PHD Public Health Doctoral Thesis Update

IMPACT OF HEALTH EDUCATION ON
KNOWLEDGE AND PERCEPTIONS OF ASTHMA AMONG
SECONDARY SCHOOL STUDENTS IN ILE- IFE, SOUTH-
WEST, NIGERIA
THESIS
Submitted to Texila American University
in partial fulfilment of the requirement for the award of the Degree of
Doctor of Philosophy in Public Health
Submitted by
[ILESANMI OLUWAFEMI TEMITAYO]
Under the Guidance of

[DR ADEGBENRO CALEB ADEREMI]
1
TEXILA AMERICAN UNIVERSITY
GUYANA
IMPACT OF HEALTH EDUCATION ON
KNOWLEDGE AND PERCEPTIONS OF ASTHMA AMONG
SECONDARY SCHOOL STUDENTS IN ILE- IFE, SOUTH-
WEST, NIGERIA
THESIS
Submitted to Texila American University
in partial fulfilment of the requirement for the award of the Degree of
Doctor of Philosophy in Public Health
Submitted by
[ILESANMI OLUWAFEMI TEMITAYO]
Under the Guidance of

[DR ADEGBENRO CALEB ADEREMI]
2
TEXILA AMERICAN UNIVERSITY
GUYANA
CERTIFICATE
This is to certify that the thesis, entitled “Impact of Health Education on Knowledge and
Perceptions of Asthma among Secondary School Students in Ile- Ife, South- West,
Nigeria” submitted to the Texila American University, in partial fulfilment for the award of
the Degree of Doctor of Philosophy in Public Health is a record of original research work
done by [ILESANMI OLUWAFEMI TEMITAYO], under my supervision and guidance
and the thesis has not formed the basis for the award of any Degree/ Diploma/ Association/
Fellowship or other similar title to any candidate of any University.
.................................................................................
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DR ADEGBENRO CALEB ADEREMI
DATED THIS DAY- 20TH OF APRIL, 2018.
DECLARATION
I, ILESANMI OLUWAFEMI TEMITAYO, declare that the thesis entitled “Impact of
Health Education on Knowledge and Perceptions of Asthma among Secondary School
Students in Ile- Ife, South- West, Nigeria” submitted in partial fulfilment of the degree of
Doctor of Philosophy is a record of original work carried out by me under the supervision of
[DR ADEGBENRO CALEB ADEREMI], and has not formed the basis for the award of
any other degree or diploma, in this or any other Institution or University. In keeping with the
ethical practice in reporting scientific information, due acknowledgements have been made
wherever the findings of others have been cited.
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...................................................................
ILESANMI OLUWAFEMI TEMITAYO
DATED THIS DAY- 20TH OF APRIL, 2018.
ACKNOWLEDGEMENTS
I want to appreciate everyone who contributed to the success of this great work with the
“Paul’s letter to the Philippians”... I thank God for each of you every time I think of you; and
every time I pray for you. I pray with joy because of the way in which you have helped me in
this work from the very first day until now. You will always be on my heart. May the Lord
Jesus Christ be with you now and always (Good News Bible).
- The President of our great University, the Faculty members of the School of Public
Health and members of staff of the Texila American University.
- Dr Caleb Aderemi Adegbenro, My local guide and supervisor, an Associate Professor
of Public Health, Obafemi Awolowo University, Ile- Ife, Osun State, Nigeria.
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- Dr Sonika Raj Goel, My research guide (an Astute Public Health expert) at the
Faculty of Public Health, Texila American University.
- Rev (Prof) Gregory Efosa Erhabor and Rev (Mrs) Ayodele Erhabor (Professor of
Respiratory Medicine and Senior Pastor, Sanctuary of Hope Church International, Ile-
Ife, Osun State, Nigeria).
- Drs Adewole Olufemi, Awopeju Olayemi, Adeniyi Bamidele, Oyewo Tinuke
(Respiratory Physicians); Dr Olatona Foluke (Consultant Community Physician) and
Dr Adesanmi Akinsulore (Mental Health Physician).
- Dr Sreevani V, Ms Jignasha Francis Muhindi, Ms Susmitha Archarya, Ms Anitha A
Anitha, Ms Divya Rajan and Ms Indu S (Student Coordinators and Sales
Representative in TAU).
- Drs Lamidi Emmanuel, Adedeji Ganiyu, Daniel Ebenezer Obi, Mrs Arilewola
Abosede and all colleagues in the Faculty of Public Health Programme in TAU.
- Prof Henry Odeyinka, Prof (Mrs) Simisola Odeyinka, Dr Tope Kehinde, Dr Victor
Okorie, Dr Joshua Awopeju, Dr Abiola Ogundele, Dr Temitope Olajubu, all body of
Ministers in Sanctuary of Hope Church and all members of Sanctuary of Hope
Church International.
- Dr Olubukola Oyelese (Director, Medical Rehabilitation Services, OAUTHC, Ile- Ife,
Osun State, Nigeria) and all members of staff of the Department of Medical
Rehabilitation, OAUTHC, Ile- Ife.
- Dr Michael Ogbonnaya Egwu, Prof Rufus Adedoyin and all members of staff of the
Department of Medical Rehabilitation, Obafemi Awolowo University, Ile- Ife, Osun
State.
- All the Principals of the Schools used for the study.
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- All the study participants in the selected secondary schools in Ile- Ife, Osun State,
Nigeria.
- Physiotherapists Rose, Sangodoyin, Oluwaseun, Akin, Funke, Joy, Omolola, Segun,
Temitope, Tomi (who are final year clinical students of Physiotherapy at the time of
the study but are now licenced PTs).
- Miss Adebimpe Ogundalu and Mr Olanrewaju Adedoyin (Research Assistants).
- Mr Augustus Oladipupo Ilesanmi (My dear Father), Mrs Grace Bosede Ilesanmi (My
dear Mother), Engr Adekunle Ilesanmi, Mr Bankole Ilesanmi, Mr Gbenga Ilesanmi,
Engr Eniola Ilesanmi (My wonderful siblings).
- Dr (Mrs) Adeyinka Oluwafunmilayo Ilesanmi (My sweetheart and ever supportive
wife- a Family Physician at OAUTHC, Ile- Ife, Osun State) and my wonderful,
gracious and supportive children (VIRTUE, OLUWASEMILORE, ERIOLUWA
AND IDUNNUOLUWA).
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...................................................................
ILESANMI OLUWAFEMI TEMITAYO (DATED THIS DAY- 20TH OF APRIL, 2018).
DEDICATIONS
THIS GREAT WORK IS DEDICATED TO THE
ALMIGHTY GOD, THE GIVER OF
IMMEASURABLE GRACE AND TO ALL
ASTHMATIC ADOLESCENTS ALL OVER THE
WORLD.
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ABBREVIATIONS
FEV1 – forced expiratory volume in one second
GINA – Global Initiative for Asthma
IgE – immunoglobulin E
PEF – peak expiratory flow
ISAAC-International Study of Asthma and Allergies in Childhood
ECRHS- European Community Respiratory Health Survey
GBAR- Global Burden of Asthma Report
WHO- World Health Organization.
NAEPP- National Asthma Education and Prevention Programme
SPSS- Statistical Package of Social Sciences
NAKQ- Newcastle Asthma Knowledge Questionnaire
IPQ-R- Revised Illness Perception Questionnaire
ANOVA- Analysis of Variance
DF- Degree of Freedom
SD- Standard Deviations
RCP3- Royal College of Physicians 3 Question Screening tool
ACQ- Asthma Control Questionnaire
ACT- Asthma Control Test
CACT- Childhood Asthma Control Test
BHR- Bronchial Hyperresponsiveness
ENO- Exhaled Nitric Oxide
AQLQ- Asthma Quality of Life Questionnaire
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PAQLQ- Pediatric Asthma Quality of Life Questionnaire
ABSTRACT
Background: Asthma is a major public health problem among adolescents with significant
functional disability. Inadequate knowledge and poor perceptions of the disease are highly
contributory to its impact. Patients’ education is vital in addressing this challenge.
Objective: The study assessed the level of knowledge and perceptions of asthma and the
impact of asthma health education programme among a group of the secondary school
students in Ile- Ife, Nigeria.
Methods: A quasi- experimental study with a repeated measure, non- equivalent groups
study design. Data for the study were obtained from both the intervention and control group
participants using a 71 item pre- tested, close ended, self- administered questionnaires to
assess the knowledge and perceptions of asthma at baseline (pre- test), one week (post test),
three weeks (post- test 2) and six weeks (post- test 3) in the intervention group and at six
weeks (post- test) in the control group. Participants were selected using multistage and
simple random sampling techniques. Data was analysed using both descriptive and inferential
statistics.
Results: The results of this study showed that perceptions and knowledge of asthma were poor
among the groups. Findings revealed that health education intervention had significant effect
on knowledge and perceptions of Asthma among the secondary school students (p< 0.05).
The result also showed significant changes over a period of time in the knowledge and
perceptions of asthma among the participants in the intervention group. The study further
revealed that there were significant associations between knowledge of asthma and the
secondary school students’ age and class level and between perceptions of asthma and
secondary school students’ class level. Only the ethnicity showed a significant association
with perceptions of asthma of the students before health education intervention.
Conclusion: The overall results showed that health educational interventions are effective as
well as essential and should be carried out to improve knowledge and perceptions of asthma
among early adolescents and older school age children such as secondary school students as
shown by this study.
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LIST OF TABLES
Table 1- Demographic characteristics of the participants
Table 2- Familial experience of the respondents in relation to asthma
Table 3- Comparisons of changes in knowledge scores in the intervention and control groups
Table 4- Comparisons of changes in perceptions scores in the intervention and control groups
Table 5- Repeated knowledge statistics for intervention group
Table 6- Repeated knowledge statistics for control group
Table 7- Repeated perceptions statistics for intervention group
Table 8- Repeated perceptions statistics for control group
Table 9- Association between socio-demographic variables and knowledge pre- test in the
intervention group
Table 10- Association between socio-demographic variables and perceptions pre- test in the
intervention group
Table 11- Association between socio-demographic variables and knowledge post- test in the
intervention group
Table 12- Association between socio-demographic variables and perceptions post- test in the
intervention group
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LIST OF FIGURES
Figure 1- Conceptual framework: Health Belief Model on asthma education
Figure 2- Conceptual framework: The model of Social Cognitive Theory
Figure 3- Research study process diagram
Figure 4- Percentage distribution of participants by gender
Figure 5- Percentage distribution of participants by age group
Figure 6- Percentage distribution of participants by class level
Figure 7- Percentage distribution of participants by ethnicity
Figure 8- Mean plot of knowledge scores for the intervention group
Figure 9- Mean plot of knowledge scores for the control group
Figure 10- Mean plot of perceptions scores for the intervention group
Figure 11- Mean plot of perceptions scores for the control group
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TABLE OF CONTENTS
CHAPTER TITLE PAGE NUMBER

COVER PAGE i
INSIDE TITLE PAGE ii
CERTIFICATE iii
DECLARATION iv
ACKNOWLEDGEMENT v
DEDICATIONS vii
ABBREVIATIONS viii
ABSTRACT ix
LIST OF TABLES x
LIST OF FIGURES xi
TABLE OF CONTENTS xii
1 INTRODUCTION 13
2 REVIEW OF LITERATURE 22
3 MATERIALS AND METHODS 69
4 RESULTS AND DISCUSSION 86
5 SUMMARY 114
6 CONCLUSION 116
7 CONTRIBUTION TO KNOWLEDGE 118
8 SUGGESTION FOR FUTURE RESEARCH 120
9 REFERENCES 121
10 APPENDIX 139
11 LIST OF PUBLICATIONS BASED ON THESIS 155
CHAPTER ONE
INTRODUCTION
The National Heart, Lung, and Blood Institute (NHLBI, 2003) defines asthma as “a chronic
inflammatory disorder of the airways in which many cells and cellular elements play a role.
In susceptible individuals, this inflammation causes recurrent episodes of wheezing,
breathlessness, chest tightness, and coughing, particularly at night or in the early morning.
These episodes are usually associated with widespread but variable airflow obstruction that is
often reversible either spontaneously or with treatment. The inflammation also causes an
associated increase in the existing bronchial hyper responsiveness to a variety of stimuli”
(NHLBI, 2003). Asthma is a chronic airway disease characterized by wheezing (a high
pitched whistling sound originating from obstructed airways). Patient usually presents with
13
chronic airways inflammation, bronchial hyper-responsiveness and reversible airflow
obstruction, resulting in the recurrent attacks of wheeze, chest tightness, breathlessness, and
occasionally cough and sputum production, all of varying severity and frequency from person
to person (WHO, 2012; GBAR, 2011; Bousquet et al, 2010; Reddel et al, 2009).According to
the World Health Organization, asthma is now a serious public health problem with about
330 million sufferers worldwide with a projection that it will increase by 100 million by year
2025 (WHO, 2007). Furthermore, studies indicate that asthma is not just a public health
problem for high income countries but is increasingly becoming widespread in the
developing world with most asthma related deaths occurring in low and lower-middle income
countries including Sub-Saharan Africa (WHO, 2008; Asher et al, 2006; Zar, 2001). The
Global Initiative for Asthma (GINA) estimates that the global prevalence of asthma ranges
from 1 to 18% of the total population of different countries (GINA, 2004). The International
Study of Asthma and Allergies in Childhood in children and the European Community
Respiratory Health Survey in adults have greatly increased our understanding of
epidemiology of asthma worldwide (ISAAC, 1998; Janson et al, 1997; ECRHS, 1996).The
highest asthma rates have been reported in affluent countries, such as the United Kingdom,
New Zealand, and Australia, whereas the lowest rates have been reported in India and
Indonesia (Lai et al, 2009).The incidence of asthma has been growing over the past 30 years
due to changing environmental factors, particularly in the low- and middle-income countries
that are least able to absorb its impact (GBAR, 2011). This increasing trend is expected due
to rise in atopic sensitizations, allergic conditions, and changing patterns of environmental
triggers (associated with environmental smoking exposure in children, population growth,
and urbanization) in Africa over the last two decades (Braman, 2006). Asthma morbidity,
mortality, and hospitalization rates have been disproportionately high among the poor and
medically underserved (Pachter et al, 2002; Shegog et al, 2001).The World Health
Organization (WHO) estimates about 250 000 deaths from asthma every year, mainly in low-
and middle-income countries (LMIC) (Bousquet et al, 2010; Braman, 2006). Fifty years ago
asthma was uncommon in Nigeria; however recent reports from different parts of Nigeria
have shown a prevalence of adolescent and adult asthma in excess of 10% and a rising trend
in the prevalence of asthma (Desalu et al, 2009; Erhabor et al, 2006; Ibe et al, 2002; Faniran
et al, 1999; Falade et al, 1998).The prevalence of asthma in Nigeria according to these studies
showed 10.7% (children) (Falade et al, 1998),14.2% (adolescents) (Ibe et al, 2002) and 5.1
-7.5%(adults) (Irusen, 2004).
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Asthma causes an estimated 340,000 deaths annually (GINA, 2014). In addition, the World
Health Organization estimates that around 15 million disability-adjusted life years (DALYs)
are lost annually through this disease (GINA, 2010). Worldwide, asthma accounts for around
1% of all DALYs lost, which reflects the high prevalence and severity of asthma. The
number of DALYs lost due to asthma is similar to that for diabetes, cirrhosis of the liver, or
schizophrenia. When ranking chronic diseases, asthma was the 25th leading cause of DALYs
lost worldwide in 2001 (Masoli et al, 2004). Asthma is a major health problem among
adolescents with studies identifying substantial under-diagnosis, poor acceptance of
diagnosis, poor compliance to treatment and poor understanding of asthma management
among this population (Oluwole et al, 2017; Musa et al, 2014). It has been suggested that
education of health care providers and the public is a vital element of the response to the
challenge posed by asthma (Braman, 2006; Ndiaye et al, 2004). Asthma education and
prevention remains the greatest opportunity for decreasing asthma incidence and mortality
(Kintner et al, 2015). Schools, rather than hospitals, are shown to be prime settings for
asthma health education for children and adolescents due to practicality and familiarity with
the environment (Valeros et al, 2001). Health education has the potential to help students
maintain and improve their health, prevent disease, and reduce health-related risk behaviours
(Kann et al, 2007). Studies have also shown that health education can enhance knowledge,
and change attitudes and behaviours (Daboer et al, 2008). Several school based asthma
education intervention studies have been conducted among students to assess the impact of
asthma health education programme with the results showing significant improvement in
their knowledge of asthma, reduction in school absenteeism, improvement in self- efficacy
perception and improvement in their quality of life (Cicutto et al, 2013; Bowen, 2013;
McGhan et al, 2010; Kintner et al, 2009). In a study by Shaw et al, 2005, health education
intervention program was tested in a non-equivalent control group design among a sample of
122 high school students recruited from two public schools out of which 19 were doctor
diagnosed asthmatics who completed the study. Asthma severity classification was not
reported. The asthma education program was given to the intervention school one week after
collecting baseline data. The efficacy of the program was evaluated at 1 week, 3 weeks, and 6
weeks after given the asthma education intervention based on multiple variables including
asthma knowledge, attitudes, self-efficacy, pediatric asthma–related quality of life, and self-
management behaviours. The result showed that self-efficacy perception demonstrated
minimal improvements over time.
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Butz et al. (2005) conducted a four hour education programme which was delivered over two
sessions to children with asthma to evaluate its effectiveness in improving knowledge of
asthma, self-efficacy, and health-related quality of life. After 10 months, children in the
intervention group reported higher mean scores on asthma knowledge (mean=12.45) than
those in the control group (mean 10.8, p<0.001). Also, Kintner and Sikorskii (2009) tested
the efficacy of a school-based academic (teaching) and counselling programme for 60
children from grades 4 to 6 in the USA (intervention n=38, control n=22). The study showed
an improvement in children’s asthma knowledge in terms of reasoning about asthma, use of
risk-reduction behaviours, and participation in life activities with significant difference
between those children who received the programme and those who did not (p<0.01). In
another study by Bowen, 2013, a total 32 children (intervention group n=15, control group
n=17) formed the sample. The intervention was the modified Open Airway for Schools
(OAS) programme. In this course, children (aged 8-12 years) were instructed in physiology
of asthma, detecting warning signs of asthma, device use, and avoidance of triggers. It was
conducted as weekly 90 minutes sessions for three weeks. Asthma Control Test, Paediatric
Asthma Quality of Life Questionnaire, and Spirometry Machine were used to measure
outcomes. The findings showed that the baseline knowledge score in the intervention group
was 70%. The knowledge score was significantly increased to 80% at first follow up and to
90% in the second follow up compared to 50% in the control group (F= 19.028, P< 0.001).
Velsor-Friedrich et al., (2004) reported that children in the intervention group that attended
an asthma education programme showed a significant improvement in self-efficacy scores
measured by the Asthma Belief Survey. The baseline score was 4.03, SD 0.10, which
increased significantly to 4.23, SD 0.10 after five months (p=0.046). Children in the
intervention group had a higher self-efficacy perception score and improved self-management
practice which correlated with improved asthma control. Also, Butz et al. (2005)
acknowledged a significant improvement in children's self-efficacy after implementing an
asthma education programme (mean score change +2.62, SD 6.3, p=0.005). The range of
social and psychological factors found to either influence, or be associated with asthma
perception and interpretation includes age, gender, Body Mass Index (BMI), history of
exercise-induced symptoms, and psychological state (Chen et al, 2006). Higher asthma
knowledge has also been found to be associated with positive attitude and internal locus of
control in asthma (Gibson et al, 1998). Also, ethnic background, age, body mass index and
residential area are significantly associated with atopic symptoms and disease as shown in a
Brazilian study done on adolescents (Gibson et al, 1998).
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Most of these data have come from developed countries and limited to students who have
asthma. To the best of my knowledge and through extensive review of literature, there is no
study conducted to evaluate the impact of health education intervention on knowledge and
perceptions of asthma among secondary school students in Ile Ife, Nigeria. This study is,
therefore, directed to assess the impact of health education on knowledge and perceptions of
asthma among secondary school students in Ile- Ife, Nigeria.
TERMS AND DEFINITIONS
Wheeze: A high pitched whistling sound originating from obstructed airways (GBAR, 2011).
“Wheeze at rest-12 months” refers to the prevalence of wheeze in a person in the last 12
months.
Asthma: A chronic airway disease characterized by wheezing (a high pitched whistling sound
originating from obstructed airways). Patient usually presents with chronic airways
inflammation, bronchial hyper-responsiveness and reversible airflow obstruction, resulting in
the recurrent attacks of wheeze, chest tightness, breathlessness, and occasionally cough and
sputum production, all of varying severity and frequency from person to person (WHO, 2012;
GBAR, 2011; Bousquet et al, 2010; Reddel et al, 2009).
Asthma ever: refers to cummulative prevalence of asthma in a person.
Asthma exacerbation (Also known as acute asthma): A sudden progressive episodes of
shortness of breath, usually characterized by chest tightness, wheezing, cough, or sputum
production (WHO, 2012)
Moderate asthma exacerbation: An event that, when recognized, should result in a
temporary change in treatment, in an effort to prevent the exacerbation from being severe
(Reddel et al, 2009)
Severe asthma exacerbation: Events that require urgent action on the part of the patient and
physician to prevent a serious outcome, such as hospitalization or death (Reddel et al, 2009)
Severe asthma: Uncontrolled asthma which can result in risk of frequent severe
exacerbations (or death), and/or adverse reactions to medications, and/or chronic morbidity,
including impaired lung function or reduced lung growth in children (Reddel et al, 2009)
Asthma control: Extent to which the various manifestation of asthma are reduced or removed
by treatment (Bousquet et al, 2010; Reddel et al, 2009)
Asthma diagnosis: GINA proposed a holistic approach involving detailed history, physical
examination and spirometry. An increase in FEV1 of ≥12% and ≥200ml after a
bronchodilator is indicative of reversible airflow limitation, which is consistent with asthma.
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Peak expiratory flow (PEF) with an improvement of 60l/min (or ≥20% of the pre-
bronchodilator PEF) after a bronchodilator, or a diurnal variation in PEF of more than 20%
(with twice daily readings more than 10%) may also be indicative of asthma. Other non-
specific diagnostic tests include methacholine or histamine test, inhaled mannitol or
exercise challenge, skin prick test and measurement of serum IgE (Cazzoletti et al, 2010;
Masoli et al, 2004)
Health education: Any combination of learning experiences designed to help individuals and
communities improve their health by increasing their knowledge or influencing their attitude
(WHO, 2013).
Knowledge: This is defined as the expertise and skills acquired by a person through
experience or education with the ability to use it for a particular purpose (Sharda, & Shetty,
2008).
Perception: Illness perceptions are the cognitive representations or beliefs that patients or a
healthy individual have about illnesses and medical conditions such as asthma (Katavic et al,
2016). Perception is the elaboration, interpretation and assignment of meaning to a sensory
experience (Promtussananon, 2003).
OBJECTIVES OF STUDY
1. Assess level of knowledge of asthma and impact of asthma health education

programme among the secondary school students in Ile- Ife, Nigeria.
2. Assess level of perceptions of asthma and impact of asthma health education
programme among the secondary school students in Ile- Ife, Nigeria.
3. Observe changes in knowledge and perceptions of asthma among the secondary
school students over a period of time.
4. Identify factors associated with knowledge and perceptions of asthma before and
following health education intervention among the secondary school students.
RESEARCH HYPOTHESIS
The following null hypotheses were tested in this study:
1. H0: There would be no significant differences between pre-test and post-test

knowledge scores among the participants (intervention) who receive the health
education programme intervention.
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knowledge scores among the participants (control) who did not receive the health
education programme intervention
perceptions scores among the participants who receive the health education
programme intervention.
4. H0: There would be no significant differences between the pre- test and post- test
perceptions scores among the participants (control) who did not receive the health
education programme intervention.
5. H0: There would be no significant change over time from pre- test to post-test (6
weeks) (follow up) in the knowledge and perceptions about asthma in the
intervention group.
6. H0: There would be no significant change over time from pre-test to post-test
(follow up) knowledge and perceptions about asthma in the control group.
7. H0: There would be no significant association between socio- demographic
factors (gender, age group, class level, religion, ethnicity, family experience (have
a relative with asthma) and family experience (have lived with or known someone
with asthma)) and pre- intervention knowledge scores.
with asthma)) and pre- intervention perception scores.
with asthma)) and post- intervention knowledge scores.
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with asthma)) and post- intervention perception scores.
Level of significance was set at α = 0.05.
STATEMENT OF PROBLEM
It is now estimated that over 300 million people of all ages, and all ethnic backgrounds, suffer
from asthma and the burden of this disease to governments, health care systems, families, and
patients is increasing worldwide (Marsden et al, 2016; Vos et al, 2013). Asthma is
characterized by a major impact on the lives of sufferers resulting in missed days of school
for school children, missed work days characterised by lack of productivity, unplanned
childcare, emergency room visits, sleep disorders and fatigue, physical limitations and
depression (Kintner et al, 2015; van Wijk, 2013). Asthma is a major health problem among
adolescents with studies identifying substantial under-diagnosis, poor acceptance of
diagnosis, poor compliance to treatment and poor understanding of asthma management
among this population (Oluwole et al, 2017; Musa et al, 2014). These have been attributed to
inadequate knowledge and the wrong perceptions about asthma (Anwar et al, 2008;
Bjorksten, 2000). Health education has been suggested as a vital element of the response to
the challenge posed by asthma especially in Africa (Braman, 2006; Ndiaye et al, 2004).
Schools have been identified as the prime settings for asthma health education for children
and adolescents due to practicality, familiarity with the environment and the magnitude of
influence that peers equipped with knowledge exert on themselves which has the potential to
reduce morbidity outcomes in asthma (Valeros et al, 2001; Thies et al, 2001). Several school
based studies have been conducted to assess the impact of asthma health education
programme on students with asthma showing significant improvement in their knowledge of
asthma, reduction in school absenteeism, improvement in self- efficacy perception and
improvement in their quality of life (Cicutto et al, 2013; Bowen, 2013; McGhan et al, 2010;
Kintner et al, 2009). Most of these data have come from developed countries and limited to
students who have asthma. To the best of my knowledge and through extensive review of
literature, there is no study conducted to evaluate the impact of health education intervention
on knowledge and perceptions of asthma among secondary school students in Ile Ife, Nigeria.
This study is, therefore, directed to assess the impact of health education on knowledge and
perceptions of asthma among secondary school students in Ile- Ife, Nigeria.
20
MOTIVATION FOR THE STUDY
Asthma is a major health problem among adolescents. Adolescents with asthma are at higher
risk of serious disease complications due to under-appreciation and denial of their disease
severity, non-adherence with medications and trigger avoidance, and other risk-taking
behaviours such as smoking tobacco or marijuana and using cocaine (Guo et al, 2010; Towns
et al, 2009; Bender, 2007). Patients in this age group may not appreciate the danger of poorly
controlled asthma. They may deny having a chronic illness, or they may view the treatment
plan as interfering with their emerging independence as they strive to reach adulthood (Burns
et al, 2006). Peers and teachers are known to exert important influences during adolescence.
Hence, increasing the knowledge and attitudes of these groups could be expected to influence
adolescents with asthma as knowledge, attitudes, and beliefs are recognised as being major
determinants of health behaviour, including compliance with therapy (Brooks et al, 1993).
All these have been shown to improve through asthma health education intervention among
school students (Valeros et al, 2001; Thies et al, 2001). Studies have shown that health
education intervention is effective in increasing knowledge, improving attitudes and reducing
students' health related risk behaviour (Daboer et al, 2008; Kann et al, 2007). Many
researchers have also demonstrated that certain asthma health education interventions have
proven to be effective in increasing knowledge, reduction of school absenteeism,
improvement in self- efficacy perception and improvement in the quality of life of
adolescents of school settings in other countries of the world (Cicutto et al, 2013; Bowen,
2013; McGhan et al, 2010; Kintner et al, 2009; Levy et al, 2006; Shaw et al, 2005). However,
the quest to know the impact of such health education intervention on the knowledge and
perceptions of asthma among the secondary school students in Ile-Ife, South-West, Nigeria
served as impetus for this study.
SIGNIFICANCE OF STUDY
The outcome of this study could reveal any gap in the knowledge and perceptions of asthma
among secondary school students in Ile- Ife, Nigeria. The study could also reveal the impact
of health education on their knowledge and perceptions about asthma. The outcome of the
study could also be helpful in determining the predictors of knowledge and perception of
asthma among the secondary school students in Ile- Ife, Nigeria. Information obtained from
21
this study could also be used by health professionals to implement health prevention and
promotion programmes relating to asthma. Furthermore, the data collected in the course of
the research could serve as baseline for further studies.
INCLUSION CRITERIA
- To be included in the study participants must be students aged 9 to 19 years in the

