Issues in Comprehensive Pediatric Nursing, 2014; 37(2): 136–146 ß Informa Healthcare USA, Inc. ISSN: 0146-0862 print / 1521-043X online DOI: 10.3109/01460862.2014.902405

EVALUATION OF A PILOT NATIONAL ONLINE ASTHMA E-LEARNING PROGRAM FOR SECONDARY SCHOOL STUDENTS*

Mary Hughes, PhD, MSc, BSc, PGDip, Hdip, RCN, RGN1 and Margaret Murphy, DN Candidate, MSc, BSc, PGDip, Hdip, RM, RGN, IBCLC

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Background: Ireland has the fourth highest incidence of asthma in the world, with Irish children losing on average 10 days of school per annum due to their asthma. It is highly probable that a large percentage of students in each class in Irish schools have asthma and are required to manage symptoms during the out-of-home period. Young people with chronic illnesses such as asthma find themselves labelled and marginalized due to a lack of awareness of others about their condition. Aims and objectives: Young people who feel supported by their peers have been shown to have higher levels of self-efficacy and fewer exacerbations of their asthma symptoms. Methods: An on-line asthma e-learning program was developed to provide support to teenagers who have asthma, and help them inform their classmates and friends about asthma. A quasi-experimental approach was used to pilot the educational intervention. Results: The results of the pilot demonstrate that the program is effective. Teenagers who have asthma found the e-learning program to be informative and relevant to them. The increase in awareness of asthma among teenagers who did not have asthma is shown to influence their confidence in assisting their peers who are experiencing asthma symptoms. Keywords: Asthma, Education, Evaluation, On-line, Young people *The Asthma Society of Ireland would like to recognize the support of Dyson in the pilot project. Received 9 January 2014; revised 26 February 2014; accepted 27 February 2014

Correspondence: Mary Hughes, School of Nursing and Midwifery, Brookfield Health Sciences Complex, University College Cork, Ireland. E-mail: [email protected] or mary.hughes@ asthmasociety.ie

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1 Asthma Society of Ireland and School of Nursing and Midwifery, University College Cork, Ireland and 2School of Nursing and Midwifery, University College Cork, Ireland

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INTRODUCTION Asthma is an inflammatory disease where there is increased sensitivity of the airways to various stimuli; viral infections are the most common causes of hypersensitivity but symptoms can also be exacerbated by exercise and allergens such as house dust mite and animal dander (Lenney, 2008; Tolomeo, 2011). Ireland has the fourth highest incidence of asthma in the world (GINA, 2008; Masoli et al., 2004). It is estimated that 20% of Irish children have asthma, making it the most common chronic disease in childhood and the most common respiratory illness in Ireland (Asthma Society of Ireland 2008). The latest figures available indicate that 18.9% of 13–15 year olds in Ireland have asthma (Kabir et al., 2011). In light of these statistics it is highly probable that a percentage of students in each class in school have asthma and are required to manage symptoms during the out-of-home period. Asthma is more common in boys than girls during early childhood, with the prevalence equalizing in adolescence (El-Gammal & O’Connor, 2006; Tolomeo, 2011). Asthma is consistently in the top 20 reasons for hospital admission in Ireland, with over 3,000 admission to hospital by children less than 14 years old for asthma annually (Health Service Executive, 2009). The average length of stay in hospital for a child is 1.9 days, with seasonal increase when children return to school after summer holidays and during the winter months. Irish children lose on average 10 days of school per annum due to their asthma (Asthma Society of Ireland, 2008). There are a number of factors that influence the control of asthma symptoms, including compliance issues with treatment and greater exposure to triggers (Edgecombe, Latter, Peters, & Roberts, 2010; Schreier & Chen 2008). It is recognized that adolescents are less likely to seek help in relation to their asthma and conceal their condition as they fear exclusion or marginalization due to lack of understanding by their peers (Bruzzese et al., 2004; Rydstro¨m et al., 2005: Taylor et al., 2008). Becoming aware of this difference during the transition through adolescence can lead to isolation and stigma from peers (Schneider, Wedgewood, Llewellyn, & McConnell, 2006). Poor knowledge and understanding of chronic conditions, such as asthma, has been found to be the greatest barrier to meaningful participation in social activities and events (Woodgate et al., 2012). Adolescents who are poorly controlled because they underestimate their symptoms have poorer psychosocial functioning (Rhee et al., 2008). If young people feel supported by their peers, in addition to family and other social supports, they have been shown to have higher levels of self-efficacy and fewer exacerbations of their asthma symptoms (Knight 2005). In light of this, normalizing

