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Effects of a Comprehensive School-Based Asthma Program on Symptoms, Parent Management, Grades, and Absenteeism^*

^* From the University of Michigan School of Public Health (Dr. Clark, Ms, Anderson, Ms. Liu, and Ms. Valerio), Ann Arbor; University of Michigan Medical School (Dr. Brown), Ann Arbor; and Henry Ford Health System (Dr. Joseph), Detroit, MI.

Correspondence to: Noreen M. Clark, PhD, University of Michigan School of Public Health, 1420 Washington Heights, Ann Arbor, MI 48109-2029; e-mail: nmclark{at}umich.edu

	Abstract

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Study objective: This study assessed the impact of a comprehensive school-based asthma program on symptoms, grades, and school absences in children, and parents’ asthma management practices.

Design: Randomized controlled trial.

Setting: Fourteen elementary schools in low-income neighborhoods in Detroit, MI.

Participants: Eight hundred thirty-five children with asthma in grades 2 through 5 and their parents.

Intervention: The intervention entailed six components for children, their parents, classmates, and school personnel to encourage and enable disease management.

Measurements and results: Parents completed telephone interviews and the schools provided data at baseline and 24 months after intervention. At follow-up, treatment children with persistent disease had significant declines in both daytime (14% fewer, p < 0.0001) and nighttime (14% fewer, p < 0.0001) symptoms. Among children with both mild intermittent and persistent disease, those in the treatment group had 17% fewer daytime symptoms (p < 0.0001) but 40% more nighttime symptoms. Treatment children had higher grades for science (p < 0.02) but not reading, mathematics, or physical education. No differences in school absences for all causes between groups were noted in school records. However, parents of treatment group children reported fewer absences attributable to asthma in the previous 3 months (34% fewer, p < 0.0001) and 12 months (8% fewer, p < 0.05). Parents of treatment children had higher scores (2.19 greater, p = 0.02) on an asthma management index. The program may have stimulated attention to symptoms at night by parents of children with mild intermittent disease. Overall, the intervention provided significant benefits, particularly for children with persistent asthma.

Key Words: asthma • childhood asthma • morbidity • randomized controlled trial • school-based education • school performance • urban children

	Introduction

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The worrisome data on the prevalence of asthma among children has led to focus on the schools as a point of intervention for asthma control.¹ On average, 6 to 8% of American children have asthma²; however, in asthma hot spots, for example, low income, urban, minority neighborhoods in Detroit, New York City, and other major cities, rates > 20% have been reported.³⁴⁵ The randomized controlled trial reported here evaluated a comprehensive asthma program introduced into elementary schools in high asthma prevalence areas in Detroit, MI. This article presents data testing the assumptions that the program would reduce symptoms, improve school grades, and reduce school absences among children with asthma in intervention schools compared to those in control schools. It was also anticipated that parents of treatment children would engage in more asthma management activities than control subjects.

	Materials and Methods

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Sample and Research Design
Fourteen elementary schools comprising the former Area D of the Detroit School System participated in the study. These schools are located in communities that are 94% African American and for which > 40% of study children met federal guidelines for poverty according to the 1990 census. Schools faced many problems during the study period, including district reorganization and significant budget reductions. No school-based health services were available at participating elementary school sites at the time of program start-up. Parents of all children in grades 2 to 5 (n = 6,351) were provided a survey form designed to identify asthma cases, and 4,576 parents returned the survey with sufficient data for analysis. Based on responses, 1,217 children were identified for participation in the randomized trial.

The survey procedures used to identify children with asthma have been discussed in detail elsewhere.³ For participation in the study reported here, enrollment criteria were as follows: (1) a physician’s diagnosis of asthma and active symptoms, or a diagnosis and received a prescription for asthma medications in the previous year; and (2) no physician’s diagnosis, but reported presence of three or more of seven asthma symptoms in the past year, or reported either of two exercise-related asthma symptoms with frequency of three times or more, in the past year.

Of 1,217 children fitting these initial criteria, parents or caretakers of 835 agreed to participate and provided useable baseline data. Two years later, 674 parents provided follow-up data. The University of Michigan Institutional Review Board approved all consent procedures. Reasons for not participating were primarily that the family moved, could not be contacted after several attempts, or believed the child did not have asthma. Schools were randomly assigned by use of a random number table to receive the program (seven schools and 416 children) or to be assigned to a wait list control group (seven schools and 419 children). The program was offered in control schools subsequent to final data collection. Schools were the unit of randomization, and children were the unit for data analysis.

