Introduction

Asthma is the most common chronic disease affecting children worldwide, with a global prevalence of approximately 10%1,2,3. Children with asthma, especially those below 10 years old, often rely on adults for support, as they may lack the capacity to independently manage their asthma4,5. Children depend on parents and teachers to assist them at home and in school, respectively. However, schools in low- and middle-income countries (LMICs) lack in supporting asthma self-management due to the absence of a school asthma guideline and training6,7. The World Health Organization (WHO) recommended that school staff support the self-management of children with asthma and receive training to act as first-line responders during asthma emergencies8,9,10.

Studies have highlighted gaps in school staff’s knowledge and preparedness in managing asthma, leading to delays in treatment and increased risk during emergencies6,7,11,12. Several studies have shown that school staff often lack adequate training in asthma management and may hold misconceptions about asthma symptoms, medication use, and triggers5,9,13,14. In response, various asthma education interventions, including pamphlets, personalised action plans, structured training, and pharmacist-led sessions were conducted and proven effective in improving school staff’s knowledge and confidence across different countries, including Malaysia15,16,17,18,19,20,21. However, widespread implementation of face-to-face training remains challenging due to logistical and financial constraints, especially in rural or under-resourced settings22. Online training has emerged as a scalable and accessible alternative, but evidence of its effectiveness remains limited. Therefore, this systematic review aims to assess the effectiveness of online asthma training programmes for school staff.

Methods

This systematic review was registered on PROSPERO (registration number: CRD42024562546) and conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines23.

Study eligibility criteria

All randomised controlled trials (RCTs), non-randomised controlled studies, and pre-post studies were included if they assessed the effectiveness of online asthma training programmes. These study designs allow for before-and-after comparisons, which are essential for assessing the effectiveness of training programmes. RCTs and non-randomised studies can help control for confounding variables, while pre-post designs provide baseline and follow-up data to measure learning outcomes. Studies were included if the online asthma training programmes were developed for teachers, final-year Bachelor of Education students, classroom assistants (staff who support teachers with classroom activities), and school nurses. In some systems, school nurses are responsible for student health, whereas in others, this role is undertaken by a designated teacher or classroom assistant. Therefore, we consider these groups collectively as school staff. Training programmes could be in any format, such as webinars, training courses, live virtual classrooms, or eBooks. To assess the effectiveness of the programmes, studies must measure asthma knowledge before and after the training as one of the study outcomes. Original studies published in English and available as full-text were included. Articles were excluded if they were published solely as editorials, commentaries, brief reports, expert opinions, case studies, or conference abstracts.

Information sources and search strategy

A literature search was performed in June 2024 across six databases: PubMed, CINAHL, Scopus, Web of Science, ProQuest, and Education Research Complete using a search strategy based on the PICO (Population, Intervention, Comparison, Outcome) method24. Keywords used were “asthma”, “technology”, “school”, and “teacher”. A combination of Medical Subject Headings (MeSH) and free text terms was used to define the search terms. The full search strategy is added as Supplementary Material 1. Reference mining was performed (via forward and backward citation tracking) to identify additional relevant studies. Additionally, nine experts were contacted for study recommendations: eight were corresponding authors of the included studies, and one was a paediatric asthma expert.

Study selection

Results of the search strategies were combined to yield a pool of preliminary studies. All studies downloaded from the databases were uploaded to Rayyan AI (https://www.rayyan.ai/) (Massachusetts, United States of America), a web-based software designed to assist with conducting systematic reviews25. Duplicate studies with the same title and author were excluded via EndNote (version 21) and Rayyan AI. Titles and abstracts were reviewed independently by authors MAIJ and MK for relevance. Full texts of any relevant titles/abstracts were retrieved and assessed for inclusion. Any discrepancies were resolved through discussion between the two reviewers or by consulting a third reviewer, CHT.

Quality assessment

The quality of each study was assessed independently by authors MAIJ and MK using the Mixed Methods Appraisal Tool (MMAT, version 2018)26. MMAT allows for the assessment of different study designs, including qualitative, quantitative, and mixed methods studies. It consists of five criteria that address specific methodological concerns specific to the study design. For clarity and ease of interpretation, we chose to present the MMAT scores for the included studies, ranging from 0% (none of the quality criteria are met) to 100% (all quality criteria are met)27. All corresponding authors were contacted to clarify items rated as “Can’t tell” in the MMAT. In cases where clarification could not be obtained, scoring was based on the best interpretation of the available information.

