CASE STUDY 4

Asthma Management for Inner-City Children:

The Partners in School Asthma Management Program

Christine Markham, Shellie Tyrrell, Ross Shegog,

María Fernández, and

L. Kay Bartholomew Eldredge

University of Texas Health Science Center at Houston School of Public Health

LEARNING OBJECTIVES

  • Specify behavioral factors and environmental conditions related to chronic disease
  • Use theory to specify behavioral performance objectives
  • Develop matrices for environmental conditions
  • Consider computer technology as a program vehicle

The literature cited in this case study represents the state of knowledge in the field of pediatric asthma management at the time of intervention development.

INTRODUCTION

Asthma is a common chronic disease in childhood and a priority for efforts to improve care and control because of its high rates of morbidity, mortality, and health care expenditures (Mannino et al., 1998). Although the prevalence of asthma is reported to be 6–8% among children under 18 years of age, it may be much higher among children living in urban areas, particularly among minority children and those with low socioeconomic status (N. M. Clark et al., 2002; C. L. Joseph, Foxman, Leickly, Peterson, & Ownby, 1996).

Asthma has a negative impact on the quality of life and functioning of many children (Centers for Disease Control and Prevention, 2001a). It can affect school performance and is a leading cause of school absence (Diette, Markson, Skinner, Nguyen, Gatt-Bergstrom, 2000; Newacheck & Halfon, 2000). Authors have found a relation between asthma and school attendance and academic performance (M. G. Fowler, Davenport, & Garg, 1992; Lieu et al., 2002). The school setting is a target for asthma intervention because it may offer unique opportunities to reach children with asthma who have not yet been diagnosed or who have poor control of their symptoms and limited access to medical care. However, the school setting can also be a cause of asthma problems related to exposure to environmental allergens and irritants or inadequate nursing or medical services for proper medication administration and management of acute symptoms (National Heart, Lung, and Blood Institute, 1997). Although national guidelines emphasize the need for collaboration between the family, school, and health care team, the school has sometimes been left out (National Heart, Lung, and Blood Institute, 1997). For example, families may not report the child’s condition to the school, provide a copy of a written action plan, or assure that medication is available. Schools may not have knowledge or resources to limit exposure to irritants such as outdoor air pollution, to create adequate indoor air exchange, and to eliminate common indoor asthma triggers.

In this chapter we describe how we used the Intervention Mapping process to develop and implement the Partners in School Asthma Management program, a school-based, multicomponent program for inner-city children with asthma. The program was a demonstration project to develop and test a feasible model for elementary schools nationwide. The project goals were to identify children with asthma and to develop partnerships with families and physicians to provide appropriate asthma care. This work was supported by the National Heart, Lung, and Blood Institute, National Institutes of Health, Contract No. NOI-HR-56079.

PERSPECTIVES

The Partners in School Asthma Management program is unique in that it emphasizes the management of asthma-related environmental factors in addition to the behaviors of children, parents, and physicians involved in managing asthma. This program addresses change at the individual level (child), interpersonal level (family, physician, school nurse, and other school personnel), and organizational level (school environment, school district policies and practices). The resulting program has four components: case finding, asthma self-management education for the child and family, a linkage system for physician care, and school environmental intervention.

The program represents innovations in asthma management because it uses interactive computer technology to individualize self-management education. This computer program allowed us to teach children using their unique asthma symptoms, triggers, and treatment characteristics. Further, this program used self-regulatory theory to specify performance objectives and to enable the explicit teaching of self-regulatory processes.

IM STEP 1: LOGIC MODEL OF THE PROBLEM

Task 1: Establish and Work with a Planning Group

Because Partners in School Asthma Management was to be implemented in an elementary school setting, the program developers made sure to include school district personnel on the program development team to represent their perspectives of asthma management and the realities of working in schools. They established a school district advisory committee, which played an important role in conceptualizing program development and implementation. The committee also assisted in identifying additional school district personnel who would be instrumental for program adoption. The school district advisory committee comprised directors and personnel from the departments of health and medical services, risk management, environmental affairs, construction management, and health education and curriculum development, as well as a school nurse, elementary school principal, and parent advocate. The advisory committee provided insight into the culture and practice of the school district community.

