Teacher initiated improvement of asthma policy in schools

Asthma education for school staff

BACKGROUND

Teachers and school staff should be competent in managing asthma in schools. Demonstrated low levels of asthma knowledge mean that staff may not know how best to protect a child with asthma in their care, or may fail to take appropriate action in the event of a serious attack. Education about asthma could help to improve this knowledge and lead to better asthma outcomes for children.

OBJECTIVES

To assess the effectiveness and safety of asthma education programmes for school staff, and to identify content and attributes underpinning them.

SEARCH METHODS

We conducted the most recent searches on 29 November 2016.

SELECTION CRITERIA

We included randomised controlled trials comparing an intervention to educate school staff about asthma versus a control group. We included studies reported as full text, those published as abstract only and unpublished data.

DATA COLLECTION AND ANALYSIS

At least two review authors screened the searches, extracted outcome data and intervention characteristics from included studies and assessed risk of bias. Primary outcomes for the quantitative synthesis were emergency department (ED) or hospital visits, mortality and asthma control; we graded the main results and presented evidence in a 'Summary of findings' table. We planned a qualitative synthesis of intervention characteristics, but study authors were unable to provide the necessary information.We analysed dichotomous data as odds ratios, and continuous data as mean differences or standardised mean differences, all with a random-effects model. We assessed clinical, methodological and statistical heterogeneity when performing meta-analyses, and we narratively described skewed data.

MAIN RESULTS

Five cluster-RCTs of 111 schools met the review eligibility criteria. Investigators measured outcomes in participating staff and often in children or parents, most often at between 1 and 12 months.All interventions were educational programmes but duration, content and delivery varied; some involved elements of training for pupils or primary care providers. We noted risk of selection, performance, detection and attrition biases, although to a differing extent across studies and outcomes.Quanitative and qualitative analyses were limited. Only one study reported visits to the ED or hospital and provided data that were too skewed for analysis. No studies reported any deaths or adverse events. Studies did not report asthma control consistently, but results showed no difference between groups on the paediatric asthma quality of life questionnaire (mean difference (MD) 0.14, 95% confidence interval (CI) -0.03 to 0.31; 1005 participants; we downgraded the quality of evidence to low for risk of bias and indirectness). Data for symptom days, night-time awakenings, restricted activities of daily living and school absences were skewed or could not be analysed; some mean scores were better in the trained group, but most differences between groups were small and did not persist to 24 months.Schools that received asthma education were more adherent to asthma policies, and staff were better prepared; more schools that had received staff asthma training had written asthma policies compared with control schools, more intervention schools showed improvement in measures taken to prevent or manage exercise-induced asthma attacks and more staff at intervention schools reported that they felt able to administer salbutamol via a spacer. However, the quality of the evidence was low; results show imbalances at baseline, and confidence in the evidence was limited by risk of bias and imprecision. Staff knowledge was higher in groups that had received asthma education, although results were inconsistent and difficult to interpret owing to differences between scales (low quality).Available information about the interventions was insufficient for review authors to conduct a meaningful qualitative synthesis of the content that led to a successful intervention, or of the resources required to replicate results accurately.

AUTHORS' CONCLUSIONS

Asthma education for school staff increases asthma knowledge and preparedness, but studies vary and all available evidence is of low quality. Studies have not yet captured whether this improvement in knowledge has led to appreciable benefits over the short term or the longer term for the safety and health of children with asthma in school. Randomised evidence does not contribute to our knowledge of content or attributes of interventions that lead to the best outcomes, or of resources required for successful implementation.Complete reporting of the content and resources of educational interventions is essential for assessment of their effectiveness and feasibility for implementation. This applies to both randomised and non-randomised studies, although the latter may be better placed to observe important clinical outcomes such as exacerbations and mortality in the longer term.

Health-care conditions in elementary schools and teachers' knowledge of childhood asthma

BACKGROUND

For the adequate control of asthma in school-age children, it is recommended that teachers, school health personnel and administrators should have sufficient knowledge of how to manage asthma during school hours.

AIM

To investigate asthma health care in elementary schools, and teachers' knowledge of childhood asthma and its management.

METHODS

The extent of knowledge of childhood asthma in 2779 teachers in 141 elementary schools (children aged 6-14, grades 1-8) in Bursa, the fourth largest city in Turkey, was evaluated. Section I comprised questions about asthma health-care in schools, Section II teachers' knowledge of the main characteristics of asthma and Section III (Likert Scale) teachers' detailed knowledge of the signs, triggering factors, treatment and general knowledge of asthma.

RESULTS

The findings of Section I demonstrated that the organisation of health-care for asthma in schools was insufficient. Of the teachers questioned, 14·7% were not even aware and only 1% and 9·6% of the teachers had been made aware by school health personnel and school records, respectively, of asthmatic children. Only 27·3% of the teachers stated that they were responsible for the health of an asthmatic child. The majority of teachers (70%) said that asthmatic children could use the medication (e.g. inhalers) themselves. In Section II, there were between 44·1% and 75·5% correct answers, while in Section III this figure ranged from 3·3% to 78·4%. The correct answer rate was 60·4% for Sections II and III combined. The results of Sections II and III showed that the teachers' knowledge of asthma was poor in many respects. Teachers who stated that they had asthma or had first-degree relatives with asthma, or those with 10 or more years' experience provided significantly more correct answers in Sections II and III combined than did those without these characteristics (P<0·001).

