Key Points
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High rates of school absenteeism affect a child’s ability to learn. Every school day in the USA 36,000 children and youth miss school because of asthma.
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Asthma has the potential to affect academic performance, starting at a young age.
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Several school-centered models have been evaluated and demonstrated benefits in asthma-related outcomes. Evaluated activities include asthma screening, asthma case identification, supervised administration of maintenance asthma medication, case management, care coordination among students, families, healthcare providers and schools, self-management asthma education programs, creating asthma friendly and supportive schools, and asthma care programs delivered through school-based health clinics.
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Asthma management at schools is important for pediatric pulmonologists and allergists, pediatricians, family care providers, and healthcare professionals providing quality asthma care. The variability of asthma care practices makes it necessary for clinicians to learn what is happening at their patients’ schools and to advocate for appropriate services.
Introduction
Asthma is a common chronic childhood condition associated with significant morbidity, high rates of school absenteeism, and excessive costs for the individual and society. Every school day in the USA 36,000 children and youths miss school because of asthma. High rates of school absenteeism affect a child’s ability to learn. A healthy student with well-controlled asthma is a student ready to learn and to be a full participant in the school experience, including physical activity and sports.
The history of asthma programs in schools dates back about 30 years; thus, a significant body of literature exists that has evaluated a variety of strategies directed at improving overall asthma management in order to reduce asthma-associated morbidity. The purpose of this chapter is to review the literature in terms of the rationale for school-centered interventions, barriers identified in school settings, strategies implemented and evaluated, strengths and limitations of the literature, future directions for research and how asthma care providers can be effective team players.
Why Center on Schools?
As mentioned, asthma is a leading cause of school absenteeism, but this is not equally distributed among those with asthma. School absenteeism is associated with family income. Recent research highlights that students attending schools with the highest proportions of low-income students were more likely to miss school because of asthma. Additional risk factors for high absenteeism rates included younger age, frequent experience of asthma symptoms and/or using asthma medications.
Asthma has the potential to affect academic performance, starting at a young age. A prospective cohort study in New Zealand observed that entering school with asthma was associated with low academic achievement. Entering school with asthma reliably predicted low reading level achievement independent of known co-variates such as high absenteeism, minority status, male gender, single-parent family, low socioeconomic status and poor academic skills at school entry. Data from the U.S. National Interview Survey noted that children with asthma missed three times more school and had a 1.7 times greater risk of having a learning disability compared to well children.
Basch expanded our understanding of this area with a systematic review that identified that asthma directly and indirectly affects academic achievement of school-aged youth. The results of this study indicated that asthma affects the student’s motivation to learn. Identified causal pathways that could affect academic achievement included cognition, high absenteeism, school connectedness and dropping out. Asthma and the causal pathways have interactive and synergistic effects that represent a complex situation that must be addressed collectively through a coordinated and partnered approach. Taken together, this work suggests the need for school-level interventions to decrease asthma-related absenteeism, especially in schools with a high proportion of low-income families.
Partnering with schools provides opportunities to reach most children with asthma and those at the highest-risk of asthma burden in need of assistance. Because schools provide reliable access for reaching large numbers of children with asthma, they have become a targeted setting for quality asthma care programs and initiatives. In addition, schools are often the only setting of affordable health care for low income and ethnic minority youth because of limited access to medical care. Schools are often advocated as the ideal setting for health education, health services and the development of supportive networks and collaborations. Accordingly, school settings are ideal settings for reaching high-risk children and youth with asthma and for reducing asthma health disparities. Several school-centered models have been evaluated and have included a variety and combination of activities: asthma screening, asthma case identification, supervised administration of maintenance asthma medication, case management, care coordination among students, families, healthcare providers and schools, self-management asthma education programs, creating asthma friendly and supportive schools, and asthma care programs delivered through school-based health clinics.
Asthma Management Challenges in Schools
Insufficient Health Team Staffing at Schools
Although school settings have several advantages over clinic settings in providing asthma care, there are several distinct challenges that must be considered. Given the prevalence of asthma and the shortage of health personnel in schools, it is not surprising that once students are identified as having asthma, schools lack the facilities for appropriate evaluation and treatment. A US national survey conducted as part of the School Health Policies and Programs Study revealed that only 36% of schools had a full-time school nurse and that only 19% of health coordinators in the school setting received professional development for asthma care, suggesting that not only do schools have a shortage of health personnel, but that these personnel also have significant knowledge gaps in asthma care. A survey of parents confirmed that learning gaps exist for school personnel and parents expressed a desire for teachers and staff to have higher levels of knowledge and understanding to support their children.
