary teachers, and to identify specific areas of
lack of understanding. The study was also done to investigate how teachers felt about
managing asthmatic children in school, and policies for giving treatment. A questionnaire

comprised of 33 statements about asthma, to be marked ■true” “ false,” or “don’t know”

was used. There were 17 additional questions on the teachers’ views and opinions about

12

asthmatic students, about their experience with children with asthma, and about their

views on policy for giving medications. Although 69% of the teachers had taught

asthmatic children, only 5% thought that they knew enough about asthmatic children, and
only 4 /o reported that they received any asthma training or teaching. Correct responses to

statements about asthma varied widely, and most teachers answered “don’t know” or
incorrectly responded to all statements about medications except Ventolin. Teachers’

understanding of the relationship between exercise and asthma was also limited, and
although 79% of teachers thought that asthmatic students should be encouraged to

participate in exercise and sports at school, only 27% recognized cold air as a trigger and
only 33% knew that premedication before exercise could prevent symptoms. The
schools’ policies on asthma medication varied. Some of the teachers reported being

unaware of a policy, and only one-half of the teachers allowed students to keep their
inhalers with them.
Noting that asthma in New Zealand is a major child health problem, Seto, Wong, and

Mitchell (1992) conducted a survey in South Auckland to examine management of
asthma in the primary schools, and the teachers’ knowledge, confidence, and attitude in
managing students with asthma. Forty-two primary schools were randomly chosen to

participate. School principals were given a questionnaire asking the number of students in
the school, the number of students with asthma, the method of notifying the school of

students with asthma, who was responsible for management of asthma in children and
supervision of medication administration, and use of a nebulizer for medication
administration.

13

Questionnaires were also given to 253 randomly selected teachers Iron, these schools

asking age and length of teaching experience, experience with students with asthma, and
their personal experience with asthma (Seto et al. 1992). Questions were also asked to

test the teachers’ asthma knowledge, their confidence in the administration of inhaled
medication, and to ascertain their sources of information about asthma in children.

The questionnaire (Seto et al. 1992) was completed by 76% of the school principals
and 66% of the schoolteachers selected. The mean percentage of students reported as
having asthma by principals was less than previously reported in the literature for this

area. Students were identified as having asthma by entrance questionnaire, parent report,
and previous school records. In 51% of the schools, the class teacher was the person
primarily responsible for supervising the needs and treatment of students with asthma.

Sixty percent of the schools allowed either the teacher or the student to keep the inhaler
medication. Although all teachers had a book on asthma management at school, only

37% reported having used it. Ninety-seven percent of the teachers reported having taught
students with asthma, and 76% had witnessed an asthma attack. Teachers were

considered to have good asthma knowledge, with the exception of knowledge about
asthma medications, with 66% recognizing Ventolin as being a symptom reliever, and
less than 50% recognizing preventive medications. Also, 52% of the teachers had the
misconception that overuse of asthma medication would result in diminished effect,

meaning that they might be reluctant to repeat treatment with a bronchodilator
medication. Teacher education, especially on practical aspects of asthma management,
was recommended based on the study.

14

Capers. Ebbutt, and Ba™ (1995) conducte(i a

schools in Wes. Gloucestershire. England

determine their level oflomwledge about

asthma, and whether increased knowledge of asthma was associated with increased
ability to help children manage asthma. TTte survey was conducted in suburban, rural, and
innerwity- areas. Sixty-one percent of schools responded to the survey, representing 235

teachers in 48 schools. The survey included background questions about the number of

students in the classroom with asthma, exposure to asthma training, experience of direct
contact with asthma, and knowledge of asthma treatment plans and location of asthma

medications in the school. There were also questions to assess general knowledge about

asthma. A trained asthma nurse coded the survey. Teachers were placed in subgroups
based on exposure to asthma training and direct contact with persons with asthma. Sixty-

one percent of the teachers had no asthma training, and no asthma knowledge related to
direct contact with asthma. Comparison for differences between these subgroups was
done using a chi-square test, with significance level at .05. The study found limited

knowledge of asthma among the teachers. All teachers recognized asthma as a respiratory

problem, but only 32% mentioned airway constriction, and even fewer were aware of
allergic and inflammatory changes. Teachers with both asthma training and direct contact
with asthmatics were more knowledgeable than those with neither. These teachers

more able to correctly identify airway characteristics of asthma, with 41 /o knowing

airway constriction (p<0.001), and 14 % more knowing airway inflammati

(B

They were also more knowledgeable about triggers of asthma symptoms, 31% more

mentioned allergies (p-0.001), and 26 % more mentioned upper respiratory infeelions
(rO.OOl). Knowledge of what to do if a child has an asthma attack was aiso limited in

15

that only 41% of all teachers mentioned administering an inhaler medication. Teachers
with asthma training or direct contact with persons with asthma were 48% more likely to
call parents (p<0.001), and 25% more likely to get medical help (p<0.001). Teachers with

asthma training were most likely to mention inhaler use (difference 40%, p=0.007).

