IMPACT OF SMALL GROUP INTERACTIVE EDUCATION, ON CHILDHOOD ASTHMA LEVEL OF CONTROL.

:-Asthma is the most common chronic disease among children, with a significant increase in its prevalence, especially in recent decades . This study was conducted at Al-Azhar university hospital allergy pulmonology follow up Clinic and included ninety children, 6 months -12 years old, and their families from Jun. to Nov. (2013). The thesis was performed to study the impact of the asthma education sessions on the out come of asthma management in children. The study revealed that asthma educational session have a positive impact on management of asthmatic children in the form of:

The educational program was targeted the parents/caregivers and child with core content adapted for age level as appropriate. Materials used are pictures with puzzle education ( fig. 5, 6, 7) videos showing a demo for using inhalers, interaction between the physician and parents or children. Results was tabulated and statistically analyzed.
The curriculum for children is part of the Asthma Awareness: Curriculum for the Elementary Classroom which was developed by the National Heart, Lung, and Blood Institute (NHBLI). There are three lessons for grades K-3, each requiring approximately 30 minutes per session. Instruction for grades 4-6 is divided into three lessons, each about 30 minutes in length.
he curriculum for parents is three lessons to educate parents caregivers of children with asthma about the proper treatment and management of the childhood asthma. The lessons were created using the Environmental Protection Agency and Centers of Disease Control booklet entitled Help Your Child Gain Control Over Asthma.

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There is also some supplementary information included from two National Heart, Lung and Blood Institute brochures: So You Have Asthma brochure, and Managing Asthma brochure: A Guide for Schools, as well as Medline Plus (Asthma -Control Drugs, How to use a nebulizer and Asthma Airways graphic which can be found on the What is Asthma?) which is an online service of the U.S. Library of Medicine at the National Institutes of Health.
he information presented in these lessons correlate with the information in the children's curriculum so that the parents and children will be learning the same information.
It is our hope that this will foster a thoughtful conversation between children and their parents and help them gain control over asthma.\

All of the lessons are designed to:
• Develop a basic understanding of asthma and help correct misinformation. • Explanation of asthma triggers and what to do to control them. • Highlight that children can lead active lives with asthma.
• Provide resources to share with parents and other family members.       This table shows that 42.2% of the studied patients has no a family history of asthma and 57.8% has a family history of asthma.     705 This table shows that reduction of days occur in both groups starting from the first follow up visit but reduction occur more in the interventional group. It was also noticed that the comparison was statistically significant starting from the first follow up visit then become highly significant at the end of the period of the follow up.   This table shows reduction occurs in both groups but more in interventional group. It was noticed that the comparison was statistically significant starting from the first follow up visit then become highly significant at the end of the period of follow up. Figure 6:-Occurrence of number of days of absence from school per week due to asthma during the study period. By using paired t-test this table clarified that comparison between number of days of absence from school per week due to asthma before follow up and each follow up visit after sessions in both interventional and non interventional group and the comparison was statistically highly significant starting from the first follow up visit in the interventional group whereas wasn't statistically significant until the third follow up visit and only highly significant at the end of the follow up period in the non interventional group.  This table shows that reduction of number of times occurs in both groups but more in interventional group. It was also noticed that comparison was highly significant from the first follow up visit.  By using paired t-test this table clarified that the comparison between number of times of E.D. visits per week due to asthma before follow up and each follow up visits in both interventional and non interventional group and the comparison was statistically highly significant from the first follow up visit but in the non interventional group whereas it was statistically highly significant only in the second follow up visit after session and highly significant at the end of the follow up period. This table shows that reduction in number of days occurs in both groups but it was more in the interventional group. It was also noticed that the comparison was highly significant from the first follow up visit.

weeks follow up visit Difference in number of times of use of rescue therapy per week before follow up and at 8 weeks follow up visit
0.017* 0.000*

