The relationship between school absence, academic performance, and asthma status

Reducing asthma attacks in disadvantaged school children with asthma: study protocol for a type 2 hybrid implementation-effectiveness trial (Better Asthma Control for Kids, BACK)

BACKGROUND

Asthma is a leading cause of children's hospitalizations, emergency department visits, and missed school days. Our school-based asthma intervention has reduced asthma exacerbations for children experiencing health disparities in the Denver Metropolitan Area, due partly to addressing care coordination for asthma and social determinants of health (SDOH), such as access to healthcare and medications. Limited dissemination of school-based asthma programs has occurred in other metropolitan and rural areas of Colorado. We formed and engaged community advisory boards in socioeconomically diverse regions of Colorado to develop two implementation strategy packages for delivering our school-based asthma intervention - now termed "Better Asthma Control for Kids (BACK)" - with tailoring to regional priorities, needs and resources.

METHODS

In this proposed type 2 hybrid implementation-effectiveness trial, where the primary goal is equitable reach to families to reduce asthma disparities, we will compare two different packages of implementation strategies to deliver BACK across four Colorado regions. The two implementation packages to be compared are: 1) standard set of implementation strategies including Tailor and Adapt to context, Facilitation and Training termed, BACK-Standard (BACK-S); 2) BACK-S plus an enhanced implementation strategy, that incorporates network weaving with community partners and consumer engagement with school families, termed BACK-Enhanced (BACK-E). Our evaluation will be guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, including its Pragmatic Robust Implementation Sustainability Model (PRISM) determinants of implementation outcomes. Our central hypothesis is that our BACK-E implementation strategy will have significantly greater reach to eligible children/families than BACK-S (primary outcome) and that both BACK-E and BACK-S groups will have significantly reduced asthma exacerbation rates ("attacks") and improved asthma control as compared to usual care.

DISCUSSION

We expect both the BACK-S and BACK-E strategy packages will accelerate dissemination of our BACK program across the state - the comparative impact of BACK-S vs. BACK-E on reach and other RE-AIM outcomes may inform strategy selection for scaling BACK and other effective school-based programs to address chronic illness disparities.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT06003569, registered on August 22, 2023, https://classic.

CLINICALTRIALS

gov/ct2/show/NCT06003569 .

Developmental health of Canadian kindergarten children with teacher-reported asthma between 2010 and 2015: A population-level cross-sectional study

Asthma can impact children's quality of life. It is unclear how asthma is associated with the developmental health (i.e. a broad range of skills and abilities associated with growth and development) of young children at school entry. The goals of this cross-sectional, population-level study were to: (1) investigate the association between teacher-reported asthma and children's concurrent indicators of developmental health (developmental vulnerability); and (2) explore whether school absences and functional impairments modified this association. Participants were a Canadian population-based sample of 564 582 kindergarten children (Mage = 5.71 years, SD = 0.32, 51.3 % male) with data on the Early Development Instrument (EDI) collected between 2010 and 2015. Adjusted binary logistic regressions were conducted to address the objectives. From the sample, 958 (0.2 %) children were identified as having a diagnosis of asthma. These children were absent on average 9.4 days and 53.5 % had functional impairments (vs. 6.7 days absent and 15.9 % with functional impairments in children without asthma). After controlling for demographic characteristics, children with asthma had between 1.51 and 2.42 higher odds of being developmentally vulnerable. Only the presence of functional impairments modified this relationship and only for physical health and well-being. In this large, population-based sample of Canadian kindergarten children, few teachers reported knowledge of their students' asthma diagnosis. Among teacher-reported cases, asthma was a risk factor for developmental vulnerability in the domain of physical health and well-being only. Functional impairments may therefore be more detrimental for child development at school entry than asthma alone.

Developing a Social Determinants of Health Needs Assessment for Colorado Kids (SNACK) Tool for a School-Based Asthma Program: Findings from a Pilot Study

Background

School-based asthma programs effectively address poorly controlled asthma and asthma disparities, especially when coupled with screening for and addressing social determinants of health (SDOH) needs. Existing screening tools are tailored to clinical settings; therefore, we sought to develop a community-based SDOH screening tool.

Design/Methods

We used a four-phase iterative design process to develop and pilot a community-based screening tool. We used a modified Delphi process to identify screening tool domains, identified validated items for inclusion, and developed an appropriate tool layout for populations with limited health/general literacy. Community advisory boards reviewed and refined a draft tool. Next, we conducted a qualitative pilot test of acceptability to parents and feasibility for staff in a community health center.

Results

Six domains are included in our SDOH screening tool: health care access, transportation, food insecurity, public benefits, housing, and utilities. In the pilot test, 41 screenings were completed, and 36 parents (16.7% Spanish speaking) provided feedback. Most families understood the purpose of the screening; felt that the questions were clear, appropriate, and quick to complete; and liked the pictures. The clinic's care coordinator expressed a preference for the pilot tool compared to their existing screening tool and recommended improvements to encourage honest reporting by patients.

Conclusion

This community-based screening tool addresses key SDOH needs that impact asthma and is acceptable to families. The next steps are to implement the tool in school-based asthma programs to support improvements in asthma outcomes and disparities by identifying and addressing families' unmet SDOH needs.

Indoor coal ash and school and social competency among children aged 6-14 years

BACKGROUND

A child's ability to succeed in social interactions and in a school setting are important for their development and growth. Exposure to environmental pollutants has been associated with poorer school performance and fewer social interaction in children. Fly ash, a waste product generated when burning coal for energy, is comprised of small glass spheres with neurotoxic heavy metal(loid)s found to be risk factors for learning and social problems in school.

OBJECTIVE

The purpose of this novel study was to assess the association of fly ash in children's homes with school and social competency.

METHODS

We recruited children aged 6-14 years old from communities located within 10 miles of two coal-burning power plants. In homes of the participants, fly ash was collected on polycarbonate filters using personal modular impactors. We measured school competency and social competency using the validated Child Behavioral Checklist. Using Tobit and linear regression we investigated the relationship of indoor fly ash with school and social competency.

RESULTS

Forty-three percent of children in the study had fly ash in their homes. In covariate-adjusted Tobit models, children with fly ash in their homes scored on average 2.63 (95% CI: -4.98, -0.28) points lower on the school competency scale than peers without ash in their homes. We did not observe that fly ash in homes was related with lower social competency.

SIGNIFICANCE

Results from this study suggest that children with fly ash in their homes had poorer performance in the school setting, compared to peers without fly ash in their homes. In the US, coal-fired power plants are being closed, however health concerns about pollution from coal ash storage facilities remains. Findings from this study can provide impetus for creating of public health policy and to highlight the need future research on children's exposure to fly ash.

IMPACT

Children's growth and development are impacted by their social interactions and ability to perform in school settings. Environmental pollutants may impact these essential elements of development. Millions of children are exposed to fly ash which is a waste product generated from burning coal. Fly ash, an environmental health threat throughout the world, is comprised of small glass spheres with trace concentrations of neurotoxic metal(loid)s. Findings from this research show that children with fly ash in their homes are significantly more likely to have poorer school performance than children without fly ash in their homes.

Predicting academic achievement and student absences in high school: The roles of student and school attributes

The present study aims at examining predictors of high school students' academic achievement from student-level and school-level predictors in the Kingdom of Saudi Arabia, especially in light of policy mandates on educational reform in accordance with Vision 2030. Participants were 528,854 individuals who took on the Standard Achievement Admission Test (SAAT), along with other demographic variables. The mean age of participants was 19.7 years with an SD = 1.87. There were 234,813 males and 294,041 females. A Multilevel Random Coefficient Modeling (MRCM) model was engaged to identify predictors of academic achievement. Results indicated the positive roles of being a female, having educational parents, being educated in religious schools or large schools, and having small student-to-teacher ratios and the negative roles of student absences, student age, and being educated in new schools. Results are viewed under the lenses of new policy mandates on educational reform in the Kingdom of Saudi Arabia.

Parent Engagement with a School-Based Health Center Consent Process Predicts Student Attendance and School Transition

BACKGROUND

School-based health centers (SBHCs) fill critical pediatric health care access gaps but typically require parental consent for enrollment. Families' responses to SBHC consent form outreach efforts may reflect broader school engagement. This study investigated whether SBHC consent form return predicted subsequent chronic absenteeism and school transition, indicators of student and family school engagement.

