Using public policy to improve outcomes for asthmatic children in schools

Air Quality and Behavioral Impacts of Anti-Idling Campaigns in School Drop-Off Zones

Vehicle emissions are a major source of pollution in urban communities and idling may contribute up to 34% or more to local air pollution levels. Reduced idling has been found to be an effective policy tool for improving air quality, especially around schools, where it may also improve outcomes for asthmatic children. We studied two anti-idling campaigns in Salt Lake County, Utah to understand if reduced engine idling leads to behavioral change and subsequent reduction in traffic-related air pollution exposure of the related school. We found a 38% decrease in idling time following an anti-idling campaign and an 11% decrease in the number of vehicles idling at the school drop-off zones. The air quality measurements showed improvement in the middle of the campaign, but seasonal variability as well as atmospheric inversion events had substantial effects on overall ambient pollutant concentrations. This study provides an encouraging starting point to develop more effective anti-idling campaigns to protect the health of children, school staff, and the surrounding community.

Current Asthma Management Practices by Primary School Teaching Staff: A Systematic Review

BACKGROUND

The likelihood of children with asthma experiencing an exacerbation at school is significantly high when considering that they spend a substantial part of their day at school. This study, therefore, aimed to systematically review the literature to determine current asthma management practices by primary school teaching staff and any existing supporting legislation/policies/guidelines.

METHODS

Search terms were adapted to search literature across databases: CINAHL, Cochrane Library, Education Database-ProQuest, IPA, MEDLINE, SCI. Primary research studies, reviews, systematic reviews, and meta-analyses in English about primary school teaching staff dated between 2007 and 2017 were included. Primary outcomes comprised teaching staff' practices regarding asthma management and supporting guidelines, policies, or legislation.

RESULTS

Analysis of the 13 papers eligible for full review identified that: teachers were unable to deal with an asthma exacerbation; they lacked knowledge regarding exercise-induced asthma and that there was poor communication between schools and parents of children with asthma. The only documented relevant asthma legislation found pertained to New York schools.

CONCLUSIONS

Limited evidence regarding asthma management practices and inadequate asthma management knowledge amongst teaching staff highlight the need for supporting teaching staff with asthma policies and guidelines to minimize risks associated with inappropriate asthma management.

A worldwide charter for all children with asthma

Childhood asthma is a huge global health burden. The spectrum of disease, diagnosis, and management vary depending on where children live in the world and how their community can care for them. Global improvement in diagnosis and management has been unsatisfactory, despite ever more evidence-based guidelines. Guidelines alone are insufficient and need supplementing by government support, changes in policy, access to diagnosis and effective therapy for all children, with research to improve implementation. We propose a worldwide charter for all children with asthma, a roadmap to better education and training which can be adapted for local use. It includes access to effective basic asthma medications. It is not about new expensive medications and biologics as much can be achieved without these. If implemented carefully, the overall cost of care is likely to fall and the global future health and life chance of children with asthma will greatly improve. The key to success will be community involvement together with the local and national development of asthma champions. We call on governments, institutions, and healthcare services to support its implementation.

Applying a biopsychosocial model to inner city asthma: Recent approaches to address pediatric asthma health disparities

Pediatric asthma in inner cities is often severe and children living in these urban locations with socioeconomic disadvantage experience greater asthma morbidity. There are many interconnected risk factors that individually, and in combination, enhance asthma morbidity. These include biologic factors innate to the child, such as genetics and allergen susceptibility, as well as factors related to the family and neighborhood context. The biopsychosocial model can be used to frame these risk factors and develop interventions specific to the inner city. Successful inner city asthma interventions exist and key characteristics include multi-tiered components that operate within the community to coordinate disease management resources between patients, families and health care systems.

The Socioecological Framework: A Multifaceted Approach to Preventing Sport-Related Deaths in High School Sports

The socioecological framework is a multilevel conceptualization of health that includes intrapersonal, interpersonal, organizational, environmental, and public policy factors. The socioecological framework emphasizes multiple levels of influence and supports the idea that behaviors both affect and are affected by various contexts. At present, the sports medicine community's understanding and application of the socioecological framework are limited. In this article, we use the socioecological framework to describe potential avenues for interventions to reduce sport-related deaths among adolescent participants.

