https://orcid.org/0000-0003-0036-2733
Figures
Abstract
Objective
To construct a comprehensive physical exercise evaluation index system for asthmatic children aged 6–12 years.
Design
Based on knowledge-attitude-practice(KAP) theory, we constructed an item pool for a physical exercise evaluation index system using a literature review and semistructured interviews and refined the index system through two questionnaire cycles with Delphi experts.
Results
For the two questionnaire rounds, the recovery rate was 100%, the experts’ authority coefficients were 0.850 and 0.836, and the coordinated coefficients were 0.167 and 0.202 (P<0.001). Finally, four first-level indicators, namely, disease factors, exercise environment, exercise practice, and exercise psychology; 11 second-level indicators; and 50 third-level indicators were developed as a physical exercise evaluation index system for asthmatic children.
Citation: Zhao Y, Meng X, Wang S (2025) Establishment of a physical exercise evaluation index system for school-age children with asthma. PLoS ONE 20(1): e0312398. https://doi.org/10.1371/journal.pone.0312398
Editor: Pisirai Ndarukwa, Bindura University of Science Education, SOUTH AFRICA
Received: February 29, 2024; Accepted: October 4, 2024; Published: January 9, 2025
Copyright: © 2025 Zhao et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Asthma is one the most common chronic respiratory disease and affects up to 18% of the population in some countries [1]. Typically, patients exhibit recurrent respiratory symptoms such as dyspnea and cough, which seriously affect their quality of life. According to statistics from the World Health Organization, in 2019, 262 million people were affected by asthma, and 455,000 people died [2].The prevalence of asthma among Chinese children was 4.90% [3]. The school age is from the beginning of primary school for 6–7 years old to pre-adolescence (generally 11–12 years old) [4]. One of the most common diseases in school-age children is asthma that has the characteristics of long course of disease and easy recurrence [5], which affects the physical and mental health of children.
Among the many triggers of asthma, exercise is a special presence. Studies have shown that exercise may induce or even aggravate asthma under certain circumstances [6, 7]. However, research in recent years has demonstrated that appropriate regular exercise can play a positive role in the management of asthma. Exercise intervention is safer and more economic than drug therapy [8]. The Global Strategy for Asthma Management and Prevention also states that regular and moderate physical activity is beneficial to the health of people with asthma [9]. The Australian Association for Exercise and Sports Science suggests that patients with asthma should participate in sports activities and exercise allows people with asthma to live as normal a physical lifestyle as possible, and with pre-exercise medication, most people with asthma can participate in exercise on an equal footing with non-asthmatic people of the same size and fitness level [10]. Children with asthma should take regular exercise, exercise can improve children’s lung function index, immune system, exercise ability, and improve quality of life [11]. Aerobic exercise is beneficial for both acute and chronic inflammatory asthma [12]. Exercise can increase forced expiratory volume in the first second (FEV1) and forced lung capacity, and improve lung function in children [13]. Children with asthma who engage in regular physical activity have a lower rate of hospitalization [14]. Physical exercise can significantly improve FVC in children [15]. And under proper management and monitoring, moderate intensity aerobic exercise has good safety and effectiveness, and can improve the exercise ability and quality of life of children with asthma [16].
Asthma continues to affect the daily life of children at school, including negative effects on their attendance and physical education by the disease and its symptoms [17]. Exercise can trigger asthma under adverse conditions, but if health care professionals can guide children to exercise properly, exercise can change from a trigger to a beneficial factor. Therefore, children with asthma should perform physical exercise and may even be prescribed physical exercise as a treatment [18]. But literature and clinical investigations suggest that exercise can trigger asthma in some cases [19], and children and their parents may face substantial psychological pressure and worry about aggravating the disease [20]. Some patients accept physical exercise, but for disease management, the choice of exercise environment and exercise practice is unreasonable and may increase the risk of asthma attack.
