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DescriptionOriginal Research Report
A School Nurse–Led Asthma Intervention
for School-Age Children: A Randomized
Control Trial to Improve Self-Management
The Journal of School Nursing
2021, Vol. 37(6) 480–490
ª The Author(s) 2020
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DOI: 10.1177/1059840520902511
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Elif Isik, PhD, RN1,2 , Nina M. Fredland, PhD, RN3,
Anne Young, EdD, RN3, and Rebecca J. Schultz, PhD, RN, CPNP, FAES3,4
Abstract
Asthma is a common disease in children, and obtaining basic knowledge and skills to manage asthma symptoms is critically
important. This study examined the effectiveness of a theoretically based school nurse–led asthma intervention on asthma
symptoms, self-management, peak flow meter usage, daily activities, and school absences in children 7–12 years old. A randomized controlled, two-group, repeated measures design was conducted in eight public schools. Data collection occurred at
three time points. The treatment group had statistically significant differences in reported symptoms (p < .001), asthma control with a peak flow meter usage (p < .001), and daily activities (p < .001) at 6 weeks and at 12 weeks. Although difference in school absences was not statistically significant, the treatment group missed fewer school days than the control group. Selfmanagement is a complex process, and school nurses can provide essential learning steps and continuity of care for school-age children living with asthma. Keywords asthma, school-age children, self-management, randomized control, trial, school nurse–led intervention Asthma is a complex chronic respiratory disease common in children and adults (Global Initiative for Asthma [GINA], 2019). Asthma is characterized by inflammation of the lungs, bronchospasm, cough, chest tightness, chest pain, difficulty breathing, wheezing, restlessness, irritability, nocturnal coughing, and wheezing (Asthma and Allergy Foundation of America, 2015; GINA, 2019). The American National Center for Health Statistics reported 26.5 million people had been diagnosed with asthma and of those 6.1 million are children under 18 years of age in the United States (Centers for Disease Control and Prevention, 2018). Despite advancing medical knowledge, asthma prevalence and exacerbation rates continue to persist among children (GINA, 2019). Symptoms and specific triggers must be known and recognized to eliminate concomitant asthma exacerbations, school and work absenteeism, disruption of daily activities, ambulance calls, emergency room visits, hospitalizations, and even death (Francisco et al., 2017; Isik & Isik, 2017). Since asthma affects both children and adults, self-management should be prioritized as a strategy to promote positive health outcomes and reduce asthma exacerbations, thus supporting healthy active lives beginning in childhood (Isik & Isik, 2019). Background Asthma is a chronic disease that can be managed through a combination of medical intervention and patient self-care. Asthma can manifest at any life stage, so all individuals who live with asthma should obtain basic knowledge and skills to manage their asthma symptoms. Children and even adults are often unaware that asthma is a lifelong disease (American Lung Association, 2018). Children with asthma can have normal days without breathing problems with good management, and this may lead to the misconception that the condition is cured rather than well managed or asymptomatic at the time (National Heart, Lung, and Blood Institute, 2013). 1 Texas Woman’s University, Houston, TX, USA Houston Independent School District, TX, USA 3 Nelda C. Stark College of Nursing, Houston Center, Texas Woman’s University, Houston, TX, USA 4 Baylor College of Medicine, Houston, TX, USA 2 Corresponding Author: Elif Isik, PhD, RN, 8823 Emerald Heights Ln., Houston, TX 77083, USA. Email: eisik@twu.edu Isik et al. There is support for implementing an effective asthma management plan for school-age children in school settings (National Institutes of Health, 2012). Asthma management programs for parents of school-age children living with asthma have been studied in the literature (van Bragt et al., 2015). Several asthma education programs are designed to increase the study subjects’ knowledge of asthma (Grover et al., 2016; Horner et al., 2016; Kintner et al., 2015; Payrovee et al., 2014; Suwannakeeree et al., 2016). These intervention programs reported increased prevention behaviors, fewer emergency room visits, decreased hospital admissions, more medication adherence, improved quality of life, and self-efficacy related to asthma management (Fiks et al., 2015; Grover et al., 2016; Horner et al., 2016; Kintner et al., 2015). However, those studies focused on parents/guardians and addressed only their concerns about asthma management (Fiks et al., 2015; Grover et al., 2016; Payrovee