528070 research-article2014
WJNXXX10.1177/0193945914528070Western Journal of Nursing ResearchKawafha and Tawalbeh
Intervention Studies
The Effect of Asthma Education Program on Knowledge of School Teachers: A Randomized Controlled Trial
Western Journal of Nursing Research 2015, Vol. 37(4) 425–440 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914528070 wjn.sagepub.com
Mariam M. Kawafha1 and Loai Issa Tawalbeh2
Abstract The purpose of this study was to examine the effect of an asthma education program on schoolteachers’ knowledge. Pre-test–post-test experimental randomized controlled design was used. A multistage-cluster sampling technique was used to randomly select governorate, primary schools, and schoolteachers. Schoolteachers were randomly assigned either to the experimental group (n = 36) and attended three educational sessions or to the control group (n = 38) who did not receive any intervention. Knowledge about asthma was measured using the Asthma General Knowledge Questionnaire for Adults (AGKQA). The results indicated that teachers in the experimental group showed significantly (p < .001) higher knowledge of asthma in the first post-test and the second post-test compared with those in the control group. Implementing asthma education enhanced schoolteachers’ knowledge of asthma. The asthma education program should target schoolteachers to improve knowledge about asthma. Keywords asthma education, knowledge of asthma, schoolteachers
1Irbid
National University, Irbid, Jordan University, Al-Mafraq, Jordan
2Al-AlBayt
Corresponding Author: Mariam M. Kawafha, Assistant Professor, Faculty of Nursing, Irbid National University, Irbid 22110, Jordan. Email: [email protected]
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Asthma is a widespread health problem mainly in developed countries and is considered a severe form of allergy that occurs in all life phases (WHO, 2011). The numbers of Jordanian students with asthma is increasing. The prevalence of asthma among Jordanians rose from 4.3% in 1996 (AbuEkteish, Alwash, Hassan, & Daoud, 1996) to 9.4% in 2009 (AbuEkteish, Otoom, & Shehabi, 2009). Asthma affects school achievement of children (Bruzzese et al., 2010; Diette et al., 2000). Students with uncontrolled asthma are more likely to have missed more school days and have poorer academic performance than healthy students (Milton, Whitehead, Holland, & Hamilton, 2004; Moonie, Sterling, Figgs, & Castro, 2006). Despite that, asthma can be controlled with proper diagnosis, education, and management (Choi & Cho Chung, 2010). The school nurse plays an essential role in providing a comprehensive health care to primary school children. Unfortunately, the role of school nurses in Jordan is underestimated. The role of school nurses in Jordan is limited to mandatory screening conducted twice a year. This mandatory screening includes measuring weight and height, and dental, vision, and hearing examination. In light of the absence of the role of school nurse in managing students with asthma at school, it is necessary to assess the level of knowledge about asthma among schoolteachers in the north of Jordan. Jordan has started efforts to improve the status of schoolchildren’s health. To combat asthma in Jordan, the Ministry of Health and the Ministry of Education need to take a leading role in gathering the required information about asthma epidemic. Although general education programs improve health-related knowledge that promotes individual ability to understand basic health information (Osborne, Elsworth, & Whitfield, 2007), there is a scarcity in the studies that clarify the effect of educational programs on knowledge of schoolteachers in Jordan as well as other countries. Therefore, it is essential to examine the effect of an asthma educational program on the level of knowledge among schoolteachers in North Jordan.
Teachers’ Knowledge and Asthmatic Children’s Health The goal of asthma management is to help control asthma symptoms (De Blic, Boucot, Pribil, Huas, & Godard, 2007). Several studies showed that asthma educational programs improved patient knowledge and control of asthma (Barnes, 2005; Brown & Levin, 2005; Choi & Cho Chung, 2010; Janson, McGrath, Covington, Cheng, & Boushey, 2009; Urek et al., 2005). The positive outcome for asthma education can be manifested by reducing critical care visits, hospitalizations, improving activities, health status,
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quality of life, and perceived control of asthma (Cicutto, 2003; Wolf, Guevara, Grum, Clark, & Cates, 2003). Tzeng, Chiang, Hsueh, Ma, and Fu (2009) used a quasi-experimental, non-equivalent control group design to assess the effectiveness of a nurse-led patient-centered asthma education program. They found that children with moderate or severe asthma in the experimental group had fewer signs and symptoms of asthma and better lung function than children in the control group. Education about asthma helps improve knowledge, attitudes, beliefs, and skills. Providing adequate knowledge is an important factor to improve one’s health. However, it is found that knowledge alone is not adequate to enhance healthy lifestyle (Falvo, 2004). However, it is crucial that schoolteachers have the ability to identify and manage asthma cases properly. Therefore, they are required to gain a fundamental understanding about asthma symptoms to be able to respond to life-threatening situations concerning schoolchildren with asthma (Ones, Akcay, Tamay, Guler, & Dogru, 2006; Sukumaran, 2011). School environment is concerned in asthma exacerbations, and schoolteachers, responsible for providing a healthy school environment, should be a target for education (Sukumaran, 2011). However, schoolteachers generally received little or no education about asthma (Abdel Gawwad & El-Herishi, 2007). Schoolteachers should have adequate knowledge about asthma. Despite that, many studies have shown that teachers have low knowledge of asthma and its management (Blaisdell, 2002; Lucas, Anderson, & Hill, 2012; Ones et al., 2006). The results indicated that educating teachers about asthma is important and affects students’ health. Improved teachers’ knowledge can help them be aware of common triggers in asthmatic children, which enable them to take a specific action (Ones et al., 2006; Sukumaran, 2011). Furthermore, Al-Motlaq and Sellick (2013) found that improving primary school teachers’ asthma knowledge helps improve confidence in dealing with children with asthma. Schoolteachers have the responsibility to care for all schoolchildren. This responsibility of care is most important for children with asthma. Al-Motlaq and Sellick (2013) concluded that schoolteachers are required to make decisions on suitable physical exercises, organize regular medications, and monitor for signs of breathing difficulties and other symptoms to be able to manage them easily. In Jordan, few studies were conducted to determine asthma knowledge. These studies focused on adolescence. Al-Sheyab, Gallagher, Roydhouse, Crisp, and Shah (2012) assessed the feasibility of Australian asthma educational program to adolescents’ Jordanian context. No studies were conducted about asthma knowledge among schoolteachers in Jordan. In light of the absence of effective school nurse roles, and the presence of few studies that
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investigate the effect of asthma education on the knowledge of schoolteachers, it is important to examine the effect of an asthma education program on knowledge and knowledge retention among schoolteachers in the north of Jordan.
Purpose The purpose of this study was to examine the effect of an asthma education program on knowledge and knowledge retention among schoolteachers in the north of Jordan.
