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Published in final edited form as:

J Pediatr Nurs. 2012 February ; 27(1): 1825. doi:10.1016/j.pedn.2010.11.001.

EFFECT OF PEAK FLOW MONITORING ON CHILD ASTHMA

QUALITY OF LIFE
Patricia V. Burkhart, PhD, RN,
Associate Dean, Undergraduate Studies and Associate Professor in the College of Nursing at the
University of Kentucky in Lexington, KY
Mary Kay Rayens, PhD, and
Professor, Colleges of Nursing and Public Health at the University of Kentucky
Marsha G. Oakley, MSN, RN
Research Associate in the College of Nursing at the University of Kentucky

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The purpose of this study was to evaluate the effect of peak flow monitoring (PFM) on
asthma quality of life (QOL) for school-age children with asthma. Healthy People 2010
recommends that clinicians address factors that promote or hinder a familys ability to
manage asthma, with a focus on increasing QOL (U.S. Department of Health and Human
Services [DHHS], 2000). QOL reflects disease control from the patients perspective, and its
measurement has become an important objective of asthma management and research
(National Asthma Education and Prevention Program [NAEPP], 2007).
The specific aims were to: (a) determine if asthma QOL improved over time with the use of
PFM; (b) examine the relationship of PFM adherence and QOL; and (c) evaluate adverse
health events (i.e., asthma attacks, health care utilization for asthma episodes, missed school
days) and QOL. PFM was expected to improve asthma QOL over a 16-week period.

BACKGROUND

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Asthma is a chronic respiratory condition affecting 10 million (14%) children in the U.S.
under the age of 18 (Centers for Disease Control and Prevention [CDC], 2009). Asthma
symptoms present as cough, wheeze, shortness of breath, and chest tightness. Episodes of
inflammation and narrowing of the small airways in response to asthma triggers (e.g.,
allergens, infection, exercise, abrupt weather changes, or exposure to airway irritants) typify
this disease (NAEPP, 2007).
Of those currently affected by asthma, approximately 4.1 million children reported at least
one asthma attack in the previous 12 months (American Lung Association [ALA] 2010). As
the leading cause of school absenteeism, asthma accounted for an estimated 14.4 million

2010 Elsevier Inc. All rights reserved.

Address correspondence to: Dr. Patricia V. Burkhart, University of Kentucky, 202 College of Nursing, Lexington, KY 40536-0232,
Phone: 859-323-6253, Fax: 859-323-1057, pvburk2@email.@uky.edu.
Co-authors: Dr. Mary Kay Rayens, University of Kentucky, 543 College of Nursing, Lexington, Kentucky 40536-0232,
mkrayens@email.uky.edu
Ms. Marsha G. Oakley, MSN, RN, University of Kentucky, 509 College of Nursing, Lexington, Kentucky 40536-0232,
mgoakl2@email.uky.edu
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missed school days in 2008 (ALA, 2010). In 2006, 3.4 million (47 per 1000) visits to private
physician offices, 500,000 (6 per 1000) hospital outpatient visits and 593,000 emergency
department visits among children aged 017 years were attributed to asthma (Akinbami,
Moorman, Garbe, & Sondik, 2009). Asthma remains the third leading cause of
hospitalization among children younger than 15 years of age and resulted in 155,000
hospital visits (21 per 10,000) among children 017 years of age in 2006. Although asthma
deaths are rare among children, 167 children ages 017 years died from this disease in 2005
(Akinbami et al., 2009). For 2010, the projected cost of treating asthma is $15.6 billion, and
indirect costs related to lost productivity will add another $5.1 billion for a total of $20.7
billion (ALA, 2010). The burden that this disease and recommended treatment can place on
children and their parents may affect the quality of their daily life. As part of the assessment
of asthma treatment goals, it is critical to explore how this disease and its treatment may
interfere with or improve the childs QOL (NAEPP, 2007).
Asthma Quality of Life

