Background

 Millions of Americans and 3.5 to 5 million children suffer from asthma, (Fanta, Cristiana, Haver and Waring, 2003) worldwide as many as 300 million people have asthma (Silverstein, 2006).  Asthma, also known as twitchy airways disease often times descried as I can’t breath has stifled the lives of million.  Many celebrities suffer also from this disease and upon diagnosis; they thought the same way others do, as though they had to give up their dreams.  It is well known that Jerome Bettis (The Bus) for the Pittsburg Steelers was diagnosed with asthma as a child.  The initial feelings The Bus felt, when he heard the news was “That’s the end of it all, I can’t play anymore”.  But his parents did not want him to give up his dreams.  “Hey you can do whatever you want to do as long as you just manage it,” his parents told him.  For the Bettis family this diagnosis was not an unfamiliar one of their other children had already been diagnosed (Silverstein, 2006).

Many people with asthma have similar feelings.  Daniel age 6 states “I can’t swim across the pool underwater, and it took me three tries to blow out all of my birthday candles”.  Margaret age 60, states “It feels like someone has their hands around your lungs and it squeezing them tightly any you are trying to break the grip.  You can’t breathe, and you can’t get away from that fierce set of hands around your lungs” (Fanta et al, 2003). The young and the old are strickened by this disease and all have similar initial feelings.

As time went on, Jerome Bettis became complacent with his asthma after high school thinking that he had it under control.  He had to learn the hard way that asthma does not go away, even when you are symptom-free.  In 1997 Bettis had an asthma attack during a televised game between the Steelers and the Jaguars.  Struggling for air he made it to the sidelines where he informed the doctors what was happening (Silverstein, 2006).

This is a common wake up call for so many asthmatics.  This is when most people become serious about the disease because it interrupts daily life function.  For Jerome Bettis he now pays close attention to his asthma and avoids triggers.  Everyone has a different trigger and symptoms of asthma.  Each medication plan or asthma action plan is tailored for that specific patient.  Olympic Gold Medalist Jackie Joyner-Kersee states “If asthma is managed carefully you can still succeed in sports” (Silverstien, 2006).  Other notable people who have been known to have asthma are JFK, Theodore Roosevelt, Dennis Rodman, Beethoven, Emmitt Smith, Winona Judd, and one of President Obama’s daughters, just to mention a few. For Jerome Bettis, Jackie Joyner-Kersee and Amy Van Dyken, an Olympic swimmer, they have all joined a national campaign called Asthma All-Stars to educate the public about Asthma, especially kids (Silverstein, 2006).

The experience of Asthma varies greatly among people who have asthma, mainly because of its variable severity.  For some people it is a minor annoyance, a tickle of a cough felt high in the throat after exercises.  For others it is the cause of restless nights with frequent awakenings due to cough and labored breathing.  For still others Asthma manifest as severe attacks, characterized by a suffocating sensation and the sense that the next breath may be the last.  Some people with asthma are Olympic athletes, able to compete at the highest level of physical strength and endurance.  Others find themselves frequently in and out of the local emergency room, unable to plan routine daily activities because of unpredictable episodes of difficult breathing (Fanta et al. 2003).

Asthma is a lung condition that causes swelling in a person’s airway.  Narrowing of the bronchial tube of your lungs leads to the symptoms of asthma (Fanta et al. 2003).  The symptoms are difficulty breathing, wheezing and coughing.  People have difficulty with breathing because of the narrowed passages in the lungs.  This is what makes the lungs wheezing.  The coughing is due to irritation of nerves in the walls of the breathing tubes and the body trying to expel excessive secretions (Fanta et al. 2003).

Asthma is often times triggered by an allergen.  Common allergic triggers are dust mites, cockroach, debris, cat and dog dander, bird feathers, seasonal pollens and mold.  Unique triggers of asthma are aspirin, sulfites and menstrual periods.  Non allergic asthmatic triggers that are common are:  exercise, particularly in cold air and viral respiratory tract infections, irritants such as, air pollution, tobacco smoke, other forms of smoke and strong fumes. Certain medications such as beta blockers and emotional stress can also be considered a common non allergic trigger (Fanta et al. 2003).

