Key Point:

School-based asthma programs can be a simple, effective way to manage asthma in inner-city children.

NEW YORK CITY—Inner-city children bear a disproportionate amount of today’s asthma burden. Adequate symptom management is often difficult in these children because of parental time constraints, lack of access to appropriate health care, and difficulties in obtaining or administering medication. To improve asthma management among inner-city children, school-based programs have been tried, with varying degrees of success.

Recently, two programs—one in Detroit and one in Rochester, New York—demonstrated significant improvement with the interventions used. However, the Rochester group found that exposure to environmental tobacco smoke negated any benefits of their program.[1,2]

EDUCATING THE SCHOOL COMMUNITY

The Detroit study’s premise was that a school-based asthma program would reduce symptoms, improve grades, and lower absence rates. Fourteen elementary schools participated; the students in these schools included 835 children with asthma. Seven schools (with 416 asthmatic children) received the intervention; the other seven served as “usual care” controls.

The intervention was a comprehensive program that included in-school education on asthma for the affected children and their peers, asthma orientation for principals and counselors, allergen briefings and building walk-throughs with custodians, school fairs (with question-and-answer sessions) for children and their parents or other caregivers, and written communication with the primary care clinicians who were managing the children’s asthma, which asked them to submit an asthma action plan to the schools. The intervention was planned to “mobilize the school community around the child with asthma.”

“The whole idea was to try and teach other children who don’t have asthma about the importance of respiratory health and to make them more empathetic about the problems that their friends with asthma confront,” explained Noreen M. Clark, PhD, Dean and Marshall H. Becker Professor of Public Health at the University of Michigan in Ann Arbor.

Parents answered telephone questionnaires at baseline and at 12 and 24 months. They were asked about the type and frequency of their child’s asthma symptoms and their efforts to manage the child’s disease. Data on academic performance and absenteeism were obtained from the schools. In addition, the parents of asthmatic children were also asked to report asthma-related school absences.

During the study, the children in the treatment group had fewer daytime symptoms than did those in the control group; this held true regardless of whether the children had persistent or intermittent asthma. However, the overall effect was reversed for nighttime symptoms: Children in the treatment group had 40% more nighttime symptoms.

Closer analysis revealed that the effectiveness of the intervention varied by the type of asthma present: The children with persistent asthma in the treatment group had 15% fewer nighttime symptoms than did the matching children in the control group, but those with mild intermittent asthma had more than twice the number of nighttime symptoms as did their control-group counterparts. According to the investigators, the increase in nighttime symptoms among the children with intermittent disease may not have been a bad thing; it may have been reported simply because parents were more aware of asthma symptoms as a result of the study’s educational component.

Two years after the intervention, parents in the treatment group had significantly higher scores on an asthma management index than did the parents in the control group. This was important, said Dr. Clark, who is also a Professor of Pediatrics, “because it’s the family that takes care of the disease 99% of the time. [Parents] need to be educated so they know how to manage the disease and how and when to change medications. When the child’s asthma status changes, parents need to change how they’re responding.”

Likewise, she continued, children with asthma and their parents “need to be educated about the fact that even if they don’t feel their medication working, it is doing its job. Children with persistent asthma should be using daily anti-inflammatory medicine.”

The intervention did not appear to affect the children’s grades or absenteeism overall, the school records indicated. However, by the end of the study, the children in the treatment group had significantly higher science grades than did those in the control group. Also, the parents reported that during the last three months of the study, the number of asthma-related school absences was 34% lower in the treatment group.

One disappointing result was the failure of the investigators to connect with the children’s primary care clinicians and obtain an asthma action plan. Baseline data indicated that only one quarter of the asthmatic children in the study were receiving adequate treatment according to the National Asthma Education and Prevention Program guidelines. A higher level of clinical care might have influenced the effects of the intervention.

“Part of this problem is related to the recognition of the importance of asthma among the primary care community—that it can be controlled and that it is important to prescribe the right medicines,” said Dr. Clark. “If physicians could have seen the way in which the schools participated in the asthma-control goals, they might have been more willing to participate.”