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asthma among young people is important if those who are self-managing their condition are to feel unburdened by it in the school environment. They are more likely to participate fully in school and social activities and manage their symptoms better if they are not seen as being different or as having a reduced capacity. Improving awareness generally about asthma and its symptoms and management may facilitate an openness to allow students to control their symptoms more effectively and efficiently. E-Learning The availability of reliable Healthcare Information (e-Health) is a topic generating much commentary in the literature. There is a global shift towards the development of online health information support for service users in tandem with the increase in use of computers and online interactions. Information and communication technology (ICT) could enable the adolescent to become healthier and have an improved social position (Koivusilta et al., 2007). It is suggested that e-Health allows consumers to be more flexible and consider their health care options (Harrison & Lee, 2006). The convenience, simplicity and privacy of sourcing health information on the internet make it an attractive option for young people according to Franck & Nobel (2007). The internet is an accepted medium for young people accessing information about issues concerning their wellbeing (Paul, 2012; Skopelja et al., 2008; Zhao, 2009). Adolescents, however, have been found to use the internet less than adults regarding health information seeking (Gray & Klein, 2006). Few adolescents use the internet for searching about issues pertaining to their health but use it to source other information (Hughes 2013; Stephens et al., 2013). It should be recognized that young people experience problems as a consequence of having poor health literacy and searching skills (Skopelja et al., 2008). In addition, there are an unlimited number of sites and sources of information available, and adolescents fear they may not all be reliable (Hughes, 2013). Adolescents do not always seek the advice or guidance of adults when consulting the internet for health information or advice (Gray et al., 2005). This could be detrimental to the sourcing of reliable health information for adolescents and inhibit their ability to participate in decision making or make independent decisions on their health to achieve their desired outcome. It is difficult to assess the quality and reliability of much of the on-line health information that is aimed at improving young peoples’ health as there is no indication that the information contained is accurate or evidence based (Brindis et al., 2007; Hughes, 2013; Stephens et al., 2013). Providing them with a source of

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reliable information will allow them access to advice they may otherwise never have consulted. Traditional face to face education can be supported and augmented by using online curricula and information (Ghaddar et al., 2012). There is evidence that e-learning, community based projects developed specifically for children and young people are effective (Kirk et al., 2013). Self-care support programs have been shown to be effective if they foster a sense of community, promote the independence of young people, improve their confidence by developing their knowledge and skill, and involve them meaningfully (Kirk et al., 2012). Multimedia approaches increase retention of information (Frisch et al., 2012). Information seeking is helpful for young people if the information is presented to them in a means that is attractive to them, age appropriate and socially supported (Borzekowski, 2009). Young people with chronic illnesses such as asthma find themselves labelled and marginalized due to a lack of awareness of others about their condition. There are a range of multimedia education programs specifically for young people with asthma aimed at improving their health (Srof, Taboas, & Velsor-Griedrich, 2012). Others are school-based programs designed to assist with symptom recognition and management of symptoms and are delivered to young people who have asthma, many of whom are provided by school-based nurses (Brasler & Lewis, 2006; Bruzzese et al., 2004; Svavarsdottir et al., 2013). Programs that increase peer acceptance of asthma and support have resulted in positive benefits in asthma management for young people with asthma (Yang et al., 2010) Public Health Nurses, who have a wide responsibility in terms of service provision, are the school nurses in the secondary school system in Ireland who support young people with asthma. As they are not fulltime in-house school nurses on a daily basis, much of what is suggested in the literature for improving knowledge and skills among young people with asthma is impossible. In light of this, an on-line asthma e-learning program for transition year students (15–16 years old) was developed by the Asthma Society of Ireland. It is available to all students in order to address the information needs of those who have asthma in addition to their peers. This will potentially enable peers to provide much needed support to their classmates and friends who have asthma (Bruzzese et al., 2004; Hughes, 2013; Taylor et al., 2008). Providing the program as part of transition year facilitates access to health information that is reliable, safe, and evidence based. This program provides students with access to information from a nationally recognized body with expertise in asthma management, research, and education. Providing teenagers with access and informing them about

