The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma

Disparities in High School Graduation by Identity and Disability Using Intermediate and Long-Term Educational Outcomes

Multiple factors influence a student's success in high school graduation. Individual factors such as disability, racial or ethnic identity, and gender may result in inequity in the school environment, interfering with learning and possibly leading to poorer educational outcomes. This secondary analysis of student educational records (N = 3,782) from 2008-2018 tested the associations among the disability, racial or ethnic identity, gender, and 5th grade attendance on high school attendance and graduation. Linear and logistic regression analysis identified students without a disability had a 40% greater chance of graduation (AOR = 1.4 [95% CI = 1.15, 1.71]) than those with a disability. Students identifying as Black, Hispanic, or Native American had half the odds of graduating compared to White students. When controlling for 9th grade attendance, these disparities decreased. Attendance in 5th grade, disability, and racial and ethnic identity influenced attendance, being on track to graduate, and high school graduation.

School Nurse Perspectives on Addressing Chronic Absenteeism

Chronic absenteeism is associated with poor health and educational outcomes. School nurses have great potential to address the health and educational needs that contribute to absenteeism. Through qualitative analysis of interviews with school nurses, we characterize their current role in reducing absenteeism and identify barriers 3 that limit their capacity to meet this goal, organized by the Framework for 21st Century School Nursing Practice. Interviewees (n = 23) identified actions perceived to reduce absenteeism aligned with domains of care coordination, leadership, quality improvement, and community and public health. Barriers perceived to limit the capacity of school nurses to address absenteeism were identified within these domains and ranged from student- and family-level to federal-level barriers. Specific healthcare system-level barriers included insufficient communication with community-based healthcare teams and the need for coordinated approaches across health and education sectors to address absenteeism. Strategic opportunities exist to address barriers to comprehensive school nursing practice and reduce absenteeism.

Prevalence, associated factors, and impact of adolescent asthma in Taiwan: Global Asthma Network phase I survey

Background

The prevalence of asthma in Taiwan was increasing in the past 30 years, causing a great impact on adolescent health. This study aimed to investigate the current prevalence, impact, and associated factors of asthma in Taiwanese adolescents.

Material and methods

Parents or guardians provided passive consent at home prior to the survey. Adolescents aged 13-14 years completed a questionnaire survey in 2017 in Taipei, Taiwan. The prevalence, impact, and associated factors of asthma were analyzed. We also compared the asthma prevalence with the prevalence in 1995 and 2001.

Results

We analyzed 3474 validated questionnaires. The prevalence of physician-diagnosed asthma was 12.4%. The prevalence of current wheezing was 9.2% in 2017, which was 5.2% in 1995 and 7.0% in 2001. 3.3% of 13-14-year-old adolescents had severe asthma symptoms. Asthma significantly impacted the lives of adolescents. Of the students with asthma, 10.9% had school absenteeism, 16.5% urgently needed to see a doctor, 9.5% went to the emergency department, and 3.5% were admitted to hospitals within the preceding 12 months. The associated factors for physician-diagnosed asthma in Taiwanese adolescents were male (prevalence ratio [PR], 1.38; 95% confidence interval [CI], 1.05-1.83; p = 0.02), maternal history of asthma (PR, 2.61; 95% CI, 1.69-4.02; p < 0.01), and recent paracetamol use at least once per month (PR, 2.60; 95% CI, 1.24-5.42; p = 0.01). The associated factors for school absenteeism were nocturnal cough (PR, 1.99; 95% CI, 1.16-3.41; p = 0.01), current wheezing (PR, 7.52; 95% CI, 4.39-12.9; p < 0.01), and recent paracetamol use (at least once per month, PR, 3.16; 95% CI, 1.10-9.06; p = 0.03; at least once per year, PR, 2.19; 95% CI, 1.25-3.83; p < 0.01).

Conclusions

The prevalence of physician-diagnosed asthma was 12.4%. Asthma substantially impacted the lives of adolescents. Reducing nocturnal cough, wheezing frequency, and paracetamol usage might help decrease school absenteeism.

The current state of international research on the effectiveness of school nurses in promoting the health of children and adolescents: An overview of reviews

OBJECTIVE

School nurses are engaging worldwide to promote and protect children's health. Many researchers who examined the effectiveness of the school nurse criticized the inadequate methodology employed in many of the studies. We therefore carried out an evaluation on the effectiveness of school nurses based on a rigorous methodological approach.

METHODS

In this overview of reviews we performed an electronic databank search and global research results on the effectiveness of school nurses were sought. We identified 1,494 records through database search. Abstracts and full texts were screened and summarized using the dual control principle. We summarized the aspects of quality criteria as well as the significance of the effectiveness of the school nurse. In the first step, k = 16 systematic reviews were summarized and evaluated following the AMSTAR-2 guidelines. In a second step, j = 357 primary studies included in these k = 16 reviews were summarized and assessed following the GRADE guidelines.

RESULTS

Research results on the effectiveness of school nurses show that school nurses play a key role in improving the health of children with asthma (j = 6) and diabetes (j = 2), results on combating obesity are less certain (j = 6). The quality of identified reviews is mostly very low with only six studies of medium quality, of which one identified as a meta-analysis. A total of j = 289 primary studies were identified. Approximately 25% (j = 74) of identified primary studies were either randomized controlled trials (RCT) or observational studies, of which roughly 20% (j = 16) had a low risk of bias. Studies with physiological variables such as blood glucose or asthma labeling led to higher quality results.

CONCLUSION

This paper represents an initial contribution and recommends further evaluation of the effectiveness of school nurses, particularly in the areas of mental health or children from low socioeconomic backgrounds. The general lack of quality standards in school nursing research should be integrated into the scientific discourse of school nursing researchers to provide robust evidence for policy planners and researchers.

Community Interventions for Childhood Asthma ED Visits and Hospitalizations: A Systematic Review

A systematic review of interventions in community environments found significant reductions in childhood asthma exacerbations leading to emergency department visits and hospitalizations.

