Bronchial Boogie - Pilot Report
 

Bronchial Boogie Pilot Project Report

Prepared by
Wendy M Andrew MA GRSM ARMCM. & Lynn Daniel RGN BSc (Hons)

The project was funded by a grant from The Children’s Fund.

For the project a partnership was developed between Oldham Music Service Oldham PCT and other interested Health Service professionals.

INTRODUCTION AND BACKGROUND TO PROJECT

Asthma incidence, prevalence and mortality

A 20-year growth in the incidence of asthma diagnosed by General Practitioners peaked in the 1990s and is now 6 times higher in children than it was 25 years ago.  5.1 million people are currently being treated for asthma in the UK. 1,500 people die annually in the UK from asthma including 25 children.  Confidential enquiries show sub-optimal care and poor adherence to medication can contribute to unnecessary death.

Socio-economic influence

Oldham is the 38 th most deprived local authority out of 354 authorities in England.  Standard Mortality Ratio for respiratory disease is 36% higher in Oldham than the UK.  Hospital admission rates for asthma in children living in deprived wards are higher in comparison with more affluent wards. The wards targeted for this project showed above average hospital admission rates for children with asthma. These children lose significant time off school and suffer much morbidity.

This project attempted to address these problems by bringing children together and offering health education, both general and respiratory specific.

The project was innovative in its use of instrumental playing intervention for which there is limited evidence of specific value. The National Asthma Campaign has said that there is a constant demand for this kind of approach from users.

The pilot project has run for 38 weeks i.e. one academic year.

The aims and objectives were

1. To develop a therapy for asthma based on breath improvement through instrumental playing.

2. To evaluate the effectiveness of this approach.

3. To bring young asthmatics together to support each other.

4. To bring young asthmatics and their parents/carers together to educate them in both general and respiratory health matters.

5. To bring young people together to advise primary and secondary care health workers both face-to-face and in written form on how to improve services particularly with regard to issues of access and youth-friendly approaches.

6. To work with schools and the PCG to implement these recommendations.

Project design

Asthmatics of the age range 7-11 were identified by school nurses in four targeted schools in acknowledged areas of deprivation in Oldham.

At the weekly sessions the children were divided into two groups for the instrumental lessons and the health education.  Where possible drinks and snacks were provided and the asthma monitoring and education was supplemented by health education games provided by the school nurses.

In addition, the bringing together of these young people was used as an opportunity for them to offer each other mutual support.

Project evaluation

With help from the nurses the children have completed weekly diaries collecting health information. To further assist in the evaluation of the project the medical project manager designed three questionnaires one for the children, one for their parents/carers and one for the staff from the schools involved in the delivery of the project. In addition the instrumental teachers and some of the health professionals involved provided written reports.

Discussion

Four schools were initially involved in the project but one school had issues that prevented the successful completion of the project.

Problems in this school were identified as:

    • A shortage of a specialist asthma nurse leading to limited health input initially.
    • Lack of an up to date asthma policy in school at beginning of project and an apparent lack of commitment from school to implement policy when introduced.
    • Children not used to working with a male teacher found this difficult.
    • Some children were discouraged from practising at home because parents found noise unacceptable.

The project highlighted the need for school and parental co-operation, commitment and involvement. Although not totally successful, six of the children from this school had some asthma education and advice on how to manage their condition. Without the scheme this small improvement would not have been achieved.

Three other schools ran the project successfully for a year and this report is based on questionnaires completed by participants in these schools.

Thirty-four children began the project and twenty-seven were still enrolled when this report was prepared. Some of the other children have moved to secondary schools and some have withdrawn from the project.

Health Findings

Health statistics were gathered from weekly diaries kept by 30 children who completed the Bronchial Boogie pilot project.

Data collected

    • Night/day/exercise symptoms
    • Compliance with medication
    • Peak flow rates
    • Days off school
    • Asthma intervention requiring referral back to GP/Practice Nurse
    • Height measured every 3 months
    • Monthly observation of inhaler technique

Results

    • Increase in the number of children reporting NO sleepless nights from 47% to 90%
    • Increase in the number of children reporting NO day symptoms from 40% to 90%
    • Increase in the number of children reporting NO activity symptoms from 23% to 83%
    • Improvement in average peak flow rate of 10% with 70% of children showing improvement in peak flow rate
    • Increase in number of children with good compliance from 70% to 90%
    • Increase in number of children with good inhaler technique from 67% to 100%
    • Increase in number of children with a peak flow of >80% of predicted from 77% to 96%
    • Increase in number of children using reliever medication less than once a day from 33% to 83%
    • 38% of children had some form of therapy change
    • 27% of children required inhaler device change due to poor technique

Comparisons of time off school, hospitalisations and GP callout will not be available for a further twelve months, as this data was not obtainable prior to the commencement of the project.