Seventy percent of children were not permitted to keep their inhalers with them. In
parallel with this survey, a group of teachers was formed in conjunction with the Asthma

Training Centre to design educational material for use in schools. Recommendations of
the study were for education of school personnel about asthma, and formation of a

national policy on asthma management in schools.
Bowen (1996) conducted a study in England to determine whether teachers had
received education in their basic teacher training, or inservice training, for dealing with

emergency situations in children with asthma, epilepsy, and diabetes. Surveys were given
to 36 teachers with varying levels of experience in five schools, and 83% were returned.

The knowledge of teachers was not tested. All of the teachers reported having students in
their class with asthma. Seventy percent of the teachers reported having received

instruction on children’s medical conditions in their teacher training, and 50% stated they
had had updates since. However, only 43% of the teachers reported feeling competent to

cope with a child having an asthma attack, and 83% of the teachers requested further
training. Subsequent to the study, a training session on each of the three conditions
surveyed was arranged.
Effectiveness of Asthma Education Programs in Schools

In conjunction with the American Lung Association of Oregon, Eisenberg, Moe and

Stillger (1993) developed an

asthma education program for medical and nonmedical

16

personnel in schools. The program was conducted statewide in Oregon, with data

reported from four programs. School personnel attendance was voluntary, with the
exception of some school districts requiring school nurses to attend. An assessment tool

was mailed to participants prior to the program. The tool consisted of 24 statements about
asthma with true,

false, or don t know” as possible responses. There were seven

additional questions asking about participants’ role at school, medication policy and

responsibility for asthma management, attitude regarding medication administration at
school, and personal experience with asthmatic children. A second assessment tool was

mailed to participants 4 weeks after program attendance. Ninety participants completed
pretest tools, and of those, 37 or 46 % completed posttest tools. On the initial assessment

tool nurses scored higher than nonmedical personnel. For each question the percentage of
correct answers increased from pretest to posttest, and there was a decreased number of

“don’t know” responses for each question. For the entire group there was a statistically

significant increase from pretest to posttest scores (p<0.001), with correct responses to 24
knowledge statements about asthma increasing from 15.9 to 20.2. Posttest scores for

nonmedical staff were nearly identical to the nurses. Although the low number of post

class assessment tools returned was identified as a possible bias of the data, as
nonresponders may have been less knowledgeable, the data indicated that nonmedical

personnel can demonstrate an increase in their level of understanding about asthma .her
attending an educational session.

Hazel, Henry, Frances, and Halliday (1995) initiated a study in New South Wales.
Australia to assess whether information about asthma acquired by individual teachers at
an asthma inservice seminar would be disseminated to other schoolteachers and staff, and

17

whether the information would lead to schools developing policies about asthma
management. A 2-hour asthma education inservice seminar for school staff was presented
by an asthma educator in each school district in the region, with at least one
representative from each school attending. Fifty schools were randomly chosen for a

telephone survey from the 149 primary schools that participated in the seminars, and
personnel at 48 of these 50 schools completed the telephone survey. The asthma educator
who presented the inservice program did the telephone survey. The survey was a 30-

minute interview that documented each school’s policy and procedure for management of
asthma before and after the seminar. The survey also asked questions about the feedback
given by the teacher who had attended the inservice program to other teachers and

personnel at the home school.
In all 48 schools feedback was given to the teachers by the person attending the

inservice and all, or most, of the staff were reached in 46 of the schools (Hazel et al.
1995). Presentation of the information obtained at the asthma inservice seminar was most
commonly done at a staff meeting, and for more then 80% of the schools the content of
the feedback included information on asthma symptoms, medications, asthma equipment

for the first aid kit, guidelines for the treatment of an asthma attack, and the issue of
having a school policy. After the seminar the number of schools with an asthma policy

increased from one to 20 (p<0.001), and the number of schools requesting written
instructions from parents about management of their child’s asthma increased from 18 to
44 (p<0.001). Prior to the seminar only four of the teachers felt that the staff at their

school knew how to recognize an asthma attack. At the time of the follow-up survey this
number had increased to 22 (£<0.001). Because the asthma educator conducted the