Problem

Do asthmatic children find their disease debilitation in that it hinders them from enjoying life and all that it has to offer?  This research is designed to compare the quality of life of an asthmatic child versus non asthmatic children.

Purpose Statement

The purpose of the research was to show asthmatic that if their disease is well managed it does not have to limit their activities, they to can have and achieve uninhibited goals.  This research will show the lives of diagnosed asthmatic and how they have learned to cope and excel with the disease.

Significance

Growing up, “Theodore ‘Teddie’ Roosevelt” as his family called was in and out of the hospital because of his severe asthma episodes. He was often bedridden with a chronic cough.  He could not even go to school regularly.  He had to be schooled at home, where he learned to love reading and writing.

During Roosevelt time (in the 1800s), asthma was not fully understood.  There was no medication that relieved the symptoms often times the doctors prescribed vacations on the coast and coffee.  Coffee was believed to contain chemicals that opened up breathing passages.  Every thing was tried but nothing worked, Teddie’s parents spent hours at his bedside reading to him, trying to help him through his asthma attacks. At age 12 Teddie’s fathers told him that he needed a strong body as well as strong mind to develop fully.  As he began to work out he had fewer attacks that were much less severe than before.  Although he could not eliminate his asthma, Roosevelt made it so manageable that he was able to live an active productive life (Silverstein, 2006). This study is important because newly diagnosed children need to know how to handle this somewhat debilitating disease.  The research is important to the asthmatic, their parents and family.  It is also of importance to school official, that have asthmatic children in their care daily, and to the Federal Government whom is strapped with the cost of treating those underprivileged children that suffer from the disease.

The goals of this research are that people will learn the difference in the way an asthmatic child goes about their day and lives their life.  In a hope to obtain funds to educate this population of people all around the world.  Every day asthma free people go about their lives and do not even stop to think about how their thoughtlessness can be affecting the way others live.  For example, car emmitants cause the air pollutants that have been know to cause million to have asthma attack.  It has been proven that we can significantly reduce pollutants that are, emitted by cars if we were to switch to electrically powered vehicles. This research can lead to the initiation of a fight against asthma pollutants and triggers that are man made.  We all have to look at our daily lives and see how we can reduce the effects of asthma.  This could be as simple as chalk free classrooms or teacher being aware that perfume is also an air pollutant.  This could also be an initiative, a way for local regulatory bodies, to reduce air pollution in their city within the United States. Similar measures are being taken in other countries of the world.  But a lot remains to be done.  Environmental Defense, a non-profit organization has proposed three steps for pollution solutions (Silverstein, 2006).  These three steps are; clean smokestacks, clean tailpipes and reduce exposure to traffic pollution, which is a huge step in the right direction.  In 2004, for example, FedEx put sixteen new diesel-electric delivery trucks into service in 3 U.S. states.  These new trucks produce 90 percent less emissions, and they are cheaper to run (Silverstein, 2006).

The role of an asthma educator is to go out and teach, treat and educate the community on the disease of asthma.  If the knowledge is not spread to those that need it the number of hospitalization will continue at a steady pace.  This affect of asthmas are missed school and work days and an uncontrollable Medicare budget.  Each year the federal government spends billions on the treatment of asthma each year.
Research Question

Many people worldwide suffer from a debilitating disease called asthma.  Are those non asthmatics of the world contributing to the disease and reducing the quality of life of those with asthma?  What can be done so that there is a significant decrease in the exacerbation of asthma?  Can those of us asthma free help in this initiative by becoming educated in Asthma triggers and reducing man-made pollutants? What is the difference in the quality of life of an asthmatic versus that of a non-asthmatic child?