CONCLUSIONS

There is a need to improve and standardise health care for asthma (asthma management policies) in schools. The implementation of asthma education programmes for teachers and other staff responsible for pupils' health should result in better control of this common disease.

Evaluation of the feasibility of a school-based asthma management programme in Taiwan

AIMS AND OBJECTIVES

To investigate the feasibility of a school-based asthma management programme for middle school children.

BACKGROUND

Asthma rates are increasing among school-aged children. Successful asthma treatment in children depends in part on clear communication and effective education.

DESIGN

This feasibility study employed a one-group only longitudinal design with four time points over 18 months.

METHODS

Nineteen female and twelve male (n = 31) seventh-grade children with asthma (13 SD 0·71 years) were identified using a six-stage asthma case-finding approach. Teachers and school staff were trained in the principles and methods of the proposed school-based asthma management programme. An individualised guided asthma self-management programme was developed for each child by a clinical team at a major academic medical centre. We assisted teachers in implementing the school programme; building a support network and monitoring children's activities. Outcome measures included lung function tests (at 0, six, 12 and 18 months), disease-related symptoms, psychosocial status and impact of asthma on learning (at 0 and 18 months). School provided data on academic achievement and school absences at 0, six, 12 and 18 months.

RESULTS

Significant improvements were noted at six, 12 and 18 months on forced vital capacity (FVC)% of predicted (p = 0·001, 0·015, 0·015, respectively), forced expiratory volume in one second (FEV(1) )% of predicted (p = 0·001, 0·006, 0·088, respectively) and FEV(1) /FVC% of predicted (p = 0·001, 0·015, 0·099, respectively). There was a trend towards improved asthma symptoms (p = 0·050) and a significant decrease in positive perception of curriculum (p = 0·017) at 18 months after adjustment for covariates.

CONCLUSIONS

This programme was associated with respiratory benefits on physiological asthma markers commonly, with a trend for symptom control. Academic and psychosocial outcomes are subject of further inquiry.

RELEVANCE TO CLINICAL PRACTICE

School-based asthma management holds promise as a feasible clinical option for middle school children with asthma in the Taiwanese school system.

[Therapeutic education in asthma management]

All guidelines, protocols and recommendations underline the importance of therapeutic education as a key element in asthma management and control. Considerable evidence supports the efficacy and effectiveness of this measure. Health personnel, as well as patients and their parents, can and should be educated with two main objectives: to achieve the best possible quality of life and to allow self control of the disease. These goals can be attained through an educational process that should be individually tailored, continuous, progressive, dynamic, and sequential. The process poses more than a few difficulties involving patients, health professionals, and the health systems. Knowledge of the various psychological factors that can be present in asthmatic patients, as well as the factors related to the highly prevalent phenomenon of non-adherence, is essential. Awareness of the factors influencing physician-patient-family communication is also highly important to achieve the objectives set in therapeutic education. The educational process helps knowledge and abilities to be acquired and allows attitudes and beliefs to be modified. Patients and caregivers should be provided with an individual written action plan based on symptoms and/or forced expiratory volume in 1 second. Periodic follow-up visits are also required.

Evaluation of asthma management policies in New York City public schools

The aim of this study was to investigate asthma management policies and protocols in Bronx, New York, public elementary schools in light of the National Heart, Lung, and Blood Institute (NHLBI) Resolution on Asthma Management in Schools. An anonymous survey was conducted in November 2001 of principals, teachers, counselors, and nurses at five Bronx elementary schools. The response rate was 62%, and the majority of respondents (84%) were teachers; 51% of respondents learned of a student's asthma only through informal conversation with the student or parent, 28% said they were usually not informed of a student's asthma status, and only 10% learned of a child's asthma through existing school protocols; 21% of respondents did not know whom in the school was responsible for supervising the health needs of children with asthma, and 30% did not know how asthma inhalers were supposed to be handled at their school. Only 1.6% of teachers were "very familiar" with Board of Education asthma policies. The results are interpreted as showing poor adherence to the NHLBI recommendations. They also reflect a lack of consistent strategies for communication of a child's asthma diagnosis and for management of the disease in the schools. Ongoing efforts to improve asthma management in public schools through teacher education and policy development should be supported and evaluated for outcomes in teacher knowledge and student health.