et al., 2014; Suwannakeeree et al., 2016). There are scant studies on school-based asthma interventions targeting elementary school-age children (Rasberry et al., 2014; van Bragt et al., 2015). The available studies were mostly descriptive studies. Best et al. (2018) emphasized the necessity of using experimental and quasiexperimental designs related to children living with asthma. School nurse–led asthma interventions can focus on schoolage children for the purpose of developing successful asthma self-management strategies (Isik et al., 2019; Suwannakeeree et al., 2016). School-based asthma interventions are often conducted by researchers who are not employed in the school settings where the programs are implemented. Implementing school nurse–led asthma intervention programs beyond the hospital setting will increase opportunities for learning about the condition and developing selfmanagement skills. Orem’s self-care theory was used to guide this study. Orem’s self-care theory centers on individuals’ self-care knowledge and skills. The theory posits that individuals should know and perform self-management activities to maintain and promote their health. Self-care is reasonably more important to individuals with a chronic illness, and self-care management requires acknowledgment of the condition, symptoms, and having the skill set to perform needed actions (Kouba et al., 2013). The individuals can be involved in activities for self-management based on their age, cognitive ability, experiences, culture, and available resources. Major assumptions of this theory are as follows: Individuals are distinct, and self-care for health and well-being is a developmental process. Engaging in self-care basics is a vital element for selfmanagement of the diseases, conditions, and optimal well-being. Individuals should be as independent as possible and accountable for their health maintenance in conjunction with family caregivers. 481 If there is a disproportion between self-care needs and self-care abilities for self-management of health, individuals would benefit from nursing intervention. Individuals must have knowledge of present and potential health conditions to promote self-care behaviors. Self-care and dependent care are activities embedded in a social and cultural environment (Orem, 2001). Orem’s self-care theory asserts the importance of the child’s awareness of asthma symptoms and acquiring the skills necessary to manage asthma in daily life. The theory has been used to direct health promotion efforts and encourage patients to be more independent in their daily lives. Studies related to self-management behaviors based on Orem’s self-care theory have shown that these behaviors improve health outcomes (Blok, 2017; Kouba et al., 2013; Mersal & El-Awady, 2017). Purpose of the Study The purpose of this study examined the effectiveness of a theoretically based school nurse–led asthma intervention on symptoms, asthma self-management with peak flow meter (PFM) usage, interruption of daily activities, and school absences in a sample of elementary school-age children between the ages of 7 and 12. Hypothesis 1: Children living with asthma, who participate in a nurse-led asthma intervention, will report fewer asthma symptoms as measured by Pediatric Asthma Quality of Life Questionnaire with standardized activities (PAQLQ(S)) than children who receive usual asthma care. Hypothesis 2: Children living with asthma, who participate in a nurse-led asthma intervention, will report better asthma self-management as measured by the Asthma Control Questionnaire (ACQ) and will demonstrate a higher mean number of usages of PFMs as recorded on PFM charts than children who receive usual asthma care. Hypothesis 3: Children living with asthma, who participate in a nurse-led asthma intervention, will report fewer interruptions of daily activities as measured by PAQLQ(S) than children who receive usual asthma care. Hypothesis 4: Children living with asthma, who participate in a nurse-led asthma intervention, will have less school absences than children who receive usual asthma care. Method Design A randomized controlled, two-group, repeated measures design (pretest, posttest, and follow-up test) was used in eight public schools between September 2018 and June The Journal of School Nursing 37(6) 482 Enrollment Assessed for eligibility (n= 76) Excluded (n= 3) Not mee ng inclusion criteria (n= 3) Randomized (n= 73) Alloca on Control Group (n= 36) Treatment Group (n= 37) Received usual asthma care (n= 36) Received allocated interven on (n= 36) Did not receive allocated interven on (moved into another city) (n= 1) Follow-Up Treatment Group (36 subjects completed follow-up) Control Group (35 subjects completed follow-up) Analysis Analyzed (n= 35 for H1, H2, and H3 ) Analyzed (n= 36 for H1, H2, H3, and H4 ) Analyzed (n= 3 6 for H4 ) Figure 1. CONSORT flow chart. 