What is already known on this topic?

Asthma is a major health problem among adolescents in Australia. There is generally a poor understanding of asthma in this age group, adherence to therapy decreases and medical supervision is less consistent. These problems are compounded by a poor understanding of asthma management.

What this study adds?

The Triple A Program addresses asthma self-management through peer-led education. This structured peer-led asthma education program can play an important role in reducing the burden of asthma in adolescents. The program improves quality of life and reduces morbidity in adolescents with asthma. Eight students need to be educated by their peers for one student with asthma to report a significant improvement in quality of life.
 

Peer-led asthma education improves quality of life and asthma morbidity in adolescents: a randomised controlled trial

Smita Shah, Jennifer K Peat, Evalynn J Mazurski, Han Wang, Doungkamol Sindhusake,Colleen Bruce, Richard L. Henry, Peter G. Gibson,

From: Primary Health Care Education and Research Unit, Westmead Hospital
and
Airway Research Centre, John Hunter Hospital,

Address for Correspondence:

Dr Smita Shah
Primary Health Care Education and Research Unit
Department of Public Health and Community Medicine
Faculty of Medicine, University of Sydney
3^rd Floor, Dental Block
Westmead Hospital, Westmead, NSW 2145
Australia

Acknowledgments: The Commonwealth Department of Health and Aged Care and Asthma NSW funded this study. We thank the Tamworth schools, staff and students and Greg Cantwell, Fiona Collier, Kate Roese and Robin Schoeffel for assistance in data collection.

ABSTRACT

Objective: To determine the effect of a peer-led asthma education program, on quality of life (QoL) and related morbidity in high school students with asthma.

Design: A randomised controlled trial.

Setting: Six high schools in rural Australia.

Subjects: Students from Years 7 (mean age12.5 yrs) and 10 (mean age 15.5 yrs); 251 students with recent wheeze, where recruited from a cohort of 1515 students.

Intervention: The intervention schools received a 3-step structured peer education program.

Main outcome measures: QoL, school absenteeism, asthma attacks and lung function.

Results: Following the intervention, total QoL scores, when adjusted for year and gender, showed significant improvement in the intervention group compared to the control group (p=0.03). Clinically important improvement (>0.5units) occurred in 25% of students with asthma in the intervention group, compared to 12% in the control group (p=0.01). This effect was greatest in Year 10 students and in females. Significant improvements also occurred in the activities domain (41% Vs 28%, p=0.03) and in the emotions domain in males (39% Vs 19%, p=0.02) in the intervention group. There was a decrease in the median number of days absent from school in the intervention group (p=0.03), with no change in the control. The proportion of students reporting asthma attacks at school, increased in the control group (p=0.02), but not in the intervention group. There was no intervention effect on lung function.

Conclusion: A structured peer-led asthma education program leads to a clinically and statistically important improvement in QoL and related morbidity in students with asthma. Effective asthma education programs in the schools can play an important role in the management of adolescent asthma.

INTRODUCTION

Asthma is a major health problem among adolescents [1,2]. Prior studies have identified substantial under-diagnosis [3] and a generally poor understanding of asthma management in this age group [4]. During adolescence, behavioural changes can have an adverse impact on the management of illnesses, since adherence to therapy decreases [5] and medical supervision becomes less consistent [6]. The resultant inadequate management of asthma often leads to frequent school absences [7,8] and hospital admissions [7,9] and can compromise a young person’s education, social skills [10] and physical activity [3,4,11].

Traditional health education often does not meet the needs of adolescents because at this age, peers have a significant and perhaps greater influence on a young person’s health behaviour than do parents or health personnel [12]. We have previously described the development of an innovative peer-led asthma education program (Triple A) to promote asthma self-management behaviours in adolescents [13]. We have also demonstrated that this program improves knowledge and attitudes about asthma [14]. The aim of the current study was to conduct a randomised controlled trial to evaluate the effect of the Triple A Program on self reported QoL and related morbidity in high school students with asthma.

Subjects and Methods

Students were recruited from six of the seven high schools in Tamworth, in rural New South Wales, Australia. One school declined to participate. The six schools were randomly allocated, to either the intervention or the control group, using a random number generator. Allocation was concealed by the closed envelope technique. Each study group comprised two government schools and one independent school. The Research Ethics Committee of the Western Sydney Area Health Service and the Department of Schools Education Ethics Committee approved the study.

