Open Airways for Schools (OAS)

A program of the American Lung Association, implemented in Office of School Health, Department of Health Anne Arundel County, Maryland.

Open Airways for Schools: Research Base

Introduction

Open Airways for Schools (OAS) is a major American Lung Association (ALA) initiative to help children in elementary schools better manage their asthma. The program is school-based, designed by physicians, and operates in a variety of elementary school settings throughout the United States. OAS is an extension of the Open Airways program, which was originally designed for delivery in health care settings with Black and Latino children from under served communities. While Open Airways is an educational program for parents and their children, OAS was designed to be a child-centered educational program.

OAS is based on the premise that a clinic-based educational program would increase parents’ and children’s ability to manage asthma and thus reduce the number of emergency room visits, hospitalizations, missed school days, and disruptions in family life that are caused by asthma.

In recognition of the lack of asthma education for children with asthma who are not involved with pediatric specialty clinics, the validated clinic based Open Airways was transferred to an elementary school setting. To insure that Open Airways would be effective in a school setting, two separate studies were conducted, using an experimental research design. For a more detailed discussion of this transfer process, refer to the September 1986 publication by D. Kaplan, J.L. Rips, N.M. Clark and others titled “Transferring a clinic based health education program for children with asthma to a school setting” in volume 56 of the Journal of School Health.

In the first study, a pilot study, parental participation remained a key feature of the intervention; however, in response to the low attendance of parents, researchers made the decision to reduce the level of parent participation in favor of a more child-centered program. As a result, the materials and format for OAS were revised to be developmentally appropriate for children in third through fifth grades, based on Piaget’s model of cognitive development in children. According to Piaget, children in grades 3 through 5 have reached the stage of concrete operations and are able to understand the concepts of causation and prevention. OAS also utilizes the concept of self-efficacy, derived from Bandura’s Social Cognitive Theory. Self-efficacy refers to one’s belief in his or her ability to perform a task effectively as a prerequisite to undertaking that task. A common method of instilling and reinforcing that belief is through repeated demonstration and practice of that specific task.

In 1984, the revised intervention was implemented in 12 schools in New York City to determine its effectiveness. The following sections discuss the goals, educational content, and evaluation design and results of the intervention as well as important characteristics of the study population. This discussion is based on an article by D. Evans, N.M. Clark, C.H. Feldman and others titled “A school health education program for children with asthma aged 8-11 years” that was published in 1987 in volume 14 of Health Education Quarterly.

Goals of the Intervention Research

According to Dr. David Evans, one of the lead researchers, OAS was conceived to address a goal set forward by the National Heart, Lung, and Blood Institute to increase the availability of asthma education programs. A school-based intervention provides the opportunity to reach a larger, more diverse group of children with asthma than in a traditional clinic setting.

In addition to this overarching goal, the intervention hoped to achieve several specific objectives:

• increase a child’s ability to recognize asthma symptoms
• increase self-efficacy with respect to managing asthma
• increase children’s positive influence over their parents’ asthma-management decisions
• improve school attendance and performance

Intervention Research

Educational Content of the Intervention
The educational sessions focused on the child’s role in asthma management and emphasized tasks children could complete without parental participation or supervision. Each session used physical, hands-on activities and allowed children to practice their newly acquired skills in class.

The intervention consisted of six 60-minute educational sessions with groups of eight to twelve children. The sessions were held during the school day and were offered over a 2-to3-week period. The six sessions covered the following topics:

• basic information and feelings about asthma
• recognizing and responding to symptoms
• using asthma medicines and deciding when to seek help
• keeping active
• identifying and controlling triggers
• handling problems related to asthma and school

Additional printed materials were designed for and provided to parents to keep them abreast of what their child was learning. Homework assignments also allowed children the opportunity to practice exercises and techniques and to share information that was learned in class with family members. For instance, one homework assignment instructed children to teach a family member a belly breathing exercise learned in class.

Evaluation Design

An experimental research design was used to evaluate OAS. Twelve elementary schools in New York City were chosen to participate in the study. Each school was paired with a comparison school selected on the basis of ethnic composition and size. One school in each of the six pairs was randomly selected to receive the intervention. Evaluation results were collected in the year following the intervention. After the study was completed, the comparison schools also received the intervention.

To detect changes in children’s knowledge, attitudes, beliefs, and skills with respect to asthma self-management, data were collected on the following outcome measures through the stated mechanisms:

Self-management skills: An index of 36 self-management activities performed by the child to prevent the occurrence of symptoms, to communicate information about current symptoms and the need for treatment to parents, and to manage asthma symptoms at home and at school

Self-efficacy: An index to measure the child’s perceived self-efficacy with respect to 13 asthma management behaviors

Influence on parental decision-making: An index of the parent’s rating of the child’s influence on parental decisions regarding school attendance and emergency room visits

School attendance and performance: School attendance (number of days absent) and performance (grades in 11 subjects or skills and performance on standardized mathematics and reading achievement tests) measured using school records and teacher-provided behavioral assessments of classroom performance

Children’s attitudes: Students were asked about their feelings about school, about asthma, and if friends or other children did anything to help them during their most recent asthma episode at school

Parental report on the frequency, duration, and severity of child’s asthma episodes: Parents’ report of the number of asthma episodes and average duration (number of days) in the past year, the number of episodes treated at home, and the number of episodes requiring treatment in emergency departments

Recruitment and Characteristics of Study Population

To recruit participants for the study, teachers sent a letter, in both Spanish and English, home with all third through fifth grade students. The letter described the symptoms of asthma and the purpose of the intervention. Interested parents were interviewed by a bilingual phone interviewer to determine whether the child met the criteria for participation in the program. Children were eligible to participate in the study if a) they were enrolled in the third, fourth, or fifth grade, b) parents reported at least three episodes of asthma in the past year, and c) parents provided written consent for participation.

The study population consisted of 239 students from 237 families with 134 children in the experimental group and 105 in the control group. The children were mainly from low-income families with 71% receiving Medicaid. Seventy percent were Hispanic, 28% were non-Hispanic Blacks, 2% were non-Hispanic whites. Fifty-nine percent were male, with an average age of 9.1 years . Ninety-three percent of the children’s parents stated that a physician had previously diagnosed asthma in their child. An additional 6% of parents reported that their child experienced wheezing, coughing, or shortness of breath, and 1% reported two or more symptoms in absence of a physician diagnosis.

Research Results

The intervention was effective in increasing children’s self management skills and self-efficacy and the child’s influence on parental decision making. Results also showed a decrease in the annual frequency and average duration of self-reported asthma attacks. During the year, the number of symptom days decreased by 43% in the intervention group and 7% in the control group. Children in the intervention group also increased the number of actions they took to manage their asthma compared with children who did not receive the intervention.

In addition, children in the intervention group reported more positive feelings about school and fewer negative feelings about asthma and were more likely to receive help from others (e.g., nurses or parents) during an attack than were children in the control group. Children in the intervention and the control groups both had fewer absences in the follow-up year than in the base year, though the difference between groups was not statistically significant. However, children in the intervention group received higher grades, especially in math and oral expression.

Research Funding

OAS research was supported by Grant R18-HL-28907 from the Division of Lung Diseases, National Heart, Lung and Blood Institutes (NHLBI) and a gift from the Spunk Fund.