2019. Subjects were randomly allocated to receive school nurse–led asthma intervention (treatment) or usual care (control). The study was approved by the Texas Woman’s University Institutional Review Board (IRB). The CONSORT flow chart is shown in Figure 1. The independent variable was time as Time 1 (baseline), Time 2 (completion of the intervention at 6 weeks), and Time 3 (follow-up at 12 weeks). The dependent variables are symptoms, self-management with PFM usage, daily activities, and school absences. Participants Subjects were recruited from eight primary schools in a diverse, urban public independent school district in Southwestern United States. The inclusion criteria consisted of English-speaking children diagnosed with asthma, 7–12 years old. Children with other disabilities or comorbid medical conditions including severe cerebral palsy, oxygendependent conditions, and cystic fibrosis were excluded. The students at eight selected schools were invited to participate in the study. The principal investigator (PI), who is also a school nurse, collaborated with the eight school administrators and nurses to send the recruitment flyer with the school newsletter. Flyers were posted on the school websites and prominently around the school building. Once a parent/guardian contacted the PI, they were informed about (a) the purpose of the study, (b) the inclusion criteria, (c) the voluntary nature of participation, (d) requirements for participants, (e) possible risks and benefits, (f) availability of study outcomes, (g) the intervention times and duration, and (h) the data collection periods. The PI answered parents’ and children’s questions before obtaining informed parental consent and children’s assent. The PI obtained written informed consent from parents/guardians and written assents from child participants prior to enrollment in the study. A mild effect size of 0.30 with the power of 0.80 and a level of .05 based on a previously published meta-analysis and statistical consultation was chosen (Kew et al., 2017; McCallum et al., 2017; Peytremann-Bridevaux et al., 2015). Based on the G-power analysis, it was determined that 62 participants were needed for the study. The PI increased the sampling size by 15% to allow for attrition, resulting in a final sample of 71 participants. PI collaborated with school Isik et al. Table 1. Intervention Components. Theoretically Based School Nurse–Led Asthma Intervention Program Session 1: Asthma disease and its pathophysiology Session 2: Peak flow meter and usage Session 3: Asthma symptoms and implementation of an asthma action plan Session 4: Techniques for using medicines and spacers Session 5: Asthma triggers and breathing exercises Session 6: Discussion of individualized choices and goal setting 483 Data collection for both treatment and control groups occurred at three time points as baseline, 6 weeks, and 12 weeks at the arranged school settings. All subjects in the treatment group received a PFM with a personal peak flow chart and a spacer. The subjects in the control group continued to receive usual asthma care. Subjects in the treatment group were offered a makeup session if they missed a class session. Both groups received a US$10 gift card after completing posttest questionnaires at 6 and 12 weeks to compensate for their time. Instruments nurses and administrators. The PI sent reminder emails and called the school nurses for having the subjects at the planned time. The sample size was 73 at study initiation with the loss of one member from the control group and one from the treatment group by the final measure for 71 participants. Data Collection Data collection occurred from September 2018 through June 2019. An initial sample of 76 children, ages 7–12, attending eight elementary schools was obtained. Three children were excluded based on eligibility criteria. Two children were not able to speak and understand English, and another child was less than 7 years old. A computer-generated randomization process assigned 73 subjects to the treatment or control group. There were 37 participants in the treatment group and 36 participants in the control group at the beginning of the study. Intervention The randomly assigned treatment group participated in a theoretically based school nurse–led asthma intervention comprised of 6 weekly 30-min group lessons. The PI, who is also a school nurse, implemented the intervention sessions at all the eight schools. Topics in the session were respectively (1) asthma disease and pathophysiology; (2) PFM, method of measurement, and the utility of PFM use; (3) identification of asthma symptoms and implementation of an asthma action plan (AAP); (4) asthma medicines for managing asthma symptoms, demonstrating correct techniques for using medicines and spacers; (5) recognition and control of asthma triggers and helpful breathing exercises; and (6) discussion of individualized choices and goal setting for self-management (see Table 1). Hands-on