Archives ofDisease in Childhood 1995; 73: 321-326

Asthma knowledge, attitudes, and quality of life inadolescents

P G Gibson, R L Henry, G V Vimpani, J Halliday

AbstractAdolescents with asthma, their peers, andtheir teachers were studied in order toestablish the level of knowledge concern-ing asthma and its management, theirattitudes towards asthma, and the degreequality oflife impairment due to asthia. Acommunity survey was conducted amongyear 8 high school students (n=4161) andtheir teachers (n=1104). There was a goodresponse rate to the questionnaires fromstudents (93%) and teachers (61%).Twenty three per cent of students had

asthma and this caused mild to moderatequality of life impairment, particularlywith strenuous exercise. Asthma wasprovoked by passive smoke exposure in30% of asthmatic students and up to 51%of students avoided situations because ofasthma triggers.Asthma knowledge was low in teachers

(mean score 14*90 out of a possible 31),students without asthma (11.25) andstudents with asthma (14.50). Specificknowledge on the prevention and treat-ment ofexercise induced asthma was poor.There was a moderate degree of tolerancetowards asthma among all three groups.Most considered internal locus of controlas important, although students withoutasthma also considered chance to be adeterminant of outcomes for people withasthma.Asthma is a common cause of quality of

life impairment among year 8 high schoolstudents. Although specific knowledge onasthma is low, students and teachers holdfavourable attitudes towards asthma.There are opportunities to intervene andimprove asthma management amongadolescents.(Arch Dis Child 1995; 73: 321-326)

Keywords: asthma, quality of life.

Department ofRespiratory Medicine,John Hunter Hospital,and Discipline ofPaediatrics, Faculty ofMedicine and HealthSciences, University ofNewcastle, AustraliaP G GibsonR L HenryG V VimpaniJ Halliday

Correspondence and reprintrequests to: Dr P Gibson,Respiratory Medicine Unit,John Hunter Hospital,Locked Bag 1, HunterRegion Mail Centre, NSW2310, Australia.Accepted 16 May 1995

Asthma is an important cause of morbidity andmortality among adolescents. It is one of themost common chronic illnesses in this agegroupl1 and a leading cause of school absence.5Some of the problems of asthma in adolescenceare common to other age groups, such as under-recognition,4 6 undertreatment,7 and non-com-pliance with therapeutic regimens.8 There are,however, specific issues relevant to asthma inadolescence. Adolescence is a period of transi-tion from childhood to adulthood, whereimportant psychological and physical changesoccur. Peers assume greater influence, andthere can be a denial of chronic illness and its

treatment.9 These issues pose particularproblems for the management of asthma duringadolescence.Asthma is now considered a chronic inflam-

matory condition of the airways and treatmentapproaches have changed.1I Many people withasthma require ongoing treatment to suppressinflammation, either on a daily basis, or forbrief periods during asthma exacerbations.The ability of adolescents to comply with thismanagement approach may be limited. Theymay reject the need for ongoing treatment,have difficulty in using existing health carefacilities,I1 or engage in risk taking behaviourssuch as smoking.'2

Although there is general acceptance of thepotential for difficulties with asthma manage-ment during adolescence, there is little specificinformation on why this occurs. Knowledge,attitudes, and beliefs are recognised as beingmajor determinants of health behaviour,including compliance.'3 Prior work hasdemonstrated a relationship between negativeattitudes and morbidity in asthma.'4 Sincepeers and teachers exert important influencesduring adolescence,'5 the knowledge andattitudes of these groups could be expected toinfluence adolescents with asthma.

In this study, we sought to establish the levelof knowledge concerning asthma and itsmanagement among adolescents with asthma,their peers, and their teachers. We alsoassessed the attitudes of these three groupstowards asthma and examined the impactwhich asthma had on the quality of life ofadolescents with asthma. The large sample sizehas allowed a comprehensive assessment ofthese issues in our community.

MethodsThe study was conduced in 32 of the 33 depart-mental, Catholic, and independent secondaryschools in the Greater Newcastle area of NewSouth Wales, Australia. Students in year 8(n=4161) were requested to complete selfadministered asthma questionnaires duringschool time. A research assistant delivered thequestionnaires to the school and teachers dis-tributed the questionnaires to students whocompleted them during a 30-45 minute class.The questionnaires were collected by teachers,retrieved by the research assistant, checkedagainst the class roll, and checked for complete-ness. Missing or incomplete questionnaires wereredistributed on one other occasion. Studentscompleted an asthma knowledge questionnaire,attitudes questionnaire, and asthma symptomsquestionnaire. Students with current asthmaalso completed a quality of life questionnaire.