Task 2: Conduct a Needs Assessment to Create a Logic Model of the Problem

The asthma needs assessment was conducted according to the PRECEDE model and began with documentation of the scope and seriousness of the rising number of asthma cases and the impact on health and quality of life of certain populations (Green & Kreuter, 1999, 2005). From the perspectives of self-management or secondary prevention, we also asked: What behaviors and environmental factors are related to better management of asthma and better health and quality-of-life outcomes?

Asthma-Related Health and Quality-of-Life Issues

At the time of our program development, asthma morbidity and mortality rates had been rising. The NHLBI expert panel’s report (1991) noted an increase in the prevalence of asthma among people less than 20years of age. The rate rose from approximately 35 cases per 1,000 persons in 1980 to a rate of approximately 50cases per 1,000 in 1987. A report from the Centers for Disease Control and Prevention (1996) established that the asthma death rate among children five to fourteen years of age almost doubled between 1980 and 1993, from 1.7 deaths per million to 3.2.

A study by Crain and colleagues (1994) reported an asthma prevalence (8.6%) among inner-city children in the Bronx, New York, twice the typical estimated rate for all U.S. children. Many studies have implicated urban residency, minority status, and lower socioeconomic status as risk factors for increased prevalence of asthma (Crain et al., 1994; P. R. Wood, Hidalgo, Prihoda, & Kromer, 1993). Poor and minority populations, particularly African Americans, living in urban areas have experienced a disproportionately high prevalence of asthma and an increase in morbidity and mortality compared to whites (Centers for Disease Control and Prevention, 1996; Crain et al., 1994; Cunningham, Dockery, & Speizer, 1996; Gergen & Weiss, 1990; M. Weitzman, Gortmaker, & Sobol, 1990). Depending on age, African Americans are three to five times more likely than whitesto die from asthma (National Heart, Lung, and Blood Institute, 1991). In a study conducted by Cunningham and colleagues (1996) among 1,416 Caucasian and African American children, race was found to be a significant predictor of the diagnosis of asthma. After adjustment for the demographic and environmental factors, being African American was a significant predictor of active, diagnosed asthma. The study by Crain and colleagues (1994) also showed that the cumulative prevalence of asthma was significantly higher among Hispanics and children from the lowest-income families from the Bronx, New York. The study by P. R. Wood and colleagues (1993) found that children with lower socioeconomic status exhibited an excess of severe asthma as well as a greater amount of functional morbidity, such as school absenteeism.

Of chronic childhood diseases, asthma is the leading cause of school absenteeism and poor academic performance (A. M. Pope, Patterson, & Burge, 1993; W. R. Taylor & Newacheck, 1992). It has been estimated that children with asthma average 7.6 school days absent, compared with 2.5 days for children without asthma (M. G. Fowler et al., 1992). Parents of children with asthma are also more likely to miss days at work than parents of children without asthma. Asthma is also responsible for more than 500,000 emergency room visits each year (K. B. Weiss, Gergen, & Hodgson, 1992). Asthma hospitalization rates for 1979 were 1.73 per 1,000 among infants to seventeen-year-olds, and by 1987 that rate had increased to 2.57 per 1,000 (Gergen & Weiss, 1990). Data from the 1988 National Health Interview Survey on Child Health also showed that poor children have diminished accessibility to appropriate health services and higher rates of asthma morbidity, as measured by hospitalization and bed days (Halfon & Newacheck, 1993).