18

interviews, and because those interviewed were the persons attending the original
seminar, the researchers acknowledged the possibility of observer bias in the study.
However, they concluded that inservice education is an efficient means of
communicating asthma education, and resulted in improved knowledge of staff about
asthma, with an increased number of schools developing appropriate policies and

procedures for asthma management.
Kaiser Permanente Medical Center implemented and studied Peak Performance USA,

an asthma education training program developed by the American Association of
Respiratory Care, at two of six school districts in San Jose, California, reaching 180

school personnel (Powell, 1998). After contacting principals, nurses in the six school

districts of the medical center’s service area were asked to attend an initial planning

meeting. Training sessions were set up in the two school districts that agreed to
participate, representing 65 schools. Schools were given a package of written material on
asthma management training, and peak flow meters and aero chambers (spacers) were
given to physical education teachers. All teachers were given Peak Performance USA
asthma management guide handouts. Either a 2-hour or a 3-hour class was also presented

and attended by 180 school personnel, including at least one person from each of the 65
participant schools.

A preprogram questionnaire was administered before the class session, and a post­
program questionnaire was administered by mail 6 months afterward (Powell, 1998).

Chi-square testing was used to compare preprogram and postprogram results for

increased knowledge and confidence, and statistical significance was p<0.05. Of the 180
persons attending, 47 completed both the pre and posttes. questionnaires used for data

19

analysis, although some preprogram data were missing and not all items were answered
by every participant.

Preprogram, 42% of 19 respondents stated they were “not at all” confident in their

ability to help a school child with asthma management, while none responded “not at all”
in matched analysis of the postprogram question (p=0.003). Of 20 personnel responding
to the question about two things a child can do to manage asthma symptoms, 65%
answered correctly preprogram, and 100% answered correctly postprogram (p=0.008).

Preprogram, 86% of responders knew that children with asthma should not avoid

exercise; this increased to 100% postprogram(p=0.007). The chief limitation of the study
was identified as the low response rate. As a result of the program, an additional school
district requested the training, and a participating district requested a review of the

training a year later.
Content of a School Asthma Education Program

The NHLBI encourages a partnership between students with asthma and their families
and health care providers and school personnel in managing and controlling asthma
(NIH, 1991). Comprehensive school asthma education for school personnel should focus
on encouraging recognition of asthma as a disease requiring ongoing care, with the

understanding that proper asthma treatment and education will improve the school
performance of students with asthma. Effective management of asthma at school
encourages a supportive learning environment for students with asthma, decreases

number of absences, decreases classroom disruption, and provides necessary support for
emergency asthma situations (NIH, 1991).

20

Managing Asthma: A Guide for Schools (NIH, 1991) was developed as a

collaborative project between several government agencies, including the NHLBI and

NAEP, and was designed to help schools develop and maintain an asthma management

program that provides school personnel with practical ways to assist students with
asthma. The informational content of the guide includes a definition of asthma and

description of asthma symptoms. Also included are measures for effectively managing
asthma, such as recognition of early warning signs of an asthma episode, identification
and avoidance or control of common asthma triggers, use of anti-inflammatory and

bronchodilator medications, and monitoring asthma with a peak flow meter.
According to the guide (NIH, 1991) schools are encouraged to help students manage

their asthma by providing support through the development of an asthma management

program. The asthma management program should include school policies and
procedures for medication administration, specific actions for staff members to perform
in asthma management, and an action plan for student asthma episodes. The action plan is

specific to each individual student, is completed by the parent and physician, and is kept
on file at the school.
Summary

This chapter reviewed the pathogenesis of asthma and current recommendations for

asthma management. A review of recent research studies done to assess teachers
knowledge of asthma, and to assess the effectiveness of asthma education programs for to

school personnel, is included in this chapter. This chapter also reviewed NHLBI, NAEP
(NIH, 1991) recommendations for content of asthma education for school personnel.

21

Chapter III
Methodology

This chapter describes the research methodology used for this study. The American

Respiratory Alliance of Western Pennsylvania conducted a school asthma initiative in
public schools in several counties in Pennsylvania. This program included asthma

education for school nurses, teachers, and students with asthma at the elementary and
middle school grade levels, and peers of students with asthma at the middle school grade

level. The curriculum for each group contained key educational messages identified by
the NHLBI National Asthma Education Program (NAEP) (NIH, 1991).

This study was done to determine the effectiveness of the asthma education program

given for teachers by the American Respiratory Alliance, as part of the schools’ asthma

initiative. Included in this chapter are the research hypothesis, operational definitions, and
method of informed consent. A description of the research design, instrumentation,

procedure for data collection, and data analysis is also included.
Hypothesis

The hypothesis of this study was that the teachers would have a statistically
significant improvement in their scores on the Asthma I.Q. test taken after the inservice

program.
Operational Definitions
The operational definitions of the study were as follows:

1. Elementary school teachers were teachers teaching students in grades kindergarten

through six in a public school in Pennsylvania who attended the asthma education
inservice program.