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credible sources of on-line information reduces the anxiety of assuring quality or reliability of information they access (Ghaddar et al., 2012). Improving general awareness of peers is important in adolescence to reduce the stigmatization of adolescents who have asthma. It will potentially improve the self-management of asthma and associated symptoms by those who have asthma The program consists of a four modules which introduce students to asthma, recognizing and understanding asthma symptoms, asthma management in the home and general environment, and asthma management related to sport and recreation for young people. These topics were selected based on the data from a recent study of young people with asthma who highlighted the aspects they felt were most important in their lives (Hughes, 2013). The modular content consists of PowerPoint Presentations, Website Links, short video clips, PDFs of information booklets and flyers such as the 5 Step Plan and Asthma Coach App which are licensed and produced by the Asthma Society of Ireland. Successful completion of a quiz consisting of 4 multiple choice questions at the end of each module enables the student to progress to the next module. Methods A quasi-experimental approach was used to pilot the educational intervention. The aim of the pilot was to measure the effectiveness of the intervention, and evaluate the user experience regarding the design, interface, and content. The objectives of the program are:     

To improve the understanding of the general adolescent population and those with asthma on asthma and asthma management; To increase the awareness of symptom control and trigger avoidance; To facilitate the normalization of asthma and thereby enable suffers to manage symptoms more effectively and efficiently; To facilitate the perception of inclusion for those with asthma in social and school activities by improving asthma management; To increase the awareness among adolescents of the Asthma Society of Ireland as a reliable source of health related information for those with asthma.

The sample was recruited from a large secondary school in the south of Ireland. Each class group were allocated four 40-minute classroom sessions in the IT lab when they completed the program and the pre-test/post-test evaluations over the course of a 5-day period. Demographic data were gathered on-line on Moodle prior to undertaking the program to ascertain the health status of the participants, their family, and friends. There was no measurement of symptom control from those

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participants who had asthma as this was not the aim of the study. Participants (n ¼ 50) completed the Knowledge of Asthma survey (Kintner, 1997) prior to undertaking the program, which was repeated on completion of the program. The survey is composed of a number of multiple choice questions which score to a total of 20. Data were analyzed for univariate descriptive statistics using Moodle program software. Qualitative feedback was obtained using a questionnaire with a series of open-ended questions where participants were asked to comment on their experience of using the program and how they felt it improved their knowledge. One focus group consisting of a sample of the participants (n ¼ 5) was also conducted when the program was completed. Data from the open-ended questions and the focus group were analyzed by qualitative content analysis. Ethical considerations in accordance with the National Guidelines on Undertaking Research with Children were incorporated into the research process (Department of Children & Youth Affairs, 2012). These guidelines are underpinned on the UN Convention of the Rights of the Child (1989) and by Children’s First (2011) guidelines. Informed voluntary consent was obtained from parents of all transition year students (n ¼ 120) who participated in the study. Students gave informed voluntary assent for participation also. RESULTS The demographic data revealed that 72% of the participants were aged 15, with the remainder aged 16 years old; 58% were female; 22% of participants had asthma; 44% had a family member with asthma; and 86% had a friend with asthma. The mean score on the pre-intervention Knowledge of Asthma survey was 8.59, with the post intervention score 11.5, a 33.8% increase in knowledge scores post intervention. The range in scores was 1.0–15.4 pre-intervention, 7.4–15.4 post intervention. The comments on the evaluation forms completed by the participants evaluated the program positively for relevance of content. It was found to be interesting and informative by participants who had asthma themselves and also by those who had a family member or friend who had asthma. One participant commented: I did not know very much about my asthma before this course . . . I can’t believe I didn’t know this stuff.