experiences, problem-based learning techniques, role-playing, case studies, storytelling, classroom discussion, colorings/drawings, and exercises to manage asthma symptoms were used to enhance class interaction and learning. The randomly assigned control group continued to receive usual asthma care. Usual asthma care refers to obtaining and administering the prescribed medicines according to the AAP written by the child’s physician. The ACQ and the PAQLQ(S) were the instruments. A demographic questionnaire assessed gender, age, ethnicity, grade level, household number, housing, and any known health problems other than asthma at baseline. The ACQ, a 7-item instrument, measures the sufficiency of asthma control and variation in asthma control on a 7point Likert-type scale (Juniper et al., 2000). Five questions relate to symptoms; one question covers quick-relief medication use, and the last question addresses pulmonary function (Juniper et al., 2000). The ACQ is a reliable tool with Cronbach’s a reported ranging from .79 to .90 (Juniper et al., 2010; Rasberry et al., 2014). The ACQ Cronbach’s a for this study was .809. The PAQLQ(S) is a widely used 23-item tool measuring quality of life in children with asthma ages 7–17. Three domains measure symptoms, activity limitations, and emotional functioning. The questionnaire is a reliable tool with Cronbach’s a reported ranging from .89 to .96 (Juniper et al., 1997; Wing et al., 2012). Scaling is a 7-point Likert-type scale weighted equally. Both questionnaires have been thoroughly established for use with pediatric populations (Cicutto et al., 2013). For this study, Cronbach’s a was .957 for the overall PAQLQ(S), .908 for Symptom subscale, .819 for Activity subscale, and .917 for Emotional Scale. Ethical Considerations An approval was also obtained from the school district’s Office of Research and Accountability and the administrators of the selected schools in addition of the university IRB approval. The study adhered to the Family Educational Rights and Privacy Act of 1974. Confidentiality was protected as required by the law. Data Analysis Data were analyzed using the Statistical Package for Social Sciences Version 25. Descriptive statistics were used for demographic data. Hypotheses 1, 2, and 3 that related to symptoms, asthma self-management with PFM usages, and activity interruption were analyzed using repeated measures analysis of variance (ANOVA) for 71 subjects, the treatment group (n ¼ 36) and control group (n ¼ 35). The fourth hypothesis related to school absences, reported at the end The Journal of School Nursing 37(6) 484 of 12 weeks, was analyzed by using an independent samples t test for 72 subjects, the treatment group (n ¼ 36) and control group (n ¼ 36). Descriptive analysis was used for demographic questionnaire that was completed by 73 participants. Results Table 2. Sample Demographic Characteristics. Variable Gender Male Female Ethnicity Hispanic African American White Asian American Indian Other Grade level First Second Third Fourth Fifth Sixth Housing situation Apartment/house Shelter With another family Car/outside Control, n ¼ 36 Treatment, n ¼ 37 Total, N ¼ 73 15 (41.7%) 21 (58.3%) 12 (32.4%) 25 (67.6%) 27 (37.0%) 46 (63.0%) 20 (55.6%) 7 (19.4%) 4 (11.1%) 3 (8.3%) 0 (0.0%) 2 (5.6%) 15 (40.6%) 10 (27.0%) 5 (13.5%) 2 (5.4%) 1 (2.7%) 4 (10.8%) 35 (47.9%) 17 (23.3%) 9 (12.3%) 5 (6.8%) 1 (1.4%) 6 (8.2%) 5 (13.9%) 5 (13.9%) 9 (25.0%) 7 (19.4%) 5 (13.9%) 5 (13.9%) 8 (21.6%) 1 (2.7%) 5 (13.5%) 6 (16.2%) 10 (27.0%) 7 (18.9%) 13 (17.8%) 6 (8.2%) 14 (19.2%) 13 (17.8%) 15 (20.5%) 12 (16.4%) 32 (89%) 1 (2.8%) 3 (8.3%) 0 (0%) 36 (97.3%) 0 (0%) 0 (0%) 1 (2.7%) 68 (93.2%) 1 (1.4%) 3 (4.1%) 1 (1.4%) One participant from the treatment group moved into another city’s school district after the first session and did not complete the study. One participant from the control group did not come in the 12th week for the follow-up test questionnaire at the scheduled time or at the makeup session time. Approximately 63% of the total sample was comprised of females with 67.6% of females in the treatment group and 58.3% of females in the control group. Participant’s ages ranged from 7 to 12 years, with a mean age of 9.29 (SD ¼ 1.67) years. The treatment group’s mean age was 9.49, and the control group’s mean age was 9.08. The grade-level median was 4.00 for this study. The Hispanic population comprised the largest ethnic group representing 48% of all subjects in this study. The treatment group consisted of 40.6% Hispanic subjects and control group of 55.6%. The second greatest ethnic population in this study was African American representing 23.2%of participants with African Americans composing 27.0% of the treatment group and 19.4% of the control group. Whites represented 12.3% of the total group. The treatment group was 13.5% White and the control group was 11.1% White. Asian students composed 6.9% of the total sample with a representation