Can Respir J Vol 17 No 2 March/April 201067
A children’s asthma education program: Roaring
Adventures of Puff (RAP), improves quality of life
Shawna L McGhan RN MN CRE1,2, Eric Wong MD3, Heather M Sharpe RN MN CRE3, Patrick A Hessel PhD1,4,
Puish Mandhane MD PhD5, Vicki L Boechler RN6,7, Carina Majaesic MD5, A Dean Befus PhD1,3,8
1Alberta Asthma Centre; 2Faculty of Nursing; 3Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry;
4Department of Public Health Sciences, Faculty of Medicine and Dentistry; 5Department of Pediatrics, Faculty of Medicine and Dentistry,
University of Alberta; 6SEARCH, Alberta Heritage Foundation for Medical Research; 7Capital Health Region, Edmonton, Alberta;
8AstraZeneca Canada Inc, Mississauga, Ontario
Correspondence: Shawna L McGhan, Alberta Asthma Centre, University of Alberta, 11402 University Avenue, Edmonton, Alberta T6G 2J3.
Telephone 780-407-3178, fax 780-407-3608, e-mail firstname.lastname@example.org
able to achieve good asthma control (4), asthma is poorly
controlled in this population (2,3,5), likely due to a multitude
of complex and continuously evolving factors (6,7). Some of
these factors include a lack of care continuity (8), inadequate
use of clinical practice guidelines (9,10), poor patient compli-
ance (11), patient characteristics (12-14) and physician char-
acteristics (13,15). Novel approaches are needed to address
the complex problem of achieving optimal asthma manage-
ment and control.
Systematic reviews and meta-analyses of childhood asthma
education programs suggest that recent approaches guided by
evidence-based strategies and a cognitively appropriate theor-
etical framework are most effective (16-18). Furthermore,
attitudes, knowledge and skills of the care givers significantly
sthma affects a child’s quality of life (1) and overall
health (2,3). Although children with asthma should be
affect the child’s ability to develop and use management
behaviours and access appropriate care (19,20). Consideration
of the child’s environment, both social and physical at school
and at home, influence the child’s asthma control and quality
of life (QOL) (19,21). School-based asthma management pro-
grams are easily accessible to children with asthma, their peers
and caregivers, and are known to be feasible strategies (22,23).
The ‘Roaring Adventures of Puff’ (RAP) is a child-centred,
school-based, asthma education program (24). RAP incorpor-
ates a multitude of childhood educational approaches based on
theory and evidence of factors that influence a child’s motiva-
tion, efficacy, management and QOL. Previously, a feasibility
study of RAP was conducted using student instructors super-
vised by the school’s community health nurse (25). Children in
the RAP intervention schools had statistically significant
improvements in unscheduled doctor visits, missed school days,
©2010 Pulsus Group Inc. All rights reserved
SL McGhan, E Wong, HM Sharpe, et al. A children’s asthma
education program: Roaring Adventures of Puff (RAP),
improves quality of life. Can Respir J 2010;17(2):67-73.
bACkGRound: It is postulated that children with asthma who receive
an interactive, comprehensive education program would improve their
quality of life, asthma management and asthma control compared with
children receiving usual care.
obJECtivE: To assess the feasibility and impact of ‘Roaring Adventures
of Puff’ (RAP), a six-week childhood asthma education program adminis-
tered by health professionals in schools.
MEtHodS: Thirty-four schools from three health regions in Alberta
were randomly assigned to receive either the RAP asthma program
(intervention group) or usual care (control group). Baseline measure-
ments from parent and child were taken before the intervention, and at
six and 12 months.
RESuLtS: The intervention group had more smoke exposure at baseline.