The organization and sequence of content was evaluated positively as the depth of knowledge increased from module to module. The PowerPoint presentations were very favorably evaluated. Having to do a

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short quiz to move from one module to another was challenging but worthwhile in that it focused the participants in their learning. Evaluation of the visual presentation was positive, although a small number of participants commented that the interface could be improved by the addition of more graphics. The interactive nature of the program appealed to participants in that the presentations, a number of the PDFs and the majority of the film-clips were short. Some comments indicated that one clip was too long and it should be removed whereas others enjoyed it. The comments included, ‘‘Long videos of more than 3 minutes plus get boring.’’ The most positive aspect of the program was commented on as being the ability to assist in the event of a friend or family member having an asthma attack. One participant who has asthma commented that . . . after this program I feel like my asthma will never stop me doing anything, I learned loads as it was relevant to teenagers.

A focus group was held 2 weeks following completion of the program. Three of the participants had asthma and all spoke positively about their learning. One student had shown the PowerPoint presentations to her mother and siblings as they all had asthma too. Students felt they learned more about their asthma in the program than in medical consultations they attended previously as the information seemed more focused on them. The participants stated that they understood their asthma, how their medications worked, and the importance of avoiding triggers better following the program. They were surprised at what they learned as they didn’t know there was more to know about asthma and its management than they had previously considered. They reported a change in their behavior regarding their inhaler use as they understood the need for the preventer more clearly and as a result use their reliever less now than before the program. They were all actively involved in sports so understanding triggers and taking medications prior to exercise was new knowledge for them and had been effective since completion of the program. None of the participants had an asthma plan prior to undertaking the program. Following its completion, however, two of the participants had made appointments to visit their General Practitioner to be assessed for a personal plan. All participants learned about the Asthma Society website for the first time and would recommend and use it as a resource for credible information. The two non-asthmatic participants felt they could help their friend more now, especially in relation to their medications and what to do in the event of an asthma attack. They didn’t know how serious it could be so it was ‘‘a wake-up call’’ for them.

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DISCUSSION The results of the pilot show that the asthma e-learning program is effective from an educational perspective in addition to being user friendly to the target audience. Participants navigated the program without difficulty and the self-paced nature of transition through the program was effective. The variety of content within each module ensured that participants remained active during the on-line experience and facilitated a positive learning experience. The style and variety of content in an educational program is important to consider during its development and evaluation, as retention of information is affected by presentation of content (Frisch et al., 2012). Use of plain language is important in increasing the use and accessibility of the tool by the intended audience (Nichol et al., 2012). This is an important feature of the program as utilization of on-line health information is a required, and has only recently come to the fore (Lintonen et al., 2008). Ensuring the development of the program is reaching the optimum level of appeal to its audience will increase the use of the program (Schneider et al., 2012). Improvements to the interface, as suggested by the participants in the pilot, and minor modifications to some of the modular content are currently being undertaken prior to the national roll-out of the program in September 2014. Teenagers who had asthma found the e-learning program to be relevant to them. They became more aware of how asthma management can impact their quality of life and that they could assume better control of their asthma if they followed the advice given. The program has also been shown to be effective in improving their management of the condition, especially in the area of medication use and involvement in exercise and other recreational activity. By improving their knowledge of asthma and management of symptoms, attitudes could change towards asthma and improve adherence. Poor adherence has been linked to negative attitudes towards asthma, whereby it was not a priority and the activities associated with it were easily forgotten. How young people perceive their asthma affects their lives and influences their trigger-avoidance behaviors and their compliance with medication. Developing and expanding their knowledge about asthma and increasing their skills in self-care, in addition to social support, are associated with better control outcomes (Altay & C ¸ avu¸sog˘lu, 2013; Knight, 2005) Increasing the awareness of asthma among teenagers who did not have asthma was shown to influence their confidence in assisting their peers or family members who experience asthma symptoms. Peers are influential in affecting compliance among young people with asthma, as lack of confidence to disclose presence of symptoms leads to

