the influence of health education on family management of childhood asthma

p&NT EdUCATioN

md CCuNSE~iN~

Patient Education and Counseling 30 (1997) 107-118

The influence of health education on family management of childhood asthma

Kevin Brazil”‘“, Leslie McLeanb, David Abbeyb, Carol Musselmanb

“St. Joseph’s Health Care Research Network, St. Joseph’s Community Health Centre, 2757 King St. E.. Hamilton, Ontario L8G 5E4. Canada

bOntario Institute for the Studies of Education, Toronto, Ontario, Canada

Received 8 August 1995; revised 26 April 1996; accepted 30 April 1996

Abstract

The purpose of this study was to examine differences in asthma management among families with a child who has moderate to severe asthma. Half of the 50 families chosen for study had participated in an intensive in-patient asthma treatment program and half had participated in an out-patient day camp. Two broad categories of outcome were examined - illness and self-management skills. Families who participated in the in-patient program exhibited a pattern of illness behaviours which indicated asthma symptoms were better managed in comparison to those families that participated in the out-patient program. It was also observed that children who participated in the in-patient program had a tendency to feel more positive about having asthma with the more self-management behaviours they practised. On the other hand, children from the out-patient program reported a more negative attitude about having asthma with the more self-management behaviours they practised.

Keywords: Childhood asthma; Health-education

1. Introduction

With increased recognition of the patient’s important role in chronic disease management, asthma education has emerged as an essential component in the medical treatment of childhood asthma. In the past decade, a number of

self-management programs have been developed [l-9]. These programs vary in their techniques but share the common goal of assisting participants, mainly children (and their parents), to develop improved management skills for both prevention and treatment of asthmatic episodes. The training seeks to increase patient adherence to medical treatment, and to help families work

* Address correspondence to: Kevin Brazil, Research, St. Joseph’s Community Health Centre, 2757 King St. E., Hamil- ton, Ontario L8G 5E4 Telephone: (905) 573-7777 ext. 8315; Fax: (905) 573-4808.

with physicians to establish a plan that is appropriate and acceptable to the family and child. The educational process typically includes the following phases: anticipation of asthma manage-

0738-3991/97/$17.00 Copyright @ 1997 Elsevier Science Ireland Ltd. All rights reserved PII SO738-3991(96)00913-5

108 K. Brazil, L. McLean I Patient Education and Counseling 30 (1997) 107-118

ment problems; determination of appropriate responses should these problems arise; and prac- tice of effective behaviours.

Health education programs for children with asthma have resulted in demonstrated increases in knowledge, changes in behaviour and de- creases in health services utilization [lo-141. Knowledge about the efficacy of these interventions would be enhanced if the relative impact of one approach over another were studied, as well as the relationships between knowledge gains, changes in behaviour and improvements in health status [9,10].

The purpose of the present study was to examine the impact of different forms of asthma management among families with a child who has moderate to severe asthma. Half the families chosen for study had participated in a family- focused in-patient asthma treatment program and half had participated in a child-focused out- patient day camp. Two broad categories of treatment outcome were examined; (1) illness and (2) asthma self-management skills.

The major hypothesis of this study was that families which have participated in a 3-month in-patient family-focused treatment program would demonstrate better asthma management skills than a comparable group of families who participated in a 3-week, child-focused out-patient program.

2. Methods

2.1. Design

As it was not possible to rely on subject randomization, a casual-comparative design was used [15]. The asthma interventions that were compared were an in-patient program and an out-patient day camp. Selected subjects were families whose child had moderate to severe asthma and had participated in one of the programs in the past 24 months.

It was not possible to collect pretest measures from respondents either on the same outcome instrument or on a parallel form of the instru- ments. In the absence of pretest observations,

archival records were used to serve as a proxy for the pretests. Proxy measures were described in this study as background characteristics. These factors were classified as either: (a) disease factors, (b) patient factors, or (c) environmental factors. Proxy variables provided a means to indicate whether there were initial differences between the two groups and whether outcome scores could be related to either initial group differences, if any, or to the treatment intervention. Outcome measures were classified as either illness or asthma self-management in nature.