Children’s questionnaires

Several common themes were identified from the twenty-one (78%) completed children’s questionnaires

The children were asked “what has been your favourite part of Bronchial Boogie and why”

They were then asked to “draw a picture of anything that makes you happy”

Eight children (38%) enjoyed the whole experience. Their replies were:

    • “All of it”
    • “The game and the prizes we win and when we have music”
    • “The games and the prizes and the colouring we did and learning the cornet at home”.

In addition twelve children (57%) commented on the instrumental lessons.

    • “Learning how to play the cornet because I have always wanted to know how to play an instrument”
    • “Learn to play the clarinet”
    • “I like it where we play the instrument because we have fun but we still get to play it”.
    • One girl commented on enjoying playing her clarinet for her peers in school.
    • “Because I like playing at home as well and in class”.

Three children (14%) specifically mentioned the instrumental lessons in relation to their asthma.

    • “Playing an instrument and making my asthma better”,
    • “My favourite part of Bronchial Boogie is the instruments because it has helped me control my asthma”.

One older child, aged eleven, appreciated the project as a whole

    • “I think the bronchial boogie was really good and made my asthma very better and I think whoever planned the bronchial boogie has the pleasure and safety for our asthma”.

The pictures that the children drew were varied e.g. a large sun, a television and a boy and a girl inside a house. Three drew their cornets, one girl drew a clarinet and one girl drew a flute and an inhaler. Several children drew pictures of themselves and a football. Throughout the project it has become apparent how some of the children feel that their asthma prevents them enjoying playing football.  The inclusion of footballs in the drawings may point to an improvement in their experience of sport.

Parent’s questionnaires

Seventeen (63%) parents returned questionnaires

Parents were asked about their own and their children’s attitude to asthma before taking part in the Bronchial Boogie project.  80% of the parents were worried and 55% of the children were unhappy about their asthma.

The severity of their children’s asthma was considered average or above by 90% of the parents with regular symptoms of breathless reported by 50%, coughing 75%, sleep disturbance 60%, school absence 35% and 45% unable to take part in sport.

It was clear that a large percentage of the children had little awareness of asthma and how inhalers work.

Common themes identified from the evaluations of the parental asthma education sessions were:

    • Identifying common triggers associated with their child’s asthma.
    • Understanding how the lungs work in relation to asthma.
    • Gaining information and the knowledge to understand how to self-manage their child’s asthma.
    • Feeling confident and competent to identify and know how to manage an asthma attack.
    • Being able to identify that their child was not able to use an inhaler correctly and therefore being re-assessed and a more suitable inhaler device given.
    • Why it is important for their child to take regular inhaler medication.

All parental comments were positive regarding asthma monitoring of their children and the increase in their, and their children’s, knowledge of asthma.

The parents were asked whether their own and their children’s attitude to asthma had changed since taking part in the Bronchial Boogie project.

85% of parents claimed that the nurse education and monitoring and instrumental playing had made their child’s asthma better.

The replies included comments such as:

    • “Is more able to control breathing pattern”
    • “Breathing technique”
    • “Correct breathing”
    • “I think playing an instrument has helped him to do breathing better”

Many parents feel happier about their child’s asthma:

    • “K enjoys playing the flute and K’s asthma has never been better, Great!”
    • “S knows how to breathe properly so she does not panic”
    • “L now seems to know how to control her breathing”.

85% of parents claimed that their child felt happier and one said;

    • “Feels it is getting much better”

When asked about the instrumental tuition some parents made comments such as:

    • “The instrument helps to open up the chest”
    • “Because it’s made a difference to her asthma”
    • “For A’s enjoyment”.