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embarrassment, sadness, and low self-efficacy, which were found to impact control (Pai & Ostendorf, 2011). Peer support has been shown to be influential in self-management of asthma by young people (Yang et al., 2010) with a decrease in control if peer support wanes during adolescence. Peer acceptance was seen as influential in explaining a healthy lifestyle for asthma management and independence. Young people who are supported by a range of influences have better control of symptoms. Support from parents, peers, teachers, and healthcare providers on a consistent basis decreases the feelings of embarrassment and isolation among young people with asthma (Knight, 2005). Providing teenagers with information on the Asthma Society and how to access further information on their website is also a positive outcome of the program. This may assist in addressing their concerns about the reliability of on-line health information. DECLARATION OF INTEREST The authors report no declarations of interest. REFERENCES Altay, N., & C ¸ avu¸sog˘lu, H. (2013). Using Orem’s self-care model for asthmatic adolescents. Journal for Specialists in Pediatric Nursing, 18, 233–242. Asthma Society of Ireland. (2008). Helping Asthma in Real People (HARP). In Preliminary Results. Borzekowski, D. L. G. (2009). Considering children and health literacy: A theoretical approach. Pediatrics, 124, S282–S288. Brasler, M. & Lewis, M. (2006). Teens: Taking control of asthma. Journal of School Health, 76, 269–272. Brindis, C. D., Hair, E. C., Cochran, S., Cleveland, K., Valderrama, L. T., & Park, M. J. (2007). Increasing access to program information: A strategy for improving adolescent health. Maternal & Child Health Journal, 11, 27–35. Bruzzese, J. M., Bonner, S., Vincent, E. J., Sheares, B. J., Mellins, R. B., Levison, M. J., Wiesemann, S., Du, Y., Zimmerman, B. J., & Evans, D. (2004). Asthma education: The adolescent experience. Patient Education and Counseling, 55, 396–406. Department of Children & Youth Affairs. (2012). Guidance for developing ethical research projects involving children. Government Publications, Dublin. Edgecombe, K., Latter, S., Peters, S. & Roberts, G. (2010). Health experiences of adolescents with uncontrolled severe asthma. Archives of Disease in Childhood, 95, 985–991. El-Gammal, A. & O’Connor, T. (2006). Asthma—achieving optimal control. The Irish Journal of Clinical Medicine, 36(9). Franck, L. S. & Noble, G. (2007). Here’s an idea: ask the users! Young people’s views on navigation, design and content of a health information website. Journal of Child Health Care, 11, 287.

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Frisch, A. L., Camerini, L. & Schulz, P. J. (2012). The impact of presentation style on the retention of online health information: A randomized-controlled experiment. Health Communication, 28, 286–293. Ghaddar, S. F., Valerio, M. A., Garcia, C. M. & Hansen, L. (2012). Adolescent health literacy: The importance of credible sources for online health information. Journal of School Health, 82, 28–36. Global Initiative for Asthma (GINA). (2008). Global Strategy for Asthma Management and Prevention. Available from: http://www.ginasthma.org/. Gray, N. J. & Klein, J. D. (2006). Adolescents and the Internet: Health and sexuality information. Current Opinion in Obstetrics and Gynecology, 18, 519. Gray, N. J. Klein, J. D., Noyce, P. R., Sesselberg, T. S. & Cantrill, J. A. (2005). Health information-seeking behavior in adolescence: The place of the internet. Social Science & Medicine, 60, 1467–1478. Harrison, J. P., & Lee, A. (2006). The role of e-health in the changing health care environment. Nursing Economic$, 24, 283–289. Health Service Executive. (2009). HIPE data 2005–2009. (Executive HS ed.). Hughes, M. (2013) Accommodating interruptions: A grounded theory of adolescent asthma. Paper presented at the 14th Healthcare Interdisciplinary Research Conference, Dublin, Ireland. Kabir, Z., Manning, P., Holohan, J., Goodman, P. & Clancy, L. (2011). Prevalence of symptoms of severe asthma and allergies in Irish school children: An ISAAC protocol study, 1995–2007. International Journal of Environmental Research and Public Health, 8, 3192. Kintner, E. (1997). Adolescent process of coming to accept asthma: A phenomenological study. Journal of Asthma, 34, 547–561. Kirk, S., Beatty, S., Callery, P., Gellatly, J., Milnes, L. & Pryjmachuk, S. (2013). The effectiveness of self-care support interventions for children and young people with long-term conditions: A systematic review. Child: Care, Health and Development, 39, 305–324. Kirk, S., Beatty, S., Callery, P., Milnes, L. & Pryjmachuk, S. (2012). Perceptions of effective self-care support for children and young people with long-term conditions. Journal of Clinical Nursing, 21, 1974–1987. Knight, D. (2005). Beliefs and self-care practices of adolescents with asthma. Issues in Comprehensive Pediatric Nursing, 28, 71–81. Koivusilta, L. K., Lintonen, T. P. & Rimpel, A. H. (2007). Orientations in adolescent use of information and communication technology: A digital divide by sociodemographic background, educational career, and health. Scandinavian Journal of Public Health, 35, 95–103. Lenney, W. (2008). Asthma in children. Medicine, 36, 196–200. Lintonen, T. P., Konu, A. I. & Seedhouse, D. (2008). Information technology in health promotion. Health Education Research, 23, 560–566. Masoli, M., Fabian, D., Holt, S. & Beasley, R. (2004). The global burden of asthma: Executive summary of the GINA Dissemination Committee Report. Allergy, 59, 469–478. Nichol, H., McIntosh, B., Woo, S. & Amed, S. (2012). Evaluation of the usefulness and accessibility of a provincial educational resource for pediatric type 1 diabetes: A guide

