Identification and education of adolescents with asthma in an urban school district: results from a large-scale asthma intervention

School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review

BACKGROUND

Asthma is a common respiratory condition in children that is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. Children with asthma may be able to manage their condition more effectively by improving inhaler technique, and by recognising and responding to symptoms. Schools offer a potentially supportive environment for delivering interventions aimed at improving self-management skills among children. The educational ethos aligns with skill and knowledge acquisition and makes it easier to reach children with asthma who do not regularly engage with primary care. Given the multi-faceted nature of self-management interventions, there is a need to understand the combination of intervention features that are associated with successful delivery of asthma self-management programmes.

OBJECTIVES

This review has two primary objectives.• To identify the intervention features that are aligned with successful intervention implementation.• To assess effectiveness of school-based interventions provided to improve asthma self-management among children.We addressed the first objective by performing qualitative comparative analysis (QCA), a synthesis method described in depth later, of process evaluation studies to identify the combination of intervention components and processes that are aligned with successful intervention implementation.We pursued the second objective by undertaking meta-analyses of outcomes reported by outcome evaluation studies. We explored the link between how well an intervention is implemented and its effectiveness by using separate models, as well as by undertaking additional subgroup analyses.

SEARCH METHODS

We searched the Cochrane Airways Trials Register for randomised studies. To identify eligible process evaluation studies, we searched MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Database of Systematic Reviews (CDSR), Web of Knowledge, the Database of Promoting Health Effectiveness Reviews (DoPHER), the Database of Abstracts of Reviews of Effects (DARE), the International Biography of Social Science (IBSS), Bibliomap, Health Technology Assessment (HTA), Applied Social Sciences Index and Abstracts (ASSIA), and Sociological Abstracts (SocAbs). We conducted the latest search on 28 August 2017.

SELECTION CRITERIA

Participants were school-aged children with asthma who received the intervention in school. Interventions were eligible if their purpose was to help children improve management of their asthma by increasing knowledge, enhancing skills, or changing behaviour. Studies relevant to our first objective could be based on an experimental or quasi-experimental design and could use qualitative or quantitative methods of data collection. For the second objective we included randomised controlled trials (RCTs) where children were allocated individually or in clusters (e.g. classrooms or schools) to self-management interventions or no intervention control.

DATA COLLECTION AND ANALYSIS

We used qualitative comparative analysis (QCA) to identify intervention features that lead to successful implementation of asthma self-management interventions. We measured implementation success by reviewing reports of attrition, intervention dosage, and treatment adherence, irrespective of effects of the interventions.To measure the effects of interventions, we combined data from eligible studies for our primary outcomes: admission to hospital, emergency department (ED) visits, absence from school, and days of restricted activity due to asthma symptoms. Secondary outcomes included unplanned visits to healthcare providers, daytime and night-time symptoms, use of reliever therapies, and health-related quality of life as measured by the Asthma Quality of Life Questionnaire (AQLQ).

MAIN RESULTS

We included 55 studies in the review. Thirty-three studies in 14,174 children provided information for the QCA, and 33 RCTs in 12,623 children measured the effects of interventions. Eleven studies contributed to both the QCA and the analysis of effectiveness. Most studies were conducted in North America in socially disadvantaged populations. High school students were better represented among studies contributing to the QCA than in studies contributing to effectiveness evaluations, which more commonly included younger elementary and junior high school students. The interventions all attempted to improve knowledge of asthma, its triggers, and stressed the importance of regular practitioner review, although there was variation in how they were delivered.QCA results highlighted the importance of an intervention being theory driven, along with the importance of factors such as parent involvement, child satisfaction, and running the intervention outside the child's own time as drivers of successful implementation.Compared with no intervention, school-based self-management interventions probably reduce mean hospitalisations by an average of about 0.16 admissions per child over 12 months (SMD -0.19, 95% CI -0.35 to -0.04; 1873 participants; 6 studies, moderate certainty evidence). They may reduce the number of children who visit EDs from 7.5% to 5.4% over 12 months (OR 0.70, 95% CI 0.53 to 0.92; 3883 participants; 13 studies, low certainty evidence), and probably reduce unplanned visits to hospitals or primary care from 26% to 21% at 6 to 9 months (OR 0.74, 95% CI 0.60 to 0.90; 3490 participants; 5 studies, moderate certainty evidence). Self-management interventions probably reduce the number of days of restricted activity by just under half a day over a two-week period (MD 0.38 days 95% CI -0.41 to -0.18; 1852 participants; 3 studies, moderate certainty evidence). Effects of interventions on school absence are uncertain due to the variation between the results of the studies (MD 0.4 fewer school days missed per year with self-management (-1.25 to 0.45; 4609 participants; 10 studies, low certainty evidence). Evidence is insufficient to show whether the requirement for reliever medications is affected by these interventions (OR 0.52, 95% CI 0.15 to 1.81; 437 participants; 2 studies; very low-certainty evidence). Self-management interventions probably improve children's asthma-related quality of life by a small amount (MD 0.36 units higher on the Paediatric AQLQ(95% CI 0.06 to 0.64; 2587 participants; 7 studies, moderate certainty evidence).