selected schools in Ile- Ife whom the parents or guardian gave an informed consent.
- They must not have also been previously diagnosed by a Physician as asthmatics and
must not be on any asthma medications.
EXCLUSION CRITERIA
- Any students with asthma and or on treatment for asthma and those students whose
parents or guardian failed to give informed consent were excluded from the study.
CHAPTER TWO
REVIEW OF LITERATURE
EPIDEMIOLOGY OF ASTHMA
According to the World Health Organization, asthma is now a serious public health problem
with about 300 million sufferers worldwide with a projection that it will increase by 100
million by year 2025 (WHO, 2007). Furthermore, studies indicate that asthma is not just a
public health problem for high income countries but is increasingly becoming widespread in
the developing world with most asthma related deaths occurring in low and lower-middle
income countries including Sub-Saharan Africa (WHO, 2008; Asher et al, 2006; Zar, 2001).
22
It is estimated that the number of people suffering from asthma will grow by more than 100
million worldwide by 2025 (WHO, 2007). The Global Initiative for Asthma (GINA)
estimates that the global prevalence of asthma ranges from 1 to 18% of the total population of
different countries (GINA, 2004). The International Study of Asthma and Allergies in
Childhood in children and the European Community Respiratory Health Survey in adults
have greatly increased our understanding of epidemiology of asthma worldwide (ISAAC,
1998; Janson et al, 1997; ECRHS, 1996).The highest asthma rates have been reported in
affluent countries, such as the United Kingdom, New Zealand, and Australia, whereas the
lowest rates have been reported in India and Indonesia (Lai et al, 2009).The incidence of
asthma has been growing over the past 30 years due to changing environmental factors,
particularly in the low- and middle-income countries that are least able to absorb its impact
(GBAR, 2011). This increasing trend is expected due to rise in atopic sensitizations, allergic
conditions, and changing patterns of environmental triggers (associated with environmental
smoking exposure in children, population growth, and urbanization) in Africa over the last
two decades (Braman, 2006). Asthma morbidity, mortality, and hospitalization rates have
been disproportionately high among the poor and medically underserved (Pachter et al, 2002;
Shegog et al, 2001).The World Health Organization (WHO) estimates about 250, 000 deaths
from asthma every year, mainly in low- and middle-income countries (LMIC) (Bousquet et
al, 2010; Braman, 2006).Fifty years ago asthma was uncommon in Nigeria; however recent
reports from different parts of Nigeria have shown a prevalence of adolescent and adult
asthma in excess of 10% and a rising trend in the prevalence of asthma (Desalu et al, 2009;
Erhabor et al, 2006; Ibe et al, 2002; Faniran et al, 1999; Falade et al, 1998). The prevalence
of asthma in Nigeria according to these studies showed 10.7% (children) (Falade et al, 1998),
14.2% (adolescents) (Ibe et al, 2002) and 5.1 -7.5% (adults) (Irusen, 2004).
GLOBAL BURDEN AND IMPACT OF ASTHMA
The Global Burden of Asthma Report (GBAR) reported an increasing trend of asthma
globally (Braman, 2006). It estimated over 235 million asthma cases worldwide, and about 50
million people living with asthma in Africa in 2004, with the highest prevalence (8.1%)
recorded in South Africa (Braman, 2006).Asthma causes an estimated 340,000 deaths
annually(GINA, 2014). In addition, the World Health Organization estimates that around 15
million disability-adjusted life years (DALYs) are lost annually through this disease (GINA,
2010). Worldwide, asthma accounts for around 1% of all DALYs lost, which reflects the high
23
prevalence and severity of asthma. The number of DALYs lost due to asthma is similar to
that for diabetes, cirrhosis of the liver, or schizophrenia. When ranking chronic diseases,
asthma was the 25th leading cause of DALYs lost worldwide in 2001 (Masoli et al, 2004).An
analysis of the burden of asthma in the US estimated the annual costs per patient at $ 1907
and the total national medical expenditure at $ 18 billion (Sullivan et al, 2011). The ERS
White book, published in 2003 estimated the total costs of asthma in Europe at approximately
€ 17.7 billion per annum. The countries with the most asthma related consultations were the
UK, followed by Greece and Germany. The countries with the least consultations were
Poland and Turkey. A 2012 analysis derived from the European Community Respiratory
Health Survey II (ECRHS II) estimated the annual costs per patient in Europe at € 1583. An
estimate of the costs of asthma in children in 25 EU countries has been published in 2005
(Accordini et al, 2013). The total costs of asthma for the 25 countries of the European Union
are estimated at € 3 billion. The use of wheeze as definition of asthma leads to considerable
higher costs of € 5.2 billion (ERS, 2003).The Conference Board of Canada estimates that in
2010 chronic lung diseases including asthma cost $12 billion including $3.4 billion in direct
health care costs and $8.6 billion in indirect costs.
AETIOLOGY OF ASTHMA
Asthma is a complex condition with no single biological marker and multiple aetiological
causes. Its development is seen as an intricate interaction between genetic and environmental
factors (Bousquet et al, 2010). Atopy, the genetic tendency to develop Immunoglobulin E
(IgE) antibodies in response to an allergen (Arshad et al, 2001) is an important factor in
allergic asthma aetiology (Arbes et al, 2007). Helminthic infections are relatively common in
Africa and are associated with bronchial hyper-responsiveness and asthma (van Gemert et al,
2011; Perzanowski et al, 2002); this is perhaps due to the presence of related raised
immunoglobulin E (IgE) and a prominent Th2 immune response (van Gemert et al, 2011;
Wjst et al, 2007).
RISK FACTORS OF ASTHMA
During infancy, exposures to house-dust mite, animal dander or pollen in predisposed

individuals can increase the risk of developing asthma (Sears, 1997).Identified risk factors for
asthma include; family history of the disease (Litonjua et al, 1998), maternal smoking during
pregnancy (Kumar, 2008), reduced antioxidant intake (Allen et al, 2009; Devereux et al,
2005), obesity (Sin et al, 2008),residence in an inner-city urban area (Bryant- Stephens,
24
2009), family size (Kinra et al, 2006) and reduced exposure to childhood infections as
postulated by the Hygiene Hypothesis (Strachan, 1989). The hygiene hypothesis proposes
that there is a lack of sufficient microbial exposure early in life due to pharmacological
manipulations and vaccines (Duran- Tauleria et al, 1995). Currently, the link between
parasitic infections and asthma is also an active research area (Yazdanbakhsh et al, 2002).
Diet
Diet is a major source of allergen exposures for people diagnosed with asthma (Crapo, et al.,
2004). Food can trigger an asthma attack due to an allergic response to foods such as peanuts,
sesame, fish, dairy products, and eggs. Some people become wheezy when they have food
containing certain additives such as tartrazine and histamine food (Fadillah, 2008).
Smoking
Generally, tobacco smoke damages tiny hair-like projections in the airways (cilia). Smoking
can also cause the lungs to produce excessive mucus which results in airway obstruction. In
children, passive smoking, which is the most common, is a problematic issue that decreases
the lung functionality and increases the symptoms of airway inflammation such as cough,
wheezing, and increased mucous production (Sarnat & Holguin, 2007). Living in a family
with parents that smoke, was also a positive risk factor for having respiratory symptoms in
general and asthma in particular (Al-Dawood, 2001; Bener, et al., 1991).
Air pollution
Outdoor air pollution is usually associated with increased hospitalisation or emergency

department visits for people with asthma. It also increases asthma mortality (Sarnat &
Holguin, 2007). Environmental pollution stimulates asthma exacerbation, especially in big
cities. It can increase the risk of an asthma attack and readmission to hospital (Arbex et al.,
2007).
Changes in weather
A sudden change in outside temperature can trigger an asthma attack such as cold air, windy
weather, poor air quality, and hot or humid days (Mireku et al., 2009).
25
Exercise
Exercise induced asthma occurs when the airways narrow as a result of exercise
(Henneberger et al., 2002). Exercise-induced symptoms occur commonly when the inhaled
air is cold or dry due to air changes during vigorous activities. Typical symptoms of asthma
present, such as shortness of breath, chest tightness, and cough (Carlsen & Carlsen, 2002).
Exercise can be a trigger for adolescents when their asthma is not under good control,
however, this does not mean that those with asthma should avoid exercise. As long as their
asthma is under control, exercise is recommended to keep their lungs and body shape in a
good posture and enhance normal growth and development. When asthma is controlled well
or effectively, exercise will strengthen respiratory muscles, improve the immune system and
help to sustain a healthy body weight. Swimming is one of the best forms of exercise for
children with asthma because it usually causes the least amount of chest tightness (Fanta &
Fletcher, 2009).
Stress
Physiologic stress such as inflammation or contagious diseases can cause wheezing and more
vigorous asthmatic signs (Kang & Weaver, 2010). Psychological stressors such as anxiety
can also result in shortness of breath and exaggerate asthma symptoms. On the other hand,
stress can develop as a result of persistent wheezing and coughing which may contribute to
further psychological stressors and depression (Schmittdiel et al., 2004).
Other factors that aggravate asthma include under-diagnosis, lack of education, and poor
health facilities and choice of treatment, along with poor adherence to the therapeutic regimes
(Siersted et al., 1998).
CLINICAL SIGNS AND SYMPTOMS OF ASTHMA
Asthma is a chronic inflammatory disorder (CID) of the air ways, which is associated with
airway dual component disease (Inflammation and broncho-spasm) whose symptoms and
signs depend on the severity of the disease. The clinical signs of asthma include a prolonged
expiratory phase of respiration, and diffuse bilateral and a reversible wheeze (rhonchi).
However, there may be no signs detectable between episodes. The defining symptoms are;
cough, which could be nocturnal or early morning especially in young children (in about one-
26
third of cases), wheeze, shortness of breath; chest tightness or soreness, prodromal symptoms
may be apparent e.g. itching of parts of the body appearance of rash, abdominal pain, mood
changes etc.(Sly, 2000). Asthma symptoms include intermittent attacks of wheezing,
breathlessness, chest tightness and cough that occur more at night and or early in the
morning. There is often broncho-constriction without any known precipitating factor.
However, some provoking agents of the airway obstruction may be specific (antigen-
antibody reaction) or non-specific stimuli (exercise, emotional stress, cold air or
pharmacological agents as histamine or metacholine).The most predominant symptom of
asthma noted in a Nigerian study is breathlessness during attacks. This is seen in 100% of
cases in that series (Oni et al, 2010). Cough and wheezing were the next most common, both
occurring in about 96% of cases in this series. Other common and frequent symptoms include
sweating (mostly profuse on the forehead), anorexia and loss of weight. These symptoms
occur while the attack lasts and abates soon after it ceases. Chest pain and headaches are
usually volunteered by patients older than five (5) years. Hemoptysis (often small and
infrequent) can also be seen in about 4% of bronchial asthma patients (Oni et al, 2010).
PATHOLOGY OF ASTHMA
The pathology is that of inflammation associated with vasodilatation, oedema, cellular

infiltrates like neutrophils, eosinophils, lymphocytes and mast cells, patchy desquamation and
squamous metaplasia of the mucosa cells lining the airway lumen. Substance-P within the
airway nerves is increased while Vasoactive Intestinal Peptide is reduced (Al- Moamary et al,
2012). Airway narrowing occurs as a result of its smooth muscle contraction, vasodilatation
of bronchial vessels, oedema of the sub mucosa tissues and hyper secretion of mucus into the
airway lumen (Al- Moamary et al, 2012).
PATHOPHYSIOLOGY OF ASTHMA
The pathophysiology of asthma can be subdivided into airways inflammation, airway hyper-
responsiveness, early and late responses, and airway remodelling.
AIRWAYS INFLAMMATION
Asthma is a complex syndrome characterized by airway hyper-responsiveness (AH) and is

caused by a multi-cellular inflammatory reaction that leads to airway obstruction (Hamid et
al, 2007). Recruitment and activation of mast cells, macrophages, antigen- presenting
dendritic cells, neutrophils, eosinophils, and T lymphocytes result in an inflammatory and
27
cellular infiltration of the airways (Cohn et al, 1997). Type 2 T- helper cells (Th 2) have a
major role in the activation of the immune cascade that leads to the release of many mediators
such as interleukins (IL) IL-3, IL-4, IL-5, IL-13, and granulocyte macrophage colony
stimulating factor (GM-CSF) (Akbari et al, 2003; Alzoghaibi et al, 2006). Some mediators
such as IL-4 activate B lymphocytes to produce immunoglobulin E (IgE), while others (IL-3,
IL-5, and GM-CSF) are related to eosinophilic airway inflammation. Severe asthma may
present various inflammatory phenotypes, such as persistent eosinophilic bronchitis,
neutrophilic infiltration of the airway, and a pauci- granulocytopenic type of inflammation
(Humbert et al, 1997). Such persistent inflammation results in airway remodelling which
includes increased deposition of extracellular proteins, smooth muscle hypertrophy and
hyperplasia, and increased goblet cells (Holgate et al, 2003). The airway epithelium becomes
fragile and thin, and the epithelial basement membrane thickens. There is also increased
mucus production and endothelial leakage which leads to mucosa edema. Mediator- induced
abnormalities in the parasympathetic and non-adrenergic non- cholinergic nervous systems
may also lead to increased brochial hyper-responsiveness.
AIRWAY HYPER- RESPONSIVENESS
Airway hyper-responsiveness (AH) to direct (histamine or metacholine) and indirect

(exercise, cold air, mannitol, adenosine monophosphate, or isocapnic hyperventilation)
challenges is a characteristic of asthma (Linzer, 2007). When asthma symptoms are present,
there is a relatively good correlation between the severity of disease and the degree of AH
(Kendrick et al, 1993). AH is not a static feature of asthma; it may increase after sensitizing
exposures and may decrease after anti-inflammatory treatments or if there is a reduction in
relevant environmental exposures. Asthma has a variable component, which is related to
airway inflammation, and a more refractory component that is largely attributed to underlying
airway structural changes that are also known as remodelling (An et al, 2007).
EARLY AND LATE PHASES
Following presentation of the antigen by dendritic cells in a sensitized patient, certain

inflammatory cascades become activated leading to the attachment of IgE antibodies to
inflammatory cells such as mast cells (Kinet, 1999). Cross- linking of IgE receptors leads to
degranulation of inflammatory cells and liberation of various mediators which are responsible
for the allergic response. The allergen- induced airway response may be immediate (early
28
response) with a fall in expiratory flows within an hour of exposure, or may be delayed (late
response) with the fall in expiratory flows observed within 2-8 hours. An increase in AH and
in the variability of airway obstruction may occur within the following 2-3 days depending on
the intensity of the response (King et al, 1999; James et al, 1989).
AIRWAY REMODELLING
Structural airway changes may develop even before the disease become symptomatic. The
most prominent changes include epithelial damage, sub-epithelial fibrosis, increased airway
vasculature, increases in extracellular matrix proteins including collagens and proteoglycans,
and increased smooth muscle mass. The mucus hyper-secretion observed in asthma is related
to an increase in the number of secretory glands and cells such as goblet cells. These changes
are generally attributed to the underlying inflammatory process, although other mechanisms
may play a role (Hamid et al, 2007). It has been proposed that remodelling may be involved
in the development and persistence of asthma, in the accelerated decline in pulmonary
function, and in the development of a more fixed component of airway obstruction in some
asthmatic patients, particularly severe asthmatics. Although a relationship has been found
between the severity of asthma and some of the components of airway remodelling,
researchers have not yet been able to adequately distinguish severe asthma from milder forms
on the basis of histological features alone (Niimi et al, 2003).
DIAGNOSIS OF ASTHMA
The diagnosis of asthma is clinically based without a single confirmatory diagnostic test, only
corroboration of the diagnosis with changes in lung function or response to
treatment.According to the Global Initiative for Asthma (GINA), detailed history, physical
examination and spirometric lung function tests are vital to the diagnosis and management of
asthma (Cazzoletti et al, 2010; Masoli et al, 2004). Generally, a reduction in forced expiratory
volume in one second (FEV1) and peak expiratory flow (PEF) may be indicative of asthma,
with the amount of reduction proportional to the severity of asthma (Braman, 2006). GINA
proposed that an increase in FEV1 of >12% and 200 mL in about 15-20 minutes following
29
the inhalation of 200-400 μg of salbutamol or a 20% increase in PEF from baseline can be
employed as standardized criteria in diagnosis of asthma (Cazzoletti et al, 2010). This,
however, lacks sensitivity, as many asthmatics, especially those on treatment, may not exhibit
an increase in FEV1 and PEF when assessed (Martins et al, 2009; Battikh et al, 2004). Thus,
although asthma is characterized by significant reversibility of airway obstruction, an absence
of reversibility may not always exclude the presence of asthma (Ehrlich et al, 1998).
The diagnosis of asthma can be made using the following criteria:

 History of recurrent cough, breathlessness, chest tightness, and wheezing.
 Physical examination indicating asthma and or expiratory wheeze with evidence of hyper
inflated lungs.
 Lung Function tests. This includes a low Peak Expiratory Flow Rate (PEFR), Forced
Expiratory Volume in one second (FEV1) and FEV1/FVC
 Reversibility test with bronchodilator shown by improvement of at least 12% and above
within 10 - 20minutes of β2 agonist aerosol inhalation in FEV1.
CLINICAL TESTS FOR ASTHMA
SPIROMETRY
Spirometry is an essential objective measure to establish the diagnosis of asthma, because the
medical history and physical examination are not reliable means of excluding other diagnoses
or of assessing lung status. Spirometry is generally recommended, rather than measurements
by a peak flow meter, due to wide variability in peak flow meters and reference values. Peak
flow meters are designed for monitoring, not as diagnostic tools. Spirometry is necessary to
detect airflow obstruction, assess severity, and demonstrate significant reversibility (The
degree of significant reversibility is defined as an improvement in forced expiratory volume
in 1 second-FEV1 ≥ 12% and ≥ 200ml from the pre- bronchodilator value). It may help to
identify other differential diagnoses, for example, large airway obstruction. However, normal
spirometry, including a failure to show reversibility, does not rule out the diagnosis of
asthma, as it can be normal with the patient still being symptomatic (Cowie et al, 2007).
PEAK FLOW MEASUREMENT
The peak flow meter is designed for the monitoring of asthmatics because it is a simple,
quantitative, and reproducible measure of airflow obstruction that can be used for managing
exacerbations and daily long-term monitoring. It may also assist in the diagnosis of asthma
30
since it can be used to demonstrate the variability of test results that is characteristic of
asthma (Fawibe, 2008). Peak flow monitoring may be particularly helpful for patients who
have difficulty perceiving symptoms, a history of severe exacerbations, or moderate or severe
asthma. Peak expiratory flows (PEF) can be divided into three zones, which are assigned
colours like those of a traffic light. These zones can be used to make decisions about the need
for treatment:
Green — Green signals that the lungs are functioning well. When symptoms are not present
or are well controlled, you should continue your regular medicines and activities.
Yellow — Yellow is a sign that the airways in the lungs are somewhat narrowed, making it
difficult to move air in and out; asthma symptoms may be more frequent or more severe. A
short-term change or increase in medication is generally required. It is advised that patient
should change or increase their medication according to the plan that was discussed with their
healthcare provider.
Red — Red is a sign that the airways are severely narrowed and requires immediate
treatment. Symptoms are usually more severe and frequent. In addition to using 2 to 4 puffs
of the quick-acting reliever inhaler (eg, albuterol), oral steroid tablets are often required to
bring relief, according to the plan discussed with the healthcare provider.
BRONCHO-PROVOCATION TESTING
It is another tool used by specialists to rule out asthma; however a diagnostic therapeutic trial
with inhaled steroids and bronchodilator may be useful in confirming a diagnosis (Tashkin et
al, 1996). Broncho-provocation with methacholine, histamine, cold air, or exercise challenge
may be useful when asthma is suspected and spirometry is normal or near normal. For safety
reasons, broncho-provocation should be carried out only by a trained individual. A positive
test is diagnostic for airway hyperresponsiveness, which is a characteristic feature of asthma
but can also be present in other conditions. Thus, a positive test is consistent with asthma, but
a negative test may be more helpful to rule out asthma.
SKIN TESTING AND RADIO-ALLERGOSORBENT TEST (RAST)
It may be helpful in identifying allergens to which the patient has been sensitized and in
developing a strategy for avoiding allergen exposure (Witteman et al, 1996). Allergy skin
testing is conducted to determine which specific substances trigger the airway inflammation
31
that can lead to asthma attacks. During skin testing, a tiny amount of allergen is scratched or
lightly pricked into the skin. If a person is allergic to a specific allergen, a large ‘wheal’ or
bump will appear on the skin. If allergies are known to be an asthma trigger, immunotherapy
then may be considered as a treatment option. Allergy test results can help individuals
become aware of and avoid their personal asthma triggers.
ASTHMA GUIDELINES
Asthma cannot be cured, however, symptoms can be prevented and controlled in most cases
when early detection of the disease is established, therapy guidelines are adhered to, and
levels of knowledge are improved (National Asthma Education and Prevention Programme,
2007). To improve care, international guidelines (such as Global Initiative for Asthma
(GINA), Global Asthma Initiative (The British Thoracic Society, 2012), Australia National
Asthma Treatment Guideline, Canadian Thoracic Society (CTS) Asthma Committee) and
national guidelines (KSA guidelines, 2012) for asthma diagnosis and treatment have been
developed and updated to help physicians and patients achieve treatment goals and objectives
of asthma. This includes preventing chronic symptoms, minimizing morbidity and mortality
rates, maintaining a normal children daily activity levels, and decreasing hospital admissions
and emergency visits. In addition, they contribute to reducing exacerbations of that disease,
maximising lung function levels, prescribing suitable drugs to minimize adverse effects,
reducing patients’ negative perceptions, and saving time and money (Schmittdiel et al.,
2004). The guidelines are based on robust evidence, and studies show that they have helped
to achieve the major objectives as well as diagnosing and treating asthma (Bateman et al.,
2004; Dashash & Mukhtar, 2003). However, other studies such as Asthma in America,
Asthma Insights and Reality in Europe (AIRE) and Asthma Insights and Reality in the Asia-
Pacific (AIRIAP) indicate that asthma management falls well short of that recommended by
the guidelines (American Lung Association, 2013). For instance, the National Asthma
Education and Prevention Programme (NAEPP) were established in the United States of
America (USA) in 1991 to counter the continual increase of asthma. The first expert panel
guidelines focused on Asthma management and the main four components of effective
asthma management are summarised in the table below.
Components of effective asthma management National Asthma Education and
Prevention Programme, 1991
32
• Use of objective measures of lung function to assess the severity of asthma and to monitor
the course of therapy.
• Environmental control measures to avoid or eliminate factors that precipitate asthma

symptoms or exacerbations.
• Patient education that fosters a partnership among the patient, his or her family, and
clinicians.
• Comprehensive pharmacologic therapy for long-term management designed to reverse and

prevent the airway inflammation characteristic in asthma as well as pharmacologic therapy to
manage asthma exacerbations.
The NAEPP recognised the importance of testing and updating the previous guidelines
according to the best available evidence. Hence, the second Expert Panel came into existence
in 1997 resulting in: “Expert Panel Report: Guidelines for the Diagnosis and Management of
Asthma—Update on Selected Topics 2002” (Bethesda et al., 1997, 2002). The “Expert Panel
Report 3: Guidelines for the Diagnosis and Management of Asthma—Full Report, 2007” was
the latest update of Asthma Diagnosis and Management (National Heart Lung and Blood
Institute & National Asthma Education and Prevention Programme, 2007).
During 2002, a major change occurred in NAEPP guidelines as the practice of asthma relied
heavily on the severity of the attack (Pollart & Elward, 2009). The 2002 guidelines divided
the patients into groups according to the severity of their asthma and suggested treatments
according to the new classification (Bethesda et al., 2002). This classification depended on
evidence provided from the recent guidelines. However, it was found that patients with a pre-
existing asthma diagnosis were more difficult to classify (Bethesda et al., 2002). The issue
was that patients who received treatment when their asthma was not controlled were difficult
to classify because these patients were more likely to receive more medication than usual and
thus, it was difficult to determine the level of severity (Pollart & Elward, 2009). However, a
large number of patients were grouped together according to their exposure at the time of
classification (Pollart & Elward, 2009). For instance, the patient during the allergic season
may present with symptoms of a severe form of asthma according to guidelines which in
other seasons may not appear. Thus, the new guidelines did not work as expected due to the
dependency placed on classifying patients with asthma according to the severity of the
disease. Therefore, NAEPP members established new guidelines in 2007 to allow
33
practitioners to classifying such special cases. A set of new concepts were integrated into the
guidelines (Pollart & Elward, 2009). These concepts were: severity, control, and
responsiveness to treatment. First, the clinicians initiated treatment according to the severity
of symptoms then physicians had to monitor and adjust the therapy to control asthma
according to response to this therapy (Pollart & Elward, 2009). Since, many institutions and
organisations have been established such as the Global Initiative for Asthma (GINA) that
aimed to increase public awareness of asthma. GINA was established in 1993 as a result of
collaboration between National Heart, Lung, and Blood Institute, National Institutes of
Health, and the World Health Organization (The Global Initiative for Asthma, 2012). The
objective of GINA is to (1) increase public understanding of asthma; (2) find the reasons for
the increased prevalence of asthma; (3) support research in the area of asthma and the
environment; (4) reduce asthma morbidity and mortality and (5) find new strategies to
manage asthma (GINA, 2012).
According to the National Asthma Council Australia (NACA) and Medicare Australia, an
integral part of the Asthma Cycle of Care is the development of a written Asthma Action Plan
(AAP), which assists the patient or carer in recognising the aggravation of asthma symptoms
and, in an effort to prevent severe exacerbations, adjust asthma therapy accordingly, (NACA,
2007; Medicare Australia, 2011). On the whole, the Asthma Cycle of Care must include:
- At least two asthma related consultations within 12 months for a patient with moderate-to-
severe asthma;
- At least one of these consultations (the review consultation) to have been planned at a
previous consultation;
- Documentation of diagnosis and assessment of asthma severity and level of asthma control;
- Review of the patient’s use of, and access to, asthma related medication and devices;
- A written asthma action plan (or documented alternative if the patient is unable to use a
written action plan);
- Provision of asthma self-management education; and
- Review of the written or documented asthma action plan.
ASTHMA CONTROL AND MONITORING
34
ASTHMA CONTROL: Asthma control is “the extent to which the manifestations of asthma
have been reduced or removed by treatment”. Asthma controls is an assessment of the current
day-to-day level of clinical control and assessment of future exacerbation risk to the patient.
There is no gold standard for measuring control. However, several surveys in developed
nations have shown that the majority of patients with asthma do not experience adequate
asthma control (Lai et al., 2003). Asthma control and the degree of severity of symptoms are
related, however, they are different. Control is defined as sufficient disease treatment; while
severity is concerned with the fundamental process of the disease (Carlton et al., 2005).
Interestingly, some studies support the use of asthma control based on an asthma
management approach rather than on severity (Yawn et al., 2006). Five symptoms, namely
being awoken at night, limitations of daily activities, morning waking with symptoms,
dyspnoea, and wheezing, as well as short β2 acting agonist use and deficiency of lung
function, are considered as the most important indications for control assessment in national
guidelines in many countries (GINA, 2002; Saudi MoH, 2000; Australian National Asthma
Council, 2004, British Guidelines on the Management of Asthma, 2013).
Asthma control is the main concern of treatment underpinning asthma management