Intervention
The comprehensive program comprised education for children with asthma to enhance their disease management skills and a series of components aimed at those in the social environment who might enable him or her to manage better. The program elements, were as follows: (1) "Open Airways for Schools"⁶ disease management training for children adapted to local needs (for example, related to smoking among elementary school-aged children⁷), which included handouts and homework assignments involving parents; (2) "Environmental Detective," two classroom sessions for classmates to enhance their understanding of factors that may influence respiratory health in general, and to help them develop empathy for children with asthma in particular; (3) orientation to asthma and control strategies for school principals and counselors; (4) briefings and building walk-throughs for custodial personnel regarding potential environmental triggers to asthma symptoms and practical means of remediation; (5) school fairs for children and their caretakers, including asthma care question-and-answer sessions for the adults; (6) written communication on behalf of the family with the child’s clinician providing information about the school program, encouraging completion of an asthma action plan for the child, and requesting provision of a copy to the school.

All elements of the program were completed with reasonable success except the last element. It was difficult to connect with the primary care physicians by telephone or letter, and a very small number provided action plans to the schools as requested (see "Discussion" section).

Data Collection and Analysis
The children’s parents or caretakers were interviewed by telephone at baseline and at 12 months and 24 months subsequent to the intervention. The questionnaire inquired extensively into the type and frequency of asthma symptoms and efforts of the parents to manage asthma. School records for all years of the study, reporting mathematics, science, reading, and physical education (PE) grades, were obtained from the Detroit Public Schools (DPS) Office of Research and Evaluation. Data on school absences were obtained from two sources: DPS data files reporting absences for all reasons during the project period, and parent interview data describing school absences due to asthma symptoms at baseline and for the previous 3-month and 12-month periods.

In addition to assessing individual grades, an academic grade index (A = 4, B = 3, C = 2, D = 1, and F = 0) was created for each child. An overall mean score and the means for class specific scores were calculated for mathematics, science, and reading grades. Mean scores were also computed for PE grades. The series of questions that tapped parents’ asthma management strategies were summed into a 15- to 60-point index. Questions included items such as administering medicines, avoiding symptoms, observing signs and symptoms, and removing triggers in the environment. Parents also reported day and nighttime asthma symptoms experienced by the child at baseline and in the past 3 months and 12 months. Symptom data were provided in a form that enabled assessment of severity adapting the National Asthma Education and Prevention Program guidelines.

All data were analyzed with Statistical Analysis System (SAS Institute; Cary, NC) version 8 (TS M0) on the SunOS 5.8 platform. To account for the correlation between the repeated measures of the outcome variables, generalized estimating equations were used throughout the analysis. Poisson or normal regression models were used depending on the variable type. Generalized estimating equations were also used to obtain correct coefficients when data may not have conformed exactly to Poisson or normal distributions. Baseline outcome measures, demographic variables (sex of child, family income, age of the child), and baseline severity were adjusted in all statistical models. There were no significant differences in asthma severity between treatment and control groups at baseline. Summary statistics were generated for outcome variables. Baseline outcomes were compared to see if the two study arms (treatment and control) were balanced for outcomes before the intervention. Main effect models were built. Interactions between covariates were also explored. Significance was taken as p < 0.05.

	Results

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Description of the Children
See the ^Appendix for data on the number of children enrolled in the research according to the study criteria and the symptoms reported by children surveyed regardless of enrollment status. Table 1 presents the number of children classified with persistent disease. There were no significant differences between groups at baseline. According to baseline interviews, 87%, 4%, and 6% of respondents (ie, child’s caregiver) were mothers, fathers, and grandmothers, respectively. Of these respondents, 87% had a high school diploma or higher education, and 53% had one or more years of college-level education. English was the first language for 99.8% of the households. Ninety-three percent of the children were between 7 years and 10 years of age. Almost all of the children (98%) were African American. Just less than half (45%) of the families had annual incomes < $15,000. Of the enrolled children, 256 reported having prescribed asthma medicines. Of these, 56% had controller medicines and 88% had reliever medicines. There were no treatment-control differences.