Poor Communication
A major obstacle to successful asthma management in schools is poor communication among students, families, healthcare providers and schools. Surveys and interviews with school nurses, school personnel, parents and healthcare providers identified communication as the greatest challenge. Most parents of students with asthma never speak to the school nurse and too often school nurses learn of a student’s diagnosis of asthma when he/she presents to the office with asthma symptoms and informs the nurse of the diagnosis. Although all parties recognize that students require individualized instructions and information to support asthma management at school, this is not happening. School nurses also identified the lack of parental support and involvement as a significant barrier to successful management. Often there is also role confusion and unclear policies and practices for managing asthma at schools that could be addressed through clearer communication by schools of existing policies and protocols. If asthma management is to improve, it is crucial that improvements in communication occur among these parties.
School Asthma Care Plans and Easily Accessible Rescue Therapy
Two key elements for successful asthma management in school settings are (1) beginning the school year with a completed school asthma care plan and (2) an on-site quick relief inhaler that is preferably carried by the student. The purpose of the written asthma care plan is to outline asthma management steps at schools and to serve as a type of medical order for schools. It is required so that students experiencing symptoms can use their quick-acting inhaler kept at school to relieve symptoms quickly, thus enabling them to return to class and avoid having to leave the school for treatment or to wait in the nurse’s office while a family member brings in the inhaler. Asthma care plans for schools differ from asthma action plans for home use in several ways and therefore home plans may not be acceptable or sufficient for the school setting. Common problems of home-based asthma action plans are that they often lack a release for sharing health information among school personnel and the student’s healthcare providers, and lack the signed indication from a parent/guardian and healthcare provider for self-carrying the inhaler or the need for assistance with medication administration. Additionally, because the action plan is seen as a medical order in schools, the inclusion of the use of maintenance asthma medication (typically containing an inhaled steroid) is problematic, as it is interpreted that the school nurse is required to administer the medication daily (often twice daily). This latter issue creates additional problems for the school in that it has insufficient personnel for daily, supervised, administration of maintenance asthma medications for all students with asthma and it requires reliance on families to supply schools with maintenance asthma medications as schools do not have funds to supply these medications. Often families have insufficient funds to purchase asthma maintenance medications for home use let alone funds to purchase extra medication to be kept at school; a steroid inhaler can cost hundreds of dollars.
Several studies highlight that these two crucial elements to successful asthma management in schools are not being fulfilled. A recent study involving five Alabama school districts observed that not one student with physician-confirmed asthma had a complete school asthma care plan/action plan on file at the school. Reported rates of students with asthma having a quick-relief inhaler at school ranged from 14% to 39% of students with asthma. This work suggests that the gap between policy and practice is dramatic and potentially life threatening. Federal laws exist and many states and school districts have legislation and policies in place permitting students to possess quick-relief inhalers and/or to receive support from school personnel in the storage and administration of the medication. However, school district policies typically require completion of an asthma care plan for school or standard forms and authorizing signatures of students’ parents/guardians and physicians/healthcare providers. A study in Minnesota developed and implemented a secure portal designed for the electronic exchange of an asthma action care plan between providers and schools. School nurses reported that this initiative resulted in more efficient asthma management and school nurse self-confidence in managing an individual student’s asthma. This type of intervention deserves additional investigation.
Physical Activity at School
Most students with asthma report experiencing symptoms during physical activity at school, prompting them to initiate the self-care activities of sitting out the activity, visiting the school nurse and/or drinking water. Barriers reported by students to participating in physical activity include the lack of a school asthma care plan or action plan detailing asthma management steps for physical activity, such as pretreatment, lack of accessible quick-relief inhalers, poor asthma control, and stigma associated with symptoms caused by physical activity and with using asthma inhalers. Most work in the area has been limited to describing the issue with little attention focused on increasing participation in physical activity in schools.