BACKGROUND AND OBJECTIVES

Structural and social determinants of childhood asthma inequities manifest within geographic communities that are often segregated. Childhood asthma disproportionately affects Black, Hispanic, and low-income populations. Community interventions have the potential to improve inequities in emergency healthcare. This systematic review was conducted to assess the effectiveness of childhood asthma community interventions and provide a conceptual model to inform implementation of future community interventions.

METHODS

Publications from PubMed, ScienceDirect, CINAHL, Cochrane Library, Web of Science, and hand searched references were examined from 2010 to 2021. Community intervention studies among children with asthma were included. Main outcomes were emergency department visits and hospitalizations. Community interventions exclusively focusing on schools or hospitals were excluded. Two reviewers independently assessed eligibility for final inclusion. Emergency healthcare findings were extracted in addition to co-benefits (eg, fewer missed school days and caregiver workdays).

RESULTS

Out of 1856 records, 26 publications met the inclusion criteria. Community interventions were categorized by care coordination (n = 8), policy and environmental changes (eg, smoke-free legislature, traffic reduction models, and green housing) (n = 8), home-based (n = 6), and community-based health services (n = 4). Selected studies indicated that community interventions significantly reduced childhood asthma emergency department visits and hospitalizations through increased caregiver self-efficacy, home environmental trigger reduction, and increased access to healthcare. Because of heterogeneity among studies, we were unable to conduct a meta-analysis.

CONCLUSIONS

Findings show significant associations between community interventions and the reduction of emergency healthcare, suggesting a protective effect for severe cases of childhood asthma.

Elementary School-Based Health Centers and Access to Preventive and Asthma-Related Care Among Publicly Insured Children With Asthma in Georgia

OBJECTIVES

We assessed the effects of 3 new elementary school-based health centers (SBHCs) in disparate Georgia communities-predominantly non-Hispanic Black semi-urban, predominantly Hispanic urban, and predominantly non-Hispanic White rural-on asthma case management among children insured by Medicaid/Children's Health Insurance Program (CHIP).

METHODS

We used a quasi-experimental difference-in-differences analysis to measure changes in the treatment of children with asthma, Medicaid/CHIP, and access to an SBHC (treatment, n = 193) and children in the same county without such access (control, n = 163) in school years 2011-2013 and 2013-2018. Among children with access to an SBHC (n = 193), we tested for differences between users (34%) and nonusers of SBHCs. We used International Classification of Diseases diagnosis codes, Current Procedural Terminology codes, and National Drug Codes to measure well-child visits and influenza immunization; ≥3 asthma-related visits, asthma-relief medication, asthma-control medication, and ≥2 asthma-control medications; and emergency department visits during the child-school year.

RESULTS

We found an increase of about 19 (P = .01) to 33 (P < .001) percentage points in the probability of having ≥3 asthma-related visits per child-school year and an increase of about 22 (P = .003) to 24 (P < .001) percentage points in the receipt of asthma-relief medication, among users of the predominantly non-Hispanic Black and Hispanic SBHCs. We found a 19 (P = .01) to 29 (P < .001) percentage-point increase in receipt of asthma-control medication and a 15 (P = .03) to 30 (P < .001) percentage-point increase in receipt of ≥2 asthma-control medications among users. Increases were largest in the predominantly non-Hispanic Black SBHC.

CONCLUSION

Implementation and use of elementary SBHCs can increase case management and recommended medications among racial/ethnic minority and publicly insured children with asthma.

Evaluating the Financial Sustainability of the School-Based Telemedicine Asthma Management Program

Using telemedicine to improve asthma management in underserved communities has been shown to be highly effective. However, program operating costs are perceived as the main barrier to dissemination and scaling up. This study evaluated whether a novel, evidence-based School-Based Telemedicine Enhanced Asthma Management (SB-TEAM) program, designed to overcome barriers to care for families of urban school-aged children, can be financially sustainable in real-world urban school settings. Eligible children (n = 400) had physician-diagnosed asthma with persistent or poorly controlled symptoms at baseline. Total costs included the cost of implementing and running the SB-TEAM program, asthma-related health care costs, cost of caregiver lost productivity in wages related to child illness, and school absenteeism fees. Using data from the SB-TEAM study and national data on wages and equipment costs, the authors modeled low, actual, and high-cost scenarios. The actual cost of administering the SB-TEAM program averaged $344 per child. Expenses incurred by families for medical care ($982), caregiver productivity cost ($415), and school absenteeism costs ($284) in SB-TEAM were not different from the costs in the control group ($1594, $492, and $318 [P > 0.05]). The study findings remained robust under sensitivity analyses for various state- and school-specific regulations, staffing requirements, and wages. The authors concluded that the SB-TEAM program operating costs may be offset by the reduction in health care costs, caregiver lost wages, and school absenteeism associated with the program health benefit.

The Impact of Asthma Education Programs on Children's Life Aspects: A Systematic Review

Objective:

This Scoping review was conducted to explore the impact of education programs on asthmatic children's knowledge of asthma, quality of life, school absenteeism, and selfmanagement.

Data sources:

The Scoping review was restricted to randomized controlled trials and quasi-experimental designs. Studies published in the English language between 2000 and 2017 were retrieved from CINAHL, MEDLINE, OvidSP, Cochrane Library, ProQuest, and Google Scholar databases.

Studies Selection:

Along with specific inclusion and exclusion criteria for selecting studies, an evaluation for the quality of the experimental research based on the level of evidence was applied to categorize studies into poor to good quality.

Results:

Of the 1256 items initially identified references, 18 studies were included in the review to cover the impact of asthma education on four major areas: children's knowledge of asthma, quality of life, school absenteeism, and self-management.

Conclusion:

Despite some inconsistencies between the reviewed studies, asthma education programs demonstrated a positive effect on children's knowledge of asthma, quality of life, school absenteeism, and self-management. Further research on the effect of asthma education on children's activity level, symptoms, and emotional domains is warranted.