guidelines. It refers to the control of the clinical manifestations of the disease, and is the
ultimate goal of asthma management (GINA, 2010). Suggested measures of asthma control
include minimising day and night symptoms, bronchodilator use, and hospitalisation or
emergency department visits; preventing asthma attacks, and maintaining normal daily
activity levels as well as normal lung function (Nathan et al., 2004).
A Turkish study involving 239 children implemented the Asthma Insights and Reality (AIR)
survey to estimate asthma control levels based on the GINA guideline classifications (Sekerel
et al., 2006). In this study just 1.3% of patients were found to have achieved an optimum
control level, and around 75% and 90% of children and adults respectively were experiencing
daytime symptoms. Inhaled corticosteroids (ICSs) have been recommended in persistent
asthma regardless of the severity of symptoms (mild, moderate, and severe), but the success
of asthma control is largely dependent on adherence to ICS daily use (Sekerel et al., 2006).
Other self-management activities, such as education, Peak Flow Meter (PFM) use,
monitoring of medication, trigger avoidance, inhaler practice, and use of Asthma Action
Plans (AAPs) are also mentioned as contributory factors for relieving asthma symptoms
(Williams et al., 2004; GINA, 2002; Rabe et al., 2000). Therefore, adherence to the
therapeutic regime is a main goal in any asthma action plan. That said; there is a clear
35
relationship between asthma severity and asthma control. The underlying severity of asthma
in a patient may be modified by changes in the environment and by the treatment strategies
which are based on strong asthma evidence. Ultimately, the changes in these environmental
and treatment factors may impact on children’s symptoms and their ability to function.
Asthma control reflects the combined effects of underlying disease severity, environmental
exposures and the effectiveness of treatment (Humbert et al., 2007).
A number of patient-related variables may influence asthma control. Laforest et al. (2006)
conducted a cross sectional study to identify factors associated with asthma. The study found
several independent patient-related determinants of inadequate asthma control, including
female gender, active smoking and overweight. Control also varied according to the type of
asthma supervision. Patients treated exclusively by specialists were more likely to have their
asthma well controlled compared to those who were treated by a General Practitioner (GP)
Patients who were dispensed combined long-acting beta-2 agonist (LABA) and ICS therapy
were also more likely to have their symptoms properly controlled, particularly at higher doses
of these drugs (Laforest et al. 2006). This good quality study controlled for the confounding
variables, making the findings transferable to other settings. Assessment of both asthma
control and severity can depend on one or more of the following factors: symptoms, changes
in expiratory flow, and airway inflammation. Assessments of results vary depending on the
methods used. As asthma is a chronic disease with varying severity and levels of control over
time, it can be difficult to accurately assess it with one method at a particular point in time
(Humbert et al., 2007; Rabe et al., 2004; Sekerel et al., 2006); therefore, the use of more than
one method has been recommended in asthma control. The WHO has reported that the levels
of asthma control and health responses in the Africa have been below recommended
standards, and that these have contributed to the size of the disease burden (Bousquet et al,
2010; Braman, 2006).
The aim of asthma management is control of the disease. The 2011 British thoracic guideline
on asthma management update found that a symptom score is the best measure of control;
that closed questions yield more information and there is little/no evidence for the addition of
biomarkers to symptom scores. Good asthma control are characterised by no (or minimal)
daytime symptoms, no nocturnal symptoms or awakenings, no (or minimal) need for “rescue”
treatment, no limitations on activities, (near) normal lung function and no exacerbations.
Well-controlled asthma requires all of the following: daytime symptoms less than twice a
week, night time awakenings less than twice a month, no disturbance of exercise tolerance,
36
and use of short-acting beta agonists for symptoms less than twice a week. Spirometry results
should show FEV1 greater than 80% predicted in well-controlled asthma. In addition, the
‘risk’ domain should show one or fewer emergency department (ED) visits for asthma, or
courses of oral steroids for exacerbations, in the last 6 months (Sadof et al, 2011).
The Asthma Control Test (ACT) is a short, validated, self- administered questionnaire to
assess asthma control. It consists of five items including limitation of activity, shortness of
breath, frequency of night symptoms, use of rescue medication, and rating of overall control
of the disease over the past 4 weeks (Nathan et al, 2004). The score of the ACT is the sum of
the five questions where each is scored from 1 (worst) to 5 (best), leading to a maximum best
score of 25. A score of ≥ 20 indicates controlled asthma, 16- 19 partially controlled asthma,
and ¿ 16 uncontrolled asthma (Schatz et al, 2006). It is a gold standard for monitoring care.
ASTHMA MONITORING: There are four settings for monitoring. They include
maintenance, step-up treatment, step-down treatment and stop preventer. Monitoring can be
symptom based e.g. RCP3, ACQ, ACT/CACT, AQLQ/PAQLQ or reliant on biomarkers e.g
PEF, FEV1, BHR, sputum eosinophilia, ENO.
ASTHMA MANAGEMENT
According to the Canadian Asthma Consensus Guidelines (2001), the goal of asthma
management is to reduce airway inflammation through environmental control measures and
the use of regular controller medication, rather than intermittent therapy that is focused on
short-term relief of symptoms. The goal of asthma management is to improve quality of life
and health outcomes of people who suffer from asthma. Approaches to asthma management
vary and include school-based education programs, environmental trigger control
education, medical-home-based programs, and community wide education programs.
Expert Panel Report (EPR)-3 recommendations for Asthma Management and control
identified 4 components of care for managing asthma as: assessment and Monitoring; assess
asthma severity to initiate therapy; education; provide self- management education- teach
self-monitoring to assess level of asthma control and signs of worsening asthma; peak flow
meter shows benefits to patients, using written action plan; avoiding environmental triggers,
develop written action plan in partnership with patient; integrate education into all points of
care where health professional interact with patients; control environmental factors and co-
morbid conditions: recommend measures to control exposures to allergens and pollutants or
irritants that make asthma worse; medications: select medications and delivery devices to
meet patient needs and circumstances. These four components form the basis for
37
accountable communities healthy together asthma (ACHT-A) program design and
activities in the United States.
In Africa, problems including those arising from the overutilization of health services, lack of
trained staff and diagnostic apparatus, and non-availability and unaffordability of inhaled
medications have hindered efforts to improve the management of asthma (Musafiri et al,
2011; Uijen et al, 2008). A review article by Fawibe A.E. noted lack of proper diagnosis and
monitoring technique like use of PEF-meter; injudicious use of asthma medication; poor
compliance in medication due to high cost, fear of side-effects, incorrect use of inhaler and
stigma associated with use of inhalers; use of traditional treatment methods like Egyptian
plant “ammivisnega” which contains sodium cromoglycate; lack of proper education as well
as presence of fake and substandard drugs as the state of asthma management in Sub-Saharan
Africa (Fawibe, 2008). The non-availability and unaffordability of inhaled steroids, and the
relative non-adherence to these medications (when available) have also had large negative
impact on the response to asthma in Africa. Studies have shown that about 50% of people
adhere to prescribed medications (Salama et al, 2010; Ait-Khaled et al, 2007), with reasons
for non-adherence including side-effects, dosing frequencies, and lack of patient education on
their illness, need for treatment, and how to take medications (WHO, 2012). There are also
inherent socio-cultural misconceptions and individual values that need to be understood and
addressed toward improving the acceptance and use of asthma medications (Zaraket et al,
2011), with continual public awareness and education being advocated, especially among
parents, relatives and colleagues of children with asthma (van Gemert et al, 2011; Zaraket et
al, 2011). The long term goal of asthma therapy is to achieve and maintain asthma control by
utilizing pharmacological and non- pharmacological measures. This should lead to utilization
of the least possible dose of medications in order to minimize the risk of side effects.
MEDICATIONS USED FOR THE TREATMENT OF ASTHMA
The medications used for asthma treatment vary according to age (young children versus
adolescents and adults), the severity of asthma, and how well the symptoms are controlled.
The asthma treatment plan must be reviewed and adjusted on a regular basis. If symptoms are
well controlled, medication can sometimes be reduced. As symptoms worsen, medication
should be increased. Although asthma symptoms may be mild for most people, failure to use
appropriate drugs or comply with treatment, coupled with an under-recognition of the
severity of the problem, can lead to unnecessary deaths, most of which do not occur in the
38
hospital. The two main categories of asthma drugs are commonly referred to as “reliever”
drugs that target acute broncho-constriction and “controller” drugs that reduce the severity of
airway inflammation and frequency of obstruction. The main reliever drugs are rapid-acting
β2-agonists (e.g., albuterol, metaproterenol, pirbuterol, levalbuterol) that are also referred to
as bronchodilators, since they relax the bronchial smooth muscle by activating β2-adrenergic
receptors. This is the treatment of choice for mild intermittent asthma. For mild persistent,
moderate, and severe asthma, reliever treatment is usually combined with controller
treatment, such as inhaled corticosteroids (ICS) and the leukotriene modifiers. ICS (e.g.,
budesonide, beclomethasone, flunisolide, and fluticasone) and leukotriene modifiers (e.g.
montelukast and zileuton) target the inflammatory micro-environment of the airway to reduce
airway obstruction and hyper-responsiveness. Controllers are medications taken daily on a
long term basis to keep asthma under clinical control mainly through their anti-inflammatory
effects (Creticos, 2003). Relievers are medications used on an “as- needed basis” that act
quickly to reverse broncho-constriction and relieve symptoms.
CONTROLLER MEDICATIONS
. INHALED CORTICOSTEROIDS
Inhaled corticosteroids (ICS) are currently the most effective anti- inflammatory medications
for the treatment of asthma (Lemanske et al, 2001; Pauwels et al, 2003). The steroids used to
treat asthma are entirely different from the ones athletes take to build muscle. Regular
treatment with an inhaled steroid reduces the frequency of symptoms (and the need for
inhaled bronchodilators for symptom relief), decreases the risk of serious attacks, improve
quality of life, improve lung function, decrease AH, control airway inflammation, reduce
frequency and severity of exacerbations, and reduce asthma mortality. Most of the benefits
from ICS are achieved in adults at relatively low doses. As tobacco smoking reduces the
responsiveness to ICS, higher doses may be required in patients who smoke. To reach
control, add- on therapy with another class of controller is preferred to increasing the dose of
ICS; however, some patients with severe asthma may benefit from long- term treatments with
high doses of ICS (Snefler et al, 2002; Masoli et al, 2005). Examples include beclomethasone
dipropionate, budesonide, circlesonide, fluticasone propionate. Unlike steroids that are taken
as tablet or liquid by mouth, very little of the inhaled steroid is absorbed into the bloodstream,
and there are few side effects. However, as the dose of inhaled steroid is increased, small
amounts of the inhaled medication are absorbed into the bloodstream, and the risk of long-
39
term side effects increases. The most common side effect of low-dose inhaled steroid is oral
candidiasis (thrush). This can usually be prevented by rinsing your mouth or brushing your
teeth and tongue immediately after inhalation and, if your inhaled steroid is delivered from a
metered dose inhaler, by using a spacer (which helps to deliver medication to the lungs, with
less deposited in the mouth). A hoarse voice and sore throat (without thrush) are less common
side effects that are usually managed by changing to a different inhaled steroid preparation or
delivery system. Rare but possible side effects of long-term high-dose inhaled steroid
treatments, besides oral candidiasis, include cataracts, increased pressure in the eye
(glaucoma), easy bruising of the skin, and increased bone loss (osteoporosis). The risk of
these complications is far less with inhaled glucocorticoids compared with oral
glucocorticoids (eg, prednisone). Nevertheless, every effort should be made to use the lowest
possible dose that controls asthma and minimizes the risk of an asthma attack.
LONG- ACTING INHALED B2- AGONISTS
Long-acting inhaled B2-agonists (LABAs), including formoterol and salmeterol, should not
be used as monotherapy in asthma. Studies show that it is harmful to use them alone to
control asthma. When used in combination with ICS, there is an improvement in symptoms,
decreased nocturnal asthma, improved lung function, decreased use of recue rapid- onset
inhaled B2-agonists, reduced number of exacerbations, and more clinical control of asthma in
more patients, more rapidly, at a lower dose of ICS. Fixed combination inhalers are available
in the form of fluticasone and salmeterol (Seretide) or budesonide and formoterol
(Symbicort). Although salmeterol and formoterol provide a similar duration of
bronchodilation and protection against bronchoconstriction, formoterol has a more rapid
onset of action than salmeterol. Therefore, combination inhalers containing formoterol and
budesonide may be used for both rescue and maintenance of control (O’Byrne et al,
2005).LABA provides longer protection to prevent exercised- induced bronchospasm than
short- acting inhaled B2-agonists (SABA) (Cates et al, 2012). Long-acting bronchodilators
(salmeterol, formoterol, vilanterol) are recommended because they work for a longer period
than short-acting bronchodilators (for 12 or more hours). A device that contains both an
inhaled steroid and a long-acting bronchodilator is usually preferred (sample brand names:
Advair, Breo Ellipta, Dulera, Seretide (in Europe), Symbicort]. A short-acting bronchodilator
is still used as needed for immediate relief of asthma symptoms.
LEUKOTRIENE MODIFIERS
40
Leukotriene modifier agents (leukotriene receptor antagonists-LTRAs) reduce airway
inflammation and improve asthma symptoms and lung function, but with a less consistent
effect on exacerbations, especially when compared to ICS. They may be used as an
alternative treatment to ICS for patients with mild asthma, especially in those who have
clinical rhinitis. When added to ICS, LTRA may reduce the dose of ICS required by patients
with uncontrolled asthma and may improve asthma control (Bjermer et al, 2002; Idrees et al,
2007). Leukotriene modifiers, such as montelukast (Singulair), zafirlukast (Accolate), or
zileuton (Zyflo) are an alternative to inhaled glucocorticoids. Leukotriene modifiers work by
opening narrowed airways, decreasing inflammation, and decreasing mucus production. They
are taken by mouth as a pill once or twice daily and have very few side effects. Mood
alteration and depression are rare side effects. However, compared with inhaled
glucocorticoids, leukotriene modifiers are generally somewhat less effective in controlling
asthma. Leukotriene modifiers can be used to prevent symptoms before exposure to a trigger
or before exercising, but need to be taken three or more hours prior to the exposure or
exercise.
THEOPHYLLINE
Theophylline is a weak bronchodilator with modest anti- inflammatory properties. It may

provide benefits as an add-on therapy in patients who do not achieve control with ICS alone,
but is less effective than LABA and LTRA. It is not recommended for use as monotherapy in
asthma treatment. Recent data have shown that low- dose theophylline may have an
important role in improving steroid resistance in patients with severe asthma requiring high-
dose ICS through activation of certain down- regulated pathways, such as histone deactylases
(Hamid et al, 2007). Theophylline is a long-acting bronchodilator available in tablet form. It
is rarely used because of frequent associated side effects, drug interactions, limited
effectiveness, and risk of life-threatening complications from medication overdose.
Anti- IgE
It is indicated for patients of 12 years and above with severe allergic asthma uncontrolled on
high dose ICS and other controllers and who have an IgE level in the appropriate therapeutic
range. It should only be prescribed by a specialist as it requires careful monitoring.
ORAL B2- AGONISTS
41
It has a side effect profile that is much higher than that of inhaled B2- agonists. Therefore,
their use is highly discouraged.
SYSTEMIC CORTICOSTEROIDS
Long- term oral gluco-corticosteroid therapy (excluding short courses for acute attacks of
asthma for a period of 1-2 weeks) may be required to control difficult asthma despite
maximum standard therapy. The dose should be reduced to the lowest possible and other
controllers should be maximized to minimize the side effects. If symptoms are not controlled
with the above medications, an oral steroid (eg, prednisone or methyl-prednisolone) may be
added to the treatment regimen. Most healthcare providers recommend a 5 to 10 day course
of oral gluco-corticoids for flares of asthma. Side effects are common, including increased
energy, insomnia, hunger, agitation, and mood alteration, but they generally can be tolerated
for a short period during which restoration of normal breathing is the priority.
RELIEVER MEDICATIONS
RAPID- ONSET INHALED B2-AGONISTS
SABA, such as salbutamol, are medications of choice for relief of symptoms of acute
exacerbations of asthma and for the pre-treatment of exercise- induced broncho-constriction.
When it is used for maintenance therapy, it should always be given with ICS. Regular, long-
term use of SABA is not recommended.
ANTICHOLINERGICS
Anti-cholinergics are less effective than SABA. However, when used in combination with
SABA in acute asthma, they have an additional effect. It can also be an alternative
bronchodilator for patients who experience adverse effects such as tachycardia, arrhythmia,
and tremor from rapid- acting B2-agonists. Benefits in the long term asthma control have
been established for the long acting anticholinergic medication, tiotropium. Tiotropium, when
combined with ICS, is superior to doubling the dose of ICS in poorly controlled asthmatics
on low dose ICS, similar to the effect of LABA to ICS. Tiotropium (Spiriva) is a once-daily,
long-acting bronchodilator that works by a different mechanism. It too is best used in
combination with an inhaled steroid. It is available as a dry-powder system (a capsule
42
containing the medication is loaded into its delivery system for each dose) or as a multi-dose,
soft-mist inhaler called Respimat.
PATIENT EDUCATION IN TREATMENT
Patients need to know that inhaled medication is preferred for asthma because it has a
superior therapeutic ratio compared with the currently available oral therapy, since high
concentrations of the inhaled medication can be delivered directly to the airway with high
therapeutic effects and few systemic side-effects. They should also know that asthma is no
longer considered a condition with isolated acute episodes of broncho-spasms but a chronic
inflammatory disorder of the airways. Therefore the use of quick-relief medication alone that
does not give long-term control, because it does not affect airway inflammation, should be
discouraged.
AEROSOL DEVICES USED IN ASTHMA
SMALL- VOLUME NEBULIZER (SVN)
They are predominately powered by a compressed gas (air or oxygen) to convert one or more
than one drug solutions or suspensions at any concentrations and dose into aerosols. Its main
advantage is that it requires minimal patient cooperation and is therefore suitable for all ages,
with normal breathing and no inspiratory pause required. Its importability and time to deliver
the medication (10-25 min), in addition to the potential of contamination is its main
disadvantage. Nebulizers use compressed air to change a medication from liquid form to a
fine spray that can be inhaled through a mask or mouthpiece. When a facemask is used, it
should be placed snugly over the face; moving the mask just 1 centimeter away from the face
reduces the dose of an inhaled medication by up to 50 percent. Nebulizers may be preferred
to metered-dose inhalers for children who are unable to use a handheld device.
PRESSURIZE METERED- DOSE INHALER (pMDI)
It is a pre-pressurized inhaler with medication and a propellant, which when actuated will
give one dose of the drug for a single inspiration. pMDIs typically require slow inspiratory
flow (<30L/min). Metered-dose inhalers dispense liquid or fine powder medications, which
mix with the air that is breathed into the lungs. The spacer and face mask help to ensure that
the greatest amount of medication is delivered to the lungs in children. Its advantage is that it
43
is premixed and the ability to provide multiple doses in a short period of time. It is also small
and portable with limited contamination. Its disadvantages include the need of patient
training to coordinate inhalation with actuation, and if this is not done properly, there is a
potential of high deposition of drug in the oropharynx. Also, because it does not have dose
counter, it is difficult to determine the dose remaining in the canister.
DRY POWDER INHALER
It is not pressurized (no propellant), and therefore requires high inspiratory flows (60-90
L/min) to disperse a full dose. It is portable; breath actuated and has a built-in dose counter. If
not used properly, the adequate inspiratory flow to disperse a full dose could cause a fairly
higher oropharyngeal impaction and exhaled humidity into mouthpiece which would affect
the function of the device. It may not be suitable for very young or very old patients.
Examples include Turbo-haler, Diskus, and Handihaler devices.
BREATH-ACTUATED INHALERS
These inhalers automatically release a spray of medication when the person begins to inhale.
They are easy to use and improve asthma control and compliance to medications.
NON- PHARMACOLOGICAL MEASURES IN ASTHMA MANAGEMENT
These include developing partnership with the patient, giving asthma education, developing a
written action plan for asthma, identifying and reducing exposure to risk factors, physical
therapy and other novel measures for the management of asthma.
DEVELOPING PARTNERSHIP WITH THE PATIENT
The major issue in the management of asthma patients is their non- adherence to therapy.
Several factors leading to this non- adherence may be related to poor inhaler technique, a
regimen with multiple drugs, concern regarding side effects from the drugs, the cost of
medications, lack of knowledge about asthma, lack of partnership in the management,
inappropriate expectations, underestimation of asthma symptoms, use of unconventional
therapy and cultural issues. A review of studies in paediatric asthma has revealed that
children and adolescents with asthma show considerable variability in perceptual accuracy
44
and frequently make clinically relevant errors that have the potential to affect self-
management behaviour (Lane, 2006). It is also clear from studies conducted in a range of
countries that people of all ages tend to underestimate their asthma symptoms and
overestimate their control (Rabe et al, 2000; Sawyer et al, 2003; Clark et al, 2002; McQuaid
et al, 2005). This tendency may lead to under-medication and erratic adherence to treatment.
Indeed, it has been estimated that adherence rates for asthma treatment range from as low as
30% to, at best, only 70% (WHO, 2003). This means that at best many children and young
people with asthma may be under-medicating themselves and settling for less exercise and a
poorer quality of life than they could achieve by following recommended management
strategies and treatment. Hence there is a need to develop a partnership between the patient
and the health care professional which leads to enhancement of knowledge, skills, and
attitude toward understanding asthma and its management. Based upon agreed goals of
management, a guided- written self- management plan is offered to the patient, which varies
from patient- based to physician- based plans which are reflected on patient adherence.
National Heart, Lung, and Blood Institute clinical practice guidelines strongly recommend
that health professionals educate children with asthma and their caregivers about self-
management (NHLBI, 1997). Asthma requires constant self-management by the patient to
maintain control of symptoms, prevent exacerbations, attain normal lung function, and
maintain normal activity levels. Self-management refers to the behaviours that people with
asthma and their family members perform to lessen the impact of this chronic illness. Self-
management includes adherence to medical regimens as well as the complex cognitive-
behavioural tasks of self-monitoring, decision making, and communicating about both
symptoms and treatment regimens (Bailey et al, 1992; Clark et al, 1990; Thorensen et al,
1983). Preference for inhaler device should be taken into account as a factor to improve
adherence in adolescents (BTSG, 2011).
Asthma Self-management process include:
Monitor:
_ Monitor symptoms of asthma “directly” and compare with personal standard. Use object
measures (e.g, peak flow meter) to monitor and compare symptoms with personal standard.
_ Monitor for personal environmental triggers
_ Monitor asthma self-management efforts and compare with personal standard
Identify problems:
_ Using monitoring (as described above), identify when a problem exists.
Implement solutions:
45
_ Keep regular appointments with health care providers.
_ Refer to asthma action plan.
_ Maintain medication for chronic condition as prescribed.
_ Maintain “normal” exercise levels.
_ On the basis of symptoms or the environment, make medication adjustments, including
administration of rescue medication, as prescribed.
_ Avoid or remove asthma triggers.
_ Call health care professional in an acute situation.
_ Communicate with family members and with health care providers.
Evaluate:
_ Evaluate success of actions and return to monitoring.
When teaching adolescents the asthma self-management techniques expected of adults,

clinicians should address adolescent developmental issues, such as building positive self-
image and confidence, increasing personal responsibility, and gaining problem-solving skills.
To accomplish this approach, it is often helpful to see the adolescent initially without parents
present and to involve the adolescent directly in setting goals for therapy, develop an
appropriate asthma action plan, and review the effectiveness of the plan at subsequent visits.
The parents can be brought in at the end of the visit to review the plan together and to
emphasize the parents’ important role in supporting the adolescent’s self-treatment efforts
(NHBLI, 2007).
ASTHMA EDUCATION
The goal of asthma education is to provide a patient with asthma (or the parents of a child
with asthma) adequate training to enhance their knowledge and skills to be able to adjust
treatment according to guided self- management. Education should include knowledge about
asthma and skills related to the devices, as their might be misperceptions about the use of
inhalers and the safety of inhaled corticosteroid. With the availability of appropriate
information, patients will be encouraged to continue on the management plan and reassured
about the control of disease. It has been documented that a well- structured asthma education
program will improve quality of life; reduce cost, and the utilization of health care resources.
The National Heart, Lung, and Blood Institute (NHLBI) guideline for treatment of asthma
strongly recommends that health professionals provide asthma education to children with
asthma and their caregivers. This guideline recommends that providers educate patients and
46
their caregivers about 4 major topics: basic facts about the patho-physiology of asthma,
correct usage of medications, techniques for monitoring symptoms, and the importance of
avoiding triggers (NHLBI, 1997). Providing pediatric asthma education reduces mean
number of hospitalizations and emergency department visits and the odds of an emergency
department visit for asthma, but not the odds of hospitalization or mean number of urgent
physician visits (Coffman et al, 2008). In a systematic review conducted by Wolf et al, 2002,
of 32 trials involving 3706 pediatric patients, asthma education programs compared to usual
care were found to improve measures of physiological function and self-efficacy; reduce days
of school absence and days of restricted activity, decrease emergency department utilization,
and perhaps reduce nights disturbed by asthma. It is estimated that more than 80 per cent of
asthma deaths could be prevented with proper asthma education (ICES, 1996).
WRITTEN ACTION PLAN FOR ASTHMA
It is considered an integral part of asthma management for patient and doctors. It helps to
recognize the loss of control of asthma and gives clear instructions for early intervention to
prevent asthma attacks. It leads to better control in both children and adults. Regular review
of the asthma action plan is important as a person’s level of asthma control may change over
time. It involves working with the healthcare provider to develop personalized directions to
follow when symptoms increase or peak flow measurement begins to decrease. Two meta-
analyses of action plans for children and adolescents confirm the efficacy of such plans in
reducing the risk of exacerbations leading to acute care visits and suggest that symptom-
based plans may be superior to peak-flow based plans, possibly due to better and longer
compliance with symptom-based plans (Duchame et al, 2008; Zemek et al, 2008). The
written asthma action plan should include the following information: instructions for
handling exacerbations (including self- administration of medication); recommendations for
long term control medications and prevention of exercise induced broncho-spasm (EIB), if
appropriate; and identification and avoidance of triggers.
IDENTIFY AND REDUCE EXPOSURE TO RISK FACTORS
Measures to prevent or reduce exposure to risk factors should be implemented wherever

possible. The factors that set off and worsen asthma symptoms are called "triggers."
Identifying and avoiding asthma triggers are essential steps in preventing asthma flare-ups.
There are different triggers leading to asthma exacerbations, which may include Allergens
(including dust, pollen, and furry animals); Respiratory infections; Irritants (such as tobacco
47
smoke, chemicals, and strong odours or fumes); Physical activity; certain medicines, known
as beta blockers; Emotional stress; menstrual cycle in some women and occupational agents.
A small number of patients will develop asthma symptoms after exposure to aspirin or other
non-steroidal anti-inflammatory medications, like ibuprofen or naproxen. They can be
classified as indoor or outdoor allergens and occupational sensitizers (Al- Moamary et al,
2012). Indoor allergens include domestic mites, furred animals, cockroaches, and fungi. Most
of the interventions to reduce exposure to these triggers will enhance asthma control (Al-
Frayh et al, 1997; Hasnain et al, 2007). The most important indoor air pollutant is related to
tobacco exposure. Measures to avoid tobacco exposure will lead to better asthma control and
avoidance of long- term lung function impairment (Troisi et al, 1995). Outdoor allergens such
as pollens and molds are impossible to avoid completely. Exposure may be reduced by
closing windows and doors, remaining indoors during dust storms and initial raining seasons,
using air conditioning if possible. It is recommended to avoid outdoor strenuous physical
activities in cold weather, low humidity, or high air pollution (Tunnicliffe et al, 1999).
Whenever an occupational sensitizer is identified, it is advisable to keep the affected person
away from that environment. The earlier the removal of this sensitizer takes place, the higher
the chance of complete recovery from occupational asthma. Annual influenza vaccination is
advised for individuals with severe asthma. Certain drugs whenever identified should be
avoided (e.g beta blockers).
CONTROLLING ASTHMA TRIGGERS
After identifying potential asthma triggers, the patient and the clinician should develop a plan
to deal with the triggers. There are three main options:
●Avoid the trigger entirely (eg, if allergic to animals, do not own pets; if sensitive to aspirin
or related medications; avoid all forms of these medications).
●Limit exposure to the asthma trigger if it cannot be completely avoided (e.g, move to
another seat if someone with strong perfume is seated nearby; have someone else do house
cleaning if allergic to dust mites).
●Take an extra dose of bronchodilator medication before exposure to an asthma trigger. This
is a common approach prior to exercise, and it is encouraged not to avoid exercise. Talk with
a healthcare provider before using this approach in other circumstances (for example, if you
48
are cat-allergic and about to be exposed to cat dander); it should only be used if limiting or
avoiding exposure is not possible. Be careful not to use more than twice the amount of
medication normally used.
●Special approaches to unavoidable allergic triggers include allergy desensitization injections

("allergy shots") and an injected medication targeting allergy proteins in the blood (anti-
immunoglobulin E antibody, called omalizumab). In specialized treatment centers, persons
who are sensitive to aspirin and related medications can be desensitized to aspirin.
Computer-based Patient Education
Computers have diverse uses in health promotion and disease prevention—for example, as
tools for education on AIDS and responsible sexuality and as adjuncts to medical therapy for
alcohol rehabilitation and rheumatoid arthritis (Paperny et al, 1989; Kann, 1987; Meier et al,
1989; Wetstone et al, 1985). Furthermore, empirical research has identified the value of using
computers to provide behaviour-change messages tailored to client belief characteristics, such
as stage of change and health beliefs, and to demographic characteristics, such as gender and
ethnicity (De Vries et al, 1999). Several computer-based applications have been developed to
assist in asthma management and education. For adult asthma patients, computer-assisted
instruction (CAI) has been used to help them monitor and avoid house dust-mite allergen
(Huss et al, 1991). Several CAI programs have been developed for children with asthma.
These include Clubhouse Asthma, Bronkie the Bronchiasaurus, Wee Willie Wheezie, Air
Academy: The Quest for Airtopia (Yawn et al, 2000), and Asthma Command (Rubin et al,
1989). Bronkie the Bronchiasaurus has been shown to positively affect knowledge, self-
efficacy, and communication about asthma in children who use it (Lieberman, 1997).
Airtopia has been shown to positively affect asthma knowledge in children when used in the
context of a general health curriculum (Yawn et al, 2000). Asthma Command has been
evaluated in clinic settings where children who used the program showed increases in
knowledge and in self-reported asthma management, compared with children in the control
group (Rubin et al, 1989). There were no demonstrated differences in visits to physicians,
emergency rooms, or hospitals.
Watch, Discover, Think and Act (WDTA) Computer-assisted Instruction
WDTA is a computer-based education program that has taken a motivational approach to

teaching asthma self-management skills to urban, minority children (Bartholomew et al,
2000). The program is a multimedia application that uses three types of computer-based
49
instructional strategies—a simulation of real-world activities in which the child can learn and
practice self-regulatory processes; tutorials with which the child can learn and practice
asthma-specific skills; and a game treatment to enhance motivation. The broad objectives of
the program are to provide asthma self-management skills training as an adjunct to medical
care and enhance clinical care provided for the asthma patient by supplying information to
health care providers and parents regarding the child’s asthma self-management capabilities
and progress. The program was developed using social cognitive theory change methods to
improve the child’s knowledge, self-efficacy, and attributions (Bandura, 1986). These
methods include verbal reinforcement, guided practice with feedback, persuasion, goal
setting, incentives, and symbolic modelling. The program addresses the need to individualize
asthma education and to teach self-regulatory skills, components of what Creer et al. refer to
as a second generation of asthma self-management programs (Creer et al, 1992). Shegog et
al, 2001 conducted a study among seventy- six asthmatic 9- 13 years old to assess the
motivational appeal of the computer- assisted instructional program (WDTA) and evaluate
the impact of the program in eliciting change in their knowledge, self- efficacy, and
attribution. The results of the study showed that knowledge scores increased significantly
among these children. It also showed that children using the program scored significantly
higher (P< 0.01) on questions about steps of self- regulation, prevention strategies, and
treatment strategies. They also demonstrated greater self- efficacy (P< 0.05) and more
efficacy building attribution classification of asthma self- management behaviours (P< 0.05)
than those children who did not use the program.
PREVENTION OF ASTHMA
Prevention of asthma occurs at two levels: primary or secondary. Primary prevention refers to
interventions introduced before the onset of disease and designed to reduce its incidence.
Secondary prevention refers to interventions introduced after the onset of disease to reduce its
impact (BTS, 2016).
Primary non pharmacological prevention includes:
Multifaceted allergen avoidance: A Cochrane review of trials comparing single (six studies)
or multiple (three studies)interventions with a no intervention control, reported that in
children who are at risk of developing childhood asthma multifaceted interventions, which
involve both dietary allergen reduction and environmental change to reduce exposure to
inhaled allergens, reduced the odds of a doctor diagnosing asthma later in childhood by half
(>5 years of age, odds ratio (OR) 0.52, 95% confidence interval (CI) 0.32 to 0.85) (Maas et
50
al, 2011). However, the effect of these multifaceted interventions on wheeze reported by
parents was inconsistent and there was no beneficial effect on night-time coughing or
breathlessness. For children at risk of developing asthma, complex, multifaceted
interventions targeting multiple allergens may be considered in families able to meet the
costs, demands and inconvenience of such a demanding programme.
Weight reduction in overweight and obese patients: Two systematic reviews based on
epidemiological studies looking at the association between being overweight or obese in
childhood and the development of asthma concluded that high BMI increases the risk of
incident asthma, with a dose dependent relationship that was stronger in boys (Chen et al,
2013; Egan et al, 2013). Weight reduction is recommended in obese patients to promote
general health and to reduce subsequent respiratory symptoms consistent with asthma. Obese
and overweight children should be offered weight-loss programmes to reduce the likelihood
of respiratory symptoms suggestive of asthma.
Microbial exposure: The ’hygiene hypothesis’ suggested that early exposure to microbial
products would switch off allergic responses thereby preventing allergic diseases such as
asthma. The hypothesis is supported by some epidemiological studies comparing large
populations who have or have not had such exposure (Strachan, 2000; Holt et al, 1997).
There is insufficient evidence to indicate that the use of dietary probiotics in pregnancy
reduces the incidence of childhood asthma. Further work with longer follow up to establish
outcomes in relation to asthma are still needed.
SECONDARY NON-PHARMACOLOGICAL PREVENTION
Cessation of smoking: Two studies have demonstrated decreases in childhood asthma