AUTHORS' CONCLUSIONS

School-based asthma self-management interventions probably reduce hospital admission and may slightly reduce ED attendance, although their impact on school attendance could not be measured reliably. They may also reduce the number of days where children experience asthma symptoms, and probably lead to small improvements in asthma-related quality of life. Many of the studies tested the intervention in younger children from socially disadvantaged populations. Interventions that had a theoretical framework, engaged parents and were run outside of children's free time were associated with successful implementation.

Optimizing community-level surveillance data for pediatric asthma management

Community-level approaches for pediatric asthma management rely on locally collected information derived primarily from two sources: claims records and school-based surveys. We combined claims and school-based surveillance data, and examined the asthma-related risk patterns among adolescent students. Symptom data collected from school-based asthma surveys conducted in Oakland, CA were used for case identification and determination of severity levels for students (high and low). Survey data were matched to Medicaid claims data for all asthma-related health care encounters for the year prior to the survey. We then employed recursive partitioning to develop classification trees that identified patterns of demographics and healthcare utilization associated with severity. A total of 561 students had complete matched data; 86.1% were classified as high-severity, and 13.9% as low-severity asthma. The classification tree consisted of eight subsets: three indicating high severity and five indicating low severity. The risk subsets highlighted varying combinations of non-specific demographic and socioeconomic predictors of asthma prevalence, morbidity and severity. For example, the subset with the highest class-prior probability (92.1%) predicted high-severity asthma and consisted of students without prescribed rescue medication, but with at least one in-clinic nebulizer treatment. The predictive accuracy of the tree-based model was approximately 66.7%, with an estimated 91.1% of high-severity cases and 42.3% of low-severity cases correctly predicted. Our analysis draws on the strengths of two complementary datasets to provide community-level information on children with asthma, and demonstrates the utility of recursive partitioning methods to explore a combination of features that convey asthma severity.

Declines with age in childhood asthma symptoms and health care use: an adjustment for evaluations

RATIONALE

Asthma is a variable condition with an apparent tendency for a natural decline in asthma symptoms and health care use occurring as children age. As a result, asthma interventions using a pre-post design may overestimate the intervention effect when no proper control group is available.

OBJECTIVES

Investigate patterns of natural decline over time with increasing age in asthma symptoms and health care use of children. Develop a statistical procedure that enables adjustment that accounts for expected declines in these outcomes and is useable when intervention evaluations must rely solely on pre-post data.

METHODS

Mixed-effects models with mixture distributions were used to describe the pattern of symptoms and health care use in 3,021 children aged 2 to 15 years in a combined sample from three controlled trials. An adaptive least squares estimation was used to account for overestimation of intervention effects and make adjustments for pre-post only data. Termed "Adjustment for Natural Declines in Asthma Outcomes (ANDAO)," the adjustment method uses bootstrap sampling to create control cohorts comparable to subjects in the intervention study from existing control subjects. ANDAO accounts for expected declines in outcomes and is beneficial when intervention evaluations must rely solely on pre-post data.

MEASUREMENTS AND MAIN RESULTS

Children under 10 years of age experienced 18% (95% confidence interval, 15-21%) fewer symptom days and 28% (95% confidence interval, 24-32%) fewer symptom nights with each additional year of age. The decline was less than 10% after age 10 years, depending on baseline asthma severity. Emergency department visits declined regardless of baseline symptom frequency (P = 0.02). The adjustment method corrected estimates to within 2.4% of true effects through simulations using control cohorts.