METHODS

Multivariable logistic regression was used to compare the odds of being chronically absent or transitioning out of a US elementary/middle school (n = 1917) during 2015-2016 and 2016-2017 for those who declined SBHC enrollment or did not return a consent form, compared to those who enrolled.

RESULTS

Compared to enrolled students, those who declined had 78% lower odds of chronic absenteeism [95% CI: 0.09, 0.54]. Families who did not respond had 2.8 times greater odds of their student transitioning out of school [95% CI: 2.15, 3.58] but were no more likely to be chronically absent.

CONCLUSIONS

Consent form return may predict aspects of broader students and family school engagement.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

Nascer de cesariana e associação com quociente de inteligência em adolescentes: contribuição do Consórcio de Coortes RPS (Ribeirão Preto, Pelotas e São Luís), Brasil

O objetivo do estudo foi avaliar a associação entre a cesariana e o quociente de inteligência (QI) em adolescentes do Município de São Luís, Maranhão, Brasil. Trata-se de um estudo longitudinal utilizando dados da coorte de nascimento em São Luís, iniciado no ano de 1997. A abordagem ocorreu na terceira fase da coorte, em 2016, com adolescente aos 18 e 19 anos de idade. A variável de exposição foi a via de nascimento e a variável de desfecho foi o QI, mensurada a partir da aplicação da terceira versão da Escala de Inteligência Wechsler para Adultos (WAIS-III). Na análise dos dados verificou-se a média do QI segundo as covariáveis e utilizou-se a regressão linear multivariada. Para controlar os fatores de confundimento foi elaborado um modelo teórico utilizando o gráfico acíclico dirigido. As variáveis confundidoras foram as socioeconômicas no momento do nascimento e as variáveis perinatais. A média do QI dos adolescentes foi 101,4. Na análise bruta, o QI dos adolescentes nascidos de cesariana foi 5,8 pontos maior em relação aos nascidos de parto vaginal (IC95%: 3,8; 7,7, p ≤ 0,001), com significância estatística. Na análise multivariada, o valor reduziu para 1,9 (IC95%: -0,5; 3,6, p = 0,141), sem significância estatística. O resultado do estudo mostrou que a cesariana não está associada ao QI dos adolescentes nessa amostra e reflete que as diferenças encontradas podem ser explicadas por outros fatores, como aspectos socioeconômicos e perinatais.

Chronic pediatric diseases and risk for reading difficulties: a narrative review with recommendations

Literacy is a major social determinant of health, rooted in skills that develop during early childhood. Children arriving at kindergarten unprepared to learn to read are more likely to have low reading proficiency thereafter. General and health literacy are highly correlated, affecting understanding of health conditions, treatment adherence, and transition to self-care and adult healthcare services. The American Academy of Pediatrics (AAP) recommends literacy and school readiness promotion during well-visits and neurodevelopmental surveillance is emphasized across primary and subspecialty care. While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and chronic medical conditions are less appreciated and under-researched. This review applies an eco-bio-developmental framework to explore literacy across five complex chronic conditions affecting millions of children worldwide: asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease. In each, integration of an efficient reading brain network may be impacted by direct factors, such as ischemia, anesthesia, and/or medications, and also indirect factors, such as altered parent-child routines, hospital stays, and missed school. By integrating literacy into care management plans for affected children, pediatric primary care and specialty providers are poised to identify risks early, target guidance and interventions, and improve academic and health outcomes. IMPACT: While genetic and environmental risk factors for reading difficulties are well-established, risks related to complex and/or chronic medical conditions such as asthma, cancer, congenital heart disease, epilepsy, and sickle cell disease are substantial, less appreciated, and under-researched. General and health literacy are highly correlated, with implications for the understanding one's health condition, treatment adherence, and transitioning to self-care, which is especially important for children with complex and/or chronic illness. Pediatric primary care and specialty providers are poised to integrate reading and literacy into care management plans for children with complex and/or chronic illness, including early screening, guidance, support, and interventions.

Association between exposure to particulate matter and school absences in Korean asthmatic adolescents

Background

Because particulate matter (PM) and asthma are closely related, the prevalence of school absence among adolescents with asthma can be affected by the concentration of PM. We aimed to investigate the relationship between school absences due to asthma and the total number of days that the PM concentration exceeded the standard.

Methods

We used the data from the 16th Korea Youth Risk Behavior Survey and the PM levels of 17 metropolitan cities and provinces gathered from the AirKorea. Information on the characteristics of asthmatic adolescents and the prevalence of school absence was obtained using a questionnaire, while the PM levels based on the total number of days with poor and very poor PM grades were collected from the AirKorea website. Both χ² test and logistic regression analysis were performed using the weights presented in the original dataset.

Results

In the case of particulate matter of 10 microns in diameter or smaller (PM₁₀), the odds ratio (OR) after adjusting for confounders (sex, school year, body mass index, smoking history, diagnosis of allergic rhinitis, diagnosis of atopic dermatitis and city size) was 1.07 (95% confidence interval [CI]: 1.01–1.13) for absents due to asthma when the total days of poor and very poor grades of PM₁₀ (81 μg/m³ or higher) increased by 1 day. In the analysis of particulate matter of 2.5 microns in diameter or smaller (PM_2.5), the OR after adjusting for confounders was 1.01 (95% CI: 1.00–1.03) for absents due to asthma when the total number of days with poor and very poor PM_2.5 grades (36 μg/m³ or higher) increased by 1 day.

Conclusions

A significant association was observed between the total number of days of poor and very poor PM₁₀ and PM_2.5 grades and school absence due to asthma; PM can cause asthma exacerbation and affect the academic life.

CHECK: Multi-level Real-World Pediatric Asthma Care Coordination: Results and Lessons Learned

OBJECTIVE

Because asthma health disparities in children remain common, innovative approaches to obtain asthma health equity are essential. Comprehensive care coordination programs may address the social determinants of health that influence these disparities. This analysis aims to ascertain if receipt of Coordination of Healthcare for Complex Kids (CHECK) program services was associated with changes in school absence, cost, healthcare utilization, and controller prescription in children with asthma.

METHODS

The CHECK program ran from December 1^st, 2014 through August 31^st, 2017. Engagement with Community Health Workers (CHW) was rolling and targeted based on risk level (low, medium or high determined by healthcare utilization). This analysis included school-aged children with asthma (n = 2,629) and sufficient Chicago Public Schools attendance data (n = 430).

RESULTS

Children engaged in CHECK were more likely to be female (p = 0.046) and to identify as Black and/or Hispanic/Latino than enrolled-only children. School absence was not different between the groups. Average total cost for engaged children was 21.3% more than enrolled-only children the first year (p = 0.027) but did not differ by the second year (p = 0.948). At baseline, 68.1% of the cohort had at least one ED visit 12-months prior to CHECK, this reduced to 49.5% post-1 and 41.9% post-2. Engaged children were 21% more likely to visit an ED (p = 0.010) and 40% more likely to have a controller.

CONCLUSIONS

CHECK program receipt was associated with reduced costs and improved healthcare utilization, and controller prescriptions. School attendance did not change. The CHECK model offers potential pathways to support low-income children with asthma.

Applying dissemination and implementation research methods to translate a school-based asthma program

Our school-based asthma program has reduced asthma exacerbations for youth with health disparities in the Denver metropolitan area, due partly to addressing social determinants of health, such as access to health care and medications. Dissemination and implementation (D&I) science approaches accelerate the translation of evidence-based programs into routine practice. D&I methods are being applied more commonly to improve health equity. The purpose of this publication was to give an overview of D&I research methods, using our school-based asthma program as an example. To successfully scale out our program across the state of Colorado, we are applying a D&I framework that guides the adaptation of our existing implementation approach to better meet our stakeholders' local context-the Exploration, Preparation, Implementation, Sustainment framework. In a pragmatic trial design, we will evaluate the outcomes of implementing the program across 5 Colorado regions, with attention to health equity, using a second commonly used D&I framework-Reach, Effectiveness, Adoption, Implementation, and Maintenance. Our central hypothesis is that our program will have broad and equitable reach to eligible students (primary outcome) and will reduce asthma attacks and symptoms. This D&I approach accelerates dissemination of our program and is an applicable process for translating other effective allergy/asthma programs to address asthma and allergy-related disparities.