Method Design Pre-test–post-test experimental randomized controlled design was used to examine the effect of an asthma education program on schoolteachers’ knowledge and knowledge retention in the north of Jordan.
Population and Study Sample The target population of this study was the Jordanian teachers of all public primary school children in the north of Jordan. The accessible population was all Jordanian teachers of random selection of three governorates of public primary school children. A cluster random sample was obtained from the entire public primary schools. The population consisted of public primary school teachers aged above 18 who agreed to participate in the study. The schoolchildren were females with the age range from 6 to 12 years. Exclusion criteria were teachers with asthma, teachers who attended an educational program about asthma in the past and all non-Jordanian nationality teachers with attention to allow them to participate and excluded them later for ethical consideration. Sample size was calculated using G* power software (Faul, Erdfelder, Lang, & Buchner, 2007). A medium effect size is required for the purpose of this study, which was 0.5. The sample size was determined according to the power level, which was 0.80 for independent t test and the use of conventional α= 0.05 two-tailed criterion of the significance. Based on that, 68 teachers were required. To overcome the problem with the attrition rate, an additional 12 teachers were added to have 80 in the final sample size. Eighty teachers were randomly allocated either to the experimental or the control group to have 40 in each.
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Setting This interventional study was conducted at public primary schools in the north of Jordan. Three areas were selected: Irbid, Jarash, and Ajlon governorates. These areas were selected because they have the second largest population density in Jordan after Amman. In addition, they consisted of urban and rural areas with different socio-economic status. The enrollment in the north of Jordan for school-age children achieved more than 99% (Jordan Department of Statistics [JDOS], 2007). The total number of schools is 1,041, 197, and 168 for Irbid, Jarash, and Ajlon governorates, respectively. The increase of these schools’ enrollment is about 0.06% annually (JDOS, 2007).
Intervention Asthma Education Program The asthma education program was presented by the primary researcher (interventionist) for the schoolteachers (recipient) in the experimental group, which was expected to result in better asthma management for schoolchildren (target). Providing adequate knowledge about asthma for schoolteachers may help them become aware of common triggers in asthmatic children and manage asthma cases, which enables them to provide appropriate health care. Seven topics of an asthma education program were selected from the textbook of Smeltzer, Bare, Hinkle, and Cheever (2011). The content of the program covered the following topics: general information about asthma, etiology, pathophysiology, severity, signs and symptoms, asthma attacks, triggers, management of asthma, and asthma and sport. Management of asthma includes how to use inhalers to treat symptoms. The intervention consisted of three sessions conducted in the conference room in the selected schools. All topics of the education program were covered. Each session lasted approximately 1 hr, and there were group sessions in which the education-based intervention was delivered to all the participants in the experimental group. The primary researcher used lecture discussion and PowerPoint presentation. During lecture discussion, the researcher asked the participants to repeat key points about asthma. Following the end of all sessions, the participants were provided with compact disks and pamphlets that summarized the content of the program. The asthma educational program was reviewed by two respiratory specialists to assess the content and the adequacy of the information provided for the participants in the study. The intervention was appropriate for all teachers in the selected schools, and no adjustment was made for the intervention to be tailored to the individual teacher. No specific preparation was carried out before the intervention; only the primary researcher tried to choose the appropriate time for the
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teachers to conduct the intervention. No compensation was given to the participants. The primary researcher who conducted the intervention has a philosophy degree in nursing and received adequate education and training about asthma from two respiratory specialists.
Measures A structured questionnaire of two sections was utilized for collecting the data to achieve the purposes of this study. Section 1 was the demographic that was developed by the primary researcher depending on the literature review. This section consisted of a checklist and fill-in-the-blank type questions concerning all the variables addressed by the study such as age, educational level, income, children with asthma in the class, and presence of one family member with asthma. Section 2 was the Asthma General Knowledge Questionnaire for Adults (AGKQA), which was developed by Allen and Jones (1998). The instrument is based on asthma knowledge and management, which measure teachers’ ability to manage schoolchildren with asthma. The AGKQA consisted of a 31-item general asthma knowledge questionnaire. The questionnaire included items that were about asthma etiology, pathophysiology, medications, assessment of severity, and symptom management including triggers and exercise. Teachers were asked to respond using True/False/Not Sure to each item statement of knowledge. The (Not Sure) response was included to discourage guessing and was scored as incorrect. An overall knowledge score was computed by totaling the number of correct responses, with a possible range from 0 to 31, and higher scores referring to greater knowledge about asthma. Permission to use the knowledge instrument was obtained from the tool’s developer. The translated version and the original instrument were reviewed by a committee comprising four experts: two of them are experts in the topic and two are experts competent in both Arabic and English to consider the equivalence of terms, clarity, and cultural adaptation. Modifications were made according to committee’s recommendations. There was no major discrepancy between the original and the translated version. Face validity was performed by four PhD holders who indicated that the tool was valid. In addition, content validity was conducted by another two PhD holders. The content validity index was 0.89, and the results revealed that the tool was valid. Items were tested for internal consistency in the current study, and the result revealed that Cronbach’s alpha reliability was .85. Pilot testing of the instrument among 30 teachers who possessed the same characteristics as the individuals who composed the main sample was
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conducted. The results showed that the instrument was clear, there was no ambiguity in the items, and no problems occurred during the administration, coding, scoring, and analysis of the items. The estimated time to complete the questionnaire was 20 min.
Data Collection Procedures A list of public primary schools in the north of Jordan including children aged from 6 to 12 years was obtained from the Ministry of Education utilizing a cluster random sampling method. The cluster sampling was usually conducted in what is called “multistage sampling.” This means that the selection of the sample was carried out using multistage-cluster sampling techniques. In this study, the researchers used four-stage cluster sampling. The first stage cluster was the selection of three governorates out of four: Irbid, Jarash, and Ajlon were drawn to be included in the study. In the second stage, all public schools in each governorate were written on slips of paper, drawn randomly, and listed in order of random drawing. The researcher went to the school according to the order of random drawing to collect the data. The third stage-cluster sampling was performed using a stratified method; all teachers in that school were listed on slips of paper and drawn according to their teaching of first, second, third, fourth, fifth, and sixth elementary classes. The fourth stage-cluster sampling was conducted by listing all teachers’ names presented in those levels on the day of data collection and written on slips of paper and were then assigned to the experimental and control groups. The primary researcher generated the random allocation sequence, enrolled participants, and assigned participants to intervention. Eighty teachers were randomly selected and were then randomly allocated either to the experimental or the control group to have 40 in each. A pre-test about asthma was administered for both groups (N = 80) on the first day in the conference rooms in the selected schools. Four teachers in the experimental group did not attend the education program on the second day. The teachers in the experimental group (n = 36) received a PowerPoint presentation followed by lecture discussion. The PowerPoint presentation and the discussion lasted approximately 1 hr. At this time, the control group (n = 38) did not receive any interventions. On the seventh day and 3 months after the intervention, the post-test about asthma was performed for both groups. The teachers who completed the pre-test did not know their group assignments, but the researcher knew the groups in which they were included. Teachers were made aware of their groups prior to the beginning of the education implementation. A code number was given to each teacher in both groups to mask their participation and keep their data confidential.