Handling asthma symptoms is a key feature of disease management. We gave scores to parents on a management index of items measuring the number and frequency of actions they took to keep the disease of their children under control. By the second follow-up period, treatment group parents had significantly higher (2.19 higher, p = 0.02) scores on the management index; that is, they took more, and more frequent, steps to manage the disease.

District Record of School Grades
Table 3 presents the model for academic grades, adjusting for baseline scores and age, sex, and income. There were no significant differences in the overall grade index scores or the mean scores for mathematics or reading. Science grades for treatment children, however, were significantly higher than control children 24 months after intervention. While all academic grades declined over the evaluation period, science grades for treatment children declined significantly less than for control subjects (– 0.2,713 vs – 0.4361, p = 0.02). No statistically significant differences between groups on PE grades reported in school records were noted. There was no significant correlation between academic grades and severity. There was a significant negative correlation at baseline between PE grades and severity (0.19, p = 0.001). Children with more severe asthma had better PE grades. This finding may reflect accommodation by the teacher or that the most ill children do not attend classes when they feel unwell and participate in PE when they are most able. There were no treatment and control group differences in correlations between severity and academic or PE grade.

	Discussion

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Symptom reduction is an important goal in asthma. The expanded intervention significantly improved daytime symptoms for all participants. However, only for children with persistent disease did nighttime symptoms also improve. Indeed, program children with mild intermittent asthma reported more nighttime symptoms than control group children subsequent to the program. One or two factors may account for this finding. Program children with intermittent disease (and their parents) likely became more aware of asthma and the nature of asthma symptoms as a result of their participation. Mild intermittent asthma requires less interaction with clinicians and less frequent use of medicines. Both situations make asthma less central in family life until something calls it to attention. It may be that taking part in the range of activities comprising the comprehensive program caused families, where the child’s disease was mild, to notice symptoms more frequently and attribute them to asthma. Control children and parents, given no program to call attention to asthma, were less likely to notice or attribute nighttime symptoms to the disease. As outcomes related to grades and absences generated benefits in the right direction for children at both levels of severity, increased attention seems a likely explanation for more nighttime symptoms being reported by intervention children with mild intermittent asthma. Findings do show that program parents exercised more efforts to manage asthma and its symptoms regardless of severity. If nocturnal symptoms were present but not recognized at baseline, some children may have been misclassified as having mild intermittent asthma. As least one study⁸ has shown that reports by low-income parents can underestimate a child’s condition. However, severity of asthma in this study was assessed through queries about frequency of symptoms that reflect National Asthma Education and Prevention Program guidelines and this way of classifying patients is thought to be reasonably accurate.²

Generally, as children progress from one grade to the next in school, their academic grades decline.⁶ Science grades for treatment children in this study declined much less steeply than those for control children. When we looked at science grades for children with more frequent attendance at asthma program sessions, the strength of the difference increased (p = 0.0001). We speculate that the science grades are better for one or two reasons. For example, the intervention included age-appropriate lessons related to the physiology and functioning of the pulmonary system. This information was likely relevant to some aspects of study in science classes. Further, the problem-solving, deductive nature of program activities, especially related to identifying environmental precipitants of asthma, may have enhanced the ability of the children to tackle science problems in general. That there were no differences in reading and mathematics grades likely indicates that program lessons were less relevant to these areas. Missing less school does not appear to play a role in higher science grades. Although treatment children missed school far less often because of their asthma, their overall absenteeism did not differ from control group children. A complication in measuring school absences is that official records do not account for the cause of the absence. Therefore, it was not possible to compare parents’ reports with school system records regarding classes missed because of asthma. While treatment parents reported fewer asthma absences, school district figures showed no differences in overall absences. This lack of difference likely reflects the many reasons children are absent from school and high levels of absenteeism in low-income urban areas. PE grades declined in both groups of children, and the decline for treatment children was less severe. However, the differences between groups did not reach statistical significance. We can speculate on why there were no changes in PE grades for treatment children despite a decline in their daytime symptoms. It may be that while health status of children changed, perceptions of teachers did not. The intervention did not specifically focus on PE teachers’ views or practices toward children with asthma. Teachers may have continued to view these students as different even if their asthma status improved. A study based in elementary schools has shown that PE teachers frequently feel uninformed about asthma and unsure about what children can and should do.⁹

This study assessed an intervention that combined a number of approaches thought to enhance the management of asthma in a child. A pivotal feature was involving the child, and indirectly the parent, in problem-centered asthma education, and emphasizing that children themselves could learn to manage the disease well. As evident in these findings, indirect involvement of parents has been shown in previous studies¹⁰ to enhance their asthma management skills. However, the study design does not enable us to say which program element contributed most to the results.

