Giving the Green Light

d02b.JPG (14016 bytes)Camp Green Zone was created to provide children with asthma the tools and knowledge they need for self-management while participating in typical summer camp activities.

Asthma has the unwelcome distinction of being the most common chronic condition in children, and one for which patient compliance is often a problem. In fact, the American Lung Association (ALA) reports that the incidence of patients not complying with their treatment regimens can range as high as 70%.1

Teaching children better management strategies is obviously of high priority in the quest to reduce asthma’s impact on quality of life, and one effective method of doing so involves teaching in environments that make learning enjoyable. According to the Consortium on Children’s Asthma Camps, “lessons initially acquired because they are fun evolve into lifelong asthma management skills that contribute to happier, healthier lives.”2

Asthma camps fit perfectly into this principle, as Rose Splitgerber, RN, manager of pediatrics at York Hospital, York, Pa, has witnessed over her 17-year career as a nurse. During that time she gained significant experience with asthma camps and saw firsthand how effective they could be. When Splitgerber became manager in 1995, addressing the facility’s lack of an asthma education program became a priority.

“Knowing that about 5% of the population has asthma, I persuaded the hospital to look at the statistics in York to determine the need in our community,” Splitgerber says.

York’s marketing and community relations/health promotions department compiled statistics from the ALA and conducted a survey of school nurses in the county. They found that in York County, school nurses identified approximately 2,000 children between the ages of 6 and 13 who had asthma.

“We looked at the hospital statistics and found that asthma was the number one admitting diagnosis for children in inpatient units,” Splitgerber says. “Our emergency department saw an additional 450 visits per year of children with asthma. We estimated that all this cost about a half million dollars per year. With such statistics, it was clear that York definitely could support an asthma program.”

d02b.JPG (14016 bytes)The resulting program, Camp Green Zone, has been a collaborative effort from the beginning, involving many departments within York Hospital as well as community resources. Staff and instructors are provided by the hospital’s pulmonary department, the hospital’s volunteer department offers assistance, and York’s pharmacy and risk management department looks over the camp’s consent forms to make sure they met the appropriate standards. York also collaborated with a local chapter of the ALA, which provides handouts and an instructor, and several area companies. A local communication company provides walkie-talkies, other community businesses supply the necessary medications, and durable medical equipment companies provide nebulizers.

“This year we have had additional support from other local places, such as York Respiratory and Medical Equipment Company, CPO2, American Home Patient, Apria, and Wasserotts, which provides a cash contribution as well as a representative every year,” says instructor Ann Wilson, RRT. “Some of those companies also send RRTs for half-days all week, while some send their therapists every day.”

“We have been able to use the same staff and instructors every year, and thus the camp is blessed with great consistency,” says Splitgerber, who spends 10 months out of every year overseeing the project, and during that time fields calls for requests to make donations.

Volunteer support
Volunteer support from the community over the years also has included an emergency preparedness class, help from the local police and ambulance service, and a visit from the Life Line Airflight ambulance from Penn State. Since York Hospital does not have a facility for the camp at the hospital, it has utilized two college campuses over the years: York College and Penn State’s York campus.

“We have had great collaboration with the school nurses, who are a major referral base to the camp,” Splitgerber says. “Overall, it has been a good experience getting to know them and showing them what we have to offer so we can become a resource.”

In fact, utilizing school nurses has proven to be the best strategy for reaching potential campers, who come from across York County and are between the ages of 7 and 13. Cost to attend the camp is a $50 fee included in the application, and scholarships are available through the York Hospital Women’s Auxiliary.

“Generally, we contact the nurses by telephone early in the year and send out a generic camp information flyer,” Wilson says. “The official applications are then sent in March. The hospital also takes out advertisements in the local newspaper.”

Camp Green Zone is held for 1 week a year in the summer, from 8 am to 5 pm each day. Though it initially served 30 children each year, Camp Green Zone has expanded over time and now accommodates 45 attendees annually. While first-time campers get preference for attending, Wilson says there always is a small percentage of repeat attendees, and the instructors try to compensate for what those children may have previously learned at the camp.

Primary Goals
In keeping with the primary goals of Camp Green Zone—to provide attendees with the knowledge and tools they need for self-management while participating in typical summer camp activities—a range of daily classes are interspersed with fun activities.

“The camp features all the typical activities of a summer day camp as well: fitness, arts and crafts, and swimming,” says Wilson, who became involved with Camp Green Zone in 1997. “There was a pool on the York College site, but Penn State doesn’t have that so we go off-site for swimming about 3 days a week. The arts and crafts program will focus on everything from assembling and painting wooden birdhouses to tie-dying T-shirts. Last year, the camp also incorporated music.”