22

2. Asthma education inservice program was an education program about asthma and
asthma management for teachers designed and given by the American Respiratory

Alliance of Western Pennsylvania. The inservice program was presented to the teachers,

as a group, in an inservice education setting.
3. Asthma knowledge was evidenced by an asthma I.Q. test, a test about asthma and

asthma management developed by the American Respiratory Alliance of Western
Pennsylvania (Appendix A).
Research Design

A preexperimental design using a pretest posttest was used for the study. A

researcher-written survey was also administered immediately prior to the inservice
program (Appendix B).
Setting and Procedure
This study was part of an education inservice program about asthma and asthma

management developed for teachers by the American Respiratory Alliance of Western
Pennsylvania. The inservice content included a 15-minute videotape about asthma

management in the school. The videotape was made by the NHLBI National Asthma

Education Program (NIH, 1995). Basic anatomy and physiology of the respiratory system
was presented and reviewed, followed by a description of the pathophysiology of asthma
and asthma symptoms. In addition, overhead illustrations were used throughout the

program to present information about triggers of asthma symptoms, early warning signs
of an asthma attack, the use of individualized school action plans for students with

asthma, and school personnel procedures. Peak flow meter use and its significance in

23

asthma management was discussed, as was the use of anti-inflammatory and
bronchodilator drugs administered via metered dose inhalers with spacers.

A period of time was allotted for questions and discussion, and questions were
encouraged throughout the program. Examination and manipulation of peak flow meters,

and metered dose inhalers and spacers, was allowed. Teachers were given a folder with
written information reflecting the content of the program to keep for future reference.
The inservice program was given for elementary school teachers from the Oil City

school district in Venango County in Pennsylvania. An asthma educator trained by the

American Respiratory Alliance of Western Pennsylvania conducted the inservice. The
inservice was mandatory, and was conducted in a group setting on a planned teacher
inservice day.

Instrumentation
An asthma I.Q. test developed by the American Respiratory Alliance of Western

Pennsylvania was administered prior to and at the completion of the inservice program.

The test was graded and scored by the researcher. The test consisted of six true/false
questions, and four free-text questions about asthma and asthma management. The pretest
questions were identical to the posttest questions. Each true/false question was marked

correct, or incorrect, and was given one point. Each of the 4 free-text questions asked the
participant to name either two or three things. One point was given for each thing
correctly named and were, thus, worth either two or three points. There were 16 possible

points on the test.
A researcher-written survey (Appendix B) of the inservice participants was conducted

prior to the inservice program. This survey consisted of eight questions to determine the

24

presence of students with asthma in each teacher’s classrooms, their perceptions of their

role in assisting students to manage their asthma, previous experience assisting a student
with asthma, previous personal experiences with asthma, previous experience in

attending an asthma education program, their number of years of teaching experience,
and the grade level taught.
Informed Consent and Protection of Human Rights

An oral introduction was given by the asthma educator to convey the importance of
the problem and the purpose of the study (Appendix C). Submission of the completed

survey constituted consent to participate in the study. Only grouped data are reported, and
no names were placed on the pretests, posttests, or surveys. The study was eligible for

expedited review for protection of human rights by the Edinboro University of
Pennsylvania review board.

Pilot Study
A pilot study of the researcher-written survey was conducted at an inservice
education day for high school teachers in Cranberry Township in Venango County,

Pennsylvania. There were 47 participants. A survey question regarding teachers’
perception of their role in assisting students to manage their asthma was added. This was
done because no literature was found examining teachers concerns regarding asthma

management. If teachers do not feel they should have a role in assisting students to

manage their asthma the inservice education program may be moot. A question regarding
personal experiences with asthma was added because the literature review revealed that

personal experiences of persons with asthma may affect knowledge of asthma and may
be useful in making comparison.

25

Data Analysis
Descriptive statistics were applied to the study survey, and the pretest and posttest

results. The survey data were analyzed by counting the frequency of responses to the
dichotomous questions. These were placed in frequency distribution and percentage
tables. Years of teaching experience was placed in a frequency distribution, and then
grouped by 5-year intervals. Numbers of students in the classroom with asthma, and the

total number of students in the classroom, were placed in a frequency distribution table.

Measures of central tendency were used to describe the survey results and sample
population.
Similarly, the pretest and posttest item results, identified as correct or incorrect, were

scored and were placed in frequency distribution and percentage tables. Pretest and

posttest results were placed in percentage tables for comparison. Pretest and posttest

score ranges and means were determined. A paired t-test was used to test the research
hypothesis.

