Children with Asthma

Schools

Bronx NY School-Based Health Centers

Article Citation(s):
Webber MP, Carpiniello KE, Oruwariye T, Lo Y, Burton WB, Appel DK. Burden of asthma in inner-city elementary schoolchildren: Do school-based health centers make a difference? Archives of Pediatric and Adolescent Medicine 2003;157:125-9.

Intervention Setting:
Six elementary schools: four with a school-based health center (SBHC) and two without a SBHC (comparison schools)

Target Population:
Children in kindergarten through fifth grade attending inner-city schools in the Bronx that were participating in the study

Program Description:
About 1,400 SBHCs provide care to 1.1 million children in the United States. Whether access to on-site health services is associated with better health outcomes, is unknown. The objective of this study was to evaluate whether the availability of SBHCs measurably affected the health and school performance of children with asthma. The study examined differences in emergency visits, hospitalizations, medication use, and school absenteeism. Bilingual Spanish and English surveys were sent home with children during the 1999–2000 school year. The survey asked about demographics, whether the child has asthma, and the presence of specific asthmatic symptoms in the last year. Of the 6,433 families surveyed, 74.2% returned completed questionnaires (72.6% from SBHC schools and 78.7% from comparison schools). Eighty-seven percent of the children at these schools whose parents or caretakers responded to the survey had health insurance coverage. The prevalence of probable asthma was 18.9% at SBHC schools and 22.4% at comparison schools. Criteria for probable asthma included responding "yes" to the question inquiring whether the child had ever had asthma and reporting that one or more of the following was true during the past 12 months: 1) taken asthma medication; 2) experienced sleep disturbance because of wheezing, coughing, or tightness in the chest; 3) coughed after or during exercise when the child did not have a cold; 4) had weather-related breathing problems; or 5) wheezed in the presence of pets, mold, strong odors or cigarette smoke. During the study period, 13.5% of all visits to SBHCs were for asthma care, with a mean annual frequency of 4.9 visits per child. About half of the children with asthma used the SBHCs for asthma care during this 1-year period.

Evaluation Design:
A cohort study design was used.

Sample Size:
The study comprised 949 children with asthma (645 from the four schools with SBHCs and 304 from the two comparison schools).

Outcome Measures/Results:
Outcome measures included activity limitation, hospitalization, emergency visits, and school absenteeism. A total of 234 (27.1%) of the 865 respondents to this question from all schools reported at least a moderate amount of activity limitation; 293 (33.9%) of the same respondents reported their child did not experience any activity limitation. No statistically significant differences were noted in activity limitation by sex, race or ethnicity, health insurance coverage, or availability of an SBHC. Of the 949 children, 120 (12.6%) from all schools had been hospitalized for asthma at least once in the previous year. Children attending the comparison schools were more likely to have been hospitalized for asthma (17.l%) than those in schools with SBHCs (10.5%). No statistically significant differences were noted between hospitalization and sex, race or ethnicity, and health insurance coverage. A total of 438 (46.2%) of the 949 parents from all schools responded that the child had emergency treatment at least once for asthma in the past year. No statistically significant differences were noted in emergency visits by sex, race or ethnicity, health insurance coverage, or availability of an SBHC. Overall, students in the comparison school missed about 2 more days of school than those in schools with an SBHC (16.4 and 14.5 days, respectively). Among children with asthma, those attending the comparison school missed an average of 3 more school days (21.3) than those attending schools with an SBHC (18.2).

Materials available:
Contact Dr. Mayris Webber at mwebber@montefiore.org. Materials can be transmitted electronically.

Community-Based Asthma Management Program

Article Citation:
Toelle BG, Peat JK, Salome CM, Mellis CM, Bauman AE, Woolock AJ. Evaluation of a community-based asthma management program in a population sample of schoolchildren. Med J Australia June 1993;158(11):742-746.

Intervention Setting:
Parent and child educational sessions were held at the child’s school.

Target Population:
Children with asthma aged 8–11 attending randomly selected schools

Program Description:
A community-based management program designed to improve outcomes for children with asthma in Sydney, Australia

The program targeted children and those responsible for the participating children: parents, pharmacists, doctors, community clinic nurses, and school teachers. Children and parents attended two 2-hour educational sessions. The first session explained asthma as a disease to help parents and children identify symptoms and triggers and use medication more effectively. The second session emphasized the importance of monitoring airway function and the use of a written asthma management plan. Doctors and pharmacists attended an evening workshop explaining the development and use of written asthma management plans. School teachers and community nurses received an in-service session about asthma symptoms and triggers.

Evaluation Design:
Children with asthma from randomly selected schools participated in the intervention group. Children with asthma from schools in a selected geographic area served as controls. Baseline data were collected on both groups of children. Knowledge of asthma and morbidity were asked of parents via questionnaire. Follow-up data were collected three months and six months after educational sessions were completed. The data were analyzed using ANOVA and paired t-tests.

Sample Size:
120 children (65 in the intervention group and 55 in the control group)

147 teachers and community nurses, 53 families, 15 pharmacists and 11 doctors attended the educational sessions.