Participants lost to follow-up had more asthma symptoms. Improvements
were significantly greater in the RAP intervention group from baseline to
six months than in the control group in terms of parent’s perceived under-
standing and ability to cope with and control asthma, and overall quality
of life (P<0.05). On follow-up, doctor visits were reduced in the control
ConCLuSion: A multilevel, comprehensive, school-based asthma
program is feasible, and modestly improved asthma management and qual-
ity of life outcomes. An interactive group education program offered to
children with asthma at their school has merit as a practical, cost-effective,
peer-supportive approach to improve health outcomes.
key Words: Asthma education; Childhood asthma; Program
evaluation; Quality of life; School-based program
L’éducation sur l’asthme pour les enfants : Le
programme Roaring Adventures of Puff (RAP)
améliore la qualité de vie
HiStoRiQuE : On postule que les enfants asthmatiques qui reçoivent un
programme d’éducation interactif complet améliorent leur qualité de vie
ainsi que leur prise en charge et leur contrôle de l’asthme par rapport aux
enfants qui reçoivent des soins habituels.
obJECtiF : Évaluer la faisabilité et les répercussions du programme Roaring
Adventures of Puff (RAP), un programme d’éducation sur l’asthme de six
semaines pour les enfants, administré par des professionnels de la santé dans
MÉtHodoLoGiE : Trente-quatre écoles de trois régions sanitaires de
l’Alberta ont été réparties aléatoirement entre le programme RAP (groupe
d’intervention) et les soins habituels (groupe témoin). Les chercheurs ont
obtenu les mesures auprès des parents et des enfants avant l’intervention,
puis au bout de six et de 12 mois.
RÉSuLtAtS : Le groupe d’intervention était davantage exposé à la fumée
du tabac en début d’étude. Les participants perdus au suivi avaient plus de
symptômes d’asthme. L’amélioration était considérablement plus marquée
dans le groupe d’intervention RAP entre le début et six mois que dans le
groupe témoin pour ce qui est de la compréhension perçue des parents, de la
capacité d’affronter et de contrôler l’asthme et de la qualité de vie globale
(P<0,05). Au suivi, les visites au médecin étaient réduites dans le groupe
ConCLuSion : Il est faisable d’offrir un programme d’éducation sur
l’asthme en milieu scolaire complet et multiniveau, et ce programme
améliore modestement la prise en charge de l’asthme et les résultats sur la
qualité de vie. Un programme d’éducation collectif interactif offert à des
enfants asthmatiques en milieu scolaire a l’avantage d’être une démarche
pratique, rentable et soutenue par les camarades pour améliorer les issues
McGhan et al
Can Respir J Vol 17 No 2 March/April 2010 68
limitations in the nature of play and correct use of medica-
tions. The study showed that a school-based asthma program
is feasible. We hypothesized that school-age children with
asthma who participated in RAP exhibit improved asthma
self-management behaviours and a better QOL, reduced symp-
toms and improved health care use than children who received
the usual asthma care.
The study was approved by the University of Alberta Health
Research Ethics Board (Edmonton, Alberta). From a listing
of all public schools in participating health regions (Capital
Health, Westview and Northwest), 34 schools were randomly
selected and agreed to participate in the study (a response
rate of 79%). A school health survey was sent home through
a school-wide mailing (n=3986; response rate 55%). Parents
who reported that their child had physician-diagnosed asthma
were identified; interested families were contacted by telephone.
Consent was obtained from each parent and child before enroll-
ment in the study. Study inclusion criteria were children attending
grades 2 to 5, with a parent-reported diagnosis of asthma by a
physician, informed consent from the parent or guardian, ability
to speak English and no previous participation in RAP.
Of the families who agreed to participate, baseline information
from each child was gathered at their school using the Pediatric
Asthma Quality of Life Questionnaire (PAQLQ) (1). Peak
flow measurements were taken for each child at their school.
One parent was asked to complete the mailed Parent RAP
Questionnaire. The same parent was also asked to complete
the PAQLQ from their child’s perspective, without help from
their child. Schools were randomly assigned to either the RAP
educational intervention or usual care (control group) using a
random number table. Both RAP and control groups com-
pleted the same questionnaires at six and 12 months after the
intervention (Figure 1).