There are recommendations and prescriptions for exercise for children with asthma, for example, the Global Strategy for Asthma Management and Prevention [9]; the American College of Sports Medicine (ACSM) Guidelines for exercise testing and prescription [21]; and expert consensus on exercise prescription for asthmatic children in China [22]. Questionnaires are available to evaluate physical activity levels from childhood to adolescence and the Physical Activity Questionnaire for Older Children (PAQ-C) and Adolescents (PAQ-A) Manual) [23]. However, at present, there is no exercise evaluation index system for patients with asthma in China or abroad, despite the high prevalence of asthma among children and need for exercise. Therefore, our study aimed to develop a set of indicators of a physical exercise evaluation system for school-aged children with asthma to provide a scientific tool for both children with asthma, their caregivers and hospital professionals to assess the physical exercise of children with asthma, which may serve as a basis for guiding the exercise management of children with asthma and reducing their risk of exercise-induced asthma (EIA).
Material and methods
Constructing the primary physical exercise evaluation index system for school-age children with asthma
Literature review.
The method of combining the topic and free words was used for retrieval. The retrieval words were bronchial asthma or asthma, exercise or physical exercise, evaluation system or assessment systems, evaluation indicators and systematic construction. The main search databases used were the Global Initiative for Asthma (GINA), Web of Science, PubMed/Medline, China National Knowledge Infrastructure(CNKI) and China Science and Technology Journal Database. In addition, a two-month field study in the pediatric asthma clinic was conducted to collect information about physical exercise in children with asthma. Knowledge, Attitude and Practice Theory(KAP theory):The theory that beliefs are influenced by knowledge and that attitude change behavior [24].This study explored the influencing factors of exercise in asthmatic children from the perspectives of knowledge, belief and behavior. To further construct the physical activity evaluation index system of school-age children with asthma. To establish measurable indicators, through the assessment of pediatric asthma specialist medical staff, timely find the shortcomings, establish a targeted education and guidance mechanism, and improve the exercise level of children with asthma.
Qualitative interview.
Five experts were selected by objective sampling to conduct semi-structured interviews. The expert inclusion criteria were as follows: ① being a pediatric nurse, respiratory nurse, medical expert, rehabilitation or community nursing expert providing medical, nursing care or rehabilitation services for asthma patients for 5 years or longer; ② having an intermediate or senior professional title; ③ having a bachelor’s degree or above in nursing or clinical medicine; and ④ consent to participate. Through literature review and interviews, finally a preliminary 3-level evaluation index system was developed, including 4 first-level indicators, 13 second-level indicators, and 39 third-level indicators.
Two-round Delphi survey.
Refer to semi-structured interview expert selection requirements, ultimately, 20 experts participated and completed two rounds of the Delphi survey. Among them, 11 experts were from the respiratory and pediatric departments of two tertiary general hospitals; 4 experts were from university nursing schools; and 5 experts were from the clinical medical technology department and vocational college nursing schools. These experts were between 36 and 57 years old (average age of 46 years) and had 13–39 years of work experience (average work experience of 24.6 years); 5 were doctors, 15 were nurses, 11 had undergraduate degrees, 7 had master’s degrees, and 2 had doctoral degrees.
The questionnaire included the research background, research purpose, system construction basis and introduction, completion instructions, text and expert basic information. The experts scored the first, second and third-level indicators in the questionnaire on a 5-point Likert scale (very important, important, moderately important, not very important, and not important), with scores ranging from 1–5 points. Moreover, experts proposed their own suggestions for modifying the items (S1 Table).
There were two rounds of Delphi expert consultation in this study. In the first round consultation, all 20 experts returned the questionnaires. Indicators with a mean importance score greater than 3.5, a full score ratio > 0.2, and a variation coefficient <0.25 were included in the second-round survey [25]. In addition, a research team with three members discussed the opinions, suggestions, and other expert feedback carefully and revised or eliminated items accordingly. Finally, 4 first-level indicators, 11 second-level indicators and 50 third-level indicators were constructed. In the second round, 20 experts scored the indicators of the system again on a 5-point Likert scale and proposed suggestions for modification (S2 Table). None of the 20 experts raised new objections. All the indicators satisfied an average importance score greater than 3.5, a perfect score ratio > 0.2, and a coefficient of variation <0.25; thus, they were retained.