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The questionnaire used to collect data relevant to demographics and other questions related to asthma was kept in an envelope with detailed instructions and distributed to teachers who were asked to retain the completed questionnaires on the same day. The primary researcher was responsible for collecting the completed questionnaires from teachers and applying the asthma education program.
Ethical Considerations The study was approved by the research ethical committees at the Ministry of Education. Written informed consent was obtained from all participants who agreed to participate in the study. A letter was sent to the Ministry of Education describing the nature and significance of the study, and requesting permission to have access to teachers. Official administrators and staff members in the primary schools were informed about the study purposes, and permission was requested to conduct the study using the appropriate channels of communication. In addition, a letter explaining the study and the purpose was sent to the teachers requesting them to complete the questionnaire. Teachers who were not willing to participate were asked to return it unfilled. Furthermore, the participants were instructed that their completion of the questionnaire was considered a written consent for their participation. The confidentiality and anonymity of the information were assured. Moreover, the instrument was coded by numbers to maintain confidentiality of the data. The subjects who were assigned to the control group were informed that the asthma education program might be given to them if they wanted after the data collection was completed. The participants were informed that they have the right to withdraw from the study at any time. All data were kept in a locked cabinet. After the study was completed, all questionnaires were disposed off. The participants were not exposed to any physical, psychosocial, or economical harm, as the data collection primarily depended on a descriptive, non-invasive questionnaire.
Data Analysis SPSS Version 17 was used to analyze the data. Descriptive statistics including mean, standard deviation, and percent were used to describe the sample characteristics. Independent t test was used to examine whether there were any statistically significant differences between the experimental and the control group at the pre-test level to assess the level of homogeneity between the study participants in terms of age, income, and pre-test knowledge about asthma. Mann–Whitney U test was conducted to examine whether there were any statistically significant differences between the experimental and the Downloaded from wjn.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
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control groups in terms of educational level. Chi square was conducted to examine whether there were any statistically significant differences between the two groups in terms of marital status Independent t test was used to examine whether there were any statistically significant differences in the mean asthma knowledge scores between the experimental and the control groups in the first and second post-test. Furthermore, paired t test was conducted to examine whether there were any statistically significant differences between the mean of the knowledge before, and at 1 week and 3 months after the application of the educational intervention for the participants in the experimental group.
Results Eighty female teachers were randomly assigned either to the control or experimental group, so there were 40 teachers in each group at the baseline. The mean age for the participants was 35.50 (SD = 8.33), and the mean monthly income for the whole sample was 680 Jordan Dinar (SD = 115.12). None of the participants received an educational session or workshop about asthma in the past. All study participants were Muslims and did not have asthma or family members with asthma. No children with asthma were in the classes of teachers in the selected sample. A majority (68%) of the participants reported a baccalaureate education, 12% have diplomas, 10% have secondary education, and 10% have primary education. Most of the participants were married (80%), and 20% were single. Of the 80 teachers at the baseline phase, 74 (92.5%) completed the study. Of those, 38 (51%) were in the control group, and 36 (49%) were in the experimental group. The schoolteachers in the experimental group were all females with a mean age of 35 years. An independent sample t test showed no statistically significant differences between the groups in terms of age, monthly income, and pre-test knowledge, showing that the two groups were homogeneous. In addition, Mann–Whitney U test indicated that there were no significant differences between the experimental and the control groups in terms of educational level (U value = 75, z = −5.5, p = .12). Chi square indicated that there were no significant differences between the two groups in terms of marital status (χ2 = 2.60, p = .18), showing that the two groups were homogeneous (Table 1). An independent t test showed that there was a statistically significant difference, t(72) = −6.08, p < .001, between the experimental group (M = 27.55, SD = 5.10) and the control group (M = 19.44, SD = 7.24) regarding knowledge of asthma. In addition, an independent t test showed that there was a statistically significant difference, t(72) = −4.26, p < .001, between the experimental group (M = 25.93, SD = 3.10) and the control group (M = 18.63, SD = 7.09) regarding knowledge of asthma in the retention phase. The paired Downloaded from wjn.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
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Table 1. Sample Characteristics at Baseline and the Pre-Test of Knowledge for the Experimental and the Control Groups (N = 80).
Experimental group (n = 40)
Control group (n = 40)
M (SD)
M (SD)
Variable
95% CI p value Lower Upper
Age (years) 36.00 (0.88) 34.00 (0.89) Monthly income 685.00 (115.31) 675.00 (115.56) (Jordanian Dinar) Pre-test for knowledge 19.40 (1.78) 19.32 (1.86)
.18 .13
−2.24, 5.50 −1.03, −.213
.91
−1.25, 1.40
Note. CI = confidence interval. *p ≤ .05 level (two-tailed).
Table 2. Knowledge of Asthma and Knowledge Retention Mean Differences in the Post-Test Between the Experimental (n = 36) and Control Groups (n = 38).
Experimental group (n = 36)
Control group (n = 38)
M (SD)
M (SD)
t(72)
p value
Lower,
Upper
19.44 (7.24) 18.73 (7.09)
−6.08 −4.26
.001 .001
−6.21, −5.55,
0.34 0.22
Variable Knowledge Knowledge retention
27.55 (5.10) 25.93 (3.10)
95% CI
Note. CI = confidence interval. *p ≤ .001 level (two-tailed).
t test indicated that there were statistically significant differences between the mean knowledge before (M = 19.40, SD = 1.78); at 1 week (M = 27.55, SD = 5.10, p < .001); t(35) = 22; and at 3 months (M = 25.93, SD = 3.10, p < .001), t(35) = 21, after the application of educational intervention (Table 2). In addition, the result indicated an improvement in the mean score for each individual item after the program application. This indicated an improvement in all fields of asthma knowledge including etiology, pathophysiology, medication assessment of severity, and symptoms management.