Before the RAP intervention, parents and teachers in the inter-
vention schools were invited to participate in a RAP parent/
teacher asthma awareness event held at the school (approxi-
mately 2 h in an evening). The event provided information on
asthma management, school asthma issues and RAP. Group
discussions explored how to best support children with asthma
and their perceived needs, including environmental control
measures, a written asthma action plan for parents and asthma
information for the school staff. A session on guidelines for
asthma management at school and related resources were
offered to school staff. Physicians of the participating children
were faxed letters informing them about the study, about RAP
and the Canadian asthma consensus guidelines (4). They were
also invited to communicate with the RAP educator about
their patients and were asked to ensure that the children had
written action plans. The RAP instructor consulted the phys-
icians when concerns regarding their patient arose that needed
The health region with jurisdiction over participating schools
identified qualified staff to be trained as instructors. Four regis-
tered respiratory therapists working in community rehabilitation
and one community health nurse attended a two-day workshop
on childhood asthma and the teaching of RAP. The RAP
instructors’ workshop included asthma information, scenarios,
simulations and a written examination. The RAP instructors
taught six 45 min to 60 min sessions on a series of asthma topics,
including getting to know each other, goal setting, use of a peak
flow meter (optional) and diary monitoring; trigger identifica-
tion, control and avoidance, and basic pathophysiology; pur-
pose of medications and proper use of inhalers; symptom
recognition, self-monitoring and the use of an action plan; life-
style, exercise, fears and managing an asthma episode; and shar-
ing information with teachers and parents (26).
RAP assumes that an individual’s behaviour is determined
by a complex interaction among environmental, personal
(physiological and cognitive) and behavioural factors. To influ-
ence these factors in children with asthma, RAP integrated the
following principles of the social cognitive theory (27): self-
regulation, observational learning, reinforcement, environ-
mental influences and perceived self-efficacy. The theoretical
framework underlying RAP has been discussed in detail previ-
ously (24). Teaching strategies included puppetry, games, role
play, model building, group interaction, team building, and
asthma symptom and management tracking.
The PAQLQ measures health-related QOL in children with
asthma through 23 questions across three domains (symptoms,
activity limitations and emotional function). The question-
naire has good measurement properties and has been shown to
Follow up at 12 mo
Lost to follow up
Lost to follow up
2 schools dropped
RAP not received n=21
Lost to follow up
Lost to follow up
RAP InterventionUsual Care
Follow up at 6 mo
Follow up at 6 mo
Follow up at 12 mo
Figure 1) Flow chart of the study timeline, the enrollment process,
and subject participation and dropout at three time points. mo
Months; RAP Roaring Adventures of Puff
Roaring Adventures of Puff improves quality of life
Can Respir J Vol 17 No 2 March/April 201069
be reliable and responsive for children seven to 17 years of age
(1). The PAQLQ is scored on a scale between 1 and 7, with a
clinically significant difference being 0.5 or more. This ques-
tionnaire was administered to both the child and their parent.
The parent was instructed to answer the questions from their
child’s perspective without assistance from the child.
The Parent RAP Questionnaire assessed demographic infor-
mation, medication use, health care use, school absenteeism,
attitudes toward asthma and global asthma ratings of change.
The questionnaire was used in our initial feasibility study (25),
and was modified to increase face validity and interpretability.
The primary analysis compared pre- and postintervention out-
comes for children with asthma receiving RAP, and those not
receiving RAP. The comparability of the intervention and con-
trol groups at baseline was tested using the Pearson c2 test.
Similar analyses were performed to assess the comparability of
those who dropped out and those who continued in the study.