CONCLUSIONS

Because of the declines in symptoms and health care use expected with increasing age of children with asthma, pre-post comparisons will greatly overestimate intervention effects. The ANDAO provides means to adequately estimate treatment effects when a control group design is not possible.

A case study of asthma care in school age children using nurse-coordinated multidisciplinary collaborative practices

Aim

To describe the role of school nursing in leading and coordinating a multidisciplinary networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting multiagency interprofessional practice.

Background

The growth of networked and interprofessional collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-discipline or -agency interventions. This paper identifies the potential of school nursing to provide the vision and multiagency leadership required to coordinate multidisciplinary collaboration.

Method

A mixed-method single-case study design using Yin’s approach, including focus groups, interviews, and analysis of policy documents and public health reports.

Results

A model that explains the integrated population approach to managing school-age asthma is described; the role of the lead school nurse coordinator was seen as critical to the development and sustainability of the model.

Conclusion

School nurses can provide strategic multidisciplinary leadership to address pressing public health issues. Health service managers and commissioners need to understand how to support clinicians working across multiagency boundaries and to identify how to develop leadership skills for collaborative interprofessional practice so that the capacity for nursing and other health care professionals to address public health issues does not rely on individual motivation. In England, this will be of particular importance to the commissioning of public health services by local authorities from 2015.

Establishing school-centered asthma programs

Asthma is a common chronic childhood disease associated with significant morbidity and high rates of school absenteeism, along with excessive costs for the patient and society. Asthma is a leading cause of school absenteeism, but this absenteeism is not equally distributed among those with asthma. Second to their home, school-aged children spend the largest portion of their wakeful hours at school. Opportunities exist to partner with schools to reach most children with asthma and those at the highest risk for asthma burden and in need of assistance. Asthma management at schools is important for pediatric pulmonologists and allergists, primary care providers, and the whole interdisciplinary team working alongside them to provide quality asthma care. The variability of asthma care services and programs provided in schools should prompt clinicians to understand their own school system and to advocate for appropriate services. Models of asthma care that place schools at the center or core of the model and coordinate evidence-based asthma care are applicable nationwide and might serve as a model for managing other chronic illnesses.

Declines with age in childhood asthma symptoms and health care use. An adjustment for evaluations

RATIONALE

Asthma is a variable condition with an apparent tendency for a natural decline in asthma symptoms and health care use occurring as children age. As a result, asthma interventions using a pre-post design may overestimate the intervention effect when no proper control group is available.

OBJECTIVES

Investigate patterns of natural decline over time with increasing age in asthma symptoms and health care use of children. Develop a statistical procedure that enables adjustment that accounts for expected declines in these outcomes and is useable when intervention evaluations must rely solely on pre-post data.

METHODS

Mixed-effects models with mixture distributions were used to describe the pattern of symptoms and health care use in 3,021 children aged 2 to 15 years in a combined sample from three controlled trials. An adaptive least squares estimation was used to account for overestimation of intervention effects and make adjustments for pre-post only data. Termed "Adjustment for Natural Declines in Asthma Outcomes (ANDAO)," the adjustment method uses bootstrap sampling to create control cohorts comparable to subjects in the intervention study from existing control subjects. ANDAO accounts for expected declines in outcomes and is beneficial when intervention evaluations must rely solely on pre-post data.

MEASUREMENTS AND MAIN RESULTS

Children under 10 years of age experienced 18% (95% confidence interval, 15-21%) fewer symptom days and 28% (95% confidence interval, 24-32%) fewer symptom nights with each additional year of age. The decline was less than 10% after age 10 years, depending on baseline asthma severity. Emergency department visits declined regardless of baseline symptom frequency (P = 0.02). The adjustment method corrected estimates to within 2.4% of true effects through simulations using control cohorts.

CONCLUSIONS

Because of the declines in symptoms and health care use expected with increasing age of children with asthma, pre-post comparisons will greatly overestimate intervention effects. The ANDAO provides means to adequately estimate treatment effects when a control group design is not possible.

Community-based interventions in asthma

Community and public health interventions provide potentially powerful means of decreasing morbidity, hospitalizations, emergency room visits, and mortality from asthma. This chapter thus provides an overview of community-based interventions, which have been demonstrated to be effective-and/or ineffective-in reducing the burden of disease, including development of asthma coalitions, interventions for both provider and patient education, environmental controls to reduce exposure to asthma triggers, and institutional policy and systems change. Perhaps most important is the demonstrated effect of integrated, comprehensive approaches to asthma management and control. A multidisciplinary approach spanning T1 through T4 translational research, coupled with public health activities is promising and has already demonstrated success in reducing the burden of disease.