2.2. Description of the measures

2.2.1. Background characteristics. The Rand Corporation in collaboration with

the Department of Medicine at the University of California developed a set of standards to be used in assessing interventions delivered to pa- tients with asthma [16]. Included in the development of these standards was a consideration of variables not under the control of medical care, but which may influence the outcome of an asthma intervention. These factors were classified into three categories; disease factors, patient factors and environmental factors.

2.2.2. Disease factors. Matching families from both programs on their

child’s asthma severity was a way to control for many disease-related factors including rhinitis, eczema and age of onset [16-191.

In this study, those families with children who had difficult to control asthma requiring continuous multiple medications including prophylaxis with cromoglycate or, more commonly, inhaled steroids were viewed as having moderate to severe asthma and were eligible for participation.

2.2.3. Patient factors. In the present study, Blishen’s [20] index of

occupational status was used to measure family occupational status. Given that behaviour problems have been related to the quality of control of asthmatic symptoms [21], it was important to assess children for behavioural disturbances. The Child Behaviour Checklist (CBCL) [22] was used

K. Brazil, L. McLean I Patient Education and Counseling 30 (1997) 107-118 109

for this purpose. Other patient-related factors that must be accounted for include the child’s age, gender [21] and previous experience with asthma education interventions.

2.2.4. Environmental factors. Family characteristics which where compared

between the two groups included: number of siblings in the family, and the presence or absence of both parents [16]. Characteristics of the home which were included for comparison were the presence of smokers and/or furry pets in the household [16]. The severity of a stressor event such as childhood asthma is related not only to the disease but it may also be compounded by the family ‘pile-up’ of stresses unrelated to the child with asthma [23]. The Family Inventory of Life Events (FILE) [23] which assesses the pile- up of life events experienced by a family was used to review the sum of recent family life events.

2.2.5. Illness outcomes. Symptom relief was assessed by parent reports

on the number of asthma attacks that their child had experienced during the 3 months prior to the interview. An asthma attack was defined as any time their child reported asthma-related discom- fort such as wheezing and chest tightness. School absenteeism and medical utilization which the child had experienced during the 3 months prior to the interview were also considered illness outcomes.

2.2.6. Asthma self-management outcomes. Parents and child were assessed on their asth-

ma knowledge/ management skills. Parents completed an inventory that included four parts: parent asthma knowledge, parental report of child’s self-management behaviour, parent’s perception of child’s adjustment to asthma, and parent’s report of asthma impact on the family. Children participated in a structured interview which assessed the child’s asthma knowledge, self-management skills and their attitude about having asthma. The standardized inventories were selected from an asthma management pack- age, ‘Air Power’ developed by the United States

Department of Health and Human Services, Public Health Services, National Institute of Health [24].

2.3. Programs

The ‘Breathless Wonders - Asthma Day Camp’ provided by the Lung Association of Metropolitan Toronto and York Region was offered through the Hugh MacMillan Rehabilita- tion Centre. The population served by the summer day camp consisted of children from 6 to 12 years of age. The Lung Association offered three consecutive 3-week sessions during the summer. The goal of the program was to improve children’s asthma self-management skills and emotional adjustment towards having asthma. Once the asthma was stabilized, through the appropriate use of medications, self-management skills were emphasized with the children. During the 3-week session children were scheduled in a rotational program which included sports, out- door recreation, swimming, drama, creative activities and community outings. These activities where designed to help them learn to deal effectively with their individual conditions of asthma. Formal teaching sessions were conducted once a week. Sessions included a physio- therapist who instructed children on proper breathing techniques and energy conservation. Nurses taught children about their medications and when and how to use them. A social worker dealt with the social and emotional issues of having asthma. Informal teaching sessions continued on a daily basis concomitant with the medical management of the child.

The 3-month in-patient program involved children admitted to the Family Asthma Rehabilita- tion Program at the Hugh MacMillan Rehabilita- tion Centre. The population served consisted of children from birth to 18 years. The goal of the program was to assist both children and their families to attain as normal a lifestyle as possible. This goal was accomplished by improving psy- chosocial functioning and asthma management skills of both the child and his/her parents. Following medical management of the asthma, education, focusing on asthma knowledge, trig-


ger factors and self-management skills, was emphasized throughout the program both for children and their parents. Formal teaching sessions with the children were conducted by nurse educators three times weekly. Informal teaching sessions continued on a daily basis concomitant with the medical management of the child. Par- ent teaching sessions were conducted by the physician and nurses once monthly, with weekly reinforcement when parents picked-up and re- turned children from week-end home visits.