School-based self-management interventions for asthma among primary school children: a systematic review

A Cochrane review of school-based asthma interventions (combining all ages) found improved health outcomes. Self-management skills, however, vary according to age. We assessed effectiveness of primary school-based self-management interventions and identified components associated with successful programmes in children aged 6-12 years. We updated the Cochrane search (March 2020) and included the Global Health database. Two reviewers screened, assessed risk-of-bias and extracted data. We included 23 studies (10,682 participants); four at low risk-of-bias. Twelve studies reported at least one positive result for an outcome of interest. All 12 positive studies reported parental involvement in the intervention, compared to two-thirds of ineffective studies. In 10 of the 12 positive studies, parental involvement was substantial (e.g. attending sessions; phone/video communication) rather than being provided with written information. School-based self-management intervention can improve health outcomes and substantial parental involvement in school-based programmes seemed important for positive outcomes among primary school children.

A Practical Approach to Severe Asthma in Children

Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.

Educators' Perspectives of Collaboration With Pediatricians to Support Low-Income Children

BACKGROUND

Educational and healthcare systems operate in silos. Few studies explore educators' perspectives of collaboration with pediatricians or cross-system solutions for school-identified concerns. We sought to investigate educators' viewpoints of collaboration with pediatricians.

METHODS

We conducted semistructured, qualitative interviews with full-time teachers, vice-principals, and principals, who worked with low-income first- or second-grade students. Interviews explored which students were concerning to educators, educators' experiences with collaboration, and barriers and facilitators of collaboration. Interview transcripts were analyzed with modified grounded theory.

RESULTS

We interviewed 12 teachers and 3 principals/vice-principals. Students' socioemotional problems were a foremost concern. Effective collaboration with pediatricians was not typical. Participants described not knowing they could communicate with pediatricians or that collaboration was often limited or unidirectional. Respecting boundaries of parental privacy and maintaining parental trust emerged as potential barriers. Some participants described negative experiences with pediatricians and reflected on societal perceptions of doctors and teachers, which could affect the development of relationships. Participants recognized potential benefits to collaboration, including gaining a holistic understanding of a child's health and home life.

CONCLUSIONS

Educators perceived collaboration with pediatricians as inadequate. More developed and tested programs that foster collaboration between schools and pediatricians are needed to support low-income youth.

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.

School Nurses and Student Academic Outcomes: An Integrative Review

The empirical evidence from previous studies has demonstrated that school nurses are effective in assisting children and families to address health concerns, reduce absenteeism, and provide children with the opportunity to reach their potential academically. Impoverished children and those with disabilities and chronic illness are at risk of school failure. An integrative review was undertaken to critique the research between 2002 and 2018 that addressed the influence of school nurses on academic outcomes such as absenteeism, missed class time, grades, and test scores. The findings of the review suggest that the presence of a school nurse is associated with reduced absenteeism and missed class time but not with academic achievement. Overall, the research in this area is weak and future research using more rigorous study designs, examining broader school nurse roles, and long-term academic outcomes is indicated to evaluate the impact of school nurses on educational outcomes.

Implementation of an Allergic Reaction Reporting Tool for School Health Personnel: A Pilot Study of Three Chicago Schools

Food allergy (FA) impacts 8% of U.S. children, thus it is critical to document allergic reactions to assist schools in managing FAs. We implemented and evaluated an online tool to assist school health personnel in tracking the characteristics of allergic reactions occurring at schools. The Online School Allergic Reaction Registry (OScARR) was modified from the Epinephrine Administration Form developed by the Massachusetts Department of Public Health, adapted for integration into existing school health records, and implemented in three Chicago schools during the 2016–2017 school year. All allergic reactions occurring at participating schools were recorded by school nurses. Twenty-five percent of the 20 allergic reactions reported were characterized as anaphylaxis by school nurses. School nurses reported that they would recommend OScARR for use in other schools. Detailed data obtained from three Chicago schools underscore the importance of proper documentation to improve the understanding of the causative allergen and location and management of allergic reactions in schools.

Interventions for autumn exacerbations of asthma in children

BACKGROUND

Asthma exacerbations in school-aged children peak in autumn, shortly after children return to school following the summer holiday. This might reflect a combination of risk factors, including poor treatment adherence, increased allergen and viral exposure, and altered immune tolerance. Since this peak is predictable, interventions targeting modifiable risk factors might reduce exacerbation-associated morbidity and strain upon health resources. The peak occurs in September in the Northern Hemisphere and in February in the Southern Hemisphere.

OBJECTIVES

To assess the effects of pharmacotherapy and behavioural interventions enacted in anticipation of school return during autumn that are designed to reduce asthma exacerbations in children during this period.

SEARCH METHODS

We searched the Cochrane Airways Group Trials Register, ClinicalTrials.gov, the World Health Organization International Clinical Trials Registry Platform, reference lists of primary studies and existing reviews, and manufacturers' trial registries (Merck, Novartis and Ono Parmaceuticals). We searched databases from their inception to 1 December 2017, and imposed no restriction on language of publication.

SELECTION CRITERIA

We included all randomised controlled trials comparing interventions aimed specifically at reducing autumn exacerbations with usual care, (no systematic change in management in preparation for school return). We included studies providing data on children aged 18 years or younger.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Two review authors independently screened records identified by the search and then extracted data and assessed bias for trials meeting the inclusion criteria. A third review author checked for accuracy and mediated consensus on disagreements. The primary outcome was proportion of children experiencing one or more asthma exacerbations requiring hospitalisation or oral corticosteroids during the autumn period.