severity when parents were able to stop smoking (Wilson et al, 2001; Murray et al, 1993).One
study in adults with asthma suggested that smoking cessation improved asthma specific
quality of life, symptoms and drug requirements (Tonnesen et al, 2005).
Electrolyte correction: Low magnesium intake has been associated with a higher prevalence
of asthma with increasing intake resulting in reduced bronchial hyper-responsiveness and
higher lung function (Britton et al, 1994). Magnesium plays a beneficial role in the treatment
of asthma through bronchial smooth muscle relaxation, leading to the use of intravenous or
inhaled preparations of magnesium sulphate for acute asthma attacks (Blitz et al, 2005).
Weight reduction in overweight and obese patients with asthma: Two more recent RCTs
(one small, one large) in adults and one pilot RCT in children investigating the effects of
interventions to reduce weight on asthma control and biomarkers of asthma severity, reported
51
reductions in BMI but varying effects on asthma control and biomarkers (Ma et al, 2015;
Jensen et al, 2013; Callister et al, 2013).Weight-loss interventions (including dietary and
exercise-based programmes) can be considered for overweight and obese adults and children
with asthma to improve asthma control.
Breathing exercises
Behavioural programmes centred on breathing exercises and dysfunctional breathing
reduction techniques (including physiotherapist-delivered breathing programmes such
as the Papworth method and the Buteyko method) can improve asthma symptoms,
quality of life and reduce bronchodilator requirement in adults with asthma, although
have little effect on lung function (O’ Connor et al, 2012).Breathing exercise programmes
(including physiotherapist-taught methods) can be offered to people with asthma as an
adjuvant to pharmacological treatment to improve quality of life and reduce symptoms.
Relaxation therapies
Muscle relaxation could conceivably benefit lung function in patients with asthma (Huntley
et al, 2002).
Physical exercise training
Physical training improves indices of cardiopulmonary efficiency (oxygen consumption,
maximum heart rate, and work capacity all increased significantly but not on PEF, FEV1,
FVC or ventilation at maximal exercise capacity (VEmax) ), it should be seen as part of a
general approach to improving lifestyle and rehabilitation in people with asthma, with
appropriate precautions advised about exercise-induced asthma (Holloway et al, 2004).
PHYSICAL THERAPY
Physical activity is generally accepted to be of advantage to young children in terms of bone

development, motor skills, improved cardiovascular fitness, and self- esteem (White et al,
2005; Trudeau et al, 2005). Physical activity is also important for children and young people
with asthma. Several studies have identified significant improvements in aerobic fitness (Ram
et al, 2000; van Veldhoven et al, 2001) and asthma-related benefits such as reduced hospital
admissions, reduced absenteeism from school, fewer consultations with health professionals,
reduced medication use (Welsh et al, 2005), and improved ability to cope with asthma (van
Veldhoven et al, 2001 ). In addition, it remains clear that being able to participate in physical
activity, particularly at school, is an important contributing factor for psychological wellbeing
by, for example, reducing the body dissatisfaction that can be associated with asthma
52
(Mansour et al, 2000; Kelsay et al, 2005; Vitulano, 2003). Furthermore, studies involving
dietary alteration have shown that weight loss for obese people with asthma can improve their
asthma symptoms (Stenius- Aarniala et al, 2000). It is therefore feasible that physical activity
that is conducive to weight loss might be helpful for obese children and young people with
asthma. In addition to the above benefits physical activity may also help protect against the
potential increased risk of osteoporosis associated by the prolonged steroid therapy that some
children and young people with asthma may experience (Villareal et al, 1996). Although
direct evidence of such benefits is currently lacking for asthma, evidence exists to show that
weight-bearing physical activity can increase bone mineral content and reduce osteoporosis
risk later in life among children with acute lymphoblastic leukaemia (White et al, 2005).
Despite these varied benefits the majority of studies of physical activity training programmes
for children and young people with asthma have shown no change in actual baseline lung
function (Carlsen et al, 2002; Strong et al, 2005) or in the occurrence or degree of exercise-
induced asthma (Welsh et al, 2005). Further RCTs and systematic reviews on the effects of
physical training need are required (Ram et al, 2000). Because of this range of physical,
psychological and social benefits, current evidence suggests that children and adolescents
with asthma should be encouraged to participate in regular physical activity. This may
improve asthma management and general health and minimise the generic risks associated
with low levels of physical activity (Mansour et al, 2000; Welsh et al, 2005). Although the
existence of a respiratory condition might be expected to prevent engagement in such
activities, the overwhelming majority of studies show that people with asthma can exercise
safely if medicated appropriately and can significantly improve their cardiovascular fitness
and quality of life by doing so (Lucas et al, 2005). Indeed, a substantial proportion of
sportsmen and women who compete at the elite international level have a diagnosis of asthma
(Orenstein, 2002) or experience exercise-induced asthma (Sheth, 2003). The consensus of
many authors is therefore that inactivity or reduced activity in the presence of an asthma
diagnosis should not be accepted (Sheth, 2003). Instead, an exercise 'prescription' should be
part of the management plan for all people with asthma (Lucas et al, 2005).
EXERCISE-INDUCED ASTHMA
Exercise induced bronchospasm (EIB), which can limit participation in normal activities if
not treated, should be anticipated in all asthma patients. It is caused by a loss of heat, water,
or both from the lung during exercise because of hyperventilation of air that is cooler and
53
dryer than that of the lung. Some, but not all, studies suggest that release of inflammatory
mediators is also involved in the cause of EIB. EIB usually occurs during or just after
vigorous activity, reaches its peak 5– 10 min after stopping the activity, and resolves in
another 20–30 min. Some reports indicate that there is a refractory period of less than 1 h
after EIB that allows an asthma symptom- free interval after warm up exercises (NHBLI,
2007). If exercise is a trigger for asthma, an extra dose of bronchodilator medication or a
leukotriene modifier can be used to prevent asthma symptoms. If these agents alone do not
fully prevent asthma symptoms with exercise, an inhaled steroid "controller" medication may
be needed to decrease inflammation in the airways.
USE OF MUSIC FOR THERAPY
In studies reviewed by Eley et al, 2010, there were increased excellent retention, improved
respiratory function, increased well- being, increased engagement of asthmatics and their
families with medical services, increased awareness of asthma and compliance with asthma
management plan, improved social skills and increased cultural awareness using music
lessons for asthmatic adolescents. They also noted that contributory factors to retention were
parental and school support for minors and other factors for adults.
THEORIES GUIDING THE DEVELOPMENT OF ASTHMA
In both research and clinical contexts, consideration of psychosocial aspects of asthma (and
of respiratory disease in general) has a long tradition. Indeed, in the very early days of
behavioural medicine, asthma was considered by psychoanalytic theorists to be one of the
few entirely psychosomatic illnesses (French et al, 1941). However, in subsequent years, such
anecdotally driven theories have been found to be empirically unsupportable. Instead,
contemporary research has seen the development of three distinct empirically based
behavioural approaches to asthma (Kaptein et al, 2007). Learning theory approaches consider
asthma symptoms to be responses that are under the influence of reinforcement (rewards) or
negative consequences (punishment). Relaxation therapy, biofeedback, and systematic
desensitization are three resultant techniques to be applied in empirical studies on asthma
patients. However, the effects of these techniques on outcome measures, such as pulmonary
function and use of health care services, have been rather unimpressive (Ritz et al, 2004).
The second empirically based behavioural approach to asthma focuses on self-management.
In a narrow sense, self- management pertains to providing patients with written action plans
54
that instruct them on when and how to use and adjust asthma medication, usually in
combination with the monitoring of pulmonary function by patients (Gibson et al, 2002). In
general, behavioural scientists adopt a broad perspective in that they maintain that self-
management also encompasses the psychological and social management of living with a
chronic illness (Barlow et al, 2002). In contrast to learning theory (or psychoanalytic)
approaches, self-management interventions tend to be associated with meaningful
improvements in outcomes. In a review of self-management in asthma, Newman et al. report
positive effects on clinical and laboratory assessments, symptoms, functioning, quality of life,
and use of health care services (Newman et al, 2004). The most recent approach in
psychosocial research and care pertains to self-regulation and is sometimes referred to as the
“Common Sense Model” (Leventhal et al, 2003). In this approach, patients with asthma–or,
for that matter, with any illness–are seen as constructing a lay theory that comprises their
perceptions of the causes, course, consequences, timeline, and identity of their illness. These
views are formed as a consequence of what physicians tell patients but also of what patients
learn from informal sources such as popular publications, television programs, and fellow
patients. Such illness perceptions have been found to determine coping behaviour, self-
management behaviour, adherence, and outcomes (such as use of health care services, days
off work, school absenteeism, and quality of life [Hagger et al, 2003]). Illness perceptions in
asthma are easily categorized into the five dimensions distinguished by the Common Sense
Model. Illness perceptions in the identity dimension comprise the complaints, signs, and
symptoms that patients attribute to their asthma. Examples of illness perceptions that belong
to the causes dimension include perceptions that asthma is caused by “stress,” “heredity,” or
“the weather.” A cure/control illness perception could be the view that “There is nothing that
can help my condition.” For the consequences dimension, an illness perception such as “My
asthma is not a serious condition” would be an example. Timeline perceptions are particularly
relevant for asthma patients in that patients who agree with statements such as “My illness
will last a short time” or “My illness will improve in time” have been found to manifest poor
outcomes. For example, in a recent paper entitled No symptoms, no asthma, scrutiny of
timeline-related illness perceptions among 198 adults with asthma allowed the authors to
conclude that: “The single question of, ‘Do you think you have asthma all of the time, or only
when you are having symptoms?’ can efficiently identify patients who are not predisposed to
think about or manage their asthma as a chronic disease”. In other words, it was found that
illness perceptions relating to timeline could be used to identify those patients who have a
high risk of non-adherence to standard treatment guidelines. The first studies to successfully
55
use interventions based on illness perceptions in clinical samples have now been published.
As an example, Petrie et al. (2002) found that an illness perception-based intervention
produced a number of enhanced outcomes (including earlier return to work and reduction in
symptoms at follow-up) among a sample of myocardial infarction patients when compared to
controls. A relatively new development in Common Sense Model research and application is
the extension of investigations to include the exploration of perceptions relating to treatment
(Horne, 2003). The possibility of an “Extended Common Sense Model” has been put forward
in particular by Horne et al. (2002), who have proposed links between illness perceptions and
treatment perceptions. In a major publication on this subject, these authors found meaningful
associations between asthma patients’ views on the illness and its treatment and non-
adherence (Horne et al, 2002).
According to the Self-Regulation Model of Common Sense Illness Representations (SRM)
(Leventhal et al, 2003; 2001, 1998; 1997; 1996; 1992; 1991; 1984; 1980), people are active
decision-makers and problem solvers and play an agentic role in self-regulation. Both healthy
and ill people construct non-specialized models about illnesses which comprise a series of
cognitive and emotional representations to create an integrated, comprehensive and
meaningful picture of a health-threatening condition. Illness representations derive from
several informational sources, including: 1) an individual’s knowledge and direct
experiences; 2) socio-cultural knowledge; and 3) information and experiences from
significant others (e.g., relatives, physicians) (Leventhal et al, 1991; 1980). Individuals use
these representations to evaluate the risks for health and well-being, and then direct diverse
behavioural and emotional efforts to face the perceived risks and to protect health.
Individuals who are already ill use these representations to manage their condition, to control
its consequences in their lives and to recover their health, well-being and quality of life.
Therefore, as for the SRM illness representations directly influence the illness-related
emotion- and problem-focused coping actions and indirectly, by a mediation path of coping,
also influence the consequences of illnesses and the adjustment to the disease (Del-Castillo et
al, 2013).
THEORETICAL FRAMEWORK
Theories and Models are important in health education research. Babbie (2003) defined
theory as a systematic explanation for the observations that relate to a particular aspect of life.
HEALTH BELIEF MODEL (HBM)
56
Individuals often combine both biomedical and alternative medical beliefs and practices in
their approach to illness, and clinicians should be aware of community beliefs and practices
in order to optimize health education and clinical management (Pachter et al, 2002).
The proponents of Health Belief Model, Becker and Maiman (1975), contend that HBM is a
psychological model that tries to give details and predict health behaviours based on the
attitudes and beliefs of individuals. According to the proponents of HBM, an individual’s
readiness to engage in a particular health-related behaviour is a function of the following
elements:
Perceived Threat: This element consists of the perceived susceptibility and perceived severity
of a particular health condition. Perceived Susceptibility is about an individual’s perceptions
of the likelihood of contracting a health condition, and perceived severity is about feelings
regarding the gravity of the consequences of contracting an illness. Together these variables
determine the likelihood of the individual following a health-related action.
Perceived Benefits: This is concerned with the individual’s beliefs/evaluations of the
effectiveness of methods designed to reduce the threat of illness.
Perceived Barriers: This is concerned with potential negative outcomes following a
particular health action.
Cues to Action: This is concerned with physical symptoms of a health condition, or media
publicity that influence people to take action.
Self-Efficacy: This variable is concerned with the belief in being able to successfully perform
the behaviour required to produce the desired outcomes (Rosenstock et al, 1994).
The HBM assumes that the likelihood of a person engaging in specific health behaviour is a
function of several beliefs. HBM is based on the core assumptions that a person will take a
health related action if that person feels that a negative health condition can be avoided, and
has a positive expectation that by taking a recommended health action he will avoid a
negative health condition, and also believes that he can successfully take a recommended
health action (Mimiaga et al, 2009). HBM provides a frame of anchor on the present study
and it will be used as a basis for determining the impact of health education intervention on
knowledge and perceptions of asthma among secondary school students in Ile- Ife, Nigeria.
57
FIGURE 1: CONCEPTUAL FRAMEWORK: HEALTH BELIEF MODEL ON ASTHMA
EDUCATION
Modifying factors
Knowledge of asthma, socioeconomic status, socio-economic characteristics (age, sex, education level), ethnicity.
Perceived benefits
Perceived susceptibility
Awareness and prevention of asthma, reduction in school absenteeism, lifestyle adjustme
Of asthma outcome risks
Perceived constraints
Perceived severity
Cost of managing asthma, inconvenience embarrassment discomfort, societal influenc
ma risk factors would have serious consequences e.g. morbidity and death.
58
Perceived threat Likelihood of taking recommended action
Of asthma complications and death that
Compliance
results with treatment, health care seeking for treatment avoi
Cues to action
cal sessions on the use of peak flow meters and inhalers, media publicity tools, practical experiences of friends, communicati
SOCIAL COGNITIVE THEORY (BANDURA’S)
Social Cognitive Theory was developed by the Canadian psychologist Albert Bandura.
Bandura conducted a series of studies with his students and colleagues to discover why and
when children display aggressive behaviours (Bandura, 2001). These research projects
demonstrated the value of understanding individual behaviours which was later explored in
Bandura’s seminal article and book (Bandura, 1986; Bandura, 1989; Clark. 1989). Bandura
claimed that Social Cognitive Theory showed a direct correlation between a person’s
perceived self-efficacy and behavioural change. The findings derived from Bandura’s early
work (Bandura, 2001; Boulet, et al., 1999) laid the foundation for further refinement and
development of the theory which has become the theoretical framework of choice for many
researchers interested in measuring the outcomes of health education programmes (Clark &
Zimmerman, 1990; Bandura, 2001; Miller, 2005; Humbert et al., 2007). For instance, Ahmad
(2009) who investigated the effect of a breastfeeding education programme on breastfeeding
outcomes among mothers of preterm infants selected Social Cognitive Theory as the
theoretical framework to develop the intervention. Other researchers have used Social
Cognitive Theory in implementing co-operative learning and continuing education for
59
community services (Alansari, 2006) and the identification of psychosocial constructs to
explain physical activity behaviours among employed women (Tavares et al, 2009). Social
Cognitive Theory is a learning theory based on the claim that people learn in part by
observing each other (Boulet, at al., 1999). For instance, observed behaviour of others can
change an individual's way of thinking (Bandura, 2001). However, the premise that Social
Cognitive Theory is particularly appropriate in explaining how young persons’ learn is
important for this study. A central tenet of Social Cognitive Theory is that change in young
persons’ individual behaviours is due to their own learning capabilities. This is consistent
with the notion of young persons’ as active agents in their own learning. Social Cognitive
Theory consists of several assumptions in relation to learning and behaviour. The first
assumption rests on the understanding that environmental, behavioural and personal factors
influence each other in a reciprocal fashion. According to Social Cognitive Theory, learning
in a classroom situation rests on a set of complex interactions between several factors; each
impacting on the others to shape the learning process. This means that the thoughts and self-
belief of students interact with their general perception of the classroom context and that all
affect learning. The reproduction of the observed behaviour is influenced by the interaction of
these determinants as follows. The first determinant is personal, in which the individual
possesses high or low self-efficacy toward the behaviour or the learner’s belief in his or her
personal abilities to undertake that behaviour. The second determinant is behavioural, in
which the individual has a certain response after performing that behaviour. It is believed that
this provides chances for the learner to experience successful learning resulting from the
correct performance of the behaviour. The third determinant is environmental, in which the
individual is influenced by the environment or setting to enhance his or her ability to
successfully complete a behaviour. Environmental conditions act to improve self-efficacy by
providing appropriate support and materials (Miller, 2005; Bandura, 2001).The second
assumption postulates that young persons’ have the ability to influence the environment and
their own behaviour in a meaningful goal-oriented fashion. This acknowledges the role of the
environment in modifying behaviour, while also acknowledging the importance of self-
reflection, self-regulation and forethought processes. It is assumed that factors determining
the extent of environmental influence on education outcomes are entirely based on personal
ability to accommodate learning within the surrounding environment. So, students are in a
position to benefit from an Asthma health Education intervention when they are actively
engaged and supported with what is being taught and learned rather than receiving education
passively in an unsupportive environment. The third assumption postulates that learning can
60
take place without behaviour change (Bandura, 2001). This means that students can learn but
that they may need additional support to complement the means of the desired behaviour in
order to demonstrate that learning. It is acknowledged that measuring behavioural change is
not always sufficient to predict success or failure of health education. Social Cognitive
Theory offers other constructs that can be used for this purpose. For instance, self-efficacy
and social support are significant predictors of behaviour, and the physical environment
construct warrants empirical attention to predict the change in behaviour (Miller, 2005). As
discussed earlier, the environmental aspect of health education is a key influence of
behavioural outcomes. Consistently, writing on Social Cognitive Theory (McGhan, 1998;
Bandura, 2001; Miller, 2005) integrates a number of discrete constructs into a robust
conceptual framework to present a theoretical understanding of human functioning and its
application across a wide range of cultural and demographic characteristics (Bandura,
2001).Young persons’ learn through observation. Learning by observation is not merely a
repetition of action as it is being observed, but it is that process in which the learner integrates
their knowledge, attitudes, perception, and skill into performed behaviours (Zimmerman &
Schunk, 2001). Thus, learning from observation rests on four processes; attention; retention;
motivation and production (Zimmerman & Schunk, 2001).According to Blooms Taxonomy,
behavioural objectives should be divided into three domains: cognitive, affective, and
psychomotor as doing so can increase the potential for learning (Gilbert et al., 2011). These
domains are reinforced through the processes of self- efficacy, goal setting, self- regulation
and environmental support. Self-efficacy is a product of past performance, present
psychological state and experience combined with perceived outcome expectations of others
in the same environment to achieve certain levels of success after the completion of particular
tasks (Bandura, 1997). Self-efficacy arises from four sources: performance accomplishments,
vicarious experience, verbal persuasion, and physiological states (McGhan, 1998; Miller,
2005). According to Social Cognitive Theory each of the previous sub-process plays an
integral part in formulating the perception towards the retained knowledge. A variety of
asthma interventions have used SCT to improve asthma management (Sudre et al, 1999;
Alanis et al, 1999; Gibson et al, 1998; McGhan et al, 1998; Christiansen et al, 1997; Clark et
al, 1993; Mesters et al, 1993). Social Cognitive Theory has been used to help to modify
individual's perception about the usefulness of modern therapeutic regimes for a number of
diseases (Becker et al, 1994; Bandura, 2001; Alansari, 2006). Similar to the learning
activities in these interventions, components of SCT such as performance accomplishments,
vicarious experience, verbal persuasion and emotional arousal were incorporated into the
61
asthma education curriculum in the studies to enhance the self-efficacy of adolescent non-
asthmatic students. Performance accomplishments included role playing to inform students of
what to do when someone is having an asthma attack, simulations of an asthma attack, and
conducting risk assessments of potential asthma triggers in their homes as a take home
assignment. Students also experienced and practiced how to use peak flow meters. Vicarious
experience included an observation of an asthma educator using a peak flow meter,
emphasizing the importance of regular peak flow monitoring. The asthma educator also used
verbal persuasion by promoting the involvement of students in asthma prevention programs
and encouraging asthmatic students to comply with asthma treatment plans. Lastly, emotional
arousal involved students by performing stress management techniques such as pursed-lip
breathing. Social Cognitive Theory (Bandura, 1986; Clark. 1989) is used to examine why
measuring outcomes beyond knowledge acquisition are important in establishing the impact
of an asthma health education programme on outcomes for students. SCT provides a frame of
anchor on the present study and it will be used as a basis for establishing the impact of health
education intervention on knowledge and perceptions of asthma among secondary school
students in Ile- Ife, Nigeria.
FIGURE 2: CONCEPTUAL FRAMEWORK: THE MODEL OF SOCIAL COGNITIVE

THEORY (Adapted from Simon et al, (1995)
Predisposing factors:
Knowledge, Perceptions, Values
Attitude, Confidence
Enabling factors:
Availability of health resources
Accessibility of health resources Specific behaviour by
Community/ government laws, individuals or by
Priority, and commitment to health, organizations
62
Health related skills
Health
Reinforcing factors:
Family, Peers, Teachers,
Health providers, Environment
Community leaders, (conditions of living)
Decision makers
STUDIES RELATED TO EDUCATION INTERVENTION
KNOWLEDGE OF ASTHMA
Butz et al. (2005) conducted a four hour education programme which was delivered over two
sessions to children with asthma to evaluate its effectiveness in improving knowledge of
asthma, self-efficacy, and health-related quality of life. After 10 months, children in the
intervention group reported higher mean scores on asthma knowledge (mean=12.45) than
those in the control group (mean 10.8) p<0.001).
Kintner and Sikorskii (2009) tested the efficacy of a school-based academic (teaching) and
counselling programme for 60 children with asthma from grades 4 to 6 in the USA
(intervention n=38, control n=22)). The study showed an improvement in children’s asthma
knowledge in terms of reasoning about asthma, use of risk-reduction behaviours, and
participation in life activities with significant difference between those children who received
the programme and those who did not (p<0.01) (Kintner and Sikorskii, 2009).
63
In a study by Levy et al, 2006, 243 children were randomly assigned to an intervention group
(n = 115) or control group (n= 128). A knowledge test as well as a telephone survey was used
to audit of hospital and emergency department visits and school attendance. The researchers
reported a significant difference in improvement in knowledge score directly after the
education programme between intervention and control groups (P<0.001). The intervention
consisted of delivery of the Open Airway for Schools programme (OAS) curriculum to
students in a weekly group setting at school, weekly monitoring of students’ health status
(following up on absences and symptoms with students, families, and teachers), and
coordination of care (contacting students, family members, school personnel, and medical
providers to facilitate disease-management and to mitigate environmental triggers at school
and at home).
In another study by Bowen, 2013, a total 32 children (intervention group n=15, control group
n=17) formed the sample. The intervention was the modified OAS programme. In this course
children (aged 8-11 years) were instructed in physiology of asthma, detecting warning signs
of asthma, device use, and avoidance of triggers. It was conducted as weekly 90 minutes
sessions for three weeks. Asthma Control Test, Paediatric Asthma Quality of Life
Questionnaire, and Spirometry Machine were used to measure outcomes. The findings
showed that the baseline knowledge score in the intervention group was 70%. The knowledge
score was significantly increased to 80% at first follow up and to 90% in the second follow
up compared to 50% in the control group (F= 19.028, P< 0.001).
A quasi-experimental study conducted in USA by Velsor-Friedrich et al., 2004, to examine

the effects of a school-based education programme on children's knowledge of asthma and
self-management practice. A total 102 children (intervention group n=40, control group
n=62) aged 8-13 years were recruited and the OAS was employed. The results showed no
significant improvement in levels of knowledge or self-management practice among the
intervention group.
SCHOOL ABSENTEEISM AND ATTENDANCE INTERUPTION
Cicutto et al. (2005) examined the effects of an asthma education programme (Roaring
Adventure of Puff programme) on children’s performance in terms of absence and quality of
life in elementary schools. The programme was delivered to children through a one hour
session every week for six weeks. The researchers recruited 256 children (intervention group
64
n=132, control group n=124) from grades 2-5 (age 8-11 years) in 26 schools. Two years after
the programme, there was a significant difference in the mean number of missed school days
between the children in intervention group (Mean 3.0, SD 4.4) and the control group (Mean
4.3, SD 5.7) showing less absenteeism in the intervention group. For children with severe
asthma symptoms, the researchers reported a significant reduction in the number of
interrupted days in the intervention group compared to control group (6.2, SD 7.3; 9.1, SD
10.3 respectively) (Cicutto et al., 2005).
Similarly, a study by McGhan et al. (2003) in Canada also showed significant difference in
mean scores for the number of missed school days for children with less missed days in the
treatment group (mean 53.4 days/year) than those in the control group (mean 64 days/year; p
< 0.05).
QUALITY OF LIFE
A study by McGhan et al., 2010, followed up a group of 206 children with asthma age 6-13
years (intervention group n=104; control group n=162,) 6 and 12 months after commencing
an education programme, and assessed the feasibility and outcomes of the programme. The
study measured children's quality of life as the main outcome using the Paediatric Asthma
Quality of Life Questionnaire, although school absenteeism, symptoms experienced,
medication use and hospitalisation were also reported in the study. The education programme
was a standardised national programme called “The Roaring Adventure of Puff”. The
programme comprised six parts (40 to 60 minutes sessions) covering different topics related
to asthma. Results showed improvement and significant difference in total quality of life
score for children in the intervention group (mean 5.9) compared to the control group (mean
4.9, P< 0.05) at 12 months follow up.
Further, Clark et al. (2005) tested the effects of the OAS programme (Chinese version) on
quality of life of children with asthma in selected Chinese schools (N=639, age 7-11 years).
Children were tested at baseline and one year after the programme with improvement and
significant difference in quality of life scores between groups (mean change: -0.132
intervention group v.-0.577 control group, p = 0.04).
Cicutto et al. (2013) evaluated a school-based asthma education programme delivered by a

public health nurse (N=1316, mean age 8.2 years). They measured the effects of the
programme on quality of life; symptom control and school absenteeism. In the one-year
65
follow up, the results showed significant difference between groups with improvement in the
intervention group in regard to quality of life (intervention mean 5.8, SD 1.2; control mean
5.4, SD 1.4, P<0.0001) and effective inhaler use(Mean= control 2.5 SD=1.2 v. intervention
3.4 SD=1.2 p< 0.0001).
PERCEPTION
Velsor-Friedrich et al., (2004) reported that children in the intervention group that attended
an asthma education programme showed a significant improvement in self-efficacy scores
measured by the Asthma Belief Survey. The baseline score was 4.03, SD 0.10, which
increased significantly to 4.23, SD 0.10 after five months (p=0.046). Children in the
intervention group had a higher self-efficacy perception score and improved self-management
practice which correlated with improved asthma control (Velsor-Friedrich et al., 2004).
Butz et al. (2005) acknowledged a significant improvement in children's self-efficacy after

implementing an asthma education programme (mean score change +2.62, SD 6.3, p=0.005).
The study conducted on 210 children and their families, of them 105 were included in the
educational intervention.
ASTHMA EDUCATION PROGRAMMES
Asthma education programs which have been utilized with adolescents include Power
Breathing for Teens, Puff City, The Roaring Adventure of Puff , Oakland Kicks Asthma, and
Asthma: it’s a family affair and First Aid for Asthma (Srof et al, 2012). These education
programs have been utilized in schools for patients with asthma, patients and their relatives
and also for population of students who are without asthma.
Open Airways for Schools Program is an interactive asthma curriculum taught to

small groups of children with asthma in the third, fourth, and fifth grades (Bowen, 2013;
Fiore et al, 2008). Kickin Asthma is a case identification and education-based program
developed for 6–10th grade (Davis et al, 2008). Puff City is a web-based program for urban
high school students linked to a health coordinator to facilitate community-based referrals
(Joseph et al, 2007).
FIRST AID FOR ASTHMA
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First Aid for Asthma is a nine-module curriculum that includes content in addressing the
epidemiology and physiology of asthma, triggers of asthma and how to control these triggers,
types of asthma medications, asthma management, and exercise and asthma. The program
was tested in a non-equivalent control group design among a sample of 122 high school
students recruited from two public schools out of which 19 who were doctor diagnosed
asthmatics completed the study. Asthma severity classification was not reported. The asthma
education program was given to the intervention school one week after collecting baseline
data. The efficacy of the program was evaluated at 1 week, 3 weeks, and 6 weeks after given
the asthma education intervention based on multiple variables including asthma knowledge,
attitudes, self-efficacy, pediatric asthma–related quality of life, and self-management
behaviours. Measures of quality of life and self-management failed to show significance,
whereas self-efficacy demonstrated minimal improvements over time (Shaw et al, 2005). The
study by Shaw and colleagues (2005) is an example of an effective method in which
researchers and nurses incorporate an asthma education program into a structured health
education class.
PUBLIC HEALTH ROLES IN ASTHMA MANAGEMENT AND CONTROL
EFFECTS OF PUBLIC HEALTH EDUCATION ON ASTHMA
It has been suggested that education of health care providers and the public is a vital element
of the response to the challenge posed by asthma (Braman, 2006; Ndiaye et al, 2004). Asthma
education and prevention remains the greatest opportunity for decreasing asthma incidence
and mortality (Kintner et al, 2015). Schools, rather than hospitals, are shown to be prime
settings for asthma health education for children and adolescents due to practicality and
familiarity with the environment (Valeros et al, 2001). Health education has the potential to
help students maintain and improve their health, prevent disease, and reduce health-related
risk behaviours (Kann et al, 2007). Studies have also shown that health education can
enhance knowledge, and change attitudes and behaviours (Daboer et al, 2008). The critical
analysis of research into specific health education programmes for students with asthma and
those without asthma supports the contention that educating those diagnosed with asthma and
67
those without asthma about asthma and how this can be managed enables potential health and
well-being benefits (Al Aloola et al, 2014; Srof et al, 2012; Shaw et al, 2005; Gibson et al,
1998). Several school based asthma education intervention studies have been conducted
among students to assess the impact of asthma health education programme with the results
showing significant improvement in their knowledge of asthma, reduction in school
absenteeism, improvement in self- efficacy perception and improvement in their quality of
life (Cicutto et al, 2013; Bowen, 2013; McGhan et al, 2010; Kintner et al, 2009). In a study
by Shaw et al, 2005, health education intervention program was tested in a non-equivalent
control group design among a sample of 122 high school students recruited from two public
schools out of which 19 were doctor diagnosed asthmatics who completed the study. Asthma
severity classification was not reported. The asthma education program was given to the
intervention school one week after collecting baseline data. The efficacy of the program was
evaluated at 1 week, 3 weeks, and 6 weeks after given the asthma education intervention
based on multiple variables including asthma knowledge, attitudes, self-efficacy, pediatric
asthma–related quality of life, and self-management behaviours. The result showed that self-
efficacy perception demonstrated minimal improvements over time.
HEALTH EDUCATIONS AS A TOOL FOR PUBLIC AWARENESS ON ASTHMA
Health education is a process aimed at encouraging people to want to be healthy, to know