Assumption

The quality of life for asthmatic children varies depends on medication and compliancy.  The reason for non-compliance are multiple and complex and not always clearly understood.  It is difficult to improve compliance overall and despite extensive research and efforts, rates of compliance remain low.  Noncompliance in asthma management is a fact of life and no single compliance – improving strategy probably will be as effective as a good physician-patient relationship (Karser, 2007).    Non compliance of asthma can range from intentional to unintentional, some patient and family have anxiety about side-effects, especially in relationship to corticosteroids.  Medications do not produce instant relief of symptoms.  Teenagers resent the awkwardness of spacers and often are in denial about the disease. Other factors that affect the quality of life are: forgetfulness, laziness and carelessness in adolescence.  Frequency of medication delivery and cost is another factor of non compliance.  There are different ways to monitor compliance, but none are fully effective.  You can monitor prescriptions, count tablets measure levels of medications in the blood or urine, and measure metered dose inhalers canister weight.  The consequences of these include increased symptoms and asthma exacerbations, both of which can lead to increased morbidity (Spector, 2000).  In Maryland alone 91 people in 2004 died from asthma, while 3,617,094 are affected by the disease.  Although education is needed on all aspects of the disease, one common hindrance that persists is how to reach the underprivileged minority population.

Limitations

There are many misconceptions about asthma medication which lead to medication non-compliance.  Most patients are in metropolitan communities which are busting with allergens and triggers.  The population comprised of African-Americans, Asians, Russians, Indians and others, many of which have little or no health insurance.  The inner city is laden with air pollution, rodents and insect infestation, and many abandoned derelict building.  Reaching this clientele has been a challenge for the community in search of solutions to this disease.

The populations of asthmatics are hard to contact and this causes a limitation in research.  The majority of people that have been studied have been clinic patients and those entering the emergency rooms across the United States.

Allergens and Pollutants

Exposure to indoor allergens and irritants play an important role in triggering asthma attacks.  Indoor air quality also plays an important role in controlling the frequency and severity of asthma attacks among children.  Researchers have com to the conclusion that careful management of indoor air quality would lead to less frequent attack. Air quality consist of outdoors and indoors pollutants.  In the book, “My House is Killing Me,” Mr. May, author, explores the home and how to clean it up to prevent it form making you ill.  Items and sources of indoor pollutants that can trigger ongoing problems for asthmatics are: Radiators and baseboards, down feathers in couches and comforters and wood burning fireplaces to name a few.

Radiators and base board’s convectors can be a source of allergens and irritants, particularly if they have never been cleaned or if previous owners had mold or mite problems or kept pets.  A couch made with down material offered a soft, comfortable retreat but unfortunately down is extremely high level of dust mites, allergens.  Dust mites love down, and the skill scales and moisture from the body supplies “Mite feed.”  (May, 2001)

Soot from wood burning fireplaces deposit on surfaces and stick.  Soot is not just a cosmetic concern.  People who have allergies or asthma may find that inhaling soot (along with other combustion products) is irritating.  Soot also contains carcinogens (such as benzo[a]pyrene), so long term exposure should be avoided. (May, 2008)

            The role of stress in viral infections has been the focus of research involving both adults and children.  Well controlled, prospective, and experimental studies have shown that adverse life events and other stresses significantly increase a person’s susceptibility to acute and recurring upper respiratory tract infections (Heisel, Reams, Raitz, Rapport, Coddington, 1973).

            Asthma and mental health conditions often coexist and studies support a link between the two disorders, indeed, an increase in the incidence of depression and anxiety has been reported in children with asthma compared to those without asthma.  Direction of causality in the relationship is unclear. Parental stress appears to be an important factor important in the development of infant wheezing.  There is support for a working hypothesis, linking inner-city violence and the development of childhood asthma via pathways that include parental mental health conditions, parental nicotine addiction, environmental tobacco smoke, and TH2 skewing in infants.  It is anticipated that a better understanding of the above relationship will lead to the development of new targeted treatment strategies for childhood asthma in the future (Gentile, 2008).

Asthma Education

            Studies have been done on educating persons with asthma and those that care for the asthmatic.  The group entitled, those that care for the asthmatic, has a broad range.  This would include parents, daycare providers, grandparents, school teachers and coaches.  Community based education is a start, free seminars could be held to help improve the education levels.  Vital information could be obtained from these seminars, and the clientele could be polled to get statistics on what they know and whether or not they have even been affected by the disease.

