Culturally tailored school-based intervention for asthma in Malaysia (CuT-AsthMa)

Abstract

INTRODUCTION: The World Health Organization launched the Global School Health Initiative in 1995 to improve child and community health through health promotion programmes in schools. The compulsory school years offer an ‘easy entry point’ for embedding healthy behaviours at a young age and, by extension, influencing families. Whilst school-based asthma awareness and training programmes have been reported in high income countries, these are rare in low- and middle-income countries such as Malaysia. In low- and middle-income countries, most successful programmes focus on preventing communicable diseases. Asthma is the commonest non-communicable disease among children potentially requiring urgent treatment during school hours, and thus an important exemplar for school-based programmes.

AIM AND OBJECTIVES: I aimed to develop and test the feasibility of the Culturally Tailored school-based Intervention for Asthma in Malaysia (CuTAsthMa) programme. My PhD work had four objectives; #1. to conduct a systematic review to synthesise the evidence on school-based asthma self-management interventions for primary school children, #2. to explore the views of stakeholders using qualitative studies to inform the development of the CuT-AsthMa programme, #3. to develop the CuT-AsthMa programme using complex intervention frameworks and build on the findings of the systematic review and qualitative studies, and #4. to test the feasibility of implementing the CuT-AsthMa programme and estimate the effectiveness of the intervention to inform a future trial.

METHODS: Guided by the Medical Research Council framework for developing and evaluating complex interventions, my PhD proceeded in four phases corresponding to each of the objectives: #1. I conducted a systematic review using the Consolidated Framework for Implementation Research (CFIR) to narratively synthesise studies on school-based asthma self-management interventions for primary school children. #2. I conducted qualitative studies to explore the views of stakeholders (children with asthma and their parents, school staff, school health team, healthcare professionals and policymakers) to inform the development of the CuT-AsthMa programme. This was conducted in two stages; a. A secondary analysis of my previous qualitative study conducted among children with asthma and their parents. b. A qualitative study conducted among school staff, school health team, healthcare professionals and policymakers. #3. Using findings from previous literature, the systematic review and qualitative studies, I developed the CuT-AsthMa programme guided by Six essential Steps for Quality Intervention Development (6SQuID) and CFIR. #4. I conducted a feasibility study to implement the CuT-AsthMa programme and estimate the effectiveness of the intervention to inform a future trial.

RESULTS: 1) I identified twenty-three studies (four at low risk of bias) that evaluated the effectiveness of school-based asthma self-management interventions among primary school children. The number of CFIR sub-domains addressed varied between studies, but the only component consistently associated with positive outcomes was substantial parental involvement. 2) a) I found that primary school children began to learn to self-manage asthma independently when they started schooling. Parents were the primary decision-makers for their children’s asthma treatment, and their beliefs and self-management practices influenced the self-management practices of their children. This study also identified different patterns of Complementary and Alternative Medicine (CAM) use in asthma and shed light on the relationship between CAM use and adherence to evidence-based medicine. b) There was poor asthma awareness among the school staff, no specific asthma school plan and reliance on a generic school plan for managing medical illnesses at schools, which could delay treatment during asthma symptoms/emergencies. A school asthma programme could deliver asthma education and introduce an asthma school plan, including first aid management. This study highlighted the importance of tailored approaches, a good partnership with schools, and early engagement with the wider community to develop a school asthma programme. 3) Guided by the 6SQuID and CFIR, I developed the CuT-AsthMa programme, a multi-level school-based intervention using the socioecological theory that aimed to improve asthma control of primary school children in Malaysia. 4) The COVID-19 pandemic had restricted the implementation of the CuTAsthMa programme, and I could not deliver the whole programme as planned. However, I tested four out of five components of the programme and found it was feasible to conduct the components including remote sessions for children with asthma and their parents. I did not assess the programme's effectiveness due to time limitations, and it was not implemented as planned. A virtual stakeholder meeting was conducted to disseminate the PhD findings and obtain input to further refine the programme.

CONCLUSIONS: The CuT-AsthMa programme is a multi-level school-based intervention developed based on previous literature, the systematic review and qualitative studies from the perspectives of different stakeholders to improve asthma control of primary school children in Malaysia. It was feasible to conduct most of the core components of the programme despite restrictions posed by the pandemic. The CuT-AsthMa programme has the potential to improve asthma control in primary school children in Malaysia, although further evaluation is needed.