School-supervised use of a once-daily inhaled corticosteroid regimen: A cluster randomized trial

BACKGROUND

School-supervised use of a once-daily inhaled corticosteroid regimen (supervised therapy) can improve medication adherence and asthma control.

OBJECTIVE

We sought to evaluate the effectiveness of supervised therapy in a unique setting and population.

METHODS

We conducted a cluster randomized trial of supervised therapy in 20 elementary schools with a disproportionate enrollment of low-income Latino students. Schools were purposively selected, matched, and randomized to receive 9 months of supervised therapy with mometasone furoate or usual care. All English- or Spanish-speaking students with self-reported asthma were eligible. The Asthma Control Questionnaire (ACQ) was interviewer administered quarterly at school. Students in supervised therapy schools were hypothesized to have lower ACQ scores than students in usual-care schools.

RESULTS

Of 393 enrolled students, 189 students receiving immediate intervention and 143 students receiving delayed intervention provided 1 or more ACQ data points, were between 6 and 10 years of age, and were included in the primary analysis. At baseline, 39% of students reported taking a controller medication, and 24% had well-controlled asthma. Eighty percent of students receiving immediate intervention were prescribed mometasone. Schools administered 98% of prescribed doses when students attended school. Absences, weekends, and holidays reduced calendar adherence to 53%. During the first year, the mean ACQ score for students receiving immediate and delayed intervention was 1.55 (95% CI, 1.41-1.70) and 1.64 (95% CI, 1.47-1.80), respectively. The estimated treatment effect was -0.08 (95% CI, -0.31 to 0.14).

DISCUSSION

Compared with usual care, supervised therapy did not improve asthma control among this population of Latino students. Additional research is warranted to confirm these results.

Addressing the Social Determinants of Health: A Call to Action for School Nurses

Social determinants of health (SDOH), the conditions in which children are born, grow, live, work or attend school, and age, impact child health and contribute to health disparities. School nurses must consider these factors as part of their clinical practice because they significantly and directly influence child well-being. We provide clinical guidance for addressing the SDOH when caring for children with three common health problems (obesity, insufficient sleep, and asthma). Given their unique role as school-based clinical experts, care coordinators, and student advocates, school nurses are well suited to serve as leaders in addressing SDOH.

School intervention in asthma for adolescents: it is time to act

Asthma is a public health problem that is responsible for significant symptomatology and in extreme cases, premature deaths among adolescents. Lack of knowledge of the disease contributes to both its morbidity and mortality. In this manuscript, we discuss school interventions in asthma, in particular their impacts on improving knowledge of the disease and their ability to both make the school environment safer and reduce morbidity indicators. These interventions have been successful when implemented in higher income countries. Thus, to address the lack of interventions in low and middle income countries, we present an example of an alternative asthma intervention in the school curriculum developed in South America. The model has been proven to be both feasible and relatively inexpensive. It is easily structured by utilizing the staff of the school itself and is capable of being adapted to other countries.

The school as a health promoter for children with asthma: The purpose of an education programme

BACKGROUND

Not only is asthma one of the leading causes of hospitalisation in children under 15 years and one of the main reasons for primary care outpatient visits, it also accounts for 13 million lost days of school annually, which can affect children's learning, integration at school and overall academic achievements.

MATERIAL AND METHODS

This review article highlights the important role of the school in helping children and adolescents to control and manage their asthma through integrated and coordinated actions of health professionals, school staff, family, and the community.

RESULTS

We recommended key elements for a multidisciplinary team asthma school programme that can be replicated and implemented especially in developing countries where children and adolescents are in a more disadvantaged environment.

CONCLUSION

This multidisciplinary asthma school intervention when demonstrated with efficacy can be applied in the context of the real world, where many children and families who need care the most currently do not receive it.

Recent advances in environmental controls outside the home setting

PURPOSE OF REVIEW

It has been well studied that aeroallergen, mold, and airborne pollutant exposure in the inner-city home environment is associated with significant childhood asthma morbidity. Although the home environment has been extensively studied, the school environment is less well understood.

RECENT FINDINGS

In this article, we discuss the relationship between environmental exposures within the school and daycare environment and pediatric asthma morbidity and novel environmental interventions designed to help mitigate pediatric asthma morbidity.

SUMMARY

Studies assessing environmental exposures outside the home environment and interventions to mitigate these exposures have the potential to reduce pediatric asthma morbidity. Further study in this area should focus on the complex cost benefit analyses of environmental interventions outside the home setting, while controlling for the home environment.

