Attitudes of Non-Asthmatic Children Towards Their Asthmatic Peers Influence of interactions with asthmatic relatives and peers *

Objectives: This study aimed to examine non-asthmatic children’s acceptance of and attitudes towards their asthmatic peers in Jordan. Methods: This descriptive cross-sectional study was conducted between September 2015 and January 2016 among 1,812 non-asthmatic children aged 9–13 years old at 10 schools in Zarqa, Jordan. Arabic versions of the Peers Attitude Towards Children with Asthma scale and the Asthma Knowledge Test for Children were used to assess attitudes towards children with asthma and asthma-related knowledge, respectively. Results: A total of 1,586 children participated in the study (response rate: 87.5%). Of these, 158 (10%) and 399 (25.2%) children reported a family history of asthma or knew at least one person with asthma, respectively. Although 50.3% stated that they would sit next to such children in the classroom, only 34.9% reported that they would be friends with an asthmatic child. However, 73.1% of the non-asthmatic children believed that asthmatic children were not pretending to be ill and 61.4% believed that such children were not ill due to their own carelessness. Female non-asthmatic children (P <0.001), those with a family history of asthma (P = 0.004) and those who knew other individuals with asthma (P <0.001) had significantly more positive attitudes towards and acceptance of their asthmatic peers. In addition, age was significantly related to attitude scores (P <0.001). However, there was no correlation between asthma-related knowledge and the children’s attitudes towards peers with asthma (P = 0.611). Conclusion: Previous interactions with asthmatic family members or peers were found to significantly influence non-asthmatic children’s attitudes towards their asthmatic peers.

due to disease-associated exacerbations, absenteeism and stress. 3,4][7][8] For children with asthma, QOL may be affected by social acceptance or rejection by their peers in light of the stigma associated with the disease. 3,9In general, Graetz et al. found that children with asthma who were more frequently hospitalised were less preferred as playmates by other children and perceived to be more sensitive and isolated. 5Another study demonstrated that symptomatic evidence of a disease negatively influenced some children's perceptions of and responses towards their sick peers. 102][13] The role of peer support in facilitating psychosocial adjustment among children has proven beneficial in improving resilience and wellbeing. 8Therefore, direct contact between healthy and ill children is highly advised in order to effectively improve the attitudes of the former towards the latter. 7,11,14,15Previous research has indicated that greater asthma-related knowledge and being female positively affect children's attitudes towards their asthmatic peers. 11,16Such research is important in order to identify appropriate interventions to improve asthma-related attitudes in schools and the wider community.Specifically, it is important to study whether having a family history of asthma or knowing others (i.e. a friend, peer or relative) with asthma positively contributes to children's acceptance of or attitudes towards their diseased peers.
In Jordan, the prevalence of asthma is comparable to that of other developed countries. 17However, this may be due to underdiagnosis of the condition; a review from the Middle East indicated a noticeable increase in the prevalence and burden of asthma due to increased public and professional awareness of the disease. 18Frequent asthma-related triggering factors include respiratory tract infections, exercise, dust and parental smoking. 17,19Nevertheless, there are few asthma health education and promotion programmes targeting children and adolescents in Jordan. 19his study aimed primarily to examine the association between attitudes towards peers with asthma among non-asthmatic children and having a family history of asthma or knowing someone with asthma.Based on the outcomes of studies evaluating perceptions of physical disability, it was hypothesised that interactions with family members or peers with asthma would positively influence acceptance of and attitudes towards asthmatic peers among nonasthmatic children. 14,15The second aim of the study was to investigate the relationship between non-asthmatic children's levels of asthma-related knowledge and their attitudes towards their asthmatic peers.Finally, the third aim was to determine asthma-related knowledge and attitudes among children without asthma.

