الفهرس 
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Abstract
Health education is an essential nursing intervention for school-age children with chronic diseases particularly BA to maintain child conditions without further complications, decrease asthma severity, lowering mortality rates, and reduce risk behaviors. Thus, there are varieties of teaching methods that can be used in health education to enable school-age children to acquire these desired outcomes. One of the most commonly used methods is GBL. Game-based learning strategies in health education are one of the innovative active teaching strategies that health educators can use effectively in educating children to change their behaviors, encourage children to cope with chronic disease, active participation, and increase concentration among children. It also enhances their learning motivation. Despite the many benefits resulting from the use of game-based learning in nursing and health education fields, it is costly to design digital games and conflict between game objectives and learning objectives.
The aim of this study is was
Todetermine the effect of breathing exercises game-based learning on asthmatic children’s respiratory health and their learning motivation.
The following hypotheses were examined and approved in the current study:
1. Asthmatic children who are instructed by a game-based learning strategy exhibit better respiratory health scores than those who do not.
2. Asthmatic children who are instructed by a game-based learning strategy exhibit higher learning motivation level than those who do not.
Research design:
A quasi-experimental research design was used in this study.
Setting:
This study was conducted at the pediatric allergic center in Smouha clinic, which is affiliated with Health Insurance Hospital, in Alexandria, Egypt (outpatients’ section).
Subjects:
The subjects of this study included seventy (70) asthmatic children who were selected by convenience sampling technique and who regularly visited the previously mentioned settings, and fulfilled the following criteria: aged from 6 to 12 years, confirmed diag¬nosed with bronchial asthma and received treatment at least for one year, visits the pediatric allergic center regularly in the Smouha clinic for follow up (every one or three months), and free from any other diseases.
Two tools were used in this study for data collection:
Tool I: Pediatric Respiratory Assessment Measure (PRAM).
This tool was developed by (Ducharme et al., 2008) to measure the level of respiratory health through determining the severity of the child’s asthma. It was adapted by the researcher after a thorough review of related literature (Herzog&Rundles, 2012; Mabrouk, 2004; Mohammad, 2016) to assess the respiratory health condition of the child during bronchial asthma attacks regarding the characteristics and clinical symptoms of bronchial asthma attacks, absenteeism from school and hospitalization due to asthma attacks, frequency of asthma treatment, and physical examination. It consisted of 15 questions.
Tool II: Asthmatic children’s Learning motivation Questionnaire (ACLMQ).
This tool was developed by (Vallerand et al., 1992) toassess students’ learning motivation. It was modified by the researcher to be congruent with the study aim and to match its utilization in the clinics, not in the classroom. It consists of 26 statements with a 5-point Likert scale ranging from strongly disagree (1) to strongly agree (5).
Method:
Approval from the Research Ethics Committee (REC) of the Faculty of Nursing, Alexandria University was obtained.
Official permission to conduct the study was obtained.
Informed consent was taken from the subjects.
Tools were modified by the researcher after a thorough review of related literature to be congruent with the study aim.
Tools were tested for their content validity by five experts in the nursing education, pediatric nursing, and psychiatric nursing fields, and then the necessary modifications were made.
A pilot study was conducted on 7 asthmatic school children, out of the sample size, to test the tool’s clarity and applicability. All needed modifications were done.
Tools were tested for reliability using Cronbach’s Alpha test. The tools were reliable and their coefficient values were 0,710 and 0.978 for tool I and tool II Respectively.
Data was collected over six months from October 2021 to March 2022.
The study was conducted through three phases: preparation, implementation, and evaluation phase.
Phase (I): Preparation phase: During this phase, the researcher, the teaching content, the learning environment, and the asthmatic children and their caregivers were prepared.
Phase (II):Implementation phase: A pre-test was done for study and control groups using the study tools on an individual basis interview as a first assessment.
For the study group: The researcher prepared the asthmatic children and their caregivers, assuring them that the proposed nursing interventions were safe and would not negatively affect their health and explaining the rules that must be followed in the intervention. In this phase, breathing exercises were taught to asthmatic children and their caregivers using the game-based learning strategy through two parts; theoretical and practical.
For the control group:the control group received routine care at the pediatric allergic center without any interference from the researcher.
Phase (III): Evaluation phase
- After four weeks, each asthmatic child in the study group was assessed individually, and after three months after the implementation of the proposed nursing interventions using study tools.
- Moreover, asthmatic children in the control group were assessed individually after four weeks and three months after receiving routine care from the pediatric allergic center using the study tools.
- To evaluate the effectiveness of the proposed breathing exercises nursing interventions using gaming, the researcher compared the differences between the pretest, the fourth week, and after three months scores of the study tools that were used with the asthmatic children in both the study group and the control group.
- Statistical analysis: data were organized; computerized; tabulated and analyzed using quantitative and qualitative approaches.
Results of this study:
The main results of the current study revealedthat:
There was a highly statistically significant differences between both groups after 4 weeks and after 3 months of applying breathing exercises game-based learning strategy in relation to using breathing exercises (p 0.000* and 0.000* respectively) in favor of the study group.
There were a highly statistically significant differences between both groups in relation to the severity of bronchial asthma attacks after 3 months of applying the intervention ( p=0.001*) in favor of the study group.
There was a highly statistically significant differences between both groups in relation to the learning motivation levels after 4 weeks and after 3 months of applying the intervention (p=0.000* and 0.000* respectively) in favor of the study group.
There was no statistically significant correlation was detected between the asthma severity and learning motivation levels for both groups before, after 4 weeks, and after 3 months of applying the intervention. But, it was noticed that (91.4%) of the study group had a high level of learning motivation, and, at the same time, no one in this percentage had severe asthma after the intervention by 3 months.
It can be concluded from the present study that:
game-based learning is a valuable intervention in the field of child health education to monitor asthma severity among school-age children with bronchial asthma. GBL is important in reducing the frequency of asthma-related symptoms and pulmonary inflammation, as well as, improving exercise capacity, asthma control, and quality of life. In addition, GBL motivates children to learn through this style of active learning, and this motivation is prognostic of the attainment of learning outcomes. Furthermore, GBL offers an interesting and attractive learning method for healthcare professionals and children to encourage patients learning retention of knowledge and the development of skills, and mainly, it is recommended for implementation, particularly in the clinical application of health education.
The main recommendations of this study:
Educational workshops should be conducted for all clinical nurse educators about game-based learning strategies to increase their competencies in applying them.
Game-based learning should be integrated into the nursing curriculum as an educational tool in the pediatric nursing field.
Nurse educators should use game-based learning in combination with traditional clinical learning with nursing students or asthmatic children.
Breathing exercises using a game-based learning handout should be given to all nursing staff and asthmatic children.
Educational workshops should be conducted for all pediatric nurses about game-based learning to develop their competencies in applying different types of breathing exercises using games for children with respiratory disorders.
Extending the duration of breathing exercises using game-based learning to 6 months or for one year to obtain a more valid result, better case improvement, and reduction of asthma severity among children.
Application of breathing exercises using game-based learning, alongside traditional treatment modalities, is recommended to be provided for children with asthma or with other pediatric illnesses.
Breathing exercises using game-based learning should be integrated into routine clinical practice for all nurses in pediatric care settings.
Counseling sessions for nurses and asthmatic children, and their families are recommended to empower them and help them overcome educational difficulties in pediatric health education.