WPS2019 and SPSS 20.0 software were used for statistical analysis of the data. The mean importance score, full score ratio, coefficient of variation, variance, expert authority coefficient, degree of familiarity, judgment basis and Kendall’s W coefficient were calculated for the indicators. Analytic Hierarchy Process, referred to as AHP, is a decision-making method that decomposes the elements related to decision into levels such as target, criterion and schemes, and then carries out qualitative and quantitative analysis [26]. The analytic hierarchy process (AHP) was used in this study. The first step involved establishing a hierarchical structure model and determining the Satty standard on the basis of the differences in the importance of the indicators among experts. System includes target level, criterion level and program level. The second step involved building a judgment matrix and calculating the weights of the indicators at all levels.
Ethics statements.
This study did not involve patient information and no patient intervention was performed. For the qualitative Interview and Delphi survey and consent was obtained from potential participants through the internet after the participants had received an adequate explanation of the study. The informed consent of all participating experts is in writing.
Results
Qualitative interview
Based on semi-structured interviews with 5 experts and literature review, four themes of the evaluation system were summarized. The basic information of the five interview experts is shown in Table 1.
Theme 1: Disease factors.
The most important factor affecting the exercise of children with asthma is the disease. Experts A, C and E mentioned that the exercise level of asthma patients was positively correlated with the asthma control level. Expert B stressed that allergic substances and medication compliance should not be ignored.
Theme 2: Exercise environment.
Experts B and E stressed that whether the exercise environment has allergens is the key, and the temperature and humidity of the air will also affect asthma symptoms. Expert C mentioned that in the stage of poor asthma control, whether the exercise has a guardian and relevant monitoring equipment is very important.
Theme 3: Exercise knowledge.
Expert D stressed that exercise for asthmatic patients should follow the exercise prescription, and choose the right time, frequency and type of exercise.
Theme 4: Exercise psychology.
Expert A mentioned that the negative perception of exercise by children or their families can affect the level of exercise. Expert D stressed that children or family members who recognize the positive effects of exercise on asthma control are key to improving exercise levels.
Two-round Delphi survey
In the first round, a total of 20 experts participated in the consultation, with 20 questionnaires distributed and a questionnaire return rate of 100%. Ten experts proposed changes to the indicator system. In the second round, the questionnaire return rate was 100%, and no expert provided new advice. The expert authority coefficient was calculated as follows: (Cr) = (Ca+Cs)/2,Cr based on Ca and Cs assignments (S3 Data). It is generally believed that when Cr ≥ 0.7, the results of expert consultation are reliable [27], and the greater the Cr is, the greater the reliability. The degree of expert authority of the two Delphi rounds was >0.7, indicating that the authority of the experts was high. The results of the two rounds of Delphi correspondence are shown in Tables 2–8 (S1, S2 Data).
The degree of coordination of expert opinions reflects the degree of agreement among experts and is expressed as the coefficient of variation (CV) and Kendall’s W coefficient (W),and the smaller the CV value, the larger the W value, and the higher the expert coordination consistency [28] (Tables 5, 8).
According to the results of the two rounds of the Delphi survey and the research team discussion, the initial evaluation indicator system was amended. In the first round of expert consultation, the rate of the experts’ opinions was high, with a total of 35 amendments proposed (Table 6). Finally, 4 first-level indicators, 11 second-level indicators, and 50 third-level indicators were identified, among them, the target level is to build a sports evaluation system for school-age children, the criterion level is the first and second indexes, and the program level is the third indexes (Table 7). The importance of the indicators at all levels, the full score ratios, the mutation coefficients and the weighted results are presented in Table 8.
Discussion
Content analysis of the physical exercise self-evaluation index system for school-age children with asthma
In our study, a set of exercise evaluation indicators for children with asthma, including 4 first-level indicators, 11 second-level indicators, and 50 third-level indicators, was developed. These indicators were grouped into four categories; disease, environment, exercise and psychology, and the factors that may trigger or exacerbate asthma and affect exercise quality in children with asthma were also included. The four first-level indicators were weighted evenly, indicating that the system was formulated reasonably. Among these factors, disease-related factors had the greatest weight, indicating that experts believe that the most important factor affecting exercise is the management of asthma. The secondary indicators are patient awareness of their disease diagnosis, asthma control level, medication, first aid knowledge and skills, with effectively balanced weights, and the asthma control level is recognized as the most influential factor. Among the environmental factors, the natural environment is considered more important than the custodial environment. Among the psychological factors, both positive and negative psychological conditions were considered, as a previous study revealed that psychological health influences behavior [29]. Positive psychological status generally helps to improve the effectiveness of practice; conversely, negative psychological status can hinder practice and development. The characteristic of this system is that the evaluation of exercise in children with asthma is not limited to exercise itself, but combines the three aspects of disease, environment and psychology to make a comprehensive evaluation, taking into account various factors affecting exercise in an all-round way, which is conducive to the evaluation of nursing staff and the establishment of scientific and systematic management of exercise in children with asthma.