Methods
This descriptive cross-sectional study was conducted between September 2015 and January 2016 at 10 schools in the second educational district of Zarqa, Jordan.These schools included nine governmental schools and one private school and were recruited from a list of 100 schools in Zarqa, including 29 male-only schools, 23 female-only schools and 48 coeducational schools.A simple random sampling technique was subsequently used to select one class of children from each grade between grades 4-7 at the selected schools.Overall, 1,812 non-asthmatic children aged 9-13 years old were invited to participate in the study.
Three questionnaire tools were utilised to gather data from the participants.Demographic information was elicited using a four-item questionnaire, including age, gender, the presence of a family history of asthma and pre-existing relations with individuals with asthma.Subsequently, the 10-item Peers Attitude Towards Children with Asthma (PACA) scale was used to measure attitudes towards (items 3, 4, 5, 7, 8 and 10) and acceptance of (items 1, 2, 6 and 9) children with asthma on two subscales. 11The children responded to each item with yes/no responses, with a score of one given to a positive response and zero to a negative response.After reverse scoring negatively-worded items, the scores were summed up to provide a total overall score, in which higher overall scores indicated more positive attitudes towards children with asthma.Finally, the 22-item Asthma Knowledge Test for Children was used to assess the children's general knowledge about asthma, including its triggers, symptoms, treatment and management. 20This questionnaire consisted of 21 true/false items and one item asking the child to list three symptoms of asthma.One point was awarded for each correct answer or symptom listed, for a maximum of 24 points.Correct responses to each item were summed to provide a total score.
All of the questionnaires were translated into Arabic and pilot-tested for comprehension and clarity among a group of children with similar characteristics to that of the study sample.The final questionnaires were distributed among selected classes with the aid of classroom teachers.When necessary, the teachers also helped the children to read and complete the forms.A total of 81 students who self-reported an asthma diagnosis were excluded from the analysis.not mind if their asthmatic peers used their inhalers in class [Table 1].With regards to asthma-related knowledge levels, the percentage of correct responses to each item ranged widely from 15.2-79.4% [Table 2].Overall, 74.1% of the children gave correct responses to six items, while 49.3% provided correct responses to 15 items.

Discussion
The current study aimed to explore the possibility that interactions with asthmatic family members or peers would have a positive influence on the acceptance of and attitudes of non-asthmatic children towards their Data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 22.0 (IBM Corp., Armonk, New York, USA).Descriptive statistics were used to illustrate the characteristics and attitude scores of the sample.In addition, a correlation coefficient test was used to examine the relationship between asthma-related knowledge and attitude scores.A P value of ≤0.050 was considered statistically significant.In order to identify the effect of a family history of asthma and previous relations with other asthmatic individuals on the children's attitudes, a multiple regression analysis was performed using all factors associated with attitude scores as independent variables.However, this technique was not successful due to the violation of multiple regression assumptions (i.e.multicollinearity).Instead, a Student's t-test and analysis of variance were performed, with a Bonferroni adjustment made to the alpha value (P <0.001).
Ethical approval to conduct this study was obtained from the Hashemite University Institutional Review Board (#2015/2014/2/3) and the Ministry of Education in Jordan (#2/7/1/8221).In addition, the appropriate authorities at each school gave permission for the study to be conducted.Parental informed consent was obtained for each of the children prior to their participation in the study.