MAIN RESULTS

Our searches returned 546 trials, of which five met our inclusion criteria. These studies randomised 14,252 children to receive either an intervention or usual care. All studies were conducted in the Northern Hemisphere. Three interventions used a leukotriene receptor antagonist, one used omalizumab or a boost of inhaled corticosteroids, and the largest study, (12,179 children), used a medication reminder letter. Whilst the risk of bias within individual studies was generally low, we downgraded the evidence quality due to imprecision associated with low participant numbers, poor consistency between studies, and indirect outcome ascertainment.A US study of 513 children with mild/severe asthma and allergic sensitisation was the only study to provide data for our primary outcome. In this study, the proportion of participants experiencing an exacerbation requiring oral corticosteroids or hospital admission in the 90 days after school return was significantly reduced to 11.3% in those receiving omalizumab compared to 21.0% in those receiving placebo (odds ratio 0.48, 95% confidence interval 0.25 to 0.92, moderate-quality evidence). The remaining studies used alternative exacerbation definitions. When data from two leukotriene receptor antagonist studies with comparable outcomes were combined in a random-effects model, there was no evidence of an effect upon exacerbations. There was no evidence that a seasonal medication reminder letter decreased unscheduled contacts for a respiratory diagnosis between September and December.Four studies recorded adverse events. There was no evidence that the proportion of participants experiencing at least one adverse event differed between intervention and usual care groups. Lack of data prevented planned subgroup and sensitivity analyses.

AUTHORS' CONCLUSIONS

Seasonal omalizumab treatment from four to six weeks before school return might reduce autumn asthma exacerbations. We found no evidence that this strategy is associated with increased adverse effects other than injection site pain, but it is costly. There were no data upon which to judge the effect of this or other seasonal interventions on asthma control, quality of life, or asthma-related death. In future studies definitions of exacerbations should be provided, and standardised where possible. To investigate possible differential effects according to subgroup, participants in future trials should be well characterised with respect to baseline asthma severity and exacerbation history in addition to age and gender.

Educational and home-environment asthma interventions for children in urban, low-income, minority families

OBJECTIVE

This review examined the impact of environmental change and educational interventions targeting young children from minority groups living in urban environments and who were from low-income families.

DATA SOURCES

A scoping methodology was used to find research across six databases, including CINAHL, ERIC, PsycINFO, PubMed, MEDLINE, and EMBASE.

STUDY SELECTION

299 studies were identified. Duplicates were removed leaving 159 studies. After reviewing for inclusion and exclusion criteria, 23 manuscripts were identified for this study: 11 featured home-environment change interventions and 12 emphasized education of children.

RESULTS

Studies were reviewed to determine key interventions and outcomes for children. Both environmental interventions and educational programs had positive outcomes. Interventions did not always impact health outcomes, such as emergency department visits.

CONCLUSIONS

Results indicated many of the environmental change and education interventions improved asthma management and some symptoms. A multipronged approach may be a good method for targeting both education and change in the home and school environment to promote the well-being of young children in urban areas. New research with careful documentation of information about study participants, dose of intervention (i.e., number and duration of sessions, booster sessions) and specific intervention components also will provide guidance for future research.

Urban-Rural Differences in School Nurses' Asthma Training Needs and Access to Asthma Resources

PURPOSE

Few studies have examined school nurses preferences' for asthma training. Our purpose was to: 1) assess school nurses' perceived asthma training needs, 2) describe nurses' access to asthma educational resources, and 3) identify urban-rural differences in training needs and access to resources in southern states.

DESIGN AND METHODS

A convenience sample of school nurses (n=162) from seven counties (two urban and five rural) in North Carolina and South Carolina completed an online, anonymous survey. Chi-square tests were used to examine urban-rural differences.

RESULTS

Although most nurses (64%) had received asthma training within the last five years, urban nurses were more likely to have had asthma training than rural nurses (χ2=10.84, p=0.001). A majority of nurses (87%) indicated they would like to receive additional asthma training. Approximately half (45%) of nurses reported access to age-appropriate asthma education materials, but only 16% reported that their schools implemented asthma education programs. Urban nurses were more likely than rural nurses to have access to asthma education programs (χ2=4.10, p=0.04) and age-appropriate asthma education materials (χ2=8.86, p=0.003).

CONCLUSIONS

Few schools are implementing asthma education programs. Rural nurses may be disadvantaged in terms of receiving asthma training and having access to asthma education programs and materials.

PRACTICE IMPLICATIONS

Schools are an ideal setting for delivering age-appropriate asthma education. By providing school nurses with access to age-appropriate asthma education resources and additional asthma training, we can help them overcome several of the barriers that impede their ability to deliver asthma care to their students.

Teaming Up for Asthma Control: EPR-3 Compliant School Program in Missouri Is Effective and Cost-Efficient

Introduction

Teaming Up for Asthma Control (TUAC) is a work force development intervention to improve asthma control among children by increasing the competency of school nurses and delivering guideline-based education. We hypothesized that the knowledge and skills of participating school nurses would improve and that this change would positively affect students’ asthma health and reduce health care utilization cost.

Methods

Asthma education for school nurses was provided online in a pretest/posttest format or in instructor-led groups. Students with persistent asthma were identified by using a checklist. Expert evaluators obtained student participants’ preassessments/postassessments before and after the 3 asthma checkups by the school nurse, and the assessments were compared. Health care costs were assessed using Medicaid administrative claims data.

Results

A total of 54 school nurses and 178 students in Missouri participated in the TUAC evaluation from 2011 through 2014. Among school nurses who completed the online education (n = 42, 77.8%), knowledge scores significantly increased from pretest (49.1%) to posttest (90.7%, P < .001). Of school nurses who completed assessments on 3 children (n = 34), 91.2% met the ±6% equivalence for 1 or more assessments on forced expiratory volume in 1 second (FEV₁) compared with the expert evaluator. At enrollment, 69.7% of students had “not well-controlled” or “very poorly controlled” asthma. Postintervention, FEV₁ significantly improved (82.9% to 92.1% predicted), and self-reported impairment and tobacco smoke exposure significantly declined (P < .001). For TUAC students enrolled in Medicaid, there was an average 12-month health care cost difference (−$1,431) compared with controls.

Conclusion

School nurses effectively assessed asthma status, students’ outcomes improved, and health care utilization costs declined. This evaluation contributed to program improvements to further improve health outcomes among students with asthma.