Pivotal to the instructional’ approach in both programs was the belief that children’s behaviour (adherence to a medical regimen) will change with the development of self-efficacy, i.e. the knowledge, belief, or expectation that the behaviour can be performed successfully [Z-27]. Learning self-management skills, and practising them during the course of the program, provides children with accomplishment experiences which help promote behavioural change.

The educational practises within the two programs reflected the current beliefs in the literature of what children need to be taught in order to manage their asthma: (1) preventive medication use; (2) environmental control and avoid- ance of precipitant; (3) effective use of medications to manage symptoms; (4) successful com- munication with health care providers and others about asthma; (5) information on maintaining overall health and well being (9). Similarities between the two programs included: (1) medical management of the child with asthma; (2) use of patient education practices to enhance self-management capabilities, (3) the reduction of school absenteeism, and the appropriate use of health care services as program goals. Differences between these programs included: (1) in-patient versus out-patient treatment, (2) intensity and duration of contact with child and family, (3) a family approach to asthma treatment is incorporated into the Hugh MacMillan Rehabilitation Centre only.

2.4. Procedure Through consultation with the program physi-

cian, children who had moderate to severe asth-

ma where identified by reviewing children’s medication usage in their medical records. Se- lected families were subsequently approached to participate in the study.

All consenting families participated in a 2-h interview carried out in their home. Typically, children were interviewed on the asthma self- management questionnaire separately from their parents. Parents responded collaboratively on the Child Behaviour Checklist (CBCL), Family Inventory of Life Events (FILE), and the Back- ground questionnaire. The Asthma Self management questionnaire was completed independent- ly by both parents. Completed questionnaires were reviewed, and if they contained ambiguous responses or omitted items, respondents were asked for clarification or further information.

3. Results

3.1. Background characteristics

Comparisons were made between the two groups of families on those variables that were characterized as background factors. The intent was to establish whether there were preselection differences between the groups which would offer alternative hypotheses in explaining possible differences in asthma management. A two- group MANOVA was used to compare the groups on continuous variables, and chi-square analyses were performed on the categorical variables.

A summary of family characteristics is shown in Table 1. The overall multivariate effect was found to be significant (Hotelling-Lawley Trace=0.44, F (7,42) =2.65, P=O.O2), with a significant univariate effect on only one variable - age of child, (F (1,48) = 2.85, P = 0.01). Chil- dren who participated in the 3-week out-patient program were on the average, younger (8.9 years) than those children who participated in the intensive 3-month program (10.0, years). No significant differences were found between the two groups on the remaining variables: age first treated for asthma; number of siblings; number

Table 1


Background Characteristics of Participating Families

In-patient program Out-patient program

Disease Factors Mean age of chid when first treated for asthma Number of children that have had eczema

Patient Factors Mean age of child at time of interview Number of boys Number of girls Number of children who have participated in a previous asthma program Mean score of Occupational status Mean score of reported level of child behavioural problems Mean score of reported level social competence

Environmental factors Mean number of siblings in the family Number of families who have someone that smokes at home Number of families that have a pet Mean score on the family inventory of life events Number of single parent families Number of parents who have not participated in a previous asthma program

2.24 2.93 (1.94)* (2.90)* 18 12

10.08 8.92 (2.53)* (2.32)* 18 17 I 8 9 14

54.65 47.84 (16.34)* (15.95)* 60.40 64.24

(11.29)* (11.79)* 42.20 44.80

(11.17)* (10.40)*

1.24 1.16 (0.92)* (0.85)* 10 4

6 4

11.36 8.68

9 5 17 18

* Standard deviation.

of family life events and changes in the past 6 months; family socio-economic index; behavioural problems; and social competence.