how to stay healthy, to do what they can individually and collectively to maintain health, and
to seek help when needed (Park, 2015). Health education can bring about changes in
lifestyles and risk factors of disease. It can help to increase knowledge and to reinforce
desired behaviour patterns. The common methods of creating asthma awareness are through
pamphlets, books, videos, audio cassettes, asthma educational courses, support groups,
television programmes, the Internet, video games and direct contact with a healthcare
professional which have all been used to spread information (Hill et al,
2000).Communication in relation to health education programme on asthma involves
different modes like lectures, group or panel discussions, symposia, poster or exhibit
presentation (Mahajan et al, 1995). Health promotion is regarded as the most important
strategy focusing on changes of both the environment and the individual to actively promote
68
the health of the public. Health promotion involves health education programmes which
emphasises the modification of social environment in which the individual lives.
CHAPTER THREE
MATERIALS AND METHODS
RESEARCH DESIGN
The study employed a quasi-experimental design. Quasi-experimental designs were

popularised by Campbell and Stanley (1963). Quasi-experimental designs are similar to
RCTs as they are used to establish the relationship between an intervention and an outcome
but with a difference in the strategies of having a control group or the random allocation of
the sample to the intervention or control group (Reichardt, 2009). According to Shadish et al.
(2002), there are 4 design types that are consistent with quasi-experimental studies: quasi-
experimental designs without control groups; quasi-experimental designs that use control
groups but no pre-test; quasi-experimental designs that use control groups and pre-test and
interrupted time-series designs without randomisation. In particular, quasi-experimental
69
designs may not satisfy the assumption of randomisation while selecting study subjects due to
obligated conditions (Harris et al., 2006). Quasi-experimental studies are often used to
examine the effects of certain interventions on a specific population (Campbell and Stanley
1963). Furthermore, quasi-experimental designs allow for comparisons between groups using
statistical analysis, which enables a detailed examination of any difference between the
treatment and control groups (Harris et al., 2006). In this study, each specific design was
considered (control group, pre-test/post-test, and repeated measures). It is non- equivalent
control group design because the subjects in the two groups (study and control groups) have
not been randomly assigned. A quasi-experimental design also satisfied ethical concerns
about excluding students who may see others benefit from the intervention. That said, the
health education programme was to be delivered to those students allocated to the control
group on completion of the final measures. Added to this, the quasi-experimental design
allowed for comparisons between the groups using statistical analysis, to enable a detailed
examination of any difference between the intervention and control groups (Harris et al.,
2006). The reason for not recruiting the study groups randomly is that the possible risk for
contamination which might occur at school level as well as at the level of the individual
student. In this study, the secondary school students from selected school were assigned
either to the intervention group to receive the health education programme intervention or to
the control group to receive no intervention. Baseline data were collected from both groups
which served as pre- test. Repeated measures in each group (intervention and control) were
taken to assess the secondary school students’ knowledge and perceptions at 1 week (post-
intervention), 3 weeks (post- intervention) and 6 weeks (post- intervention) for the
intervention group and at 6 weeks from the pre- test for the control group. After the end of
data collection and collation, health education programme on asthma were then given to all
the students in the control group to compensate for denying them health education
intervention during the research work. This served to correct the temporary imbalance in
health education benefits experienced by the control group during the study.
SAMPLING TECHNIQUE
The sampling technique employed was a multistage sampling technique. The first stage was
the selection of the intervention study site and the control study site from the four local
government areas in Ile- Ife, Nigeria. Two local government areas were selected from the
four local government areas in Ile Ife using simple random sampling and they are Ife Central
70
and Ife North local government areas. Each of the two local government areas were assigned
to either intervention or control group through the process of simple balloting. Ife Central
was the intervention group while Ife North was the control group. The two local government
areas are far apart enough to minimize contamination of the control group by the intervention
group. The second stage was the selection of 3 wards from the wards in each local
government study site (Ife Central LGA has 11 wards and Ife North LGA has 10 wards)
using convenience sampling technique. The third stage was the selection of one school from
each ward making a total of three schools from each study site by simple random technique.
The last stage consisted of the selection of at least forty- seven students from each school to
make a total of 140 secondary school students as research participants in all for each study
group based on the study criteria using purposive sampling technique. The pre-test was
carried out among secondary school students in Ife East LGA, an entirely different LGA from
the two that were used in this study. The results were analyzed and necessary corrections
were made in the questionnaire before being administered to the study participants. This was
done to ensure that the questions were clear and acceptable; there was willingness to answer
them and that they were appropriate in eliciting responses that were consistent with study
objectives. Ambiguous questions were re-phrased.
SAMPLE SIZE DETERMINATION
In determining the sample size, the formula for the comparison of proportions of two
independent groups was used for the baseline comparison of the intervention and control
groups while the formula for the comparison of proportions of related groups/ within groups
was used for the comparison of before and after intervention data.
The formula for the comparison of proportions of two independent groups is given by:
n = (u + v)2 (P1(100-P1) + P2 (100 – P2) (Varkevisser et al, 2003)

(P1 – P2)2
Where: n = Minimum required sample size
P1 = Estimated proportion of secondary school students who had good level of
knowledge of asthma before intervention (44%) (Shaw et al, 2005).
71
P2 = Estimated proportion of secondary school students who had good level of
knowledge of asthma after intervention. (62%) (Shaw et al, 2005)
u = the critical value corresponding to power of the study at 80%
= 0.84
V = percentage of the normal distribution corresponding to the significance level (at
5% significance level, v = 1.96 for two sided significance and 1.65 for one sided
significance). The significance involved in this study is two sided at baseline to find
out the difference between the two groups but will be one sided after intervention
since it is to determine the impact of health education and the effect is expected to be
in one direction i.e positive. The two- sided hypothesis (v = 1.96) demands a larger
sample size and therefore will be used in the determination of the sample size.
Using proportion of secondary school students who have a good level of
knowledge of asthma.
P1= proportion of secondary school students who have good level of knowledge
before intervention estimated at 44% (Shaw et al, 2005) and
P2 = proportion of secondary school students who have good level of knowledge after
intervention estimated at 62% (Shaw et al, 2005).
n = (1.96 + 0.84)2 (44 (100-44) + 62(100-62)
(62 – 44)2
= 7.84 (2464 + 2356)
324
= 37788.80
324
= 116.63
The formula for comparing proportions within groups/between two related groups is given
by:
n= (Zα√ Πo (1- Πo) + Zβ√ Π1 (1- Π1) 2
(Π1- Π0 )
Where
72
Zα = Percentage of the normal distribution corresponding to the one sided significance level (at
5% significance level Zα = 1.65)
Zβ = the critical value corresponding to power of the study at 80%
= 0.84
Πo = Estimated proportion of secondary school students who have good level of knowledge
asthma before intervention estimated at 44 % (Shaw et al, 2005).
Π1 = Estimated proportion of secondary school students who had good level of knowledge of
asthma after intervention. (62%) (Shaw et al, 2005)
The minimum sample size calculated was 117.
To compensate for non- responses misplaced or improperly completed questionnaires and

attrition, the calculated sample size was increased by 20%; it is calculated as follows:
0.2 (117) =23.4 = 23
23+ 117 = 140
The former gave the larger sample size and was therefore be used for the study. However, the
sample size of 140 secondary school students per group (intervention and control) was
calculated to be used for the study to cater for drop- out rate. However, to cater for drop- outs
a total of 180 questionnaires were each taken to the Intervention and Control sites. One
hundred and sixty two (162) participants completed the study in the Intervention group (a
90% completion rate) and 153 participants completed the study in the Control group (an 85%
completion rate).
OUTCOME MEASURES
The purpose of most health education is to improve knowledge and change behaviour and
attitudes in people who have partial or complete deficit in issues related to their health and
that of those living close to them. The purpose of the health education intervention proposed
in this study was to enhance outcomes related to students' knowledge and perceptions of
asthma. As such, two standard instruments were selected to ensure that the impact of the
intervention on these outcomes could be examined.
73
QUESTIONNAIRES
ASTHMA KNOWLEDGE QUESTIONNAIRE
The participants completed a modified version of the Newcastle asthma knowledge

questionnaire adapted to assess the knowledge of asthma among adolescents. The instrument
consists of 31 questions (31 true/false items/ I don’t know answer). The original Newcastle
Asthma Knowledge Questionnaire aimed to assess the knowledge of parents of children with
asthma. The instrument was initially tested through the face validity and appropriateness of
the 31 items on the NAKQ for the target population (Fitzclarence and Henry, 1990). The final
version of the NAKQ consists of 25 true/false items and six open ended questions that
provide a comprehensive assessment of the key domains of asthma knowledge including:
general data about asthma, triggers, symptoms, and asthma treatment and management. The
tool has been used extensively by the researchers to test adults with and without asthma
(Allen et al., 2000), the child care workforce (Hazell et al., 2006), asthma educators (Allen et
al., 2000), teachers (Gibson et al., 1995; Henry et al., 2004) and parents of children with
asthma (Leonardo Cabello et al., 2013; Ho et al., 2003; Khan, 2003). The domains of the
NAKQ are well constructed, with evidence of construct and discriminate validity, high
internal consistency of items and test-retest reliability (AlMotlaq & Sellick, 2011). The
modified version consists of 31 questions which were adapted to the study population. The
reliability of the questionnaire was done in a school in one of the local governments in Ile Ife
which was not included in the study.
REVISED ILLNESS PERCEPTION QUESTIONNAIRE (IPQ-R)
The participants completed a modified version of the Revised Illness Perception

Questionnaire (IPQ-R) by Moss-Morris et al. (2002) adapted to assess illness perceptions
among healthy people (Figueiras and Alves, 2007). The IPQ- R evaluates nine dimensions
from Leventhal and colleagues’ SRM model and research findings (Moss- Morris et al,
2002): Identity (symptoms associated with the illness and label); Time-line (duration and
chronicity); Consequences (effects of the illness on an individual’s lifestyle, health and well-
being); Personal Control (personal influence on preventing and managing the disease);
Treatment Control (availability and efficacy of treatments to manage or cure the disease and
its symptoms); Illness Coherence (personal understanding of the disease); Evolution (course
and temporal changeability or fluctuation of the illness and symptoms); Emotional
74
Representations (emotional impact of the disease) and Aetiology or Causes (psychological,
behavioural, biological, chance and external causes of the disease). The modified version of
this questionnaire which was used among the study population consists of 30 questions (30
YES/ NO items/ NOT SURE answers) which are statements regarding asthma perceptions.
VALIDITY OF THE INSTRUMENTS
According to Liljequist (2010), validity of the research instruments is important as it allows

for effective analysis of the collected information and usefulness and meaningfulness of the
study. In other words, validity means to what extent the selected instrument measures the
intended research objectives (Polit and Beck, 2008). Validity can be divided in two types;
internal and external validity. While internal validity means the extent to which the
independent variable significantly causes and influences the dependent variable (Polit and
Beck, 2008), the external validity is that validity which reinforces the meaning of
generalisation which can be fulfilled by maintaining the sample representativeness ( Metzger
& Wu 2008; Bannigan and Watson 2009).
CONTENT VALIDITY
According to WHO (2007), content validity encompasses the demonstration of the existence
of a strong relationship between the content that was used in the study and the variables under
investigation. As such, it provides information related to the representation of the population
by a specific study sample. Content validity analysis was performed to determine the
appropriateness of the language, content, and structure of the modified versions of the
questionnaires for measuring the research variables. The variables included knowledge and
perceptions about asthma in secondary school students without asthma. The snowballing
technique was used to recruit a panel including six experts to perform a content validity
analysis of the questionnaires. The process entailed contacting a small group of people with
experience in asthma management who were known to the researcher, those people identified
other colleagues who were then invited to participate in the content validity assessment. The
process was done in accordance with the procedure described by Polit and Beck (2006). The
six individuals included three pulmonologists experienced in the management of asthma, a
Consultant Psychiatrist that have been involved in the treatment of asthmatic adolescents, a
Consultant Cardiopulmonary Physical Therapist that have regular contact with asthmatic
adolescents, and one secondary school teacher. This was a sufficient number of experts to
75
perform the process of content validity as acknowledged by Polit and Beck (2006). Each
panel member was sent a questionnaire that included the revised list of asthma knowledge
items and asthma perception items, and asked to rate each item using a 5-point Likert scale
for appropriateness (1=not appropriate to 5=most appropriate). Panel members were also
invited to comment on the wording of items and response format, and to suggest other items
to be added to the instrument. The panel members were able to scrutinise the questionnaire
for representativeness which identifies to which extent the item is representative of a scale
within an instrument, and for clarity which identifies the clarity of the item to the reader. The
result of their inputs led to the final version of the questionnaires which were eventually used
to collect the data. The panel members’ comments were very helpful in providing a wider
perspective about the appropriateness of the questionnaire among the study population.
RELIABILITY OF THE INSTRUMENTS
To determine the feasibility and if any modifications were needed before using the
instruments in the main study, a pre-test pilot study using the modified NAKQ and adapted
modified IPQ-R was conducted with 30 secondary school students who are without asthma.
The recruitment of 30 students rested on the recommendations of Lackey and Wingate (1998)
that a pilot test should be carried out on at least the equivalent of one tenth of the main
sample. Pilot testing is conducted to refine a tool or instrument to ensure clarity,
understanding, and acceptability (Polit and Hungler, 1999). In this case both the modified
NAKQ and adapted modified IPQ-R were tested. The group consisted of 15 male and 15
female secondary school students in a school in Ife East local government area who are not
part of the main study. Their ages ranged between 9 to 19 years. The answers of the pilot
study population suggested that all items in both modified NAKQ and adapted modified IPQ-
R and their options for response were clear and understandable. Reliability means the extent
of measurement for certain participants is similar on applying this tool at different time (Polit
and Beck, 2008). So, it can be achieved when keeping results at a consistent level despite
changing of time and place. Internal consistency comprises testing the homogeneity that
assesses the extent to which personal items are inter-correlated, and the extent to which they
correlate with overall scale findings (Polit and Beck 2008). This can be performed by using
Cronbach‘s alpha test. Many references state that an alpha 0.70 or above indicates adequate
internal consistency, meaning, findings are consistent, so the items are representative (Polit
and Beck, 2008). Other sources reported that the acceptable values should be more than
76
(60%) according to (Sekaran, 2006, 311). or 70% in other sources, therefore the value
exceeding the foregoing proportion indicates that the survey/ questionnaire is reliable.
Cronbach's Alpha for both scales from the pilot testing were measured and revealed high
internal consistency values in modified NAKQ (0.627) and adapted modified IPQ-R (0.718).
These results established that there was no further need to modify any of the questionnaires
before field-testing with the target population. However, it is important to note that the
students that took part in the pilot test were not considered eligible for the main study. This
was simply carried out when establishing the final list of eligible students. However, those
included in the pilot study were given the chance to have the asthma health education
programmes but they were not allowed to contribute to the study findings through completing
the study instruments.
DATA COLLECTION PROCESSES
Negotiating Access to Schools
I received permission from the State Ministry of Education Zonal Officer in charge of the
Local governments in Ile-Ife. I later met the school principals in charge of the selected
schools and showed them the ethics approval gained from the State Ministry of Education
Zonal Officer in charge of the Local governments in Ile-Ife. I explained to them the aim of
the study, explained the process of conducting the study and its stages in their schools, and
gave them a detailed description of each step. Sufficient information about the whole study
was provided to the intervention and control schools to create awareness and enable them to
assist students in making a decision regarding whether or not to take part. Strengthening
support from the key stakeholders was an important part of ensuring the success of the
research. The success of any study often depends on the contribution of the gatekeepers. The
gatekeepers play the role of representing the interests of the host organisations, and their
members (Burns and Grove, 2010). The education programme was started after the students
and parents had been informed about the study requirements and had given their consent.
Data for this quasi- experimental study was collected using pre- tested, structured, close
ended, self- administered questionnaires to assess the knowledge and perceptions of asthma
among these secondary school students in Ile- Ife, Nigeria. As mentioned earlier, the students
attending the three schools from the Ife Central Local Government Area were allocated to the
intervention group and their counterparts from the Ife North Local Government Area were
77
allocated to the control group. The questionnaire contained three sections. The first section
contained information on demographic data. The second section which is a modified
Newcastle asthma knowledge questionnaire adapted for the study population is an instrument
which consisted of 31 questions (31 true/false items/ I don’t know answer) and investigated
respondents’ general knowledge of asthma, knowledge of recognition, triggers and
management of acute asthma, maintenance treatment and false myths about asthma. The third
section which was a modified Revised Illness Perception questionnaire (IPQ-R) which have
been adapted to assess illness perceptions among healthy people (Figueiras and Alves, 2007)
is an instrument which consists of 30 questions (30 Yes/No/ Not sure answers) and contained
statements regarding asthma perceptions in which the respondents were asked to indicate
whether in each case they agree with the statement or not, or they are not sure. The health
education programme was for a period of two weeks. The first data collection was the
baseline (pre- test) data. It was collected from the control group and the intervention group.
This was collected one week prior to the health education intervention which was given to the
intervention group. This was followed by delivering of health education programme to the
intervention group participants across the 3 selected schools for the period of two weeks. The
second data was collected from the intervention group at post- test date (1 week). The third
data was collected from the intervention group at post- test date 2 (3 weeks). The fourth data
was collected from the intervention group at post- test date 3 (6 weeks) and also from the
control group at post- test date (6 weeks) for their second data. This was then followed by
delivery of health education programme to the control group participants after the research
study had been completed to compensate them. The reasons for selecting these intervals is
based on a similar study conducted by Shaw et al, 2005 where the outcomes being tested
were measured at the post intervention dates (1, 3 and 6 weeks) in the intervention group and
Social Cognitive Theory which confirmed that observing young person’s behavioural change
should occur after a short period of time (at least 3 weeks) to assess the point of maximum
benefits where learning by observation will be intensified. Over this first three weeks, the
students were assumed to follow the process of learning by observation (attention, retention,
and motivation). However, the last assessment post intervention (6 weeks later) was aimed to
assess students’ ability to retain the acquired learning over a short period of time. The
outcomes can still be measured over an extended period of time but this present study was
however limited to 1, 3 and 6 weeks post intervention date in the intervention group. The 2
instruments discussed earlier (Modified Newcastle Asthma Knowledge Questionnaire and
modified Revised Illness Perception Questionnaire) administered by the research assistants to
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both the control and intervention groups, maintained the consistency of the data collection
process. Questionnaires were completed on an individual basis without the students sharing
ideas in the classroom. A brief introduction about the questionnaire was given by the research
assistant to help the students understand how to complete them.
FLOW CHART FOR THE DATA COLLECTION IN THE TWO GROUPS
WEEKS 0 1 2 3 4 5 6 7 8 9
A B C D E F
A- Week 0 when the baseline data were collected from both the intervention and the
control groups.
B- 1 week after, when the health education commenced for the intervention group.
BC- 2- weeks of health education programme for the intervention group (between week 1
and week 3).
D- Post intervention test date 1 for the intervention group (1 week after the intervention)
i.e. CD.
E- Post intervention test date 2 for the intervention group (3 weeks after the intervention)
i.e. CE and Post- test date for the control group i.e AE.
F- Post intervention test date 3 for the intervention group (6 weeks after the intervention)
i.e. CF
THE HEALTH EDUCATION INTERVENTION
The critical analysis of research into specific health education programmes for students with
asthma and those without asthma supports the contention that educating those diagnosed with
asthma and those without asthma about asthma and how this can be managed enables
potential health and well-being benefits (Shaw et al, 2005; Gibson et al, 1998).In this section,
Social Cognitive Theory (Bandura, 1986; Clark. 1989) and Health Belief Model were used to
79
examine why measuring outcomes beyond knowledge acquisition are important in
establishing the impact of an asthma health education programme on outcomes for students.
It is known that health education can enhance knowledge, and change attitudes and
behaviours. According to Bloom's taxonomy, educational objectives can be divided into three
main categories or domains: cognitive, affective, and psychomotor. These learning domains
are normally integrated with each other and can be experienced simultaneously (Gilbert et al.,
2011). In each domain, there is a range of suggested learning strategies that can be used to
improve the effectiveness of teaching strategies targeting one domain over another. For
instance, some domains need informal methods for learning rather than formal methods such
as gaming and role-playing in the affective domain while lecturing is commonly used for the
cognitive domain and demonstration and re-demonstration are used for the psychomotor
domain (Gilbert et al., 2011). These recommendations were given careful consideration when
designing and developing the classroom based asthma health education programme for
children aged 9 to 19 years. A health educator should have the responsibility for
understanding barriers impeding learning processes.
HOW MESSAGES WERE GIVEN AND OTHER COMPONENTS OF THE HEALTH

EDUCATION INTERVENTION: The intervention sessions of health education on asthma
which are components of Health Belief Model (HBM) were in form of interactive lectures
using Microsoft PowerPoint® presentations with a projector, use of posters, focused group
discussions and practical sessions on the use of peak flow meters and inhalers. The
curriculum for the health education on asthma included provision of adequate information to
these students on the modules of general knowledge of asthma aetiology, epidemiology and
physiology of asthma, identification of common triggers of asthma and how to control these
triggers, types of asthma medications, and asthma management, and exercise and asthma,
prognosis of asthma and myths about asthma which were delivered by me using Microsoft
PowerPoint® lectures (equipped with speaker’s notes and formatted on zip disks), activity
hand-outs, discussion dialogues, examination with answer keys, case studies, and resource
lists. The educational sessions I gave integrated cognitive theory with the information
provided by the British Thoracic Society. Similar to the learning activities in these
interventions, components of social cognitive theory (SCT) such as performance
accomplishments, vicarious experience, verbal persuasion and emotional arousal were
incorporated into the asthma health education programme by me to enhance the self-efficacy
perceptions of the secondary school students. Performance accomplishments included role
80
playing to inform students of what to do when someone is having an asthma attack,
simulations of an asthma attack, and conducting risk assessments of potential asthma triggers
in their homes as a take home assignment. Students also experienced and practiced how to
use peak flow meters with my supervision assisted by the research assistants. Vicarious
experience included an observation of my using a peak flow meter by the students,
emphasizing the importance of regular peak flow monitoring. I also used verbal persuasion
by promoting the involvement of students in asthma prevention programs through their health
clubs and how to encourage the asthmatic students to comply with asthma treatment plans.
Lastly, emotional arousals were taught to the students by me on how to perform stress
management techniques such as pursed-lip breathing which they can teach those that have
asthma attacks. All these incorporated the cognitive, affective, and psychomotor domains of
behavioural change rooted in social cognitive theory which can increase the potential for
learning (Gilbert et al., 2011). I also placed emphasis on the students taking notes from the
lectures so that they can retain the knowledge passed across and they can later serve as peer
instructors in their school health clubs. The school students were given “hand bills” as
memory aids after the health talk and discussions. These hand bills reiterated the key points
on the modules given on the information about asthma.
DURATION OF INTERVENTION: A health education programme of two weeks duration

was employed (two hours per day) by me to the three schools in the intervention group. The
health education was also given to the control group after the whole study was completed so
as to compensate them. There was no data collection again among the control group after the
health education was given to them by me.
ETHICAL CONSIDERATIONS
Consent
Ethical approval for the study was obtained from Ethical and Research Committee of
Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC), Ile- Ife, Nigeria.
Approval to conduct the study was also obtained from the Ministry of Education zonal office.
Permission was also obtained from the school authority (Principal) of each selected school
for the study. Permission was also sought from the parents of the participants.
RISK-BENEFIT ANALYSIS
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Risk-benefit analysis is one of the most important ethical considerations to which researchers
have to pay attention (Long & Johnson, 2007). The degree of risk to be taken by participants
in any research should never exceed the potential benefits of their participation (Polit &
Beck, 2004), otherwise, participation is no longer be accepted. With respect to research risks,
Long & Johnson, (2007) recommended researchers to identify the potential risks and set out
planned measures to avoid, minimise, or treat any possible risk that ensued. Additionally,
Polit & Beck (2004) argued that participants should be informed of any possible harm to
allow them to make an informed decision regarding their participation in the study. Key in
this study was minimising any potential risk. Throughout respecting the rights and dignity of
the participants was paramount and assessed using the universal guidelines (Polit and Beck,
2008). The following are descriptions of the ethical considerations undertaken to preserve
participants' rights;
Once the potential participants were identified, a letter and information sheet outlining the
study was sent to parents through the school principal (See appendix C). Potential
participants were given the opportunity to discuss their participation in the study and to ask
any questions by contacting the researcher directly by telephone within two days if they had
any queries. To ensure that the information was accessible for parents and students, two
information sheets were provided; one targeted at the students and the other one targeted at
the parents. The information sheet was offered in English; the common language of people in
Nigeria. Those parents that consented to their children’s participation in the study were asked
to sign the consent form and return it to the school. The students were also asked to signal
their consent by signing or making a mark on the consent form. Even when parents gave
consent for their children to participate, no pressure was put on the students at any time to do
so should they state or signal their wish to decline. The consent forms were also written in
English to ensure understanding. Participants were assured that the information they provided
would be handled in a private and confidential manner. Each student was identified by a
research number. Personal details and signed consent forms were stored separately from the
data in a secure, locked filing cabinet in the researcher’s office before being transferred to a
locked filing cabinet at the Researcher’s residence. The data will be stored for five years and
then destroyed in line with the perceived risks for non-clinical studies considered by the
NHS. During the study, data were stored in a password-protected computer of the researcher,
with materials archived to a non-rewritable CD each week and stored by the supervisor in
case of technical failure. Data was not disclosed to third parties without the consent of the
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individual participant. This was maintained until the study finished and will be treated in the
same manner for future purposes in accordance to the global ethical practice regulations. In
case of using the data for the purpose of publications, conference presentations and for
teaching purposes no names or personal details will be disclosed in these circumstances.
According to the beneficence and non-malficience ethical principles, preventive measures

that maintain maximum benefit and minimised harm were used. For instance, virtual devices
were used safely to prevent any transmission of micro-organisms between students while
performing inhaler practice and using peak flow meter. In addition, none of the students were
excluded deliberately from group discussion because of his/her misbehaviour to prevent
negative psychological impact of censure. In addition, those students in the control group
were given the same opportunity to benefit from asthma health education programme at the
end of the study to ensure that they could also benefit.
POTENTIAL FOR COERCION
According to Polit & Beck (2004), coercion is defined as “an explicit or implicit threat of
penalty from failing to participate in a study or excessive rewards from agreeing to
participate.” Coercion violates codes of research ethics such as openness and
straightforwardness alongside honesty during the research. With respect to this ethical issue,
the voluntary nature of participation in this study was addressed in the information sheet for
the students in that they were informed that their agreement to participate in the study was
voluntary and that they could decide to opt out of the study at any time without any
consequence. As mentioned earlier, all shortlisted students were only approached once
permission to do so had been given by their parents. The information sheet designed for
parents included a clear statement detailing their right to withdraw permission for their
child’s continued participation in the study at any time. This ensured that both the parents and
students knew that their participation was voluntary.
DATA ANALYSIS
Data analysis is a crucial step in any study. These processes were completed under the
guidance of the supervisory team. Quantitative data analysis aims to summarise the large
number of numerical data into statistical inferences that can translated and interpreted for use
in practice. Statistical analysis was conducted on the basis of eliminating the risk for type I
83
and type II errors as mentioned before (Polit and Beck, 2008). Preparation and processing of
the quantitative data included transfer of questionnaire responses into a spread sheet where
each response was given a numerical value. Then, the survey data were managed using the
Statistical Package of Social Sciences (SPSS version 20.0- (IBM, Armonk, NY, USA).). The
logical sequence of statistical analysis was to start with the descriptive statistics moving
towards inferential statistics. The descriptive statistics of all items were examined in order to
establish their normality. Means, percentages, and standard deviations (SD) were used to
describe the distribution of demographics between the study groups (control Vs. intervention)
and over study stages (pre-test, post-test I, post- test II and post- test III). Means, standard
deviation (SD), Degree of Freedom (DF), and significant level which was set at 0.05, were
included as the nature of the variables held the continuous level of measurement. Since the
instruments produced continuous data which met the assumptions of the parametric statistics,
such as normality, parametric statistics were conducted to show the comparisons between
groups using one way ANOVA test to determine the association between some demographic
variables and the knowledge and perception scores over the study duration in the intervention
group. A one-way ANOVA within groups indicates that a single group is being compared
over time, and was used in this study to examine how one group changes at three points in
time (Steinberg, 2008). The independent variable is categorical since it represents a single
sample or group, and the dependent variable is scaled (interval or ratio). For this study, one-
way ANOVA repeated measures tests were utilised to measure the change over time in each
of the groups' knowledge, and then perceptions of asthma. Other tests such as Paired sample
t-tests were conducted to examine differences between pre-test and post-test scores. Paired
sample t-test is used to compare one unique group at two points in time (Steinberg, 2008). I
examined the differences in the pre-test and post-test scores of participants in the
experimental group, and the pre-test and post-test scores of the control group. Therefore, one
paired sample is represented by the experimental group, and the second paired sample is
represented by the control group. The independent variable is the pre-test score, and the
dependent variable is the post-test score. The Indepedendent- t tests were also used in some
comparisons to determine the association between some socio-demographic variables and the
knowledge and perceptions scores in the intervention group over the study duration.
84
FIGURE 3: RESEARCH STUDY PROCESS DIAGRAM
Potential Participants (n=360)
Actual Participants (n=315)
Intervention group (n=162) Control Group (n=153)
Pre-test
Pre-test
Health Education
Intervention
85
One week later