The Role of School Health Services in Addressing the Needs of Students With Chronic Health Conditions

Children and adolescents in the United States spend many hours in school. Students with chronic health conditions (CHCs) may face lower academic achievement, increased disability, fewer job opportunities, and limited community interactions as they enter adulthood. School health services provide safe and effective management of CHCs, often for students with limited access to health care. A systematic review to assess the role of school health services in addressing CHCs among students in Grades K-12 was completed using primary, peer-reviewed literature published from 2000 to 2015, on selected conditions: asthma, food allergies, diabetes, seizure disorders, and poor oral health. Thirty-nine articles met the inclusion criteria and results were synthesized; however, 38 were on asthma. Direct access to school nursing and other health services, as well as disease-specific education, improved health and academic outcomes among students with CHCs. Future research needs to include standardized definitions and data collection methods for students with CHCs.

The Impacts of Educational Asthma Interventions in Schools: A Systematic Review of the Literature

Objective. To review the literature on the impact of educational asthma interventions in schools regarding the knowledge and morbidity of the disease among children and adolescents. Methods. A systematic review was conducted for controlled clinical trials investigating the effectiveness of educational asthma interventions for students, asthmatic or nonasthmatic, families, and school staff. Databases were CENTRAL, PubMed, LILACS, MEDLINE, and SciELO. Articles published in any language were considered, in the period from 2005 to 2014, according to the PRISMA guidelines. Results. Seventeen articles were selected (N = 5,879 subjects). 94% of the interventions (16 of 17 studies) were applied in developed countries that were led by health professionals and most of them targeted asthmatics. Asthma education promotes the improvement of knowledge about the disease in at least one of the evaluated areas. 29% of the interventions (5 of 17 studies) showed a reduction of the asthma symptoms, 35% (6 of 17 studies) reduction of the hospitalization instances and emergency visits, 29% (5 of 17 studies) reduction of school absenteeism, and 41% (7 of 17 studies) increase in the quality of life of the individuals. Conclusions. Educational interventions in schools raise the awareness of asthma and weaken the impact of morbidity indicators.

Using Tailored Videos to Teach Inhaler Technique to Children With Asthma: Results From a School Nurse-Led Pilot Study

Our purpose was to test whether a tailored inhaler technique video intervention: (1) could be feasibly implemented by school nurses and (2) improve the inhaler technique of children with asthma.

METHODS

School nurses recruited a convenience sample of 25 children with asthma (ages 7-17) and assessed their inhaler technique. Children then watched a tailored video that provided: (1) step-by-step feedback on which steps (out of 8) they performed correctly, (2) praise for correctly-performed steps, and (3) statements about why incorrectly-performed steps are important. Nurses reassessed the child's inhaler technique immediately after watching the video and again 1month later. Non-parametric Wilcoxon signed rank tests were calculated to assess whether children's technique significantly improved from baseline to post-video and baseline to 1-month follow-up. A focus group with the school nurses was conducted post-intervention to discuss feasibility issues.

RESULTS

Children's inhaler technique improved by 1.2 steps (with spacer; p=0.03) and 2.7 steps (without spacer; p<0.01) from baseline to post-video. These improvements were maintained at 1-month follow-up. School nurses believed the intervention was feasible to implement and met an important educational need.

CONCLUSIONS

A school nurse-led tailored video intervention is feasible to implement and a promising method for improving children's inhaler technique.

Asthma-Related School Absenteeism, Morbidity, and Modifiable Factors

INTRODUCTION

Asthma is a leading cause of chronic disease-related school absenteeism. Few data exist on how information on absenteeism might be used to identify children for interventions to improve asthma control. This study investigated how asthma-related absenteeism was associated with asthma control, exacerbations, and associated modifiable risk factors using a sample of children from 35 states and the District of Columbia.

METHODS

The Behavioral Risk Factor Surveillance System Child Asthma Call-back Survey is a random-digit dial survey designed to assess the health and experiences of children aged 0-17 years with asthma. During 2014-2015, multivariate analyses were conducted using 2006-2010 data to compare children with and without asthma-related absenteeism with respect to clinical, environmental, and financial measures. These analyses controlled for sociodemographic and clinical characteristics.

RESULTS

Compared with children without asthma-related absenteeism, children who missed any school because of asthma were more likely to have not well controlled or very poorly controlled asthma (prevalence ratio=1.50; 95% CI=1.34, 1.69) and visit an emergency department or urgent care center for asthma (prevalence ratio=3.27; 95% CI=2.44, 4.38). Mold in the home and cost as a barrier to asthma-related health care were also significantly associated with asthma-related absenteeism.

CONCLUSIONS

Missing any school because of asthma is associated with suboptimal asthma control, urgent or emergent asthma-related healthcare utilization, mold in the home, and financial barriers to asthma-related health care. Further understanding of asthma-related absenteeism could establish how to most effectively use absenteeism information as a health status indicator.

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.

Barriers to Asthma Management as Identified by School Nurses

Asthma rates are increasing in children. School nurses have opportunities to care for children with asthma but need to overcome barriers impacting their ability to manage asthma in the school setting. This study (a) assessed barriers present in the school setting, (b) determined the impact of barriers on performance of asthma management behaviors, and (c) determined the impact of barriers on importance ratings of asthma management behaviors, asthma self-efficacy, and asthma attitudes (N = 537). Results revealed 72% of the nurses reported at least one barrier. As numbers of barriers increased, performance of asthma management behaviors decreased. Significant relationships were found between specific asthma management behaviors and specific barriers. No significant relationships were found between barriers and asthma self-efficacy, asthma attitude, or importance ratings of asthma management behaviors. Removing barriers may allow the nurse to perform at greatest effectiveness, enhancing the positive outcomes that result from appropriate asthma management.

