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

Abstract: Pediatric asthma rates are reaching epidemic proportions, adversely affecting children's quality of life, educational potential, and health care costs, especially those in the inner city. This study evaluated the effectiveness of a school-based asthma case management (CM) approach with medically underserved inner-city children attending Memphis City schools. Fourteen elementary schools with high rates of asthma-related hospital utilization were grouped according to school size, percentage of children with asthma enrolled, and percentage of children eligible for free or reduced-price lunch. Schools were randomized to either a nurse CM intervention or a usual care (UC) condition. The CM group included 115 students; 128 students were in the UC group. A longitudinal design was used to follow students' progress. Students were primarily African-American children diagnosed with asthma. In CM schools, nurse case managers conducted weekly group sessions incorporating the Open Airways curriculum, followed up on students' school absences, and coordinated students' asthma care with families, school personnel, and medical providers. In UC schools, students received routine school nursing services. CM students had fewer school absences than their counterparts in UC schools (mean 4.38 vs 8.18 days, respectively) and experienced significantly fewer emergency department visits (p < .0001) and fewer hospital days (p < .05) than UC students. No such differences existed before program initiation. Replication and follow-up in year 2 showed continued significant improvements. School-based nurse CM can achieve significant improvements in school attendance and medical utilization. (J Sch Health. 2006;76(6):320-324)     

Evaluation and sustainability of the healthy learners asthma initiative

The Healthy Learners Asthma Initiative (HLAI) involved collaboration between Minneapolis Public Schools (MPS), local health care providers/payors, parents, and other partners. The intervention included development of enhanced asthma care in school health offices and clinic performance improvement projects to foster adoption of National Institutes of Health asthma guidelines. Goals were to improve asthma management among school children and reduce asthma-related school absences, hospitalizations, and emergency department visits. The effectiveness evaluation utilized a randomized community trial design with 16 elementary and middle schools matched and randomly assigned to either an intervention or a control group. Outcomes investigated were (a) school health office impacts and (b) school attendance. Data sources included school health office records, district attendance, enrollment, and demographics files. Following implementation of the HLAI, asthma visits to health offices were significantly lower in intervention schools compared to control schools (91 vs 121 visits per 100 students with asthma per month), and intervention schools had greater availability of medication and asthma action plans and more peakflow measurements, asthma education, and parent communication. Clinics initiated significantly more asthma action plans and sent them to MPS. Attendance differences between groups were limited to students who received asthma care through the school health office. Monitoring of asthma management activities provided through school health offices from 2002 to 2005 indicates sustained implementation of enhanced asthma care in schools and increased asthma communication between school, parents, and health care providers.     

Partners in school asthma management: evaluation of a self-management program for children with asthma

The "Partners in School Asthma Management" program for inner-city elementary school children comprises (1) case finding; (2) linkage of school nurses, parents, and clinicians; (3) a computer-based tailored educational program; and (4) school environmental assessment and intervention. Case finding identified 1730 children in 60 elementary schools with probable asthma; 835 (96% Hispanic or African American) joined the study. Baseline, posttest, and follow-up measures of asthma knowledge, self-efficacy, and self-management behavior were obtained from the children, and data on symptoms, emergency department visits, and hospitalizations were obtained from their parents. The schools provided data on grades and absences. Each school had a baseline and follow-up environmental assessment. The children in the intervention group showed greater increases in knowledge, self-efficacy, and some aspects of self-management. No differences between groups were found in health status variables, school performance, attendance, or levels of environmental allergens in schools. In 15 schools, an enhanced intervention allowed children and their parents to meet with a project physician, develop an asthma action plan, and receive a 1-month supply of medication; the project physician then followed up with the child's community physician. Children participating in this enhanced intervention had better school performance and fewer absences than the comparison group. Overall, the program was effective in improving children's asthma self-management but not in improving their health status. While the case-finding, computer-based self-management training program and linkage system were successfully implemented, the program failed in creating needed changes in the medical (action plans by community physicians) and physical environments (reduced school allergen levels) of the children.     