The scientific nature of the physical exercise evaluation index system for school-age children with asthma
According to the SMART principle(Specific, Measurable, Achievable, Relevant, Time-bound), the initial indicator formulation of the evaluation index system was based on a literature review; literature with Grade A evidence was preferentially selected, and the indicators were developed by combining semistructured clinical interviews. In addition, two rounds of expert correspondence consultations and an analytic hierarchy process were combined with qualitative and quantitative research to form a three-level evaluation indicator system and index weights. In addition, the Delphi expert consensus method was adopted to review and revise the preliminary evaluation index system. To collect comprehensive and scientific views and ideas, 20 experts from related disciplines, such as respiratory and pediatric nursing, medicine, nurse educators, and respiratory rehabilitation, were invited to participate. The Delphi survey was conducted for two rounds until the agreement among the experts was met and there were no further suggestions. The general number of experts required for the Delphi technique is 15–30. At present, there are many exercise prescriptions for children with asthma, but most of them start from the single dimension of exercise, and do not include the evaluation content of disease, environment and psychology. In contrast, the exercise evaluation of asthmatic children in this system is more comprehensive, and pays attention to the evaluation of exercise-related factors.
Impact
In clinical practice, a safe and reasonable physical exercise evaluation index system for children with asthma is lacking, and school-age children have a lower physical exercise safety coefficient than adults do; thus, more guidance is needed. The establishment of a physical exercise evaluation index system for school-age children with asthma has practical clinical significance.
When children with asthma play sports, they are affected by the disease, the environment, exercise conditions and psychological factors. These factors and corresponding measures were carefully and comprehensively considered when developing the physical exercise evaluation system for children with asthma. Therefore, this physical exercise evaluation index system can be used as an evaluation tool for children with asthma and nursing staff can use the relevant indicators of this evaluation system to assess exercise conditions and provide targeted health education regarding physical exercise for children with asthma. Moreover, nurses and other health care professionals, such as doctors and respiratory rehabilitation personnel, can also use the index system to assess the physical exercise of children with asthma and develop effective care plans. Physical activity is an economical and healthy treatment strategy for asthma control. The application and promotion of this system can also help caregivers and patients attach importance to physical exercise, fully understand the relationship between asthma and exercise, and improve the management of asthma through safe and effective exercise programs.
Limitations of the study
This study is an original index built on the basis of literature review and clinical internship, and a three-level evaluation index system formed after two rounds of Delphi expert letter consultation is still lacking in the actual application of indicators to the target population, and will be gradually carried out in the future.
Conclusion
For children with asthma, exercise is a double-edged sword. Levels of physical activity that are too low or too high are related to poor asthma management effects and negative psychological reactions in children. A poor choice of exercise environment and exercise practices may aggravate asthma, preventing individuals from engaging in exercise. The physical exercise evaluation index system for school-aged children with asthma established in this study includes 4 primary indicators, 11 secondary indicators and 50 tertiary indicators, which comprehensively cover the exercise practices of asthmatic children as well as their influencing factors, such as disease factors, exercise environment factors, and exercise psychology factors. In addition, it is practical and operable. The evaluation index system can be used by children with asthma, their caregivers, and health care professionals to monitor the exercise practices of children with asthma and identify influential factors, which can lay the foundation for follow-up targeted interventions aimed at improving exercise practices.
Supporting information
S1 Table. First letter questionnaire template.
https://doi.org/10.1371/journal.pone.0312398.s004
(DOCX)
S2 Table. Second letter questionnaire template.
https://doi.org/10.1371/journal.pone.0312398.s005
(DOCX)
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