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for families: Diabetes care for children and teens. Canadian Journal of Diabetes, 36, 263–268. Pai, A. L. H. & Ostendorf, H. M. (2011). Treatment adherence in adolescents and young adults affected by chronic illness during the health care transition from pediatric to adult health care: A literature review. Children’s Health Care, 40, 16–33. Paul, L. (2012). Improving health in adolescents with the use of information technologies. Online Journal of Nursing Informatics, 16, 25–31. Rhee, H., Belyea, M. J. & Elward, K. S. (2008). Patterns of asthma control perception in adolescents: Associations with psychosocial functioning. Journal of Asthma, 45, 600–606. Rydstro¨m, I., Hartman, J. & Segesten, K. (2005). Not letting the disease get the upper hand over life: Strategies of teens with asthma. Scandinavian Journal of Caring Sciences, 19, 388–395. Schneider, F., van Osch, L. & de Vries, H. (2012). Identifying Factors for optimal development of health-related websites: A Delphi study among experts and potential future users. Journal of Medical Internet Research, 14, e18. Schneider, J., Wedgewood, N., Llewellyn, G. & McConnell, D. (2006). Families challenged by and accommodating to the adolescent years. Journal of Intellectual Disability Research, 50, 926–936. Schreier, H. M. C. & Chen, E. (2008). Prospective associations between coping and health among youth with asthma. Journal of Consulting and Clinical Psychology, 76, 790–798. Skopelja, E. N., Whipple, E. C. & Richwine, P. (2008). Reaching and teaching teens: Adolescent health literacy and the internet. Journal of Consumer Health on the Internet, 12, 105–118. Srof, B., Taboas, P. & Velsor-Friedrich, B. (2012). Adolescent asthma education programs for teens: Review and summary. Journal of Pediatric Health Care, 26, 418–426. Stephens, R., Ryan, F. S. & Cunningham, S. J. (2013). Information-seeking behavior of adolescent orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics, 143, 303–309. Svavarsdottir, E. K., Garwick, A. W., Anderson, L. S., Looman, W. S., Seppelt, A. & Orlygsdottir, B. (2013). The international school nurse asthma project: Barriers related to asthma management in schools. Journal of Advanced Nursing, 69, 1161–1171. Taylor, R. M., Gibson, F. & Franck, L. S. (2008). The experience of living with a chronic illness during adolescence: a critical review of the literature. Journal of Clinical Nursing, 17, 3083–3091. Tolomeo, C. (2011). Nursing care in pediatric respiratory disease. Hoboken, NJ: John Wiley & Sons. Woodgate, R. L., Edwards, M. & Ripat, J. (2012). How families of children with complex care needs participate in everyday life. Social Science & Medicine, 75, 1912–1920. Yang, T. O., Sylva, K. & Lunt, I. (2010). Parent support, peer support, and peer acceptance in healthy lifestyle for asthma management among early adolescents. Journal for Specialists in Pediatric Nursing, 15, 272–281. Zhao, S. (2009). Parental education and children’s online health information seeking: Beyond the digital divide debate. Social Science & Medicine, 69, 1501–1505.

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Evaluation of a pilot national online asthma e-learning program for secondary school students.

Ireland has the fourth highest incidence of asthma in the world, with Irish children losing on average 10 days of school per annum due to their asthma...
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