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Table 1 Characteristics of 958 students with currentasthma

No (%o) of students

School absence due to asthma 756 (78)Days missed 5 (1-99)*Asthma attacks at school 416 (43)Current smoking 206 (22)Medication (ever used)

Bronchodilator 727 (76)Sodium cromoglycate 192 (20)Inhaled corticosteroid 401 (42)Ingested corticosteroid 90 (9)

*Days missed is mean (range).

The asthma knowledge and attitudesquestionnaires were also given to the schoolsecretary for distribution to the teachers(n= 1815) at each of the participatingsecondary schools. Teachers were asked tocomplete the questionnaires in their own timeand return them without personal identifica-tion to the school secretary. The researchassistant then collected the questionnaires.Reminders were given to teachers to improvecompletion rates.The study was approved by the ethics com-

mittee of the Hunter Area Health Service,the Hunter Region Department of SchoolsEducation, and the Catholic EducationDepartment.

MEASUREMENTSAsthma knowledge questionnaireThe 31 item self administered Newcastleasthma knowledge questionnaire was used toassess knowledge of asthma, its symptoms,triggers, and treatments.'6 Response optionswere presented as true/false/unsure (25 ques-tions) or brief narratives (six questions). Thequestions were scored as previously and addedto give a score out of 31.

Asthma attitudes questionnaireA 15 item self administered questionnaireassessed attitudes to asthma in four domains(appendix). The domains assessed were toler-ance towards asthmatics (eight questions), andlocus of control which was based on internalcontrol (two questions), powerful others (threequestions), and chance (two questions). Locusof control is a concept of representing thedegree to which a person feels able to controlevents and circumstances in their life.'7 Theinternal locus of control domain assesses thedegree to which a person believes that theirown decisions and actions influence their ill-ness (asthma) and its effects. Students withstrong internal locus of control are more likelyto comply with a medical regimen.18 The'powerful others' domain assesses the degreeto which an individual believes that their scopefor action concerning asthma and its manage-ment is under the control of important externalpeople such as a doctor or teacher. Peopleresponding strongly in the chance domain con-sidered that asthma and its effects were largelya result of chance. Responses were presentedas six point Likert scales, ranging from'strongly agree' (scored as 6), to 'strongly dis-

agree' (scored as 1). Higher scores representedstronger attitudes in the domains assessed.

Asthma symptoms questionnaireSubjects completed an 18 item questionnaireconcerning their personal history of asthmasymptoms, use of asthma treatments, andschool absenteeism due to asthma. Based uponthis questionnaire, current asthma was definedas the combination of a prior doctor's diag-nosis of asthma together with either one ormore attacks of asthma in the past 12 monthsor the use of asthma medication for asthma inthe past 12 months.

Asthma quality of life questionnaireStudents with current asthma completed a 30item self administered asthma quality of lifequestionnaire.'9 Responses were presented asseven point Likert scales describing the degreeof limitation experienced in the past two weeksand rated from none at all (scored as 7) tototally limited by asthma (scored as 1). Theitems were grouped into four domains asfollows: asthma symptoms (12 questions),activities limited by asthma (nine questions),environmental triggers (four questions), andemotions (five questions). The results for eachdomain were summarised as a mean score,ranging from 1 to 7. Overall quality of lifewas summarised as the mean score for the 30items in the questionnaire. An additional itemwas included to assess the effect of personalsmoking on asthma symptoms.

ANALYSISCategorical data were summarised as percent-ages and compared using the x2 statistic. Datafrom the knowledge, attitudes, and quality oflife questionnaires were compared using oneway analysis of variance. Associations betweenvariables were examined using Pearsonsproduct moment correlation coefficient. Sig-nificance was accepted at the p<005 level.

ResultsThirty two of the 33 schools agreed to partici-pate in the study. Completed questionnaireswere returned by 4161/4475 (93%) of theyear 8 students and 1104/1815 (61%) of theteachers. The prevalence of current asthmawas 23% (n=958). Most (756) of thesechildren reported missing school due toasthma in the past year '(table 1). Ninety(9%) students with asthma reported usingprednisolone, indicating a severe asthmaexacerbation in the past. About 22% of theasthmatics reported that they were currentsmokers with 86 (42%) of them claiming thatthey experienced no asthma symptoms whensmoking.