A prospective comparison of moderating relationships among stressors, hopelessness, and internalizing symptoms in low-income urban youth with asthma

There are many risk factors associated with the development of internalizing symptoms in low-income urban youth, and youth with asthma appear to be at greater risk for experiencing stressors in multiple domains. The purpose of the current study was to examine stressors, hopelessness, and the interaction between them, as predictors of trajectories of anxious/depressed and withdrawn symptoms over a 4-year period of adolescence. Participating in the study were 53 youth from Chicago public schools, the majority of whom identified themselves as African American or Latino. Multi-level modeling was used to examine major life events, daily hassles, exposure to violence, poverty, and hopelessness as predictors of both types of symptoms. Major life events and exposure to violence predicted anxious/depressed symptoms but not withdrawn symptoms. Hopelessness predicted both types of symptoms and further interacted with major life events to predict both anxious/depressed and withdrawn symptoms. Hopelessness also moderated the effects of daily hassles on anxious/depressed symptoms and poverty on withdrawn symptoms. Results of this study provide insight into the psychosocial risk factors associated with the experience of asthma in urban adolescents.

Asthma and adolescents: review of strategies to improve control

One of every 10 adolescents in the United States has asthma. Adolescents who lack asthma control are at increased risk for severe asthma episodes and death. The National Heart, Lung, and Blood Institute 2007 asthma guidelines and research studies indicated that school nurses are instrumental in assisting adolescents to monitor their asthma, learn asthma self-management skills, and improve health outcomes. This integrative review examines the research from 2005 to 2011 to identify strategies for school nurses to employ with adolescents to foster self-management skills. The research reviewed here supports the need for school nurses to engage adolescents with asthma to practice self-management behaviors. They should educate the adolescent for asthma, monitor how well the adolescent controls asthma, manage acute asthma episodes by using an asthma action plan, and coordinate care by obtaining written consent from parents to share health information with health care providers.

Asthma and the achievement gap among urban minority youth

OBJECTIVES

To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems.

METHODS

Literature review.

RESULTS

Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts.

CONCLUSIONS

Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.

Medication use patterns among urban youth participating in school-based asthma education

Although pharmaceutical management is an integral part of asthma control, few community-based analyses have focused on this aspect of disease management. The primary goal of this analysis was to assess whether participation in the school-based Kickin' Asthma program improved appropriate asthma medication use among middle school students. A secondary goal was to determine whether improvements in medication use were associated with subsequent improvements in asthma-related symptoms among participating students. Students completed an in-class case-identification questionnaire to determine asthma status. Eligible students were invited to enroll in a school-based asthma curriculum delivered over four sessions by an asthma health educator. Students completed a pre-survey and a 3-month follow-up post-survey that compared symptom frequency and medication use. From 2004 to 2007, 579 participating students completed pre- and post-surveys. Program participation resulted in improvements in appropriate use across all three medication use categories: 20.0% of students initiated appropriate reliever use when "feeling symptoms" (p < 0.001), 41.6% of students reporting inappropriate medication use "before exercise" initiated reliever use (p < 0.001), and 26.5% of students reporting inappropriate medication use when "feeling fine" initiated controller use (p < 0.02). More than half (61.6%) of participants reported fewer symptoms at post-survey. Symptom reduction was not positively associated with improvements in medication use in unadjusted and adjusted analysis, controlling for sex, asthma symptom classification, class attendance, season, and length of follow-up. Participation in a school-based asthma education program significantly improved reliever medication use for symptom relief and prior-to-exercise and controller medication use for maintenance. However, given that symptom reduction was not positively associated with improvement in medication use, pharmaceutical education must be just one part of a comprehensive asthma management agenda that addresses the multifactorial nature of asthma-related morbidity.