Outcomes for a comprehensive school-based asthma management program

This article describes the evaluation of a comprehensive school-based asthma management program in an inner-city, largely African-American school system. All 54 elementary schools (combined enrollment 13,247 students) from a single urban school system participated in this study. Schools were randomly divided between immediate and delayed intervention programs. The intervention consisted of 3 separate educational programs (for school faculty/staff, students with asthma, and peers without asthma) and medical management for the children with asthma (including an Individual Asthma Action Plan, medications, and peakflow meters). Children with asthma were identified using a case detection program and 736 were enrolled into the intervention study. No significant differences were observed in school absences, grade point average, emergency room visits, or hospitalizations between the immediate and delayed intervention groups. Significant increases in knowledge were observed in the immediate intervention group. This study of a school-based asthma management education and medical intervention program did not show any differences between the intervention and control groups on morbidity outcomes. Our experience leads us to believe that such measures are difficult to impact and are not always reliable. Future researchers should be aware of the problems associated with using such measures. In addition, connecting children with a regular source of health care in this population was difficult. More intensive methods of medical management, such as school-based health centers or supervised asthma therapy, might prove more effective in inner-city schools.     

Validity and recall of information from questionnaires concerning respiratory infections among schoolchildren

The aim of the study was to assess the reliability of questionnaire information on visits to a physician and the use of antibiotics taken for respiratory infections among schoolchildren attending a water-damaged school and a reference group of schoolchildren attending an undamaged school. Two similar questionnaires on respiratory morbidity in two consecutive years were sent to the parents. The information given on the questionnaires was compared with the patient's records of the local health centre. Although the overall total numbers of ambulatory visits in the patients' records and questionnaires seemed to indicate good reliability, a more detailed individual investigation showed poor recall validity from the questionnaires, including a high percentage of unreported visits to the local health centre from both schools. Underreporting was commoner in the control school than in index school. Recall was best for the children who had no visits to a doctor. Use of antibiotics had a better recall than ambulatory visits in both schools. The study indicates that information on health services in questionnaires is not reliable, at least when occurrences in a period of one year or more are evaluated. The use of patient records as a reference of accuracy is also unreliable, unless all the health care services available to the people in the community are covered.     

Playground equipment injuries in a large, urban school district

We studied the epidemiologic features of playground equipment-related injuries occurring in a large, urban school district over a two-year period. Nurses in each of the district's 68 elementary schools completed self-coded reporting forms on all injuries meeting standardized criteria. A total of 511 equipment-related injuries were reported, an incidence of 8.9 injuries per 1,000 student-years. One-fourth of the injuries were severe, and climbing equipment was disproportionately represented among playground equipment associated with injuries. Extreme variability was found among school-specific rates of equipment injury, with schools at the two extremes separated by as much as a 40-fold difference in incidence. Two school characteristics--smaller student enrollments and the presence of alternative educational programs--were significantly associated with higher equipment-related injury rates.     

Study of higher schooling load effect on the health status of schoolchildren]

Higher schooling load, non-observance of school routine, inactivity, etc. have a negative impact on health. The purpose of the study was to determine the impact of intensive training on the health status of schoolchildren. An intensive training college, a physico-mathematical school, a private school-gymnasia were chosen as objects of studies. A general educational school was matched as a control object. In each educational establishment, 180-320 schoolchildren from the 8th-10th forms were examined. The examination ascertained that the schooling load at new-type schools was greater than the standards established. Before going to new-type schools, schoolchildren had a better health status than did the general educational school children of their age; during schooling, worse health was, however, more noticeable in new-type school children than in the matched schoolchildren. A higher schooling load also affects the performance of schoolchildren unfavorably.     