Pre- and postintervention changes in categorical outcome vari-
ables were assessed using McNemar’s test. Ordinal variables were
assessed using the Wilcoxon’s rank test. The number of children
who improved or worsened was assigned based on the degree of
change calculated from pre- minus postintervention values at
both six and 12 months. Using the Pearson c2 test, differences in
the number of children who improved or worsened were com-
pared between the intervention and control groups. A univari-
ate ANOVA was performed on the ordinal variables (using
pre- minus postintervention ratings) that showed significant dif-
ference from the t test, clustering the intervention and control
group, and the smoking and nonsmoking subjects.
From 34 schools at baseline, 104 children (not including those
who enrolled but did not receive the intervention [n=21]) were
assigned to the intervention group and 162 to the control
group. The mean age was 8.6 years and diagnosis of asthma
occured at a mean age of 3.6 years. Most of the predominantly
Caucasian participants lived in the greater Edmonton area, and
the small cities of Hinton, Edson, Stony Plain, Spruce Grove
and Peace River, Alberta. More than one-half of the partici-
pants were male (RAP 55.6%, control 66.7%). More than one-
third had other medical problems (RAP 32.4%, control 41.8%)
and one-fifth had a cat in the home (RAP 20.4%, control
17.9%). The majority of participants had received some form
of asthma education in the past (RAP 53.4%, control 62.3%).
Two differences were found between the groups at baseline
(Table 1). The RAP group experienced significantly more
smoke in the home than the control group (RAP 41.7%, con-
trol 23%; P<0.05). In addition, at baseline, the percentage of
parents stating that their ‘ability to control their child’s asthma
improved over the past year’ was greater in the control group
(RAP 36.2%, control 51.6%; P<0.05). More than two-thirds of
parents stated that their child’s asthma rarely interferes with
lifestyle (RAP 73.8%, control 64%). Yet, approximately one-
half of the parents stated that their child was limited in the
nature (RAP 48.5%, control 36.6%) and amount (RAP 55.3%,
control 55.9%) of play.
individuals lost to follow-up
The attrition rate was approximately one-quarter (27%) and
did not significantly differ between the two groups (RAP 32%,
n=33; control 22%, n=36; P>0.05) (Figure 1). Two interven-
tion schools (not included in any analysis) did not receive the
Baseline demographics and disease characteristics of
intervention and control (includes dropouts) groups
Age range, years
Live in town or city
Other medical problems
Ever had an allergic reaction
Life-threatening allergic reaction
Past asthma education
Education >2 years previously
Limitation of activity
Impact of asthma
Missed school days in past year
Limited in nature of play
Limited in amount of play
Level of control/severity
Unscheduled doctor visit in the
ED visits in past year
Ever in intensive care unit
Use of medication
Used inhaled short-acting
bronchodilators in past 2 weeks
Used inhaled steroids in past 2 weeks
Used inhaled steroids only
Used short course of oral steroids
in past year
Uses correct medication for
Uses correct medication to prevent
Experienced side effects
Any smoke in home*
Cat(s) in the home
Animals in the home
Have written action plan
Use peak flow meter
*P<0.05. ED Emergency department
McGhan et al
Can Respir J Vol 17 No 2 March/April 201070
intervention within the study time and were dropped from
analysis (n=26). None of the children in the educational
intervention dropped out once it commenced. At the six- and
12-month follow-up, most of the individuals lost to follow-up
were no longer attending the study school or were not able to
be contacted (58%). The remaining individuals chose to dis-
continue or not complete the questionnaire for various reasons
(eg, parent believed the child no longer had asthma or was not
interested). Those who were lost to follow-up were significantly
older than the participants who remained in the study and
appeared to have significantly worse asthma (Table 2), includ-
ing a higher overall symptom score, more frequently affected
by asthma and more limitation in the nature of play. Dropouts
also appeared to have poorer asthma management behaviour,
including correct use of preventive medication and avoidance
of triggers. Their environmental exposures also appear to be
significantly worse, including smoke and cats in the home.