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Although there is no universal definition for health-related QOL, most QOL experts relate it
to how individuals perceive and react to their health status and those aspects of their lives
affected by the health condition and its treatment (Rapoff, 1999; Reddel et al., 2009). It is a
multidimensional construct that includes physical health, activity, and emotional health
(Chiang, 2005; Juniper et al., 2004; Reddel et al, 2009). Specific health conditions have
different physical symptoms and recommended treatment. Thus, disease-specific measures
are more useful than generic measures in assessing a patients perception of the impact of
the particular disease and treatment process on QOL (Eiser & Morse, 2001).
The NAEPP Expert Panel (2007) recommends assessing four key areas of asthma QOL: (a)
missed school days; (b) any reduction in usual activities; (c) sleep disturbances, and (d) any
change in caregivers activities due to the childs asthma. Education and adherence to
prescribed treatment, leading to symptom relief and prevention of exacerbations, are
positively associated with higher QOL for children with asthma and their families. That is,
patients with better control of their asthma symptoms have a more positive QOL
(Bloomberg et al., 2009; Georgiou et al., 2003; Schmier et al., 2007). Disease severity alone
does not always correlate with well-being and functional ability (Kwok, Walsh-Kelly,
Gorelick, Grabowski & Kelly, 2006; Skoner, 2001).

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In a qualitative study of 36 children ages 9 to 15 years who were diagnosed with asthma,
asthma interfered with factors related to well-being, especially peer interactions (PenzaClyve, Mansell, & McQuaid, 2004). Children reported being embarrassed when taking
medications in front of others and received verbal attacks from other children in response to
their physical limitations. This led to medication avoidance by the children to prevent being
viewed as different. They also reported feeling annoyed and tied down by burdensome
medication schedules and that medicine side effects could be troublesome. Reduced
motivation, difficulty remembering, social barriers and limits to accessibility were also
identified. Overall, this combination of obstacles impedes adherence to prescribed treatment
(Penza-Clyve et al., 2004) which can lead to exacerbations of symptoms, with resultant
increased healthcare utilization.
The areas of physical functioning and family activities are key issues in child asthma QOL
(Cicutto et al., 2005; Georgiou et al., 2003). In a study of 801 children with asthma, 53% of
the children reported that they experienced some limitations, while 18% reported major
limitations due to asthma (Fuhlbrigge, Guilbert, Spahn, Peden, & Davis, 2006). Maintaining
an active lifestyle is an essential part of childrens routine. To minimize symptom
exacerbation, children with asthma frequently restrict their physical activity (e.g., running,
playing basketball, and playing outdoors). This is a burden for some children who want to
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fully participate in activities they enjoy (Fuhlbrigge et al., 2006; Skoner, 2001). Asthma
symptom control lays the foundation for improving their QOL (Bloomberg et al., 2009;
Bruzzese et al., 2004; Schmier et al., 2007).
Peak Flow Monitoring
The treatment goal for the pediatric patient with asthma is to reduce the frequency and
severity of asthma symptoms so that the child can maintain normal activities. Delays in
asthma treatment are frequently the result of inaccurate perceptions of symptom severity.
Symptom perception of airway obstruction is generally poor for asthmatic children and their
parents (Kotses, Harver, & Humphries, 2006; Harvener, Humphries, & Kotses, 2009; Yoos,
Kitzman, McMullin, & Sidora, 2003) and has been associated with functional morbidity
(Feldman et al., 2007). Monitoring pulmonary airflow is integral to asthma management.
The most reliable objective measure of an asthma episode at home is a drop in peak
expiratory flow (PEF). A peak flow meter is a simple device that can detect airway
obstruction, often prior to the appearance of clinical signs. PFM is essential to: (a) assess the
severity of asthma exacerbations; (b) detect early stages of asthma episodes; (c) monitor
response to medication; and (d) establish an objective measure for detecting asthma triggers
(NAEPP, 2007).

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PFM is recommended for individuals who have moderate or severe persistent asthma (i.e.,
those patients experiencing daily symptoms or prescribed daily medication for symptom
control) (NAEPP, 2007). With proper instruction on the importance of and the technique for
using a peak flow meter (Callahan, Panter, Hal, & Slemmons, 2010), asthma patients can
objectively measure their lung function and become actively involved in managing their
asthma. This may result in improved health outcomes and better asthma QOL.