Respiratory Morbidity among Children Following Renovation of a Water-Damaged School

The authors sought to determine whether exposure to molds, resulting from moisture damage in a school, was associated with increased respiratory symptoms and morbidity among schoolchildren and whether the renovation of this building resulted in a decrease in prevalence of respiratory symptoms and morbidity. The study was a follow-up (1-y interval) of children between the ages of 7 and 12 y from two elementary schools in a Finnish suburb. In addition to a questionnaire completed by the parents, the authors assessed the respiratory health of children by examining the health records of a local health center. In the cross-sectional study, the prevalence of symptoms and infections were higher in the exposed group, as were visits to a physician and use of antibiotics. The school was renovated, after which all prevalence decreased and no significant differences remained, except for visits to a physician (according to questionnaire responses). Therefore, moisture damage and exposure to molds increased the indoor air problems of schools and affected the respiratory health of children.     

Respiratory morbidity among children following renovation of a water-damaged school

The authors sought to determine whether exposure to molds, resulting from moisture damage in a school, was associated with increased respiratory symptoms and morbidity among schoolchildren and whether the renovation of this building resulted in a decrease in prevalence of respiratory symptoms and morbidity. The study was a follow-up (1-y interval) of children between the ages of 7 and 12 y from two elementary schools in a Finnish suburb. In addition to a questionnaire completed by the parents, the authors assessed the respiratory health of children by examining the health records of a local health center. In the cross-sectional study, the prevalence of symptoms and infections were higher in the exposed group, as were visits to a physician and use of antibiotics. The school was renovated, after which all prevalence decreased and no significant differences remained, except for visits to a physician (according to questionnaire responses). Therefore, moisture damage and exposure to molds increased the indoor air problems of schools and affected the respiratory health of children.     

Comprehensive Pediculosis Screening Programs for Elementary Schools

Pediculosis (head lice) is a major school and community health problem with an estimated 6-12 million cases annually resulting in $367 million a year in consumer costs, lost parental wages, and school system expenses. The greatest incidence is seen in children ages 5-12; however, the incidence in the 24-36 year old group is increasing due to their exposure to infested children. Developing comprehensive pediculosis screening programs in elementary schools provides an effective method for preventing epidemics from occurring by accomplishing early detection. These programs also promote primary health care and education among elementary schoolchildren, school officials, educators, and parents. An effective program includes screening the entire school three times a year: mid-September, December, and near spring vacation, and enforcing a "No Nit" policy. Establishing a successful approach to control pediculosis results in decreased incidence and transmission, reduced absenteeism, and financial savings for parents and school districts.     

Smoking Policies of Secondary Schools in Arizona

ABSTRACT: The cigarette smoking policies of all accredited secondary schools in Arizona (N = 169) were analyzed in this study. One hundred sixty principals (94.7%) responded to a 16–item questionnaire. Data collected included the existence of a written smoking policy, how students, faculty/staff, and visitors were informed of the policy, the extent to which smoking was permitted on school grounds, the availability of smoking cessation programs and who facilitated those programs, and the inclusion of health education in the school curriculum. Findings indicated a trend toward prohibiting student smoking both during and outside of school hours and restricting faculty/staff smoking to designated areas. However, penalties were imposed only for student violation of the policy. Few schools offered smoking cessation programs and no major differences existed in policy components by school size or the existence of a written policy or health education program. Recommendations to develop or revise smoking policies for secondary schools are offered.     

The incidence of school-related injuries among adolescents in Kaohsiung,Taiwan

Objectives: To determine the incidence of nonfatal school-related injuries in adolescent schoolchildren.Design: Nurses completed a Student Accident Report Form (SARF) on all injuries in schools meeting standardized criteria from September 1995 to June 1996.Setting: Six junior high schools in Kaohsiung city, Taiwan.Subjects: 13,335 adolescents aged 13–15 in six schools.Results: A total of 3,640 injuries were reported among the city’s 13,335 students, for an overall injury rate of 27.3 injuries/100 student years. Injury rates were higher for boys than for girls at all grade levels. The seventh-grade students had the highest incidence rate. Injuries not involving other students accounted for nearly 64% of all injuries. Injuries occurring on the playground/gymnasium and classroom were the two most common types and were more than twice as frequent as injuries occurring in the hall or stairs. Contusions, abrasions, and swelling were the most frequently reported types of injuries. The body sites most frequently injured were the extremities. When exposure time is taken into account, injury rates were higher in the unsupervised areas of the schools.Conclusions: School-related injury incidence among adolescents attending junior high school is higher than has been previously reported and should be recognized as a significant public health problem in Taiwan.     