of 5.4% in the treatment group and 8.3% in the control group. Only one (1.4%) subject was American Indian and was assigned to the treatment group. There were six (8.2%) subjects from other ethnic groups that subjects did not identify, with four (10.8% of unknown ethnicity) subjects in the treatment group and two (5.6% of unknown ethnicity) subjects in the control group. The mean number of members living in a household was 4.38 for the treatment group and 4.06 for the control group. Over 93% of participants lived in a house or apartment; one subject from the treatment group who lived in a house or apartment did not have running water or electricity, one subject from the control group lived in a shelter, and one subject from the treatment group lived in a car, and three subjects from the control group lived with another family in a house or apartment. Only four subjects, two from the treatment group and two from the control group, had other health problems that did not affect asthma or participation in intervention (Table 2). Analysis indicated that the groups were well-balanced and comparable. Items 4, 6, 8, 10, 12, 14, 16, 18, 20, and 23. There was a statistically significant difference in mean symptom scores for the treatment group when compared to the control group throughout three time points, F(2, 138) ¼ 29.83, p < .001, partial Z2 ¼ .302. Statistical power was adequate and equal to 1.000. A post hoc test was used for multiple comparisons by using least significant difference (LSD) comparisons. There was no significant difference at baseline between the two groups (p ¼ .056). Subjects in the treatment group reported significantly higher symptom score suggesting that they had less asthma symptoms than the students in the control group at 6 weeks (Figure 2). The symptom scores further increased from 6 to 12 weeks. The mean score for the treatment group demonstrated a statistically significant effect from baseline to 6 weeks (p < .001, SD ¼ 1.97), baseline to 12 weeks (p < .001, SD ¼ 2.15), and 6–12 weeks (p ¼.002, SD ¼ 1.41). The control group symptoms did not significantly improve. The mean score for the control group significantly decreased, which indicates subjects’ asthma symptoms increased from baseline to 6 weeks (p ¼ .005, SD ¼ 1.99) and baseline to 12 weeks (p ¼ .027, SD ¼ 2.18). The mean score did not significantly change from 6 to 12 weeks (p ¼ .552, SD ¼ 1.43). Hypothesis 1 Hypothesis 2 Symptoms (coughing, feeling tired, asthma attacks, wheezing, tightness in chest, shortness of breath, waking up during the night, out of breath, difficulty taking a deep breath, and trouble sleeping at nights) were measured by PAQLQ(S) There was a statistically significant difference in mean ACQ scores in the treatment group compared to the control group from baseline to 6 weeks and baseline to 12 weeks, F(2, 138) ¼ 16.62, p < .001, partial Z2 ¼ .194. Statistical power was Isik et al. 485 Symptoms Means 70 60 50 40 30 20 10 0 Baseline 6-week 12-week Baseline control 6-week 12-week treatment Mean Std. Error Figure 2. Asthma symptoms. Table 3. Asthma Management: Tests of Within-Subjects’ Effects. Source Time Sphericity assumed Greenhouse–Geisser Huynh–Feldt Lower bound Time Group Sphericity assumed Greenhouse–Geisser Huynh–Feldt Lower bound df F Sig. Partial Observed Powera Z2 2 1.743 1.811 1.000 8.466 8.466 8.466 8.466 .000 .001 .001 .005 .109 .109 .109 .109 0.963 0.943 0.949 0.818 2 1.743 1.811 1.000 16.624 16.624 16.624 16.624 .000 .000 .000 .000 .194 .194 .194 .194 1.000 0.999 0.999 0.980 Note. aComputed using a ¼ .05. df ¼ degrees of freedom. adequate and equal to 0.999 (Table 3). A post hoc test was used for multiple comparisons using LSD comparisons. No significant differences between the two groups were found at baseline (p ¼ .524). Subjects in the treatment group reported a comparatively lower score, suggesting that they had better asthma management than the students in the control group at both 6 and 12 weeks. The mean score for the treatment group demonstrated a statistically significant effect on time between baseline to 6 weeks (p < .001, SD ¼ 0.98), baseline to 12 weeks (p < .001, SD ¼ 1.02), and from 6 to 12 weeks (p ¼ .03, SD ¼ 0.73). There were no statistically significant differences in the control group asthma self-management scores over time. The mean score for the control group did not show a statistically significant effect from baseline to 6 weeks (p ¼ .33, SD ¼ 1.00), from baseline to 12 weeks (p ¼ .35, SD ¼ 1.04), and from 6 to 12 weeks (p ¼ 1.00, SD ¼ 0.73). There was a statistically significant effect on the usage of PFM frequency treatment group compared to the control group over time, F(2, 138) ¼ 162.04, p < .001, partial Z2 ¼ .701. Statistical power was adequate and equal to 1.00. A post hoc test was used for multiple comparisons using LSD comparisons. Before the intervention, none of the subjects in the treatment group used a PFM tool (μ ¼ 0.00, SD ¼ 0.000). At the end of the intervention at 6 weeks, 32 (88.9%) subjects in the treatment group reported that they used the PFM 5 or more times per week and record their peak expiratory flow rate to monitor their pulmonary function level, 3 (8.3%) subjects reported that they used a PFM 2 times weekly, and 1 (2.8%) subject did not use a PFM (μ ¼ 4.61, SD ¼ 1.153). At the 12th week, 17 (47.2%) subjects in the treatment group reported they used a PFM 5 or more times per week, 2 (5.6%) subjects reported PFM use 4 times per week, 4 (11.1%) subjects used a PFM 3 times per week, 8 (22.2%) subjects used a PFM 2 times per week, 4 (11.1%) subjects used a PFM once a week, and 1 (2.8%) subject did not use the PFM tool (μ ¼ 3.47, SD ¼ 1.647). Only one subject (2.8%) in the control group reported PFM use 2 times per week (μ ¼ 0.06, SD ¼ 0.333) at baseline. All subjects in the control group reported that they did not use the PFM (μ ¼ 0.000, SD ¼ 0.000) at 6 weeks, and only one subject (2.8%) reported PFM use 2 times per week at 12 weeks (μ ¼ 0.06, SD ¼ 0.338; Table 4). PFM usages significantly increased for assessing pulmonary function in the treatment group following the intervention. Hypothesis 3 There was a statistically significant difference in mean interruption of daily activities scores in the treatment group compared to the control group, F(2, 138) ¼ 14.15, p < .001, partial Z2 ¼ .170. Statistical power was adequate and equal to 0.998. A post hoc test was used for multiple comparisons using LSD comparisons. There was no statistically significant difference at baseline between the two groups (p ¼ .350). Subjects in the treatment group reported a The Journal of School Nursing 37(6) 486 Table 4. Peak Flow Meter (PFM) Report. Treatment or Intervention PFM Usages in Time 1 School absence days PFM Usages in Time 2 PFM Usages in Time 3 70 66 60 50 Control Mean n SD Treatment Mean n SD 0.06 36 0.333 0.00 36 0.000 0.06 35 0.338 0.00 37 0.000 4.61 36 1.153 3.47 36 1.647 42 40 30 20 10 0 control treatment Figure 3. School absence days. Table 5. Activity Interruption. Control Treatment Time Time Standard Error Sig. Baseline Baseline 6 weeks Baseline Baseline 6 weeks 6 weeks 12 weeks 12 weeks 6 weeks 12 weeks 12 weeks 1.002 1.043 0.738 0.988 1.029 0.728 .193 .885 .104 .000 .000 .420 significantly higher score, suggesting that they had fewer interruptions in their daily activities than the students in the control group at 6 and 12 weeks. The mean score for the treatment group demonstrated a statistically significant effect between baseline to 6 weeks (p < .001, SD ¼ 0.988) and from baseline to 12 weeks (p < .001, SD ¼ 1.029). There was no statistically significant effect between 6 and 12 weeks (p ¼ .420, SD ¼ 0.728). The mean score for the control group did not show a statistically significant effect between baseline to 6 weeks (p ¼ .193, SD ¼ 1.002), baseline to 12 weeks (p ¼ .885, SD ¼ 1.043), and 6–12 weeks (p ¼ .104, SD ¼ 0.738; Table 5). Hypothesis 4 School absences were measured for 12 weeks over the duration of study and reported as a frequency. An independent samples t test was used to test this hypothesis. There were no statistically significant differences in mean absences between the treatment group (μ ¼ 1.33, SD ¼ 1.57) and the control group (μ¼ 1.83, SD ¼ 1.54; t(70) ¼ 1.35, p ¼ .179). However, the treatment group missed fewer school days than the control group over the 12 weeks. As shown in Figure 3, the treatment group (n ¼ 36) missed 42 days total (ranging from 0 to 8 per subject) and the control group (n ¼ 36) missed 66 days total (ranging from 0 to 7 per subject) throughout the study. Specific causes for the missed school days were not determined. Total PAQLQ scores were also analyzed using repeated measures ANOVA to determine the significance of the relationships between participating in a nurse-led asthma intervention and the children’s quality of life. There was a statistically significant difference on the quality of life scores in the treatment group compared to the control group, F(2, 138) ¼ 20.66, p < .001. Post hoc testing for multiple comparisons using LSD comparisons was performed. There was no statistically significant difference at baseline between the two groups (p ¼ .160). Subjects in the treatment group reported significantly higher scores, suggesting that they had a better quality of life in their daily lives than the students in the control group at 6 and 12 weeks. The mean score for the treatment group demonstrated a statistically significant difference from baseline to 6 weeks (p < .001, SD ¼ 4.34), baseline to 12 weeks (p < .001, SD ¼ 4.97), and 6–12 weeks (p ¼ .016, SD ¼ 3.00). The mean score for the control group decreased significantly, indicating poorer quality of life between baseline and 6 weeks (p ¼ .018, SD ¼ 4.40). There was no significant change for the control group from baseline to 12 weeks (p ¼ .182, SD ¼ 5.04) or from 6 to 12 weeks (p ¼ .213, SD ¼ 3.04). The analysis demonstrated that children living with asthma, who participated in the nurse-led asthma intervention, reported better quality of life as measured by higher PAQLQ(S) scores than children who received usual asthma care. The treatment group had statistically significant differences in reported symptoms, ACQ scores with PFM usage, and interruptions in daily activities immediately postintervention at 6 weeks and again at 12 weeks in comparison to the control group. Although school absences were not statistically significantly different, the treatment group missed fewer school days. The repeated measures ANOVA was also used to test the overall quality of life, and there was a statistically significant difference on the quality of life between the treatment and control groups between baseline, 6 weeks, and 12 weeks. Discussion The study was conducted to determine the effectiveness of participating in a school nurse–led asthma intervention on symptoms, asthma self-management with PFM usages, daily activities, and school absences. These study results were Isik et al. consistent with previous studies, which found that children who participated in asthma programs had fewer asthma symptoms (Fiks et al., 2015; Grover et al., 2016; Horner et al., 2016; Kintner et al., 2015; Lv et al., 2019; Payrovee et al., 2014; Rasberry et al., 2014; Suwannakeree et al., 2016), increased their knowledge and skills about asthma management (Fiks et al., 2015; Grover et al., 2016), used the PFM more often (Suwannakeeree et al., 2016), missed less school days (Fiks et al., 2015; Suwannakeeree et al., 2016), and they reported better quality of life (Grover et al., 2016). When children are accountable for their own health, they may feel more responsible and ready to manage their own health, which may lead to a smoother transition into puberty and adulthood. Orem’s self-care theory was foundational throughout the study, including preparation of the intervention topics and how to deliver the intervention sessions to the subjects. Orem’s self-care theory has three main processes that were considered to increase children’s knowledge and skills to manage their asthma. The three processes are estimative process, transitional process, and productive process. Estimative process refers to having knowledge of the condition, transitional process infers knowing the specific situations of the condition and having skills appropriate for the present situation, and productive process relates to using knowledge and skills to manage the condition and to evaluate results. These three processes were critical in this study and should be considered when implementing interventions related to managing chronic conditions for all individuals including children. Kouba et al. (2013) conducted a study to examine the effectiveness of the I Can Control Asthma and Nutrition Now intervention program for schoolchildren. Orem’s self-care theory served to guide this study, and it demonstrated that the subjects’ asthma knowledge, quality of life, asthma selfcare, and self-efficacy increased after the intervention (Kouba et al., 2013). This study demonstrated that individuals, including children, must know their own health condition; therefore, offering an age-appropriate health intervention is essential to increase awareness and self-management of health. Children, who actively participate in managing their asthma symptoms effectively, are more likely to experience a healthy and active life. Children living with asthma should be educated to help them acquire skills for managing their asthma in daily life leading to fewer exacerbations and interruptions in activities and better school attendance. The recent reviews support implementing an asthma selfmanagement education program for school-age children, their parents, and school personnel (Isik et al., 2019; Kew et al., 2017; McCallum et al., 2017; Peytremann-Bridevaux et al., 2015). This study demonstrated that a school nurse– led asthma intervention was a supportive program that increased awareness of asthma management techniques and self-care abilities. 487 Limitations The outcomes were measured for a 12-week period. It would be important to capture the long-term retention and self-care ability at 3, 6, and 12 months. There may be some benefit to implement booster sessions that extend learning and reinforce the skills to manage asthma successfully. The subjects’ age, cognitive ability, and experiences may influence the understanding of the concepts. Furthermore, the sample was drawn from one urban school district of the region, which limits generalizability. The study was limited by the school schedules, rules, and regulations including the time and place of the intervention program. Another limitation is that the parents’ thoughts and experiences were not included in this study. Conclusion This study supports the benefits of implementing an ongoing school