            The 4-point Likert-scale questions assess the respondent’s level of comfort with and ability to identify a child who needs medical attention for asthma, familiarity with the components of an asthma control plans, likelihood of having an asthmatic child in the childcare facility, and care for a child with asthma (Saville, 2008). Education on any subject just makes it easier to handle a situation if it should arise.  Increase knowledge for all involved could decrease severity of attack.

What is Asthma Education?

            Asthma education is designed to be patient-specific, portable, and useful in almost any situation, and presented at a level of sophistication beyond initial assessment, diagnosis and treatment.  Specifics are given on long term and short term medications, and explicit directions are given as to when and how the patient should use them.  The person with asthma should continuously monitor it with a peak flow meter and asthma diary, and take their medications as prescribed, with the goal of good asthma control.  (Masini, 2008)

 A study found that poor patient-clinician communication was a primary factor associated with adherence problems with inhaled steroids therapy among adults asthmatics particularly those who were poorly educated and had lower socioeconomic status (SES) (Apter, Resine, Barrows, & ZuWallack, 1998).

            Parents and physicians need to change your ways to thinking.  A study showed problems in parent-physician relationship among parents of children with severe asthma and their pediatricians found that both pediatricians and parents were dissatisfied.  Pediatricians complained that parent’s ways of thinking about asthma management differed from those that they were trying to communicate and that this typically resulted in non adherence with their recommendations.  Parents on the other hand, reported problems and negative relationship with their pediatrician, even though pediatricians perceived no problems with how they believed parents felt about them (Cohen & Wamboldt, 2000).

Clean Yourself

            Some of my clients with serious allergies report having symptoms when they are near certain people.  People who have pets, for example, carry dander on their clothing and in the hair.  The author talked about in previous chapter yeast that causes eczema and dandruff as well as asthma symptoms.  Good old fashion soap has biocidal properties, and the longer you keep soap on your body, the more effective it is killing bacteria and yeast.

            While we’re on the subject, hair collects allergens and can be a source of irritants long after exposure.  For example, on most typical non winter days, mold spurs and pollen grains are in the air.  If you go outside your hair will accumulate these particles, and when you disturb hair allergens can become airborne.  If you are particularly sensitive, your allergy symptoms may increase.  When you put your head on a pillow, your hair is around your face.  It’s a good idea to shampoo your hair after you’ve spent time outside in the pollen or mold season (fallen leaves can be moldy), or after you’ve been in moldy spaces or spent time with pets.  Don’t go to bed with wet hair, because mold may grow in a damp pillow.  If you don’t like washing your hair so often, wear a hat when you are near irritants (May, 2001).

Clean Your House

            How often should you vacuum?  Mr. May recommends cleaning floors and stuffed furniture with a HEPA vacuum at least once a week.  If you have a regular vacuum cleaner and you are very allergic to dust, wear an N95 N10SH mask and air the house out after vacuuming.  (May 2001). Chemical and cleaning products are pollution that triggers asthma.  May suggest limit your use of products that have fragrances.  If you are chemically sensitive, don’t live down wind form a commercial laundry or dry cleaning establishment.  Check labels on cleaning products to avoid mixing chemicals that may react adversely with one another.  Never mix ammonia with bleach, store pool chemicals safely, preferably not in the house.  Limit the use of pesticides indoors (May, 2001).