Impact of a school-based health center on emergency department use by elementary school students

While school-based health centers (SBHC) improve student access to health services, it remains unclear if use of the centers can reduce hospital emergency department visits. This study evaluated the impact of an elementary school SBHC on emergency department visits by children enrolled in the center. Major reasons for visits included trauma (32%), otitis media (15%), upper respiratory infections (9%), and gastroenteritis (6%). Implementation of an elementary SBHC resulted in a significant decrease (p < 0.03) in non-urgent emergency department visits. No difference existed in urgent emergency department visits. Medicaid-insured children were more likely to use the emergency department than privately insured or uninsured children. Reducing emergency department visits can decrease medical costs and support the cost effectiveness of SBHCs.     

A School-Based Clinic for Elementary Schools in Phoenix, Arizona

ABSTRACT: A community hospital, a school district, and a private pediatrician's office collaborated to ensure all children enrolled in five elementary schools had access to health care services. The school nurse at each school identified children needing health care services and obtained parental consent. The school nurse referred children to a nurse practitioner who visited one school each day. School nurses and space in the nurse's office were provided by the school district. The hospital provided a nurse practitioner as well as pharmacy, radiology, laboratory, and emergency department services. The pediatrician as medical director for the program provided vision, training, and community connections, and served as collaborating physician for the nurse practitioner.     

A School-Based Clinic for Elementary Schools in Phoenix, Arizona

ABSTRACT: A community hospital, a school district, and a private pediatrician's office collaborated to ensure all children enrolled in five elementary schools had access to health care services. The school nurse at each school identified children needing health care services and obtained parental consent. The school nurse referred children to a nurse practitioner who visited one school each day. School nurses and space in the nurse's office were provided by the school district. The hospital provided a nurse practitioner as well as pharmacy, radiology, laboratory, and emergency department services. The pediatrician as medical director for the program provided vision, training, and community connections, and served as collaborating physician for the nurse practitioner.     

Prevalence of health-related behaviors among alternative high school students as compared with students attending regular high schools.

PURPOSE: To provide national data on health-risk behaviors of students attending alternative high schools and compare the prevalence of these risk behaviors with data from the 1997 national Youth Risk Behavior Survey. METHODS: The national Youth Risk Behavior Survey uses a three-stage cluster sampling design. Data were collected from 8918 students in alternative high schools in 1998 (ALT-YRBS) and 16,262 students in regular high schools in 1997 (YRBS). The health-risk behaviors addressed include behaviors that contribute to unintentional injuries and violence, tobacco use, alcohol and other drug use, sexual behaviors, unhealthy dietary behaviors, and physical inactivity. A weighing factor was applied to each student record to adjust for nonresponse and varying probabilities of selection. SUDAAN was used to compute 95% confidence intervals, which were considered significant if the 95% confidence intervals did not overlap. RESULTS: Students attending alternative high schools were at significantly greater risk than students in regular high schools for violence-related injury; suicide; human immunodeficiency virus infection or other sexually transmitted diseases; pregnancy; and development of chronic disease related to tobacco use, unhealthy dieting practices, and lack of vigorous activity. CONCLUSIONS: Many students in alternative high schools are at risk for both acute and chronic health problems. Because these youth are still in a school setting, alternative high schools are in a unique position to provide programs to help decrease the prevalence of risk-taking behaviors.     