Developing, Implementing, and Evaluating a School-Centered Asthma Program: Step-Up Asthma Program

BACKGROUND

Asthma is a significant health problem among children: 9.3% of children in the United States suffer from asthma. Children with persistent asthma in inner cities have increased health care utilization, worse health care outcomes, increased school absences, and worse academic performance.

OBJECTIVE

We sought to create and evaluate a school-centered asthma program to reduce asthma morbidity and create asthma-friendly schools.

METHODS

We developed, implemented, and evaluated the Step-Up Asthma Program, a multidisciplinary school-centered asthma program. The program was designed as an outreach program with asthma counselors as a bridge between subspecialty asthma care, primary care providers, school nurses, and children with asthma. The core components of the program involve identifying children with asthma, providing evidence-based asthma education, and case management. Students' asthma knowledge, inhaler technique, and number of asthma exacerbations were evaluated over a 2-year period (2010-2012) as a pre-post study.

RESULTS

A total of 252 students enrolled in the Step-Up Asthma Program over a 2-year period. Significant improvements were noted in number of asthma action plans, rescue medications at school, and asthma controllers. Program participants had significant improvements in asthma knowledge scores (P < .001) and inhaler technique (P < .0001). There were significant reductions in asthma exacerbations defined as oral steroid courses, urgent care visits, and missed school days (P < .05) that persisted over time.

CONCLUSIONS

A guideline-based school-centered asthma program can significantly reduce asthma morbidity. The asthma counselor is the cornerstone of the program, providing asthma education and care coordination. The Step-Up Asthma Program is in its 10th year, and we believe the key elements of this program can be implemented in other school systems.

Examining causes of the urban (inner city) asthma epidemic: Implementing new management strategies

Asthma in the inner city contributes to high morbidity and mortality, and, in school children, reduced school attendance and alteration in academic performance. There is a need to improve asthma care in the inner city by reducing asthma exacerbations. Methods are currently available to predict and prevent seasonal exacerbations of asthma. In addition, new medications are being developed that will be effective in improving pulmonary function and reducing asthma exacerbations. School-centered asthma programs can also be helpful to assist children and clinicians in applying asthma treatment plans and assuring optimal adherence to these plans.

The school environment and asthma in childhood

In this article, we discuss the relationship between environmental exposures within the school environment and pediatric asthma morbidity. This article will conclude by reviewing novel school based asthma education and therapeutic programs and environmental interventions designed to help mitigate pediatric asthma morbidity.

Implementing school asthma programs: Lessons learned and recommendations

Despite significant advances in the treatment of asthma and the development of evidence-based and evidence-informed guidelines, childhood asthma morbidity remains high. One measure of asthma-associated morbidity is school absenteeism. In this rostrum we summarize key themes from 3 articles in this special issue on school-centered asthma programs. All 3 articles in this series describe several common themes that are essential for successful school-based interventions. These themes include the importance of trust and building strong partnerships, the importance of interaction and communication between multiple key stakeholders (ecological framework), the central and often overlooked role of the primary care clinician, the need for sustainable resources, and the importance of context and public policy. We then discuss how to apply the framework of implementation research to inform and evaluate school-based interventions. Finally, we make a series of recommendations for future work.

Advances in pediatric asthma in 2014: Moving toward a population health perspective

Last year's "Advances in pediatric asthma in 2013: Coordinating asthma care" concluded that, "Enhanced communication systems will be necessary among parents, clinicians, health care providers and the pharmaceutical industry so that we continue the pathway of understanding the disease and developing new treatments that address the unmet needs of patients who are at risk for severe consequences of unchecked disease persistence or progression." This year's summary will focus on further advances in pediatric asthma related to prenatal and postnatal factors altering the natural history of asthma, assessment of asthma control, and new insights regarding the management of asthma in children as indicated in Journal of Allergy and Clinical Immunology publications in 2014. A major theme of this review is how new research reports can be integrated into medical communication in a population health perspective to assist clinicians in asthma management. The asthma specialist is in a unique position to convey important messages to the medical community related to factors that influence the course of asthma, methods to assess and communicate levels of control, and new targets for intervention, as well as new immunomodulators. By enhancing communication among patients, parents, primary care physicians, and specialists within provider systems, the asthma specialist can provide timely information that can help to reduce asthma morbidity and mortality.