January 2002, Vol 24, No. 1 |
Original Article
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Knowledge of asthma and its management: A study in primary schoolteachers in Hong KongK L Tse 謝國麟 , T S Yu 余德新 HK Pract 2002;24:4-14 Summary Objective: Asthma is a prevalent disease among school children. The quality of care provided to asthmatic students during school hours depends largely on the teachers' competency in handling their illnesses. This study looked into the knowledge of asthma among primary schoolteachers in Hong Kong and the possible determinants of their knowledge. Design: This was a cross-sectional survey in which schools were randomly selected from the primary school registry and all teachers of the participating schools (N=1502) were included. A self-administered questionnaire was sent out to each teacher and included questions on knowledge of asthma, personal experience with asthma and training, and basic demographic data. Subjects: Primary schoolteachers in Hong Kong. Main outcome measures: Teachers' competency as reflected by their answers to individual question and summary scores to each subsection. Results: 1162 (77.5%) of the teachers returned the questionnaires. Less than half of the teachers knew that medication may be taken before exercise to prevent acute attacks, and that the asthmatic child was as competent as normal children in sports. Around a quarter of them knew the prevalence of the disease, or that cough could be the only symptom. Only 16% knew that children should use a bronchodilator inhaler for mild attacks. Their scores on general concept of asthma, asthma and exercise and asthma medication and management were 67%, 52% and 39% respectively of the maximum scores. Previous education on asthma was found to be the only important modifiable factor affecting their knowledge. Conclusion: We concluded that primary schoolteachers in Hong Kong were deficient in knowledge of asthma, especially in the care of asthmatic children, and that asthma education programs might be able to improve their knowledge on this matter. Keywords: Childhood asthma, knowledge, primary school teachers, education programs 摘要 目的：哮喘是學齡兒童中常見的疾病，教師對這病的 認識及對病發兒童的照顧尤其重要，這研究之目的，在於探討香港小學教師對兒童哮喘病的認識，從而評 估有關編制哮喘教育課程之需要。 設計：從香港教育署所提供之香港小學註冊登記，用 隨機抽樣揀選出八十多間學校參與調查，研究主要以郵寄問卷方式進行，問卷內容包括教師對哮喘病的認 知，他們個人對這病的經驗，及有關哮喘病教育課程的問題。 對象：香港小學教師。測量內容：教師對獨立問題提供正確答案的百分比及 他們在每組問題的總得分，從而反映他們對哮喘病的認知及照顧病發學童的能力。 結果：共有1162(77.5%)教師作出回應。少於一半的教師知道運動前吸用擴張氣管藥物可以預防哮喘突發，以及哮喘病患者在運動的表現不會遜色於沒有這病的人。只有四份之一知道咳可以是哮喘唯一的徵狀 及這病的重要性。不足兩成知道病發初期便需要使用吸入氣管擴張前，以防病情惡化。有關哮喘病的課程 及講座是影響教師表現唯一的可改變因素。 結論：香港小學教師對哮喘病的認識極之貧乏，尤以 照顧病發學生方面。而研究指出有關哮喘的教育課程極有可能提高教師們對這病的認知及處理的能力。 主要詞彙：兒童哮喘、知識、小學教師、教育課程 Introduction Asthma is a prevalent disease in Hong Kong, especially among young children. According to a recent report of the International Study on Asthma and Allergies in Children (ISAAC) from Hong Kong in 1995, the cumulative and 12-month prevalence of wheezing in 6-7 years old children was 16.8% and 9.2% respectively.1 Compared to previous studies in Hong Kong,2,3 the prevalence seems to have increased. Children spend a considerable amount of time in school every day. Schoolteachers are responsible for making decisions concerning the amount of physical exercise that asthmatic children should take and actions to be taken when acute asthmatic attacks occur. According to the British Guidelines on Asthma Management,4 each Health Authority should liaise with all education authorities and establishments to ensure that each school has an asthma policy. The Asthma Special Interest Group of the Thoracic Society of Australia and New Zealand also recommended that training of schoolteachers in appropriate asthma care should be improved, and that schools should encourage a policy of exercise for all students with asthma.5 It is important for primary schoolteachers to be equipped with a certain level of knowledge of asthma and its management so that optimal care will be provided to asthmatic students during school hours. Assessment of schoolteachers' competency is essential as it can provide evidence-based guidelines for the implementation of asthma education programs in schools. There are only a few studies on this issue, including those done by Bevis and Taylor6 in London in 1990, Brookes and Jones7 in 1992 in Southampton, Seto etal8 in 1992 in Auckland, Brook and Shiloh9 in 1994 in Israel and Madsen etal10 in Denmark in 1993. All these studies revealed that the knowledge of primary schoolteachers on asthma was very limited, particularly regarding the care and treatment of students with acute attacks. However, no similar study has been conducted in an Asian country. It is believed that substantial differences exist between the general public in Western and Asian countries in relation to their general medical knowledge. Thus, there is need to assess the magnitude of the problem among schoolteachers in Hong Kong, which will in turn provide guidelines for the planning of any remedial program, if necessary. The specific objectives of this survey were:
Method A cross-sectional survey among primary schoolteachers in Hong Kong was conducted using a self-administered questionnaire. The primary school registry supplied by the Education Department served as the sampling frame. A number was assigned to each school in the registry. Eighty-two were then randomly selected by using a random number computer program. All teachers in the selected schools were invited to participate to achieve a target sample size of over 1000. A questionnaire was sent to every teacher in the participating schools after consent was obtained from the principals. Completed questionnaires were returned to the investigators using self-addressed envelopes. Part I of the questionnaire consisted of 37 items on the general concept of asthma, asthma and exercise and asthma medication and management. These items were set with reference to the asthma education pamphlet published by the Central Health Education Unit of Department of Health of Hong Kong and the Hong Kong Asthma Society. Response to each item carried a score (ranging from 2 to 4) according to its relative importance as graded by a group (20 in total) of paediatric respirologists (Table 1). Part II consisted of questions regarding training and on sources of further training. Personal information such as age, sex, marital status, education level, teaching experience, personal experiences with asthma was included in Part III.
The major dependent variable was the knowledge level of asthma, and the independent variables included the teacher's teaching experiences, education level, previous training received on asthma, personal experience with asthma and demographic data. The percentages of correct response to individual items and the mean scores of the different sub-sections of the knowledge questionnaire (general concept of asthma, asthma and exercise, asthma medication and management) were calculated together with the corresponding 95% confidence intervals. Selected individual important items from the knowledge questionnaire were further analysed to find out the associated independent factors by logistic regression using the forward stepwise procedure. Summary scores of the sub-sections were also analysed for their associated independent factors by stepwise multiple linear regression. All analyses were done using the SPSS for Windows. Results Response rates A total of 82 schools were contacted, 52 agreed to participate in the study and included 9 government, 38 government-aided and 5 private schools. The response rate for schools was 63.4%. 1502 questionnaires were sent out and 1162 questionnaires were returned giving a response rate of 77.5%. Demographic data Around 79% of the respondents were female and 71% of them were over the age of 30. Thirty-two percent of them had received tertiary education above the minimal requirement for primary schoolteachers. Eighty-three percent had more than 3 years of teaching experience. Seventy-five teachers (6.5%) were themselves asthmatic; 6.7% had asthmatic children at home; 28.2% had an asthmatic relative and 59.0% had the experience of having asthmatic students in class. General concept of asthma Table 1 shows the responses of the teachers to items on knowledge of asthma. The percentages of correct responses ranged from 16.0% to 97.2%. Although most teachers knew that difficulty in breathing, wheezing and chest tightness were the main symptoms of asthmatic attack, only 28.7% knew that cough could be the only symptom of the disease and 41.4% of them did not know that blue discoloration of the lips indicates a severe attack. Almost one third of them thought that asthmatic children were slow learners. Nearly half of them did not know that asthmatic attacks could be triggered by emotion. Not surprisingly, only 26.5% of them were aware of the prevalence of childhood asthma in Hong Kong though the majority of them knew that the disease might be fatal. Asthma and exercise Almost one third of the teachers were not sure or thought that asthmatic children should avoid physical education lessons. Only 39.6% of them knew that asthmatic children were as competent as normal children in sports and more than half of them did not know that drugs taken before exercise might help some asthmatic children. Asthma medication and management Although 77.1% of the teachers knew that bronchodilators were used to relieve acute asthmatic attacks, only 16% of them knew that children should use a bronchodilator inhaler even when the attacks were very