Myths, Misconceptions Compliance and Noncompliancy

Compliancy issues are a major factor in asthma management.  The objective of the study was to describe belief about asthmas and asthma treating in a Hispanic (Dominican-American) community to determine how alternative belief systems affect compliance with medical regimen.  The method used was twenty-five mothers of children with asthma were interviewed in their homes, in their primary language, Spanish.  Mothers were questioned about their beliefs regarding asthma etiology, treatment, prevention of acute episodes, and sue of prescribed medications.  The results showed most mothers (72%) said that they did not use prescribed medicines for the prevention of asthma:  instead, they substituted folk remedies called “ZUMOS.”  The home remedies were derived from the folk belief about health and illness.  Most mothers (60%) thought that their child did not have asthma in the absence of an acute experience.  Eight-eight percent said that medications are over used in this country and that physicians hide therapeutic information from them.  In conclusion mothers’ reliance on home remedies for asthma prevention leads to a high rate of noncom pliancy with the prescribed regulations.  Yet they perceived themselves as compliant with an effective regimen that suffers from standard medical practice.  Further studies should explore ways of promoting physician/patient communication in order to find ways of coordinating medical folk belief to enhance compliance with medical prescribed regimens.

Fear factors include: Fear of dependency on the medication and suspicion of physician’s failure to disclose medication side effects (Berison et al, 2002).

Factors that improve compliance: Once or twice daily regimen, open and honest reporting of compliance, discussion of agreed treatment plan, a written treatment plan, one to one professional relationship with doctor or nurse, patient education, leaflet and videos (Dinwiddle, 2002).

Asthma Facts and Figures

Everyday in America:

·         40,000 people miss school or work due to asthma

·         30,000 people have an asthma attack

·         5,000 people visit the Emergency Room due to asthma

·         1,000 people are admitted to the hospital due to asthma

·         11 people die from asthma

·         Asthma is slightly more prevalent among African Americans than Caucasians

·         Asthma is the most chronic condition among children

·         Asthma causes more hospitalizations than any other childhood disease. It is estimated that children with asthma spend nearly 8 million days per year restricted to bed.  (Unknown Author, 2009).

The Things Non-Asthmatics Take For Granted

            A respiratory illness, such as a cold or flu, can trigger an asthma attack. Cold weather, stress and crying or laughing can set off an attack. Exercise is a common trigger for people with asthma. When people exercise, their muscles use up extra oxygen.  So their lungs work harder, breathing faster and taking in more air.  During exercise, the nose does not have enough time to warm up the air before it goes to the lungs.  The air may be cold and dry when it gets to the lungs.  The cold air entering the airways may make them suddenly get narrow.  As dry air passes through them, the airways lose the moist mucus that normally protects them.  Since people with asthma have very sensitive airways, cold, dry air is more likely o bring on an attack (Silverstein, 2002).

Smoking and Asthmatics

            Everyone knows that smoking cigarettes is bad for you.  When you breathe in cigarette smoke, the harmful chemicals in it – such as carbon monoxide – go right into your lungs.  Carbon monoxide is very dangerous because it keeps the blood from bringing oxygen to the brain, heart, lungs, and other important organs in the body. Cigarettes smoke also damages the cilia in the lining of the airways.  Eventually, they are unable to sweep mucus and foreign particles out of the lungs.  They can cause some serious illnesses, such as bronchitis, emphysema or lung cancer.  If these things can happen to a person with healthy lungs, can you image what smoking can do to someone with asthma?

            Studies have shown that smoking is not only bad for the smoker.  It is also harmful to anybody who is around that person.  Second hand smoke – the smoke that people around a smoker breathe – can be very dangerous for someone with asthma.  Smokers who have children with asthma should never smoke around their children.

Even smoking in the same house can leave harmful chemicals that can linger for hours (Franklin, 2002).  Experimentation with smoking usually starts in adolescence, and smoking during adolescence is a strong predictor of regular smoking in adulthood (Pierce & Gilpin, 1996).  Therefore preventing the onset of smoking among adolescents with asthma is an adequate way to reduce regular smoking in adulthood and reducing the health risks for people with asthma.  Several studies have shown that the prevalence rate of smoking among adolescents with asthma are similar or even higher than among their non-asthmatic peers(Forero, Bauman, Young, Booth,& Nutbeam, 1996; Ferero, Bauman, Young& Larkin, 1992; Precht, Keiding, Madsen, 2003; Zbikowski, Klesges, Robinson, Alfano, 2002).

What Happens When Parents go to Work?

