Triple A: The Adolescent Asthma Action Program, A Breath of Fresh Air

Primary Health Care Education and Research Unit (PERU), Western Sydney Local Health District

Nature of the problem 

4 students demonstrating pufferDespite advances in knowledge about asthma and medical management, asthma remains the most common chronic illness in youth. The high prevalence of asthma is of particular concern in Indigenous communities, who report smoking at more than double the rate than other Australians.

The Triple A program

Triple A is an award winning, internationally acclaimed, evidence-based peer-led asthma and smoking prevention program. Triple A has the potential to reduce the burden of disease and inequalities in respiratory health in Indigenous and non-Indigenous youth in high schools, through a commitment to address asthma self-management and reduce smoking amongst youth from disadvantaged communities.

The program aims to:

  • improve self-management of asthma and promote the resilience of high school students against smoking
  • develop the leadership of young people to promote asthma and smoke free messages to their family and communities

medical students training Triple A Peer LeadersBy using an innovative student-centered approach, students become the drivers of both the teaching and learning processes. The intervention strategies of the Triple A program are based on a solid theoretical framework of empowerment education (Freire, 1970) and social learning theory (Bandura 1986). A variety of strategies including videos, games, role-plays and quiz shows are used in the program, with the elements of participation and fun being central to all aspects of learning. Through the program students take control of their asthma and develop "refusal skills" for behaviours such as smoking, within a supportive school environment.

Triple A is implemented through a three step process. In the first step, university students, health and education professionals are trained to become Triple A Educators. A one day workshop provides them with the practical knowledge, skills and tools needed to implement the program in a school. As Educators they visit a high school to deliver a one day workshop to train volunteer Year 10 students. The students are guided to critically analyse the issues faced by young people with asthma, such as taking medication, risk taking behaviours such as smoking, visiting their doctor.

Triple A Peer Leaders, in turn deliver three asthma lessons to their younger peers (Years 7 or 8), using the strategies mentioned above. The younger students then disseminate core asthma messages to the entire school community, through creative performances or art. A recent addition to the program is to encourage the younger students take a pledge to remain smoke free for three months as a group or class.


The success of this program has been demonstrated over the last 20 years and has reached more than 20,000 high school students in Australia. The program has proven to make a positive difference to the lives of students with asthma and builds resilience of the students to resist smoking in a supportive school environment. Prior research has demonstrated that Triple A leads to significant clinical improvements in quality of life (QOL), decreasing asthma attacks and school absenteeism.

Feedback from students and staff at schools that have received the program indicate that Triple A is rated highly by all involved. In addition, by involving medical and other health and education professionals as Triple A Educators, the program offers valuable hands-on experience in community action, education and prevention.

More recently the program has targeted schools with high levels of students from Indigenous and refugee backgrounds. In 2011 and 2012, with support of the University of Sydney, the Asthma Foundation of NSW and the Thoracic Society of Australia and New Zealand the program was implemented in schools across Western Sydney, with particular emphasis on reducing the burden of smoking and promoting smoke free communities.

Triple A has gained national and international recognition as an innovative public health and initiative in high school populations. In 2011, the efforts of Associate Professor Shah respiratory health, particularly in socially disadvantaged communities have been acknowledged through the prestigious Presidents Award by The Thoracic Society of Australia & New Zealand (TSANZ).

In the international arena, the program has been promoted in the Canadian asthma guidelines and has been implemented successfully in schools in Jordan. A randomised-controlled trial of the program in Jordan has also just been completed, with positive results in key outcomes such as quality of life and in smoking prevention. It is also being trialled in schools in Detroit (USA) through a National Institutes of Health funded study.

Strategic Importance

The project addresses two national priority areas: asthma and tobacco smoking. It relates to the goals and strategic directions of NSW Health in a number of ways:

  • First, it makes prevention everybody's business by improving adolescent health and well-being, providing education on chronic disease prevention and reducing asthma morbidity risk factors such as smoking
  • Second, it provides an opportunity for future health professional to engage with young people in the community. As such, they act as role models for high school students.
3 students with completion certificates with teachers

Triple A resources

The standardised Triple A Educator's kit and training program have been recently updated. The program resources including three new videos are available on the website of the Asthma Foundation of Victoria, and can be obtained by contacting Dr Smita Shah (please see below contact details).

SALSA and Triple A. University of Sydney

Triple A - Adolescent Asthma Action Facebook page


Publications 1994-2012

  1. Donelly A, Shah S, Bosni-Anticevich S. Effect of two educational interventions on pharmacy students’ confidence and skills in dealing with adolescents with asthma. Health Education Journal, 2012 0(0) 1-8 DOI: 10.1177/0017896912438310.
  2. Al-sheyab N, Gallagher R, Crisp J, Shah S. Peer-led Asthma Education for Adolescents with Asthma in Jordan: A Cluster-RCT. Pediatrics 2012; 129; e106-e112.
  3. Al-sheyab N, Gallagher R, Shah S, Roydhouse J, Crisp J. Peer-led Health Education Program for adolescents with asthma: Does it work for high schools in Jordan? EMHJ. 2011; 18(5): 468-473.
  4. Saini B, Shah S, Keary P, Bosnic-Anticevich S, Grootjans J, Armour C. An Interprofessional Learning Module on Asthma Health Promotion. Am. J. Pharm. Edu 2011; 75(2): Article 30.
  5. Shah S, Roydhouse JK, Sawyer S. Medical Students go back to school: The Triple A Journey. Australian Family Physician 2008; 37(11): 952-4.
  6. Kritikos V, Saini B, Bosnic-Anticevich, Krass I, Shah S, Taylor S and Armour C. Innovative asthma health promotion by rural community pharmacists: a feasibility study. Health Promotion Journal of Australia, 2005: 16 (1) 69-73.
  7. Shah S, Peat JK, Marzurski EJ, Wan H, Sindhusake D, Bruce C, Henry RL, Gibson PG. Peer-led asthma education improves quality of life and asthma morbidity in adolescents: a randomised controlled trial. BMJ 2001; 322:583-5.
  8. Shah S, Cantwell G. Adolescent Asthma Action Project 1993-2000, Final Report, Commonwealth of Australia 2001. ISBN 0 642 73566 2.
  9. Triple A Educator's Kit, Commonwealth of Australia 2000. ISBN 1 876109831.
  10. AAA Champion’s Guide, 2001.
  11. Boulet LP. A peer led asthma education programme in adolescents was more effective than no programme for improving quality of life. Evid Based Med 2001;6 148.
  12. Gibson PG, Shah S, Mamoon HA. Peer-led asthma education for adolescents: Impact evaluation. Journal of Adolescent Health 1998; 22: 66-72.
  13. Shah S, Mamoon HA, Gibson PG. Peer-led asthma education for adolescents: Development and formative evaluation. Health Promotion Journal of Australia 1998; 8: 177-181.
  14. Shah S, Mazurski E, Wang H, G Cantwell, Gibson P. Asthma morbidity in young people in rural NSW: A Time for Action. 5th National Rural Health Conference, Adelaide. National Rural Health Alliance Publication 1999.
  15. Shah S. The Adolescent Asthma Action Program. Masters of Community Health Thesis University of Sydney Library, 1994.


  1. Freire P. Pedagogy of the Oppressed. New York: Seabury Press, 1970.
  2. Bandura A. Social foundations of thought and action. Englewood Cliff: Prentice-Hall; 1986. 


Director, Primary Health Care Education & Research Unit (PERU)
Western Sydney Local Health District
Phone: 02 9845 6505


Date created: 14th Oct 2008 | Date reviewed: 31st Jul 2013