“We worked with some of our adult pulmonary rehabilitation patients who visited the camp and played harmonicas for the kids,” says Cathy Hendrix, RRT. “One gentleman in his late 70s talked to the kids about how, when he grew up, there were no televisions or radios, so he played the harmonica for enjoyment. We did this early in the week, and by the end of the week the kids had learned a song to play to their parents. It was a great way to teach them how to control their breathing, and they loved it.”

In addition, the instructors are matched with a class for the entire day, and follow them through all their activities. Hendrix, who has been a camp instructor for 4 years and focuses on children ages 10 through 13, says this method works well.

“I find that it works really well to have the kids for a solid week,” says Hendrix, who teaches anatomy, peak flow readings, and asthma management and care planning. “Fifteen years ago, I did evening instruction with kids four evenings over a month’s time period and there was not the same continuity. In day camp, the kids have fun and incorporate learning into those activities. For instance, when they are playing and become short of breath, they can learn some relaxed breathing techniques or how to set their peak flow meter. That’s more effective than explaining such techniques in a classroom setting.”

Even when the kids are having fun, the camp intentionally stresses the decision-making process, according to Splitgerber. “For example, using peak flow readings, we want to show kids how they can make good asthma management choices,” Splitgerber says. “The camp also teaches proper use of all the paraphernalia involved with asthma management so they get the maximum benefit. Those two factors are very much responsible for some of the nice results that we get.”

Camp Green Zone is very aware of its outcomes, which it measures through pre- and post-camp tests. These tests monitor the program’s effectiveness by measuring knowledge level, behaviors, and attitudes.

“The short-term impact is that the campers all relax after the first day, when they realize that everyone has asthma,” Hendrix says. “Friendships grow as well, especially among the girls.”

There is a long-term impact as well, which was evidenced in an abstract and a poster put together by Wilson and Hendrix and presented at last year’s Open Forum at the American Association for Respiratory Care International Congress. The poster showed that children attending the camp demonstrated improvements in cognitive measures of their asthma, and that the effects appeared to improve asthma control at 3 months.

Over a 4-year period, 160 campers participated in Camp Green Zone, and outcome results were evaluated according to age group: 6 to 7, 8 to 9, and 10 to 13. According to Wilson and Hendrix’s research, the youngest group developed a mean increase in asthma knowledge of 19%, an improvement in behavior and management skills of 14%, and an improvement in attitude of 9%. The 8- to 9-year-olds had increases of 15%, 11%, and 3%, respectively, while the oldest group showed increases of 17%, 16%, and 11%. The overall response rate from parent surveys indicated that 84% of families had fewer disruptions from asthma, with 82% reporting less severe episodes.

“In terms of anecdotal notes, camps like this appear to impact the child’s self-esteem,” Splitgerber says. “The feedback from parents is that their children’s self-esteem is improved by being around other kids with asthma. Within the camp, they are in an environment where everyone is taking medications and checking their peak flow meters, and that really normalizes the experience for them.

“The camp has helped kids make good choices about what they are supposed to be doing and about how to manage their asthma,” Splitgerber continues. “The parents typically report that the family has experienced less disruption in their life because of the asthmatic child, which is a big morbidity factor in the statistics.”

Family Value
Though concrete statistics perhaps carry more clinical weight, Wilson says that sometimes what families say is so much more valuable. She cites a recent letter from the mother of a 7-year-old girl who attended the camp. When the girl was first diagnosed with asthma, the school would call home three or four times a week because of her breathing difficulties. As a result, the parents and the child were nervous about her going away to camp.

“She loved it, and the whole family learned more about asthma,” Wilson says. “Afterward, the little girl asked if someone had to have asthma to go to the camp, and she said she wanted to outgrow all but a little of her asthma so she could go again. Through her experience there, the girl learned that she can do anything she wants as long as she monitors her breathing. The parents said that increased her confidence in everyday situations, and now she has an attitude of ‘I have asthma, but so what—I can do anything.’

“This camp represents a high comfort level for asthmatic kids, as well as a great opportunity for hands-on activity,” continues Wilson, whose own child is asthmatic and has attended camp twice. “I have gotten letters of gratitude that talk about how the camp really made a difference in the daily lives of the kids and their families. My son wants to go again this year, but we want to give other children an opportunity to participate.”

Liz Finch is a contributing writer for RT Magazine.

1. American Lung Association fact sheet. Available at: html. Accessed May 17, 2002.
2. The Consortium on Children’s Asthma Camps information page. Available at: Accessed May 17, 2002.