QUALITY OF LIFEThe quality of life questionnaire was com-pleted by 796/958 (83%) of the students with

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Asthma knowledge, attitudes, and quality of life in adolescents

Table 2 Quality of life in students with asthma

Domain Mean score (SD) Activity Students limited by asthma (%)

Activity limitation 5-2 (1-3) Playing sport 63Symptoms 4 9 (1-3) Swimming 45Emotions 5-2 (1-5) Cycling 55Environment 4-9 (1-3) Running up hills 78Overall 5 0 (1-5) Surfing 33*

Students rated limitation due to asthma in the domains using a seven point Likert scale where 7represented no limitation at all, and 1 represented totally limited by asthma.*p<0.05 surfing v other activities.

asthma. The overall quality of life impairmentdue to asthma was in the mild to moderaterange, with a mean (SD) value of 5 0 (1-3)(table 2, fig 1). Severe limitation due to asthmawas reported by 174/796 (22%) (fig 1) of theasthmatics. In the symptoms domain, noctur-nal asthma occurring at least most of the timein the past two weeks was reported by 167/751(22%) of students. Environmental triggerssuch as dust, weather, air pollution, and strongsmells were reported to have provoked recentasthma symptoms in about half of the students(530/o). Passive smoke exposure had provokedasthma in 36% of students. Between 37% and51% of students reported avoiding situationsbecause of potential exposure to these triggers,and 31 6% of the students had felt frustratedas a result of asthma, or concerned abouthaving asthma in the past two weeks. A similarpercentage (42%) however, reported noemotional limitations due to asthma.Asthma had limited the activities of 34-6%

of students. Students identified specific activi-ties which were limited by asthma from a list of17 activities. The most frequently identifiedindividualised activities that were impairedbecause of asthma were sleeping (n= 743),playing sports (n=462), swimming (n= 274),bicycling (n=237), going for a walk (n= 153),and surfing (n= 1 10) (table 2). Students ratedthe severity of the limitation by asthma in fiveactivities. Strenuous activities such as runningupstairs or uphill and walking upstairs or uphillled to activity limitation by asthma in 78%and 79% of students respectively. Sportingactivities in general caused limitation in 60%of the asthmatics. Although surfing is astrenuous physical activity, only 30% of the1 10 asthmatics who had surfed in the past twoweeks reported activity limitation by asthmawhile surfing (p<005, table 2).

ASTHMA KNOWLEDGEKnowledge about asthma was, in general, low(table 3). Students with asthma had a meanasthma knowledge score of 14-5, which is alevel seen in a general community sample, andconsiderably less than informed parents whoscore at a level of 25.16 Students with asthmaknew significantly more about asthma thanstudents without asthma (p<0001). Theasthma knowledge score among teachers was14-9, which is similar to that of students withasthma and significantly higher than studentswithout asthma (p<0O001). Female teachers(n= 589) had higher knowledge scores thanmale teachers (15.80 v 13-88, p<0 001).Higher knowledge scores were also seen in

personal development/health/physical educa-tion teachers when compared with the remain-der of the teaching body (16'91 v 14-54,p<OlOO1).

Important knowledge deficits were in thearea of asthma recognition and the manage-ment of exercise induced asthma (table 3). Avery low percentage of students and teacherscould identify ways to prevent exercise inducedasthma. Between 50% and 75% identifiedsalbutamol as a treatment of acute asthma butfew could name three asthma treatments whichcan be used during an attack of asthma. Adisturbingly large percentage considered thatasthmatic teenagers could become addicted totheir drugs.

ATlTIUDES TOWARDS ASTHMAThere was a moderately high degree of toler-ance expressed towards a person with asthma(table 4, fig 2). This was greatest in studentswith asthma, and least in teachers (p<0001).Forty six per cent of teachers agreed with thestatement that 'students are embarrassedabout using their inhalers in class' whereas38% of students considered this to be the case(p<005) (table 4). The majority of students(81%) and teachers (70%) agreed with thestatement that 'there would be fewer problemswith asthma at school if students could carrytheir puffers around with them'.The locus of control domains (fig 2) indi-

cated that teachers and students with asthmasupported control of the illness by the individ-ual (internal control) as being more importantthan control by others (powerful others, forexample, teacher, doctor) or by chance alone.Twenty five per cent of the students withasthma reported a high degree of internalcontrol (score 6/6). Students without asthmasaw chance as playing a greater role inasthma than did teachers or students withasthma (p<0 001).