Difference in number of times of use of rescue therapy per week before follow up and at 12 weeks follow up visit
0.003* 0.000* Non sig. >0.05 Sig. <0.05* High sig. <0.001 By using paired t-test this table clarified that comparison between number of times of rescue therapy per week before follow up and each follow up visit after sessions in both interventional and non interventional group and the comparison was highly significant from the first follow up visit in the interventional group whereas it was significant in the second follow up visit in the interventional group. This table shows that reduction of night disturbance occurs in both groups but occurs more in the interventional group and it was also noticed that the comparison was significant from the first follow up visit then become highly significant in the following follow up visit.   By using paired t-test this table clarified that comparison between number of night disturbance per week due to asthma before follow up visit and each follow up visit in both groups and the comparison was statistically highly significant from the first follow up visit whereas it was statistically significant only at the third follow up visit after sessions. This table shows that reduction of times occurs in both groups but occurs more in the interventional group and it was also noticed that the comparison was significant from the first follow up visit and become highly significant at the end of the follow up period.  By using paired t-test this table clarified that the comparison between number of times of admission to hospital per week due to asthma before follow up and each follow up visit after sessions in both groups and the comparison was statistically significant from the first follow up visit and become highly significant in the next follow up visit whereas in the interventional group the comparison was statistically significant only in the third follow up visit.

Paired t-test Non intervention
Intervention Difference between esinophilic count before and after follow up visits 1.000 0.048* By using paired t-test there is statistically significance in comparison between eosinophilic count in intervention group before and after follow up visits. And no statistically significance in comparison between esinophilic count before and after follow up visits in non intervention group.    week.         This table shows the effects of education on asthma control level in intervention group using eosinophilic count. It was noticed that no statistically significance in comparison between subgroups.    720 By using paired t-test this table shows comparison between number of days of restricted activities per week due to asthma before follow up and at each follow up visit in all subgroups (B1, B2, B3) and it was noticed that no statistically significance in comparison in all subgroups .

before follow up and at 8 weeks follow up visit Difference in number of days of absence from school per week due to asthma before follow up and at 12 weeks follow up visit
0.000 0.000 0.000 By using paired t-test this table shows comparison number of days of absence from school per week due to asthma before follow up and at each follow up visit in all subgroups (B1, B2, B3) and it was noticed that no statistically significance in comparison in all subgroups

weeks follow up visit Difference in number of times of E.D. visits per week due to asthma before follow up and at 4 weeks follow up visit
0.000 0.000 0.000