Health care use
The number of unscheduled doctor and emergency visits due to
asthma was reduced in both groups (Table 3). The average
number of doctor visits per year decreased at follow-up but was
only statistically significant in the control group. When exam-
ining the percentage of children whose doctor visits were
reduced, the control group showed a slightly higher improve-
ment but the difference was not significant. The annual aver-
age of emergency department (ED) visits declined significantly
at 12 months in the control group.
Limitation of activity
The intervention group improved in schools days missed due
to asthma, compared with few changes in the control group in
both the annual number of missed school days and per cent of
children who had a decrease in missed school days at six and
12 months (Table 3). Both the intervention and control group
had significant improvements in limitation in nature of play.
However, the intervention group had improvement in limita-
tion of activity by 54% at 12 months follow-up compared with
38% in the control group.
The intervention group had inconsistent improvements in
medication use (Table 3). The frequency of inhaled broncho-
dilator use improved in 50% of the children in the interven-
tion group compared with 31% in the control group at six
months. The number of children using less than three puffs per
day of beta-2 agonist significantly increased at the six- and
12-month intervals for both groups; the intervention group
had a 127% improvement at six months compared with 33%
improvement in the control group. The use of inhaled steroids
in the past two weeks did not improve in the control group
over the two time periods. Many children were using inhaled
corticosteroids only when they were sick. However, this ‘as
needed’ use was reduced by 24% in the intervention group at
six months compared with 7% in the control group, although
this was not sustained at 12 months (RAP group: 51.1% at
baseline to 38.8% at six months, to 53.5% at 12 months; con-
trol group: 68.3% at baseline to 63.8% at six months, to 60.8%
at 12 months).
Asthma management behaviour improved in the RAP group
in several outcome measures (Table 3). Access to action
plans improved by 35% for the RAP group compared with
no improvement in the control group in the first six months.
Surprisingly, after 12 months, the percentage of children with
an action plan in both groups declined. The use of peak flow
meters statistically increased in the RAP group by 28% and by
Demographics, level of control, medication, environment
and management for participants and dropouts
Age, years (mean) 8.5 8.9*
Other medical problems40.1 29.4
Any past asthma education 59.7 56.5
Level of control/severity
Impact of asthma
Missed schools days in the past year, mean 3.44.3
Limited in nature of play 35.9 56.5*
Limited in amount of play 52.863.8
Mean asthma symptom score6.8 8.0*
Unscheduled doctor visit in the past year 58.552.9
Unscheduled doctor visits, mean 1.51.3
Emergency department visits in the past year, mean0.040.04
Cough in past 2 weeks
Mild to moderate49.7 60.3
Marked to severe10.3 4.7*
Wheeze in past 2 weeks
Mild to moderate35.439.7
Marked to severe 4.97.4
Shortness of breath in past 2 weeks
None 57.4 41.2
Mild to moderate37.451.5
Marked to severe 5.17.4*
Use of medication, environment and management
Used short-acting bronchodilators in
past 2 weeks
Used inhaled steroids in past 2 weeks63.5 68.1
Uses correct medication for quick relief 61.261.2
Uses correct medication to prevent symptoms25.313.4*
Experienced side effects36.542.6
Any smoke in home25.144.9*
Hours of smoke exposure/week, mean 16.27 32.8*
Cat(s) in the home 15.329.0*
Have written action plan26.018.8
Use peak flow meter37.6 27.5
Data presented as %, unless indicated otherwise. *P<0.05
Roaring Adventures of Puff improves quality of life
Can Respir J Vol 17 No 2 March/April 201071
36% at the two time periods. Almost 50% improvements in
avoidance of triggers were significantly different from baseline
at both six and 12 months in the RAP group compared with
approximately 25% improvement in the control group. Changes
to the environment were less significant. The RAP group
showed reduced smoking in the home at six months (28%)
compared with 4% in the control group, despite the higher
baseline in the RAP group. Cats or other animals in the home
The intervention group scored significantly better than the
control group for all global rating questions (Table 3). Parents
of children in the RAP group indicated a significant increase in
their understanding of asthma at six months and this improve-
ment was significantly better than in the control group. The
per cent of parents stating that their ability to control their
child’s asthma improved over the past year was significantly
greater than the RAP group and between groups at six months.