The ISAAC video questionnaire [15] was administered to all students in Years 7 and 10, present on the test day, at each school in February 1998. Students reporting recent wheeze and who gave consent, underwent baseline spirometry and completed an asthma QoL questionnaire. The Triple A Program was then implemented in the three intervention schools, during the following months. All students completed the same measures in October 1998, three months following the completion of the intervention program.

Intervention

The Triple A Program entrusts young people with the responsibility of educating their peers about asthma. The details of the intervention have been reported previously [13,14]. The intervention involved a three-step empowerment education approach [16]. In Step 1, student volunteers from Year 11, in each school, were trained as Asthma Peer Leaders during a six-hour workshop conducted by the study team. The students learnt how to educate their peers about asthma and its management through games, videos, worksheets and discussions. In Step 2, teams of three to four Asthma Peer Leaders conducted three 45 minute health lessons for each Year 10 class in their school. A key concept of their teaching was to guide students to critically analyse the barriers to asthma management. In Step 3, Year 10 students developed and presented key messages, learnt in the lessons, to Year 7 students and invited guests. These performances took the form of short acts, dramas, comedy skits and songs, with titles such as: "Don’t Smoke", "Asthma Can Kill", "Visit Your Doctor" and "How to Manage an Asthma Attack".

Community support

There were regular reports of the study in the local print and electronic media. In addition, all schools received Asthma First Aid Kits, asthma workshops for school staff and the asthmatic students were issued with a Student Asthma Record Card to be completed by their doctor [17]. A workshop on management of asthma in adolescents was held for the local doctors, with all participants receiving an asthma device kit for their surgeries.

Measurements

Students who reported recent wheeze, as assessed by the ISAAC questionnaire completed a validated Paediatric Asthma Quality of Life Questionnaire (PAQLQ) [18]. The questionnaire contained 23 items with responses presented as a 7-point Likert scale. The items were organised in three domains: symptoms (10 items), activities (5 items), and emotional impact of asthma (8 items). The total score of the questionnaire (mean of all responses) ranged between 7 (no impairment) and 1 (most severe impairment). The score for each domain was calculated as the mean of the items in that domain. Students also completed a questionnaire regarding school absenteeism, asthma attacks at school, prior doctor’s diagnosis and current asthma medications [19].

Lung function was assessed using a Vitalograph bellows spirometer (Vitalograph Ltd, Buckingham, England). Students performed at least 3 reproducible forced expiratory manoeuvres in the sitting position with nose clips applied. Salbutamol (200ug) was administered via a pressurised metered dose inhaler with a valved holding chamber (Volumatic, Allen and Hanburys, Victoria Australia). Spirometry was repeated10 minutes later. FEV1 and FVC were recorded as the best of at least 3 reproducible manoeuvres, and values were compared to predicted values for Australian adolescents [20]. Bronchodilator response was calculated as the change in FEV1 as a percentage of the baseline value.

Analysis

Data were entered into an Access database and analysed using STATA (STATA Corp. College Station Texas, USA). Continuous data were summarised as the mean with standard deviation (SD) or 95% confidence intervals (CIs) and categorical data were summarised as the percentage with 95% CIs. Data were analysed using either parametric methods if normality was satisfied or non-parametric methods otherwise. Comparability of groups was examined using an unpaired t-test or chi-squared test as appropriate. The effect of the intervention was described by the within-subject change from baseline to post-intervention and compared between groups using 2-way analysis of variance with repeated measures. ANOVA was used to assess the effect of confounding by gender, year (7 or 10) and school cluster, and adjusted effect sizes were calculated. To test for a cluster effect, intra-class (school) correlation coefficient (ICC) was calculated using one way ANOVA [21].

The primary outcome measure was QoL score. The mean difference in overall QoL scores was normally distributed and analysed as the total questionnaire score and as scores for each domain. QoL was also classified as the proportion of students who achieved a clinically important improvement in scores, which has previously been determined as a change of >0.5 units [22]. These proportions were then compared using chi-squared statistics. The proportions of students reporting asthma attacks at school were analysed using McNemar’s test. School absenteeism was compared using Wilcoxon Signed Rank test. For all statistical tests, significance was accepted when p<0.05.

RESULTS

A total of 1379 (91%) students in Years 7 and 10 completed the asthma-screening questionnaire (ISAAC). In this group, 317 students reported recent wheeze, of whom 86% gave consent for further testing. However, matched baseline and post intervention data were only available for 251 students. Missing data occurred when students moved schools, were absent on the day of testing or failed to complete the questionnaire. These students were not different to the study subjects in terms of QoL or related morbidity measures.