Summary
The purpose of this study was to determine the effectiveness of an asthma education

inservice program given for elementary school teachers. A pretest-posttest design was
used. A researcher-designed survey was also given. A description of the research design
and instrumentation, method of informed consent, a pilot study, and data analysis were
included in this chapter

26

Chapter IV
Research Results

This chapter presents the results of the Asthma IQ test given to elementary school

teachers prior to and following an asthma education inservice program. Thirty-six
elementary school teachers in the Oil City school district in Venango County

Pennsylvania completed a survey, and Asthma IQ pretest and posttest, and were included
in the study. Data on the sample population, teacher survey, and individual test item

comparison are also included in this chapter.
Sample Population

Forty-six elementary teachers completed the survey and were eligible for the study.
Of these, 36 teachers completed both the pretest and the posttest, and their data were used

for the study. There were 26 regular classroom teachers grades kindergarten through five.
The remaining ten teachers included two reading teachers, two physical education
teachers, two learning support teachers, one special education teacher, and one school

librarian.

The teachers’ number of years of teaching experience ranged from 1 to 35 years, with
more than one-half of the participants having taught for more than 15 years (Table 1).

Three teachers reported having taught for 35 years.
Classroom teachers of kindergarten through fifth grade reported a range in classroom

size from 16 to 30 students. The average class size was 23 students.
Of all the teachers, 66% reported having students in their classrooms with asthma.
Eighteen of the 26 regular classroom teachers reported having students with asthma, and
eight reported having none. The reported number of students in the classroom with

27

asthma ranged from one student to five students, with one or two students being reported
most often (Table 2). The teacher who reported five students in her classroom with

asthma commented that in the last few years there had been one student per year with
asthma.

Table 1

Years of Teachine; Experience (N=36)

Years of Teaching

2

1 to 5

7

6 to 10

6

11 to 15

1

16 to 20

4

21 to 25

4

26 to 30

11

31 to 35

3

Six of the ten teachers who did not have a regular classroom reported having students

with asthma. One of the physical education teachers estimated that of 700 total students,
30 have asthma, and the other physical education teacher reported having lots of

students with asthma. Both music teachers, who see children grades kindergarten through

fifth, reported having students with asthma: one had ten students, the other wrote that she
had “many.” A reading teacher who sees 60 students reported three students with asthma,
and a learning support teacher reported two.

28

Table 2
Classroom Teachers Report of Students with Asthma (N=26)

Students

n

0

8

1

7

2

7

3

3

4

0

5

1

Nine of the teachers, or one-quarter of participants, reported having personal

experience with asthma. Only two of all 36 teachers had ever attended any other asthma
education program.
In response to the survey question “Have you ever had to assist a student who was
having asthma symptoms?” 17 teachers, or 47%, reported they had, and 19, or 53%,

reported they had not (Table 3).

Thirty-three of 36 teachers responded to the question “What role should elementary

teachers have in assisting students to manage their asthma?” No teacher responded that
they should have no role.

Study Results
The hypothesis of this study was that the teachers would have a statistically

significant improvement in their scores on the Asthma LQ. test taken after the inservice
program.

29

Table 3

Teachers Having Assisted a Student Having Asthma Symptoms (N=36)

Had to Assist a Student

Regular Classroom Teachers

Other Teachers

Yes

11

6

No

15

4

The pretest and posttests were graded by the researcher. One point apiece was

assigned to each correct true/false question. One point was given for each part of each
free-text question answered correctly. A total of 16 points were possible on the test.
When calculating percentages, values were calculated to the nearest whole percentage

point.

The range of scores on the pretest was 7 points (44%) to 16 points (100%)(Table 4).
The mean score was 11.7, and the SD was 3.19. The range of scores on the posttest was
12 points (75%) to 16 points (100%). The mean score on the posttest was 14.5, or 91%,

and the SD 1.13.

Data were analyzed using a one-tailed paired t -test. Pretest scores were subtracted
from posttest scores. The difference in scores was squared and the mean difference
between scores was calculated. A t-test score of 7.10 at 35 degrees of freedom was

compared to a list of critical values to test the hypothesis (Pagano, 1998, p. 527). Smce
the t-score of 7.10 was greater than the table value of 2.42 (p <0.01) the research
hypothesis was accepted. Thus, this study revealed that asthma knowledge, as tested by
the Asthma I.Q. test, was significantly higher after the inservice program.