Chi-square analyses revealed no significant difference in the number of single parent families that were in each group, prevalence of smoking and children with eczema. The same number of children from both programs received formal asthma education training before participating in their respective programs. Both programs were comparable in reporting that most children received their first medical treatment for asthma before the age of three. A similar proportion of boys and girls participated in both programs. A similar number of parents from both programs reported having a furry pet at home.

3.2. Illness outcomes

Table 2 shows the means and standard deviations for both groups on this revised set of illness behaviours. Scores for medical utilization (number of scheduled physician visits, number of emergency or unscheduled physician visits and number of hospitalizations) were converted to standard scores and averaged to represent a global score for medical utilization [28].

Hotellings’s T* provided a means of testing whether the two groups differed on any of the three illness behaviour outcomes. The multivariate group effect for illness behaviours was statistically significant (Hotelling-Lawley Trace = 0.26, F (3,46) = 3.95, P = 0.01).

112

Table 2

K. Brazil, L. McLean I Patient Education and Counseling 30 (1997) 107-118

Revised Mean Scores on Child Illness Behaviours

In-patient Program

Mean SD.

Out-patient Program

Mean SD.

Number of asthma attacks 25 2.89 1.94 25 4.76 2.19 School absenteeism 25 3.88 8.24 25 4.32 6.12 Medical utilization’ 25 -0.19 0.55 25 0.19 0.99

r Average standardized score on doctor’s visit, hospitalizations, and emergency visits.

Univariate testing revealed that parents who matrices that were calculated on children’s scores participated in the in-patient program reported on the asthma inventory. A multivariate test for that their children had significantly fewer asthma homogeneity of dispersion matrices revealed attacks than what was reported by parents whose significant departures between the two groups on children had participated in the out-patient pro- the correlation matrices for children’s scores on gram. The two groups did not differ significantly the asthma inventory, indicating that the assump- on either school absenteeism or medical utilization of covariance equality was violated (F = tion. 6.59, P = 0.002).

3.2.1. Asthma knowledge/self-management behaviours.

Table 3 shows the means and standard deviations for family members responses on the asthma inventory. Shown on Table 4 are correlation

As an alternative to calculating a two-group MANOVA, independent t tests were calculated on the three variables that comprise the child version of the asthma inventory. Children’s scores on asthma knowledge were not significantly different between the two groups ( t

Table 3 Family Mean Scores on the Asthma Inventory

In-patient program

Mean S.D.

Out-patient program

Mean S.D.

Children’s Scores Asthma knowledge Self-management behaviour Attitude about having asthma

25(22) 9.36 25( 22) 68.86 25( 22) 7.45

Fathers’ Scores Asthma knowledge Report on child Self- management behaviour Report on child adjustment to asthma Report on impact of asthma to the family

25(17) 10.24 25( 17) 63.53

25( 17) 6.53

25( 17) 33.71

1.89 25(22) 8.17 2.18 8.23 25(22) 67.00 8.06 2.46 25(22) 7.05 2.13

0.75 25( 18) 9.89 1.18 6.90 25( 18) 63.33 6.51

2.24 25( 18) 7.00 2.00

7.33 25( 18) 33.06 7.25

Mothers’ Scores Asthma knowledge Report of child self- management behaviour Report on child adjustment to asthma Report on impact of asthma to the family

25(24) 10.08 25(24) 66.33

25(24) 6.92

25(24) 33.50

1.14 25(25) 10.04 0.98 7.20 25(25) 65.00 7.20

2.87 25(25) 7.00 2.35

11.77 25(25) 32.04 5.08


Table 4 Pearson Correlations Between Children’s Responses on the Asthma Inventory

Variable

Variable 0) (2) (3)

In-patient program (1) Astham knowledge (2) Self-management behaviour 0.478* (3) Attitude about asthma 0.402* 0.722* Out-patient program (1) Asthma knowledge (2) Self-management behviour 0.286 (3) Attitude about asthma -0.035 -0.533*

* p < 0.05.

(43) = 1.72, P = 09). While not significant by conventional standards, the effect suggests a trend where children from the in-patient program obtained higher asthma knowledge scores than children from the out-patient program. No difference was observed between the two groups on either children’s report of asthma self-management behaviour (t (43) = 0.76, P > 0.05) or their feelings about having asthma (t (43) = 0.59, P > 0.05).