Post test
CHAPTER FOUR
RESULTS AND DISCUSSION
A DESCRIPTION OF THE PARTICIPANTS' DEMOGRAPHICS
The sample consisted of secondary school students (n=315). Table 1 below shows the
distribution of the participants to either the control group (n=153) or the intervention group
(n=162). It showed there were more female respondents (53.97%) than male respondents
(46.03%). Majority of the respondents (59.05%) were in the 13-16 years age group. Also,
Classes SSS 1 and SSS 2 had most respondents with fifty seven (18.1%) each. Largest
percentages of the respondents were Christians (92.06%) as shown by the result. The result
also showed that largest percentages of them were Yoruba tribe (93.02%). Figures 4 to 7 are
the pie- chart showing the percentage distribution by Gender, age group, Class levels and
ethnic groups of the participants.
86
Table 1: Demographic Characteristics of the Participants
Participants’ Study Groups

Characteristics Intervention Group Control Group
(N= 162) n (%) (N= 153) n (%) Total
Gender
Male 81 (50.0) 64 (41.8) 145
Female 81 (50.0) 89 (58.2) 170
Age Group
9- 12 59 (36.4) 35 (22.9) 94
13-16 95 (58.6) 91 (59.5) 186
17-20 8 (4.9) 27 (19.6) 35
Class level
JSS 1 23 (14.2) 20 (13.1) 43
JSS 2 29 (17.9) 27 (17.6) 56
JSS 3 30 (18.5) 25 (16.3) 55
SSS 1 27 (16.7) 30 (19.6) 57
SSS 2 27 (16.7) 24 (15.7) 51
SSS 3 26 (16.0) 27 (17.6) 53
Religion
Christianity 151 (93.2) 140 (91.5) 290
Islam 11 (6.8) 12 (7.8) 23
Others - 1 (0.7) 1
Ethnic Groups
Yoruba 143 (88.3) 150 (98.0) 293
Igbo 13 (8.0) 1 (0.7) 14
Hausa 1 (0.6) - 1
Others 5 (3.1) 2 (1.3) 7
FIGURE 4: PERCENTAGE DISTRIBUTION OF PARTICIPANTS BY GENDER
GENDER
MALE
FEMALE
FIGURE 5: PERCENTAGE DISTRIBUTION OF PARTICIPANTS BY AGE GROUP
87
AGE GROUP
9- 12 YEARS
13- 16 YEARS
17- 20 YEARS
FIGURE 6: PERCENTAGE DISTRIBUTION OF PARTICIPANTS BY CLASS LEVEL
CLASS LEVEL
JSS 1
JSS 2
JSS 3
SSS 1
SSS 2
SSS 3
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FIGURE 7: PERCENTAGE DISTRIBUTION OF PARTICIPANTS BY ETHNICITY
ETHNIC GROUP
YORUBA
IGBO
HAUSA
OTHERS
Table 2: Familial experience of the respondents in relation to asthma
Characteristics Study Groups Total

Intervention Group Control Group
(N= 162) n (%) (N= 153) n (%)
Family Experience
1
(Have a relative
with asthma)
Yes 24 (14.80) 18 (11.80) 42
No 138 (85.20) 135 (88.20) 273
Family experience 2
(Have lived with or
known someone
with asthma)
Yes 74 (45.70) 39 (25.50) 113
No 88 (54.30) 114 (74.50) 202
89
Awareness of
asthma?
Yes 145 (89.50) 95 (62.10) 240
No 17 (10.50) 58 (37.90) 75
Sources of
knowledge about
asthma?
School 26 (16.05) 27 (17.65) 53
TV & Radio 41 (25.31) 54 (35.29) 95
Books 13 (8.02) 16 (10.46) 29
Relatives & Family 20 (12.35) 12 (7.84) 32
Friends 17 (10.49) 8 (5.23) 25
Newspaper & 17 (10.49) 5 (3.27) 22
Magazine
Doctor/ Healthcare 14 (8.64) 6 (3.92) 20
Practitioner
Others 14 (8.64) 25 (16.34) 39
The result showed in table 2 above that 42 (13.3%) of the respondents have a relative with
asthma. The results also showed that 113 (35.9%) have lived or known someone with asthma.
Two hundred and forty (76.2%) of the respondents had heard about asthma before. Television
and Radio constituted the largest source of information about asthma accounting for 30.2% of
all the responses. These were followed by School (16.8%), with Doctor or Healthcare
Practitioner accounted for the least source of Information (6.3%).
OTHER RESULTS
For the Inferential statistics, the independent sample t-test is used to compare observations
from two populations. It tests if they have equal means or if the means of observations from
two groups from one population are the same. When we deal with more than two populations
or groups, we use Analysis of Variance (ANOVA). Similarly, paired t-test is used when a
single sample of participant is measured twice on the same dependent variable. However,
when the measurements are made more than two times repeatedly over a period of time on
the same dependent variable repeated measure ANOVA should be used. Repeated measures
analysis deals with response outcomes measured on the same experimental unit at different
90
times or under different conditions. Longitudinal data is a common form of repeated
measures in which measurements are recorded on individual subjects over a period of time.
Repeated-measure design is a research design in which subjects are measured two or more
times on the dependent variable. Rather than using different participants for each level of
treatment, the participants are given more than one treatment and are measured after each.
This means that each participant will be its own control. In repeated-measures analysis,
scores for the same Individual are dependent, whereas the scores for different individuals are
independent. The following are the assumptions underlying this type of study design: The
dependent variable is measured on interval or ratio scale (dependent variable is continuous);
The sample was randomly selected from the population. The cases represent a random sample
from the population, and there is no dependency in the scores between participants; The
dependent variable is normally distributed in the population for each level of the within-
subjects factor; The population variances for the test occasions are equal. The population
correlation coefficients between pairs of test occasion scores are equal. The population
variance of difference scores computed between any two levels of a within-subjects factor is
the same value regardless of which two levels are chosen. This assumption is sometimes
referred to as the sphericity assumption or as the homogeneity-of-variance-of-differences
assumption. The sphericity assumption is meaningful only if there are more than two levels
of a within-subjects factor (Keselman et al, 2001; Keselman et al, 1999; Ellis, 1999; van Der
Leeden, 1998; Huck et al, 1975). The results from paired samples t-test were utilised to
compare the mean differences in the participants' pre-test and post-test knowledge and
perceptions scores, given that the assumptions of normality were satisfied.
KNOWLEDGE TESTS RESULTS
Table 3: Comparisons of Changes in knowledge scores in the Intervention and Control groups
Group n Pre-test Post-test t Df Sig (2

mean± SD mean± SD tailed)
Intervention 162 43.14± 15.71 72.14± 14.06 - 18.551 161 0.000*
Control 153 44.66±14.58 44.38± 14.83 0.184 152 0.855
 Significant at α< 0.05
Table 3 showed the paired sample t-test of the pre-test and post-test knowledge scores in the
intervention and control groups. The intervention group scored much higher on the
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knowledge post-test (M=72.14, SD=14.06) than on the knowledge pre-test (M=43.14,
SD=15.714). The increase in the mean level of knowledge between the pre-test and the post-
test stage was 29, which indicated an increase of 67.22%. The relationship between the pre-
test and post-test knowledge scores for participants in the intervention group was positive
(r=.101). This demonstrated a linear relationship between the two variables such that post-test
knowledge scores were correlated to pre-test scores. The mean difference between the
intervention group pre-test and post-test knowledge scores was -29.008 (SD= 19.902), and
statistically significant (t (161) = -18.551, p= 0.000). The null hypothesis was rejected, and
participants who received the health education programme intervention showed a significant
difference in their knowledge pre-test and post-test scores. The intervention was shown to
increase students’ knowledge. The participants in the Control group scored slightly lower on
the knowledge post-test (M=44.38, SD=14.86) than they did on the knowledge pre-test
(M=44.66, SD=14.58). The decrease in the mean level of knowledge between the pre-test and
the post-test stage was 0.28, which indicated a decrease of 0.63%. The relationship between
the pre-test and post-test knowledge scores for participants in the control group was positive
(r=.181). This shows a linear relationship between the variables such that post-test knowledge
scores were correlated to pre-test scores, indicating a consistency of treatment effect across
participants. The mean differences between the control group pre-test and post-test
knowledge scores was 0.272 (SD=18.827) and statistically not significant (t (152)=0.184, p=
0.855), so the null hypothesis was retained, and participants (control) who did not receive the
health education programme intervention did not experienced a significant difference
between their knowledge pre-test and post-test scores, though the level of knowledge
decreased.
PERCEPTIONS TESTS RESULT
Table 4: Comparisons of Changes in perceptions scores in the Intervention and Control groups
Group n Pre-test Post-test t Df Sig (2

mean± SD mean± SD tailed)
Experimental 16 52.72± 48.98 67.40± 13.69 -3.774 161 0.000*
2
Control 15 53.05± 15.22 52.76± 15.40 0.193 152 0.848
3
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Table 4 showed the paired sample t-test of the pre-test and post-test perceptions scores in the
experimental control groups. The participants in the experimental group had better
perceptions of asthma following the health education programme (M=67.40, SD=13.691)
than before the intervention (M=52.72, SD=48.978). This was an increase in the mean of
14.68 which represented a 27.85% increase in perceptions scores. The relationship between
the experimental group's pre-test and post-test attitude scores was positive (r=.099). This
demonstrated a linear relationship between the two variables such that post-test perceptions
scores were correlated to pre-test scores, indicating a consistency of treatment effect across
participants. The mean difference between the experimental group pre-test and post-test
perceptions scores was -14.684 (SD=49.525) and statistically significant (t (161)= -3.774, p=
0.000). Therefore the null hypothesis was rejected and participants who received the health
education programme intervention demonstrated a significant improvement between their
pre-test and post-test perceptions scores. The participants in the control group had slightly
lower perceptions of asthma after six weeks, (M=52.76, SD=15.40) than they did at the onset
of the study (M=53.05, SD=15.221). This was a decrease in the mean of 0.29 which
represented a 0.55% decrease in perceptions scores. The relationship between the control
group pre-test and post-test attitude scores was positive (r=.26). This demonstrated that post-
test attitude scores were correlated to pre-test scores. The mean difference between the
control group pre-test and post-test attitude scores was 0.290 (SD=18.627), but not
statistically significant (t (152) = 0.193, p= 0.848). The null hypothesis was retained, and
participants who did not receive the health education programme intervention showed no
significant difference between their pre-test and post-test perceptions scores, though the level
of their perceptions decreased.
REPEATED MEASURES
Knowledge Levels for the Intervention Group
Table 5 shows that the participants in the experimental group improved their knowledge
scores over time. Their highest knowledge scores came one week after they were exposed to
the health education programme (M=72.14, SD=14.062), whilst their lowest scores were
recorded prior to the intervention (M=43.14, SD=15.714). This shows that the participants
93
had increased their knowledge at the post-test stage (1 week), dropped slightly at post-test
stage 2 (3 weeks) and then increased again at the post-test 3 stage (6 weeks).
Table 5: Repeated Knowledge Statistics for Intervention Group
Knowledge test scores N mean± SD

Pre-test 162 43.14± 15.71
Post-test 162 72.14± 14.06
Post-test 2 162 69.89± 16.07
Post-test 3 162 70.01± 14.24
Greenhouse-Geisser; F=231.804(df=2.027, 326.391), p=0.000
The results of Mauchly's test were significant (X2(2) =107.364, p=0.000), which violated the
assumption of sphericity. Consequently, the Greenhouse-Geisser corrected value of F was
used to determine significance. The results of repeated measures ANOVA indicated that the
knowledge levels of participants in the experimental group were affected over time (F (2.027,
326.391) = 231.804, p=0.000). The differences in the mean scores were statistically
significant, so the null hypothesis was rejected. The results show that there was a significant
change in knowledge over time for the participants in the experimental group, over a period
of 1 week, 3 weeks and over a period of 6 weeks. Figure 8 shows the unweighted means of
knowledge for the intervention group calculated to control for the effect of other variables.
The results are consistent with the findings and the plot shows that the level of knowledge of
the experimental group significantly increased at the post-test stage, slightly decreased
compared to post-test at post-test 2 stages and continued to increase up until the post-test 3
stage.
FIGURE 8: Mean Plot of Knowledge Scores for the Intervention Group
94
Knowledge levels for the Control group
Table 6: Repeated Knowledge Statistics for Control Group
Knowledge test scores N mean± SD

Pre-test 153 44.66± 14.58
Post-test 153 44.38± 14.86
Greenhouse-Geisser; F=0.034(df =1.000, 152.000), p=0.855
Table 6 indicates that the participants in the control group had higher knowledge scores at the
onset of the study (M=44.66, SD=14.58) than the post- test knowledge scores six weeks after
participating in the study (M=44.38, SD=14.86). There was a drop of 0.28 at the mean score
which revealed a 0.63% decrease in knowledge score. The results of Mauchly's test were not
considered because it was repeated over two measurements. Therefore the Greenhouse-
Geisser corrected value of F was used to determine significance. The results of repeated
measures ANOVA, indicated that the knowledge levels of participants in the control group
were affected over time (F (1, 152) = 0.034, p=0.855). The differences in the mean scores
were not statistically significant, so the null hypothesis was retained. There was no significant
change in knowledge over time for the control group. Figure 9 shows the unweighted means
of knowledge for the control group calculated to control for the effect of other variables. The
plotted results show that the level of knowledge of the control group decreased significantly
at the post-test stage. The final level of knowledge ended at a point lower than at the
beginning.
Figure 9: Mean Plot of Knowledge Scores for the Control Group
95
Perceptions Levels for the Intervention Group
Table 7 shows that the participants in the experimental group had the highest perceptions
scores at the post-test 3 stage (6 weeks) (M=67.69, SD=14.605) and the lowest scores at the
onset of the study (M=52.72, SD=48.976). The 14.68 increase in the mean score at the post-
test stage represented an increase of 27.84%, the 13.85 increase in the mean score at the post-
test 2 stage represented an increase of 26.27% and the 14.97 increase in the mean score at the
post-test 3 stage represented an increase of 28.40%. The results of Mauchly's test were
significant, X2(2) = 536.936, p= 0.000, which violated the assumption of sphericity.
Therefore the Greenhouse-Geisser corrected value of F was used to determine significance.
Table 7: Repeated Perceptions Statistics for Intervention Group
Perceptions test scores N mean± SD

Pre-test 153 52.72± 48.98
Post-test 153 67.40± 13.69
Post-test 2 153 66.57± 15.30
Post-test 3 153 67.69± 14.60
Greenhouse-Geisser; F= 12.830(df=1.164, 187.454), p=0.000
The results of repeated measures ANOVA indicated that the perceptions levels of participants
in the experimental group were affected overtime (F (1.164, 187.454) = 12.830, p= 0.000).
The differences in mean scores were statistically significant, so the null hypothesis was
rejected. There was a significant change in perceptions overtime in the experimental group.
Figure 10 shows the unweighted means of perceptions for the intervention group calculated
to control for the effect of other variables. The plotted results show that the estimated
marginal means of perceptions significantly increased up until the post-test stage, slightly
decreased at the post-test stage 2 and increased again at the post-test 3 stage, scores
remaining much improved on the pre-test score.
96
Figure 10: Mean Plot of Perceptions Scores for the Intervention Group
Perceptions levels for the Control group

Table 8 indicates that the participants in the control group had higher perceptions scores at
the onset of the study (M=53.05, SD=15.22) than the post- test perceptions scores six weeks
after participating in the study (M=52.76, SD=15.40). There was a drop of 0.29 at the mean
score which revealed a 0.54% decrease in perceptions score.
Table 8: Repeated Perceptions Statistics for Control Group
Perceptions test scores N mean± SD

Pre-test 153 53.05± 15.22
Post-test 153 52.76± 15.40
Greenhouse-Geisser; F=0.037(df=1.000, 152.000), p=0.848
The results of Mauchly's test were not considered because the measurements were repeated
over two measurements. Therefore the Greenhouse-Geisser corrected value of F was used to
determine significance. The results of repeated measures ANOVA, indicated that the
perceptions levels of participants in the control group were affected over time (F (1, 152) =
0.037, p=0.848). The differences in the mean scores were not statistically significant, so the
null hypothesis was retained. There was no significant change in perceptions over time for
the control group. Figure 11 shows the unweighted means of perceptions for the control
group calculated to control for the effect of other variables. The plotted results show that the
level of perceptions of the control group decreased significantly at the post-test stage. The
final level of perceptions ended at a point lower than at the beginning.
97
Figure 11: Mean Plot of Perceptions Scores for the Control Group
DIFFERENCES BETWEEN DEMOGRAPHIC CATEGORIES IN RELATION TO

THE STUDY VARIABLES
This section presents the results obtained from comparisons made between each demographic
category (gender, age group, class level, religion, ethnicity and familial experience) with
regards to the study variables (knowledge and perceptions). The findings were based solely
on the intervention group which consisted of 162 participants. Comparisons were also made
on the value of parametric statistics using a series of one-way between-subject ANOVA tests
and Independent t-tests.
Knowledge Pre-test and Socio-demographic variables
Table 9: Association between socio- demographic variables and knowledge pre-test in the
Intervention group
Socio-demographic N (%) Pre- test knowledge

variable mean (SD) Intervention
Gender
Male 81 (50.0) 45.01 (15.04)
Female 81 (50.0) 41.26 (16.24)
t (160)= 1.527, p= 0.129
Age group (Years)

9- 12 59 (36.4) 41.41 (18.23)
13- 16 95 (58.6) 44.48 (14.28)
17- 20 8 (4.9) 39.92 (11.16)
F (2,159)= 0.871, p= 0.420
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Class Level
JSS 1 23 (14.2) 46.00 (22.44)
JSS 2 29 (17.9) 42.60 (14.02)
JSS 3 30 (18.5) 39.36 (15.26)
SSS 1 27 (16.7) 43.88 (14.08)
SSS 2 27 (16.7) 42.76 (13.79)
SSS 3 26 (16.0) 45.16 (14.94)
F (5,156)= 0.601, p= 0.699
Religion
Christianity 151 (93.2) 43.56 (15.52)
Islam 11 (6.8) 37.24 (17.92)
t(160)= 1.291, p= 0.199
Ethnic Group
Yoruba 143 (88.3) 43.00 (15.81)
Igbo 13 (8.0) 45.91 (15.92)
Hausa 1 (0.6) 48.39
Others 5 (3.1) 38.71 (15.64)
F (3,158)= 0.304, p= 0.823
Family Experience 1
(Have a relative with
asthma)
Yes
No 24 (14.8) 44.35 (17.18)
138 (85.2) 42.92 (15.50)
t(160) = 0.408, p = 0.684
Family Experience 2
(Have lived with or
known someone with
asthma)
Yes 74 (45.7) 42.54 (13.85)
No 88 (54.3) 43.63 (17.19)
t (160) = -0.439, p = 0.662
Table 9 shows the independent samples test and One-way ANOVA of the associations
between knowledge pre-test and socio-demographic variables. There were equal males
(n=81) and females (n=81) in the experimental group, and males scored slightly higher at the
knowledge pre-test stage (M=45.01, SD=15.037) than females (M=41.26, SD=16.239). The
variances between the groups were equal since the results of Levene's test were not
significant (p=.381). The results of the Independent t-test were not statistically significant (t
(160) = 1.527, p= 0.129) (Table 9) therefore, the null hypothesis was retained. There were no
statistically significant differences between genders based on their knowledge pre-test scores.
Table 9 also shows that the largest age group was the 13 to 16 year-olds (n=95) and the
smallest age group was the 17 to 20 year- olds (n=8). Participants in the 13 to 16 year-old age
group had the highest knowledge pre-test scores (M=44.48, SD=14.280) and participants in
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the 17 to 20 year- old age group had the lowest scores (M=39.92, SD=11.164). The results of
the one-way ANOVA were not significant (F (2, 159) =.871, p=.42), therefore the null
hypothesis was retained. There were no statistically significant differences between the age
groups based on their knowledge pre-test scores.
Table 9 also shows that the largest class level participants were the JSS 3 (n=30) and the
smallest class level participants were the JSS 1 (n=23). Participants in the JSS 1 class level
had the highest knowledge pre-test scores (M=46.00, SD=22.439) and participants in the JSS
3 class level had the lowest scores (M=39.36, SD=15.259). The results of the one-way
ANOVA were not significant (F (2, 159) =.601, p= 0.699), therefore the null hypothesis was
retained. There were no statistically significant differences between the class levels based on
their knowledge pre-test scores.
Table 9 also shows the independent samples test of the association between knowledge pre-
test and religion. There were more participants practicing Christianity (n=151) than Islam
(n=11) in the experimental group, and Christianity participants scored higher at the
knowledge pre-test stage (M=43.56, SD=15.521) than Islam participants (M=37.24,
SD=17.923). The variances between the groups were equal since the results of Levene's test
were not significant (p=.466). The results of the Independent t-test were not statistically
significant (t (160) = 1.527, p= 0.129) (Table 9) therefore, the null hypothesis was retained.
There were no statistically significant differences between religions based on their knowledge
pre-test scores.
Table 9 also shows that the largest ethnic group were the Yoruba (n=143) and the smallest
ethnic group were the Hausa ethnic group (n=1). Participant in the Hausa ethnic group had
the highest knowledge pre-test scores probably because of being the only one (M=48.39) and
participants in the other less predominant ethnic groups had the lowest scores (M=38.71,
SD=15.64). The results of the one-way ANOVA were not significant (F (3, 158) = 0.304, p=
0.823), therefore the null hypothesis was retained. There were no statistically significant
differences between the ethnic groups based on their knowledge pre-test scores.
Table 9 also shows the independent sample test of the association between knowledge pre-
test and familial experience (have a relative with asthma). The results were not statistically
significant. Therefore, the null hypothesis was retained. There were no statistically significant
differences between familial experience (have a relative with asthma) based on their
knowledge pre- test scores.
100
Table 9 also shows the independent sample test of the association between knowledge pre-
test and familial experience (have lived or known someone with asthma). The results were
not statistically significant. Therefore, the null hypothesis was retained. There were no
statistically significant differences between familial experience (have lived or known
someone with asthma) based on their knowledge pre- test scores.
Perceptions Pre-test and Socio- demographic variables
Table 10: Association between socio- demographic variables and perceptions pre-test in the
Intervention group
Socio-demographic N (%) Pre- test perceptions

Gender
Male 81 (50.0) 52.51 (14.53)
Female 81 (50.0) 52.92 (67.94)
t (160)= -0.053, p= 0.958
Age group (Years)

9- 12 59 (36.4) 47.18 (18.96)
13- 16 95 (58.6) 56.28 (62.04)
17- 20 8 (4.9) 51.25 (8.15)
F (2,159)= 0.630, p= 0.534
Class Level
JSS 1 23 (14.2) 46.09 (18.11)
JSS 2 29 (17.9) 52.41 (16.69)
JSS 3 30 (18.5) 45.11 (17.89)
SSS 1 27 (16.7) 73.45 (112.82)
SSS 2 27 (16.7) 50.37 (18.61)
SSS 3 26 (16.0) 48.59 (16.71)
F (5,156)= 1.257, p= 0.286
Religion
Christianity 151 (93.2) 53.18 (50.46)
Islam 11 (6.8) 46.36 (19.46)
t(160)= 0.444, p= 0.657
Ethnic Group
Yoruba 143 (88.3) 48.95 (16.89)
Igbo 13 (8.0) 94.36 (163.31)
Hausa 1 (0.6) 73.33
Others 5 (3.1) 48.00 (11.45)
F (3,158)= 3.662, p= 0.014*
Family Experience 1
asthma)
Yes 24 (14.8) 73.59 (13.15)
No 138 (85.2) 71.89 (14.24)
t (160) = 0.546, p = 0.586
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Family Experience 2
(Have lived with or
known someone with
asthma)
Yes 74 (45.7) 68.54 (14.59)
No 88 (54.3) 66.44 (12.88)
t (160) = 0.974, p = 0.332
between perceptions pre-test and socio-demographic variables. There were equal males
(n=81) and females (n=81) in the experimental group, and females scored slightly higher at
the perceptions pre-test stage (M=52.51, SD=14.525) than males (M=52.51, SD=67.942).
The variances between the groups were equal since the results of Levene's test were not
(160) = -0.053, p= 0.958) (Table 10) therefore, the null hypothesis was retained. There were
no statistically significant differences between genders based on their perceptions pre-test
scores.
group had the highest perceptions pre-test scores (M=56.28, SD=62.043) and participants in
the one-way ANOVA were not significant (F (2, 159) = 0.630, p= 0.534), therefore the null
groups based on their perceptions pre-test scores.
smallest class level participants were the JSS 1 (n=23). Participants in the SSS 1 class level
had the highest perceptions pre-test scores (M=73.45, SD=112.821) and participants in the
JSS 1 class level had the lowest scores (M=46.09, SD=18.108). The results of the one-way
ANOVA were not significant (F (2, 159) = 1.257, p= 0.286), therefore the null hypothesis
was retained. There were no statistically significant differences between the class levels
based on their perceptions pre-test scores.
Table 10 also shows the independent samples test of the association between perceptions pre-
knowledge pre-test stage (M=53.18, SD=50.459) than Islam participants (M=46.36,
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There were no statistically significant differences between religions based on their
perceptions pre-test scores.
ethnic group were the Hausa ethnic group (n=1). Participant in the Igbo ethnic group had the
highest perceptions pre-test scores (M=94.36, SD=163.306) and participants in the other less
predominant ethnic groups had the lowest scores (M=48.00, SD=11.449). The results of the
one-way ANOVA were significant (F (3, 158) = 3.662, p= 0.014). The post hoc tests could
not be performed to ascertain where the significance is present because at least one group has
fewer than two cases. Therefore, the null hypothesis was rejected. There were statistically
significant differences between the ethnic groups based on their perceptions pre-test scores.
Table 10 also shows the independent sample test of the association between perceptions pre-
differences between familial experiences (have a relative with asthma) based on their
perceptions pre- test scores.
Table 10 also shows the independent sample test of the association between perceptions pre-
someone with asthma) based on their perceptions pre- test scores.
Knowledge Post-test and Socio-demographic variables
Table 11: Association between socio- demographic variables and knowledge post-test in the
Intervention group
Socio-demographic N (%) Post- test knowledge

Gender
Male 81 (50.0) 71.87 (14.10)
Female 81 (50.0) 72.42 (14.11)
t (160)= -0.250, p= 0.803
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Age group (Years)
9- 12 59 (36.4) 68.77 (15.50)
13- 16 95 (58.6) 74.24 (12.96)
17- 20 8 (4.9) 72.18 (12.06)
F (2,159)= 2.811, p= 0.063
Class Level
JSS 1 23 (14.2) 63.65 (14.30)
JSS 2 29 (17.9) 69.97 (15.45)
JSS 3 30 (18.5) 74.45 (12.29)
SSS 1 27 (16.7) 68.83 (14.81)
SSS 2 27 (16.7) 78.95 (9.10)
SSS 3 26 (16.0) 75.81 (13.51)
F (5,156)= 4.297, p= 0.001*
Religion
Christianity 151 (93.2) 72.81 (13.76)
Islam 11 (6.8) 63.05 (15.69)
t(160)= 2.249, p= 0.026*
Ethnic Group
Yoruba 143 (88.3) 71.65 (14.32)
Igbo 13 (8.0) 76.18 (12.87)
Hausa 1 (0.6) 80.65
Others 5 (3.1) 73.98 (10.13)
F (3,158)= 0.561, p= 0.642
Family Experience 1 \
asthma)
Yes 24 (14.8) 73.59 (13.15)
No 138 (85.2) 71.89 (14.24)
t (160) = 0.546, p = 0.586
Family Experience 2
(Have lived with or
known someone with
asthma)
Yes 74 (45.7) 72.65 (13.17)
No 88 (54.3) 71.72 (14.83)
t (160) = 0.417, p = 0.672
between knowledge post-test and socio-demographic variables. There were equal males
the knowledge post-test stage (M=72.42, SD=14.099) than males (M=71.87, SD=14.108).
104
no statistically significant differences between genders based on their knowledge post-test
scores.
group had the highest knowledge post-test scores (M=74.24, SD=12.962) and participants in
the one-way ANOVA were not significant (F (2, 159) = 2.811, p=.063), therefore the null
groups based on their knowledge post-test scores.
had the highest knowledge post-test scores (M=78.95, SD=9.102) and participants in the JSS
1 class level had the lowest scores (M=63.65, SD=14.30). The results of the one-way
ANOVA were significant (F (2, 159) = 4.297, p= 0.001). The post hoc analysis showed that
the significance was noted between the JSS 1 and SSS 2 class levels (p= 0.008). Therefore,
the null hypothesis was rejected. There were statistically significant differences between the
class levels based on their knowledge post-test scores.
Table 11 also shows the independent samples test of the association between knowledge post-
knowledge post-test stage (M=72.81, SD=15.694) than Islam participants (M=63.05,
were not significant (p=.863). The results of the Independent t-test were statistically
significant (t (160) = 2.249, p= 0.026) (Table 11) therefore, the null hypothesis was rejected.
There were statistically significant differences between religions based on their knowledge
post-test scores.
ethnic group were the Hausa ethnic group (n=1). Participant in the Hausa ethnic group had
the highest knowledge post-test scores probably because of being the only one (M=80.65)
and participants in the Yoruba ethnic group had the lowest scores (M=71.65, SD=14.32). The
results of the one-way ANOVA were not significant (F (3, 158) = 0.561, p= 0.642), therefore
105
the null hypothesis was retained. There were no statistically significant differences between
the ethnic groups based on their knowledge post- test scores.
Table 11 also shows the independent sample test of the association between knowledge post-
knowledge post- test scores.
Table 11 also shows the independent sample test of the association between knowledge post-
someone with asthma) based on their knowledge post- test scores.
Perceptions Post- test and Socio-demographic variables
Table 12: Association between socio- demographic variables and perceptions post-test in the
Intervention group
Socio-demographic N (%) Post- test Perceptions

Gender
Male 81 (50.0) 66.79 (15.36)
Female 81 (50.0) 68.01 (11.85)
t (160)= -0.566, p= 0.572
Age group (Years)