mild and that would not result in dependence. Summary scores In general, the teachers performed best in the sub-section on general concept of asthma, with a mean score of 54.33 (95% confidence interval: 53.62 - 55.04) out of the maximum of 81 or 67%. They performed worst in the sub-section concerned with asthma medication and management with a mean score of 6.55 (95% confidence interval: 6.31 - 6.79) out of the maximum of 17 or 39%. The mean score for the sub-section on asthma and exercise was 12.65 (95% confidence interval: 12.34 - 12.96) out of the maximum of 24 or 53%. Teachers' concerns and opinion on asthma education Only 4% of the teachers had ever received specific training on asthma and 9.2% of them regarded themselves as competent in taking care of asthmatic students. The majority of them (89.7%) wanted more education on asthma. Among these teachers, 53% thought that talks or seminars were appropriate, 59.5% preferred pamphlets, while 63.9% regarded videotapes as the suitable media for education. Determinants of level of knowledge Logistic regressions on selected individual questions showed that in general, male and younger teachers, those with previous education on asthma, those who taught physical education, those who were asthmatic themselves or had asthmatic children or relatives performed better (Table 2). Multivariate analysis on the sub-section scores also showed that male teachers, those with previous education on asthma, those who were asthmatic themselves or had asthmatic children or relatives generally performed better (Table 3). In addition, those with longer teaching experience had higher scores on general concepts of asthma.
School policies Eighty percents of the surveyed schools kept a formal registry of asthmatic students. The computed prevalence of asthma according to information supplied by them was 3.1%. None of the school had a nurse and only 4% had staff who has ever received specific training on the care of asthmatic children. Although children were allowed to keep their inhalers at school, only in 12% of them were the teachers supervising the use of medication. Discussion This was the first study conducted in Asia on the knowledge of schoolteachers on asthma. With 52 schools and 1162 teachers participating, this was in fact the largest survey among similar studies in the world. The results showed that primary schoolteachers in Hong Kong were quite deficient in knowledge about asthma, especially concerning medication and management. The main modifiable factor associated with better knowledge was previous training/education on asthma. Not surprisingly, either personal experience or family experience with asthma was a predictor of better knowledge. The lack of knowledge about childhood asthma in primary schoolteachers in Hong Kong was in line with the findings of previous studies in other western countries.6-10 However, the deficiency in knowledge might have been underestimated in the current study. The response rate was satisfactory among teachers (77.5%) but was relatively low for schools (63.4%). Some schools refused to participate on the ground that their teachers had little knowledge about asthma or that there was no asthmatic student in their schools. It was also likely that teachers with more knowledge would be more willing to participate while those with less knowledge of this issue might refuse to answer the questionnaire. Since the questionnaire was self-administered, it was possible that teachers discussed the questions among themselves, looked up information from books, newspaper and journals, or even sought advice from professionals before answering. This would have led to a spuriously high level of knowledge among the participants thus underestimating of the deficiency in knowledge on asthma. If the teachers were not fully aware of the high prevalence of the disease, the precipitating factors and the signs of attacks, and the appropriate use of bronchodilators during mild attacks, asthmatic children would be deprived of the necessary care and treatment should any asthmatic attack occur at school. Misconceptions about the relationship between asthma and sport might lead to the reduction of asthmatic children's opportunities in pursuing their potential in sports. Teachers should encourage asthmatic children to take full part in sport and exercise and should allow and encourage children with exercise-induced asthma to use pre-exercise bronchodilator inhalers. The results of the multivariate analyses showed that an education program on asthma was likely to be beneficial in improving teachers' knowledge. This was in agreement with the findings of the studies by Brook and Shiloh9 and Madsen etal.10 Shah etal11 also demonstrated that teachers' knowledge of asthma