Correlation matrices of children’s responses on the asthma inventory revealed a pattern where asthma knowledge was significantly related to in-patient children’s report of attitude about having asthma and the practise of asthma self- management behaviours. A similar pattern was not present among the children who participated in the out-patient program. Figs. 1 and 2 are a visual representation of the correlation - children’s report of attitude about having asthma against the practise of asthma self-management behaviours, selected from the correlation matrices. The scatterplots revealed dramatic differences between the groups on the relationship between these two variables. In the case of children from the in-patient program, the association was positive, children’s attitude about having asthma was more positive with the more self-management behaviours they practise. On the other hand, children from the out-patient program reported a more negative attitude about having asthma with the more self-management behaviours they practised.

0 J

40 50 60 70 60 90

Asthma Self-Management Behaviour

Fig. 1. Scatterplot based on children’s reports of attitude about having asthma against asthma self-management be-

l l

. .

. . . ..*..*

l

l l l

. . . ..*..*

l

l l l

i i l l l l l l ee l l ee

,e l ,e l

..,. . . . . . . . . . . ..-. ,. . . . . . . . . . . ..-. ..- ..-

l e l e

l j l j

haviour for families in the in-patient program.

15

2 II: 2 i

0 10 .I.* .._.. :e .I. C

‘5 0; .

2 l , l e : l

i l ‘e l 3 0 l e l

9 5 : . . . . . . ..*.....e. .*

$ 6

3 c

2 l

0 40 50 60 70 60 90

Asthma Self-Management Behaviour

Fig. 2. Scatterplot based on children’s reports of attitude about having ashtma against ashtma self-management behaviour for families in the out-patient program.

The overall multivariate group effect for fathers’ responses on the asthma inventory was not statistically significant (Hotelling-Lawley Trace = 0.07, F (4,30) = 0.46, P > 0.05). Similar to fathers, the overall multivariate group effect for mothers’ responses on the asthma inventory


was also not statistically significant (Hotelling- Lawley Trace = 0.02, F (4,44) = 0.27, P > 0.05).

(F (1,32) = 0.41, P > 0.05). The interaction of treatment by report was not significant (F (1,32) = 0.01, P > 0.05).

3.2.2. Parent differences within intact families. The measurement of both parents on outcome

measures permitted investigation of parents’ asthma knowledge and self-management skills.

In families where both parents were present, parents’ scores on outcome measures were sub- jected to a Multivariate Analysis of Variance (MANOVA) with two dependent variables (mother/father report within the family). Table 5 shows the means and standard deviations for parents’ responses on the asthma inventory.

As with the previous variables, no significant main effect for either treatment (F (1,32) = 0.99, P > 0.05) or parents’ report (F (1,32) = 0.44, P > 0.05) was found for parents’ rating of the impact of asthma on the family. The interaction of treatment by report was not significant (F (1,32) = 2.09, P > 05).

Parents’ scores on asthma knowledge showed no significant main effect for treatment (F (1,32) = 0.46, P > 0.05) or source of report (F (1,32) = 0.10, P > 0.05). The interaction of treatment by report was not significant (F (1,32) = 0.67, P > 0.05). Parents’ ratings of child self-management behaviour revealed no significant main effect for treatment (F (1,32) = 0.31, P > 0.05) or report (F (1,32) = 1.02, P > 0.05). The interaction of treatment by report was not significant (F (1,32) = 0.34, P > 0.05).

These findings held clinical significance by indicating that within families, parents did not differ significantly on their level of asthma knowledge, their report of impact that asthma had on the family, or their child’s level of self- management behaviour and emotional adjustment to having asthma.

4. Discussion

4.1. Background characteristics

Parents’ ratings of child’s adjustment to asthma revealed no significant main effect for either treatment (F (1,32) = 0.66, P > 0.05) or report

The description of the background characteristics of the families showed that children who participated in the out-patient program were, on average, 1 year younger than those who participated in the in-patient program. The considera-

Table 5 Parents’ Mean Scores Within Intact Families on the Asthma Inventory

Father

Mean S.D.