This perceived improvement decreased in the control group at
six and 12 months follow-up. In addition, parents of the inter-
vention group stated that their ability to cope improved signifi-
cantly at six months. At 12 months, parents in the control
group exhibited a significant decrease in their perceived ability
to cope with their child’s asthma.
QOL improved in the intervention group in all categories com-
pared with the control group (Table 4). At six months, RAP
had significant improvements in three of the four QOL domains
including symptoms, emotions and overall scores compared
with the control group, which had significant improvement
only in the emotions domain. Improvements from baseline to
12 months were statistically significant for all domains in the
intervention group. The overall QOL score between the two
groups was significantly better in the RAP group at 12 months.
The overall QOL score at six and 12 months and the emotions
score at 12 months for the intervention group (improvement
of 0.5) could be considered clinically significant (1). The con-
trol group also had significant improvements at 12 months in
the emotions and symptoms domain. There was no significant
interaction between RAP and sex on childhood QOL out-
comes. The univariate analysis of the variance for QOL ratings
between the intervention and control group over the three
time points, and controlling for the baseline difference of any
smoking in the home, neared statistical significance only for
the overall QOL domain (P=0.096, n=79).
The RAP group showed an overall improvement in outcome
measures at six and 12 months and significant improvements
from baseline to at least one time period in select variables.
This included any smoke in the home, use of peak flow meters,
improved understanding of asthma, ability to cope and asthma
control, and QOL domains including activity, emotions, symp-
toms and overall. Improvements were significantly greater in
the RAP intervention group from baseline to six months com-
pared with the control group in parent’s perceived understand-
ing and ability to cope with and control asthma, and overall
QOL. Some improvements were seen in both groups, likely due
to differences in the intervention and control groups at base-
line, and participants and those lost at follow-up.
A significant outcome from the present study is the extent
to which RAP improved the child’s perception of their QOL,
including well-being and functional impairment of every-
day life activities. Statistically significant improvement in
symptoms, emotions and overall domain scores were seen at
six months, and all domain scores continued to significantly
increase at 12 months. Clinical significance (a difference of
greater than 0.5 between pre- and postscores ) was seen in
Level of control variables between Roaring Adventures of
Puff (RAP) and control groups at three time points
Health care use
Unscheduled doctor visit
in past year
Unscheduled doctor visits in
past year, n (mean)
Emergency department visits
in past year
Emergency department visits
in past year, n (mean)
Limitation of activity
No missed school in
Missed school days in
past year, n (mean)
Limitation in nature of play*†
Limitation in amount of play
Used inhaled steroidsRAP
Used <3 puffs short-acting
Any smoke in the home RAP
Cat(s) in home
Animals in home
Have written action planRAP
Use peak flow meter
Improved ability to control*‡
Improved ability to cope
Data presented as %, unless indicated otherwise. *P<0.05 (baseline versus
six months); †P<0.05 (baseline versus 12 months); ‡P<0.05 (RAP versus
control at six months)
McGhan et al
Can Respir J Vol 17 No 2 March/April 201072
the overall QOL domain at both time periods for the interven-
High importance is placed on measuring QOL in children
with asthma (28). Some studies have suggested that QOL is
predicted by the child’s level of anxiety (29). School-age chil-
dren are sensitive to the actions and attitudes of their peers, and
children with asthma often feel isolated and different (1). These
beliefs and feelings can impact disease management behaviour
(28). We suggest that participation in RAP with school peers
helped individuals recognize their involvement in the social
group and, in turn, improved their QOL. This repeat exposure
to asthma issues in a group setting allows children to share their
feelings, work through various emotions and build confidence as
they practice managing asthma in various situations.
Indicators of management behaviour significantly improved
in association with the program. This was a key objective of
RAP. Self-efficacy and self-regulation can have a powerful
impact on whether and how a behaviour is expressed (27,28).