One parent commented on both aspects of the course:

    • “B enjoys playing her instrument and I feel if she can be taught to control breathing this way it would help her asthma although I feel that the education and monitoring of asthma has been just as useful if not more”

The parents reported that symptoms had reduced: previous figures in brackets.  Breathless now 30% (50%), coughing 40% (75%), sleep disturbance 40% (60%), school absence 5% (35%) and 15% (45%) unable to take part in sport.

Additional comments from parents included:

“Thank you to everybody for all your help”

“K is enjoying this course and she is a lot better with her asthma mum happy as well so now that K’s asthma to me is in control now and never has been before always been up and down”

“Keep up the good work. Thanks.”

School teachers’ comments

Throughout the year the school headteachers and teachers have been supportive of the project and at this stage expressed positive comments. The social aspect of the sessions was commented on.

    • “Children have enjoyed the social aspect of the activity”.
    • Confidence and self-esteem are sometimes lacking in children with health problems and this was mentioned several times
    • “The chance to learn a new skill i.e. playing a musical instrument has boosted their self-esteem e.g. playing in assembly.”
    • “I think it built her self-esteem by being able to play her flute to her classmates.”
    • “The children have become more confident in their attitude to life in school.”
    • “The children are proud of their instruments and do well taking good care. Performing in front of school was a first for them and very character building.”
    • As mentioned earlier in this report the importance to children of taking part in sport was referred to
    • “Children who do not normally participate in extra curricular sports activities have an opportunity to be included in an alternative activity.”
    • School staff have detected an apparent improvement in the pupils’ respiratory health
    • “The children developed a sound understanding of their medication and the need to keep their asthma under control.”
    • “They have become better at managing their own breathing and hence are more able to deal with an asthma attack.”
    • “Their use of their inhalers has improved (i.e. how they take them) and the number of times they need them has decreased significantly.”
    • “The children are more aware of the signs of an attack and how they can be avoided.”
    • The teachers observed the children’s enjoyment of the sessions
    • “Pupils attending the club regularly were enthusiastic and keen to improve musical skills alongside breathing techniques and asthma control.”
    • “The children involved have really enjoyed the sessions and are becoming proficient musicians.
    • “They (the children) obviously enjoyed this judging by their keenness’ to take care of the instruments and none of them wanted to miss a session.

One final comment was added by one of the headteachers

“Please maintain and, if possible, expand this excellent initiative to more children”

 

Comments from health professionals

An Asthma Nurse Specialist made the following comments about the group that she was involved with.

    • All the children were happy to come and their knowledge of asthma improved through out the year. 100% being the rule for asthma quizzes.
    • Their asthma became more controlled as the year progressed with fewer symptoms.
    • Inhaler technique and peak flows are excellent and all but one now regularly uses preventers.
    • The overall absenteeism has reduced since Bronchial Boogie was introduced.
    • Overall a very positive project with the children’s interest and knowledge of their asthma greatly improved.
    • Their musical interest also improved.  All wish to carry on.

A School Health Advisor made the following comments.

Although the children’s peak flows have not changed much they all say that they do not have as many symptoms as they used to. They now know to take relievers before sport or exercise and to keep a record of peak flows etc.  Generally their increased knowledge seems to have given them more confidence; they feel more in control of their asthma and in fact their lives.  One girl in particular, who was very shy when she first joined the group, volunteered to play her flute in a school assembly and did so very well.

Despite teething troubles our Bronchial Boogie group has been a success. The children have worked well and appear to have enjoyed themselves. As a consequence all parties appear to have improved their knowledge and understanding of asthma.

Another School Health Advisor made a different point.

The children in the group that I have worked with all needed some degree of therapy or device change.

Comments from instrumental teachers

The instrumental teachers have found teaching the asthmatic children a different and sometimes frustrating experience from teaching their usual pupils.

One teacher describes the problems and achievements in detail.

Differences in the lessons were apparent from the very start.  Usually children would request to play their chosen instrument, motivated by the sound and seeing their friends in concerts. The children in the asthma project had not requested to play the flute so were not motivated in the same way.

Most of the children were enthusiastic but out of the initial group of twelve, three showed no interest at all. After a few weeks four children had left, one child due to muscle abnormalities in his arm. His mother felt that his physical difficulties were too great for him to continue with playing the flute.

From November 2002 to July 2003, I worked with a group of eight children.  One child was particularly difficult and had behaviour problems. I do not know if this was connected to his asthma problems, or if missing a lot of school, due to his illness, was a major contributory factor to his behavioural problems.