Outcome Measures/Results:
Although morbidity varied, most of the participating children had mild asthma. The outcome measures in this study were lung function as measured by forced expiratory volume in one-second (FEV1) bronchial responsiveness to histamine and airflow variability. The prevalence of symptoms such as wheezing or night coughs, the number of doctor and emergency room visits, and days absent from school due to asthma were also measured. At six months, bronchial hyper-responsiveness and night cough were significantly reduced and FEV1 was improved compared to both baseline measurements and the control group. Unscheduled (emergency) visits were reduced in both the intervention and control groups. Days absent from school did not change in either group.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

Inner-city School-based Health Center Program

Article Citation:
Lurie N, Bauer EJ, Brady C. Asthma outcomes at an inner-city school-based health center. Journal of School Health 2001;71(1):9-16.

Intervention Setting:
A health clinic in a large, inner-city elementary school

Target Population:
Minority children aged 6–14 years with asthma attending an inner-city elementary school

Program Description:
An initial sample survey of 400 students indicated that approximately 17% of children in the school had asthma. School-wide screening then identified all the students with asthma. Families of these children were interviewed to assess asthma symptoms and morbidity. Children were then grouped into three categories based on severity. Those classified with severe or moderate asthma were prioritized for immediate intervention at the school health center. The initial visit consisted of confirming the asthma diagnosis by history, physical exam, and spirometry. Individualized information about asthma management, medications, and environmental control (based on parental knowledge) was provided in individual sessions to parents and children by a health educator. Asthma education group sessions were also held at the school for students and parents. An asthma symptom-control plan was developed for each child without a plan, and each child received a written asthma plan that included the use of rescue medications. Health center staff attempted to identify a primary-care provider (PCP) for each child and encouraged each family to obtain regular asthma checkups with that provider. Health center staff communicated their findings regarding the asthma diagnosis and the care plan to the PCP. All children with severe and moderate asthma were prescribed anti-inflammatory medications. Inhaler technique was emphasized, and spacers and peak flow meters were provided. Children experiencing asthma symptoms during the school day could go to the health center on a walk-in basis or by referral from the school nurse. Asthma care in the health center was tailored to individual need. Many high-risk students with compliance issues began taking their daily anti-inflammatory medication at school.

Evaluation Design:
This study used a pre- and post-intervention comparison with longitudinal and cross-sectional cohort of children. A baseline survey completed by parents addressed self-rated health, asthma-related symptoms the prior 3 months, asthma morbidity, asthma management practices, home environment, demographic characteristics, health insurance, and health care use in the prior 3 months. Baseline data were collected at the beginning of the school year and again about 9 months later.

Sample Size:
This intervention comprised 156 children with asthma who attended the same school, had physician-diagnosed asthma, had asthma symptoms such as wheezing and nocturnal coughs within the past 12 months, and were taking asthma medication. The sample included all children in the baseline who remained in school through the study period as well as children who entered school during the year after the baseline screening and the beginning of the intervention and were enrolled in school for at least 6 months of the study year.

Outcome Measures and Results:
Outcome measures included school absenteeism, hospitalization rates for asthma, outpatient visits for asthma in the absence of asthma symptoms, percentage of students seeing a specialist for asthma, use of peak flow meters, use of asthma-care plans, use of inhalers, and school absenteeism. The percentage of students who were patients overnight in a hospital because of asthma during the prior 12 months decreased from 15% to 3% for the longitudinal population and from 10% to 2% for the cross-sectional sample, a reduction of 75%-80%. School absenteeism associated with asthma did not change. Parents reported substantially fewer nights that the child awakened because of asthma and substantially fewer days the family had to change plans because of the child’s asthma. The mean number of scheduled well-child physician visits significantly decreased. The percentage of students who ever visited a specialist for asthma markedly increased, and children were more likely to use a peak flow meter and take appropriate medications.

Availability of Protocol and Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

Open Airways

Article Citation:
Clark NM, Feldman CH, Evans D, Levinson MJ, Wasilewski Y, Mellins RB. The impact of health education on frequency and cost of health care use by low income children with asthma. J Allergy & Clin Immunol 1986;78:108-115.

Evans D, Clark NM, Feldman CH, Rips J, Kaplan D, Levison MJ, Wasilewski Y, Levin B, Mellins RB. A school health education program for children with asthma aged 8-11 years. Health Educ Q Fall 1987; 14(3):267-279.

Intervention Setting:
Elementary schools

Target Population:
Predominantly low-income African American and Latino children between the ages of 8 and 11 years old

Program Description:
The Open Airways program, originally designed for delivery in health care settings with predominantly African American and Latino children from underserved communities, was adapted for delivery in the New York City school system. The program, which is grounded in social learning theory, consisted of six group sessions where children learned basic information about asthma, how to recognize symptoms and triggers, how to use medicine effectively and how to handle problems at school. Parents were also mailed educational materials.

Evaluation Design:
Twelve schools were chosen. Schools were matched in pairs as closely as possible on demographic characteristics. Of the 6 pairs, one school was randomly assigned to the control group and one to the intervention group. Multivariate and univariate analyses of covariance were used to analyze the data.