            Childcare workers may play an important role in promoting improved air quality in their facilities and communicating asthma control strategies to parents and families.  (Saville et al, 2008).  Parents should question a facility/healthcare provider on their knowledge and skill level of asthma.

            Mr. May, of My House is Killing Me, believes a large portion of the increase in asthma can be attributed to our sedentary lifestyles.  Years ago children and parents in the country spent much more time outdoors.  Now family time is mostly dedicated to more passive pursuits such as playing video games, surfing the Internet or watching TV.  The longer we spend sitting on cushions or lying on mattresses and couches, the more favorable are the conditions for mite infestations (May, 2001). 

            In most cases, a tendency to develop asthma is inherited. 

Research Design

          The research design chosen for this prospectus were interview questions and peak flow meter diary documentation.  Participants would be questioned separately so that an honest description could be given without possible future damage to the family unit.  Participants’ selection would be done by convenience sampling. The participants are acquaintances that where comfortable with answering question about their family and their child’s disease.

Research Question

A single research question guides this research: What is the difference in the quality of life of an asthmatic versus that of a non-asthmatic child?

Procedure

The questions for the parents are:

1.      How does the asthma attack affect your family?

2.      How did you feel upon initial diagnosis of the disease?

3.      What would you like to see happen in regards to your child’s asthma?

4.      Do you allow your child to play sport or other outdoor activities?

5.      What is your child predicted peak flow?

6.      What is the normal range that they blow on a good day?

The questions for the asthmatic are:

1.    What is your predicted peak flow?

2.    What is your average good day rage on your peak flow?

3.    How do you feel about your asthma?

4.    When you have an asthma attack what does it feel like?

5.    Do you play sports?

6.    How often do you use your inhaler?

7.    What medications do you take?

8.    Do you have any allergies?

9.    What do your friends say or think when you use your inhaler?

10. Is your asthma a problem that prevents you from doing certain things?

Data Collection

1.    Peak flow meter

2.    Observation of technique  

3.    Interview questions

4.    Recording device

5.    Shannon Coles Researcher collecting instrument.

Data Analysis

The priori coding was used in decoding data. A preliminary test would observe proper technique of the peak flow meter. A follow up test would follow after the participant was given proper instruction on the usage and proper body and device positioning along with lip placement and the force in which to expire.  The latter results would be used in data collection.

Normal Predicted Average Peak Expiratory Flow for Children
(in liters/minute)

Normal Predicted Average Peak Expiratory Flow (Post-pubertal)

(Steele, 2009).

Appendix

Permission Slip/Insurance Form

East Tennessee State University

Contact person: Shannon Coles

REFERENCE PAGE

Apter, A. J., Resine, S.T., Barrows, E., Zuwaller, R. L. (1998).  Adherence with twice daily dosing of inhaled steroids:  Socioeconomic and health-belief differences.  American Journal of Respiratory Critical Care Medicine, 157, 18010-1817.

Bearison, David J., Minian, N., & Granowetter, L., (2002).    Medical Management of Asthma and Folk medicine in a Hispanic Community. Society of Pediatric Psychology; Journal of Pediatric Psychology Volume 27 (4) 385-392.

Cohen, S. Y. and Wamboldt, F. J. (2000).  The parent-physician relationship in pediatric asthma care.  Journal of Pediatric Psychology, 25, 69-77.

Dinwiddle, R., & Muller, W. (2002). The journal of the royal Society of Medicine. The Royal Society of Medicine, 95(2) 68-71.

Fanta, Christopher H., Cristiano, Lynda M., Haver, Kenan & Waring, Nancy (2003). The Harvard Medical School guide to taking control of asthma a compressive prevention and treatment for you and your family. New York: Free Press p 3-6.

Foreero,R.,  Bauman,A., Young, l., Booth, M., & Nutbeam,D., (1996); Forero,R., Bauman, A., Young, L., & Larkin, P.,  (1992); Precht, D.H., Keiding, L., & Madsen, M., (2003); Tercyah, (2003); Zbilcowski; Kiesges, Robinson, and Alfano, (2002).  Pierce, J. P. and Gilpin, E. (1996).  How long will today’s new adolescent smoker be addicted to cigarettes?  American Journal of Public Health 86(2), 253-256.