Randomized controlled trial of a teacher-led asthma education program

Our objective was to determine whether an asthma education program in schools would have 1) a direct impact on student knowledge and attitudes to asthma and quality of life of the students with asthma, 2) an indirect impact on teacher knowledge and attitudes to asthma and on school policies about asthma, and 3) a sustainable program after the resources to implement the research were withdrawn. Seventeen intervention and 15 control schools participated in a controlled trial. Baseline knowledge and attitudes were measured in year 8 students (ages 13-14 years) and their teachers together with quality of life in the students with asthma. A three-lesson package about asthma was delivered by teachers as part of the Personal Development/Health/Physical Education (PD/H/PE) curriculum. Follow-up questionnaires were administered to students and staff. Efforts to change school policies were documented. Five years after the intervention, PD/H/PE teachers were contacted to determine whether the program was still operating. Main outcome measures included asthma knowledge, attitudes, and quality of life. Questionnaires were returned by 4,161/4,475 of the year 8 students at baseline and by 3,443 at follow-up. In intervention schools, compared with control schools, students showed improved asthma knowledge (P < 0.0001), improvement in tolerance to asthma (P = 0.02), internal control (P = 0.03), and less tendency to believe in the role of chance in asthma control (P = 0.04). Students from intervention but not control schools showed significant improvements in overall quality of life (P = 0.003 vs. P = 0.82, respectively). Teachers from intervention schools showed significant increases in knowledge compared to control schools (P < 0.0001). Intervention schools were more likely to seek further health education about asthma (P < 0.01). Five years after the 35 schools involved in the development of the materials or the trial had been offered the Living With Asthma package, 25 (71%) were still teaching the program to most or all of their students. Fifty-nine of the 61 (97%) high schools in the Hunter Region now have the program. Management and distribution of the Living With Asthma program have been taken over by the Asthma Foundation of New South Wales. The package has been updated and is being offered to all high schools throughout New South Wales as part of the National Asthma-Friendly Schools Project. In conclusion, a teacher-led asthma education program in secondary school had direct and indirect beneficial outcomes and was sustained at a high level for 5 years in most schools in the Hunter Region, despite minimal ongoing maintenance and support from health workers.

Primary school nurses' knowledge/competence pertaining to childhood asthma and its management prior to and following a National Asthma Education Program in Taiwan

The main purpose of the National Asthma Education Program was to provide asthma education to school nurses in Taiwan. It was also designed to enhance the knowledge and competence of school nurses in managing the asthmatic problems that children experience while in school. In addition to providing instruction about current asthma management skills, tools, and other relevant information, the program demonstrated the use of the peak flow meter for asthmatic children. A single, 4-hr session conducted in each county and city in Taiwan, the National Asthma Education Program began on August 1, 1999, and ended December 31, 2000. A total of 829 school nurses joined the program, with an overall attendance rate of 74%. Significant effects of this program on nurses' asthma care knowledge and competence and case management efficacy were noted. The participating school nurses' demographics, however, were found to be irrelevant to these effects. Expecting the training activities to help relieve the anxieties of managing asthmatic cases in the school environment, participants reported that the training was of much benefit to them. Development of a teaching program to elevate school nurses' capabilities in asthmatic student care in the school environment and the implications of such a program within Taiwanese schools were also discussed.

Emergency asthma inhalers in school

Despite there being a lack of direct evidence of the effectiveness of providing emergency inhalers to schools, the balance of evidence at present suggests the benefits outweigh any possible harm. However, unless UK prescribing law or its interpretation is changed, this will remain an action which opens teachers, nurses, and doctors to possible legal and professional sanctions, and may nullify their institutional or professional indemnity. As a consequence, provision will remain patchy and research into the value of emergency inhalers will be inhibited. A position statement from one or more responsible organisations such as the Royal College of Paediatrics and Child Health, the British Thoracic Society, or the British Paediatric Respiratory Society could persuade a reassessment from the Medicines Control Agency. This is also an issue which could be addressed in the forthcoming National Service Framework for children.

School preparation for the asthmatic student

Questionnaires given to school nurses were used to collect data regarding emergency asthma equipment and plans. Sixty-three percent reported <10 asthmatic visits per month, 25% reported 10-50, and 12% reported >50. Only 20% of school nurses reported that 75%-100% of asthmatic students had an emergency plan, and 24% did not know if asthmatic students had a plan. Only half of the nurses had input into the plan. Equipment varied: 16% had oxygen, 45% had peak flow meters, 0% had MDIs, and 20% had nebulizers available. Many asthmatic students lack emergency plans, and many school nurses are not involved in the plans.

Asthma knowledge, roles, functions, and educational needs of school nurses

In October 1997, 790 school nurses in Maryland and the District of Columbia were surveyed to determine their attitudes, knowledge, and beliefs about asthma. Results for 550 (70%) nurses indicated school nurses possess a generally appropriate level of knowledge concerning asthma, and most asthma myths have been replaced with knowledge. However, school nurses also have varied responsibilities that affect their ability to provide health education and support services to children with asthma at school. Little time is available for a proactive role. Concerns about the criteria and follow-up for delegating medication administration within the school setting were reported. A lack of communication existed with parents about the child's asthma. Open communication between school nurses and the family is recommended to establish a partnership and improve asthma management outcomes. In addition, school policies and procedures should be updated to meet the demands of children with asthma.