There were more females in the intervention group (66%) than in control group (44%). This occurred because cluster randomisation was used to assign the schools to study groups; four schools were co-educational and two were single sex. A prior diagnosis of asthma was reported in 75% of the students who had recent wheeze. At baseline students reported mild to moderate impairment of QoL due to asthma, with females reporting greater impairment than males (5.3 Vs 5.7 respectively). The mean (SD) QoL score was 5.6 (1.3) in the control group and 5.3 (1.3) in intervention group. (Table 1). All components of the Program were implemented to plan, with full participation by the target group.

Total mean QoL scores following the intervention were 5.7 for the control schools, with a mean difference of 0.12 (CI 0.05,0.18), and 5.5 in the intervention schools, with a mean difference of 0.21(CI 0.12,0.30). There was significant improvement in total QoL scores, after adjusting for year and gender, in the intervention group when compared to the control group; the intervention group QoL improved on average by 0.12 units more than the control group (p=0.03). Similarly, there was a significant effect of the intervention in the activities domain (p=0.03) when adjusted for gender. Although QoL improved in the symptoms and emotions domains, this was not significant. There was no significant effect of clustering due to the study design. The ICC was less than 0.002 for the total score in all domains.

A clinically relevant improvement in QoL (or a change in total score of greater than 0.5 units) was reported by 25% of students with asthma from the intervention group, compared to 12% in the control group (p=0.01, Table 2). In the intervention group significant improvements in QoL scores occurred in the activities domain (p=0.03) and there were improvements in both the symptoms and emotions domain but this did not reach significance. However, males showed a significant improvement in the emotions domain (p=0.02) and females improved in the activities domain (p=0.06, Figure 1).

Following the intervention, there was significant decrease in the median number of days absent from school from baseline, (8 days Vs 5 days) in Year 10 students in the intervention group (p=0.04, Figure 2), with no change in the control group (8.5 days Vs 8.2 days). The proportion of students reporting asthma attacks at school in Year 10 increased in the control group (21.2% Vs 34.8%, p=0.02). There was no change in the intervention group (24.2 % Vs 25.8%, Figure 3). There was no significant intervention effect on school absenteeism and asthma attacks in Year 7 students.

At baseline, both the intervention and control groups had generally good lung function (Table 1). Following the intervention, although there was an overall improvement in lung function in both groups (% predicted FEV₁ pre and post bronchodilator and FVC pre-bronchodilator), there was no effect on lung function as a result of the intervention. The FEV₁/FVC ratio and percent improvement in FEV₁ remained stable over time (Table 3).

DISCUSSION

This study showed that a structured peer-led asthma education program can lead to an improvement of self-reported QoL in adolescents with asthma. We found that on average, 8 students would need to be educated by their peers, for one student with asthma to report a clinically significant improvement in QoL. However, we also found that the education program influenced different domains in males and females. For males, the effect of the intervention was most apparent in the emotions domain; for females it was in the activities domain. This is of particular clinical importance because the gender differences are indicative of areas that need to be targeted [2, 3,23].

The measurement tools included the ISAAC questionnaire, which has been widely used to assess asthma prevalence [15]. The prevalence of wheeze in the last 12 months was 23% in the target student population, which was consistent with that recorded in neighbouring regions [2,4], suggesting that these students were representative of adolescents in rural regions.

The assessment of QoL in adolescents with asthma was complicated by several factors. Foremost, intermittent symptoms of asthma and the seasonal variation could have influenced fluctuations in their QoL. The baseline study was undertaken in February (end of summer), whilst the post data were collected in mid-October (spring), in order to meet the schools’ timetables. Secondly, the respondents did not always use the same activities (35 options) when completing the QoL questionnaires at baseline and post testing, making it difficult at times to interpret the results. Finally the school community knew they were participating in a study, which was receiving a considerable amount of local publicity. This could have introduced a bias, known as the "Hawthorne effect" [23], resulting in perceived improvements in the control group.

There is increasing recognition of QoL questionnaires as a relevant health outcome measure in asthma [25]. QoL measures the individual’s perception of symptoms caused by their illness, the consequent emotional impact and the impact of their illness on daily activities. The PAQLQ has been evaluated and reported to be a reliable instrument that is responsive to change and discriminates among asthmatics with varying impairment caused by asthma [18]. A concern with the PAQLQ is that although includes symptoms, activity and emotional domains, it does not include social and environmental domains [26], often essential components of effective health promotion programs.