Discussion The purpose of this study was to examine the effect of an asthma education program on schoolteachers’ knowledge and knowledge retention in the north of Jordan. The results indicated that schoolteachers’ knowledge about asthma
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was limited. This finding is consistent with the result of several studies that revealed that asthma knowledge among participants was limited (Abdel Gawwad & El-Herishi, 2007; Choi & Cho Chung, 2010; Janson et al., 2009; Templeton & Coates, 2004). Schoolteachers should have adequate knowledge of asthma to provide a safe environment for the child with asthma. Schoolteachers’ knowledge and understanding of asthma can have a major effect on the health status of students with asthma (Ones et al., 2006). Deficient knowledge among Jordanian schoolteachers in this study can be justified due to lack of asthma education and training, the workload that the schoolteachers have, and limited educational resources about asthma at schools. In a study, Abdel Gawwad and El-Herishi (2007) examined the effect of educational pamphlets on primary school teachers’ knowledge about asthma. Only 5.7% received education about asthma. Results indicated a low knowledge about asthma, which can be related to lack of education and training about asthma. Templeton and Coates (2004) and Tawalbeh and Ahmad (2013) found that adequate educational resources and programs would improve knowledge among patients with different health problems. In addition, in Jordan, there is no school policy to raise schoolteachers’ knowledge about asthma and asthma management. Schoolteachers have a vital role in managing asthma for schoolchildren by supporting the development of an asthma management plan. This plan needs school policies on how to use inhalers, and what should schoolteachers act when a student has an asthma attack (Asthma and Allergy Foundation of America, 2013). Schoolteachers have a major role in providing asthma management in the help of the family, the child, and health care professionals (Al-Dawood, 2002). Moreover, the workload that the schoolteachers have and the limited support of asthma education from educational authority may contribute to low level of knowledge about asthma. The results of the current study indicated that the knowledge of schoolteachers in the experimental group improved significantly in the first posttest and in the retention phase compared with those in the control group. This result is consistent with the findings of Templeton & Coates (2004), which demonstrated that educational sessions had a significant effect on knowledge, quality of life, and satisfaction with care. In addition, Abdel Gawwad and El-Herishi (2007) found that asthma educational programs had a significant impact on the mean total score of the staff asthma related-attitudes, which became more favorable toward school asthma management and education after intervention. Furthermore, Janson et al. (2009) found that asthma management educational sessions enhanced the symptoms of patients with moderate to severe asthma. In addition, the results of the present study indicated that knowledge retention was significantly higher in the experimental group compared with those in the control group. Likewise, in Demüralay’s (2004) Downloaded from wjn.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
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study, the mean change in the knowledge retention score was still significantly high at 2 months after the interventions. The significant effect of asthma education on knowledge in the experimental group in this study may be attributed to many factors. The use of multi-teaching materials such as data show, educational video, and pamphlet may contribute to the success of the educational program. Abdel Gawwad and El-Herishi (2007) add evidence on the effectiveness of pamphlets as an educational material for improving schoolteachers’ knowledge about asthma. The teaching methods and interaction between the researcher and teachers used in this study would improve teachers’ knowledge of asthma. The previous features used in the application of the educational program applications have a significant impact on the ability of individuals to learn (Fletcher, 1987; Mullen et al., 1997). In addition, this finding is supported by the study of Hemsley-Brown (2004), which showed that financial, human, and physical resources are essential factors that may help improve knowledge among participants. As well, Williams, Lindsell, Rue, & Blomkalns (2007) found that the educational video intervention enhanced knowledge and knowledge retention among participants. In Jordan, school nurses are not available in schools. Therefore, primary school teachers have the responsibility to take care of children with asthma. For this reason, it is worthwhile that teachers be equipped with the important knowledge regarding asthma etiology, pathophysiology, medications, assessment of severity, and symptom management including trigger minimization and exercise. Based on these results, the authors suggested that stakeholders train primary school teachers as well as school nurses to be well prepared in caring for asthmatic children, through workshops and health education programs. Findings of this study supported that health education programs help schoolteachers gain more knowledge that sequentially may reduce problems occurring to asthmatic children. Thus, it is beneficial to conduct future studies to examine the effect of such an educational program on the schoolteachers’ ability to provide the required health care for children with asthma in schools. In this perspective, school nurses and health professionals should teach teachers how to assess asthmatic children as a basis of care, especially for primary school children. Nurse educators should be aware that schoolteachers need solid education programs to enhance primary school teachers’ knowledge about asthma. This in turn may promote children’s health status. Some limitations should be highlighted in this study, which in turn may limit generalizability of findings to the total population of Jordan. The study sample was restricted to female schoolteachers in the primary schools in the north of Jordan; a broader geographically diverse sample including male and
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female schoolteachers may produce different results. As well, in the current study, the retention of knowledge was examined only at 3 months after the intervention. It is recommended asthma knowledge among schools teachers is better to be examined 3 months after the application of the educational program. Asthma educational intervention significantly improves teachers’ knowledge of asthma. This improvement in knowledge is good retained at 1 week and 3 months, which suggests that teachers may benefit from further educational intervention to help children with asthma. The asthma education program should be implemented to target all schoolteachers in Jordan. Acknowledgment The authors would like to thank the study participants.
Authors’ Note This article has been approved by all authors, and all authors agree to submit the manuscript solely to the Western Journal of Nursing Research. Mariam M. Kawafha and Loai Issa Tawalbeh were involved in this article, including study conception/ design, data collection/analysis, writing up manuscript, critical revisions for important findings, discussion, and intellectual contents. This study is an empirical research consists of an article on original research that has not been previously published in its current format.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Hemsley-Brown, J. (2004). Facilitating research utilization: A cross-sector review of research evidence. International Journal of Public Sector Management, 17, 534-552. Janson, S., McGrath, K., Covington, J., Cheng, S., & Boushey, H. (2009). Individualized asthma self-management improves medication adherence and markers of asthma control. Journal of Allergy and Clinical Immunology, 123, 840-846. Jordan Department of Statistics (JDOS). (2012). Statistical yearbook of Jordan. Retrieved from http://www.dos.gov.jo/dos_home_a/main/yearbook_2012. pdf Lucas, T., Anderson, M., & Hill. P. (2012). What level of knowledge do elementary schoolteachers possess concerning the care of children with asthma? A pilot study. Journal of Pediatric Nursing, 27, 523-527. Milton, B., Whitehead, M., Holland, P., & Hamilton, V. (2004). The social and economic consequences of childhood asthma across the life course: A systematic review. Child Care Health and Development Journal, 30, 711-728. Moonie, S., Sterling, D., Figgs, L., & Castro, M. (2006). Asthma status and severity affects missed school days. Journal of School Health, 76, 18-24. Mullen, P., Simons-Morton, D., Ramirez, G., Frankowski, R., Green, L., & Mains, D. (1997). A meta-analysis of trials evaluating patient education and counseling for three groups of preventative health behaviors. Patient Education and Counseling, 32, 157-173. Ones, U., Akcay, A., Tamay, Z., Guler, N., & Dogru, M. (2006). Asthma knowledge level of primary schoolteachers in Istanbul, Turkey. Asian Pacific Journal of Allergy and Immunology, 24, 9-15. Osborne, R., Elsworth, G., & Whitfield, K. (2007). The Health Education Impact Questionnaire (HEIQ): An outcomes and evaluation measure for patient education and self-management interventions for people with chronic conditions. Patient Education and Counseling, 66, 192-201. Smeltzer, S., Bare, B., Hinkle, J., & Cheever, K. (2011). Brunner and Suddarth’s textbook of medical surgical nursing (12th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Sukumaran, T. (2011). Asthma training module (ATM), asthma by consensus (ABC), and asthma education. Indian Pediatrics, 48, 433-435. Tawalbeh, L., & Ahmad, M. (2013). The effect of cardiac education on knowledge and adherence to healthy lifestyle. Clinical Nursing Research. Advance online publication. doi:10.1177/1054773813486476 Templeton, H., & Coates, V. (2004). Evaluation of an evidence-based education package for men with prostate cancer on hormonal manipulation therapy. Patient Education and Counseling Journal, 55, 55-61. Tzeng, L., Chiang, L., Hsueh, K., Ma, W., & Fu, L. (2009). A preliminary study to evaluate a patient-centered asthma education program on parental control of home environment and asthma signs and symptoms in children with moderate-tosevere asthma. Journal of Clinical Nursing, 19, 1424-1433.