The children have made slower progress than groups who don’t have illness/asthma problems.  Initially, the children missed a lot of lessons, due to illness, some of them having to be admitted to hospital. The time of year, approaching winter, was more difficult for them to manage their asthma. After Christmas and as we approached spring there were less absentees.  Another factor could be that the asthma education helped them to manage their asthma better.

The children in the Bronchial Boogie project generally were less confident than other beginner flute groups I have taught. Comments I would often hear, and still hear; “I’m rubbish”, “Can’t do that”, “Wont ever be able to do that”, “Too difficult”.  They seemed to be frightened to even try something new and it took a lot of gentle persuading for them to try.

The children have all responded well to reading music and there has been no difference in their progress in this aspect.  Generally their co-ordination has taken longer to develop and since I started teaching them, I would surmise that their overall progress is about 4 months behind what I would have anticipated. Their stamina is not as developed but there is progress from week to week.

I have been concentrating on developing their confidence.  They were all reluctant to play individually at the start of this project and I have encouraged group solos, creating their own music and maybe just performing one bar of the music but treating it as an important solo.

I believe that this had great results and the children are displaying a lot more confidence.  They are now wanting to play the flute to members of their class and are very happy to show me what they have practised, wanting to perform their solos first.

Since September, I have been teaching a group of six. Due to family circumstances the child with behavioural problems no longer attends. He did not leave because of the problems but since he has left, the other children all work much better now. As there are now only three in each group that is much easier to manage and I can now work more closely with them.  They seem to respond to that very well.

Another music teacher has found the experience very satisfying.

I have been teaching eleven children the cornet, as part of the above project, since October 2002. They have made steady progress and have taken a very visible role in the musical life of the school.

We first performed in a school assembly after just fourteen weeks of playing and received a very positive reaction from staff and pupils alike. In fact the interest was such, I could easily have taken on a dozen more pupils! We were featured in the school newsletter and we were photographed by the headteacher for future evidence for Ofsted etc.

The school is situated in an area of Oldham which holds an annual Whit Friday Band contest. This was for many of the children within the school community a rather strange event, not from their own culture and something they did not understand. Seeing the brass instruments in assembly and seeing their own friends playing them, gave them a new insight and gave me the chance to explain the history behind the contest. Many of the children went out to watch some of the bands this year, something they had not done before.

After the success of our first assembly, we were asked to make another appearance in the summer term. We were able to demonstrate the progress we had made and emphasis the importance of dedication and perseverance in success. The young brass players have developed a love of performing and feel very special to be one of the school musicians.

To my eyes there is no question that the children I teach seem more confident and relaxed and the pauses during lessons to catch breath cough and recoup after strenuous playing, have reduced markedly. I am in no doubt that the children have benefited physically, intellectually and spiritually from this experience. The same could be said about myself also.

The future of Bronchial Boogie

At the time of writing this report we have managed to find funding until the end of the financial year in April. The Health Service PCT has expressed a willingness to fund the medical side of the project and the Music Service will support the maintenance of the instruments. However, this leaves funding required to pay for the instrumental tuition. We need approximately £2,000 per teacher per year to continue after April.   We would like to extend the project to secondary schools, where pupil absences are an issue, and for this we would need funding for teachers and extra instruments. We also feel that the children benefited from the drinks and snacks we were able to provide, largely due to a generous gift from Asda stores, which they do not feel they can repeat. Some of the money from the Children’s Fund was spent on social events for the children which were regarded as beneficial to the cohesion of the project as it allowed asthmatic children from different schools to meet.

Conclusion

There have been many problems with this pilot project and lessons learned. Most importantly parental involvement and commitment are vital and the co-operation of the schools is essential for the smooth running and prestige of any project.

The children parents and teachers involved have all expressed a positive outcome from their participation and a desire to continue with the project.

All health outcome measures have been achieved thus showing asthma education alongside musical intervention has been successful.

Final comments from project participants.

From an instrumental teacher

“In conclusion, this has been a very beneficial and rewarding experience for all involved.”

From a school headteacher

“A worthwhile innovative project.  Thank you”

From a parent

“She is much happier now her asthma is at ease and she has never been better”

Finally from an asthmatic child

“I think the bronchial boogie was really good and made my asthma very better”.