Mother

Mean S.D.

In-patient program Asthma knowledge Report of child self- management behaviour Report of child adjustment to asthma Asthma impact on family

Out-patient program Asthma knowledge Parent report of child behaviour Parent report of child attitude Asthma i.mpact on family

25( 16) 10.25 0.77 25( 16) 25( 16) 63.75 7.06 25( 16)

25( 16) 6.43 2.27 25( 16)

25( 16) 33.37 7.45 25( 16)

25( 18) 9.89 1.18 25( 18) 25( 18) 63.33 6.51 25( 18)

25( 18)

25( 18)

7.00

33.06

2.00 25( 18)

7.25 25( 18)

10.00 1.03 65.62 6.81

6.81 2.88

35.62 5.40

10.00 0.97 63.83 6.41

7.27 2.27

32.22 4.50


tion of age raises questions concerning children’s ability to process information and the effectiveness of an education intervention.

There is evidence that children’s health beliefs begin to differentiate in a coherent belief system at approximately 9 years of age, corresponding to Piaget’s concrete operational period. According to Natapoff’s [29] analyses of children’s concept of health, ‘8 and 9 year olds are able to become active health consumers and make their own health decisions’ (Natapoff, p. 43). While children from the two programs may differ in age they appear to overlap in the same sequence of cognitive development based on the theories of Jean Piaget. This consideration suggests that the children in the two programs were equivalent in their ability to process information provided through the asthma interventions. Because of the lack of control of participants in the two groups, the ‘older’ in-patient group could represent a slight bias where the older group may be prone to practise preventative tactics because of ma- turity. Thus, offering an alternate explanation than program characteristics for those differences found between the two groups.

It is noteworthy that a high percentage of families from both programs indicated that they had not participated in any form of asthma education prior to participating in the programs in the study, suggesting a need for early access to asthma education programs. Children with moderate to severe chronic asthma should be a high priority group for asthma education intervention. The literature shows that educational programs produce improved skills in self-management and are considered a key to enhancing the medical management of asthma. Indeed, Hindi-Alexan- der & Cropp [5] found their self-management program to be more effective for children with asthma that was moderate to severe than for asthma mild and episodic. Yet apparently most of the families in this study had coped without self-management programs for approximately 5 years.

4.2. illness outcomes

Analyses of illness outcomes revealed marked differences between the two groups. Families in

both programs were similar in their reports of school absenteeism and medical utilization. How- ever, families who participated in the in-patient program reported fewer asthma attacks than those families who participated in the out-patient program. The pattern of illness behaviours reported by children who participated in the out- patient program suggests poor compliance with a medical regimen. Children who participated in the out-patient program may not have received enough training to enhance the prevention skills which reduce asthma attacks. In contrast, graduates of the in-patient program attained a level of self-management marked by successful prevention skills, and they reported relatively fewer asthma attacks.

4.3. Asthma knowledge and self-management skills

Children who participated in the in-patient program were similar to those children who participated in the out-patient program on levels of asthma knowledge, self-management behaviour and attitude about having asthma.

While both programs in this study were com- mitted to the same teaching philosophy, and in fact use the same staff, the findings suggest that the duration and intensive nature of the in-patient program is more successful in changing not only children’s behaviour and attitudes but also having an impact on illness behaviours. These findings are reinforced with the observation that children who participated in the in-patient program had a tendency to feel more positive about having asthma with the more self-management behaviours they practised. Children from the out-patient program, on the other hand, reported a more negative attitude about having asthma with the more self-management behaviours they practised. These findings have implications for the relative merit of asthma self-management programs for children with moderate to severe asthma that take place over the course of a few weeks on an out-patient basis. Such programs may not provide children with the accomplishment experiences in managing their asthma which would promote the belief or expectation that the behaviour can be performed successful-


ly. As a consequence, while children may perform the appropriate behavioural strategies, it is accompanied with anxiety as they have not developed feelings of mastery or self-efficacy in the management of their asthma [25,26]. This program outcome may be exacerbated depend- ing on what parents expectations are as a consequence of their child participating in a self-management program. Some parents may feel their child does not warrant the degree of attention as was felt necessary prior to participating in such a program, thus reinforcing children’s negative attitudes about having asthma.