Environment

The risk factors for asthma are multifactorial, comprising genetic susceptibility, early history of pulmonary problems, poor medical management, and environmental factors such as indoor and outdoor aeroallergen and irritant exposure (National Heart, Lung, and Blood Institute, 1991; C. B. Sherman, Tosteson, Tager, Speizer, & Weiss, 1990; M. Weitzman et al., 1990). Sensitivity to specific allergens is quite common among persons with asthma, and estimates are that as many as 80% of children with asthma have some allergic hypersensitivity to aeroallergens (Burrows, Martinez, Halonen, Barbee, & Cline, 1989; Gergen & Turkeltaub, 1992; Platts-Mills, 1994; Pollart, Chapman, Fiocco, Rose, & Platts-Mills, 1989). Because children spend most of their time indoors, the home and school environments are important sources of allergen exposure for children with asthma. Asthma has been significantly associated with reactivity to house dust mites, mold, cockroaches, cat dander, and pollens (Gergen & Turkeltaub, 1992; Ingram et al., 1995; Kang, Johnson, & Veres-Thorner, 1993; Platts-Mills, 1994; Platts-Mills & Pollart, 1997; Rosenstreich et al., 1997). For example, in inner-city residents of Chicago, both indoor and outdoor aeroallergen sensitivity was observed in 75% of children less than 15 years of age with asthma, and sensitivity to cockroach allergens was observed in 59% of children less than 15years (Kang et al., 1993). A study of inner-city houses in Atlanta found significant levels of either mite or cockroach allergens in 86% of homes (Call, Smith, Morris, Chapman, & Platts-Mills, 1992). These types of studies are only now being conducted in schools, but the same conditions are thought to exist (Tortolero et al., 2002).

Environmental tobacco smoke has been consistently reported to cause increased lower respiratory infections and increased risk for asthma and asthma exacerbations in children (Emerson et al., 1994; A. B. Murray & Morrison, 1989; Overpeck & Moss, 1991; Samet, Cain, & Leaderer, 1991). A study by Cuijpers, Swaen, Wesseling, Stumans, and Wouters (1995) found passive smoking (during a child’s entire life) to be significantly correlated with impairments to all spirometry parameters tested. Smoking in the child’s environment should be eliminated, as it has been shown to be an irritant to airways (Hovell et al., 1994). The National Cooperative Inner-City Asthma Study showed that exposure to environmental tobacco smoke is common among inner-city children with asthma: 59% reported at least one smoker in the home. Additionally, at the study’s baseline testing, 48% of children had a cotinine/creatine ratio above 30 ng/mg, a level of significant exposure to tobacco smoke in the last 24 hours (Kattan et al., 1997).

Irritants include strong odors such as outside air pollution, paint fumes, chalk, perfume, scented talcum powder, hair sprays, and pesticides (A. M. Pope et al., 1993; Swanson & Thompson, 1994). Pesticides must be used with caution in the indoor environment because unsuspected surface contamination of pesticides may occur through air transport through venting ducts, which can become repeated point sources of contamination (U.S. Environmental Protection Agency, 1995). A steady supply of uncontaminated outside air is recommended by many indoor air studies to keep allergens and irritants to a minimum and carbon dioxide levels to less than 1,000 parts per million (Ruhl, Chang, Halpern, & Gershwin, 1993; U.S. Environmental Protection Agency, 1991). The air ventilation recommendations from the 1989 American Society of Heating, Refrigerating, and Air-Conditioning Engineers Standard 62 for classrooms is 15 cubic feet per minute.

To confirm suspected asthma-related environmental conditions in local schools, we conducted environmental surveys in 60 elementary schools and dust sampling and allergen assays in a subsample of 20 schools in a southeast Texas city. Especially high levels of dust-mite allergens and mold were found in many schools, and moderate levels of cockroach allergens were found in some schools. The presence of environmental irritants was also a problem in many schools. Factors that seemed to underlie these conditions included high humidity, poor ventilation, dirty heating, ventilation, and air conditioning systems, and water and carpet damage (Abramson et al., 2000; Tortolero et al., 2002; Tyrrell, 2000).

Eliminating exposure to allergens and irritants has been identified as an important factor in managing asthma in children. Recommendations for control of indoor allergens such as dust mites, cockroaches, and mold include regular vacuum cleaning, washing bedding and stuffed animals weekly and at a high temperature, removing carpet, and reducing humidity. Extensive cleaning and dust-proofing have been shown to reduce asthma symptoms and medication requirements (Bahir et al., 1997; A. B. Murray, 1988; Peroni, Boner, Vallone, Antolini, & Warner, 1994; Sarsfield, Gowland, Toy, & Norman, 1974). Although it has been shown that rigorous measures can reduce allergen levels and symptoms, most of these measures are difficult for families and schools to accomplish. There has been little research on allergens and irritants in inner-city elementary schools or on recommendations for the reduction of these contaminants in the school environment (Dungy, Kozak, Gallup, & Galant, 1986; Neuberger et al., 1991; Norback, Torgen, & Edling, 1990). No studies were available at the time of this program development on school environmental intervention to reduce asthma morbidity. Investigations and recommendations for one elementary school in Kansas City were reported in 1991; however, this investigation focused on sick-building syndrome and did not look at allergens in the school environment, nor were all the irritants investigated specific to asthma (Neuberger et al., 1991).