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Urek, Tudoric, N. M., Plavec, D., Urek, R., Koprivc-Milenovic, T., & Stojic, M. (2005). Effect of educational programs on asthma control and quality of life in adult asthma patients. Patient Education and Counseling, 58, 47-54. WHO. (2011). Asthma. Retrieved from http://www.who.int/mediacentre/factsheets/ fs307/en/index.html Williams, A., Lindsell, C., Rue, L., & Blomkalns, A. (2007). Emergency department education improves patient knowledge of coronary artery disease risk factors but not the accuracy of their own risk perception. Preventive Medicine Journal, 44, 520-525. Wolf, F., Guevara, J., Grum, C., Clark, N., & Cates, C. (2003). Educational interventions for asthma in children. Cochrane Database of Systematic Reviews, 1, CD000326.
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WJNXXX10.1177/0193945914528070Western Journal of Nursing ResearchKawafha and Tawalbeh
Intervention Studies
The Effect of Asthma Education Program on Knowledge of School Teachers: A Randomized Controlled Trial
Western Journal of Nursing Research 2015, Vol. 37(4) 425–440 © The Author(s) 2014 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0193945914528070 wjn.sagepub.com
Mariam M. Kawafha1 and Loai Issa Tawalbeh2
Abstract The purpose of this study was to examine the effect of an asthma education program on schoolteachers’ knowledge. Pre-test–post-test experimental randomized controlled design was used. A multistage-cluster sampling technique was used to randomly select governorate, primary schools, and schoolteachers. Schoolteachers were randomly assigned either to the experimental group (n = 36) and attended three educational sessions or to the control group (n = 38) who did not receive any intervention. Knowledge about asthma was measured using the Asthma General Knowledge Questionnaire for Adults (AGKQA). The results indicated that teachers in the experimental group showed significantly (p < .001) higher knowledge of asthma in the first post-test and the second post-test compared with those in the control group. Implementing asthma education enhanced schoolteachers’ knowledge of asthma. The asthma education program should target schoolteachers to improve knowledge about asthma. Keywords asthma education, knowledge of asthma, schoolteachers
1Irbid
National University, Irbid, Jordan University, Al-Mafraq, Jordan
2Al-AlBayt
Corresponding Author: Mariam M. Kawafha, Assistant Professor, Faculty of Nursing, Irbid National University, Irbid 22110, Jordan. Email: [email protected]
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Asthma is a widespread health problem mainly in developed countries and is considered a severe form of allergy that occurs in all life phases (WHO, 2011). The numbers of Jordanian students with asthma is increasing. The prevalence of asthma among Jordanians rose from 4.3% in 1996 (AbuEkteish, Alwash, Hassan, & Daoud, 1996) to 9.4% in 2009 (AbuEkteish, Otoom, & Shehabi, 2009). Asthma affects school achievement of children (Bruzzese et al., 2010; Diette et al., 2000). Students with uncontrolled asthma are more likely to have missed more school days and have poorer academic performance than healthy students (Milton, Whitehead, Holland, & Hamilton, 2004; Moonie, Sterling, Figgs, & Castro, 2006). Despite that, asthma can be controlled with proper diagnosis, education, and management (Choi & Cho Chung, 2010). The school nurse plays an essential role in providing a comprehensive health care to primary school children. Unfortunately, the role of school nurses in Jordan is underestimated. The role of school nurses in Jordan is limited to mandatory screening conducted twice a year. This mandatory screening includes measuring weight and height, and dental, vision, and hearing examination. In light of the absence of the role of school nurse in managing students with asthma at school, it is necessary to assess the level of knowledge about asthma among schoolteachers in the north of Jordan. Jordan has started efforts to improve the status of schoolchildren’s health. To combat asthma in Jordan, the Ministry of Health and the Ministry of Education need to take a leading role in gathering the required information about asthma epidemic. Although general education programs improve health-related knowledge that promotes individual ability to understand basic health information (Osborne, Elsworth, & Whitfield, 2007), there is a scarcity in the studies that clarify the effect of educational programs on knowledge of schoolteachers in Jordan as well as other countries. Therefore, it is essential to examine the effect of an asthma educational program on the level of knowledge among schoolteachers in North Jordan.
Teachers’ Knowledge and Asthmatic Children’s Health The goal of asthma management is to help control asthma symptoms (De Blic, Boucot, Pribil, Huas, & Godard, 2007). Several studies showed that asthma educational programs improved patient knowledge and control of asthma (Barnes, 2005; Brown & Levin, 2005; Choi & Cho Chung, 2010; Janson, McGrath, Covington, Cheng, & Boushey, 2009; Urek et al., 2005). The positive outcome for asthma education can be manifested by reducing critical care visits, hospitalizations, improving activities, health status,
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quality of life, and perceived control of asthma (Cicutto, 2003; Wolf, Guevara, Grum, Clark, & Cates, 2003). Tzeng, Chiang, Hsueh, Ma, and Fu (2009) used a quasi-experimental, non-equivalent control group design to assess the effectiveness of a nurse-led patient-centered asthma education program. They found that children with moderate or severe asthma in the experimental group had fewer signs and symptoms of asthma and better lung function than children in the control group. Education about asthma helps improve knowledge, attitudes, beliefs, and skills. Providing adequate knowledge is an important factor to improve one’s health. However, it is found that knowledge alone is not adequate to enhance healthy lifestyle (Falvo, 2004). However, it is crucial that schoolteachers have the ability to identify and manage asthma cases properly. Therefore, they are required to gain a fundamental understanding about asthma symptoms to be able to respond to life-threatening situations concerning schoolchildren with asthma (Ones, Akcay, Tamay, Guler, & Dogru, 2006; Sukumaran, 2011). School environment is concerned in asthma exacerbations, and schoolteachers, responsible for providing a healthy school environment, should be a target for education (Sukumaran, 2011). However, schoolteachers generally received little or no education about asthma (Abdel Gawwad & El-Herishi, 2007). Schoolteachers should have adequate knowledge about asthma. Despite that, many studies have shown that teachers have low knowledge of asthma and its management (Blaisdell, 2002; Lucas, Anderson, & Hill, 2012; Ones et al., 2006). The results indicated that educating teachers about asthma is important and affects students’ health. Improved teachers’ knowledge can help them be aware of common triggers in asthmatic children, which enable them to take a specific action (Ones et al., 2006; Sukumaran, 2011). Furthermore, Al-Motlaq and Sellick (2013) found that improving primary school teachers’ asthma knowledge helps improve confidence in dealing with children with asthma. Schoolteachers have the responsibility to care for all schoolchildren. This responsibility of care is most important for children with asthma. Al-Motlaq and Sellick (2013) concluded that schoolteachers are required to make decisions on suitable physical exercises, organize regular medications, and monitor for signs of breathing difficulties and other symptoms to be able to manage them easily. In Jordan, few studies were conducted to determine asthma knowledge. These studies focused on adolescence. Al-Sheyab, Gallagher, Roydhouse, Crisp, and Shah (2012) assessed the feasibility of Australian asthma educational program to adolescents’ Jordanian context. No studies were conducted about asthma knowledge among schoolteachers in Jordan. In light of the absence of effective school nurse roles, and the presence of few studies that
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investigate the effect of asthma education on the knowledge of schoolteachers, it is important to examine the effect of an asthma education program on knowledge and knowledge retention among schoolteachers in the north of Jordan.