and confidence with the management of acute asthma at school improved following asthma education workshops. However, some studies failed to show any statistically significant beneficial effect of asthma education programs.6,12 Experience of education about asthma among teachers was very uncommon as in other studies.7,10 Only 4% of the teachers had ever received specific training on asthma. According to the current prevalence of the disease in Hong Kong, there should be at least four students suffering from asthma in an average class of 40 students. Therefore, the lack of training and confidence of teachers in taking care of asthmatic children should be rapidly remedied in order to provide optimal care to asthmatic children during school hours. The need was further reflected by the fact that the majority of teachers demanded more education on asthma. Ideally, every school should be equipped with full-time health professionals who are competent in taking care of school children should any health problem occur during school hours. However, before we can afford that, teachers remain the most immediately available and appropriate persons in providing essential health care or advice to school children during school hours. In view of the high prevalence of childhood asthma and the inadequacy of school teachers' knowledge, education programs should be provided to improve teachers' capability in taking care of asthmatic children. These programs can be in the form of health talks, seminars, education pamphlets as well as audiovisual material. According to the information provided by the Department of Health and the Education Department, there has been no well-organised, structured education program for schoolteachers on this issue. In order to rectify the shortcomings and improve the future care of asthmatic children in school, it is strongly recommended that the health authorities, family physicians and the Education Department collaborate to provide structured education programs on asthma for teachers. Ideally, such programs should also be incorporated into the curricula of teachers training colleges so that even new graduates would be equipped with a minimum level of knowledge on the subject. Together with the provision of continued in-service training for current teachers, it is hoped that the care provided to asthmatic children during school hours can be improved, both in terms of quality and quantity, and that the associated morbidity and mortality can be reduced in the future. Further research should also be conducted to evaluate the effectiveness of various education programs, in terms of approach and contents, and to compare their cost-effectiveness. Conclusion This was the first survey conducted in Asia on the knowledge of asthma in primary schoolteachers. The main aim was to describe the competency of primary schoolteachers in Hong Kong in relation to the knowledge of asthma and its management. It was also aimed at exploring the determinant(s) of such knowledge. School policies and teachers' attitude towards asthma education were also studied. The chief objectives were fulfilled and the results were valid, despite certain limitations. In summary, we have described the deficiency in knowledge about asthma among primary schoolteachers in Hong Kong and identified that proper education on asthma may help to improve their knowledge. It is recommended that structured education programs be organised to improve teachers' knowledge on asthma, through the collaboration of the various health authorities, family physicians as well as the Education Department. Acknowledgements Special thanks should be addressed to Prof J A Dickinson and other teaching staff of the Department of Community and Family Medicine, CUHK, who have provided invaluable advice and assistance throughout the whole process and made this survey possible. The authors would also like to express sincere gratitude to Dr Theresa NH Leung who has made substantial contributions to the design of the study and provided regular revision throughout whole period. Thanks should also be given to doctors of the Hong Kong Paediatric Respiratory Study Group who have played an important role in validation of the questionnaire and scoring of the questions. Finally, the authors would like to thank the clerical staff of the Health Assessment Department of the Hong Kong Sanatorium and Hospital for their efforts in assisting the handling of questionnaires, as well as other clerical support. Key messages
K L Tse, MBBS(HK), FRACGP, MPH(CUHK), DFM(CUHK) T S Yu, MBBS(HK), MPH, FAFOM Correspondence to : Dr K L Tse, Out-patient Department, Hong Kong Sanatorium & Hospital, 2 Village Road, Happy Valley, Hong Kong. References
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