Asthma Management

The cornerstone of good medical management of asthma is appropriate pharmacological therapy to control the airway inflammation that underlies asthma episodes (Global Initiative for Asthma, 2015; National Heart, Lung, and Blood Institute, 1991; 1997). For acute exacerbation, bronchodilators act quickly to relieve constriction and the accompanying cough, chest tightness, and wheezing. However, bronchodilators are not recommended as the only treatment for persistent moderate to severe asthma (National Heart, Lung, and Blood Institute, 1991). Recent studies strongly suggest that anti-inflammatory agents, particularly inhaled corticosteroids, are the most effective medications in controlling persistent asthma (Britton, Earnshaw, Palmer, & European Study Group, 1992; Djukanovic et al., 1992; Global Initiative for Asthma, 2015; Juniper et al., 1990; Salmeron et al., 1989). In spite of the fact that asthma treatment guidelines from the National Institutes of Health were publicized and widely disseminated to primary care physicians and specialists in 1991 and 1997, there are still misconceptions among physicians about optimal pharmacological therapy; and as a result, anti-inflammatory agents may be underused (Finkelstein et al., 1995; National Heart, Lung, and Blood Institute, 1991; 1997). In particular, Latino and African American children aged one to six years are less likely than non-Hispanic whites to have used either beta agonists or steroids prior to hospitalization for asthma or to be prescribed a nebulizer on discharge (Finkelstein et al., 1995). Inner-city minority children are not very likely to be treated with anti-inflammatory medications; the reported rates vary from 11% to 17% of children with moderate to severe asthma (Homer et al., 1996; Huss et al., 1994; Lieu et al., 1997). Furthermore, even though written action plans with medication schedules and criteria have been shown to be associated with lower rates of hospitalizations and emergency department visits, they are seldom provided to patients and families (Dawson, Van Asperen, Higgins, Sharpe, & Davis,, 1995; Wasilewski et al., 1996).

Many urban minority children with asthma may be unable to obtain appropriate diagnosis or treatment for asthma (Crain et al., 1994). For example, in a survey of Baltimore public school children, 32% of first graders and 43% of sixth graders with asthma had received care in emergency rooms rather than from a consistent primary health care provider (Mak, Johnston, Abbey, & Talamo, 1982). Among African Americans, 44% used the emergency room as the primary source of care compared with 24% of whites, and those using emergency rooms also reported a greater number of school days missed (Mak et al., 1982). P. R. Wood and colleagues (1993) indicated that Mexican American parents were more likely to use emergency department services as the primary source of care than were non-Hispanics.

Even though school nurses are in a position to assist the child and family with adherence to asthma medications and to serve as a liaison with primary healthcare personnel to obtain appropriate care for asthma, their role is largely overlooked by families and physicians. Case-finding data from the Partners in School Asthma Management program showed that 62% of students identified as having asthma or having symptoms of asthma were unknown to the school nurse (Bartholomew et al., 1999). This finding means that a large number of students who develop asthma symptoms during the school day are unable to receive timely treatment to reduce or prevent more serious exacerbations.

Child and family behavior should play a crucial role in asthma management. However, the foregoing discussion should make it clear that, without environmental support, families cannot do their part to manage asthma. In general, families need support to recognize asthma symptoms and to take steps to prevent the onset or escalation of symptoms. These steps include following prescription guidelines for use of routine control (preventive) medications and relief medications for symptoms or episodes; avoiding and controlling indoor and outdoor irritants and allergens; and maintaining a medical care relationship for the primary care of asthma. These behaviors require time and commitment from the child and family. For example, to manage indoor irritants, parents must protect their children from environmental tobacco smoke, and older children must do their part to avoid it. Because children at different ages have different capacities to manage their own daily treatment regimens, another important asthma-management behavior is the transfer of specific responsibilities from parent to child as the child matures.