The Roaring Adventures of Puff (RAP): A Childhood Asthma Education Program

Implemented in Edmonton, Alberta, Canada by MAS Consultants Inc., P.O. Box 5130 Aiken, South Carolina 29804.

The Roaring Adventures of Puff: Research Base

Introduction

An estimated 13% of Canada’s children have asthma, of whom two thirds are limited in their activities. Recent data indicate that asthma is not optimally controlled among Canadian children, and both the prevalence and burden of the disease have increased in recent years. In Alberta, children account for 60% of hospital discharges for asthma. Thirty-six percent of children in the province who were hospitalized with asthma were readmitted for asthma within 4 years. Outdoor allergens such as dry pollens, molds, trees, and grasses, combined with windy conditions, account for some of Alberta’s asthma problems. Animal dander is a common indoor asthma trigger.

Parents, teachers, and health-care professionals in Edmonton, Alberta, believed that an asthma education program targeting children would be a valuable community resource that would enhance the lives of children with asthma and their families. Dr. Dean Befus, the Director of the Pulmonary Research Group at the University of Alberta in Edmonton, Astra/Zeneca Chair in Asthma Research and Director of the Alberta Asthma Centre, responded to this need, and a program was developed that would provide knowledge to children, promote problem solving, and provide peer support. With funding from the Kinsmen Club of Edmonton for education initiatives, Dr. Befus directed the development of a multisession asthma education program for children with asthma that complies with the Canadian Consensus Guidelines for Asthma Care. The program was initiated in 1993 as the Roaring Adventures of Puff (RAP). Dr. Befus and his staff have been active over the years with the development and management of other asthma programs, including developing a School Asthma Policy, education programs for the Asthma Summer Camp for Kids, a Professional Certification in Asthma Management for health professionals (now offered as a distance learning program online in partnership with The University College of the Caribou), and a day-care asthma education program. The Alberta Asthma Centre, located on the University of Alberta campus in Edmonton, Alberta, Canada, has been in operation since 1993. The director and a staff of six include full- and part-time employees of the clinic.

RAP was written and developed by Shawna McGhan, RN, MN, CAE, Coordinator, Asthma Education at the Alberta Asthma Centre, with the assistance and advice of various health and education professionals, including Eugene Krupa, Ph.D., and Angela Estay, MA, RN. The RAP Instructor’s Manual was revised in 1996 and again in 2000. The developers created the program to be flexible to the needs of the community, allowing RAP to be implemented in a variety of settings such as schools, clinics, hospitals, and community health centers. The program has been implemented in many communities across Canada, principally in Alberta and Ontario. Added information is available in the manuscript by S.L. McGhan, H.M. Wells, and A.D. Befus titled "The Roaring Adventures of Puff: A Childhood Asthma Education Program" which was published in 1998 in the Journal of Pediatric Health Care.

RAP integrates the theoretical assumptions of the social cognitive theory and the principles of teaching and learning that meet children’s learning needs. The social cognitive theory states that individuals are influenced by a complex interaction among the environment, person, and behavior. Factors that influence these three interactions include self-regulation, observational learning, reinforcement, social and physical environmental support, and self-efficacy. Consequently, a network of sociocultural relationships that surround a person determines his/her perception of learning needs and willingness to begin learning. Furthermore, behavioral changes resulting from learning are likely to occur when supported by individuals who have a primary social relationship with the learner. The program uses innovative and creative games and activities to facilitate the learning of new skills and knowledge. A fictional dinosaur, Puff the Asthmasaurus, is featured as a large interactive puppet that shares his asthma stories and experiences with the children. Puff guides the children as they seek better understanding of asthma and how to improve their quality of life. The cartoon representation of "Puff the Dino" is copyrighted. It appears on the children’s asthma questionnaire, their RAP Fun Book (a children’s workbook) and asthma action plan diary and throughout the instructor’s manual and handouts.

Goal of the Intervention Research

The goal of the study was to determine whether an interactive childhood asthma education program called RAP, based on the principles of the Social Cognitive Theory, would improve asthma management behaviors and health status of elementary school children.

