I love reading new research on school-based asthma programs and thinking about how it can be useful to real life community asthma programs. Here are my thoughts on a paper recently published in the Journal of Asthma & Allergy Educators.
According to the 2006 CDC School Health Policy and Practices Study, the majority of schools and school districts provide school-based asthma programs that include obtaining asthma action plans, teaching self management and providing case management. Very few school health programs have sufficient resources to provide a full range of extra services to all students with asthma. Determining which students should be targeted may seem easy but it’s probably harder than you think.
Schools are encouraged to target students with the greatest need. The National Asthma Education and Prevention Program Expert Panel Report-3 (EPR-3) clarified that the level of asthma control (not severity) is the preferred measure of ongoing asthma management. School asthma programs are not the primary audience for EPR-3, so it doesn’t include specific guidance on how to select students for school-based asthma programs.
Which students need extra services? In many programs, school nurses pick those who go to the health room with wheezing, coughing, or shortness of breath and those who report using their quick relief bronchodilator for asthma symptoms. Students with frequent health room visits (frequent flyers) clearly do not have well controlled asthma. Is this method sufficiently sensitive and specific?
A team of school health nurses and researchers found that it wasn’t, at least not for Charlotte-Mecklenburg Schools (CMS). The Centers for Disease Control and Prevention funded technical assistance to evaluate the school-based asthma program in their elementary schools using a rapid evaluation approach. As part of this evaluation, the program wanted to assess whether the students with greatest need were enrolled in student-level asthma service components. Some high need students were identified by the nurses and most of them got services. Other high need students were only found by a self-report asthma management difficulty (AMD) survey.
The authors recommend that “school districts employ systematic procedures to proactively assess symptoms and self-management skills among students with asthma early in the school year using self-report surveys or short one-on-one interviews.” This reminds me of the lessons many of us have been reviewing in the Asthma Community Network Program Evaluation Webinar series. In addition to looking at outcomes, CMS appropriately evaluated outputs.
It is my experience that school health program implementation is most successful when program evaluation is built into the system so that everyone—the front line school nurse, the supervisor, the program manager and the program designer—learns what is going well and what isn’t so they can work together to enhance the effectiveness of the school nurse. School nurses can get swamped with every day duties. I think asthma programs can provide the best evidence of school nurse effectiveness. School nurses need support to implement programs appropriately and evaluate them.
Let’s go back to the original question: Are school nurse ratings sufficiently sensitive and specific to identify students in need of school-based asthma service? I think the generic answer is maybe not. In the CMS case, the absence of nurse assessments was a major limiting factor. It is possible that other school-based asthma programs have successfully addressed the variability issue. EPR-3 guidance makes it clear that assessment of control needs input from the student or family, not just school nurse observation.
Information about symptoms outside of school, especially nighttime awakening due to asthma, can be obtained via interviews or surveys. I’m looking forward to learning if school-based asthma programs can use self-report surveys to help prioritize student-level services to help students have well controlled asthma. We all want students to expect nothing less.
What lessons have you learned? Remember, lessons don’t need to be only total success stories to be helpful to someone else.
Considering the health of
Considering the health of every student is important. Like what this post said, there are instances that there are students with health problems like asthma. Well, considering a extra school- based service will be a good idea. The economic stimulation plan given by Obama that give schools in America an amount of $4.35 billion will be a big help to finance the additional expenses of every school. There is a reward given to schools in the “Race to the Top” program.
We are also struggling with
We are also struggling with how best to identify/target students with asthma in order to prioritize services. I was interested to read about this new program which indicated that school nurse observation was not sufficient. We are considering using standardized clinical assessments of asthma control (as recommended for use in clinical practice) in addition to school nurse ratings. However, these clinical measures are difficult to apply in a standard manner to wide age groups of children since many are intended to have a parental component as well. Our research has indicated that parents and children report very different levels of symptoms and it is difficult to know which person is closer to the "true" symptom burden experienced. The reporting of asthma control seems to vary widely depending on the method used for asking about symptoms/problems; the individual who asks (the interviewer) about the symptoms/problems; and the reason for asking (i.e. in a clinic, at school or for a research study). We have a lot to learn about the best way to target students who have poor asthma control and how to validate the measures that we use so that they can be easily applied by others.
Thoughtful comments by all.
Thoughtful comments by all. Since asthma continues to be a constant concern in excessive student absences, as a school physician, I always welcome any asthma programs that allow students to gain better control. What I have found in practice is that districts tend not to want to allow any level of "selection" by a school nurse as to which students can participate in a program. In fact, the programs in upstate NY often are held after school when school nurses are not even present unless they stay voluntarily. So, districts that have allowed asthma programs to use their facilities generally advertise open enrollment to any student a parent identifies as having a need. School administrators express more comfort doing it this way because allowing parents to elect to participate eliminates any suggestion that discrimination occurred by the school nurse who chose one student over another. They also have told me that when the parent is empowered to choose, they become more invested in the process and stick with the program. Finally, they indicate that there are students with asthma that might not be known to the school because the child is well-controlled on medicines at home and the parent has not even alerted the school of the situation. They expressed concern those children might be missed by school selection. This is all anecdotal, however, and I cannot say for certain that any of their impressions reflect what is actually happening. Additionally, Open Airways and "Asthma School", which are the two programs that have been used in my districts both use student self-assessment/survey as a tool. Apparently, this appears somewhat successful from a management perspective since school nurses tend to report back that the children enrolled in these programs tend to have improved attendance and fewer trips to the health office for rescue medicines. Again, this is anecdotal. I have nothing that documents if their impressions are accurate or wishful. It would be terrific to gather more data on these topics, because in this day of tight money and decreasing health services in schools, the more we can show the cost value of having asthma management programs in schools, including during the school day dare I say, the more likely the programs will be supported. Administrators know that per capita funding for students who do not miss school is where they get their bread and butter.