Therefore, strategies that were designed to improve behaviour
were used. For example, to help gain confidence in using their
action plan, ‘Puff’, the Asthmasaurus puppet, modelled its use
and a game of charades called ‘lights-camera-action’ reinforced
the key principles. An asthma diary helped them record the
impact of the action plan, and follow-up discussions with peers
praised appropriate behaviours and gave feedback on their
A key limitation of the study was the size difference between
groups, and the differences in dropouts and participants. Those
that did not complete the questionnaires appeared to have
more problems with their asthma and more smoke in the home.
Because our unit of randomization was the school and not the
students, it is possible that selection bias may have occurred.
Another limitation is the higher exposure to smoke in the
home in the intervention group. Studies have suggested that
smokers tend to experience higher stress (30), increased airway
inflammation (31), are less likely to participate in education
programs (12), have poor asthma knowledge and skills (32),
are less likely to seek health care (33) and have worse out-
comes after patient education (34). Future research needs to
explore whether a targeted intervention for children and their
parents who smoke would be efficacious.
The measurement tools that we used may not have been
appropriately targeted or responsive enough to determine the
full impact of the program. Qualitative data may have provided
more information about the perceptions of the child and par-
ent, how the program affected their lives and whether we
measured what was most important to the patient.
The RAP program is an effective way to influence children
with asthma at an early age and in a peer setting. A secondary
goal of the program was to influence the child supports, such as
parents, school staff, clinicians and friends, because these indi-
viduals are important targets in change behaviour. The present
study prompted a pilot study and an initiative that examines
how students with asthma can be better supported in schools.
The RAP implementation guide and training program for
instructors is now available online (26).
RAP attempted to promote communication between parent
and child. We did this by offering a parent session, encouraging
the child to share what they learned, and asked parents to learn
from the child and sign the ‘fun book’ after each session.
Studies have shown that parent reports can significantly differ
from those of the child (35). In a subsequent paper, we identify
discordance between the parent and children ratings of QOL
in this study population (36). This difference between parent
and child ratings was improved after RAP, emphasizing the
importance of collecting data from and educating both the par-
ent and child. Clearly, educators should consider the best strat-
egies to optimize parent/child communication.
Overall, the RAP program had a modest effect on patient out-
comes and generated enormous interest and positive feedback
from children, parents and schools. By reaching not just the
child but the child’s immediate care and support community, we
likely had a broader impact than what we undertook to meas-
ure. Additional understanding of what impact the program had
on creating a supportive environment to help sustain and
reinforce the program objectives would help in making improve-
ments. The foundations developed from our research in a school
setting have helped to strengthen our partnership with schools
in asthma care, including the development of school asthma
guidelines linked with ongoing health care support.
FundinG: Funded by the Alberta Heritage Foundation for
Medical Research – Health Research Fund.
ACknoWLEdGMEntS: The authors thank participating RAP
instructors, health regions, schools, parents, teachers and children
for making this study possible. They thank the Childhood Asthma
Foundation of Canada for supporting this work and the expansion
of RAP to other communities. The authors thank Dr A
Senthilselvan, Public Health Sciences, University of Alberta
(Edmonton, Alberta), for his support in statistical analyses. All
patient/personal identifiers have been removed.
diSCLoSuRE: The authors disclose no financial interests associ-
ated with this study.
Child-rated quality of life scores (on a 7-point scale for the
past two weeks) for Roaring Adventures of Puff (RAP) and
control groups at three time points
Quality of life
Activity levelRAP4.5 4.64.9
Control 5.75.9 5.1
Control 4.85.0 4.9––
*Pre- versus postintervention; †Intervention versus control; ‡Baseline versus
12 months, P<0.05; §Baseline versus six months, P<0.05; ¶Intervention versus
control at 12 months, P<0.05
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Can Respir J Vol 17 No 2 March/April 201073
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