Data extraction

Data was extracted and recorded independently by authors MAIJ and MK in a standardised extraction form. When disagreements occurred between the two reviewers, they met to discuss the issues that were raised. After reviewing the evidence, the two reviewers then reached a consensus via discussion or were resolved by consulting a third reviewer, CHT. The included articles were categorised into different levels using the Kirkpatrick evaluation model, facilitating the analysis and presentation of findings28,29. The four levels are: (1) level 1 (reaction): assessment of participants’ reactions to the training or learning experience; (2) level 2 (learning): change in participants’ knowledge or skills; (3) level 3 (behaviour): change in participants’ behaviour; (4) level 4 (results): change in organisational practice. All corresponding authors were contacted to obtain any missing or incomplete data.

Data synthesis

Extracted data were synthesised using the Kirkpatrick evaluation model, which offers a structured approach to assess both short- and long-term impacts of training interventions and enables consistent comparisons across diverse study designs29. A narrative synthesis was conducted to identify key patterns in training effectiveness30. Effect size was assessed using Cohen’s d. Outcome measures were presented as mean and standard deviation (SD). A Cohen’s d of <0.2 indicates a small effect, 0.2–0.6 is considered a medium effect, and >0.6 suggests a large effect31.

Results

Study selection

Eight studies were included in this systematic review (Fig. 1).

Fig. 1
figure 1

PRISMA diagram for identification and selection of studies.

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General characteristics of included studies

The systematic review included eight studies conducted across two countries – two in Australia32,33 and six in the United States of America (USA)34,35,36,37,38,39. The studies employed different designs, primarily six pre-post studies33,34,35,36,37,38, one RCT32, and one non-randomised controlled study39. Sample sizes ranged from 10 to 369 participants. Participants were schoolteachers32,36,37, school nurses32,34,35,38,39, classroom assistants32, final-year Bachelor of Education students33, and administration staff32 (Table 1).

Table 1 General characteristics of the included studies.
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Overall intervention characteristics

The online training programmes varied in delivery and content. Asynchronous formats refer to learning methods where participants learn at their own pace without real-time interaction. These included eBooks32, PowerPoint presentation36, and web-based training programmes33,34,35,37. In contrast, synchronous formats involve live interactions with instructors and were delivered through platforms such as Google Classroom38 and Wimba Live Classroom39. Most online training programmes typically lasted for one hour32,33,36,37,38. The content of the interventions commonly covered basic asthma knowledge32,33,34,35,36,37,38,39, asthma triggers and symptoms32,33,34,35,36,37,38,39, asthma management32,33,35,36,37,38,39, and asthma medications32,33,34,35,36,37,38,39. One study included broader school-relevant topics such as asthma myths and facts38. Some incorporated national guidelines like the Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma and the National Institute of Health (NIH) National Asthma Education Prevention Program (NAEPP) to ensure evidence-based practice34,39. Interactive features such as quizzes, videos, and case scenarios were also used to enhance engagement and learning32,33,34.

Out of the eight included training programmes, four were accessible for direct review: Teaming Up for Asthma Control by the University of Missouri34, Asthma First Aid for Schools by Asthma Australia33, Asthma Basics37, and Kickin’ Asthma by the American Lung Association (ALA)35, though the latter required a fee. The remaining four online training interventions were not accessible at the time of review and attempts to contact the corresponding authors were unsuccessful32,36,38,39. Accessibility was assessed to determine whether the training programmes were still available in their original version, acknowledging that some may have been removed, revised, or updated. If newer versions were identified, they were clearly stated. As the latest versions may differ from those used in the original studies, all data on intervention characteristics and outcomes were extracted solely from the information reported in the published articles.

Knowledge questionnaire used

Six studies used validated questionnaires to assess asthma knowledge, such as the Asthma First Aid Knowledge Questionnaire (AFAKQ)32,33, the Newcastle Asthma Knowledge Questionnaire (NAKQ)36, standard tests by the ALA37, the Asthma Knowledge Survey38, and the School Personnel Questionnaire (SHPQ)39. Two studies used a self-developed instrument34,35. The questionnaires ranged from 11 to 31 items in length and typically included open-ended, true/false, or Likert-scale questions.

Quality assessment

The overall quality of the studies varied, with scores ranging from 40 to 80%. Luckie et al.33 and Nowakowski et al.37 achieved high-quality scores of 80%33,37. Hacker-Talyor35, McAuliff36, Nwabuzor38, and Putman-Casdorph and Pinto39 obtained a moderate score of 60%35,36,38,39, while Francis et al.32 and Francisco et al.34 scored 40%32,34 (Table 2).