9- 12 59 (36.4) 65.54 (13.08)
13- 16 95 (58.6) 68.62 (14.13)
17- 20 8 (4.9) 66.67 (12.60)
F (2,159)= 0.934, p= 0.395
Class Level
JSS 1 23 (14.2) 60.00 (14.80)
JSS 2 29 (17.9) 70.69 (10.89)
JSS 3 30 (18.5) 65.89 (10.67)
SSS 1 27 (16.7) 62.43 (18.48)
SSS 2 27 (16.7) 74.20 (10.92)
SSS 3 26 (16.0) 70.13 (10.93)
F (5,156)= 4.432, p= 0.001*
Religion
Christianity 151 (93.2) 67.83 (13.39)
Islam 11 (6.8) 61.52 (16.89)
t(160)= 1.482, p= 0.140
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Ethnic Group
Yoruba 143 (88.3) 67.17 (14.00)
Igbo 13 (8.0) 69.74 (10.67)
Hausa 1 (0.6) 56.67
Others 5 (3.1) 70.00 (13.74)
F (3,158)= 0.401, p= 0.753
Family Experience 1
asthma)
Yes 24 (14.8) 66.81 (12.10)
No 138 (85.2) 67.50 (13.98)
t (160) = -0.230, p = 0.819
Family Experience 2
(Have lived with or
known someone with
asthma)
Yes 74 (45.7) 68.54 (14.59)
No 88 (54.3) 66.44 (12.88)
t (160) = 0.974, p = 0.332
between perceptions post-test and socio-demographic variables. There were equal males
the perceptions post-test stage (M=66.79, SD=15.361) than males (M=68.01, SD=11.846).
no statistically significant differences between genders based on their perceptions post-test
scores.
group had the highest perceptions post-test scores (M=68.62, SD=14.134) and participants in
the one-way ANOVA were not significant (F (2, 159) = 0.934, p= 0.395), therefore the null
groups based on their perceptions pre-test scores.
had the highest perceptions post-test scores (M=74.20, SD=10.923) and participants in the
107
JSS 1 class level had the lowest scores (M=60.00, SD=14.804). The results of the one-way
ANOVA were significant (F (2, 159) = 4.297, p= 0.001). The post hoc analysis showed that
the significance was noted between the JSS 1 and SSS 2 class levels (p= 0.014). Therefore,
the null hypothesis was rejected. There were statistically significant differences between the
class levels based on their perceptions post-test scores.
Table 12 also shows the independent samples test of the association between perceptions
post-test and religion. There were more participants practicing Christianity (n=151) than
Islam (n=11) in the experimental group, and Christianity participants scored higher at the
perceptions post-test stage (M=67.83, SD=13.392) than Islam participants (M=61.52,
There were no statistically significant differences between religions based on their
perceptions post-test scores.
ethnic group were the Hausa ethnic group (n=1). Participant in the other less predominant
ethnic groups in Nigeria had the highest perceptions post-test scores (M=70.00, SD=13.742)
and participants in the Hausa ethnic group had the lowest scores (M=56.67). The results of
the one-way ANOVA were not significant (F (3, 158) = 0.401, p= 0.753) therefore, the null
hypothesis was retained. There were no statistically significant differences between the ethnic
groups based on their perceptions post-test scores.
Table 12 also shows the independent sample test of the association between perceptions post-
perceptions post- test scores.
Table 12 also shows the independent sample test of the association between perceptions post-
someone with asthma) based on their perceptions post- test scores.
108
DISCUSSION
This study was conducted to determine the impact of asthma health education
programme on knowledge and perceptions of asthma among secondary school students in Ile-
Ife, Nigeria. The sex distribution in this study had more female participants than male
participants. This result is also similar to the study conducted by Shaw et al (2005) which
reported female participants higher in number than male participants. This can be explained
also that girl- child education is given an utmost priority among the study population. The
result also showed higher Christian participants and Yoruba participants than any other
religion and tribes respectively. This result can be explained by the fact that the sampled
study population reflects the dominant religion being practiced in the communities and they
are located in Yoruba land. This invariably shows that the study environment will usually
reflect the characteristics of the study population. The result also showed that more
participants in the intervention group have more family experiences and have heard about
asthma more than the control group. This can be explained by the fact that prevalence of
asthma is likely to be more in the urban/ semi- urban community which the population in the
intervention group belongs than in the rural communities which the control group participants
belong. This is corroborated by a study done by Pesek et al (2010) and Falade et al (2009).
Impact of health education on knowledge of asthma among the secondary school
students
The result of this study showed that there was a significant difference in the pre- test and
post- test knowledge scores of the secondary school students in the intervention group
following health education programme intervention. The knowledge score increased from
43.14 to 72.14 that was 67.24% increase. On the other hand, the result of this study showed
that there was no significant difference in the participants’ pre- test and post- test knowledge
scores in the control group (who did not receive health education programme intervention).
The secondary school students from the intervention schools recorded significant
improvement in their knowledge of asthma compared to the secondary school students in the
control group after the health education intervention. Therefore, the improvement in
knowledge of asthma obtained from this study could be attributed to the effect of health
education administered on the secondary school students in the intervention group. This
reflects both the quality of the materials used in the classes and high reflective adherence to
the study manuals which were given to them after the health education intervention. The
109
result of this study is in agreement with a similar study by Shaw et al, 2005 where asthma
knowledge score increased significantly from 43.96 to 62.23 showing a 41.56% increase
among secondary school students who received health education intervention. The result of
this study is also in agreement with a study by Gibson et al, 1998 where asthma knowledge
score which was poor at baseline increased significantly post- intervention among asthmatic
and non-asthmatic students. The result is also in agreement with a similar study by Desalu et
al, 2013 where asthma knowledge level increased significantly from baseline to post-
intervention among post basic nursing students. There was also no significant difference in
the control group (who did not receive health education intervention) in the study. The result
is also in agreement with a similar study by Bowen, 2013 where asthma knowledge level
increased significantly from baseline 60% to 70% post- intervention score showing a 14.3%
increase and with no significant difference in the control group who did not receive health
education intervention. Other studies that are in agreement with the result of this study are
(Al- Sheyab et al, 2012; Kintner and Sikorskii, 2009; Levy et al, 2006; Butz et al, 2005;
Shegog et al, 2001) whose results showed that health education intervention significantly
increased the knowledge score in the intervention group compared to the control group who
did not receive the health education intervention.
Impact of health education on perceptions of asthma among the secondary school
students
There was a significant difference between the pre- test and post- test perceptions scores of
the secondary school students in the intervention group following health education
programme. Their perceptions scores increased from 52.72 to 67.40 which represent a
27.85% increase. There was no significant difference in the participants’ pre- test and post-
test perceptions scores in the control group. It could be inferred from this result that the
secondary school students in the intervention schools recorded significant improvement in
their perceptions of asthma over the secondary school students in the control group after the
health education intervention. Therefore, the improvement in perceptions of asthma obtained
from this study could be attributed to the effect of health education administered on the
secondary school students in the intervention group. A closely related study done by Velsor-
Friedrich et al (2004) supported the outcome of this study. It was reported that participants in
the intervention group that attended an asthma education programme showed a significant
improvement in self-efficacy scores measured by the Asthma Belief Survey. The baseline
110
score was 4.03, SD 0.10, which increased significantly to 4.23, SD 0.10 after five months
(p=0.046). Self-efficacy is a contextual-related judgment of personal ability to organize and
execute a course of action to attain designated levels of performance (Chemers et al, 2001).
Self-efficacy arises from performance accomplishments, vicarious experience, verbal
persuasion, and physiological states all of which were employed in this study. Perceived self-
efficacy represents the belief that one has the capability to change risky health behaviours by
personal action. A closely related study done by Butz et al, (2005) also supported the
outcome of this study. They reported that self- efficacy perceptions in the intervention group
of rural early- adolescents of school age who received health education improved
significantly after the health education in the intervention group. The result of this study is
also in agreement with a closely related study by Shegog et al (2001) where the self efficacy
perceptions improved significantly post- intervention in those that received health education
intervention.
Changes in secondary school students’ knowledge levels over a period of time for the
intervention and control group
The knowledge levels of participants in the intervention group were affected overtime. The
results showed that there was a significant change in knowledge overtime for the participants
in the intervention group, over a period of 1 week, 3 weeks and over a period of 6 weeks. The
level of knowledge of the intervention group significantly increased at the post- test stage
sustained at the post- test 2 and post- test 3 stages though slightly less than the immediate
follow up. From this result, it can be inferred that the secondary school students experienced
the greatest rise in knowledge retention one week after the intervention but still managed to
maintain their knowledge levels even six weeks following health education. This outcome
was supported by close related study conducted among high school adolescents using
adolescent asthma education intervention on their knowledge of asthma. Their result showed
that the baseline knowledge score of asthma among the participants was mean 7.64 which
significantly increased to mean 16.44 at immediate post- intervention but declined to mean
score 8.80 at the 5 week follow up in the intervention group (Zografos et al, 2010). The result
was also in agreement with a similar study among early adolescents conducted by Bowen,
2013 which showed that the knowledge levels significantly improved overtime in the
intervention group. The result of this study is also in agreement with a similar study by
Horner et al (2008) which showed there was a significant improvement in asthma knowledge
111
score overtime among rural adolescents. The result of this study is however, in contrast with
a similar quasi-experimental study conducted in USA by Velsor-Friedrich et al (2004), to
examine the effects of a school-based education programme on children's aged 8-13 years
knowledge of asthma. Their results showed no significant improvement in levels of
knowledge among the intervention group. The result of this study, on the other hand showed
that there was no significant change in the knowledge of asthma in the control group. The
level of knowledge of the control group decreased slightly but was not significant at the post-
test stage compared to the beginning. This result was also in agreement with the study of
Bowen, 2013 which showed that there was no significant improvement in the knowledge
level overtime among the control group (who did not receive health education intervention).
Changes in secondary school students’ perceptions levels over a period of time for the
intervention and control group
The perceptions levels of participants in the intervention group were also affected overtime.
The result showed that there was a significant change in perceptions over time in the
intervention group. The level of perceptions significantly increased from pre- test stage to
post- test stage to post- test 2 stage and up until post- test 3 stages. From this result, it can be
inferred that the health education intervention was effective beyond the immediate period and
that the secondary school students were able to sustain and improve on their levels of
perceptions of asthma up to the period of six weeks. This therefore suggests that the effect of
health education intervention on perceptions of asthma among these secondary school
students has some lasting effect over a period of time. The result is in agreement with a
similar study by Horner et al (2008) which showed that there was statistically significant
improvement in self efficacy perception overtime in the intervention group who received
health education intervention. On the other hand, the result of this study showed that there
was no significant change in the perceptions of asthma over time in the control group. The
level of perceptions of the control group decreased slightly at the post- test stage at a point
lower than at the beginning of the study. The result of the study by Horner et al (2008) also
showed there was no significant improvement in the self efficacy perception in the control
group of rural adolescents who did not receive health education intervention.
112
Associations between socio- demographic variables and knowledge and perceptions of
asthma among the secondary school students
This study revealed that prior to health education intervention, only ethnicity factor of the
socio- demographic factors considered in this study was significantly associated with the
perceptions levels of the participants at the pre- test stage. Other socio- demographic factors
considered were not significantly associated with the knowledge and perceptions levels of the
participants at the pre- test stage. This result was in agreement with some close related studies
but also at variance with some (Ilesanmi et al, 2017; Chen et al, 2006; Fadzil et al, 2002;
Meyer et al, 2001; Gibson et al, 1998). On the other hand, the study revealed that there were
significant associations between socio- demographic variables (class level, religion) and post-
test knowledge of asthma in the intervention group. The result by inference showed that the
increased knowledge of asthma obtained subsequent to the health education intervention was
associated to class level and religion of the secondary school students. This outcome was in
line with a closely related study carried out by Fadzil et al (2002) which found a significant
association between parental asthma knowledge and level of education. The result was also in
line with a similar study carried out by Meyer et al (2001) among adults with asthma which
showed that better knowledge was associated with higher education. The outcome is in
contrast to a similar study conducted by Gibson et al (1998) which found a significant
association between asthma knowledge and ethnic background, age, body mass index and
residential area of the high school students. The outcome is also in line with a closely related
study which found that higher asthma knowledge scores were associated with higher level of
parent education, race (white versus non- white), higher socioeconomic status and child-
reported family functioning. The result of the significant association between post- test
asthma knowledge and religion could not be supported by related studies. However, because
majority of the participants in the study were Christians (93.2%), it could be inferred that the
influence of their religion significantly contributed to how they were able to receive the
health education programme intervention on asthma. Also in this study, class level alone was
found to be in significant association with post- test perceptions levels of the participants.
From this result, it can be inferred that following health education intervention increase in
perceptions of asthma of the studied participants was associated with class level. This result
is in contrast with the result of a study by Chen et al (2006) who found a significant
association between asthma perceptions and age, gender, Body mass index, history of
113
exercised- induced symptoms and psychological state of the children with asthma who were
studied. The result of this study is closely related with a study by Abubakari et al (2016) who
studied illness perceptions representation among diabetes patients. They found that
educational attainment contributed significantly in predicting patients’ illness perception
representations about their diabetes.
114
CHAPTER FIVE
SUMMARY
Background: There is a rising burden of asthma in developed and developing world with
most asthma related deaths occurring in low and lower- middle income countries including
Sub- Saharan Africa. Early adolescents and older school age children have the reported
higher mortality and morbidity due to asthma which causes have been attributed to
inadequate knowledge and wrong perceptions about asthma among this age group.
Knowledge, attitudes, and beliefs are recognized as being major determinants of health behaviour.
Improved understanding of perceptions, local belief and behaviour regarding asthma of this target
group are crucial if public health programmes are to prove sustainable. Several school- based
studies have been conducted to assess the knowledge and perceptions of asthma but much
less are known about the impact of health education programme on knowledge and
perceptions of asthma among secondary school students. Most of these data have come from
developed countries and limited to students who have asthma. But much less is known about
the impact of health educational intervention on knowledge and perceptions of asthma among
non- asthmatics secondary school students. This study is, therefore, a maiden study, directed
to assess the impact of health education on knowledge and perceptions of asthma among
secondary school students in Ile- Ife, Nigeria.
Method: A quasi- experimental study with a repeated measure, non- equivalent groups study
design. Data for the study were obtained from both the intervention and control group
participants using pre- tested, close ended, self- administered questionnaires to assess the
knowledge and perceptions of asthma at baseline (pre- test), one week (post test), three weeks
(post- test 2) and six weeks (post- test 3) in the intervention group and at six weeks (post-
test) in the control group. Participants were selected using multistage and simple random
sampling techniques.
Results: Findings revealed that health education had significant impact on knowledge and
perceptions of Asthma among the secondary school students. The result also showed
significant changes over a period of time in the knowledge and perceptions of asthma among
the participants in the intervention group. The study further revealed that there were
significant associations between knowledge of asthma and the secondary school students’ age
and class level and between perceptions of asthma and secondary school students’ class level
115
after health education intervention. Only the ethnicity showed a significant association with
perceptions of asthma of the students before health education intervention.
Conclusion: The overall results showed that health education are effective as well as
essential and should be carried out to improve knowledge and perceptions of asthma among
early adolescents and older school age children such as secondary school students as shown
by this study.
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CHAPTER SIX
CONCLUSION
The outcome of this study also reveals that there is significant difference between the pre and
post- test asthma knowledge scores (which increased from 43.14 to 72.14) and perceptions
scores (which increased from 52.72 to 67.40) of the secondary school students in the
intervention group following health education programme intervention. It also showed that
there is no significant difference between the pre and post- test asthma knowledge scores
(which decreased from 44.66 to 44.38) and perceptions scores (which decreased from 53.05
to 52.76) of the secondary school students in the control group who did not receive health
education. The study also shows a significant improvement in knowledge and perceptions of
asthma overtime for the participants in the intervention group. The study further showed that
there were associations between knowledge of asthma and the secondary school students’ age
and class level and between perceptions of asthma and secondary school students’ class level
after health education intervention. Only the ethnicity showed a significant association with
perceptions of asthma of the students before health education intervention. The study
therefore concluded that health educational intervention has significant positive effect on
knowledge and perceptions of asthma among secondary school students in Ile- Ife, Osun
State, South West, Nigeria.
Limitations of the study
This study is an example of an effective method in which researchers and school teachers
incorporate an asthma health education program into a structured health education class.
However, the competing demands for students' time during a typical school day posed
problems during the conduct of the school-based study as corroborated in the study by Shaw
et al., 2005. Attrition during each follow-up phase could also have affected the study results.
Reasons for diminishing sample size from baseline included: 1) absent during data collection,
2) possible voluntary refusal to complete questionnaire, or 3) absent during intervention,
therefore follow-up data are not valid. These were handled by the increasing of the sample
size at the onset of the study. Despite potential problems with attrition, the school-based
environment is fitting for asthma research as well as other clinically based programs. Also,
the study is based on self- reported information and thus is subject to self- report bias. To
117
correct this, effort was made to reduce the impact of this bias by making the questionnaire a
guided self- administered process.
118
CHAPTER SEVEN
CONTRIBUTION TO KNOWLEDGE
It is a known fact that asthma is a major health problem among schoolage children and
youth with studies identifying substantial under-diagnosis, poor acceptance of diagnosis, poor
compliance to treatment and poor understanding of asthma management especially in
developing countries like Nigeria. This is often due to inadequate knowledge and the wrong
perceptions about asthma among this population. The societal relevance of this study is
therefore associated with the fact that its findings will be used to inform future health
education intervention for secondary school students about asthma in Nigeria and to help
health care providers in other countries to understand the effect of asthma health education
intervention on the knowledge and perceptions of asthma among secondary school students
aged 9-19 years. The scientific relevance is associated with the fact that it revealed that health
education intervention is essential in improving present level of knowledge and perceptions
of asthma among the study population. It is also relevant scientifically in that it provided a
rationale for the formulation of health education policies that will be targeted towards
prevention of asthma occurrence among secondary school students. In addition, the outcome
of the study has also identified some socio- demographic factors that should be taken into
consideration while working on improving the knowledge and perceptions of asthma through
the medium of health education intervention. Finally, as this study is a maiden study, the
outcome of this study, as it will be made readily available to other researchers, will then serve
as and provide baseline data which will be useful for other similar studies in the future.
119
RECOMMENDATIONS
Recommendations for policy
• Asthma education curriculum should be developed for these students to improve their
asthma knowledge and perceptions.
• Collaborations between the State ministry of Education and ministry of Health should be enhanced
in order to establish policies that will encourage instituting well equipped health centre facilities in the
schools where students with asthma can be attended to in case of emergencies and regular monitoring
of those with symptoms related to asthma.
Recommendations for practice
• Establishment of several free health clinics in schools that will cater for the needs of
asthmatic adolescents is very necessary. There is ample evidence that such facilities are very
helpful for young people, are economical in terms of service delivery and can help in the
training of health workers who can care for these students. In other words school based
clinics should be given utmost consideration.
• There is a need to utilize the mass media more as a medium of advocacy for asthma
education.
• Peer- led asthma education programme should be encouraged among students in the study area to
allow older and advanced students to teach and interact with students from lower classes in order
reinforce their knowledge and help those with asthma to be well received among their peers.
• Primary prevention strategies should be taken to the community levels through the students
with a view to reduce the impact of some trigger factors which have the propensity to
increase the incidence of asthma in the population.
• Urban and environmental planning should be given utmost priorities especially in the citing
of some industries which can increase the effect of urban pollution.
120
CHAPTER EIGHT
SUGGESTION FOR FUTURE RESEARCH
1. Further researches are needed on impact of health educational intervention

programme on knowledge and perceptions of other health issues such as HIV, sexual
transmitted infections (STI), epilepsy, diabetes and obesity which are also significant
health issues among adolescents and older school age children.
2. Further researches of this same type over a longer period of 6 months, 12 months and
24 months can be carried out to provide insight into whether a longer health education
programme intervention could ensure better or permanent results.
3. The study should be repeated in a different geographical area to identify
commonalities and differences between the two populations.
4. It is also important to survey those adolescents not currently attending school.
5. There is a need to conduct the research among the teachers of these students so as to
improve their knowledge and perceptions of asthma especially as the result of this
study indicated that the major source of information for the students about asthma is
not from school.
121
CHAPTER NINE
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139
CHAPTER TEN
APPENDIX
(A) OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX, ILE-IFE.
Effect of health educational intervention on knowledge and perceptions of asthma among

secondary school students in Ile- Ife, South- West, Nigeria
SUBJECT INFORMATION SHEET
Principal Investigator: Mr Ilesanmi OluwafemiTemitayo

Telephone No:- 08028102047 E-mail: aboundinggrace08@yahoo.com
E-mail: aboundinggrace08@yahoo.com
Institution/Department: Medical Rehabilitation
Co – Investigators: None
Sponsor (If any): None
- Some general things to know about the study:

Asthma is a serious global health problem that affects people of all backgrounds
and ages. In Nigeria, asthma is a major health problem among adolescents with
studies identifying substantial under-diagnosis, poor acceptance of diagnosis, poor
compliance to treatment and poor understanding of asthma management causing
significant unwholesomeness and death. This study seeks to know the present
levels of and the effects of health intervention education on your knowledge and
perceptions of asthma.
- What is the purpose of this study:

The purpose of the study is to evaluate the effect of health educational
intervention knowledge and perceptions of asthma among secondary school
students in Ile-Ife, South-west, Nigeria.
- Procedures:
You will be given questionnaires to assess your knowledge and perceptions of
asthma. You will also receive health education on asthma.
- Benefits:
You are going to acquire adequate knowledge on asthma symptoms, risk factors,
prevention and management.
- Costs of Participation: You will not pay for the study
- Risks: You are not at any risk
- Compensation: You will not be compensated
- Confidentiality: Your name and address will not be included in the data collection
instrument and the result will be kept on a pass-worded computer
140
- Respondents’ Rights: You have right to withdraw from participating in the study anytime
as wishes.
- Conflict of Interest: There is no conflict of interest.
- For the Records: Not applicable
141
(B) OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX, ILE-IFE.

Subject’s Agreement/Consent Form:
I have read the information provided in the Subject Information Sheet, or it has been read to me.
I have had the opportunity to ask questions about the research and all questions I have asked have
been answered to my satisfaction. I consent voluntarily to participate in this study and understand that
questionnaire will be given to me to provide information to the best of my understanding on my
knowledge and perceptions of asthma and that I have the right to withdraw from the study at any time.
I also understand that my photograph may be taken during the process of the study.
Yes No
------------------------------------------------------------------------------------------------------
Signature/Thumb print of Research Respondent. Date:
If participants cannot read: Signature of Mother or Legal Guardian.
Signature/thumb print of Person Obtaining Consent.Date:
Name of witness Signature

Date
Printed Name of Person Obtaining Consent.
142
(C) OBAFEMI AWOLOWO UNIVERSITY TEACHING HOSPITALS COMPLEX, ILE-IFE.
ASSENT

Parent/Guardian Consent Form:
I have read the information provided in the Subject information Sheet, or it has been read to me.
I have had the opportunity to ask questions about it and any questions I have asked have been
answered to my satisfaction. I consent voluntarily to allow my child/ward participate in this study
and understand that questionnaire will be given to him/her to provide information to the best of
his/her understanding on his/her knowledge and perceptions of asthma and that he/she have the right
to withdraw from the study at any time. I also understand that his/her photograph may be taken during
the process of the study.
Yes No
No
------------------------------------------------------------------------------------------------------
Signature/Thumb print of Research Respondent’s Mother or Legal Guardian. Date:
Signature/thumb print of Person Obtaining Consent Date:
Name of witness & Signature
Printed Name of Person Obtaining Consent.
Child/Ward Agreement (Verbal)

Although I am not yet 18 years old but I have had the opportunity to ask questions about this research
and any questions I have asked have been answered to my satisfaction. I consent voluntarily to
participate in this study and understand that I have the right to withdraw from the study at any time.
143
144
145
IFE CENTRAL LOCAL GOVERNMENT (INTERVENTION SITE)- SAMPLE OF
COMMUNITIES IN EACH WARD FROM WHERE THE SCHOOLS WERE SELECTED
ILARE WARD 1 ILARE WARD 2 ILARE WARD 3
- Igboya quarters - Fajuyi road - Oduduwa street
- Mbabi Mbayo - Ajegunle line 1 - Ilare street
- Oluwasanmi - Ibukun- olu line 1 - Ile Kenani street
- OAU Juniour staff Qtrs - Irebami line 1 - Ayedun street
- Idi- Obi - Irebami line 8 & 9 - Akui street

ILARE WARD 4 IREMO WARD 1 IREMO WARD 2
- Olumogbe - Power line - Town planning area
- Ayedun - Moremi Estate - Ebenezer way
- Oduduwa college - Adesanmi Oduduwa str - Nitel way
- Oluere - Ooni layoutline 1- 4 - Tadenikawo
- Aguro Eleshin nla - Modomo line 1- 4 - Ojutalayo area

IREMO WARD 3 IREMO WARD 4 IREMO WARD 5
- Gbelenkan - Akui - Ita akogun
- Odo ogbe - Akile - Atobatele
- London communities - Iremo - Obalejugbe
- Ayibiowu - Otigun - Isale agbara
- Onireke - Oduduwa - Aderemi

AKARABATA WARD (10) MOORE/OJAJA
- Lagere- ile atiki
- Akarabata Line 1- 3 - Agbedegbede
- Orunto
- Apalara - Oke- Isokun
- Obalufe
- Urban day school - Aladanla
- Ile- timi
- Lagere - Ikoyi
146
147
MAP OF IFE NORTH LOCAL GOVERNMENT (CONTROL STUDY SITE)
SHOWING THE WARDS FROM WHICH THE SCHOOLS WERE SELECTED
FROM
TOOL A: MODIFIED VERSION OF THE NEWCASTLE ASTHMA KNOWLEDGE

QUESTIONNAIRE (NAKQ)
S/N YES NO DON’T

KNOW
1 An asthma attack is caused by redness and swelling in
the airways
2 Asthma is an infectious disease (can be spread from
person to person)
3 Smoking does not affect people with asthma
4 People with asthma should not consume food from
animals like cow’s milk
5 The three main symptoms of asthma are coughing,
whistling sound and shortness of breath
6 If one child in a family has asthma, then their brothers
and sisters will have asthma too
7 People with frequent asthma symptoms should take
preventive drugs
8 A ventolin puffer (inhaler) should be used when a
person has asthma attack
9 People with asthma are usually tensed up during attack
10 Asthma is more of a problem at night than during the
day
11 Asthmatics should be discouraged from sporting
activities
12 Most people with asthma have an increase in mucus
when they drink cow’s milk
13 Allergy shots cure asthma
14 Asthma damages the heart
15 With the right treatment, an adolescent with asthma can
live a normal life with no restriction on activity
16 Most adolescents with asthma are smaller in stature than
other adolescents
17 People with asthma become addicted to their asthma
drugs (cannot get off them)
18 Having catarrh can cause an asthma attack
19 Asthma is a respiratory condition in which the airways
are narrowed, resulting in impaired breathing
20 Weekly washing of the bedding in hot water to rid them
of dust mites and infections can prevent asthma attack
21 Asthma attack can be triggered by getting excessively
angry
22 People who are fat, compared to those who are not, have
a higher chance of having asthma
23 Some people with asthma have allergies
148
24 Asthma can be diagnosed by listening to chest
25 Antibiotics are an important part of treatment for most
people with asthma
26 During an asthma attack, the wheezing may be due to
the contraction of the muscles that form the walls of the
lung
27 During an asthma attack,wheezing may be due to the
swelling of the lining of the lungs
28 Inhaled medications for asthma have fewer side effects
than tablets and syrups
29 Prolonged use of oral steroids can result in stunted
growth
30 Some asthma medicines (such as ventolin) can damage
the heart
31 Every patient with asthma must do a spirometry
149
TOOL B: MODIFIED VERSION OF THE REVISED ILLNESS PERCEPTION
QUESTIONNAIRE (IPQ-R)
S/N YES NO NOT

SURE
1 Asthma will last for a short time
2 Asthma is likely to be permanent rather than temporary
3 Asthma will improve as patients grow older
4 Asthma does not have much effect on patient’s life
5 Asthma has a serious financial consequence
6 Asthma causes difficulties for the people close to those that
have it
7 Asthma is a serious condition
8 There is a lot those with asthma can do to control their
symptoms
9 Difficult breathing is usually not associated with asthma
10 Difficulty in sleeping is associated with asthma
11 Patients with asthma usually have lack of appetite
12 Patients with asthma are usually irritable
13 People with asthma can determine whether they get better or
worse
14 Asthma can be prevented
15 Asthma is very unpredictable
16 Asthma is a mysterious disease
17 Actions of people with asthma will have no effect on the
outcomes of their illness
18 Asthma can be cured on its own
19 There is nothing which can help those with asthma
20 Treatment for asthma can control it and its negative outcome
21 The course of asthma depends on the patient
22 There is very little that can be done to improve when
someone is ill with asthma
23 Asthma will get better by itself without treatment
24 Asthma does not make any sense. It is a myth.
25 The symptoms of asthma come and go in cycles
26 Asthma can be cured by the use of herbs
27 Asthma can lead to death if not treated
28 The symptoms of asthma change a great deal from day to
day
29 Asthma is a spiritual illness caused by witches, wizards and
wicked people
30 Asthma can be cured by pouring hot water on the chest or by
150
drinking hot water
QUESTIONNAIRE FOR THE RESEARCH PARTICIPANTS
Serial Number …………………………….