Using the Health Belief Model to Understand School Nurse Asthma Management

Ten million children in the United States have asthma. Since children are in school about 6 hr a day, school nurses are positioned to intervene and influence asthma outcomes. A descriptive correlational study was designed to investigate performance of school nurses' asthma management behaviors in relationship to asthma knowledge, asthma attitude, asthma self-efficacy, and rating of importance of asthma management behaviors. Results indicated that asthma attitude, asthma self-efficacy, and rating of importance of asthma management behaviors were associated with performance of asthma management behaviors. The higher the rating of importance of asthma management behaviors, the more likely school nurses were to perform the behaviors (p < .05). Higher levels of asthma self-efficacy were associated with performance of asthma management behaviors, indicating the importance of strengthening school nurses' asthma self-efficacy in asthma management. By understanding factors influencing performance of asthma management behaviors by school nurses, interventions can be implemented to increase asthma management behaviors, leading to improved outcomes for students with asthma.

Interventions to Improve Asthma Management of the School-Age Child

Improvement of medication adherence in the school-age child can lead to improvement in quality of life, decreased morbidity, and a potential decreased risk of deferred academic, social, and emotional development. The objective of this article is to review barriers to asthma medication adherence and identify evidence-based techniques that improve medication management of the asthmatic child 5 to 12 years of age. A literature review was performed and articles were obtained through database searches within Medline, CINAHL (Cumulative Index to Nursing and Allied Health Literature), and PubMed. Research indicates that barriers to the adherence of medication regimens required for asthmatic children include poor understanding of the medication regimen, substandard education on symptom recognition and environmental triggers, rejection of the diagnosis, and a lack of support or understanding within the community. Researched techniques aimed to improve medication management in 5- to 12-year-olds include: computer-based education; workshops for parents, teachers, and children; incorporation of asthma education into classroom lessons; use of case managers; the introduction of a nurse practitioner in the school to provide care, including medication prescriptions for the asthmatic child; and assessment and evaluation of environmental and emotional triggers in the home and school. Collaboration of current data may help lead to a successful interventional model that can improve asthma management in this population.

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.

School nurses and care coordination for children with complex needs: an integrative review

Health care for students with chronic needs can be complex and specialized, resulting in fragmentation, duplication, and inefficiencies. Students who miss school due to chronic conditions lose valuable educational exposure that contributes to academic success. As health-related disabilities increase in prevalence so does the need for the coordination of care within the school and between the school and service providing agencies. This integrative literature review provides a synthesis of published evidence identifying and describing the core concepts associated with the role of school nurses in providing care coordination/case management to students with complex needs. Six core essentials of nurse-provided care coordination were identified: collaboration, communication, care planning and the nursing process, continuous coordination, clinical expertise, and complementary components. Recommendations for improving care coordination were elucidated in the review. Analysis of the literature can help assure application of best practice methods for the coordination of care for students in the school setting.

Development of an International School Nurse Asthma Care Coordination Model

AIM

To identify and compare how school nurses in Reykjavik, Iceland and St. Paul, Minnesota coordinated care for youth with asthma (ages 10-18) and to develop an asthma school nurse care coordination model.

BACKGROUND

Little is known about how school nurses coordinate care for youth with asthma in different countries.

DESIGN

A qualitative descriptive study design using focus group data.

METHODS

Six focus groups with 32 school nurses were conducted in Reykjavik (n = 17) and St. Paul (n = 15) using the same protocol between September 2008 and January 2009. Descriptive content analytic and constant comparison strategies were used to categorize and compare how school nurses coordinated care, which resulted in the development of an International School Nurse Asthma Care Coordination Model.

FINDINGS

Participants in both countries spontaneously described a similar asthma care coordination process that involved information gathering, assessing risk for asthma episodes, prioritizing healthcare needs and anticipating and planning for student needs at the individual and school levels. This process informed how they individualized symptom management, case management and/or asthma education. School nurses played a pivotal part in collaborating with families, school and healthcare professionals to ensure quality care for youth with asthma.

CONCLUSIONS

Results indicate a high level of complexity in school nurses' approaches to asthma care coordination that were responsive to the diverse and changing needs of students in school settings. The conceptual model derived provides a framework for investigators to use in examining the asthma care coordination process of school nurses in other geographic locations.

School nurses' role in asthma management, school absenteeism, and cost savings: a demonstration project

BACKGROUND

With increasing budget cuts to education and social services, rigorous evaluation needs to document school nurses' impact on student health, academic outcomes, and district funding.

METHODS

Utilizing a quasi-experimental design, we evaluated outcomes in 4 schools with added full-time nurses and 5 matched schools with part-time nurses in the San Jose Unified School District. Student data and logistic regression models were used to examine predictors of illness-related absenteeism for 2006-2007 and 2008-2009. We calculated average daily attendance (ADA) funding and parent wages associated with an improvement in illness-related absenteeism. Utilizing parent surveys, we also estimated the cost of services for asthma-related visits to the emergency room (ER; N = 2489).

RESULTS

Children with asthma were more likely to be absent due to illness; however, mean absenteeism due to illness decreased when full-time nurses were added to demonstration schools but increased in comparison schools during 2008-2009, resulting in a potential savings of $48,518.62 in ADA funding (N = 6081). Parents in demonstration schools reported fewer ER visits, and the estimated savings in ER services and parent wages were significant.

CONCLUSION

Full-time school nurses play an important role in improving asthma management among students in underserved schools, which can impact school absenteeism and attendance-related economic costs.

Improving pediatric patient outcomes: comparing two case management models

PURPOSE OF THE STUDY

Case management (CM) is a growing and evolving profession. Outcomes-based research that identifies the role of CM is needed in health care today. Case management has been recognized as a way to help patients experience high-quality and cost-effective care. The purpose of this nonexperimental, retrospective research study was to examine two CM models and their effect on patient outcomes, including length of hospital stay and readmission to the hospital within 30 days of discharge with the same diagnosis.

PRIMARY PRACTICE SETTING

The study was completed at two acute care pediatric hospitals in separate geographical regions of the country.

METHODOLOGY AND SAMPLE

Two CM models were compared by conducting a retrospective patient chart review. Seven hundred pediatric patient charts were reviewed to determine whether the patient outcomes met patient outcomes of interest. All patients were diagnosed with asthma and were between the ages of 2 and 18 years.