Purpose The purpose of this study was to examine the effect of an asthma education program on knowledge and knowledge retention among schoolteachers in the north of Jordan.
Method Design Pre-test–post-test experimental randomized controlled design was used to examine the effect of an asthma education program on schoolteachers’ knowledge and knowledge retention in the north of Jordan.
Population and Study Sample The target population of this study was the Jordanian teachers of all public primary school children in the north of Jordan. The accessible population was all Jordanian teachers of random selection of three governorates of public primary school children. A cluster random sample was obtained from the entire public primary schools. The population consisted of public primary school teachers aged above 18 who agreed to participate in the study. The schoolchildren were females with the age range from 6 to 12 years. Exclusion criteria were teachers with asthma, teachers who attended an educational program about asthma in the past and all non-Jordanian nationality teachers with attention to allow them to participate and excluded them later for ethical consideration. Sample size was calculated using G* power software (Faul, Erdfelder, Lang, & Buchner, 2007). A medium effect size is required for the purpose of this study, which was 0.5. The sample size was determined according to the power level, which was 0.80 for independent t test and the use of conventional α= 0.05 two-tailed criterion of the significance. Based on that, 68 teachers were required. To overcome the problem with the attrition rate, an additional 12 teachers were added to have 80 in the final sample size. Eighty teachers were randomly allocated either to the experimental or the control group to have 40 in each.
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Setting This interventional study was conducted at public primary schools in the north of Jordan. Three areas were selected: Irbid, Jarash, and Ajlon governorates. These areas were selected because they have the second largest population density in Jordan after Amman. In addition, they consisted of urban and rural areas with different socio-economic status. The enrollment in the north of Jordan for school-age children achieved more than 99% (Jordan Department of Statistics [JDOS], 2007). The total number of schools is 1,041, 197, and 168 for Irbid, Jarash, and Ajlon governorates, respectively. The increase of these schools’ enrollment is about 0.06% annually (JDOS, 2007).
Intervention Asthma Education Program The asthma education program was presented by the primary researcher (interventionist) for the schoolteachers (recipient) in the experimental group, which was expected to result in better asthma management for schoolchildren (target). Providing adequate knowledge about asthma for schoolteachers may help them become aware of common triggers in asthmatic children and manage asthma cases, which enables them to provide appropriate health care. Seven topics of an asthma education program were selected from the textbook of Smeltzer, Bare, Hinkle, and Cheever (2011). The content of the program covered the following topics: general information about asthma, etiology, pathophysiology, severity, signs and symptoms, asthma attacks, triggers, management of asthma, and asthma and sport. Management of asthma includes how to use inhalers to treat symptoms. The intervention consisted of three sessions conducted in the conference room in the selected schools. All topics of the education program were covered. Each session lasted approximately 1 hr, and there were group sessions in which the education-based intervention was delivered to all the participants in the experimental group. The primary researcher used lecture discussion and PowerPoint presentation. During lecture discussion, the researcher asked the participants to repeat key points about asthma. Following the end of all sessions, the participants were provided with compact disks and pamphlets that summarized the content of the program. The asthma educational program was reviewed by two respiratory specialists to assess the content and the adequacy of the information provided for the participants in the study. The intervention was appropriate for all teachers in the selected schools, and no adjustment was made for the intervention to be tailored to the individual teacher. No specific preparation was carried out before the intervention; only the primary researcher tried to choose the appropriate time for the
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teachers to conduct the intervention. No compensation was given to the participants. The primary researcher who conducted the intervention has a philosophy degree in nursing and received adequate education and training about asthma from two respiratory specialists.
Measures A structured questionnaire of two sections was utilized for collecting the data to achieve the purposes of this study. Section 1 was the demographic that was developed by the primary researcher depending on the literature review. This section consisted of a checklist and fill-in-the-blank type questions concerning all the variables addressed by the study such as age, educational level, income, children with asthma in the class, and presence of one family member with asthma. Section 2 was the Asthma General Knowledge Questionnaire for Adults (AGKQA), which was developed by Allen and Jones (1998). The instrument is based on asthma knowledge and management, which measure teachers’ ability to manage schoolchildren with asthma. The AGKQA consisted of a 31-item general asthma knowledge questionnaire. The questionnaire included items that were about asthma etiology, pathophysiology, medications, assessment of severity, and symptom management including triggers and exercise. Teachers were asked to respond using True/False/Not Sure to each item statement of knowledge. The (Not Sure) response was included to discourage guessing and was scored as incorrect. An overall knowledge score was computed by totaling the number of correct responses, with a possible range from 0 to 31, and higher scores referring to greater knowledge about asthma. Permission to use the knowledge instrument was obtained from the tool’s developer. The translated version and the original instrument were reviewed by a committee comprising four experts: two of them are experts in the topic and two are experts competent in both Arabic and English to consider the equivalence of terms, clarity, and cultural adaptation. Modifications were made according to committee’s recommendations. There was no major discrepancy between the original and the translated version. Face validity was performed by four PhD holders who indicated that the tool was valid. In addition, content validity was conducted by another two PhD holders. The content validity index was 0.89, and the results revealed that the tool was valid. Items were tested for internal consistency in the current study, and the result revealed that Cronbach’s alpha reliability was .85. Pilot testing of the instrument among 30 teachers who possessed the same characteristics as the individuals who composed the main sample was
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conducted. The results showed that the instrument was clear, there was no ambiguity in the items, and no problems occurred during the administration, coding, scoring, and analysis of the items. The estimated time to complete the questionnaire was 20 min.