METHODS
Design
Data for this one-group pretest-posttest longitudinal study were collected at baseline, week
8, and week 16 of a randomized controlled trial that tested an intervention to promote
childrens adherence to asthma self-management (Burkhart, Rayens, Oakley, Abshire, &
Zhang, 2007; Burkhart, Rayens, Revelette, & Ohlmann, 2007). All children were taught how
to use an electronic peak flow meter. Data collected at the three time points included:
asthma quality of life, adherence to PFM, and adverse health events.
Sample

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A convenience sample of 77 children with asthma and their parent or guardian was recruited
from pediatric practices in central Kentucky. Inclusion criteria were: 7 through 11 years of
age; English-speaking; diagnosed with moderate or severe persistent asthma (i.e., daily
symptoms or prescribed daily controller medication) at least 6 months prior to study
enrollment; and parent or guardian willing to participate with their child. Siblings of
participants, children with other chronic conditions besides asthma, and children currently
using a PEF meter on a daily basis were excluded.
The mean age of the children who completed the 16-week study was 9.1 years (SD = 1.4);
they were predominantly male (58%, n = 45), Caucasian (79%, n = 61), and from two parent
families (73%, n = 56). Most of the mothers and fathers had at least some college education
(see Table 1).
Baseline asthma characteristics (Table 2) indicated that, on average, the children were
diagnosed with asthma at about four years of age (M = 4.4, SD = 2.7). More than half of the

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children had a previous emergency department visit for asthma, but only one-third had ever
been hospitalized for their asthma. Almost all of the children were prescribed daily asthma
medications, including inhaled corticosteroids (61%, n = 47), yet only 12% (n = 9) had ever
used a PFM. Compared with the previous year, 35% (n = 27) of the parents reported that the
childs asthma was better; 37% (n = 28) reported the childs asthma was the same; and 28%
(n = 21) reported the childs asthma was worse.
Measures
Asthma Quality of LifeAsthma QOL was measured using the Childrens Health
Survey for Asthma [CHSA]. It was developed by the American Academy of Pediatrics
[AAP] (2000) to address the impact of asthma and its medical treatment on the lives of
children and their families. It is a self-report measure with a sixth grade reading level and is
completed by the parents of 5- to 12-year-old children with chronic asthma. The instrument
evaluates a broad spectrum of 48 child-focused items comprising five scales (Physical
Health of the Child, Activity of the Child, Activity of the Family, Emotional Health of the
Child, and Emotional Health of the Family). All scale items require a parents response on a
5-point Likert-type scale to recall information over the previous two months.

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To test the instruments psychometric properties, more than 275 parents or guardians of
school-age children with asthma across three samples completed the CHSA (Asmussen,
Olson, Grant, Fagan, & Weiss, 1999). Internal consistency reliability for each of the scales
was strong (Cronbachs alpha = .81 to .92) and test-retest reliability ranged from .62 to .86.
For the sample in the current study, Cronbachs alpha for the 48 items was .95 at baseline.
For the purposes of this study, the three scales related to the childs QOL will be discussed.
All responses were self-reported by the parents as a proxy for their child. Parents were told
that the purpose of the survey was to find out how much asthma affected the everyday life of
their child.
Physical Health of the Child: Physical health of the child was defined as physical
symptoms and pain experienced by the child and was assessed by 15 items, rated on a 5point scale of 1 (all of the time) to 5 (none of the time). Questions included how often during
the past 8 weeks the child experienced asthma symptoms (e.g., shortness of breath,
wheezing, coughing) and side effects of asthma medications (e.g., headache, irritability,
difficulty sleeping). In this sample, the reliability for the Physical Health of the Child
subscale at baseline was .90.

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Activity of the Child: Activity of the child was defined as the childs ability to carry out
everyday activities. The five scale items related to child activity (e.g., school gym classes,
sports, and play) are rated on a 5-point scale of 1 (totally limited) to 5 (not limited).
Cronbachs alpha for this sample at baseline was .90
Emotional Health of the Child: Emotional health of the child was defined as the impact
asthma has on the mental well-being of the child. It was assessed by five items related to
frustration with dimensions such as having asthma, relying on asthma treatments, and
activity limitations. A 5-point scale of 1 (all of the time) to 5 (none of the time) was used.
Cronbachs alpha for this sample at baseline was .93.
Each of the three scales is scored separately. Raw mean scale scores are computed by
summing scale item responses and dividing the total score by the number of items
completed. Raw mean scores are transformed to a 0100 scale. Higher scores for each of the
three scales indicate better or more positive outcomes (Asmussen, et al., 1999).