30

Table 4

Teachers Pretest and Posttest Scores (N=36)

Teachers Score

Pretest

Posttest

7 (44%)

1

0

8 (50%)

3

0

9 (56%)

5

0

10 (63%)

2

0

11 (69%)

6

0

12 (75%)

4

1

13 (81%)

5

7

14 (88%)

3

7

15 (94%)

5

13

16(100%)

2

8

Comparison of Individual Pretest and Posttest Items

True false statements There were six true-false statements regarding asthma. These
were marked correct or incorrect, and were scored one point apiece. A comparison of
pretest and posttest results by statement follows.

Before the inservice program thirty-two teachers, or 89% of participants, correctly
responded “true” to the statement “Asthma is a lung disease that makes it difficult to

breathe.” After the program all but one participant responded correctly to the statement.

31

On the pretest all of the teachers correctly responded “true” to the statement “You can
be having an asthma attack without wheezing.” However, two teachers incorrectly
marked the statement as false after the program.
Before the inservice program 32 teachers, or 89%, correctly responded “false” to the
statement “Asthma is an emotional problem.” This number increased to 34 teachers, or
94 %, after the program. One of the teachers failed to answer the question and put a

question mark after it. Two teachers who responded correctly wrote comments next to the
statement including “it can be,” and “emotions can make the attack more difficult.” All

teachers recognized as false the statement “You cannot get asthma from someone else”
before and after the program.

Before the inservice program 94%, or all but two teachers, knew that asthma rescue
medications can start to work in 3 to 5 minutes. On the posttest there was no difference in
the number of teachers correctly responding to the statement. However, the two post­

program teachers who were incorrect failed to answer the question, rather than marking
the statement as false.

Free text questions In each of the four free-text questions the teachers were asked to
name either two or three things in relation to asthma. The questions were scored by being
given 1 point for each thing named correctly. Following is a comparison of the results of
the pretest posttest free-text questions.

Prior to the inservice program 17 teachers, or 47 % of participants, were unable to
name anything that happens to the lungs during an asthma attack (Table 5). After the
program there were no teachers who were unable to do so. The number of teachers able

32

to name three things that happen to the lungs during an asthma attack rose from four, or
11 % on the pretest, to 18 or 50 % of teachers on the posttest.

Although the second free-text question “name two early warning signs of an asthma

attack” asked for signs, subjective symptoms such as tightness in chest or shortness of
breath were marked as correct. Prior to the inservice program seven teachers or 19 %
were unable to name any early warning signs of an asthma attack, and 21 teachers or 59%
were able to name two. On the posttest all participant were able to name two.

Table 5

Name Three Things that Happen to Lungs During an Asthma Attack (N=36)
Pretest Posttest Comparison

Pretest

Posttest

Able to name none

17

0

Able to name one

6

6

Able to name two

9

12

Able to name three

4

18

Prior to the inservice program wheezing was named as an early warning sign of

asthma by 15 teachers (41%), and cough was named by 7 teachers (19%) (Figure 1). On
the posttest 28 teachers (77%) wrote wheezing, and 31 teachers (86%) wrote cough as

early warning signs.

Prior to the inservice program 22 teachers, or 61% of participants, were able to name
three triggers of an asthma attack; after the program 34 teachers, or 94% of participants,
were able (Table 6). The remaining two teachers correctly identified two triggers of

asthma. Included in some of the responses to identify triggers of asthma were smoke,

33

allergens, pollens, dust, molds, irritants, pollution, cold air, colds, exercise, infections,
chemicals, and animal dander.

100 86

90 -

80 1
70

c
O

60
50 4030 -

20 10 -

0 -

■■

77

I I

41 I

o
v

15

Wheeze

Pretest
■ Post-test

_____

Cough

Figure 1. Percentage of teachers naming wheeze or cough as early warning signs of
asthma attack.

In response to the question “Name two things you can do to help a friend/student who
is having an asthma attack,” the number of teachers who were unable to name anything

they could do to help decreased from ten (28%) before the program, to five (14%)

afterward (Table 7). Twenty-three teachers were able to name two things on the posttest,
as opposed to 15 teachers on the pretest.

Some of the correct methods of assisting included getting medication or inhaler,
allowing the child to medicate as directed, keeping them calm, getting help from the

nurse or calling 911, and allowing the child to sit and rest. Also mentioned was giving the
child a beverage with caffeine, which was mentioned by the asthma educator during the

inservice program.

34

Table 6
Name Three Triggers of Asthma (N=36)

Teachers Responses

Pretest

Posttest

Able to name none

0

0

Able to name one

2

0

Able to name two

12

2

Able to name three

22

34

On the pretest 23 teachers mentioned getting a student medication to assist in an
asthma attack, with 14 teachers specifically referring to inhaler use (Figure 2). On the
posttest 22 teachers mentioned medication use as a method of assisting, and only five
specified inhaler use.