Table 2 Quality assessment of included studies.
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Summary of outcomes measured

The included studies evaluated the effectiveness of online asthma training programmes for school staff using various outcome measures. Overall, all eight studies32,33,34,35,36,37,38,39 demonstrated positive outcomes at level 2 (learning), with two studies35,37 also reporting positive outcomes at level 1 (reaction). However, no study extended its evaluation to include observable behaviour change (level 3) or organisational outcomes (level 4).

Kirkpatrick level 1: reaction

Only two studies35,37 evaluated participants’ satisfaction with the asthma training programmes (Table 3). Both reported high levels of satisfaction, with participants perceiving the content as relevant and valuable for managing asthma in school environments. In the Kickin’ Asthma intervention, 56% of participants expressed being very satisfied with the training35. Similarly, 83% of participants in the online Asthma 101 programme were very or somewhat satisfied with all aspects of the training37. Notably, participants found the section on recognising signs and symptoms of respiratory distress to be the most useful.

Table 3 Impact of asthma online training on school staff’s perception and skills.
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Kirkpatrick level 2: learning

All eight included studies evaluated changes in asthma knowledge by comparing pre- and post-intervention scores using various asthma knowledge questionnaires, including validated tools such as the AFAKQ32,33 and the NAKQ36. All studies reported improvements in asthma knowledge scores post-intervention (Table 4).

Table 4 Impact of asthma online training on school staff’s knowledge.
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The extent of knowledge improvement following the training varied, with percentage score increases ranging from 2.439 to 84.7%34. Similarly, effect sizes ranged from a small effect of d = 0.13839 to a very large effect of d = 3.40936, reflecting significant differences in the magnitude of knowledge gains. Two studies that compared the outcomes with a control group reported no significant difference in the knowledge between online training and face-to-face training post-intervention32,39.

In addition to improvements in knowledge, several studies also assessed perceived learning outcomes, such as self-confidence and skills in managing asthma (Table 3). Four studies (50%)32,35,38,39 reported increases in school staff’s self-confidence or self-efficacy in managing asthma following the intervention. In contrast, practical skills were assessed less frequently. Only one study assessed asthma first aid skills using scenario-based assessments33, while another measured asthma management and communication skills through the SHPQ39. These assessments, although practical in nature, still fall under level 2 as they reflect demonstrated learning in simulated or self-reported contexts rather than observable behavioural changes in real-life school settings.

Discussion

This systematic review identified eight studies examining online asthma training programmes for school staff, conducted between 2011 and 202332,33,34,35,36,37,38,39. All included studies were from high-income countries and focused on immediate knowledge gains. The overall quality of the included studies varied, with only two studies rated as high quality33,37, which is an important consideration when interpreting the findings. All studies demonstrated significant knowledge improvements in effect size with more than 50% reporting medium to large effect sizes (Cohen’s d range: 0.537–3.409). Furthermore, direct comparisons between online and face-to-face formats found no significant difference in learning outcomes32,39. However, none evaluated longer-term behavioural or organisational outcomes, representing a critical evidence gap.

The positive outcomes observed at Kirkpatrick levels 1 and 2 establish a foundation for effective online asthma training32,33,34,35,36,37,38,39. The improvement in knowledge scores and high satisfaction ratings indicate that participants found the training relevant and engaging. These findings align with evidence from other fields, such as virtual training in nursing and sexual health education, where participants reported increased knowledge and satisfaction with e-learning content40,41. This is particularly important in the school context, where school staff often have limited time for professional development and may feel unprepared to manage students with asthma8. The inclusion of self-efficacy measures in some studies further supports the idea that participants not only gained knowledge but also felt more confident in their ability to respond to asthma emergencies32,35,38,39. The training programmes covered a wide range of topics, including asthma pathophysiology37,39, symptom identification32,33,34,35,36,37,38,39, medication use32,33,34,35,36,37,38,39, and provision of first aid for asthma32,33,35,36,37,38,39, which reflects a comprehensive approach to asthma education. However, the use of scenario-based assessments in several studies suggests that knowledge alone may be insufficient for effective real-world application32,33.

A key issue in the current evidence is the variation in how asthma knowledge was assessed. For instance, the NAKQ includes open-ended questions that may be too complex for school staff, potentially limiting its suitability36. Several studies used self-developed questionnaires, which were not validated34,35. While these tools may be tailored to the training content, the lack of standardisation makes it difficult to compare results across studies and ensure accurate measurement of knowledge change. Developing validated instruments specifically for school staff would allow for more consistent evaluation of training outcomes.