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Asthma Health OutcomesThe CHSA also addresses the impact of asthma and
medical treatment on the lives of children. The CHSA parent report was administered at
weeks 1 (baseline), 8, and 16. The incidence of asthma episodes, health care utilization, and
missed school days because of asthma for the prior two-month period were measured.
Asthma episodes: Asthma episodes were measured by CHSA item 2: During the past 2
months, how many times has your child had an asthma attack or trouble breathing when
your child needed rest or extra medical care (such as more medicines or trips to the
doctor)?
Health care utilization: Health care utilization was measured by CHSA items 3, 4, and 5:
During the last two months because of problems with asthma, how many times has your
child: (a) stayed overnight in the hospital; (b) been seen in the emergency department; (c)
been seen in the doctors office or clinic for a sick visit?
Missed school days because of asthma: Missed school days because of asthma were
measured by CHSA item 13, During the past 2 months, how many days of school did your
child miss because of asthma?
Accutrax Personal Diary Spirometer

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At-home adherence to daily PFM during the 16-week study was assessed by a computerized
monitor, the Accutrax Personal Diary Spirometer (Ferraris Medical and PDS
Instrumentation, Louisville, Colorado). This lightweight, handheld electronic monitor
measures PEF and forced expiratory volume in the 1st second (FEV1). A built-in microchip
records the date, time, and PEF value each time the device is used. It provides an objective
measure of PFM adherence. Data can be stored in the device and downloaded to a computer
for analysis. PEF data was downloaded at weeks 8 and 16 for all children and included PEF
as well as the date and time PFM was performed. Adherence was defined as the proportion
(expressed as a percentage) of electronically-recorded compared with prescribed PFM in
each of the study periods, weeks 8 and 16.
Procedure

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The study was approved by the medical institutional review board at a southern university.
Interested parents of children with persistent asthma contacted the study group in response
to recruitment flyers available in pediatric clinics, physician letters recommending the
program, or through personal contact with the physician. During the initial phone contact
with parents, the research nurse briefly described the study, determined eligibility, obtained
verbal consent and scheduled the first face-to-face session. Children were accompanied by at
least one parent to each of the sessions.
During week 1, all of the children (N = 77) and their parents received instruction on PFM
and use of the AccuTrax PEF electronic monitor. Children were told to use the monitor in
the morning and evening before taking their asthma medicine.
At the week 8 session, the research nurse reviewed the PFM process and the parents
completed the CHSA for the prior 2-month period. After data collection at week 16, the
AccuTrax monitor was replaced with the Truzone manual PEF meter (Monaghan Medical
Corporation, Lebanon, Ohio) for continued home use by the child at the conclusion of the
study.

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Data Analysis

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The longitudinal effect of PFM on asthma quality of life was assessed using repeated
measures analysis of variance (ANOVA), with separate models for each asthma QOL
dimension. For the ANOVAs with significant overall F-values, post-hoc analysis for the
main effect of time was conducted using Fishers least significant difference procedure. The
relationships between asthma QOL and adherence to PEF monitoring were assessed using
two-sample t-tests, with adherence groups formed by an 80% cutoff. Two-sample t-tests
were used to determine differences in asthma QOL between those with and without adverse
health events in the last two months, including asthma attacks, emergency department visits
due to asthma, acute care visits for asthma, and missed school days due to asthma. Data
analysis was conducted using SAS for Windows; to control the overall Type I error rate in
light of multiple comparisons, a Bonferroni-type correction was used to decrease the alpha
level for individual tests.

RESULTS
Asthma Quality of Life

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Childs Physical HealthThe repeated measures model for the physical health subscale
of the CHSA was significant (F2, 152 = 41.7, p < .0001; see Figure), indicating that the main
effect of time was significant. Post-hoc analysis of the childs physical health scores at
baseline, 8 weeks, and 16 weeks demonstrated that the means at 8 and 16 weeks were
significantly greater than the mean at baseline (p < .01), suggesting an improvement in
parent-rated child health post-baseline. The difference between weeks 8 and 16 was not
significant.
Childs ActivityThe repeated measures model for the childs activity over time was
significant (F2, 153 = 10.9, p < .0001; see Figure). Post-hoc analysis indicated that the
parent-rated child activity score was significantly greater at each of 8 and 16 weeks,
compared with baseline (p < .01 for each comparison), while there was no change in child
activity score between 8 and 16 weeks.