Table 7
Name Two Things You Can Do To Help a Student Having an Asthma Attack (N=3 6)

Pretest

Posttest

Able to name nothing

10

5

Able to name one thing

11

8

Able to name two things

15

23

Teachers Responses

35

40

35 :
2
30
(D
o

GJ
0)

H
o
Q

S
3
Z

25 ■

23

22
□ Pretest

20 1

sil
J
15-1
5 -

- .

■ Post-test

14

ns
5

.1

0 -

Medication

Inhaler

Figure 2. Teachers mentioning medication, or inhaler use, as means of assisting
students with asthma.

Summary
This chapter presented the results of the research study. The purpose of this study was to

determine the effectiveness of an asthma education inservice program given for
elementary school teachers. A paired t-test was used to test the research hypothesis that
teachers attending the inservice program would improve their asthma knowledge. The

teachers had a statistically significant increase on their posttest scores, and the research
hypothesis was supported. A description of the sample population of teachers was given.

Also in this chapter was a pretest-posttest comparison of responses on individual test item
questions.

36

Chapter V

Discussion
This chapter discusses the results of the research study. The purpose of the study was

to determine the effectiveness of an asthma education inservice program for elementary

school teachers. The inservice was given for teachers in the Oil City School District in
Venango County, Pennsylvania by a trained asthma educator for the American

Respiratory Alliance of Western Pennsylvania A paired t-test was used to test the
research hypothesis that the teachers who attended the inservice program would increase
their asthma knowledge as tested by the Asthma I.Q. test. The research hypothesis was

accepted. A discussion of the research findings, conclusions, and recommendations for
further research are included in this chapter.
Findings

The results of this study suggest that elementary school teachers can increase their
understanding of asthma after a single inservice program. These results are consistent

with other studies reported in research literature (Eisenberg, Moe & Stillger, 1990;
Powell, 1998).

Prior to the inservice program two teachers mentioned the potentially harmful

measure of having a student breathe into a paper bag as a method of assisting a student
having asthma symptoms. No potentially harmful interventions were mentioned after the

program. The asthma educator typically used a pretest and posttest when giving an
inservice program. Later pretest assessment could be done to help identify common or

specific misinformation teachers have, in order to help tailor future inservice discussion
and emphasis.

37

After the inservice program more teachers identified wheeze and cough as early

warning signs of an asthma attack, with cough identified most frequently. Recognition of
cough is important because, although it may be a typical sign a teacher may see, if not
recognized the teacher may take an inappropriate action such as excusing the student to

the hallway.
In this study the number of teachers who were correctly able to name two things they

could do to help a student having an asthma attack rose from 15 teachers to 23 teachers.
However, that is still only 64% of the teachers who attended the inservice program. Some
of the incorrect posttest responses included general supportive measures for students with
asthma such as “encourage asthma awareness” and “plan in advance.” One explanation

for this may be that the teachers misunderstood that the question was asking for a specific
intervention while a student was having asthma symptoms. Also, fewer teachers

mentioned getting or assisting with inhalers on the post-test then on the pretest.
One explanation may be that teachers were mentioning interventions suggested by the
asthma educator during the program that they could take in addition to inhaler use, such

as stopping and resting, sitting with elbows positioned on knees, or offering a caffienated
beverage. It is also possible the teachers were mentioning things in addition to what they
wrote on the pretest. If future posttest assessments have similar findings, inservice
programs could be revised to spend additional time and discussion on rescue inhaler use.

Importance of the Study

Asthma is the most common chronic childhood illness affecting between 4% and 7%
of children (Adams & Marano, 1990; CDC, 1995). As children enter school much of their

day is spent with teachers. Children with asthma need proper support at school (NIH,

38

1991). In this study, 66% of teachers reported having students with asthma, and nearly

had experienced having to assist a student who was having asthma symptoms. In
spite of this, only two of the teachers had previously had any other asthma education.

The survey conducted with the program was important because almost all of the
teachers indicated that they should have some role in assisting students to manage their

asthma. Among the roles mentioned by the teachers were awareness of symptoms,

assistance with medications, education, awareness of procedures to follow for the
individual child, and general supportive measures. Assessment of health and health
education needs of the community in which they practice is within the scope of practice

for the nurse practitioner. Childhood asthma is a common problem identified in primary
care. Because the teachers identified themselves as being, in part, caregivers of students

with asthma, it would be important for the nurse practitioner to assist in identifying and
meeting their learning needs.
Support for Conceptual Framework

The asthma educator used a variety of educational techniques during the inservice
program, including videotape, lecture and equipment manipulation. The question and
answer period and the posttest assessment allowed for immediacy of application of

knowledge. These techniques are consistent with Androgogy, the Adult Learning Theory
described by Malcolm Knowles. The use of these techniques, and the fact that the

research hypothesis was accepted supports the use of Malcolm Knowles Adult Learning
Theory as the conceptual framework for this study.