Perceptions of School Life and Academic Success of Adolescents With Asthma

Adolescents spend approximately one-third of their day at school. With the growing prevalence of adolescent asthma, 1 in every 10 adolescents copes with asthma throughout the day, including in the school environment. Yet, little is known about the school experiences of adolescent students with asthma. Guided by the social-ecological model, this study aimed to explore the links between asthma and school experiences in middle and high school as perceived by students with asthma. In-depth interviews were conducted with 20 adolescents with asthma aged 12 to 17 who attended middle or high school around the mid-west area of Florida. Students shared insights on their school experiences and academic performance. Data were analyzed and interpreted using thematic analysis. Four overarching and intertwined themes shaped the school experiences of students with asthma: 1. Asthma control and management; 2. Social support; 3. Asthma knowledge and awareness; and 4. Accommodation of health and academic needs. Study findings suggest addressing the school disparities of adolescent students with asthma through a comprehensive, multi-level approach. Schools should create asthma education opportunities, improve the school system and environmental accommodations, enhance asthma control, and increase continuous social support by peers and school personnel.

Breathing Room: Industrial Zoning and Asthma Incidence Using School District Health Records in the City of Santa Ana, California

Background: Traffic and industrial emissions are associated with increased pediatric asthma morbidity. However, few studies have examined the influence of city industrial zoning on pediatric asthma outcomes among minoritized communities with limited access to air monitoring. Methods: In this cross-sectional analysis of 39,974 school-aged students in Santa Ana, CA, we investigated the effect of proximity to areas zoned for industrial use on pediatric asthma prevalence, physical fitness, school attendance, and standardized test scores. Results: The study population was 80.6% Hispanic, with 88.2% qualifying for free/reduced lunch. Compared to students living more than 1 km away from industrial zones, those living within 0.5 km had greater odds of having asthma (adjusted OR 1.21, 95% CI 1.09 to 1.34, p < 0.001). Among children with asthma, those living between 0.5−1.0 km had greater odds of being overweight or obese (aOR 1.47, 95% CI 1.00, 2.15, p = 0.047). Industrial zone proximity was not significantly associated with worse fitness and academic outcomes for students with asthma. Conclusion: These findings suggest that industrial zone proximity is associated with increased pediatric asthma in a predominantly Latino community in Southern California.

Impact of house dust mite-driven asthma on children's school performance and activity

Evidence regarding asthma's impact on children's daily lives is limited. This prospective and cross-sectional, observational, multicenter study assessed school/work and activity impairment in children and adolescents with allergic asthma and their caregivers and allergen immunotherapy (AIT) effects. Included patients were schooled children and adolescents (5 to 17 years) with allergic asthma due to house dust mites (HDM). Impairment of school/work (i.e., absenteeism and presenteeism) and activity was measured in patients and their caregivers using the Work Productivity Impairment Questionnaire plus Classroom Impairment Questions: Allergy Specific (WPAI + CIQ:AS). HDM allergic patients with school impairment received subcutaneous AIT with a MicroCrystalline Tyrosine-associated allergoid. WPAI + CIQ:AS and effectiveness variables were compared between baseline and 1-year post-AIT. Of the 113 patients included, 59 (52.2%) and 51 (45.1%) showed school and activity impairment, respectively, missing a mean (SD) of 37.6 (24.4) % and 42.6 (25.6) % of school and activity time, respectively. Twenty-six (23%) caregivers reported activity impairment and, of the 79 (69.9%) employed, 30 (38%) reported work impairment. Of the 65 patients with school/activities impairment, 41 (63.1%) received AIT, of which 21 (51.2%) completed 1 year of treatment. Effectiveness variables and WPAI + CIQ:AS significantly improved: Mean (SD) school impairment decreased from 39.7 (26.7) to 2.1 (7.1) % (p < 0.001) and activity impairment from 46.2 (34.6) to 1.4 (3.6) % (p < 0.001).

CONCLUSION

Allergic asthma due to HDMs results in school/work and activity impairment in children and adolescents and their caregivers. One year of AIT provided clinical benefits and reduced school and activity impairment.

WHAT IS KNOWN

• Allergic asthma impairs children's school performance and daily activities. • Allergen immunotherapy modifies allergic disease course and ameliorates its symptoms.

WHAT IS NEW

• Asthma symptoms due to allergy to house dust mites impair children's school attendance and productivity and daily activity and their caregivers' work performance and daily lives. • Allergen immunotherapy with a house dust mite MicroCrystalline Tyrosine (MCT)-associated allergoid seems to provide clinical benefits, associated with decreased school and activity impairment, supporting it as an effective treatment option.

Classrooms with high rates of absenteeism and individual success: Exploring students' achievement, executive function, and socio-behavioral outcomes

Research and policy dialogue surrounding absenteeism has predominately focused on the school when it comes to reducing student absences, with little focus on the classroom. Further, there has also been minimal attention paid to effects of absenteeism beyond achievement outcomes. To address both, we focused on the classroom and asked whether classrooms with typically higher rates of absenteeism were linked to students' individual achievement, executive function, and social skills. We used a nationally representative dataset of children who started in kindergarten in 2010-2011 (N = 18,170) - when absenteeism is at its highest point not seen again until adolescence. Using school and student fixed effects, our findings revealed that as the percent of absent classmates increases, individual student performance worsens consistently across achievement and executive function domains. Evidence for links between classmate absenteeism and student performance in socio-behavioral domains was less conclusive. Finally, the findings were unique to different student groups.

The impact of Traffic-Related air pollution on child and adolescent academic Performance: A systematic review

BACKGROUND

The negative health impacts of traffic-related air pollution (TRAP) have been investigated for many decades, however, less attention has been paid to the effect of TRAP on children's academic performance. Understanding the TRAP-academic performance relationship will assist in identifying mechanisms for improving students' learning and aid policy makers in developing guidance for protecting children in school environments.

METHODS

This systematic review assessed the relationship between TRAP and academic performance. Web of Science, PubMed, CINAHL, Medline, PsycINFO, SPORTDiscus, Scopus and ERIC databases were searched for relevant, peer reviewed, articles published in English. Articles assessing exposure to TRAP pollutants (through direct measurement, local air quality monitoring, modelling, or road proximity/density proxy measures) and academic performance (using standardised tests) in children and adolescents were included. Risk of bias was assessed within and between studies.

RESULTS

Of 3519 search results, 10 relevant articles were included. Nine studies reported that increased exposure to some TRAP was associated with poorer student academic performance. Study methodologies were highly heterogeneous and no consistent patterns of association between specific pollutants, age groups, learning domains, exposure windows, and exposure locations were established. There was a serious risk of bias within individual studies and confidence in the body of evidence was low.

CONCLUSIONS

This review found evidence suggestive of a negative association between TRAP and academic performance. However, the quality of this evidence was low. The existing body of literature is small, lacks the inclusion of high-quality exposure measures, and presents limitations in reporting. Future research should focus on using valid and reliable exposure measures, individual-level data, consistent controlling for confounders and longitudinal study designs.

The impact of childhood asthma on academic performance: A matched population-based cohort study

BACKGROUND

There is inconclusive evidence of the effect of asthma on the academic performance of young people. This study aims to compare scholastic performance and high school completion of young people hospitalized with asthma compared to matched peers not hospitalized with asthma.

METHOD

A population-based matched case-comparison cohort study of young people aged ≤18 years hospitalized for asthma during 2005-2018 in New South Wales, Australia using linked birth, health, education and mortality records. The comparison cohort was matched on age, gender and residential postcode. Generalized linear mixed-modelling examined risk of school performance below the national minimum standard (NMS) and generalized linear regression examined risk of not completing high school for young people hospitalized with asthma compared to matched peers.

RESULTS

Young males hospitalized with asthma had a 13% and 15% higher risk of not achieving the NMS for numeracy (95%CI 1.04-1.22) and reading (95%CI 1.07-1.23), respectively, compared to peers. Young males hospitalized with asthma had a 51% (95%CI 1.22-1.86) higher risk of not completing year 10, and around a 20% higher risk of not completing year 11 (ARR: 1.25; 95%CI 1.15-1.36) or year 12 (ARR: 1.27; 95%CI 1.17-1.39) compared to peers. Young females hospitalized with asthma showed no difference in achieving numeracy or reading NMSs, but did have a 21% higher risk of not completing year 11 (95%CI 1.09-1.36) and a 33% higher risk of not completing year 12 (95%CI 1.19-1.49) compared to peers.