Sample Size:
A total of 239 children, of which 135 were in the intervention group and 105 were in the control group.

Outcome Measures/Results:
Outcome measures included changes in behavior, changes in feelings expressed by children, school attendance, school performance, frequency of asthma episodes, and the number of attacks requiring a doctor visit or treatment at home. Participants showed significant improvement in school performance, self-management behaviors and decreased number of episodes.

Availability of Protocol/Materials:
Open Airways for Schools is disseminated through local American Lung Association (ALA) affiliates. Individuals and organizations interested in implementing the program or serving as instructors in the schools should contact ALA at 1-800-LUNG-USA. Collaborating organizations and instructors receive training in the curriculum and are expected to stay in contact with the Lung Association for technical assistance and results reporting.

Case Study:
Open Airways for Schools; Office of School Health,Department of Health; Anne Arundel County, Maryland

The Alberta School-Based Asthma Education Program: The Roaring Adventures of Puff

Article Citation(s):
McGhan SL, Wong E, Jhangri GS, Wells HM, Michaelchuk DR, Boechler VL, et al. Evaluation of an education program for elementary school children with asthma. J Asthma 2003; 40(5):523–33.

Intervention Setting:
Elementary schools in Edmonton, Alberta, Canada

Target Population:
School children ages 7–12 years with physician-diagnosed asthma

Program Description:
The purpose of the study was to determine whether The Roaring Adventures of Puff (RAP), an interactive childhood asthma education program, improved asthma management behaviors and health status, and quality of life in elementary school children. The RAP intervention schools received parent and teacher asthma awareness events, recommendations for school asthma guidelines, and six educational sessions for the children with asthma. Children in the control schools received regular medical care. Using the 300-page manual, the instructors taught six 60-minute asthma educational sessions. Topics by session number included

1. getting to know each other, goal setting, use of a peak flow meter, diary monitoring;
2. trigger identification, control and avoidance, basic pathophysiology;
3. medications and proper use of inhalers;
4. symptom recognition and action plan;
5. lifestyle, exercise, managing an asthma episode; and
6. sharing this information with teachers and parents.

Sessions were held during the students’ lunch hour. Teaching strategies included puppetry, games, role play, model building, discussions, and asthma diary recording. The puppet is a dinosaur named Puff who has asthma. Puff interacts with the children, instructing them on what to do to better control their own asthma. Puff is featured in the workbook that children complete during the week between sessions, share with their parents at home, and use in class. Over the course of the instructional period, the instructor worked with teachers and parents as needed for individual child asthma concerns and with teachers and principals to develop practical school guidelines for asthma.

Evaluation Design:
This study was a cohort, pre-post intervention design. The study compared children with asthma in randomly assigned intervention schools with those in control schools. The unit of randomization was the school. All participating students in each school were assigned to the same group. Children, however, were the primary unit of analysis. All children with asthma in the intervention and control schools and their parents completed questionnaires at the beginning of the project and following the intervention. Questionnaires included the pediatric asthma quality of life questionnaire, parent’s RAP questionnaire, and the childhood asthma self-efficacy scale. The RAP questionnaire assessed demographic information, perception of their child’s symptom severity, medication use, health care utilization, school absenteeism, and attitudes toward asthma. The primary analysis compared pre-intervention and post-intervention outcomes for the children with asthma receiving the education program and those not receiving the program.

Sample Size:
This study involved 76 children in the intervention group and 86 in the control group. The two groups, including those who dropped out, were comparable for demographic and disease related variables.

Outcome Measures:
Unscheduled doctor visits in the last year, emergency department visits in the last year, missed school days, asthma symptoms, limited type and amount of play.

Results:
For most indicators of asthma control, the intervention group improved after the RAP intervention. Statistically significant improvements for the intervention group included over-all parent-rated severity, unscheduled physician visits in the last year, moderate-to-severe shortness of breath, limitations in the kind of play, and any missed school days in the last year.

Details:
In the year before RAP, 76.2% of the intervention children had unscheduled doctor visits. Followup after RAP showed that 33.8% of RAP participants had unscheduled doctor visits. Before RAP, 87.7% of intervention children missed some school because of asthma. Post intervention followup showed that 38.5% of children missed some school because of asthma. Some characteristics of asthma improved at followup among the controls, whereas others remained the same or got worse. Unscheduled physician visits and any missed school days were the only statistically significant improvements also seen in the control group. However, the improvement in the control group was just over half that of the RAP group for both variables. Although not significant, the reduction in the number of emergency visits in the RAP group was more than twice that of the control group. The intervention group demonstrated a significant improvement in use of appropriate medication for relief of symptoms (20.6% improvement) and preventing symptoms (31.4% improvement) at followup, in contrast to the control group of (17.4% and 3.7%, respectively).

Materials Available:
The Roaring Adventures of Puff asthma education program is available from the Alberta Asthma Centre, Box 4033, 11402 University Avenue, Edmonton, AB T6E 6K2, Canada.