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Childs Emotional HealthFor the outcome of parent rated child emotional health, the
repeated measures ANOVA overall F test was significant (F2, 153 = 14.4, p < .0001),
indicating that there was a significant change over time in this outcome (see Figure).
Consistent with the other quality of life outcomes, post-hoc comparisons demonstrated a
significant increase from baseline to week 8, and this was maintained at 16 weeks. In
particular, the mean at baseline was significantly lower than the means at 8 and 16 weeks (p
< .01 for each comparison). There was no difference between weeks 8 and 16.
Asthma Quality of Life and Adherence to PEF
There were no differences between adherent and non-adherent children on all three of
asthma QOL scales at week 8. At week 16, the children who were adherent had a higher
mean score for physical health (M = 88.6) compared with the physical health ratings for
non-adherent participants (M = 80.6, t = 2.7, p = .01). There were no group differences on
any other scale.
Asthma Quality of Life and Adverse Health Events
Examination of differences in QOL between those with health events in the two months
prior to the survey and those without are shown in Table 3. Due to the number of
comparisons for this analysis of the relationship between health events and QOL, an alpha
of .001 was used. Children who did not experience one or more health events (asthma

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attacks, emergency department visits, health care provider visits, or missed school days due
to illness) had better asthma QOL than those who experienced one or more health events
(see Table 3). These differences in asthma QOL are particularly pronounced for the subscale
that measures the childs physical health.

DISCUSSION
QOL improved for all children who were taught PFM as part of an asthma self-management
program. Scores on all three QOL scales increased over time for participating children. For
each outcome, there was a significant increase between baseline and Week 8 that was
maintained in Week 16. These results indicate that teaching and reinforcing the use of PFM
increases childrens physical health, activity, and emotional heath (as rated by the parent),
and that these increases in QOL outcomes are maintained over a 4-month period.
Adherence to PFM was defined as use of the PFM at least 80% of the time (i.e., use of
monitor at least 67 days a week). For children who were adherent during week 16, parentrated child physical health was higher than for those who were non-adherent. Parents shared
qualitatively that PFM, as an objective measure of the childs symptom control, empowered
them to intervene early as their child manifested asthma symptoms. It also allowed them to
communicate more effectively with their healthcare provider.

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Asthma QOL was higher for the children who did not experience the health events of one or
more asthma attacks, emergency department visits, health care provider visits or missed
school days due to illness. These differences in asthma QOL were particularly pronounced
for the subscale that measured the childs physical health.
The study was limited by use of self-reported asthma QOL by the parent as the childs
surrogate. Recall bias on the CHSA could be a concern, since parents were asked to report
QOL indicators over the previous two-month period at three data collection points.

CONCLUSIONS

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The results of this longitudinal study support the growing evidence that asthma selfmanagement interventions, such as PFM aimed at providing data related to changes in
airflow, can result in early intervention to improve symptom control. When asthma
symptoms are controlled, children are less restricted in their ability to participate in various
activities and experience less emotional distress. Since physical symptoms are a major
indicator of asthma control, interventions designed to assist the child and parent to intervene
early when asthma symptoms appear are crucial to promoting positive health-related QOL.
In this study, PFM may have increased childrens awareness of their asthma symptoms that
led to early intervention, resulting in improved symptom control. With the alleviation of
asthma symptoms, childrens QOL scores improved.
Inadequately controlled asthma has a significant negative impact on asthma QOL
(Bloomberg et al., 2009; Schmier et al., 2007). Findings of this study suggest that
controlling asthma symptoms improves the QOL of children. When children were adherent
to recommended asthma treatment, their asthma was better controlled.
Nurses providing care to children with asthma and their parents need to understand that
appropriate asthma self-management can result in symptom control that impacts QOL.
Nurses play a pivotal role as patient advocates for individualized care and educators about
asthma self-management. Effective asthma management requires comprehensive assessment
of the childs and familys ability to adhere to treatment and development of simple
strategies to assist the child and family to manage the childs asthma at home.
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Acknowledgments
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This study was supported by Grant #R15 NR08106-01 from the National Institute of Nursing Research at the
National Institutes of Health. The authors gratefully acknowledge the contributions of the participants, primary care
providers, and research team. The authors appreciate the editorial review of the manuscript by Dr. Lynne A. Hall,
Professor and Associate Dean for Research and Scholarship, University of Kentucky College of Nursing.
The results of this study have not been submitted for publication review to any other journals. There is no
commercial financial support disclosure that is necessary.

