Despite impressive advances in knowledge about asthma, it remains a significant health problem in Australia, in particular the management of adolescent asthma. The Triple A (Adolescent Asthma Action) program was implemented across schools in Auburn (western Sydney). It is an innovative, peer-led approach, to improve asthma self-management in young people. Specifically, Triple A leads to significant clinical improvements in quality of life (QOL), decreasing asthma attacks and school absenteeism.

In addition, by involving medical and other health and education professionals as educators, Triple A offers valuable hands-on experience in community action, education and prevention.

An unexpected program benefit has been that through role modelling, high school students in rural, indigenous and disadvantaged communities have been encouraged to aspire to university education.

To improve adolescent asthma self-management and reduce health harming behaviours such as smoking in a supportive school environment.

Two million Australians have asthma (Asthma Foundation, NSW). Inappropriate asthma management can lead to multiple negative health outcomes, including school absenteeism and emergency department presentation.

Adolescent asthma management is especially challenging due to increased risky behaviours which exacerbate asthma morbidity (Sawyer and Shah 2004), and traditional educational engagement is less effective due to developmental and behavioural changes.

The Triple A program arose from a need to improve management of asthma in secondary schools in Auburn. The combination of high asthma prevalence as well as the relative ineffectiveness of traditional educational methods identified the need for a new approach in order to work effectively with adolescents.

Asthma is a significant health problem in Australia. One in eight Australian adolescents has asthma (DoHA). Inadequate education and poor understanding of asthma has long been noted as a concern for adolescents with asthma.

The Triple A program is the first peer-led program that has attempted to address this gap. Continuous concerns from high schools in the Auburn Municipality regarding the high rate of asthma attacks in their students led to the development of the Triple A program. Schools provide an appropriate setting for health promotion as they have the capacity to affect the lives of students, staff and families. This is especially relevant for Indigenous, non-English speaking, and rural communities. In addition peer-led education has been shown to be an effective method for engaging adolescents about health issues (Shah et al 2001). The involvement of older peers such as medical students in peer-led education with adolescents has also been shown to be effective as well as beneficial for both parties (Towle et al 2006).

The project relates to the goals and strategic directions of NSW Health in three 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 creates better experiences for people using health services by having future clinicians engage with their community.

Finally, it also builds a sustainable health workforce by contributing to future health professionals’ training, in particular improving future health professionals’ knowledge of asthma, primary health prevention, and the benefits of community health outreach.

In 1993, The Triple A program was developed following a needs assessment and focus groups held with students, staff and parents in Auburn schools.

A literature review was conducted in developing an effective program to educate adolescents aasthma (Shah, 1994) and with support from Asthma Foundation of NSW; a peer-led approach was employed to improve self management of asthma in adolescents.

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 11 students as Asthma Peer Leaders, who in turn deliver three asthma lessons to their younger peers, using the strategies mentioned above.

The younger students then disseminate core asthma messages to the entire school community, often several hundred pupils and their families through brief performances such as drama, songs and dance.

Since its inception, the program has been implemented in schools across Australia and has reached more than 20,000 high school students in Australia and is now an integral component of the National Asthma Friendly Schools Project in secondary schools.

The Triple A program has undergone rigorous scientific review and testing, including a randomised controlled trial in schools in Tamworth, NSW (Shah et al 2001).

Students in the intervention schools experienced significant improvement in QOL and decreased asthma attacks and school absenteeism compared to the control schools. Triple A has also undergone subjective testing and evaluation, over e well accepted and highly rated by participating students and staff (Shah et al, 2008).

“….Through my involvement in the program, I not only gained practical experience in health prevention but also learned first hand how empowering knowledge can be in fighting health problems” - Medical student

Findings from the Triple A program have been presented at numerous national and international conferences. In addition, the results have been published in prestigious journals such as the BMJ and Evidence-Based Medicine. The program has received significant international recognition, including citation as an exemplary program in the Canadian National Asthma Guidelines, the Asthma Health Outcomes Project (USA) and the BioCommunications Associations (USA). A randomised-controlled trial of the program in Jordan has also just been completed, with equally 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.

Triple A is now an integral component of the National Asthma Friendly Schools Project in secondary schools. Through recent funding from Commonwealth Department of Health and Ageing we have updated the program manuals and videos to be hosted on the  Asthma Foundation website. Training programs will be made available through the Foundation. The program is also currently being tested at the University of Sydney as an inter-professional learning subject. In this subject, university students from pharmacy, nursing and medicine will deliver the program in schools in partnership with the national Asthma Friendly Schools Program. If continued, this approach will ensure sufficient numbers of Triple A educators to sustain the program and its vital benefits.

Triple A provides dual benefits by enhancing the education of future health workforce members while empowering adolescents to manage asthma appropriately, thus reducing asthma morbidity. The standardised Triple A Educator’s kit and training program which have been recently updated make it easily transferable across health services and settings. The program resources including three new videos will be made available freely on the website of the Asthma Foundation.

The program model is applicable to address a range of chronic diseases and has been successfully adapted to prevent obesity and overweight in adolescents through the Students As Lifestyle Activists (SALSA program).

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3. Sawyer SM, Shah S. Improving asthma outcomes in harder-to-reach populations: challenges for clinical and community interventions. Paediatr Respir Rev 2004; 5: 207-213.
4. Australian Government Department of Health and Ageing; HealthInSite, Asthma. [last accessed 4 April 2012].
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6. Towle A, Godolphin W, Van Staalduinen S. Enhancing the relationship and improving communication between adolescents and their health care providers: A school based intervention by medical students. Patient Education and Counselling 2006; 62:189-192.
7. Shah S, Roydhouse JK, Sawyer SM. Medical students go back to school: The Triple A journey. Manuscript accepted by Australian Family Physician to be published November 2008.
8. Freire P. Pedagogy of the Oppressed. New York: Seabury Press, 1970.
9. Bandura A. Social foundations of thought and action. Englewood Cliff: Prentice-Hall; 1986.
10. Bosnic-Anticevich SZ, Krass I, Shah S, Saini B, Armour C. Comparison of two methods of training of undergraduate pharmacy students in asthma knowledge confidence and skills. Am J Respir Crit Care Med 2002; 165(8):A709.
11. Ming L, Shah S, Roydhouse JK, Lim K-S, Dibley MJ. Students as Life Style Activists (SALSA): Program feasibility and process evaluation of a peer-led approach to prevent obesity in high school students in Australia. Manuscript in preparation.

Associate Director - Clinical Governance, Clinical Governance Unit
Sydney West Area Health Service
Phone: 02 9881 7524