School-Centered Implemented and Evaluated Strategies
Poor and minority children experience the greatest asthma morbidity and are also least likely to receive adequate asthma care. As a way to target these high-risk children, school-centered asthma care management programs have been evaluated, mainly in inner cities. A variety of strategies have been evaluated and typically involve some degree of partnership among school personnel, community health providers and families. The types of direct services implemented and evaluated vary in strategy, targeted audiences for intervention and human resources for staffing the intervention. The focus of these interventions was to increase the quality of asthma care, but the process to achieve this goal varied from direct asthma service provision, case management and care coordination to asthma self-management educational programs and creating supportive school environments.
Human Resource Supplementation of the School Health Team
To address the shortage of trained health professionals on site at schools, strategies evaluated have included adding physicians and other community healthcare providers, and extending the hours of school nurses to full-time. Although not evaluated through a controlled study, it was observed that a program that provided a consulting physician a half day per week to work with school nurses increased the delivery of quick-relief medications at school instead of home, which led to reductions in the number of students leaving school or requiring a 911 call for urgent care, thus keeping them engaged in school activities. In a similar non-randomized controlled study, the same trend for a reduction in sending students home because of asthma was reported, although the difference was very small (13.8% vs 12.6%). Similarly, in a quasi-experimental study, adding a full-time school nurse versus a part-time nurse (often 1 day/week) to care for students with asthma, improvements were noted: a decrease in absenteeism, fewer emergency department visits and cost savings. Healthcare provider support can also be brought into the school through school-based health centers. These centers provide on-site care delivered by physicians, physician assistants or nurse practitioners for students at school. Two studies focusing on improving asthma care through school-based health clinics demonstrated improvements in the need for emergency department visits, hospitalizations and school absenteeism. Bringing a mobile health clinic to the school to provide healthcare staff, diagnostics and regularly scheduled visits is an alternative strategy to improve asthma outcomes, again leading to improvements in reducing hospitalizations, emergency department visits, asthma symptoms, rescue inhaler use and school absenteeism.
Directly Observed Therapy
Several small and larger randomized controlled studies have evaluated the benefits of directly observed asthma maintenance therapy (primarily inhaled corticosteroids) by school nurses that involved the partnership and coordination of care among school nurses, primary care providers and families. The approach involved identifying students requiring daily maintenance asthma therapy, review and agreement of therapy and dosages by both study physicians and students’ physicians, and school nurse provision of daily maintenance controller therapy on school days. Because adherence to asthma medications is typically below 50%, it is an important factor in achieving asthma control. These studies have typically observed improvements in medication adherence and asthma-related outcomes such as symptoms-free days, asthma control, reduced number of exacerbations and school absenteeism. In one of the larger randomized controlled studies, the improvements observed were marginal and not as consistent as in the other studies. Similarly, one study only noted improvements in those not exposed to second-hand smoke. An important consideration when determining the generalizability and application of this work is that the success of this intervention may be related to the study physicians supporting asthma guideline-recommended care and that supervised medication use may not have the desired benefit if the level of treatment is not consistent with the level of asthma control.
Case Management and Care Coordination
Case management involves spending time contacting and then patiently and persistently working with the family to build a trusting relationship. Care coordination services ensure timely, coordinated care to provide appropriate levels of health, psychosocial and support services, and continuity of care through ongoing assessment of the client’s and family members’ needs. Care coordination and case management activities include: an initial assessment of service needs; development of a comprehensive, individualized plan; coordination of services required to implement the plan; monitoring of the client and family to assess the plan’s effectiveness; and re-evaluation and revision of the plan as necessary. Case management strategies applied through schools to higher risk students with asthma hold promise. Many of the school-centered interventions evaluated have included case management as an element of the intervention. The case management activity most frequently reported was working with the family followed by contacting healthcare providers. Extensive care coordination and case management services are typically only needed by students who continue to experience poorly controlled asthma despite having the usual support systems. Benefits observed included improved asthma control, reduced use of healthcare services related to asthma exacerbations and reduced school absenteeism. However, many of the studies highlighted that a great deal of effort is needed to engage the community asthma care providers.