CONCLUSIONS

Educational attainment is worse for young people hospitalized with asthma compared to matched peers. Early intervention and strategies for better management of asthma symptoms may enhance academic performance for students.

Pediatric Asthma Is Associated With Poorer 3-Year Academic Achievement in Urban Elementary and Middle-School Students

OBJECTIVE

Asthma has been associated with worse academic performance in a single school year, yet this association may be magnified over time as students with asthma continue to fall behind. This study examined the relationship between asthma and standardized test performance aggregated across 3 school years, including whether performance varied by likelihood of having significant asthma.

METHODS

Data were from students in grades K-8 at 2 urban public schools in the Northeastern United States (2015-2018). Asthma was based on parent- and self-report and school health center records. Standardized test performance was assessed using Measures of Academic Progress (MAP) and Partnership for Assessment of Readiness for College and Careers (PARCC). Mixed effects linear and logistic regression models were used to evaluate the relationship between asthma and performance during 3 school years.

RESULTS

Any asthma was associated with worse MAP performance across the 3 academic years. Students with the most significant asthma demonstrated worse performance on MAP and PARCC. Aggregating across 3 school years, students scored 3.17 points worse on MAP reading (95% confidence interval [CI]: 0.7-5.63; P = .012) and 3.56 points worse on MAP mathematics (95% CI: 0.52-6.6; P = .022); they had 48.8% (95% CI: 1.9%-73.2%; P = .044) and 58.0% (95% CI: 21%-78%; P = .007) lower odds of proficiency on PARCC English/Language Arts and Mathematics, respectively compared to those without asthma.

CONCLUSIONS

The relationship between asthma and poorer academic achievement in 1 school year may be magnified over multiple years, particularly among those with more significant asthma. School-based asthma interventions may support academic growth and more equitable health outcomes.

Going to sleep and going to school: Linking bedtime to student absenteeism

Educators continuously regard health as being a major driver of school attendance. While physical health factors have been explored in regards to reducing student absenteeism, no attention has been given to the role of bedtime. The present study explored associations between having a regular bedtime, the hour of going to sleep, and school start time to student attendance. Our findings indicate that a regular bedtime reduces kindergartners' absences and decreases their likelihood of being chronically absent. However, the time of bed was not associated with absenteeism, nor was the start time of kindergarten each morning. Potential mechanisms involve school-going routines and practices, and therefore we discuss how schools and communities can play an influential role in helping to address student absenteeism.

The Many Roles of Pediatric Integrated Behavioral Health Specialists

The primary care pediatric setting is intended to provide continuous and comprehensive care throughout a child's life, ensuring overall well-being. Routinely scheduled well-child visits are ideal to assess developmental progress, environmental health, behavior/psychosocial issues, and other concerns. Delivering integrated behavioral health (IBH) in the primary care setting may aid in identifying any early concerns or difficulties and provides resources and support when these issues first emerge; thus, promoting the child's well-being. IBH should be engaged early and often to establish a relationship with families and follow them as the child develops, regardless of the presence of a precipitating behavior concern.

Effect of filter collection efficiency on the clean air delivery rate in an air cleaner

The performance of an air cleaner is evaluated by the clean air delivery rate (CADR), which is defined as the measure of the delivery of contaminant-free air. Herein, we conducted comparative analyses of various particulate air filters with various collection efficiencies. We installed each filter in identical commercial air cleaners to determine the effects of the collection efficiency on the CADR. Three different filters (E11, E12, and H13 classes) were prepared to determine the effects of the filter collection efficiency and pressure drop on the air cleaner performance (ie, the CADR). Based on experimental data, filters E11 and E12 had similar CADRs and flow rates. However, filter H13, which had the highest collection efficiency and the lowest flow rate, had the lowest CADR. This indicates that even if a filter with higher collection efficiency is installed in an air cleaner, the larger pressure drop causes a reduction in the air flow rate. The CADR value is widely distributed for a flow rate range for commercially available models; however, the collection efficiencies for most air cleaners on the market lie in a narrow range. Therefore, the flow rate has the most direct impact on the performance of a commercial air cleaner.

Universal School Meals and Associations with Student Participation, Attendance, Academic Performance, Diet Quality, Food Security, and Body Mass Index: A Systematic Review

The school environment plays an important role in children's diets and overall health, and policies for universal free school meals have the potential to contribute to positive child health outcomes. This systematic review evaluates studies examining the association between universal free school meals and students' school meal participation rates, diets, attendance, academic performance, and Body Mass Index (BMI), as well as school finances. The search was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA). A search for studies published in economically developed countries published through December 2020 was performed in PubMed, Education Resources Information Center (ERIC), Thomson Reuters' Web of Science, and Academic Search Ultimate, followed by examining the references in the resultant literature. A total of 47 studies were identified and the Newcastle-Ottawa Scale (NOS) was applied to assess bias. Nearly all studies examining universal free school meals found positive associations with school meal participation. Most studies examining universal free school meals that included free lunch found positive associations with diet quality, food security, and academic performance; however, the findings of studies examining only universal free breakfast were mixed. Research findings were similarly mixed when examining attendance as an outcome. Concerns about adverse outcomes on student BMI were not supported by the literature; in fact, several studies detected a potentially protective effect of universal free school meals on BMI. Research examining the impact of universal free meals on school finances was limited, but suggest that lower-income school districts in the U.S. may have positive financial outcomes from participation in universal free school meal provisions. Additionally, providing free meals to students may be associated with improved household incomes, particularly among lower-income families with children. Further research is needed to examine the financial implications of universal free meals for both school districts and families. Overall, universal free school meals may have multiple benefits for students and countries should consider universal free school meal provisions with strong nutrition guidelines. (PROSPERO registration: CRD42020221782).

Managing respiratory emergencies at school: A county-wide stock inhaler program

BACKGROUND

A total of 15 states allow schools to manage respiratory emergencies among multiple students by using a single albuterol inhaler (stock inhaler) paired with a disposable holding chamber.

OBJECTIVE

Our aim was to evaluate implementation barriers and facilitators, as well as satisfaction with a stock inhaler program across K through12 schools in Pima County, Arizona.

METHODS

All public, charter, private, and parochial schools were offered supplies, web-based training, and technical assistance at no cost. The RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance) framework was used to evaluate program implementation. School documentation logs were reviewed, school health personnel were surveyed, and a convenience sample of health personnel were interviewed. Chi-square tests evaluated categoric outcomes and Poisson hurdle regression examined stock inhaler use by school organization type, grade levels served, and type of school health personnel employed.

RESULTS

In all, 229 schools (68%) participated, reaching 82% of students in the county. A total of 152 schools (66%) used a stock inhaler, accounting for 1038 events. The mean number of puffs administered was 2.7 (SD = 1.2) per event, and most events (79%) involved students with asthma. Although most events (83.9%) resulted in the student returning to class, 15.6% resulted in students being sent home. Only 6 events resulted in 911 calls, and 5 of these led to an ambulance transport. School health personnel reported high levels of satisfaction, and all schools renewed participation for a second year. Program costs were $156 per school.

CONCLUSION

With technical assistance, stock inhaler programs can be feasibly implemented by schools in a wide range of settings, thereby increasing their capacity to safely manage respiratory emergencies.