Study Limitations

There were limitations of this research study. The study pretest and posttest were

39

graded and scored by the researcher, and there could have been some bias in interpreting
the free-text item answers. This study had a small sample size, and was conducted during
only one inservice program in one school district. Therefore, results of this study may not

be generalizable to other elementary school teachers.
Another limitation of this study was that for sampling convenience asthma knowledge

was tested prior to and immediately after the inservice program. Therefore, the study may
not reflect the teachers’ retention of the information given.
Data were not included for elementary school teachers who attended the inservice
program but did not complete both the pretest and the posttest. It is possible the teachers

did not complete the tests because they did not know the information.

Finally, the Asthma I.Q. test used in this study addresses asthma knowledge, but does
not test the teacher’s ability to use that knowledge with an individual student having
asthma symptoms. During the inservice program the asthma educator discussed and

encouraged the use of school action plans for students with asthma, and sample action
plans were distributed. It is hoped that the classroom teachers’ awareness of the

availability of these plans will facilitate their use and help the teachers effectively assist a
student having asthma symptoms.
Recommendations
Recommendations for future research includes additional pretest-posttest assessments
of elementary school teachers’ understanding of asthma during other asthma inservice
programs, and sampling teachers’ knowledge of asthma at a later date after the inservice
is conducted.

40

Conducting surveys regarding teacher’s experiences with students with asthma and
other chronic illnesses in which they may be assisting with students care, such as diabetes

or epilepsy, is also recommended. These surveys may reveal that teachers indeed have
some role as caregivers in the management of these students, and may help identify
additional educational needs.

Summary
This chapter discussed the findings of a research study conducted to assess the

effectiveness of an asthma education inservice program given for elementary teachers at a

school in Oil City in Venango County, Pennsylvania. Research findings suggest that

elementary school teachers can increase their understanding of asthma after a single
inservice program. The limitations of the study, importance of findings, and
recommendations for future research are included in this chapter.

41

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Szilagyi, P., & Kemper, K. (1999). Management of chronic childhood asthma in the

primary care office. Pediatric Annals, 28 (1), 43-52.

43

Appendix A

AMERICAN RESPIRATORY ALLIANCE OF NORTHWEST PA
Asthma I.Q.
True/False

1. Asthma is a lung disease that makes it difficult to breathe.

True

False

2. You can be having an asthma attack without wheezing.

True

False

3. Asthma is an emotional problem.

True

False

4. You can get asthma from someone else.

True

False

5. People with asthma should not exercise.

True

False

6. Asthma rescue medications can start to work in 3-5 minutes.

True

False

Write in your answers.

1. Name 3 things that happen to lungs during an asthma attack.

1.
2.
3.
2. Name 2 early warning signs of an asthma attack.

1.
2.
3.
3. Name 3 triggers of an asthma attack.

1.
2.
3.
4. Name 2 things you can do to help a friend/student who is having an asthma attack.

1.
2.
American Respiratory Alliance of Northwest Pennsylvania
352 West 8th Street
Erie, PA 16505

44

Appendix B

SURVEY

To assist in the study, please complete each of the following questions. Do not put your
name on this form. Submission of this form constitutes permission to participate in the
research. Thank you very much for your assistance.

1. Do you have any students in your current, or, if the school year has not yet
started, most recent classroom with asthma?

If yes, how many?

2. Have you ever had to assist a student who was having asthma symptoms?
3. Do you have any personal experiences with asthma?
4. Have you attended any other asthma education programs?
5. How many years have you been teaching?

6. How many students are in your classroom?

7. What grade level do you teach?
8. What role should elementary teachers have in assisting students to manage their
asthma?

45

Appendix C

Oral Introduction

Asthma is the most common chronic childhood illness, and it affects 48 million
U. S. children. Asthma is the most common reason for school absence, and children with

asthma have a higher risk of academic problems. Improperly managed asthma can be life

threatening.
Children with asthma need proper support at school. Because between 4% and &

7% of U.S. children have asthma, it is likely that as elementary school teachers you will

have students with asthma, and may therefore need to assist them in their asthma

management.
A graduate nursing student at Edinboro University of Pennsylvania is conducting
a study on the effectiveness on the asthma education program being given today by the

American Respiratory Alliance of Western Pennsylvania as part of the School Asthma
Initiative. The researcher is asking for your participation by having you complete the

survey and the pretest prior to the program (now), and the posttest at the completion of
the program. If you do not wish to participate, please keep all the forms. Thank you very

much for your help.