ASSOCIATIONSHigher asthma knowledge was associated withpositive attitudes and internal locus of controlin asthma. The coefficient describing therelationship between asthma knowledge and

50 r

40 FU,ca)

4-0-

30K

20K

10

0'Some Very Totally

limited limitedLimitation

Figure 1 Frequency histogram of the degree of limitationcaused by asthma in year 8 high school students withasthma.

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Table 3 Asthma knowledge in students and teachers

Students with Students without Teachersasthma (n= 958) asthma (n=3203) (n= 1104)

Mean (SD) asthma knowledge score 14-5 (5 2) 11-25 (4.55)* 14-90 (5-2)Specific knowledge itemsWhat are the three main symptoms of

asthma? (% correct) 16-9 10 1 21-7Prevention of exercise induced asthma(% correct) 1.0 0.1 5-7

Asthma treatments which are usefulduring an attack of asthma02 Agonist named (%) 71 53-3 76-3Three treatments named (%) 0-3 0 3-4

Teenagers with asthma become addictedto their drugs (% correct) 42-2 58-6 50 9

Name two asthma treatments taken everyday to prevent asthma attacks fromoccurring (% correct) 3-5 0 3 13-8

*p<0.001. Responses for specific knowledge items are the % of subjects in each group with acorrect response for that item.

internal control was positive, indicating thatstudents with higher internal control knowmore about asthma (r=0-22, p=00001). Therelationships between asthma knowledge andthe powerful others domain (r=-0 18,p=00001) and between asthma knowledgeand the chance domain (r=-0 16, p=00001)had negative signs. This indicates that asthmaknowledge was greater in those students whorated chance and powerful others as lessimportant in attitude domains in asthma.There was a positive association betweentolerance towards asthmatics and asthmaknowledge (r=0 21, p=00001) which isconsistent with the concept that improvedknowledge of a health problem promotesgreater understanding and tolerance of indivi-duals with that illness.

DiscussionAsthma was quite common in this group, andled to significant school absence and limitationin sporting activities. Asthma also caused mildto moderate impairment in quality of life.There was a low level of knowledge aboutasthma among teachers and adolescentstudents. Despite this, the groups appearedtolerant towards asthma during adolescence,and to the use of medications in the schoolenvironment.The study targeted a restricted age group

(13-14 years) but achieved a broad representa-tion from this group with over 90% of studentscompleting questionnaires. The results aretherefore generalisable to this age group,within the sociodemographic confines of ourpopulation. The measurement tools included

Table 4 Specific attitudes towards asthma in students and teachers (% agree)

Students with Students withoutTeachers asthma asthma

'There would be fewer problems with asthmaat school if students could carry theirpuffers with them' 70Q3* 82 0 79-6

'Someone with asthma should not use his/herpuffer in class' 4.0* 8-6 13-0

'Students are embarrassed about using theirinhalers in class' 45-4* 35-8 37-3

'Students play on their asthma' 30.7* 48-2 49-1'Teachers are wornied about taking someonewith asthma on a school camp or excursion' 47-1* 53 9 56-21

'School teachers have a negative attitude tostudents with asthma' 6-4* 19-8 18-4

*p<-OOOl .

asthma knowledge, attitudes, symptoms, andquality of life questionnaires. The Newcastleasthma knowledge questionnaire has beenextensively validated and demonstrated toperform reliably and to discriminate amonghigh and low knowledge groups.'6 The qualityof life questionnaire has undergone extensiveevaluation and can be demonstrated to be areliable instrument that is responsive to changeand able to discriminate among asthmatics.'9The attitudes questionnaire contained itemsrelating to locus of control and tolerance. Thelocus of control items were based on priordevelopmental work with an asthma specificlocus of control questionnaire.7 The items forthe tolerance domain were derived fromresponses of adolescent students with asthmaduring a focus group, from the comments ofparents in an asthma support group on asthmamanagement in schools and from the profes-sional experience of the investigators. Theseitems were screened for face validity by amultidisciplinary management team and eachof the questionnaires underwent pilot testing ina neighbouring school before use in this study.The questionnaires were self administered in aschool classroom setting to enhance theresponse rate.The teacher questionnaires were also self