There was an overall improvement in lung function, from baseline to follow up. However there was no observed effect of the intervention on lung function. These results are consistent with other studies of asthma education that have demonstrated improvement in QoL following asthma education without changes in lung function [27,28].

Asthma self-management is recognised as an effective strategy in reducing morbidity [29]. In the past asthma self-management programs have tended to focus on primary school-age children or adults [30,31, 32]. Asthma education initiatives for young people, which focus on the individual with asthma, have had minimal impact on asthma morbidity [30,31], and asthma education programs conducted in hospitals have problems attracting young people [32]. In our study the students who received the peer-led education reported decreased asthma attacks and school absenteeism compared to the control group. This builds on earlier work in which we showed that the program is well received by adolescents and improves knowledge about asthma and its management [13,14].

Interventions using peer education appear to have a higher chance of success in adolescence than other types of interventions[34]. In a meta-analysis of 143 adolescent drug prevention programs, the effect size was largest for peer teaching programs, as opposed to other teaching strategies [35]. Young people seem to prefer to turn to peers for advice and change is more likely to occur if someone they can relate to or perceive as a role model relays the message. Additionally, peer educators may enhance the program’s effect by helping to channel peer pressure in a positive direction [10].

To our knowledge, the Triple A Program is the first peer-led asthma education program to address asthma self-management using senior students as educators. This study demonstrates that a structured peer education program improves QoL in students with asthma. Effective asthma education programs in the schools can clearly play an important role in the management of adolescent asthma.

REFERENCES

1. Robertson CF, Bishop J, Dalton M, Caust J, Nolan TM, Olinsky A, Phelan PD. Prevalence of asthma in regional Victorian school children. Med J Aust 1992; 156: 831-833.
2. Forero R, Bauman A, Young L, Larkin P. Asthma prevalence and management in Australian adolescents: Results from three community surveys. J Adolesc Health 1992;13:707-12.
3. Siersted HC, Boldsen J, Hansen HS, Mostgaard, G, Hyedebrandt N. Population based study of risk factors for underdiagnosis of asthma in adolescence: Odense schoolchild study. BMJ 1998;316:651-7.
4. Gibson PG, Henry RL, Vimpani GV, Halliday J. Asthma Knowledge, attitudes, and quality of life in adolescents. Arch Dis Child 1995: 73:321-326.
5. Fotheringham MJ, Sawyer MG. Adherence to recommended medical regimes in childhood and adolescence. J Pediatr Child Health 1995; 31:72-8
6. Warner JO. Asthma In: Brook CGD, Ed. The Practice of Medicine in Adolescence. Ed Arnold, London, Boston, Melbourne, Auckland 1993
7. Taylor WR, Newacheck PW. Impact of childhood asthma on health. Pediatrics 1992;657-62.
8. Fowler MG, Davenport MG, Garg R. School functioning of US children with asthma. Pediatrics 1992;90:39-44.
9. Strachan DP, Anderson HR. Trends in hospital admission rates for asthma in children. BMJ 1992;304:819-20.
10. Graetz B, Shute R. Assessment of peer relationships in children with asthma. J Paediatr Psychology. 1995;20: 205-16.
11. Bicho A, Damas L, Chieira ML. Asthma in Adolescents. Pediatr Asthma, Allergy & Immunol 1992; 6: 197-203.
12. Nutbeam D, Haglund B, Farley P, Tillgren P, Eds. Youth Health Promotion: From Theory to Practice in School and Community. London, England. Forbes publications Ltd, 1991: 89-107.
13. Shah S, Mamoon AH, Gibson PG. Peer-led Asthma Education for Adolescents: Development and Formative Evaluation. Health Prom. Aust. 1998;8:177-182.
14. Gibson PG, Shah S, Mamoon AH. Peer-led Asthma Education for Adolescents: Impact Evaluation. J Adolesc Health 1998;22:66-72.
15. Crane J, Beasley R, Stewart B, Shaw R, Pearce N, Burgess C. The international asthma video questionnaire for measuring asthma prevalence in different populations. Int Arch Allergy Immunol. 1995 ; 107: 450-1
16. Wallerstein N, Bernstein E. Empowerment education: Frieire’s ideas adapted to health education. Health Education Quarterly 1988;15:379-94.
17. Shah S, Gibson PG, Wachinger S. Recognition and crisis management of asthma in schools. Paediatrics Child Health 1994;30, 312-315.
18. Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend. Measuring quality of life in children with asthma. Qual Life Res 1996;5:35-46.
19. Henry RL, Gibson PG, Hazell J, et al. Integrated health and education input in the development of an educational package about asthma for schools. J Pediatr Child Health 1994;30:492-6.
20. Hibbert ME, Lannigan A, Landau IL, Phelan PD. Lung Function Values From a Longitudinal Study of Health Children and Adolescents. Paediatr Pulmonol 1989;7:101-109.
21. Rosier M. Some further ideas on analysis of cluster samples. Aust Epid 1999;6:10-13.
22. Juniper EF, Guyatt GH, Willan A, Griffiths LE. Determining a minimal important change in a disease-specific quality of life instrument. J Clin Epidemiol 1994; 47: 81-87.
23. Forero R, Bauman A, Young L, Booth M, Nutbeam D. Asthma, health behaviours, social adjustment and psychosomatic symptoms in adolescence. Asthma 1996 33:157-164.
24. Sackett DL. Bias in analytic research. J Chron Dis 1979;32:51-63.
25. Jones PW. Quality of life measurement in asthma. Eur Respir J 1995;8:885-887.
26. Rutishauser C, Sawyer SM, Bowes G. Quality-of-life assessment in children and adolescents with asthma. Eur Respir J 1998;12:486-494.
27. Ringsberg KC, Wiklund I, Wilhelmsen L . Education of adult patients at an "asthma school": effects on quality of life, knowledge and need for nursing. Eur Respir J 1990; 3:33-7.
28. Yoon R, McKenzie DK, Bauman A Miles DA. Controlled trial evaluation of asthma education programme for adults. Thorax. 1993. 48: 1110-1116.
29. Gibson PG, Wilson AJ, Coughlan J, Hensley MJ, Abramson MJ, Bauman A, Walters EH. The effects of self-management asthma education and regular practitioner review in adults with asthma. In Cates C, DuCharme F, Gibson PG, Jones P, Rowe B, Wolf F, Airways Module Cochrane Database of Systematic Reviews, Update Software , Oxford UK, 1998 issue 4.
30. Bernard-Bonnin AC, Stachenko S, Bonin D, Charette C Rousseau E. Self-management teaching programs and morbidity of paediatric asthma: a meta analysis. J Allergy Clin Immunol 1995;95:34-41.
31. Wigal JK, Creer TL, Kotses H, Lewis P. A critique of 19 self-management programmes for childhood asthma. Pediatr Asthma Allergy Immunol 1994;4:17-39.
32. Yoon R, McKenzie DK, Miles DA, Bauman A. Characteristics of attenders and non-attenders at an asthma education programme. Thorax 1991; 46: 886-890.
33. Brook U, Kishon Y. Knowledge and attitude of health high school students toward bronchial asthma and asthmatic pupils. Chest. 1993; 103:455-7.
34. Millistein SG, Petersen AC, Nightingale EO. Promoting the Health of Adolescents. New Directions for the Twenty–First Century. New York: University Press, 1993.
35. Tobler NS. Drug Prevention Programs Can Work: Research Findings. J of Addictive Diseases 1992; 11: 12-28.

