The RAP group showed an overall improvement in outcome measures at six and 12 months and significant improvements from baseline to at least one time period in select variables. This included any smoke in the home, use of peak flow meters, improved understanding of asthma, ability to cope and asthma control, and QOL domains including activity, emotions, symptoms and overall. Improvements were significantly greater in the RAP intervention group from baseline to six months compared with the control group in parent’s perceived understanding and ability to cope with and control asthma, and overall QOL. Some improvements were seen in both groups, likely due to differences in the intervention and control groups at baseline, and participants and those lost at follow-up.
A significant outcome from the present study is the extent to which RAP improved the child’s perception of their QOL, including well-being and functional impairment of everyday life activities. Statistically significant improvement in symptoms, emotions and overall domain scores were seen at six months, and all domain scores continued to significantly increase at 12 months. Clinical significance (a difference of greater than 0.5 between pre- and postscores [1
]) was seen in the overall QOL domain at both time periods for the intervention group.
High importance is placed on measuring QOL in children with asthma (28
). Some studies have suggested that QOL is predicted by the child’s level of anxiety (29
). School-age children are sensitive to the actions and attitudes of their peers, and children with asthma often feel isolated and different (1
). These beliefs and feelings can impact disease management behaviour (28
). We suggest that participation in RAP with school peers helped individuals recognize their involvement in the social group and, in turn, improved their QOL. This repeat exposure to asthma issues in a group setting allows children to share their feelings, work through various emotions and build confidence as they practice managing asthma in various situations.
Indicators of management behaviour significantly improved in association with the program. This was a key objective of RAP. Self-efficacy and self-regulation can have a powerful impact on whether and how a behaviour is expressed (27
). Therefore, strategies that were designed to improve behaviour were used. For example, to help gain confidence in using their action plan, ‘Puff’, the Asthmasaurus puppet, modelled its use and a game of charades called ‘lights-camera-action’ reinforced the key principles. An asthma diary helped them record the impact of the action plan, and follow-up discussions with peers praised appropriate behaviours and gave feedback on their accomplishments.
A key limitation of the study was the size difference between groups, and the differences in dropouts and participants. Those that did not complete the questionnaires appeared to have more problems with their asthma and more smoke in the home. Because our unit of randomization was the school and not the students, it is possible that selection bias may have occurred.
Another limitation is the higher exposure to smoke in the home in the intervention group. Studies have suggested that smokers tend to experience higher stress (30
), increased airway inflammation (31
), are less likely to participate in education programs (12
), have poor asthma knowledge and skills (32
), are less likely to seek health care (33
) and have worse outcomes after patient education (34
). Future research needs to explore whether a targeted intervention for children and their parents who smoke would be efficacious.
The measurement tools that we used may not have been appropriately targeted or responsive enough to determine the full impact of the program. Qualitative data may have provided more information about the perceptions of the child and parent, how the program affected their lives and whether we measured what was most important to the patient.
The RAP program is an effective way to influence children with asthma at an early age and in a peer setting. A secondary goal of the program was to influence the child supports, such as parents, school staff, clinicians and friends, because these individuals are important targets in change behaviour. The present study prompted a pilot study and an initiative that examines how students with asthma can be better supported in schools. The RAP implementation guide and training program for instructors is now available online (26
RAP attempted to promote communication between parent and child. We did this by offering a parent session, encouraging the child to share what they learned, and asked parents to learn from the child and sign the ‘fun book’ after each session. Studies have shown that parent reports can significantly differ from those of the child (35
). In a subsequent paper, we identify discordance between the parent and children ratings of QOL in this study population (36
). This difference between parent and child ratings was improved after RAP, emphasizing the importance of collecting data from and educating both the parent and child. Clearly, educators should consider the best strategies to optimize parent/child communication.