These findings appear to thwart the effectiveness of this otherwise promising asthma out- patient treatment approach for children with moderate or severe asthma. The public health benefits of research can only be realized if proven treatment strategies retain their effectiveness when translated in to readily usable pro- cesses and materials. To accomplish this, a sys- tematic transfer is needed. There is a tendency to abbreviate asthma programs due to the anticipated difficulty of getting individuals to attend more than one educational session. Wilson has noted [9] when programs are abbreviated it is the more powerful behaviour change strategies that are dropped in preference for the transmission of information. Two features from the in-patient program which needs to be retained in out-patient programs include the opportunity for children to preform accomplishment experiences in managing their asthma in controlled conditions and parent involvement in child asthma education and training to reinforce a lasting behavioural change.

Parents’ scores in the two programs were similar on the variables that comprise the asthma inventory. These findings were unexpected; it was anticipated that parents who participated in the family- oriented in-patient program would perform better than those families who participated in the child-focused out-patient program. These findings suggest that parents with a child who has asthma acquire asthma knowledge and self-management skills through informal educational activities such as using the library to find information on asthma or through regular contact with health care professionals.

It was noteworthy that in both programs where both parents were present in the family, fathers did not differ from mothers in their level of asthma knowledge, their report of impact that asthma had on the family, or their perception of their child’s level of self-management behaviour and emotional adjustment to having asthma. These findings suggest that fathers were more involved in their child’s illness management than has traditionally been observed for fathers with a chronically-ill family member. It will be of inter- est to see if these findings are corroborated in future research, indicating whether there has been a shift in recent years on the role fathers assume in the management of illness within the family.

5. Conclusions

The present study presents evidence that an in-patient treatment approach which makes both medical and teaching practises more effective holds specific advantages over an out-patient approach. Children who participated in the in- patient program were observed to be more adjusted about having asthma with the more self-management behaviours they practised. On the other hand, children who participated in the out-patient program were less adjusted about having asthma with the more self-management behaviours they practised. Differences were observed between the two groups in the frequency of asthma attacks. Families who participated in the in-patient program exhibited a pattern of illness behaviours which indicated asthma symptoms were better managed in comparison to those families that participated in the out-patient program.

The intensive nature of the in-patient program permits children to learn I and practise self-management skills during the course of the program, thus providing children with accomplishment experiences which help promote both attitudinal and behavioural change. Inpatient placement also permits the child to be monitored over time allowing for accurate assessment and appropriate changes in a therapeutic regimen. In short, in an in-patient program, a comprehensive intensive


approach can be developed and implemented which helps the family to achieve control over asthma. This advantage to hospital-based asthma care has been noted elsewhere [30].

Given that families could not be assigned at random to one of the two programs, the most obvious flaw in the study design is the absence of randomization and the use of pretests encourag- ing caution in the interpretation of causality. However, this study is useful for identifying possible causes of observed variation between groups which can be verified in subsequent experimental studies.

A number of issues emerged from the study regarding the transfer of self-management Qrain- ing technology from the highly-controlled in-patient program to an out-patient program approach for the treatment of asthma. A 3-month period of hospitalization is not feasible for large numbers of young people with asthma. Further, cost containment issues require service providers to consider cost-efficient service options. The present study has identified two key components which must be incorporated in the instructional design of out-patient self-management programs: the opportunity of children to perform accomplishment experiences in managing their asthma in controlled conditions; and parent involvement in child asthma education and training to reinforce lasting behavioural and attitudinal change.

References

[l] Clark NM, Feldman CH, Evans D, Millman EJ, Wasilewski Y, Valle IM. The effectiveness of education for family management of asthma in children: A pre- liminary report. Health Educ Q 1981; 8: 166-174.

[2] Clark NM, Feldman CH, Evans D, Levison MJ, Wasilewski Y, Mellins RB. The impact of health education in frequency and cost of health care use by low income children with asthma. J Allergy Clin Immunol 1986; 78: 108-115.

[3] Feldman CH. Asthma education: General aspects of childhood programs. J Allergy Clin Immunol 1987; 80: 494-497.