nurse–led asthma intervention program for improved asthma self-care practice among elementary school-age children. Self-management is a complex process, especially among children, which necessitates professional contribution and guidance. School nurses can provide essential learning steps and continuity of care for schoolchildren. This study’s findings indicated that elementary schoolage children are quite capable of taking responsibility for managing their asthma and that school nurses are critical in the process of increasing children’s awareness, knowledge, and skills for managing asthma. Orem’s self-care theory is sustained in that the child’s awareness of asthma symptoms and self-skill to manage asthma for normal daily life is enhanced. The findings indicated that Orem’s self-care theory supports education programs for schoolage children to learn and adapt skills for asthma selfmanagement. Nurses routinely explore ways to support and promote people’s knowledge and teach skills that enhance individuals’ self-management of chronic disease such as asthma. Elementary school-age children should have the opportunity to practice self-monitoring and goal setting for asthma self-management with the guidance of school nurses. This study has the potential to motivate school nurses and health leaders to implement school nurse–led interventions for chronic diseases such as asthma, thus empowering children with knowledge and skills for optimal well-being. Further research studies with high school students in various geographic locations are also warranted. Implications for School Nursing Practice 1. School nurses are strategically placed in school settings to deliver essential learning steps and provide continuity of care for elementary school children. The Journal of School Nursing 37(6) 488 School nurses have a unique opportunity to establish a trusting relationship with students, foundational for better asthma management and likely to improve health outcomes. 2. Nurses who take a prominent role in fostering selfmanagement skills in children living with asthma under their care will be instrumental in improving health outcomes for the children such as quality of life, sleep, school attendance, and in turn school performance. 3. School nurses can deliver age-appropriate positive messages that convince children that they have the capability to manage their condition independently, thus enhancing self-efficacy and transitioning care to the individual level. 4. If school nurses intervene early in elementary school years, children will have the knowledge, skills, and confidence to allow for a smoother transition to higher grade levels. 5. Successful asthma self-management requires knowledge of asthma facts and symptoms, triggers, and correct medication techniques. School nurse–led asthma intervention programs should be periodic and reinforce learning while providing opportunities to practice self-monitoring and goal setting for asthma self-management with the guidance of school nurses. Nurses have the experience to determine whether the children have acquired asthma self-management knowledge and skills. 6. Nurse researchers can partner with school nurses and other school professionals in school settings to conduct, implement, and replicate studies designed to improve the health and well-being of children of all ages with chronic conditions in the school setting. Acknowledgments I would like to thank the school principals, health service managers, and school nurses who supported this research as a means to improve the health of students living with asthma. I also want to thank the American Lung Association—Houston Office and school nurses for supporting this research study for healthier students. I wish to thank all the children who willingly assented and participate in this study. Author Contribution All authors contributed to conception of the article, critical revisions, approved the final text and agreed to be accountable for all aspects of work ensuring integrity and accuracy. E. Isik and N. Fredland contributed to the acquisition and analysis of the data. The article was drafted by E. Isik. 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. 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Fredland, PhD, RN, is a professor at Texas Woman’s University’s Nelda C. Stark College of Nursing in Houston. The Journal of School Nursing 37(6) Anne Young, EdD, RN, is a Professor Emerita at Texas Woman’s University’s Nelda C. Stark College of Nursing in Houston. Rebecca J. Schultz, PhD, RN, CPNP, FAES, is an associate professor at Texas Woman’s University’s Nelda C. Stark College of Nursing in Houston and an assistant professor at Baylor College of Medicine in Houston. Copyright of Journal of School Nursing is the property of Sage Publications Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. Purchase answer to see full attachment

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