Data Collection Procedures A list of public primary schools in the north of Jordan including children aged from 6 to 12 years was obtained from the Ministry of Education utilizing a cluster random sampling method. The cluster sampling was usually conducted in what is called “multistage sampling.” This means that the selection of the sample was carried out using multistage-cluster sampling techniques. In this study, the researchers used four-stage cluster sampling. The first stage cluster was the selection of three governorates out of four: Irbid, Jarash, and Ajlon were drawn to be included in the study. In the second stage, all public schools in each governorate were written on slips of paper, drawn randomly, and listed in order of random drawing. The researcher went to the school according to the order of random drawing to collect the data. The third stage-cluster sampling was performed using a stratified method; all teachers in that school were listed on slips of paper and drawn according to their teaching of first, second, third, fourth, fifth, and sixth elementary classes. The fourth stage-cluster sampling was conducted by listing all teachers’ names presented in those levels on the day of data collection and written on slips of paper and were then assigned to the experimental and control groups. The primary researcher generated the random allocation sequence, enrolled participants, and assigned participants to intervention. Eighty teachers were randomly selected and were then randomly allocated either to the experimental or the control group to have 40 in each. A pre-test about asthma was administered for both groups (N = 80) on the first day in the conference rooms in the selected schools. Four teachers in the experimental group did not attend the education program on the second day. The teachers in the experimental group (n = 36) received a PowerPoint presentation followed by lecture discussion. The PowerPoint presentation and the discussion lasted approximately 1 hr. At this time, the control group (n = 38) did not receive any interventions. On the seventh day and 3 months after the intervention, the post-test about asthma was performed for both groups. The teachers who completed the pre-test did not know their group assignments, but the researcher knew the groups in which they were included. Teachers were made aware of their groups prior to the beginning of the education implementation. A code number was given to each teacher in both groups to mask their participation and keep their data confidential.
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The questionnaire used to collect data relevant to demographics and other questions related to asthma was kept in an envelope with detailed instructions and distributed to teachers who were asked to retain the completed questionnaires on the same day. The primary researcher was responsible for collecting the completed questionnaires from teachers and applying the asthma education program.
Ethical Considerations The study was approved by the research ethical committees at the Ministry of Education. Written informed consent was obtained from all participants who agreed to participate in the study. A letter was sent to the Ministry of Education describing the nature and significance of the study, and requesting permission to have access to teachers. Official administrators and staff members in the primary schools were informed about the study purposes, and permission was requested to conduct the study using the appropriate channels of communication. In addition, a letter explaining the study and the purpose was sent to the teachers requesting them to complete the questionnaire. Teachers who were not willing to participate were asked to return it unfilled. Furthermore, the participants were instructed that their completion of the questionnaire was considered a written consent for their participation. The confidentiality and anonymity of the information were assured. Moreover, the instrument was coded by numbers to maintain confidentiality of the data. The subjects who were assigned to the control group were informed that the asthma education program might be given to them if they wanted after the data collection was completed. The participants were informed that they have the right to withdraw from the study at any time. All data were kept in a locked cabinet. After the study was completed, all questionnaires were disposed off. The participants were not exposed to any physical, psychosocial, or economical harm, as the data collection primarily depended on a descriptive, non-invasive questionnaire.
Data Analysis SPSS Version 17 was used to analyze the data. Descriptive statistics including mean, standard deviation, and percent were used to describe the sample characteristics. Independent t test was used to examine whether there were any statistically significant differences between the experimental and the control group at the pre-test level to assess the level of homogeneity between the study participants in terms of age, income, and pre-test knowledge about asthma. Mann–Whitney U test was conducted to examine whether there were any statistically significant differences between the experimental and the Downloaded from wjn.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
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control groups in terms of educational level. Chi square was conducted to examine whether there were any statistically significant differences between the two groups in terms of marital status Independent t test was used to examine whether there were any statistically significant differences in the mean asthma knowledge scores between the experimental and the control groups in the first and second post-test. Furthermore, paired t test was conducted to examine whether there were any statistically significant differences between the mean of the knowledge before, and at 1 week and 3 months after the application of the educational intervention for the participants in the experimental group.
Results Eighty female teachers were randomly assigned either to the control or experimental group, so there were 40 teachers in each group at the baseline. The mean age for the participants was 35.50 (SD = 8.33), and the mean monthly income for the whole sample was 680 Jordan Dinar (SD = 115.12). None of the participants received an educational session or workshop about asthma in the past. All study participants were Muslims and did not have asthma or family members with asthma. No children with asthma were in the classes of teachers in the selected sample. A majority (68%) of the participants reported a baccalaureate education, 12% have diplomas, 10% have secondary education, and 10% have primary education. Most of the participants were married (80%), and 20% were single. Of the 80 teachers at the baseline phase, 74 (92.5%) completed the study. Of those, 38 (51%) were in the control group, and 36 (49%) were in the experimental group. The schoolteachers in the experimental group were all females with a mean age of 35 years. An independent sample t test showed no statistically significant differences between the groups in terms of age, monthly income, and pre-test knowledge, showing that the two groups were homogeneous. In addition, Mann–Whitney U test indicated that there were no significant differences between the experimental and the control groups in terms of educational level (U value = 75, z = −5.5, p = .12). Chi square indicated that there were no significant differences between the two groups in terms of marital status (χ2 = 2.60, p = .18), showing that the two groups were homogeneous (Table 1). An independent t test showed that there was a statistically significant difference, t(72) = −6.08, p < .001, between the experimental group (M = 27.55, SD = 5.10) and the control group (M = 19.44, SD = 7.24) regarding knowledge of asthma. In addition, an independent t test showed that there was a statistically significant difference, t(72) = −4.26, p < .001, between the experimental group (M = 25.93, SD = 3.10) and the control group (M = 18.63, SD = 7.09) regarding knowledge of asthma in the retention phase. The paired Downloaded from wjn.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
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Table 1. Sample Characteristics at Baseline and the Pre-Test of Knowledge for the Experimental and the Control Groups (N = 80).
Experimental group (n = 40)
Control group (n = 40)
M (SD)
M (SD)
Variable
95% CI p value Lower Upper
Age (years) 36.00 (0.88) 34.00 (0.89) Monthly income 685.00 (115.31) 675.00 (115.56) (Jordanian Dinar) Pre-test for knowledge 19.40 (1.78) 19.32 (1.86)
.18 .13
−2.24, 5.50 −1.03, −.213
.91
−1.25, 1.40
Note. CI = confidence interval. *p ≤ .05 level (two-tailed).