EFFECT OF HEALTH EDUCATIONAL INTERVENTION ON KNOWLEDGE AND
PERCEPTIONS OF ASTHMA AMONG SECONDARY SCHOOL STUDENTS IN
ILE- IFE, SOUTH-WEST, NIGERIA.
QUESTIONNAIRE
I am a PhD student of Public Health at Texila American University, Guyana in South
America. I am conducting a research to assess the effect of health educational intervention on
knowledge and perceptions of asthma among secondary school students of Ile-Ife, South-
West, Nigeria. This study is designed to know the present level of knowledge and perceptions
of asthma among secondary school students of Ile-Ife and to give the health education on
everything they need to know about asthma in order to prevent and limit its occurrence
among them since asthma is known to be increasing with poor understanding of its
management and compliance with treatment causing avoidance of school and school related
activities among adolescents in Nigeria and the world at large.
INFORMED CONSENT
• You are free to participate or opt out from this interview as you so desire.
• Your participation in this interview is greatly appreciated but it is completely voluntary.
• All information made available for this study will be kept confidential. Your name will not
be on the questionnaire. Your responses to the questions will be identified only by number
and not by your name.
Researcher: ILESANMI OLUWAFEMI TEMITAYO
Respondents’ sign
…………………….
SECTION A: RESPONDENTS’ SOCIO-DEMOGRAPHIC DATA (Please tick as

appropriate)
(1) Age (a) 9-12 [ ] (b) 13- 16 [ ] (c) 17- 20 [ ] (d) More than 20 [ ]
(2) Sex (a) Male [ ] (b) Female [ ]
(3) Class (a) JSS 1[ ] (b) JSS 2[ ] (c) JSS 3[ ] (d) SSS1[ ] (e) SSS2 [ ] (f) SSS3 [ ]
(4) Religion (a) Christianity [ ] (b) Islam [ ] (c) Others (please specify) ……………….
(5) Ethnic group (a) Yoruba [ ] (b) Igbo [ ] (c) Hausa [ ] (d) Others (please specify) ...............................
(6) Have you ever been diagnosed to have asthma or do you have asthma. Yes [ ], No[ ]
(7) Are you currently taking any asthma medications? Yes [ ], No[ ]
(8) Family Experience
151
Have a relative with asthma [ ], Have lived with or known someone with asthma [ ]
(9) Have you heard about asthma before? Yes [ ], No [ ]

(10) Where did you find out about it: School [ ], Television &Radio [ ], Books [ ], Relatives& Family
members [ ], Friends [ ], Newspaper & Magazines [ ], Doctor/Healthcare Practitioner [ ],
Others (please specify) ……………………………
SECTION B: RESPONDENTS’ KNOWLEDGE ABOUT ASTHMA (Please tick as appropriate)
S/N YES NO DON’T
KNOW
1 An asthma attack is caused by redness and swelling in
the airways
2 Asthma is an infectious disease (can be spread from
person to person)
3 Smoking does not affect people with asthma
4 People with asthma should not consume food from
animals like cow’s milk
5 The three main symptoms of asthma are coughing,
whistling sound and shortness of breath
6 If one child in a family has asthma, then their brothers
and sisters will have asthma too
7 People with frequent asthma symptoms should take
preventive drugs
8 A ventolin puffer (inhaler) should be used when a
person has asthma attack
9 People with asthma are usually tensed up during attack
10 Asthma is more of a problem at night than during the
day
11 Asthmatics should be discouraged from sporting
activities
12 Most people with asthma have an increase in mucus
when they drink cow’s milk
13 Allergy shots cure asthma
14 Asthma damages the heart
15 With the right treatment, an adolescent with asthma can
live a normal life with no restriction on activity
16 Most adolescents with asthma are smaller in stature than
other adolescents
17 People with asthma become addicted to their asthma
drugs (cannot get off them)
18 Having catarrh can cause an asthma attack
19 Asthma is a respiratory condition in which the airways
are narrowed, resulting in impaired breathing
20 Weekly washing of the bedding in hot water to rid them
of dust mites and infections can prevent asthma attack
21 Asthma attack can be triggered by getting excessively
angry
22 People who are fat, compared to those who are not, have
a higher chance of having asthma
23 Some people with asthma have allergies
24 Asthma can be diagnosed by listening to chest
25 Antibiotics are an important part of treatment for most
people with asthma
26 During an asthma attack, the wheezing may be due to
the contraction of the muscles that form the walls of the
152
lung
27 During an asthma attack,wheezing may be due to the
swelling of the lining of the lungs
28 Inhaled medications for asthma have fewer side effects
than tablets and syrups
29 Prolonged use of oral steroids can result in stunted
growth
30 Some asthma medicines (such as ventolin) can damage
the heart
31 Every patient with asthma must do a spirometry
SECTION C: RESPONDENTS’ PERCEPTIONS ABOUT ASTHMA (Please tick as
appropriate)
S/N YES NO NOT

SURE
1 Asthma will last for a short time
2 Asthma is likely to be permanent rather than temporary
3 Asthma will improve as patients grow older
4 Asthma does not have much effect on patient’s life
5 Asthma has a serious financial consequence
6 Asthma causes difficulties for the people close to those that
have it
7 Asthma is a serious condition
8 There is a lot those with asthma can do to control their
symptoms
9 Difficult breathing is usually not associated with asthma
10 Difficulty in sleeping is associated with asthma
11 Patients with asthma usually have lack of appetite
12 Patients with asthma are usually irritable
13 People with asthma can determine whether they get better or
worse
14 Asthma can be prevented
15 Asthma is very unpredictable
16 Asthma is a mysterious disease
17 Actions of people with asthma will have no effect on the
outcomes of their illness
18 Asthma can be cured on its own
19 There is nothing which can help those with asthma
20 Treatment for asthma can control it and its negative outcome
21 The course of asthma depends on the patient
22 There is very little that can be done to improve when
someone is ill with asthma
23 Asthma will get better by itself without treatment
24 Asthma does not make any sense. It is a myth.
25 The symptoms of asthma come and go in cycles
26 Asthma can be cured by the use of herbs
27 Asthma can lead to death if not treated
28 The symptoms of asthma change a great deal from day to
day
29 Asthma is a spiritual illness caused by witches, wizards and
153
wicked people
30 Asthma can be cured by pouring hot water on the chest or by
drinking hot water
CHAPTER ELEVEN
LIST OF PUBLICATIONS BASED ON THE THESIS AND OTHER PUBLICATIONS

1). Ilesanmi, O.T., Adegbenro, C.A., Erhabor, G.E., Olatona, F.A., Adewole, O.F.,
Awopeju, O.F., Adeniyi, B.O (2018). Effect of Health Educational Intervention on
Knowledge and Perceptions of Asthma among Secondary School Students in Ile- Ife, South-
West, Nigeria. Texila International Journal of Public Health. Volume 6. Issue 1. February
2018. 117- 132. ISSN 2520- 3134. DOI:10.21522/TIJPH.06.01.Art 011.
2). Ilesanmi, O.T., Adegbenro, C.A., Awopeju, O.F., Olatona, F.A (2017). Knowledge
and Perceptions of Asthma in a Nigerian High School. Texila International Journal of Public
Health. Volume 5. Issue 4. December 2017. 601- 615. ISSN 2520- 3134. DOI:
10.21522/TIJPH.2013.05.04.Art058.
3). Ilesanmi, O.T, Egwu, M.O., Adedoyin, R.A., Esan, O.K (2017). Effect of Vertical
Oscillatory Pressure on Pain Intensity and Respiratory Variables in Patients with Cervical
Spondylosis. Texila International Journal of Clinical Research. Volume 4, Issue 1, Jun 2017.
19-32. ISSN 2520-3096. Doi: 10.21522/TIJCR.2014.04.01.Art03.
4). ILESANMI, O.T (2017). Knowledge and Practices of Food Safety among Senior
Secondary School Students of International School, Obafemi AwolowoUniversity, Ile- Ife,
Nigeria. Texila International Journal of Public Health. Volume 5, Issue 1, Mar 2017. 163-
178. ISSN 2520-3134. DOI: 10.21522/TIJPH.2013.05.01.Art018.
5). ILESANMI, O.T (2016). Determining the Relationship between Home Environment and
Academic Performance. A case of Clinical Medical Rehabilitation Students of Obafemi
Awolowo University. Texila International Journal of Public Health. Volume 4, Issue 4, Dec
2016. 605-617.ISSN 2309-6470. DOI: 10.21522/TIJPH.2013.04.04.Art052.
6). ILESANMI, O.T (2016). Knowledge and Practices of Personal Hygiene among Senior
Secondary School Students of Ambassadors College, Ile- Ife, Nigeria. Texila International
Journal of Public Health. Volume 4. Issue 4. 625-636. ISSN 2309-6470.DOI:
10.21522/TIJPH.2013.04.04.Art054.
154
PLAGIARISM TEST
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1. Assess level of knowledge of asthma and effect of asthma health education programme
among the secondary school students in Ile- Ife, Nigeria.- Unique 3. Observe changes in
knowledge and perceptions of asthma among the secondary school students over a period of
time.- Unique 1. H0: There would be no significant differences between pre-test and post-test
knowledge scores among the participants (intervention) who receive the health education
programme intervention.- Unique 3. H0: There would be no significant differences between
pre-test and post-test perceptions scores among the participants who receive the health
education programme intervention.- Unique 5. H0: There would be no significant change
over time from pre- test to post-test (follow up) in the knowledge about asthma in the control
group.- Unique 7. H0: There would be no significant change over time from pre-test to post-
test (follow up) perceptions about asthma in the control group.- Unique 9. H0: There would
be no significant association between socio- demographic factors (gender, age group, class
level, religion, and ethnicity) and pre- intervention knowledge scores.- Unique 11. H0: There
would be no significant association between socio- demographic factors (gender, age group,
class level, religion, and ethnicity) and post- intervention 1 knowledge scores.- Unique Level
of significance was set at α = 0.05.- Unique families, and patients is increasing worldwide
(Marsden et al, 2016; Vos et al, 2013).- Unique unplanned childcare, emergency room visits,
sleep disorders and fatigue, physical limitations and depression (Kintner et al, 2015; van
Wijk, 2013).- Unique population (Oluwole et al, 2017; Musa et al, 2014). These have been
attributed to inadequate knowledge and the wrong perceptions about asthma (Anwar et al,
2008; Bjorksten, 2000).- Unique Schools have been identified as the prime settings for
asthma health education for children and adolescents due to practicality, familiarity with the
environment and the magnitude of influence that peers- Unique Several school based studies
have been conducted to assess the impact of asthma health education programme on students
with asthma showing significant improvement in their knowledge of asthma, reduction-
Unique Most of these data have come from developed countries and limited to students who
have asthma.- Unique of asthma among secondary school students in Ile Ife, Nigeria.-
Unique
155

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The outcome of this study could reveal any gap in the knowledge and perceptions of asthma
among secondary school students in Ile- Ife, Nigeria.- Unique The outcome of the study
could also be helpful in determining the predictors of knowledge and perception of asthma
among the secondary school students in Ile- Ife, Nigeria.- Unique Furthermore, the data
collected in the course of the research could serve as baseline for further studies.- Unique -
Students who have not been previously diagnosed by a Physician as asthmatics and are not
currently on medications for the treatment of asthma.- Unique - Students of study age group
(9- 19 years) that are not registered members of the chosen secondary schools.- Unique The
sampling technique employed was a multistage sampling technique.- Unique Two local
government areas were selected from the four local government areas in Ile Ife using simple
random sampling and they are Ife Central and Ife North local government areas.- Unique Ife
Central was the intervention group while Ife North was the control group.- Unique The
second stage was the selection of 3 wards from the wards in each local government study site
(Ife Central LGA has 11 wards and Ife North LGA has- Unique The last stage consisted of
the selection of at least forty- seven students from each school to make a total of 140
secondary school students as research participants in- Unique The pre-test was carried out
among secondary school students in Ife East LGA, an entirely different LGA from the two
that were used in this study.- PlagiarizedThis was done to ensure that the questions were
clear and acceptable; there was willingness to answer them and that they were appropriate in
eliciting responses that were consistent- Unique formula for the comparison of proportions of
related groups/ within groups was used for the comparison of before and after intervention
data.- Unique The purpose of most health education is to improve knowledge and change
behaviour and attitudes in people who have partial or complete deficit in issues related to
their health and- Unique As such, two standard instruments were selected to ensure that the
impact of the intervention on these outcomes could be examined.- Unique The instrument
consists of 31 questions (31 true/false items/ I don’t know answer). The original Newcastle
Asthma Knowledge Questionnaire aimed to assess the knowledge of parents of children with
asthma.- Unique The final version of the NAKQ consists of 25 true/false items and six open
ended questions that provide a comprehensive assessment of the key domains of asthma
knowledge including:- Unique The tool has been used extensively by the researchers to test
adults with and without asthma (Allen et al., 2000), the child care workforce (Hazell et al.,
2006), asthma- Unique The domains of the NAKQ are well constructed, with evidence of
construct and discriminate validity, high internal consistency of items and test-retest
156
reliability (AlMotlaq & Sellick, 2011).- Unique The reliability of the questionnaire was done
in a school in one of the local governments in Ile Ife which was not included in the study.-
Unique

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According to WHO (2007), content validity encompasses the demonstration of the existence
of a strong relationship between the content that was used in the study and the variables under
investigation.- Unique Content validity analysis was performed to determine the
appropriateness of the language, content, and structure of the modified versions of the
questionnaires for measuring the research variables.- Unique The snowballing technique was
used to recruit a panel including six experts to perform a content validity analysis of the
questionnaires.- Unique The process was done in accordance with the procedure described
by Polit and Beck (2006).- Unique Therapist that have regular contact with asthmatic
adolescents, and one secondary school teacher.- Unique Each panel member was sent a
questionnaire that included the revised list of asthma knowledge items and asthma perception
items, and asked to rate each item using a 5-point- Unique Panel members were also invited
to comment on the wording of items and response format, and to suggest other items to be
added to the instrument.- Unique which identifies the clarity of the item to the reader. The
result of their inputs led to the final version of the questionnaires which were eventually used
to collect the data.- Unique To determine the feasibility and if any modifications were
needed before using the instruments in the main study, a pre-test pilot study using the
modified NAKQ and adapted modified IPQ-R- Unique The recruitment of 30 students rested
on the recommendations of Lackey and Wingate (1998) that a pilot test should be carried out
on at least the equivalent of one- Unique In this case both the modified NAKQ and adapted
modified IPQ-R were tested.- Unique The answers of the pilot study population suggested
that all items in both modified NAKQ and adapted modified IPQ-R and their options for
response were clear and understandable.- Unique So, it can be achieved when keeping results
at a consistent level despite changing of time and place. This can be performed by using
Cronbach‘s alpha test.- Unique Other sources reported that the acceptable values should be
more than (60%) according to (Sekaran, 2006, 311).- Unique Cronbach's Alpha for both
scales from the pilot testing were measured and revealed high internal consistency values in
modified NAKQ (0.627) and adapted modified IPQ-R (0.718).- Unique However, it is
important to note that the students that took part in the pilot test were not considered eligible
for the main study.- Unique However, those included in the pilot study were given the
chance to have the asthma health education programmes but they were not allowed to
contribute to the study findings- Unique
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The researcher received permission from the State Ministry of Education Zonal Officer in
charge of the Local governments in Ile-Ife.- Unique The researcher explained to them the
aim of the study, explained the process of conducting the study and its stages in their schools,
and gave them a detailed description- Unique Strengthening support from the key
stakeholders was an important part of ensuring the success of the research. The success of
any study often depends on the contribution of the gatekeepers.- Unique The education
programme was started after the students and parents had been informed about the study
requirements and had given their consent.- Unique As mentioned earlier, the students
attending the three schools from the Ife Central Local Government Area were allocated to the
intervention group and their counterparts from the Ife North- Unique The second section
which is a modified Newcastle asthma knowledge questionnaire adapted for the study
population is an instrument which consisted of 31 questions (31 true/false items/ I don’t-
Unique The third section which was a modified Revised Illness Perception questionnaire
(IPQ-R) which have been adapted to assess illness perceptions among healthy people
(Figueiras and Alves, 2007) is an- Unique agree with the statement or not, or they are not
sure. The health education programme was for a period of two weeks.- Unique This was
collected one week prior to the health education intervention which was given to the
intervention group.- Unique The second data was collected from the intervention group at
post- test date (1 week).- Unique The fourth data was collected from the intervention group
at post- test date 3 (6 weeks) and also from the control group at post- test date (6 weeks) for-
Unique The reasons for selecting these intervals is based on a similar study conducted by
Shaw et al, 2005 where the outcomes being tested were measured at the post intervention-
Unique (at least 3 weeks) to assess the point of maximum benefits where learning by
observation will be intensified.- Unique However, the last assessment post intervention (6
weeks later) was aimed to assess students’ ability to retain the acquired learning over a short
period of time.- Unique The 2 instruments discussed earlier (Modified Newcastle Asthma
Knowledge Questionnaire and modified Revised Illness Perception Questionnaire)
administered by the research assistants to both the control and intervention groups,
maintained- Unique A brief introduction about the questionnaire was given by the research
assistant to help the students understand how to complete them.- Unique
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In this study the intervention being tested was a specific health education programme
delivered over two weeks using two-hour sessions per day for the intervention group.-
Unique without asthma about asthma and how this can be managed enables potential health
and well-being benefits (Shaw et al, 2005; Gibson et al, 1998).In this section, Social
Cognitive Theory (Bandura,- Unique According to Bloom's taxonomy, educational
objectives can be divided into three main categories or domains: cognitive, affective, and
psychomotor.- Unique In each domain, there is a range of suggested learning strategies that
can be used to improve the effectiveness of teaching strategies targeting one domain over
another.- Unique cognitive domain and demonstration and re-demonstration are used for the
psychomotor domain (Gilbert et al., 2011).- Unique A health educator should have the
responsibility for understanding barriers impeding learning processes.- Unique The
educational sessions integrated cognitive theory with the information provided by the British
Thoracic Society.- Unique use of posters, focused group discussions and practical sessions
on the use of peak flow meters and inhalers.- Unique asthma, identification of common
triggers of asthma and how to control these triggers, types of asthma medications, and asthma
management, and exercise and asthma, prognosis of asthma and myths about- Unique
Similar to the learning activities in these interventions, components of social cognitive theory
(SCT) such as performance accomplishments, vicarious experience, verbal persuasion and
emotional arousal were incorporated into the asthma- Unique Performance accomplishments
included role playing to inform students of what to do when someone is having an asthma
attack, simulations of an asthma attack, and conducting risk assessments of- Unique
Vicarious experience included an observation of the researcher using a peak flow meter,
emphasizing the importance of regular peak flow monitoring.- Unique Lastly, emotional
arousal involved students being taught how to perform stress management techniques such as
pursed-lip breathing which they can teach those that have asthma attacks.- Unique Emphasis
was placed on the students taking notes from the lectures so that they can retain the
knowledge passed across and they can later serve as peer instructors in- Unique These hand
bills reiterated the key points on the modules given on the information about asthma.-
Unique Approval to conduct the study was also obtained from the Ministry of Education
zonal office.- Unique

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This study was conducted to determine the effect of asthma health education programme on
knowledge and perceptions of asthma among secondary school students in Ile- Ife, Nigeria.-
Unique This result is also similar to the study conducted by Shaw et al (2005) which reported
female participants higher in number than male participants.- Unique The result also showed
higher Christian participants and Yoruba participants than any other religion and tribes
respectively.- Unique This invariably shows that the study environment will usually reflect
the characteristics of the study population.- Unique This can be explained by the fact that
prevalence of asthma is likely to be more in the urban/ semi- urban community which the
population in the intervention group- Unique Effect of health educational intervention on
knowledge of asthma among the secondary school students- Unique The knowledge score
increased from 43.14 to 72.14 that was 67.24% increase.- Unique group (who did not receive
health education programme intervention).- Unique This reflects both the quality of the
materials used in the classes and high reflective adherence to the study manuals which were
given to them after the health education intervention.- Unique 41.56% increase among
secondary school students who received health education intervention.- Unique There was
also no significant difference in the control group (who did not receive health education
intervention) in the study.- Unique 14.3% increase and with no significant difference in the
control group who did not receive health education intervention.- Unique 2005; Shegog et al,
2001) whose results showed that health education intervention significantly increased the
knowledge score in the intervention group compared to the control group who did not
receive- Unique There was a significant difference between the pre- test and post- test
perceptions scores of the secondary school students in the intervention group following health
education programme.- Unique There was no significant difference in the participants’ pre-
test and post- test perceptions scores in the control group.- Unique in the control group after
the health education intervention.- Unique A closely related study done by Velsor-Friedrich
et al (2004) supported the outcome of this study.- Unique The baseline score was 4.03, SD
0.10, which increased significantly to 4.23, SD 0.10 after five months (p=0.046).- Unique
Self-efficacy arises from performance accomplishments, vicarious experience, verbal
persuasion, and physiological states all of which were employed in this study.- Unique A
closely related study done by Butz et al, (2005) also supported the outcome of this study.-
Unique

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The knowledge levels of participants in the intervention group were affected overtime.-
Unique The level of knowledge of the intervention group significantly increased at the post-
test stage sustained at the post- test 2 and post- test 3 stages though slightly less- Unique their
knowledge levels even six weeks following health education.- Unique Their result showed
that the baseline knowledge score of asthma among the participants was mean 7.64 which
significantly increased to mean 16.44 at immediate post- intervention but declined to-
Unique The result was also in agreement with a similar study among early adolescents
conducted by Bowen, 2013 which showed that the knowledge levels significantly improved
overtime in the intervention group.- Unique The result of this study is however, in contrast
with a similar quasi-experimental study conducted in USA by Velsor-Friedrich et al (2004),
to examine the effects of a school-based- Unique The result of this study, on the other hand
showed that there was no significant change in the knowledge of asthma in the control
group.- Unique This result was also in agreement with the study of Bowen, 2013 which
showed that there was no significant improvement in the knowledge level overtime among
the control group- Unique The result showed that there was a significant change in
perceptions over time in the intervention group.- Unique From this result, it can be inferred
that the health education intervention was effective beyond the immediate period and that the
secondary school students were able to sustain and- Unique This therefore suggests that the
effect of health education intervention on perceptions of asthma among these secondary
school students has some lasting effect over a period of time.- Unique On the other hand, the
result of this study showed that there was no significant change in the perceptions of asthma
over time in the control group.- Unique The result of the study by Horner et al (2008) also
showed there was no significant improvement in the self efficacy perception in the control
group of rural adolescents- Unique This study revealed that prior to health education
intervention, only ethnicity factor of the socio- demographic factors considered in this study
was significantly associated with the perceptions levels of the- Unique This result was in
agreement with some close related studies but also at variance with some (Ilesanmi et al,
2017; Chen et al, 2006; Fadzil et al, 2002; Meyer- Unique The result by inference showed
that the increased knowledge of asthma obtained subsequent to the health education
intervention was associated to class level and religion of the secondary school students.-
Unique The outcome is in contrast to a similar study conducted by Gibson et al (1998) which
found a significant association between asthma knowledge and ethnic background, age, body
mass- Unique The outcome is also in line with a closely related study which found that
higher asthma knowledge scores were associated with higher level of parent education, race
(white versus- Unique
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However, because majority of the participants in the study were Christians (93.2%), it could
be inferred that the influence of their religion significantly contributed to how they were able-
Unique From this result, it can be inferred that following health education intervention
increase in perceptions of asthma of the studied participants was associated with class level.-
Unique index, history of exercised- induced symptoms and psychological state of the
children with asthma who were studied.- Unique They found that educational attainment
contributed significantly in predicting patients’ illness perception representations about their
diabetes.- Unique Early adolescents and older school age children have the reported higher
mortality and morbidity due to asthma which causes have been attributed to inadequate
knowledge and wrong perceptions about- Unique Improved understanding of perceptions,
local belief and behaviour regarding asthma of this target group are crucial if public health
programmes are to prove sustainable.- Unique Most of these data have come from developed
countries and limited to students who have asthma.- Unique Method: A quasi- experimental
study with a repeated measure, non- equivalent groups study design.- Unique asthma at
baseline (pre- test), one week (post test), three weeks (post- test 2) and six weeks (post- test
3) in the intervention group and at six weeks (post- test)- Unique Results: Findings revealed
that health education intervention had significant effect on knowledge and perceptions of
Asthma among the secondary school students.- Unique The study further revealed that there
were significant associations between knowledge of asthma and the secondary school
students’ age and class level and between perceptions of asthma and secondary- Unique
Conclusion: The overall results showed that health educational interventions are effective as
well as essential and should be carried out to improve knowledge and perceptions of asthma
among early adolescents- Unique The aim of this study was to measure the effect of health
educational intervention on the knowledge and perceptions of asthma among secondary
school students in Ile- Ife, Osun State,- PlagiarizedThe research objectives were to
incorporate the measurements of knowledge and perceptions of secondary school students
taken at pre- test (baseline), post- test (1 week), post- test 2 (3- Unique Through the study,
pre- test, and post- test 3 measures (knowledge and perceptions) in the intervention group and
pre- test and post- test measures (knowledge and perceptions) were established;- Unique of
one week, three weeks and six weeks were observed and assessed in the intervention group
and over a period of six weeks in the control group.- Unique Therefore, the aim and
objectives for this research study were explicitly met.- Unique
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This study is an example of an effective method in which researchers and school teachers
incorporate an asthma health education program into a structured health education class.-
Unique Despite potential problems with attrition, the school-based environment is fitting for
asthma research as well as other clinically based programs.- Unique To correct this, effort
was made to reduce the impact of this bias by making the questionnaire a guided self-
administered process.- Unique treatment and poor understanding of asthma management
especially in developing countries like Nigeria. This is often due to inadequate knowledge
and the wrong perceptions about asthma among this population.- Unique asthma in Nigeria
and to help health care providers in other countries to understand the effect of asthma health
education intervention on the knowledge and perceptions of asthma among secondary-
Unique Finally, as this study is a maiden study, the outcome of this study, as it will be made
readily available to other researchers, will then serve as and provide- Unique •
Collaborations between the State ministry of Education and ministry of Health should be
enhanced in order to establish policies that will encourage instituting well equipped health
centre facilities in- Unique • Establishment of several free health clinics in schools that will
cater for the needs of asthmatic adolescents is very necessary.- Unique In other words school
based clinics should be given utmost consideration.- Unique • Peer- led asthma education
programme should be encouraged among students in the study area to allow older and
advanced students to teach and interact with students from lower classes- Unique • Primary
prevention strategies should be taken to the community levels through the students with a
view to reduce the impact of some trigger factors which have the propensity to- Unique 1.
Further researches are needed on effect of health educational intervention programme on
knowledge and perceptions of other health issues such as HIV, sexual transmitted infections
(STI), epilepsy, diabetes and- Unique 2. Further researches of this same type over a longer
period of 6 months, 12 months and 24 months can be carried out to provide insight into
whether a longer- Unique 4. It is also important to survey those adolescents not currently
attending school.- Unique this study indicated that the major source of information for the
students about asthma is not from school.- Unique

163

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IMPACT OF HEALTH EDUCATION ON

KNOWLEDGE AND PERCEPTIONS OF ASTHMA AMONG

SECONDARY SCHOOL STUDENTS IN ILE- IFE, SOUTH-

Doctor of Philosophy in Public Health

[ILESANMI OLUWAFEMI TEMITAYO]

Under the Guidance of

IMPACT OF HEALTH EDUCATION ON

KNOWLEDGE AND PERCEPTIONS OF ASTHMA AMONG

SECONDARY SCHOOL STUDENTS IN ILE- IFE, SOUTH-

Doctor of Philosophy in Public Health

[ILESANMI OLUWAFEMI TEMITAYO]

Under the Guidance of

done by [ILESANMI OLUWAFEMI TEMITAYO], under my supervision and guidance

Fellowship or other similar title to any candidate of any University.

DATED THIS DAY- 20TH OF APRIL, 2018.

I, ILESANMI OLUWAFEMI TEMITAYO, declare that the thesis entitled “Impact of

Health Education on Knowledge and Perceptions of Asthma among Secondary School

wherever the findings of others have been cited.

ILESANMI OLUWAFEMI TEMITAYO

DATED THIS DAY- 20TH OF APRIL, 2018.

Health and members of staff of the Texila American University.

- Dr Caleb Aderemi Adegbenro, My local guide and supervisor, an Associate Professor

Faculty of Public Health, Texila American University.

Ife, Osun State, Nigeria).

- Drs Adewole Olufemi, Awopeju Olayemi, Adeniyi Bamidele, Oyewo Tinuke

(Respiratory Physicians); Dr Olatona Foluke (Consultant Community Physician) and

Dr Adesanmi Akinsulore (Mental Health Physician).

- Dr Sreevani V, Ms Jignasha Francis Muhindi, Ms Susmitha Archarya, Ms Anitha A

Anitha, Ms Divya Rajan and Ms Indu S (Student Coordinators and Sales

Okorie, Dr Joshua Awopeju, Dr Abiola Ogundele, Dr Temitope Olajubu, all body of

Ministers in Sanctuary of Hope Church and all members of Sanctuary of Hope

- Dr Olubukola Oyelese (Director, Medical Rehabilitation Services, OAUTHC, Ile- Ife,

Rehabilitation, OAUTHC, Ile- Ife.

Department of Medical Rehabilitation, Obafemi Awolowo University, Ile- Ife, Osun

- All the Principals of the Schools used for the study.

- Physiotherapists Rose, Sangodoyin, Oluwaseun, Akin, Funke, Joy, Omolola, Segun,

the study but are now licenced PTs).

- Miss Adebimpe Ogundalu and Mr Olanrewaju Adedoyin (Research Assistants).

dear Mother), Engr Adekunle Ilesanmi, Mr Bankole Ilesanmi, Mr Gbenga Ilesanmi,

Engr Eniola Ilesanmi (My wonderful siblings).

- Dr (Mrs) Adeyinka Oluwafunmilayo Ilesanmi (My sweetheart and ever supportive

gracious and supportive children (VIRTUE, OLUWASEMILORE, ERIOLUWA

ILESANMI OLUWAFEMI TEMITAYO (DATED THIS DAY- 20TH OF APRIL, 2018).

THIS GREAT WORK IS DEDICATED TO THE

ALMIGHTY GOD, THE GIVER OF

IMMEASURABLE GRACE AND TO ALL

ASTHMATIC ADOLESCENTS ALL OVER THE

FEV1 – forced expiratory volume in one second

GINA – Global Initiative for Asthma

PEF – peak expiratory flow

ISAAC-International Study of Asthma and Allergies in Childhood

ECRHS- European Community Respiratory Health Survey

GBAR- Global Burden of Asthma Report

WHO- World Health Organization.

NAEPP- National Asthma Education and Prevention Programme

SPSS- Statistical Package of Social Sciences

NAKQ- Newcastle Asthma Knowledge Questionnaire

IPQ-R- Revised Illness Perception Questionnaire

ANOVA- Analysis of Variance

DF- Degree of Freedom

SD- Standard Deviations

RCP3- Royal College of Physicians 3 Question Screening tool

ACQ- Asthma Control Questionnaire