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Skoner DP. Why we must do a better job controlling asthma. Contemporary Pediatrics. 2001; 49:111.
Retrieved November 11, 2009 from http://www.modernmedicine.com/modernmedicine/Features/
Why-we-must-do-a-better-job-controlling-asthma/ArticleStandard/Article/detail/131450.
U.S. Department of Health and Human Services [DHHS]. Healthy people 2010 (2nd ed., Vol. II): 24
Respiratory Diseases. 2000 January. Retrieved May 4, 2009 from
http://www.healthypeople.gov/Document/HTML/Volume2/24Respiratory.htm#_Toc48904825
Yoos HL, Kitzman H, Mc Mullen A, Sidora K. Symptom perception in childhood asthma: How
accurate are children and their parents? Journal of Asthma. 2003; 40(1):2739. [PubMed:
12699209]

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Figure 1. Comparison of asthma quality of life subscale scores over time for the sample (N = 77)

Note. Significant differences for subscales at each time point are indicated by an asterisk.

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Table 1

Baseline Sociodemographic Characteristics of the Children in the Sample (N = 77)

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Characteristic

n (%)

Sex
Male

45 (58)

Female

32 (42)

Age
7 years

21 (27)

89 years

32 (42)

1011 years

24 (31)

Race
Caucasian

61 (79)

African-American

10 (13)

Other

6 ( 8)

Child lives with

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Two Parents

56 (73)

One Parent

21 (27)

Education of father
< High School

5 ( 6)

High School

16 (21)

Some College or College Graduate

52 (68)

Did not know or no response

4 ( 5)

Education of mother
< High School

4 ( 5)

High School

9 (12)

Some College or College Graduate

64 (83)

Annual family income

>$60,000

32 (42)

$30,000 to $60,000

23 (30)

$15,000 to $29,999

14 (18)

< $15,000

8 (10)

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Type of insurance
Public

10 (13)

Self Pay

2 ( 3)

Private

62 (80)

Other

3 ( 4)

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Table 2

Baseline Asthma Characteristics of the Children in the Sample (N = 77)

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Characteristic

n (%)

Hospitalized for asthma

Yes

25 (33)

No

51 (66)

No Response

1 ( 1)

Emergency Department visits for asthma

Yes

45 (59)

No

31 (40)

Did not know

1 ( 1)

Ever used a peak flow meter (PFM)

Yes

9 (12)

No

65 (84)

Did not know what a PFM was

3 ( 4)

Child is on asthma medication:

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Everyday

75 (98)

Few times a week

1 ( 1)

With symptoms only

1 ( 1)

Does your child take medication as directed?

All or most of the time

69 (90)

Some of the time

7 ( 9)

None of the time

1 ( 1)

Asthma Symptom Control

Very Good or Good

40 (52)

Fair

25 (32)

Poor

12 (16)

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Table 3

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Comparisons of Mean Scores of Children with No Health Event versus One of More Health Event in the 2
Months Prior to Each Survey
Time
Outcome

Health Event
(Asthma Related)

Baseline
(yes/no)

8 weeks
(yes/no)

16 weeks
(yes/no)

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Childs

Asthma attack

65.9/84.7*

75.3/90.2*

76.8/89.7*

Physical

ED visit

66.4/70.8

54.7/81.3*

59.2/84.2

Acute care visit

65.0/80.2*

70.1/85.7*

71.7/89.2*

Missed school

63.5/77.4*

70.6/83.1*

66.7/88.5*

Childs

Asthma attack

74.1/91.1*

80.8/91.7

75.6/94.5*

Activity

ED visit

70.6/79.0

56.0/85.4*

52.5/87.0

Acute care visit

73.0/87.4*

75.3/88.7

76.6/90.7

Missed school

72.2/84.3

74.5/87.3

73.5/89.7

Asthma attack

59.1/82.2*

72.7/79.8

68.4/81.3

ED visit

55.6/65.7

38.0/76.5*

17.5/77.2*

Acute care visit

58.7/75.2

59.8/83.0*

65.0/80.9

Missed school

60.7/70.0

58.1/80.0*

52.9/82.2*

Health

Childs
Emotional
Health

Note. Group means that are significantly different from each other (with p .001) are indicated by an asterisk.

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