Intervention Research

Educational Content of the Intervention
Parents and teachers in the intervention schools were invited to participate in a RAP parent/teacher asthma awareness event at the school. The event provided information about asthma management, school asthma issues, and the RAP program. Families with a child with asthma in the intervention schools received information letters about RAP to share with their doctors, including suggested guidelines for written action plans for the parents and their children to use at school and at home.

The instructors were third-year nursing and pharmacy students trained to teach RAP under the guidance of the RAP supervisor. Instructors used lesson checklists and other materials outlining the course content and the specific learning goals for each session plus a detailed instructor’s manual to teach six 60-minute sessions. Each session was interactive. Teaching strategies included puppetry, games, role-play, model building, discussions, and asthma diary recording. The six session topics were:

1. Getting to know each other, goal setting, using a peak flow meter, diary monitoring
2. Identifying, controlling and avoiding triggers, basic pathophysiology
3. Properly using medications and inhalers
4. Recognizing symptoms and using the asthma action plan
5. Modifying lifestyle, exercising, managing an asthma episode
6. Sharing this information with teachers and parents

Evaluation Design
Eighteen volunteer elementary schools were randomized to intervention and control groups. Approximately 76 students with asthma participated from the intervention schools as did 86 students from the control schools. All children with asthma in the intervention and control schools and their parents completed the following questionnaires at the beginning of the project and again 9 months later:

• Pediatric asthma quality of life questionnaire
• Childhood asthma pictorial scale
• Parent’s RAP questionnaire
• Childhood asthma self-efficacy scale, and
• School information form

The quality-of-life questionnaire asked children to identify three activities in which they had been bothered most by their asthma in the previous week, then describe how much they were bothered using a Likkert scale of 1 (extremely bothered) to 7 (not bothered). Then children described how often during the last week they were frustrated, tired because of asthma, worried, and concerned or troubled because of asthma. Additional questions included level of severity of an asthma attack and of the following asthma symptoms: wheezing, irritability, tightness in the chest, shortness of breath, and loss of sleep.

The Childhood asthma pictorial scale is used to gauge how well children take care of their asthma. Each statement in the questionnaire includes the same four possible responses: always, usually, sometimes, and never. Sample statements are:

• I play with pets
• I have trouble with school work because of asthma
• I use a peak flow meter
• I take my medicine when I have asthma problems
• I get exercise every day
• I keep a record of my asthma signs
• I take my inhaler before sports
• I leave the building when someone is smoking
• I know when my asthma is getting worse
• I like gym class
• My parents yell at me about my asthma
• My asthma bothers me

The parent’s RAP questionnaire assesses demographic information such as age, gender, and ethnic background and the parents’ perception of their children’s symptom severity, medication use, health-care use, school absenteeism, and attitudes toward asthma.

Recruitment and Characteristics of the Study Population
More than 100 letters were sent to Edmonton elementary schools inviting them to participate. All 18 schools that volunteered were enrolled. A letter was sent to all parents inviting them to enroll their children with asthma in the study. All 162 children who volunteered were enrolled. Children with asthma aged 7-12 years constituted the target population. Criteria for selection included:

• A diagnosis of asthma by a physician and "current asthma" as reported by parents
• An informed consent from the parent or guardian
• The ability to speak English
• No previous participation in RAP

To facilitate accessibility and to prevent cross-contamination between groups, the unit of randomization was the school. All participating students in each school were assigned to the same group. However, children were the primary unit of analysis.

The two groups were comparable for demographic and disease related variables (Table 1).

Research Results

The primary analysis compared pre-intervention and post-intervention outcomes for the children with asthma receiving and not receiving the program. (Those in the control schools received regular medical care.)

The intervention group improved following RAP for most indicators of asthma control. Some pre- and post- intervention changes were statistically significant (Table 2).

The only statistically significant difference for the control group was the unscheduled physician visits, an improvement that was only about half of that of the RAP group.

The intervention group demonstrated significant improvement in the use of appropriate medication for relief of symptoms (20.6%) and preventing symptoms (31.4%) at follow-up. By contrast, the control group improvements were 17.4% and 3.7% respectively.

Research Funding

The study was funded by the Alberta Asthma Network of the Alberta Lung Association and by the Alberta Asthma Centre.