RESULTS

Analysis of data indicated that the length of hospital stay at Hospital A was significantly shorter than the length of hospital stay for patients admitted to Hospital B. However, hospital readmission rates within 30 days of discharge at Hospital A versus Hospital B indicated no significant difference.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

Further research that examines different CM models must account for variables such as complexity of disease process, age of patient on admission to the hospital, and relevance of discharge teaching.

A framework to evaluate the cultural appropriateness of intervention research

Marked racial disparities exist in the prevalence, mortality, and treatment of asthma, between African American and White children and adolescents, despite increases in intervention trials to improve asthma outcomes. Yet, interventions to improve African American children's health must be culturally appropriate. To date, limited frameworks are available to decide whether an intervention tested with a targeted minority population employs a culturally appropriate design. In this article, we applied Bernal, Bonilla, and Bellido's ecological validity model to examine the cultural appropriateness of 12 randomized controlled trials of asthma self-management interventions published from 2000 to 2010. Most frequently met criteria were culturally appropriate methods of development and/or adaptation of interventions and inclusion of theoretical models. Least often met criteria were incorporating metaphors pertinent to participants and application of the language dimension. Based on this analysis, it is clear that an overarching framework is needed to guide the development of culturally targeted interventions.

School asthma screening and case management: attendance and learning outcomes

Asthma is related to school absenteeism and underperformance in elementary students. This pilot study assessed whether school nurse case management (CM) in children identified with asthma impacts academic performance and school absenteeism in one school. A validated questionnaire was used to identify children at risk for asthma and CM was provided to link these students to medical care and assure asthma action plans at school. In the 40 children with confirmed diagnosis who received CM, academic performance on standardized testing postintervention was similar to the 76 children who were low risk for asthma. Average days absent due to illness in the CM group were reduced from 5.8 to 3.7 days in the postintervention school year. School nurse screening, CM, and collaboration with a medical provider resulted in early identification, referral, and subsequent treatment of students at risk for asthma and may have contributed to reduced illness absences.

Children with behavioral/mental health disorders and school mental health nurses in Australia

TOPIC

This review of the literature addresses Australian school mental health nursing is an emergent field of practice.

PURPOSE

Children with behavioral/mental health disorders present challenges to schools, teachers, and their families. They can be disruptive in class, inappropriate with their peers, and perform poorly academically. Often this group of children do not respond to the school's usual strategies to support appropriate behavior. When children with behavioral/mental health disorders do not receive specialized support based on their problems and needs, their problems can escalate over time and in adolescence their behavior may become more challenging, with increased aggression, substance use, contact with the criminal justice system, and school failure with or without dropout.

CONCLUSION

Mental health nurses, working as case managers, could be effective in the support of children with behavioral/mental health disorders in schools. Mental health nurses, because of their professional education and clinical practice, work not only with the individual child but also with family members. They are well prepared to case manage in schools and support individual teachers and health and welfare services in their management of their clients with behavioral/mental health disorders.

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.

What about your friends? Exploring asthma-related peer interactions

PURPOSE

School-based asthma interventions have been shown to be effective, but many may not be sensitive to the influence of peer interactions in shaping asthma-related emotional experiences. This exploratory study describes associations between peer interactions and asthma-related emotional experiences, asthma control, and outcomes among elementary-aged children with asthma.

METHODS

Data come from the baseline assessment of a randomized trial evaluating the effect of a school-based asthma intervention. Univariate and multivariate statistics were completed to examine associations between peer interactions and asthma-related variables of interest.

RESULTS

Eight hundred and thirty-five caregiver and child interviews were used in the analysis. Both males and females were enrolled in this study, 31% had not well controlled or poorly controlled asthma and 44% reported taking asthma medications. Overall, 26% of children talked to friends about asthma. Females were significantly more likely to talk to friends about asthma (p < .05) and more likely to report that they were worried, concerned, or troubled about asthma (p < .01). Significant differences in emotional quality of life between males and females were also found. Children who reported talking to friends about asthma were more likely to report teasing about asthma (OR = 2.47; 95% CI 1.57, 3.89) and to report that friends help with their asthma (OR = 1.79; 95% CI 1.07, 3.01).

CONCLUSIONS

School-based asthma interventions should be sensitive to emotional-related outcomes associated with asthma and the influence of asthma-related peer interactions. Providing children with communication strategies for disclosure of asthma status to peers that result in more supportive interactions may be needed.

NASN position statement: caseload assignments

It is the position of the National Association of School Nurses (NASN) that schools should employ professionally prepared Registered Nurses, to conduct and supervise school health programs which address the variety of health problems experienced by school children. NASN recommends a formula-based approach with minimum ratios of nurses-to-students depending on the needs of the student populations as follows: 1:750 for students in the general population, 1:225 in the student populations requiring daily professional school nursing services or interventions, 1:125 in student populations with complex health care needs, and 1:1 may be necessary for individual students who require daily and continuous professional nursing services. Other factors that should be considered in the formula-based approach are number of students on free or reduced lunch, number of students with a medical home, and average number of emergency services per year.

Follow-up of an elementary school intervention for asthma management: do gains last into middle school?

OBJECTIVE

Albuquerque Public Schools (APS), in collaboration with the Centers for Disease Control and Prevention, conducted an evaluation to examine whether students who were exposed to the APS asthma program in elementary school retained benefits into middle school.

METHODS

APS middle school students who participated in the APS asthma program in elementary school, including the Open Airways for Schools (OAS) education curriculum, responded to a follow-up questionnaire (N = 121) and participated in student focus groups (N = 40). Asthma management self-efficacy scores from the follow-up questionnaire were compared to scores obtained before and after the OAS education component. Additional items assessed students' asthma symptoms, management skills, avoidance of asthma triggers, and school impact.

RESULTS

Although asthma management self-efficacy scores declined in middle school among students exposed to the asthma program in elementary school, they remained significantly higher than scores obtained during elementary school prior to the OAS intervention.