[4] Fireman P, Friday G, Gira C, Vierthale W, Michaels L. Teaching self-management skills to asthmatic children and their parents in an ambulatory care setting. Pediat- rics 1979; 64: 878-881.

[5] Hind&Alexander MC, Cropp GJ. Evaluation of a family asthma program. J Allergy Clin Immunol 1984,74: 505- 510.

[6] Klingelhofer EL, Gershwin ME. Asthma self-management programs: Premises, not promises. J Asthma 1988; 25: 89-101.

[7] Parcel GS. Theoretical models for application in school health educgation research. School Health Res 1984; 54: 39-55.

[8] Rakos R, Grodak M, Mach K. The impact of a self- administered behavioral intervention program on paediatric asthma. J Psychosom Res 1985; 29: 101-108.

[9] Clark N, Shope J. The current knowledge base for education programs for chronically ill children. Adv Health Educ Promotion 1986; 397-434.

[lo] Wilson S, Starr-Schneidkraut N. State of the art in asthma education: The US Experience. Chest 1994; 106: 197-205s.

[ll] Toelle B, Peat J, Salome C, Mellis C, Bauman A, Woolcock A. Evaluation of a community-based asthma management program in a population sample of school children. Med J Aust 1993; 158 (11): 742-746.

[12] Deaves D. An assessment of the value of health education in the prevention of childhood asthma. J Adv Nursing 1993; 18 (3): 354-363.

[13] Colland V. learning to cope with asthma: A behavioral self-management program for children. Patient Educ Counselling 1993; 22: 141-152.

[14] Hughes D, Mcleod M, Garner B, Goldbloom R. Con- trolled trail of a home and ambulatory program for asthmatic children. Pediatrics 1991; 87(l): 54-61.

[15] Borg W, Gall M. Educational Research. New York: Longman, 1983.

[16] Lelah T, Harris L, Avery, Brook R. Asthma in children and adults: Assessing the quality of medical care using short-term outcome measures. Med Care, 1977; 15: 110- 165.

[17] McNichol KN, Williams HE. Spectrum of asthma in children - I, clinical and physiological components. Br Med J 1973a; 4: 7-11.

[18] McNicol KN, Williams HE. Spectrum of asthma in children - II, allergic components. Br Med J 1973b; 4: 12-16.

[19] McNicol KN, Williams HE, Allan J, McAndrew I. Spectrum of asthma in children - III, psychological and social components. Br Med J 1973; 4: 16-20.

[20] Blishen B. A revised socio-economic index for occupa- tions in Canada. Can Rev Social Anthropol 1967; 4: 41-53.

[21] Noorish M, Tooley M, Godfrey S. Clinical, physiological, and psychological study of asthmatic children at- tending a hospital clinic. Arch Dis Childhood 1977; 52: 912-925.

[22] Achenbach TM, Edelbrock C. Manual for the child behaviour checklist and revised child behaviour profile. Burlington, VT: University of Vermont, 1983.

[23] McCubbin HI, Patterson JA. FILE family inventory of life events and changes. In: McCubbin HI, Thompson A


editors. Family assessment inventories for research and practise. Madison: University, University of Wisconsin- Madison. 1987; 81-100.

[24] United States Department of Health and Human Ser- vices, Public Health Services, National Institute of Health. Air Power. (NIH publication number 85-2362). Washington, DC: U.S. Government Printing Office, 1984.

[25] Bandura A. Self-efficacy mechanism in human agency. Am Psycho1 1982; 37: 122-147.

[26] Green L, Frankish J. Theories and principles of health

education applied to asthma. Chest 1994; 106 (4): 219- 230.

[27] Creer T. The application of behavioral procedures to childhood asthma: current and future perspectives. Pa- tient Educ Counselling 1991; 17: 9-22.

[28] Glass G, Stanley J. Statistical Methods in Education and Psychology. Prentice-Hall: New Jersey, 1970.

[29] Natapoff J. A developmental analysis of children’s ideas of health. Health Educ Q 1982; 9: 34-45.

[30] Newhouse M. Hospital-based asthma education. Chest 1994; 1061 237-241s.

the influence of health education on family management of childhood asthma

Documents