Discussion:-
Asthma is a common cause of emergency room visits and hospital admissions. the burden of asthma is higher than generally recognized, particularly in children. For example, in Egypt up to one in four children with asthma is unable to attend school regularly because of poor asthma control (7).
Asthma education that is directed at self-management can reduce morbidity, improve lung function, feelings of self control, reduce absenteeism from school, number of days with restricted activity, number of visits to the emergency department, and possibly the number of sleep disturbed nights (8).
The present study included 61 male child and 29 female child. Generally, asthma is more common in boys at school age (9). The reasons for this sex related difference are not clear. However, lung size is smaller in males than in females at Birth. Age and sex had no relation, in the present study, to asthma symptoms, restricted child's physical activity or the rate of asthma attacks .
In the present study there was statistically significant reductions in the mean number of days with restricted activities from (1.97±0.80) in the first visit to (0.28±0.15) in the fourth follow up visit with P value < 0.001. The reduction of days with asthma symptoms was progressively increasing in the follow up visits.
These results were in agree with the results obtained by Clark , et al 2004 which showed a significant decline in daytime symptoms by the time of the second follow-up. Treated children experienced fewer days with symptoms when compared to control children (P value < 0.0001).
The results also matched with the study done by Butz (10) to determine the effectiveness of an asthma educational intervention in improving asthma knowledge, self-efficacy, and quality of life in rural families. Their results revealed that asthma education of children 6 to 12 years of age was associated with statistically significant reductions in the mean number of days with asthma symptoms.
Number of nights disturbed by asthma symptoms was, also statistically significant less in the fourth follow up visit (0.25±0.12), compared to the first visit (0.87±0.45), with P value< 0.001. These results were in agree with the results obtained by Toelle et al., (11) who assessed whether school-based asthma education affected the number of nights on which children experienced nocturnal symptoms and found that asthma education led to a statistically significant reduction in nights disturbed by asthma symptoms relative to children who received usual care. The results also agree with that obtained by Deaves, (12), who reported significant improvement in night symptoms during assessment of the value of health education in the prevention of childhood asthma.
Regarding school absences in the present study, it was found that there was a decrease in the number of schoolabsence days from (0.98±0.41) in the first follow up visit to (0.25±0.10) at the fourth follow up visit. Levy et al. (13); reported similar findings among children who received the asthma education intervention compared to children who received usual care.
The present study showed a decrease in ED. visits for asthma from (0.67±0.51) in the first follow up visit to (0.42±0.50) at the fourth follow up visit. These results also agree with the results obtained by Tinkelman and Schwartz, (14) who showed that a comprehensive, school-based asthma management program can successfully reduce unscheduled doctor visits by two thirds. This can be attributed to educating parents and their children about self monitoring of exacerbation by symptoms and managing these exacerbations by modifying the dosages of drugs, especially controlled medication.
In the current study, it was found that there was decrease in the use of use of rescue therapy from (1.02±0.75) in the first follow up visit to (0.85±0.65) at the fourth follow up visit. . Similar results were reported in the study done by Levy et al. (2000) which showed that the educated patients in hospital-based nurse specialist delivered selfmanagement education during three sessions had significantly decreased in the use of SABA for quick relief of symptoms for asthma after 6 months Compared to patients receiving usual care.
Not only asthma symptoms improved but also patient and family satisfaction with asthma self-management program was obvious. Same conclusion was reported by Maridee Jones, (16).
In the present study age and sex did not show to influence the response to the education session.
In the present study the educational intervention was conducted to the children and their family through individual meeting with patients and their families, supported with an asthma action plan and reassessment through four follow up visits.
In the current study only 90 children out of 177 (50%) asthmatic children continued follow up for next 5 visits. Several factors might contribute to non adherence of 50% of patients who received the first education session. Costs of traveling may be one factor but undiscussed fears or concerns and unclear message on part of the instructor may be another factor.
Increasing awareness of nature of the diseases allowed patients and families to adopt a self management plan of the diseases at home and decreased the rush in seeking medical advice for each episode of worsening symptoms.
Asthma symptoms during night and days became significantly less, however after the 3 rd visit; representing the time when the educational sessions resulted in virtual control of the diseases. The number of puffs per day of quick-relief medication became, also significantly less after the 3 rd visit significant.
The number of asthma attacks requiring visiting the doctor or emergency room, however became significantly less by the 4 th visit. Although this result would suggest incomplete control of asthma, it may, on the other hand, represent appropriate judgment of patients and their families as when to seek medical advice.
The key factor in the present study was the interactive educational sessions by a physician to provide and reinforce the educational endeavor which increase adherence to the asthma guidelines, improve quality of care and patient outcomes.
It was noted in the present study that education level and age doesn't affect the outcome any of parameter that used in the research that used to assess the outcome of the AEP on childhood asthma.
So we can consider that AEP is a sufficient curriculum to be used in small group interactive education to different age groups and education level.
Also, eosinophilic count decline significantly after control of the six parameter mentioned previously from (2.60±1.66) before follow up visits to (1.97±1.37) after follow up visits in the intervention group.
Collectively, education session during chest clinic visit could result in a better asthma control. It is not surprising that children who knew more about asthma and who had better self-management skills, avoidance of environment triggers, better inhalation technique, and closer adherence to therapeutic regimens could have a reduction in asthma symptoms