administered, but were completed by teachersin their own time. This led to a reducedresponse rate from the teachers. The likely biasfrom this is that those teachers who wereinterested in the issue of asthma at schoolwould have responded. If this were the case,our results for the teachers may actually be anoverestimate of their knowledge and attitudes.This could be one explanation for the higherknowledge scores among teachers.The level of knowledge concerning asthma

was low. These results contrast with an earlierreport of high knowledge among adolescentstudents.20 The knowledge questionnaire usedin our study was more extensive. In addition totesting knowledge with regard to commonlyheld myths about asthma, the asthma knowl-edge questionnaire tested knowledge of treat-ments and management of exercise inducedasthma.

6r

5

0a)C',V

4-0

4

3

2

W TeachersStudents without

E asthmaStudents withasthma

Internalcontrol

Powerful Chance Toleranceothers

Figure 2 Attitudes towards asthma in teachers, studentswithout asthma, and students with asthma scoredfrom 1(disagree) to 6 (strongly agree). The four attitude domainsassessed were interval locus of control, powerful others locusof control, chance locus of control, and tolerance towardsasthmatics; *p<0OO1.

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Asthma knowledge, attitudes, and quality of life in adolescents 325

The prevalence of asthma was relatively highat 23%. This is similar to the prevalence ofasthma recorded in recent epidemiologicalsurveys.2A Asthma led to school absence for alarge number of the children and limited theactivities ofone third ofthe asthmatic children.This indicates that asthma was having a signifi-cant impact on the lives of the adolescentstudents in this community.

Almost half of the asthmatic childrenreported having attacks of asthma at school.The management of these episodes at theschool is quite important. As there is a highlikelihood that adolescents will have asthmaattacks at school or during sport, there is aneed for them to receive bronchodilator treat-ment promptly. This could be achieved byallowing students to carry their broncho-dilators with them. The majority of studentsand teachers were supportive of this proposi-tion (table 4). However, a recent survey ofschool principals did not identify uniform sup-port for students carrying their medications.21This issue should be addressed at each schooland incorporated into the school policy for themanagement of asthma in schools. There areexamples of national policies to assist in theformulation of local school policies.22Even if students were allowed to carry their

puffers, this may not be sufficient to ensureappropriate management of asthma attacks atschool. The knowledge questionnaire identifiedsignificant defects in the understanding of howto manage exercise induced asthma amongstudents and teachers. In agreement with this,many respondents (students and teachers) con-sidered that teachers were worried about takingstudents with asthma on school camps or excur-sions. This indicates a need for specific trainingof teachers in the recognition and managementofasthma attacks in students under their care. Aprogramme to improve teacher knowledgeand use of an asthma first aid kit has led to thesatisfactory management of asthma attacks inprimary schools.23The knowledge deficit of students could be

addressed by covering issues of asthma in theschool. There are two programmes in highschools in New South Wales to address this.The high schools in this study have nowentered a controlled trial of a three lessonasthma package delivered by teachers as partof the revised personal development/health/physical education curriculum.24 A secondintervention involves a peer led student asthmaprogramme in high schools from a neighbour-ing region. These programmes will use similarevaluation strategies to allow comparison ofthe two interventions.We found that the school environment was

quite supportive of the issues regarding effec-tive asthma management at school. Bothteachers and peers of the students with asthmaexpressed tolerant attitudes towards asthma,and considered that dominant control of theillness should remain with the individual.These are positive findings which indicatethat the school environment is receptive tointervention concerning asthma. The non-asthmatic peers should be included in these

interventions. The peers are an importantinfluence on the attitudes and behaviours ofstudents with asthma, and the attitudes ofpeers towards asthma were clearly differentfrom the students with asthma. The non-asthmatic peers tended to favour a greaterrole for external influences such as chance,teachers, and doctors in determining healthoutcomes in asthma. This differed from thestudents with asthma who expressed strongerattitudes towards internal control.