Information Technology Infrastructure
Information technology that permits data sharing is an important component of an infrastructure to promote coordination of care across schools, families and healthcare providers to achieve successful asthma management. A project in the Charlotte Mecklenburg Schools suggests that databases maintained by nurses, asthma program staff and school personnel can be successfully integrated into a single asthma program evaluation database. Benefits reported as a result of their shared database included an ability to identify students with an elevated level of need in order to receive priority care status from the asthma education program, and an ability to evaluate program outcomes that were not possible before such as academic performance, school attendance, school behavior and quality of life. Others have focussed on developing a web-based system to make previously evaluated effective programs that require intense study staff participation potentially sustainable and transferable because web-based systems are viewed as less expensive and more accessible. However, work is needed to determine if these assumptions are valid. A study in Denver Public Schools is currently underway to evaluate an asthma-specific tab as part of the district’s electronic academic platform. This system includes monitoring receipt of a school asthma care/action plan, availability of an on-site quick-relief rescue inhaler, monitoring of at-risk asthma status, monitoring of school absenteeism, calculating the percentage of school absenteeism, tracking visits to the school health office for asthma, and 911 calls for asthma. Studies are needed to evaluate the effectiveness and added value of information technology platforms that are intended to improve communication and coordination of care among schools, families and healthcare providers, provide asthma care support to school nurses and promote sustainability, while reducing costs.
Interventions to Improve Asthma Self-Management Skills
The National Heart, Lung and Blood Institute Expert Panel Guidelines for the Diagnosis and Management of Asthma stress the need for asthma education and the development of asthma management skills to achieve successful disease control. A number of studies have assessed the effectiveness of providing asthma education in schools. These educational programs incorporate health education theories and asthma practice guidelines. Most school-based educational programs have focussed on building skills for elementary school-aged children and have demonstrated improvements in asthma knowledge, confidence/self-efficacy, asthma management skills and associated asthma morbidity outcomes, such as improved quality of life, and reduced symptoms, emergency department visits, urgent care visits, hospitalizations and school absenteeism. Some studies have extended these benefits to improvements in school grades and academic performance.
Recently, school-centered asthma education efforts have targeted adolescents of low income living in urban settings. Studies in adolescents, an identified difficult-to-reach group, have demonstrated acceptance, involvement and retention by this age group: over 75% of those eligible participated and over 70% were retained. Benefits observed included improved self-confidence in asthma management skills, appropriate use of controller and quick-relief asthma medications, fewer days with symptoms and activity limitation, fewer interrupted nights due to asthma, decreased hospitalizations, emergency department visits, and school absenteeism, and improved quality of life. Interventions are starting to address the complexity of and co-morbidities associated with asthma. A pilot study completed in Chicago high schools combined asthma management and nutrition and weight management for all students with asthma, regardless of weight. The program consisted of nutrition and weight management, asthma education, a family education event, and two-monthly reinforcement visits with behavioral counseling provided by a nurse and dietetic intern to increase asthma and nutrition knowledge, asthma and nutritional self-efficacy, asthma control and quality of life. Web-based asthma self-management programs have also been developed to attract and educate adolescents with asthma. Puff City, a web-based tailored asthma intervention with a case manager, led to improved symptoms, restricted days and school absences; however, improvements in medical care were not observed. With the exception of a few studies, this work was completed through non-randomized, controlled study designs with relatively short follow-up periods. This area is worthy of studies using more rigorous study designs.
Synthesizing findings in this area is difficult due to the heterogeneity of interventions, age of students, interventional populations and outcomes assessed. For instance, interventions varied in educational components, number and duration of sessions and personnel type. Target populations included exclusively students with asthma or these students in combination with one or more of the following groups: parents/guardians, healthcare providers, classmates and school personnel. Study personnel providing the intervention ranged from certified asthma educators to school nurses to health professional students to lay providers. Teaching modalities also varied from individualized one-on-one teaching to group teaching to computer-based programs. Although several randomized controlled trials have been conducted, limitations remain: studies do not clearly describe usual care; several studies included students with mild asthma and did not perform subgroup analyses to determine if asthma severity, asthma control, age, race/ethnicity, socioeconomic status or location (inner-city, suburban, city, rural) predicted interventional response; studies were often limited in their ability to draw conclusions about differences between comparison groups due to a lack of power with smaller sample sizes; and studies did not include a follow-up period to determine if improvements continue, are sustained or regress. Although results across studies have not been consistent, systematic reviews suggest that school-centered asthma education has positive clinical, humanistic, health, economic and academic outcomes.
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