Forero, R. , Bauman, A.,  Young, L., Larkin, P. (1992).  Asthma, health behaviors, social adjustments, and psychosomatic symptoms in adolescence.  Journal of Asthma, 33(3), 157-164.

Forero, R. Bauman, A., Young, L. Booth, M. Nutbeam, D. (1996).  Asthma, health behaviors, social adjustments, and psychosomatic symptoms in adolescence.  Journal of Asthma, 33(30), 157-164.

Forero, R., Bauman, A., Young, L., and Larkin, P., (1992). Asthma Prevalence and Management in Australian adolescents:  Results from three community surveys.  Journal of Adolescent Health, 13(8), 707-712.

Gentile, D. (2008).  Links Between Childhood Asthma and Mental Health Conditions. Journal of Asthma, Vol. 4 (Supplement S1): 37-40.

Heisal, J. S., Reams, S., Raitz, R., Rapport, M. Coddington, R. D., (1973). The Significance of Life Events as Contributing factors in the Disease of Children Behavioral Pediatrics; 83:119-23:

Karser, Harold B (2007). Compliance and noncompliance in asthma. Allergy and Asthma, 28, 514-516.

Levert, S., (1993). Teens Face to Face with Chronic Illness.  New York, NY.

Masini, D. E., Krishndewamy, G. (2008). The Challenge of Improving the Healthcare Literacy of the Asthma Community. Respiratory Care Irving TX Volume 53 (12) 1665.

May, J. C. (2001). My House Is Killing Me.  The John Hopkins University Press Baltimore, Maryland. P30-192.

Precht, D. H., Keiding, L., & Madsen, M. (2003).  Smoking patterns among adolescents when asthma attending upper secondary schools:  A Community –based study. Pediatrics, 111 (5pt1) e 562-568.

Saville, S., Wetta-Hall, R., Hawley, S., Molgaard, C., Romain, T., and Hart, T. (2008). As Assessment of a Pilot Asthma Education Program for Childcare Workers in a High-Prevalence County.  Respiratory Care, Volume 53, (12) 1691-2.  

Sestilli, D., & Ryan, K. (2009). Optimizing patient education to control Asthma exacerbation. The American Association for Respiratory Care: Albert Einstien Medical Center in Philadelphia, Pa 32(2) 8-10.

Silverstien, Alvin and Virginia, Nunn, Laura Silverstien (2006). The Asthma Update pp 11-30, 96-98.

Spector, S. (2000). Noncompliance with asthma therapy- are there solutions? California Allergy andAsthma Medical Group Inc, The Journal of Asthma, 37(5), 381-388.

Steele, R. (2009).  Asthma: Normal peak flow meter readings copyright 2000-2009 Ivillage Inc. Ivillage Total Health Network.http://parenting.ivillage.com/tweens/twhealth/0,,3qk5,00.html data retrieved 3/24/09.

Tercyak, K. P. (2003).  Psychological Risk Factors for Tobacco use among adolescents with asthma.  Journal of Pediatrics Psychology, 28(7), 495-504.

Unknown Author, (2009) Asthma Facts and FiguresAsthma and Allergy Foundation of America – Information about Asthma. Allergies, Food Allergies, Asthma:  A Concern for Minority Population NCHS, vs. CDC 2002 within http://www.aafa.org/display.cfm?id=8

Watts, . (2002). My Health Series; A division of Scholastic Inc. p25 

Zbilcowski; Kiesges, Robinson, and Alfano, (2002).  Pierce, J. P. and Gilpin, E. (1996).  How long will today’s new adolescent smoker be addicted to cigarettes?  American Journal of Public Health 86(2), 253-256.

Zibkowski, S. M., Klesges, R. C, Robinson, L. A., and Alfoino, C. M. (2002) Risk factors for smoking among adolescents with Asthma.  Journal of Adolescent Health, 30 (suppl. 4) 279-287.