Factors affecting variability in gaseous and particle microenvironmental air pollutant concentrations in Hong Kong primary and secondary schools

School-age children are particularly susceptible to exposure to air pollutants. To quantify factors affecting children's exposure at school, indoor and outdoor microenvironmental air pollutant concentrations were measured at 32 selected primary and secondary schools in Hong Kong. Real-time PM₁₀ , PM_2.5 , NO_2, and O₃ concentrations were measured in 76 classrooms and 23 non-classrooms. Potential explanatory factors related to building characteristics, ventilation practice, and occupant activities were measured or recorded. Their relationship with indoor measured concentrations was examined using mixed linear regression models. Ten factors were significantly associated with indoor microenvironmental concentrations, together accounting for 74%, 61%, 46%, and 38% of variations observed for PM_2.5 , PM₁₀ , O_3, and NO₂ microenvironmental concentrations, respectively. Outdoor concentration is the single largest predictor for indoor concentrations. Infiltrated outdoor air pollution contributes to 90%, 70%, 75%, and 50% of PM_2.5 , PM₁₀ , O_3, and NO₂ microenvironmental concentrations, respectively, in classrooms during school hours. Interventions to reduce indoor microenvironmental concentrations can be prioritized in reducing ambient air pollution and infiltration of outdoor pollution. Infiltration factors derived from linear regression models provide useful information on outdoor infiltration and help address the gap in generalizable parameter values that can be used to predict school microenvironmental concentrations.

Association of asthma severity and educational attainment at age 6-7 years in a birth cohort: population-based record-linkage study

Background

There is conflicting research about the association between asthma and poor educational attainment that may be due to asthma definitions. Our study creates seven categories of current chronic and acute asthma to investigate if there is an association for poorer educational attainment at age 6–7 years, and the role of respiratory infections and school absence.

Methods

This study used a population-based electronic cross-sectional birth cohort 1998–2005, in Wales, UK, using health and education administrative datasets. Current asthma or wheeze categories were developed using clinical management guidelines in general practice (GP) data, acute asthma was inpatient hospital admissions and respiratory infections were the count of GP visits, from birth to age 6–7 years. We used multilevel logistic regression grouped by schools to ascertain if asthma or wheeze was associated with not attaining the expected level in teacher assessment at Key Stage 1 (KS1) adjusting for sociodemographics, perinatal, other respiratory illness and school characteristics. We tested if absence from school was a mediator in this relationship using the difference method.

Results

There were 85 906 children in this population representative cohort with 7-year follow-up. In adjusted multilevel logistic regression, only asthma inpatient hospital admission was associated with increased risk for not attaining the expected level at KS1 (adjusted OR 1.14 95% CI (1.02 to 1.27)). Lower respiratory tract infection (LRTI) GP contacts remained an independent predictor for not attaining the expected level of education. Absence from school was a potential mediator of the association between hospital admission and educational attainment.

Conclusions

Clinicians and educators need to be aware that children who have inpatient hospital admissions for asthma or wheeze, or repeated LRTI, may require additional educational support for their educational outcomes.

School-Based Telemedicine for Asthma Management

Asthma affects 10% of school-age children in the United States. These numbers nearly double in high-risk populations such as low-income and minority populations. Patients in these populations frequently live in communities that are medically underserved, with limited resources to implement comprehensive asthma interventions. It is important for researchers and clinicians to explore avenues to reduce the burden of illness in this population. Incorporating innovative strategies such as school-based telemedicine programs can potentially reduce morbidity, health care utilization, work absenteeism for caregivers, and school absenteeism for children with asthma. The aim of this review is to discuss the potential benefits of school-based asthma telemedicine programs, explore potential implementation models, and provide a comprehensive review of the literature including programs that use telemedicine in schools to assist with the management of asthma. Telemedicine is a feasible approach to increasing access to primary and specialty asthma care; however, there is a need for future randomized trials to establish best practices for implementation of telemedicine programs to aid in the care for children in school settings.

Academic Differences Between an Urban Nativity School and an Urban Public School District

Previous research suggests that both poverty and minority status significantly influence academic achievement. Nativity schools, which have been extensively researched, have been found effective for students coming from low socioeconomic statuses and diverse backgrounds. Differences were examined between an urban public school district and an urban parochial school that uses the Nativity model (henceforth referred to as Nativity School). The purpose of this study was to determine if students from Nativity School were able to achieve significantly above that which urban public school students achieved. Specifically, academic achievement in the areas of mathematics, language arts, and science were analyzed, as well as high school dropout rate, high school graduation rate, and entrance into postsecondary education. Nativity School used the Iowa Test of Basic Skills (ITBS) to measure achievement longitudinally and reported stanines and local and national percentile ranks, while the public school system used the Missouri Assessment Program (MAP) and provided four descriptor categories (i.e., Below Basic, Basic, Proficient, and Advanced). Below Basic and Basic referred to students who demonstrate the skills outlined by the Missouri Show-Me Standards inconsistently and/or incorrectly, while students who perform in the Proficient and Advanced categories demonstrate these skills consistently, at or above grade level. Results revealed Nativity School students significantly improved their academic achievement scores and were more likely than urban public school students to graduate high school and enroll in postsecondary school. Interpretation and implications of these results and limitations are explored.

Effect of Elementary School-Based Health Centers in Georgia on the Use of Preventive Services

INTRODUCTION

This study measures effects on the receipt of preventive care among children enrolled in Georgia's Medicaid or Children's Health Insurance Program associated with the implementation of new elementary school-based health centers. The study sites differed by geographic environment and predominant race/ethnicity (rural white, non-Hispanic; black, small city; and suburban Hispanic).

METHODS

A quasi-experimental treatment/control cohort study used Medicaid/Children's Health Insurance Program claims/enrollment data for children in school years before implementation (2011-2012 and 2012-2013) versus after implementation (2013-2014 to 2016-2017) of school-based health centers to estimate effects on preventive care among children with (treatment) and without (control) access to a school-based health center. Data analysis was performed in 2017-2019. There were 1,531 unique children in the treatment group with an average of 4.18 school years observed and 1,737 in the control group with 4.32 school years observed. A total of 1,243 Medicaid/Children's Health Insurance Program-insured children in the treatment group used their school-based health centers.

RESULTS

Significant increases in well-child visits (5.9 percentage points, p<0.01) and influenza vaccination (6.9 percentage points, p<0.01) were found for children with versus without a new school-based health center. This represents a 15% increase from the pre-implementation percentage (38.8%) with a well-child visit and a 25% increase in influenza vaccinations. Increases were found only in the 2 school-based health centers with predominantly minority students. The 18.7 percentage point (p<0.01) increase in diet/counseling among obese/overweight Hispanic children represented a doubling from a 15.3% baseline.

CONCLUSIONS

Implementation of elementary school-based health centers increased the receipt of key preventive care among young, publicly insured children in urban areas of Georgia, with potential reductions in racial and ethnic disparities.

Dissemination of Evidence-Based School Asthma Management Programs: Piloting Asthma 411 in an Urban Texas School District

BACKGROUND

The dissemination and implementation (D&I) of evidence-based initiative (EBIs) is critical to improved public health. The Asthma 411 EBI was piloted in Texas from 2013 to 2015. The pilot's evaluation assessed its effectiveness and identified approaches to support D&I of school-health EBIs.

METHODS

The pilot study was conducted in two schools; service categories included: a consulting physician, enhanced school asthma services, and support for links to community health resources. Data was collected on Emergency Medical Service (EMS) calls, aggregated nursing services, demographic characteristics, availability of medication provided through existing policies, and informal interviews.

RESULTS

During the pilot, school-day asthma-related Emergency Medical Service (EMS) calls were eliminated. Documented asthma self-management education, authorization for rescue medication, and efforts to communicate with parents and health providers increased. Between year-1 and year-2, the gap between unadjusted, weighted mean absences among students with and without asthma was reduced by 1.1 days. However, this difference was not seen in a fully adjusted negative, binomial regression model.

CONCLUSIONS

Evaluation of the Asthma 411 pilot suggests many EBI benefits were retained and identifies factors that may facilitate D&I of school health EBIs. Future research will clarify impacts on absenteeism and determine if observed benefits are sustained.

Children and young people with inflammatory bowel disease attend less school than their healthy peers

OBJECTIVE

Chronic diseases, such as inflammatory bowel disease (IBD), can impact negatively on education and social development. Examining the impact of IBD on school/college attendance for children and young people (CYP) is vital to provide targeted support to patients, families and schools.

METHODS

We performed a cross-sectional survey to determine the school/college attendance rates, the reasons for absence related to IBD and facilitators or barriers to school/college attendance. In a subset of patients followed up locally, we performed a detailed review of hospital attendance data to assess healthcare burden.