INCREASING MEDICATION COMPLIANCE

Researchers in Rochester, New York, studied a different type of school-based intervention, one that involved having inhaled corticosteroids administered daily by the school nurse. The investigators reasoned that by having medication administered at school, adherence is guaranteed—at least on school days. The primary outcome was the number of symptom-free days.

“The reasons for inadequate preventive therapy for asthma among inner-city children are not entirely clear,” admitted Jill S. Halterman, MD, MPH, Assistant Professor of Pediatrics at the University of Rochester. “Some studies have suggested that families may be uncertain about the effectiveness of medicines or may have concerns about side effects. Other factors, such as financial barriers and problems with access to care, also have been noted.” Furthermore, she added, primary care clinicians are not always aware of the symptoms that inner-city children with asthma experience—or even whether those children have been hospitalized for asthma exacerbations.

The study was conducted during the 2000–2001 and 2001–2002 school years. One hundred eighty-four children with asthma from 54 schools participated: 93 children were randomly assigned to the intervention, and the other 91, who received usual care, served as the controls.

For each child in the intervention group, two metered dose inhalers containing fluticasone were provided. One was used by the school nurse to administer one puff (110 mg) per day. The other inhaler was given to caregivers to administer at home. Thus, all children in the treatment group received the corticosteroid daily; they were also permitted to continue with whatever other asthma medications they were already using.

In the usual care group, parents were responsible for filling the children’s prescriptions and administering the asthma drugs. All families were contacted monthly and asked about daily symptoms for the preceding two weeks, as well as the need for rescue medications. Parents were also asked about any asthma-related visits to clinicians or the emergency department.

The children in the intervention group missed a mean of 6.8 days of school, compared with 8.8 days missed in the usual care group. However, the number of symptom-free days did not differ between the groups. Furthermore, the need for rescue medication was similar in the two groups, as was the number of clinician or emergency department visits due to asthma.

When the groups were stratified according to environmental tobacco smoke exposure, a striking finding emerged: There were no differences between the intervention and control groups among the children exposed to smoke at home. In contrast, among the children not exposed to smoke at home, the intervention group had significantly more symptom-free days, fewer absences from school, and fewer physician visits than did the control group, and they needed rescue medication less frequently (Figure).

Effectiveness of Intervention According to Secondhand Smoke Exposure

In other words, the intervention was ineffective for children who were exposed to secondhand smoke at home, but it was highly effective for the other children. The authors noted that in studies of adults with asthma, inhaled corticosteroids did not decrease inflammation in the airways of smokers.

SMALL CHANGES MAKE A BIG DIFFERENCE

One key feature of a successful school-based program is ease of implementation. In the Detroit study, said Dr. Clark, “the schools were very cooperative. They really wanted to help their kids with asthma. We had trained health educators who went into the schools, so it didn’t cost a lot in terms of time for the teachers or the principals. What’s required for this program is a group of dedicated volunteers who are willing to be trained and are ready to work in inner-city schools to help children.”

Dr. Halterman also found her group’s intervention easy to carry out. “Since schools already routinely provide daily medications, such as methylphenidate for ADHD, the addition of provision of preventive asthma medication is a simple system change that can improve asthma care.”

“I think the important point is that elementary school children and their families can learn to manage asthma and stay out of the hospital and emergency department,” Dr. Clark noted. “We really need to have the will to see that programs like these are applied and disseminated in communities where kids really need the help.”

—Gale Jurasek

References
1. Clark NM, Brown R, Joseph CLM, et al. Effects of a comprehensive school-based asthma program on symptoms, parent management, grades, and absenteeism. Chest. 2004;125:1674-1679.
2. Halterman JS, Szilagyi PG, Yoos HL, et al. Benefits of a school-based asthma treatment program in the absence of secondhand smoke exposure. Arch Pediatr Adolesc Med. 2004;158:460-467.

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