Self management of asthma is promoted aspart ofimproved asthma care. Adolescence is aperiod of transition from parental control toself management in many life areas, includinghealth behaviours. Self care has previouslybeen linked to high internal locus of control. Inthis study, only 25% of the students withasthma reported high internal control. Thismay be due to the developmental stage ofthe students. The school environment dur-ing adolescence provides an opportunity topromote positive health care behaviours, andin particular, responsible self management.Tobacco smoking is an important concern

for respiratory health in adolescents, particu-larly those with asthma. Many adolescentsbegin smoking during this period and arevulnerable to its effects. Smoking is associatedwith undertreatment of asthma7 and passivesmoking is a clinically significant risk factor forloss of lung function among young adults.2526Asthmatics are particularly susceptible to thiseffect, and can also develop acute airwaynarrowing after passive smoke exposure.27Passive smoke exposure had an adverse effecton many of the asthmatics in this study. Overone third reported asthma symptoms provokedby recent passive smoke exposure and a similarproportion had to avoid situations because ofpotential tobacco smoke exposure. The preva-lence of self reported cigarette smoking wasalarmingly high for a group with asthma. It wassimilar to that reported among non-asthmaticadolescents28 and is consistent with worksuggesting that the presence of asthma doesnot necessarily deter students from smoking.29There is a need to target smoking duringadolescence. The findings of this study are thatover half of the asthmatic smokers continuesmoking despite experiencing asthma symp-toms when smoking. This suggests a need toidentify the attitudes and beliefs associatedwith smoking among adolescents, and to usethis information to design effective smokingcessation messages.

In conclusion, this study has identified thequality of life impairment associated withasthma in adolescence and found a low level ofknowledge about asthma and its management.The attitudes towards this illness among peersand teachers were generally positive, andindicate an opportunity to improve asthmamanagement in the school environment.This study was funded by the NH&MRC. Gaye Sheather pro-vided secretarial assistance. The authors acknowledge theassistance of Pauline Brown, Robyn Hankin, Patricia Kiehne,and Megan Valentine with data collection. Ian Shepherd andWendy Arthur from the Departmnent of Schools Education pro-vided invaluable support during the planning of this project. Wealso thank the efforts of the year 8 students and their teacherswho participated in this project.

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7 Gibson PG, Henry DA, Francis L, et al. Associationbetween availability of non-prescription 2 agonist inhalersand undertreatment of asthma. BMJ 1993; 306: 1514-8.

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9 Hoffman D, Becker D, Gabriel H. The hospitalised adolescent:a guide to managing the ill and injured youth. New York:The Free Press, 1976.

10 Warner J, Gotz M, Landau L, et al. Management of asthma:a consensus statement. Arch Dis Child 1989; 64: 1065-79.

11 Blum R. Youth's views of health and health services.Interdisciplinary adolescent health training workshop series.Compendium of materials. Rockville, Maryland: US DeptHealth and Human Services, 1980.

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14 Charlton I, Charlton G, Broomfield J, Campbell M. Anevaluation of a nurse-run asthma clinic in general practiceusing an attitudes and morbidity questionnaire. Fam Pract1992; 9: 154-60.

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AppendixASTHMA ATTITUDES QUESTIONNAIREBelow are some statements made by peopleabout their asthma. For each statement pleaseshow how strongly you agree or disagree. Dothis by placing in the box the number that bestdescribes your feelings. Please answer allquestions.

1 2 3 4 5 6Strongly Agree Tend to Tend to Disagree Stronglyagree agree disagree disagree

1. If someone with asthma takes care ofhim/herself, he/she can avoid most asthmasymptoms.

2. When someone has an attack of asthmasymptoms at school, it is usually becausehe/she has been careless.

3. How soon someone recovers from anattack of asthma at school depends mainly onhow well the teacher takes care of him/her.

4. When someone has an attack of asthmaduring sport, it is because the teacher hasn'tchecked up on whether the student has takenhis/her medication.

5. If someone is going to have an attack ofasthma, it will happen no matter what anyonedoes.

6. How soon someone recovers from anattack of asthma symptoms is mostly a matterof luck.

7. Most people can control their asthmawell without seeing a doctor regularly.

8. Someone with asthma should not usehis/her puffer in class.

9. Students are embarrassed about usingtheir inhalers in class.

10. Students without asthma have a nega-tive attitude to students with asthma.

11. Students play on their asthma.12. There would be few problems with

asthma at school if students could carry theirpuffers around with them.

13. Teachers are worried about takingsomeone with asthma on a school camp orexcursion.

14. Students with asthma are just as fit asstudents without asthma.

15. School teachers have a negative attitudeto students with asthma.

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