RESULTS

Two hundred and thirty-one questionnaires were given to CYP with IBD aged 5-17 years. Response rate was 74% (final sample 169). The median school/college attendance rate was 92.5%, significantly lower than all children in England (95.2%). 39.6% of children with IBD were persistently absent, defined nationally as missing 10% or more of school. Only five children (3%) had a 100% attendance record. Increasing age and use of monoclonal therapy were predictors of poor school attendance. Concerns about feeling unwell at school/college, access to toilets, keeping up with work and teachers' understanding of IBD are the main issues for CYP with IBD. There was a significant negative correlation between number of days in hospital and school attendance.

CONCLUSION

IBD has a significant impact on school/college attendance, with hospital attendance, disease burden and school difficulties being major factors. Employing strategies to minimise healthcare burden and developing a partnership between health and education to support children with IBD will serve to facilitate school/college attendance.

Prevalence and impact of asthma in schoolchildren in the city of Caxias do Sul-RS

OBJECTIVE

To analyze the prevalence and impact of asthma in schoolchildren from the city of Caxias do Sul, RS, Brazil.

METHODS

Cross-sectional observational and case-control study with children and adolescents between 7 and 15 years old, from public schools in Caxias do Sul, RS. The study is composed of two phases: Phase I analyzed the prevalence of asthma in the delimited population, investigating 1915 schoolchildren; Phase II quality of life questionnaires, asthma control and classification (for the asthmatic group), physical activity, school performance, pulmonary function tests and anthropometric measures were applied to 266 asthmatics and 288 controls.

RESULTS

The estimated prevalence of asthma was 16.1%. In the comparison between asthmatics and nonasthmatics premature birth (p<0.001) and diagnosis of another chronic disease at birth (p<0.001) were found. Regarding pulmonary function, significant differences were found in the values between groups in FEV₁, FEV₁/FVC and forced expiratory flow in the 25 and 75% (FEF_25-75%), being that asthmatics presented lower values. Among asthmatics, 133 (50.8%) did not have the disease controlled. In the anthropometric variables, significant differences were observed, with higher values in controls, in the the waist-to-height ratio (p=0.009) and in the perception of health (p<0.001). Quality of life is lower in asthmatics in the physical well-being domain (p=0.001) and in the total score (p=0.016). The total school performance score did not present a statistically significant difference between the groups.

CONCLUSION

The prevalence of asthma is similar to that of other industrialized urban centers and may negatively affect some areas of the development of schoolchildren.

Asthma and subsequent school performance at age 15-16 years: A Swedish population-based sibling control study

Asthma may negatively affect children’s school performance, such as grades and exam results. Results from previous studies have shown varying results and may have suffered from confounding and other biases. We used a Swedish population-based cohort of 570,595 children with data on asthma (including severity and control) in Grades 7–8 and 9, school performance from Grade 9 (grade point sum, non-eligibility for upper secondary school and national test results) and measured confounders from national registers. We used sibling comparisons to account for unmeasured familial factors. Children with asthma and severe asthma performed slightly better in school than children without asthma when adjusting for measured confounders, but the associations were attenuated in sibling comparisons. In contrast, children with uncontrolled asthma performed slightly worse (e.g. Grade 9: β_adj = −9.9; 95% CI −12.8 to −7.0; Cohen’s d = 0.16). This association remained for uncontrolled asthma in Grade 9 in sibling comparisons (Grade 9: β = −7.7 points; 95% CI −12.6 to −2.6; Cohen’s d = 0.12), but not for Grades 7–8. The attenuation of estimates when controlling for familial factors using sibling comparisons suggests that the differences were due to familial factors, rather than being causal. The remaining associations in sibling comparisons between uncontrolled asthma in Grade 9 and school performance are consistent with a causal association.

Preparing Students for Success: Differential Outcomes by Preschool Experience in Baltimore City, Maryland

An early adopter of public preschool (i.e., pre-kindergarten, "pre-k"), evidence from Baltimore City, Maryland, can provide insight for those working to improve access to early education opportunities. We followed a cohort of children entering kindergarten in Baltimore City Public Schools during the 2007-2008 year through the 2010-2011 academic year. Students were grouped by pre-k experience: public pre-k (n = 2828), Head Start (n = 839), Head Start plus public pre-k (n = 247), private pre-k (n = 993), or informal care (n = 975). After adjusting for individual- and school-level characteristics, students from the Head Start plus public pre-k group were the most likely to enter kindergarten with the foundational skills and behaviors needed to be successful (vs. all groups, P ≤ .001). Students in informal care were the least likely to enter kindergarten with this skillset (vs. all pre-k groups P ≤ .001). Children from informal care were also significantly more likely than all other groups to be chronically absent in kindergarten (P ≤ .001). By third grade, children from informal care were least likely to be reading on grade level and most likely to have been retained a grade (vs. all pre-k groups P ≤ .001). Children from disadvantaged populations who were not enrolled in pre-k faced significant difficulties keeping up with their peers throughout elementary school; interventions to improve their transition to school and increase their likelihood of academic success are warranted. Universal preschool is likely to improve education outcomes for children in urban areas.

COPE for asthma: Outcomes of a cognitive behavioral intervention for children with asthma and anxiety

Asthma is the most common childhood chronic condition and a major contributor to school absences and lost instructional time. Children with asthma have a higher risk of internalizing disorders, such as anxiety and depression, which can further complicate asthma management. The purpose of this pilot study was to assess the feasibility, acceptability, and preliminary effects of a manualized, cognitive-behavioral skills-building intervention for children with asthma and anxiety. The design for this study was a one-group, pre/posttest preexperimental with a 6-week follow-up. This article presents the immediate posttest follow-up results. Children between 8 and 12 years of age and their caregivers were recruited from three elementary schools in a large public school district in Ohio. Thirty-two children with asthma and symptoms of anxiety completed the Creating Opportunities for Personal Empowerment (COPE) for Asthma program. Caregivers completed surveys, but they did not participate in the intervention. Results indicated that the program was feasible to implement in small groups during the school day. Self-reported findings indicated a significant reduction in separation anxiety and increased personal beliefs, child-management self-efficacy, and asthma illness representations. Parents and caregivers reported symptom reduction in their children on the Pediatric Symptom Checklist. The subgroup of children scoring high on anxiety at baseline showed reductions with the intervention, having large positive effect sizes for separation and social anxiety as well as medium and large positive effect sizes on the personal beliefs and asthma illness representations, respectively. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Asthma and Academic Performance Among Children and Youth in North America: A Systematic Review

BACKGROUND

The increasing prevalence of asthma among adolescents and the limited studies exploring the educational outcomes for youth coping with asthma makes the inquiry in this field of special interest. This paper reviews the literature on empirical studies exploring the relationship between asthma and academic performance among adolescents.

METHODS

Five databases (CINAHL, PubMed, ERIC EBSCO, Web of Science, and PsycINFO) were searched for peer-reviewed empirical studies exploring the link between asthma and academic performance utilized. Studies were reviewed, logged, and assessed studies for their research design, methods, and findings. Data synthesis incorporated strengths, limitations, and recommendations for future research and practice.

RESULTS

Twenty studies met the inclusion criteria. Of these, 13 employed a survey design and 7 evaluated school-based interventions implementing an experimental design. Whereas researchers applied quantitative methods in all the studies, qualitative and mixed-method designs were infrequently used. Studies showed a link between school absenteeism and asthma; other academic indicators (eg, graduation and test-scores) showed inconsistent correlation.

CONCLUSIONS

Future research should deploy more variable research designs and methods to improve understanding of the factors contributing to the relationship between adolescent asthma and academic performance. Additional topic-specific inquiry is needed to inform school practices and policies.

Implementation of Asthma Management Guidelines and Possible Barriers in Korea

BACKGROUND

There could be a gap between asthma management guidelines and current practice. We evaluated the awareness of and compliance with asthma management guidelines, and the internal and external barriers to compliance, for the first time in Korea.

METHODS

From March to September of 2012, 364 physicians treating asthma patients at primary, secondary, and tertiary teaching hospitals were enrolled. They completed a questionnaire on the awareness of and compliance with asthma management guidelines, and the barriers and alternatives to their implementation.