Although knowledge gain is essential, true impact depends on demonstrating safer practices (level 3) and organisational improvements (level 4). The predominance of single-group designs33,34,35,36,37,38 and lack of long-term follow-up32,33,34,35,36,38,39 make it impossible to assess real-world applications or school health improvements. Level 3 evaluations are achievable, as demonstrated in other health studies, through methods such as long-term follow-up with supervisor observations, participant self-reports, or workplace audits40,42,43. Similarly, level 4 impacts have been documented when public health courses led to institutional policy changes44. The lack of level 4 outcomes is concerning, as schools need evidence of organisational benefits to support the continued implementation of training programmes. Potential level 4 outcomes might include reduced asthma-related school absenteeism, fewer hospitalisation and emergency visits, and a decrease in days with interrupted activities due to asthma45,46. Face-to-face school asthma programmes were found effective for these outcomes47. However, online programme lacks such evidence, and it becomes challenging for schools to justify spending time and resources on these programmes, which may hinder their adoption and sustainability. None of the included studies reported cost-effectiveness comparisons between online and face-to-face training. Such data could help schools make informed decisions, especially given that online training is likely to be more cost-effective and less labour-intensive when implemented on a larger scale. While these assessments require more resources, they provide the most meaningful evidence of training effectiveness48.

Online training programmes offer several practical benefits for school settings. Its broad accessibility, cost-effectiveness, standardised content delivery, and the flexibility of self-paced learning make it a feasible option for school staff who often struggle to find time for professional development49. The two included studies that directly compared delivery modalities, such as online versus face-to-face, or synchronous versus asynchronous formats, reported no significant difference in learning outcomes32,39. Therefore, based on this limited evidence, it can be assumed that online training programmes were not inferior to face-to-face training approaches. However, online formats still fall short in providing the hands-on experience, peer interaction, and real-time feedback that in-person training can offer22. This also highlights the importance of considering technological access, such as reliable internet access, availability of digital devices, and adequate digital literacy, when planning online interventions, which could be significant barriers in LMICs50. A pragmatic approach is a hybrid model, using online modules for foundational knowledge and refreshers, complemented by targeted in-person sessions to reinforce skills51.

In terms of the design of the online interventions, among the four studies using the web-based modules, those that used a combination of videos, voice-over slides, quizzes, and scenario-based learning, showed greater knowledge improvements33,34,35. Francisco’s Teaming Up for Asthma Control (TUAC) programme achieved the highest knowledge improvement (84.73%), likely due to its focused content, alignment with state policy, and contextual relevance to local school needs34. In contrast, Nowakowski’s Asthma 101 programme showed small knowledge gain (5.33%)37. The programme covered broader foundational topics but reused similar slide content from the in-person training. In addition, participants already had a high level of baseline knowledge, which likely contributed to the limited knowledge gain37. This suggests that simply transferring traditional teaching materials into an online format is insufficient without attention to engagement and content relevance52.

There are several limitations to this systematic review. First, only eight studies met the inclusion criteria, and all were conducted in the USA and Australia, which limits the generalisability of the findings to other cultural and educational contexts. Secondly, the review included only English-language publications, potentially excluding relevant non-English studies. Thirdly, many studies have a small sample size and lack complete statistical reporting, particularly standard deviations required for calculating effect sizes, and attempts to obtain this information from authors were largely unsuccessful33,34,37. Finally, a meta-analysis was not feasible due to significant heterogeneity in study designs, outcome measures, and intervention formats, which led us to adopt a narrative synthesis approach30.

Implications for practice and future research

Despite evidence gaps, consistent knowledge gains across online formats suggested that schools can adopt online asthma training for school staff. A hybrid approach may offer the most practical solution, offering the strengths and limitations of both modalities. Regardless of the delivery method, effective training should align with school policies, emergency plans, and strong partnerships with healthcare providers and families8,53.

Future studies should (i) use robust designs (e.g., RCTs), (ii) include 3–6-month follow-up with behavioural measures (level 3) and school-level outcomes (level 4), (iii) employ validated, school-appropriate instruments with standardised reporting tied to Kirkpatrick levels, and (iv) incorporate implementation and economic evaluations to inform scale-up54. Current studies often focus only on knowledge retention and programme satisfaction, which may not show real-world effectiveness.

Conclusion

Online asthma training programmes have proven to improve school staff’s knowledge and satisfaction, and appear to be non-inferior to face-to-face training. Their true effect on student health outcomes remains inconclusive due to lack of evidence on behavioural change or organisational impact. Future research should focus on long-term behavioural and organisational outcomes to bridge the gap between knowledge and practice.