Figure 1: Percentage of students whose total quality of life score improved >0.5 in each domain. *p<0.05
 
 

Histogram Data
Figure 1: Percentage of students (%) whose total quality of life score improved >0.5units in each domain.

Activities                                  27.5% (38)                                  40.7% (46)

Symptoms                                   18.1% (25)                                  25.7% (29)

Emotions                                    19.6% (27)                                   27.4% (31)
 

Figure 2: School absenteeism for Year 10 Students with asthma (median number of days absent from school) *p<0.05
 

Histogram Data
Figure 2: School Absenteeism for Year 10 students with asthma (median number of days absent from school)

                                                         Baseline                                 Post AAA

Control n=67                                     5.5 days                                 4 days

Intervention n=66                                 8 days                                    5 days

Figure 3: Proportion of Year 10 students reporting asthma attack at school *p<0.05
 
 

Histogram Data
Figure 3: Proportion of Year 10 students reporting an asthma attack at school.

                                                          Baseline                                Post AAA

Control n=67                                      21.2%                                   34.8%

Intervention n=66                               24.2%                                   25.8%

Table 1: Baseline data
 

TABLE 1 Second version
 

Table 2: Proportion of students (%) with clinically significant improvement in QoL scores in control and intervention groups.
 

TABLE 2-Second version
 

Table 3: Average lung function variables with 95% confidence intervals at baseline and after intervention. Matched for pre and post n=253.
 

TABLE 3-Second vesion
 

Figure 1