RESULTS

Of the 364 physicians, 79.1% were men and 56.9% were primary care physicians. The mean age was 40.5 ± 11.2 years. Most of them were aware of asthma management guidelines (89.3%). However, only a portion (11.0%) of them complied with the guidelines for asthma. Pulmonary function tests for diagnosis of asthma were performed by 20.1% of all physicians and 9.2% of primary care physicians, and by 9.9% of all physicians and 5.8% of primary care physicians for monitoring. Physicians stated that 'asthma monitoring' was the most difficult part of the guidelines, followed by 'environmental control and risk factors.' Only 39.6% (31.9% of the primary care physicians) prescribed an inhaled corticosteroid (ICS) as the first-line treatment for persistent asthma. The internal barriers were physician's preference for oral medications, difficulty in use even with inhaler training, and concern over ICS side effects. The external barriers were possible rejection of medical reimbursement by health insurance, refusal by the patient, cost, and a poor environment for teaching the patient how to use the inhaler. Alternatives proposed by physicians to implement asthma management guidelines were to improve medical reimbursement policies and the level of awareness of such guidelines.

CONCLUSION

Compliance with the asthma management guidelines, including ICS prescription, is low despite the awareness of the guidelines. It is necessary to develop a strategy to overcome the internal and external barriers.

Using machine learning to examine the relationship between asthma and absenteeism

In this study, we found that machine learning was able to effectively estimate student learning outcomes geo-spatially across all the campuses in a large, urban, independent school district. The machine learning showed that key factors in estimating the student learning outcomes included the number of days students were absent from school. In turn, one of the most important factors in estimating the number of days a student was absent was whether or not the student had asthma. This highlights the importance of environmental public health for student learning outcomes.

Asthma and academic performance in urban children

BACKGROUND

Urban minority children experience high levels of asthma morbidity. Poor school performance can be an indicator that asthma is in poor control. Little attention has been paid to examining real-time links between asthma and academic performance, particularly in high-risk groups.

OBJECTIVE

Examine 1) academic performance across a range of indicators in a group of urban children with asthma and urban children without chronic illness and ethnic differences in these associations, and 2) associations between asthma and academic performance in the group of urban children with asthma and ethnic differences in these associations.

METHODS

Two hundred sixteen black/African American (33%), Latino (46%), and non-Latino white (21%) urban children, ages 7 to 9 years completed a clinic- and home-based protocol that assessed asthma and allergy status, objective measurements of lung function, and academic functioning.

RESULTS

Analyses revealed that children with asthma experienced a higher number of school absences when compared with healthy controls. Greater disparities in academic outcomes emerged when examining ethnic differences within the groups of children with and without asthma. Poor academic outcomes were observed in Latino children with asthma. Furthermore, a strong correspondence of poor asthma outcomes and decrements in academic performance were seen in the full sample, and these associations emerged across ethnic groups.

CONCLUSION

Asthma activity contributes to poorer academic outcomes across a range of indicators, and urban minority children with asthma, particularly Latino children, may be at heightened risk for poorer academic performance. School management guidelines for asthma need to be consistently implemented and tailored for school staff, caregivers, and students with asthma to address challenges of managing asthma within the urban school setting.

The impact of sickle cell anemia on the quality of life of sicklers at school age

Background

Sickle cell anemia (SCA) is prevalent in Sudan in general, and in particular in the western part of the country among Misseria tribe. School absence, depressive symptoms, embarrassment, social disturbances, and emotional disturbance present negative impact for sicklers. Therefore, an urgent call for improving the quality of life of sicklers is needed.

Objectives

To examine the impact of SCA on the quality of life of school-age children affected by the disease from the perspective of three dimensions: psychological, social, and schooling.

Materials and Methods

This is a prospective, cross-sectional, observational study carried out over 2 weeks' period in April 2011 in Western Sudan, Gineana District. This study included 107 patients within the age group of 7-15 years with confirmed diagnosis of SCA in a steady state. A sickler with SCA who had hemoglobin genotype "SS" on hemoglobin electrophoresis without crises over the past 4 weeks was considered to be in steady state. Questionnaires designed by expert covering social and psychological aspects of the disease were filled by the authors.

Results

Of 107 patients with confirmed diagnosis of SCA in steady state, 54.2% of them were male. About 17.8%, 29.6%, 23.4%, 48.6%, 16.8%, and 45.8% of the patients suffered from school absence, teasing, embarrassment due to bedwetting, embarrassment due to jaundice, failure to contribute to school activities such as sport, and depressive symptoms, respectively. Around 8.4% of the patients repeated classes. Divorce and anxiety among sicklers' families were found in 6.5% and 8.4%, respectively. Twenty-one (19.6%) families had less interest in social activities in the community.

Conclusion

Sickle cell disease has many social and psychological problems which need to be addressed. Enuresis, depressive symptoms, school absentees, and deterioration in school performance were the common problems encountered.

Mapping inequality: Childhood asthma and environmental injustice, a case study of St. Louis, Missouri

As a geographic continuum of poverty and affluence has emerged, so too has a geographic continuum of good and poor health. Asthma is currently one of the most prevalent chronic childhood diseases. Over the past three decades, the greatest increases in asthma rates have been in urban areas and have disproportionately affected youth in poverty and those in racial and ethnic minority groups. Neighborhoods serve as a mechanism fostering environmental injustice and perpetuating these disparities in health outcomes and life opportunity for our most vulnerable populations. Using Geographic Information Systems (GIS) methods in a case study of St. Louis Missouri, this study examines local environmental risk by identifying 'hotspots,' or statistically significant spatial clustering of high or low levels of childhood asthma, and associations with neighborhood characteristics, socio-demographic characteristics, and access to healthcare resources within these hotspots. Results revealed statistically significant clustering of high asthma rates in areas with more non-White and poor residents, higher rates of public housing, deteriorating housing, and violent crime. High asthma hotspots were also located in areas with limited physical access to healthcare resources, such as physicians and medication, and lower school attendance rates. Residents of these high asthma hotspots experience greater environmental risk, and significant disparities in health and education outcomes, physical and financial healthcare resources, and overall well-being. This study demonstrates these place-based inequalities and presents clear evidence of environmental injustice, supporting the need for investments and interventions to improve the environments, health, and economic resources of our most vulnerable youth.

Academic achievement of adolescents with asthma or atopic disease

Background

Over a fifth of children and adolescents suffer with asthma or atopic disease. It is unclear whether asthma impacts academic performance in children and adolescents, and little is known about the association of eczema, food allergy or hayfever and academic performance.

Objective

To examine whether asthma, eczema, food allergy or hayfever impacts on adolescent academic performance and to assess the role of unmeasured confounding.

Methods

This study used the Childhood and Adolescent Twin Study of Sweden cohort born 1992‐1998. At age 9‐12 years, parents reported on their child's ever or current asthma, eczema, food allergy and hayfever status (n = 10 963). At age 15, linked national patient and medication register information was used to create current and ever asthma definitions including severe and uncontrolled asthma for the same children. Academic outcomes in Grade 9 (age 15‐16 years) included: eligibility for high school (Grades 10‐12), and total mark of the best 16 subject units, retrieved from the Grade 9 academic register. Whole cohort analyses adjusted for known covariates were performed, and co‐twin control analyses to assess unmeasured confounders.

Results

There were no associations found for asthma or food allergy at 9‐12 years and academic outcomes in adolescence. In addition, at age 15, there were no statistically significant associations with current, ever, severe or uncontrolled asthma and academic outcomes. Eczema and hayfever at age 9‐12 years were found to be positively associated with academic outcomes; however, co‐twin control analyses did not support these findings, suggesting the main analyses may be subject to unmeasured confounding.

Conclusion and clinical relevance

Having asthma or an atopic disease during childhood or adolescence does not negatively impact on academic performance. This information can be used by clinicians when talking with children and parents about the implications of living with asthma or atopic disease.

Childhood Disability and Educational Outcomes: A Systematic Review

PROBLEM

Graduation from high school is an important milestone for all adolescents and affects future health in adulthood. Children with chronic illnesses have additional challenges that affect school attendance, grade retention and graduation. If children with chronic conditions are not able to participate fully in education, this may limit their opportunities for future health. The aim of this study was to integrate the evidence in the past 28 years about educational outcomes of children and adolescents with chronic conditions causing disability.

ELIGIBILITY CRITERIA

Quantitative studies reporting on a chronic condition and attendance, grade retention, or high school graduation, from a peer-reviewed journal in the English language, data collection since 1990, and research conducted with a population in the United States were eligible for review.