Results
A total of 1,586 non-asthmatic children participated in the study (response rate: 87.5%).Of these, 659 (41.6%) were male and 927 (58.4%) were female.A family history of asthma was reported by 158 children (10%), while 399 (25.2%) stated that they knew at least one person with asthma.The mean total PACA score was 4.97 ± 2.11 out of 10, with mean total scores for the acceptance and attitudes subscales being 1.73 ± 1.10 out of 4 and 3.24 ± 1.47 out of 6, respectively.Total knowledge scores ranged from 0-21, with a mean score of 11.5 ± 3.09 out of 24.
In terms of attitudes towards and acceptance of asthmatic children, the percentage of positive responses ranged from 30.1-59.9% for positivelyworded items and 26.9-56.9%for negatively-worded items.While 73.1% of students in the current study believed that children with asthma do not pretend to be sick and 61.4% believed that asthmatic children were ill due to factors other than carelessness, only 34.9% reported that they would be happy to accept children with asthma as their friends.In addition, only 30.1% believed that such children could participate in sports, while just over half (50.3%) did not mind sitting next to them.However, despite these generally negative attitudes, most children (59.9%) stated that they did asthmatic peers.,22 In the present study, the majority of asthma knowledge-related items were answered incorrectly by most non-asthmatic children.This lack of knowledge extended across all aspects of the disease, including its causes, symptoms, treatment and management.A previous study conducted in northern Jordan similarly reported low levels of asthma-related knowledge among adolescents in contrast to studies from the USA. 19,23,24Additionally, the findings of the current study indicated a negative attitude trend extending across all components of the scale.Moreover, high knowledge scores did not necessarily correlate with more positive attitudes.This is in contrast to a previous study of Australian children which found that higher knowledge scores correlated positively with attitude scores. 11This variation in findings may be attributable to differences in the average knowledge scores between the two samples, particularly as the Australian children had higher total scores than children in the current sample. 11This finding suggests that attitudes should be measured while controlling for knowledge scores, particularly when assessing potential influences such as a family history of asthma or knowing others with asthma.A previous study found that a family history of asthma and prior knowledge of others with asthma were not significantly related to attitudes towards asthmatic peers among non-asthmatic Australian children. 11This finding was attributed to the high level of acceptance of asthmatic peers among their studied sample.In contrast, both of these factors along with being female were found to positively contribute to total attitude scores in the current study.The low level of acceptance of asthmatic peers noted in the present study underlines the importance of social interactions between non-asthmatic and asthmatic children so as to foster positive attitudes and acceptance among the former group towards the latter. 12Children with asthma have reported feelings of anxiety and embarrassment about their illness which affected their attitudes towards self-treatment. 25It is therefore important to change social perceptions of chronic illnesses in order to foster a positive attitude towards affected patients. 6,10,16Healthcare providers in Jordan should therefore seek to educate children regarding childhood asthma as well as promote positive attitudes towards asthmatic children among their non-asthmatic peers.
The current study was limited by its crosssectional nature which does not imply a causal relationship; an interventional case-control study might have produced more valid results.In addition, a longitudinal rather than descriptive design would have contributed to the strength of the findings.However, this could not be achieved due to feasibility-related constraints such as lack of time and funds.Another limitation of the study was the reliance on selfreported data potentially subject to reporting bias.In addition, this study was conducted in only one region of Jordan; as such, the results cannot be generalised on a national level.

Conclusion
The results of this study indicated low levels of asthmarelated knowledge and generally negative attitudes towards asthmatic peers among non-asthmatic students in Zarqa, Jordan.Gender, age, a family history of asthma and prior knowledge of someone with asthma positively influenced attitudes towards asthmatic peers.Therefore, additional interactions between non-asthmatic and asthmatic children may be helpful in improving children's attitudes towards their asthmatic peers.Healthcare professionals should encourage positive interactions between nonasthmatic and asthmatic children in order to improve the knowledge and attitudes of non-asthmatic children towards their asthmatic peers.

Table 1 :
Attitudes towards children with asthma* among non-asthmatic children in Jordan (N = 1,586) 11ssessed using an Arabic version of the 10-item Peers Attitude TowardsChildren with Asthma scale.11†Percentages are not calcul-ated out of the total sample due to missing data for certain items.

Table 3 :
Factors influencing attitudes towards children with asthma* among non-asthmatic children in Jordan (N = 1,568) †

Table 2 :
Asthma-related knowledge* among non-asthmatic children in Jordan (N = 1,586) 20ssessed using an Arabic version of the 22-item Asthma Knowledge Test for Children.20†Percentages are not calculated out of the total sample due to missing data for certain items.