CONCLUSION

The results indicate that although students benefited from the asthma program delivered in elementary school, they need booster sessions and continued school support in middle school.

Assessing the potential influence of asthma on student attendance/absence in public elementary schools

OBJECTIVES

Student health, well-being, and productivity are determined in part by attending school daily. Increased annual average daily attendance (ADA) increases public funding for school district-based enrichment programs. Asthma is reported as the number 1 cause of American school absenteeism due to chronic illness; however, only limited, estimated national data exist. Accurate, precise ways to assess potential disparities in disease-driven absence do not yet exist. The authors summarize part of their community-based participatory research (CBPR), namely planning then testing a set of matching field sheet (data collection) and computer-based spreadsheets (database) based on previous school-based research to track attendance and reasons for absence.

METHODS

The CBPR process occurred mid-2005 to mid-2008, with final activities in DeKalb County, Georgia, August-December 2007 (fall semester) for this portion. The authors tracked absence, with an ability to examine data overall and at classroom, grade, and school levels by gender, race/ethnicity, and doctor-diagnosed asthma as reported to schools on student emergency cards.

RESULTS

The authors characterized their study sample, consisting of 914 4th-5th grade children (overall, 9.2% of children with asthma) from seven randomly selected, consenting participating schools (n = 21 classrooms per grade, 2 to 4 classrooms per grade per school). Six schools used paper versions of tools while one school used electronic versions. The authors presented attendance results in various aggregated manners. Absence was higher (ADA lower) among 4th grade asthmatic students compared to the entire classroom.

CONCLUSIONS

This study can inform future interdisciplinary school-based research combining health and student academic productivity, adult work performance outcomes, and other measures.

Defining, Delivering, and Documenting the Outcomes of Case Management by School Nurses

Case management is a component of school nurse practice that provides an opportunity to demonstrate the contribution that school nurses make to the health and academic success of children, particularly children with chronic health conditions. However, case management programs vary in their mission and scope, leading to confusion about what it means to be a case manager. Many programs acknowledge the difficulty in tracking outcomes and sustaining results. Using a capacity-building approach, the Case Management Project (CMP) developed a definition of case management and a set of baseline and outcome measures to assist school nurses to become effective case managers and track their outcomes.

Do school-based asthma education programs improve self-management and health outcomes?

CONTEXT

Asthma self-management education is critical for high-quality asthma care for children. A number of studies have assessed the effectiveness of providing asthma education in schools to augment education provided by primary care providers.

OBJECTIVE

To conduct a systematic review of the literature on school-based asthma education programs.

METHODS

As our data sources, we used 3 databases that index peer-reviewed literature: MEDLINE, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature. Inclusion criteria included publication in English and enrollment of children aged 4 to 17 years with a clinical diagnosis of asthma or symptoms consistent with asthma.

RESULTS

Twenty-five articles met the inclusion criteria. Synthesizing findings across studies was difficult because the characteristics of interventions and target populations varied widely, as did the outcomes assessed. In addition, some studies had major methodologic weaknesses. Most studies that compared asthma education to usual care found that school-based asthma education improved knowledge of asthma (7 of 10 studies), self-efficacy (6 of 8 studies), and self-management behaviors (7 of 8 studies). Fewer studies reported favorable effects on quality of life (4 of 8 studies), days of symptoms (5 of 11 studies), nights with symptoms (2 of 4 studies), and school absences (5 of 17 studies).

CONCLUSIONS

Although findings regarding effects of school-based asthma education programs on quality of life, school absences, and days and nights with symptoms were not consistent, our analyses suggest that school-based asthma education improves knowledge of asthma, self-efficacy, and self-management behaviors.

[Non-physician health care providers for the treatment and care of the chronically ill (focusing on DMP diagnoses)]

BACKGROUND

This systematic review will investigate the question of how non-physician health care providers may be involved in the care and treatment of patients with chronic disease and which role they could play within the scope of the German Disease Management Programmes (DMP).

METHODS

This article is limited to the German DMP diagnoses asthma, COPD, coronary heart disease, and type-1 and -2 diabetes mellitus. Several databases were systematically searched to find national and international studies with interventions carried out by non-physician health care providers such as nurses, dieticians, physiotherapists or occupational therapists.

RESULTS

More than 300 studies and reviews were included in this systematic review. Nurses and dieticians were by far the prevailing professional groups performing the largest number of the interventions identified. Transferring. the results of the literature review to the German setting, non-physician health care providers could both undertake certain tasks on their own responsibility and provide other services in support of the medical treatment of the chronically ill. Some interventions are given as examples.

School-based asthma programs

Asthma is prevalent in school-age children and contributes to school absenteeism and limitation of activity. There is a sizable literature on school-based interventions for asthma that attempt to identify children with asthma and improve outcomes. The purpose of this review is to describe and discuss limitations of screening tools and school-based asthma interventions. Identification of children with asthma may be appropriate in schools located in districts with a high prevalence of children experiencing significant morbidity and a high prevalence of undiagnosed asthma, provided there is access to high-quality asthma care. We review strategies for improving access to care, for teaching self-management skills in schools, and for improving school personnel management skills. Although studies indicate that school-based programs have the potential to improve outcomes, competing priorities in the educational system present challenges to their implementation and emphasize the need for practical, targeted, and cost-effective strategies.

Asthma disparities in urban environments

Asthma continues to disproportionately affect minority and low-income groups, with African American and Latino children who live in low-socioeconomic-status urban environments experiencing higher asthma morbidity and mortality than white children. This uneven burden in asthma morbidity has been ever increasing despite medical advancement. Many factors have contributed to these disparities in the areas of health care inequities, which result in inadequate treatment; poor housing, which leads to increased exposure to asthma allergens; and social and psychosocial stressors, which are often unappreciated. Interventions to reduce individual areas of disparities have had varying successes. Because asthma is a complex disease that affects millions of persons, multifaceted comprehensive interventions that combine all evidence-based successful strategies are essential to finally closing the gap in asthma morbidity.