SAMPLE

Forty-three studies from a literature search of CINAHL, MEDLINE, ERIC, Teacher Reference Center, Psychology & Behavioral Science Collection, and Academic Search Elite databases, followed by ancestry searches, were included in this review.

RESULTS

In general, chronic conditions are significantly associated with increased absenteeism, grade repetition and not completing high school within four years, although hemophilia does not follow this pattern. Additionally, increased severity of the condition is associated with poorer educational outcomes.

CONCLUSIONS

Nurses and other healthcare providers should include an educational assessment as part of psychosocial assessment of children and adolescents to identify risk, intervene early and limit risk.

Trends in the prevalence and distribution of teacher-identified special health-care needs across three successive population cohorts

AIM

Some children's special health-care needs (SHCN) are formalised at the start of schooling (established SHCN), but a larger proportion start with difficulties that are milder or not yet diagnosed (emerging SHCN). This study explores whether: (i) the prevalence of teacher-identified SHCN (both overall and according to type of needs) and (ii) distribution across disadvantaged communities have changed over three successive population cohorts of Australian children.

METHODS

We draw on repeated cross-sectional data from the Australian Early Development Census, a teacher-reported checklist completed on full populations of Australian school entrants in 2009, 2012 and 2015. It includes a measure of SHCN, as well as demographic information.

RESULTS

The proportion of children with emerging and established needs was mostly stable from 2009 to 2015 (emerging needs: 17.1-18.9%; established needs: 4.4-4.9%). Change over time was observed in the prevalence of some specific types of impairment. Speech impairment rose by 14.7% for children with emerging needs, and emotional problems rose by 13.7% for children with established needs. Children living in the most disadvantaged neighbourhoods had higher odds of SHCN in all years (e.g. emerging needs relative risk ratio 1.65 (99% confidence interval 1.55-1.75) in 2015; established needs relative risk ratio 1.88 (99% confidence interval 1.71-2.06) in 2015).

CONCLUSIONS

A large proportion of children starting school each year have SHCN. The types of SHCN that children present with increasingly reflect complex difficulties that require input from both the health and education sectors. Effective responses also need to consider the added impact of disadvantage.

Access to the School Breakfast Program Is Associated with Higher Attendance and Test Scores among Elementary School Students

BACKGROUND

The School Breakfast Program (SBP) has grown and evolved substantially since its inception, yet relatively little is known about its impact on school engagement and academic outcomes.

OBJECTIVES

The purpose of this study is to estimate the impact of the SBP on school attendance and standardized test scores, as well as how impacts differ among student subpopulations and between traditional and nontraditional program models.

METHODS

The study uses administrative data from ∼1000 Wisconsin elementary schools during 2009-2014, including almost all public elementary schools in the state except those in Milwaukee Public School District. Over the 5-y period, 168 schools in our sample introduced a new SBP and/or changed the location of breakfast (classroom or cafeteria) or the payment structure. The impact of breakfast availability and type was evaluated using multivariable regression models with school fixed effects and extensive demographic controls, leveraging within-school changes in SBP availability and type.

RESULTS

Implementing the SBP was associated with a 3.5-percentage-point reduction in the percentage of students with low attendance and an increase of 0.08 SD in normalized reading scores among likely-participant boys (P = 0.015), with no impact among girls. When breakfast was offered free to all students, the probability of low attendance was 3.5 percentage points lower than with traditional SBP for a broad cross-section of students (P < 0.001), and math and reading scores were 0.07 and 0.04 SD higher among the higher-income sample, respectively (P = 0.001 and P = 0.035, respectively). When breakfast was offered in the classroom, neither attendance nor reading scores differed relative to cafeteria-based SBP, whereas math scores among likely-participant boys were 0.05 SD lower (P = 0.045).

CONCLUSIONS

Offering breakfast at school can modestly improve educational engagement and performance, but benefits differ across children and by program structure. Universally free breakfast appears particularly beneficial to both attendance and test scores.

A Comparison of the Academic Performance and Intelligence Scores of Asthmatic and Nonasthmatic Primary School Pupils in Enugu State, Nigeria

BACKGROUND

Children with asthma (subjects), just as their non asthmatic colleagues, are expected to perform optimally academically and with a good intelligent score. A number of activities in children with asthma may be affected by asthmatic attacks including their education/academic performance. Report on academic performance and IQ of school children with asthma and comparisons with those without asthma (controls) within and outside Nigeria are scanty.

AIMS

This study compared the academic performance and IQ of asthmatics and nonasthmatic school children.

MATERIALS AND METHODS

One hundred and twenty children with asthma aged 5-11 years were consecutively recruited at the asthma clinic of UNTH Enugu and their age, gender and socio-economic class-matched normal classmates were enrolled as controls. Academic performance of the children with asthma was studied using the overall scores achieved in the three term examinations in the preceding academic year (2012/2013), while their IQ was determined using the Draw-A-Person-test. The findings were compared with that of the 120 controls.

RESULTS

The median (range) overall academic scores for the subjects 79.04% (36.08%-99.57%) was similar to that of controls 80.01% (50.65%-97.47%) (U = 6804, P = 0.461). However, a significant number of subjects compared to controls had poor academic performance. The mean IQ scores for subjects (123.28 ± 21.45) and controls (118.41 ± 19.87) did not differ significantly (t = 1.83; P = 0.069). There was also a significant and negative correlation (Pearson's) between age and mean DAPQ in both the subjects and controls (r = -0.377, P < 0.001; r = -0.492, P < 0.001 respectively.

CONCLUSIONS

The intelligence scores and overall academic performance of children with asthma compares favorably with that of children without asthma.

Health problems during childhood and school achievement: Exploring associations between hospitalization exposures, gender, timing, and compulsory school grades

Aims

To investigate while accounting for health at birth 1) associations between health problems during childhood, measured as hospitalizations, and school achievement in the final year of compulsory school, measured as overall grade points and eligibility for upper secondary education, 2) if and how gender moderates the association between health problems and school achievement, 3) if and how the timing of a health problem during childhood is associated with later school achievement.

Methods

Analyzes were performed on a population-based cohort (n = 115 196) born in 1990 in Sweden (51.3% boys, 48.7% girls) using data from several national registries. Multiple linear regression and logistic regression were used to analyze associations between study variables.

Results

Overall grade points and eligibility for continuation to upper secondary school were lower for individuals exposed to hospitalizations. Only the association between hospitalizations and overall grade points was moderated by gender and only for ages 13–16 years. Exposure close to actual grading had worst outcomes.

Conclusions

Health problems, measured through hospitalizations, was significantly associated with lower school achievements among Swedish children. Girls exposed to health problems requiring hospitalizations had relatively poorer school achievements as compared to boys. Health problems requiring hospitalization during junior high school had the greatest negative association with final achievement at compulsory school.

A qualitative study of parent perspectives on barriers, facilitators and expectations for school asthma care among urban, African-American children

Objectives: Minority children experience the disproportionate burden of asthma and its consequences. Studies suggest ethnic groups may experience asthma differently with varied perceptions and expectations among parents of African-American and Latino children. Because parents coordinate asthma care with the school, where children spend a significant amount of their day, this study's goal was to determine parents' perspectives on school asthma management. Methods: Focus groups were conducted with parents of children with asthma at four urban schools whose student population is predominantly African-American. A semi-structured guide was utilized focusing on barriers, facilitators and expectations for asthma care at school. Grounded theory principles were applied in this study. Results: Twenty-two parents (91% females) representing 13 elementary and 10 middle school children with asthma (61% boys) participated in four focus groups. Most children (87%) had persistent asthma. The identified barriers to effective school-based asthma care included limited awareness of children with asthma by teachers/staff, communication issues (e.g. school/parent, within school), inadequate education and lack of management plans or systems in place. In contrast, the identified facilitators included steps that fostered education, communication and awareness, as supported by management plans and parent initiative. Parents described their expectations for increased communication and education about asthma, better systems for identifying children with asthma, and a trained asthma point person for school-based asthma care. Conclusions: Parents of children with asthma identified important barriers, facilitators and expectations that must be considered to advance school asthma management. Improved school-based asthma care could lead to better health and academic outcomes.