One program component, connecting clinicians and school personnel, did not occur as envisioned. Few physicians could be contacted by program staff, and only a handful provided information to the school about a child’s asthma condition and clinical regimen. Baseline data indicated that the level of asthma medical treatment provided to study children was inadequate. Across all severity levels, just over one quarter of the children were on regimens meeting National Asthma Education and Prevention Program guidelines.³ Control of asthma is dependent on an effective partnership between a patient and a clinician who treats the disease according to recommended protocols.² School-based programs can augment, but not replace, this partnership. Children in the areas where this study was conducted need improved clinical care.³ Had clinical care been at a higher level of quality, intervention effects may have been greater.

	Conclusion

TOP Abstract Introduction Materials and Methods Results Discussion Conclusion Appendix References

 
A comprehensive school-based intervention enhanced health status and school performance for elementary school-aged children. Fewer symptoms, higher academic grades in science, and reduced school absences for asthma resulted. Children, their disease, the environment, clinical care, and family situations change over time. Programs provided periodically over the course of elementary school, as children mature and new challenges arise, may help them and their families to manage the disease. That in this study children with persistent asthma were most likely to improve regarding symptom control suggests that these children may be the priority for school-based interventions.

	Appendix

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	Acknowledgements

	Footnotes

 
Abbreviations: DPS = Detroit Public Schools; PE = physical education

The work presented here was supported by the Lung Division of the National Heart, Lung, and Blood Institute grant HR-56028.

Received for publication April 25, 2003. Accepted for publication December 8, 2003.

	References

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1. Lara, M, Rosenbaum, S, Rachelefsky, G, et al (2002) Improving childhood asthma outcomes in the United States: a blueprint for policy action. Pediatrics 109,919-930[Abstract/Free Full Text]
2. Guidelines for the Diagnosis and Management of Asthma: Asthma Education and Prevention Program 1997 National Heart, Lung, and Blood Institute. Bethesda MD: expert panel report II. Bethesda, MD: National Asthma Education Program, Office of Prevention, Education, and Control
3. Clark, NM, Brown, R, Joseph, CLM, et al Issues in identifying asthma and estimating prevalence in an urban school population. J Clin Epidemiol 2002;55,870-881[CrossRef][ISI][Medline]
4. Kass, D, Brown, C, Garg, R, et al The burden of asthma among elementary school-aged children in central Harlem, Manhattan. 2002 (Spring) NYC Department of Health and Mental Hygiene. New York, NY:
5. Joseph, CL, Foxman, B, Leickly, FE, et al Prevalence of possible undiagnosed asthma and associated morbidity among urban schoolchildren. J Pediatr 1996;129,735-742[CrossRef][ISI][Medline]
6. Evans, D, Clark, NM, Feldman, CH, et al A school health education program for children with asthma aged 8–11 years. Health Educ Q 1987;14,267-279[ISI][Medline]
7. Joseph, CM, Clark, NM, Brown, R, et al Factors associated with smoking in urban elementary school children [abstract]. 2000 ALA/ATS International Conference. Toronto, Canada:
8. Cabana MD, Slish KK, Lin X, et al. Asking the correct question: parent’s description of their child’s asthma severity [abstract]. Presented at European Respiratory Society Annual Congress, Vienna, Austria, September 27 to October 1, 2003
9. Neuharth-Pritchett, S, Getch, YQ Asthma and the school teacher: the status of teacher preparedness and training. J Sch Nurs 2001;17,323-328[Medline]
10. Evans, D, Clark, NM, Levison, MJ, et al Can children teach their parents about asthma? Health Educ Behav 2001;28,500-511[Abstract/Free Full Text]

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