Crime, neighborhood deprivation, and asthma: a GIS approach to define and assess neighborhoods

Exposure to neighborhood factors remains difficult to quantify when neighborhoods are often predefined and imprecisely measured. This study examines the association between neighborhood deprivation and participation in a community-based asthma case management (CM) program in Oakland, CA. We estimated neighborhoods by calculating walking distances of , and miles around each child's (n=2892) residence. The model assesses deprivation by the addition of weighted factors within a child's neighborhood-crime rates, alcohol outlets, and eight 2000 US Census characteristics. The results illustrate that neighborhood deprivation is weakly associated with greater levels of program participation, but neighborhood education level, measured by percentage of residents with less than a high school education, is strongly associated with greater program participation (OR: 4.43, 95% CI: [1.23, 15.99]). Neighborhood deprivation factors were significantly different between neighborhoods defined by walking distances and census blockgroups (Wilcoxon-signed rank test: p<0.05).

Different setting, different care: integrating prevention and clinical care in school-based health centers

School-based health centers (SBHCs) are widely credited with increasing students' access to care by making health services affordable and convenient. SBHCs can also provide a qualitatively different type of health care for children and adolescents than that delivered by community providers. Health services offered in a school setting can integrate clinical care with public health interventions and environmental change strategies. This ability to reach outside the walls of the exam room makes SBHCs uniquely positioned to address the multiple determinants of health. We describe innovative California SBHC programs focusing on obesity prevention, asthma, mental health, and oral health that represent new models of health care for children and adolescents.

The management of the allergic child at school: EAACI/GA2LEN Task Force on the allergic child at school

Allergy affects at least one-quarter of European schoolchildren, it reduces quality of life and may impair school performance; there is a risk of severe reactions and, in rare cases, death. Allergy is a multi-system disorder, and children often have several co-existing diseases, i.e. allergic rhinitis, asthma, eczema and food allergy. Severe food allergy reactions may occur for the first time at school, and overall 20% of food allergy reactions occur in schools. Up to two-thirds of schools have at least one child at risk of anaphylaxis but many are poorly prepared. A cooperative partnership between doctors, community and school nurses, school staff, parents and the child is necessary to ensure allergic children are protected. Schools and doctors should adopt a comprehensive approach to allergy training, ensuring that all staff can prevent, recognize and initiate treatment of allergic reactions.

An evaluation of asthma interventions for preteen students

BACKGROUND

Asthma is a serious problem for low-income preteens living in disadvantaged communities. Among the chronic diseases of childhood and adolescence, asthma has the highest prevalence and related health care use. School-based asthma interventions have proven successful for older and younger students, but results have not been demonstrated for those in middle school.

METHODS

This randomized controlled study screened students 10-13 years of age in 19 middle schools in low-income communities in Detroit, Michigan. Of the 6,872 students who were screened, 1,292 students were identified with asthma. Schools were matched and randomly assigned to Program 1 or 2 or control. Baseline, 12, and 24 months data were collected by telephone (parents), at school (students) and from school system records. Measures were the students' asthma symptoms, quality of life, academic performance, self-regulation, and asthma management practices. Data were analyzed using multiple imputation with sequential regression analysis. Mixed models and Poisson regressions were used to develop final models.

RESULTS

Neither program produced significant change in asthma symptoms or quality of life. One produced improved school grades (p = .02). The other enhanced self-regulation (p = .01) at 24 months. Both slowed the decline in self-regulation in undiagnosed preteens at 12 months and increased self-regulation at 24 months (p = .04; p = .003).

CONCLUSION

Programs had effects on academic performance and self-regulation capacities of students. More developmentally focused interventions may be needed for students at this transitional stage. Disruptive factors in the schools may have reduced both program impact and the potential for outcome assessment.

Recent innovations to improve asthma outcomes in vulnerable children

PURPOSE OF REVIEW

Despite overall improvements in asthma care through an increasing evidence base, disparities in outcomes of children of ethnic minorities and low socioeconomic status are well documented across healthcare systems. New interventions to reduce gaps in outcomes among these children are continually being evaluated. This article reviews the most relevant and influential recent studies.

RECENT FINDINGS

A number of interventions aimed at vulnerable children with asthma have been successful. Most of these include a component of education and self-management. There is some evidence that culturally competent care produces improved outcomes, whereas stronger evidence exists for multifaceted programs and community health workers providing home visits for education and environmental allergen reduction. Targeting children and families through school-based programs may be an effective outreach strategy. Use of novel technologies such as educational messages on MP3 players shows promise in reaching at-risk adolescents.

SUMMARY

There are promising strategies proven to significantly decrease disparities in asthma among vulnerable children. Further research must be performed to elucidate the interventions that produce the greatest impact on asthma-related outcomes while being feasible, sustainable, and cost-effective.