Table 2. Knowledge of Asthma and Knowledge Retention Mean Differences in the Post-Test Between the Experimental (n = 36) and Control Groups (n = 38).
Experimental group (n = 36)
Control group (n = 38)
M (SD)
M (SD)
t(72)
p value
Lower,
Upper
19.44 (7.24) 18.73 (7.09)
−6.08 −4.26
.001 .001
−6.21, −5.55,
0.34 0.22
Variable Knowledge Knowledge retention
27.55 (5.10) 25.93 (3.10)
95% CI
Note. CI = confidence interval. *p ≤ .001 level (two-tailed).
t test indicated that there were statistically significant differences between the mean knowledge before (M = 19.40, SD = 1.78); at 1 week (M = 27.55, SD = 5.10, p < .001); t(35) = 22; and at 3 months (M = 25.93, SD = 3.10, p < .001), t(35) = 21, after the application of educational intervention (Table 2). In addition, the result indicated an improvement in the mean score for each individual item after the program application. This indicated an improvement in all fields of asthma knowledge including etiology, pathophysiology, medication assessment of severity, and symptoms management.
Discussion The purpose of this study was to examine the effect of an asthma education program on schoolteachers’ knowledge and knowledge retention in the north of Jordan. The results indicated that schoolteachers’ knowledge about asthma
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was limited. This finding is consistent with the result of several studies that revealed that asthma knowledge among participants was limited (Abdel Gawwad & El-Herishi, 2007; Choi & Cho Chung, 2010; Janson et al., 2009; Templeton & Coates, 2004). Schoolteachers should have adequate knowledge of asthma to provide a safe environment for the child with asthma. Schoolteachers’ knowledge and understanding of asthma can have a major effect on the health status of students with asthma (Ones et al., 2006). Deficient knowledge among Jordanian schoolteachers in this study can be justified due to lack of asthma education and training, the workload that the schoolteachers have, and limited educational resources about asthma at schools. In a study, Abdel Gawwad and El-Herishi (2007) examined the effect of educational pamphlets on primary school teachers’ knowledge about asthma. Only 5.7% received education about asthma. Results indicated a low knowledge about asthma, which can be related to lack of education and training about asthma. Templeton and Coates (2004) and Tawalbeh and Ahmad (2013) found that adequate educational resources and programs would improve knowledge among patients with different health problems. In addition, in Jordan, there is no school policy to raise schoolteachers’ knowledge about asthma and asthma management. Schoolteachers have a vital role in managing asthma for schoolchildren by supporting the development of an asthma management plan. This plan needs school policies on how to use inhalers, and what should schoolteachers act when a student has an asthma attack (Asthma and Allergy Foundation of America, 2013). Schoolteachers have a major role in providing asthma management in the help of the family, the child, and health care professionals (Al-Dawood, 2002). Moreover, the workload that the schoolteachers have and the limited support of asthma education from educational authority may contribute to low level of knowledge about asthma. The results of the current study indicated that the knowledge of schoolteachers in the experimental group improved significantly in the first posttest and in the retention phase compared with those in the control group. This result is consistent with the findings of Templeton & Coates (2004), which demonstrated that educational sessions had a significant effect on knowledge, quality of life, and satisfaction with care. In addition, Abdel Gawwad and El-Herishi (2007) found that asthma educational programs had a significant impact on the mean total score of the staff asthma related-attitudes, which became more favorable toward school asthma management and education after intervention. Furthermore, Janson et al. (2009) found that asthma management educational sessions enhanced the symptoms of patients with moderate to severe asthma. In addition, the results of the present study indicated that knowledge retention was significantly higher in the experimental group compared with those in the control group. Likewise, in Demüralay’s (2004) Downloaded from wjn.sagepub.com at UNIVERSITY OF SASKATCHEWAN LIBRARY on March 18, 2015
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study, the mean change in the knowledge retention score was still significantly high at 2 months after the interventions. The significant effect of asthma education on knowledge in the experimental group in this study may be attributed to many factors. The use of multi-teaching materials such as data show, educational video, and pamphlet may contribute to the success of the educational program. Abdel Gawwad and El-Herishi (2007) add evidence on the effectiveness of pamphlets as an educational material for improving schoolteachers’ knowledge about asthma. The teaching methods and interaction between the researcher and teachers used in this study would improve teachers’ knowledge of asthma. The previous features used in the application of the educational program applications have a significant impact on the ability of individuals to learn (Fletcher, 1987; Mullen et al., 1997). In addition, this finding is supported by the study of Hemsley-Brown (2004), which showed that financial, human, and physical resources are essential factors that may help improve knowledge among participants. As well, Williams, Lindsell, Rue, & Blomkalns (2007) found that the educational video intervention enhanced knowledge and knowledge retention among participants. In Jordan, school nurses are not available in schools. Therefore, primary school teachers have the responsibility to take care of children with asthma. For this reason, it is worthwhile that teachers be equipped with the important knowledge regarding asthma etiology, pathophysiology, medications, assessment of severity, and symptom management including trigger minimization and exercise. Based on these results, the authors suggested that stakeholders train primary school teachers as well as school nurses to be well prepared in caring for asthmatic children, through workshops and health education programs. Findings of this study supported that health education programs help schoolteachers gain more knowledge that sequentially may reduce problems occurring to asthmatic children. Thus, it is beneficial to conduct future studies to examine the effect of such an educational program on the schoolteachers’ ability to provide the required health care for children with asthma in schools. In this perspective, school nurses and health professionals should teach teachers how to assess asthmatic children as a basis of care, especially for primary school children. Nurse educators should be aware that schoolteachers need solid education programs to enhance primary school teachers’ knowledge about asthma. This in turn may promote children’s health status. Some limitations should be highlighted in this study, which in turn may limit generalizability of findings to the total population of Jordan. The study sample was restricted to female schoolteachers in the primary schools in the north of Jordan; a broader geographically diverse sample including male and
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female schoolteachers may produce different results. As well, in the current study, the retention of knowledge was examined only at 3 months after the intervention. It is recommended asthma knowledge among schools teachers is better to be examined 3 months after the application of the educational program. Asthma educational intervention significantly improves teachers’ knowledge of asthma. This improvement in knowledge is good retained at 1 week and 3 months, which suggests that teachers may benefit from further educational intervention to help children with asthma. The asthma education program should be implemented to target all schoolteachers in Jordan. Acknowledgment The authors would like to thank the study participants.
Authors’ Note This article has been approved by all authors, and all authors agree to submit the manuscript solely to the Western Journal of Nursing Research. Mariam M. Kawafha and Loai Issa Tawalbeh were involved in this article, including study conception/ design, data collection/analysis, writing up manuscript, critical revisions for important findings, discussion, and intellectual contents. This study is an empirical research consists of an article on original research that has not been previously published in its current format.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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