The PedsQLTM 4.0 as a School Population Health Measure: Feasibility, Reliability, and Validity

Background: The application of health-related quality of life (HRQOL) as a school population health measure may facilitate risk assessment and resource allocation, the tracking of student health at the school and district level, the identification of health disparities among schoolchildren, and the determination of health outcomes from interventions and policy decisions at the school, district, and county level. Objective:To determine the feasibility, reliability, and validity of the 23-item PedsQL^TM 4.0 (Pediatric Quality of Life Inventory^TM) Generic Core Scales as a school population health measure for children and adolescents. Design: Survey conducted in 304 classes at 18 elementary schools, 4 middle schools, and 3 high schools within a large metropolitan school district. Methods:The PedsQL^TM 4.0 Generic Core Scales (Physical, Emotional, Social, School Functioning) were completed by 2437 children ages 8–18 and 4227 parents of children ages 5–18. Results:The PedsQL^TM 4.0 evidenced minimal missing responses, achieved excellent reliability for the Total Scale Score (α = 0.89 child, 0.92, parent report), and distinguished between healthy children and children with chronic health conditions. The PedsQL^TM 4.0 was related to indicators of socioeconomic status (SES) at the school and district level. The PedsQL^TM School Functioning Scale was significantly correlated with standardized achievement scores based on the Stanford 9. Conclusion: The results demonstrate the feasibility, reliability and validity of the PedsQL^TM 4.0 Generic Core Scales as a school population health measure. The implications of measuring HRQOL in schoolchildren at the school, district, and county level for identifying and ameliorating health disparities are discussed.     

Chile: Perspectives in School Health

The leading health problems of children and adolescents in Chile is reviewed. The Chilean educational system and how the system addresses its principal health problems are described. A school health program is described as well as other educational programs designed and developed by nongovernmental institutions which have a smaller coverage. Current research studies regarding growth and development, child morbidity, nutritional level, and mental health studies are reviewed. In addition, principal challenges that include developing more efficient ways of referring children, enriching the curriculum and teacher training, assigning school hours for health teachers, and enlarging coverage of the health care evaluation programs are outlined. Of special importance is developing prevention programs for parents and children using school and community leaders to prevent health problems in areas such as human sexuality education, decision-making, social abilities, and alcohol and drug abuse. Main efforts should be directed toward low-income families and children to improve life conditions.     

Does the School Nurse‐to‐Student Ratio Make a Difference?

Public schools must provide an appropriate education for students with complex health needs. Chronic illnesses such as asthma and diabetes, social morbidities, injuries, and conditions that limit learning such as poor vision commonly affect school-aged children. School nurses often assume a leadership role in providing services for these children. However, although a national standard for school nurse/student ratio has been proposed, little research has examined the relationship between different school nurse-to-student ratios, level of health services provided in schools, and student outcomes. This study examined data in a 21-county region in eastern North Carolina served by a regional school nurse consultant. The school nurse-to-student ratio in these counties ranged from 1:451 to 1:7,440 based on full-time equivalencies. Two systems offered no school nursing services. Data from school years ending in 2000-2002 were considered in the analysis. A significant correlation was found between the increased presence of school nurses and services provided to children with diabetes (r = -.52, p = .000) and asthma (r = -.43, p = .002). Schools with better ratios provided more counseling services to children for social conditions such as depression and unintended pregnancy (r = -.38, p = .006), and more follow-up for school-related injuries (r = -.43, p = .003), and a higher percentage of children with vision problems received follow-up care (r = -.37, p = .007). A case analysis of one school district that experienced a significant improvement in nurse/student ratio over the study period provides further evidence that school nurses make a difference.     

Safety makes sense: a program to prevent unintentional injuries in New York City public schools

Estimates suggesting that 10% to 25% of unintentional injuries to school-aged children occur in and around American schools are alarming. Information from the National Health Information Survey indicates as many as 3.7 million children are injured in schools annually. To address these concerns, The New York Academy of Medicine and the Board of Education of the City of New York in 1998 launched Safety Makes Sense, a multidimensional school-based, injury prevention initiative. The Safety Makes Sense program integrates unintentional injury prevention into comprehensive school health education in elementary and middle school classrooms and is implemented by interdisciplinary teams within a coordinated school health program. The multifaceted program also integrates safety and music education, and includes development of a handbook for teachers and staff, student booklets, staff development training workshops, and evaluation.