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The Awesome Asthma School Days Program: Educating Children, Inspiring a Community John R. Meurer, Sue McKenzie, Elaine Mischler, Steve Subichin, Marsha Malloy, Varghese George

ABSTRACT: Program planners developed an educational progruni to improve the health of children nith asthma in grades three to five in Milwaukee ( Wis.) Public Schools. During 1997-1 998, 1,400 students,from 74 elementary schools participated in the Awesome Asthma School Days education program. In a cross-sectional survey, about 40% of children reported play interrupted and sleep disturbed by asthma, more than 50% of children reported exposure to smoke in their home, most children lacked usthma self-care tools, and most children with persistent symptoms did not use an anti-inflammatory inhaler. The educationul program improved students' expectations about normal play and sleep and improved their understanding of asthma. Leaders in Milwaukee used the survey results to develop a community action plan. The educational program, surveys, communiv partner~ships, and strategic plans can be replicated in other schools. (J Sch Health. 1999;69(2):63-68)

sthma is the most common chronic disease of child- A hood, affecting more than 4.8 million children in the United States. Asthma-related illness results in restricted activity, emergency department visits, and hospitalization for many children. Children with asthma have an increased risk of academic problems when compared with well children. Among low-income families, children with asthma have twice the odds of school failure compared with children without asthma.' The costs of asthma for children, families, and society are immense. The total estimated medical cost for persons with asthma in the United States reached $5.8 billion in 1994.2

Because educational init iatives in as thma have contributed to improved disease management by patient^,^ Awesome Asthma School Days was created by Tandem Efforts for Asthma Management, a community partnership in Milwaukee led by the Health Education Center of Wisconsin, Inc. The Center is a nonprofit organization dedicated to fostering healthy lifestyles for people of all ages, especially school-aged children. The facility in down- town Milwaukee uses interactive learning theaters to enhance the educational experience for class attendees. The partners in Tandem Efforts for Asthma Management included school teachers, family members, medical providers, environmental activists, health plan directors, financial supporters, community leaders, and policymakers. A health education program for low-income, central city children with asthma was designed by the partners for implementation in a nonclinical, nonschool setting. The effort was driven by knowledge that health education programs for children with asthma in either clinic or school settings have been effective.' Such programs can improve

John R. Meurer, MD, MM, Assistant Professor, Pediatrics, Medicnl College of Wisconsin, 8701 Wutertown Plank Road, Milwaukee, WI 53226. or <[email protected]>; Sue McKenzie, MEd, former Director of Education, Health Education Center of Wisconsin, Inc., 1533 N. Rivercenter Drive, Milwaukee. WI 53212-3913, or <[email protected]>: Elaine Mischler, MD, Medical Director, Medical Management Services, Wausau Insurunce, 1800 W. Bridge St.. Wausau, WI 54401 -2472; Steve Subichin, MS, MBA, Biostatistician; Marsha Malloy, RN, BSN, MBA, Research Coordinator; and Varghese George, PhD, Medical College of Wisconsin, 8701 Wutertown Plank Road, Milwaukee, WI 53226. The Children's Hospital o f Wisconsin Foundation, Glen and Gertrude Humphrey Foundation, and Primecare Health Plan supported development of Awesome Asthma School Days. This article was submitted September 17, 1998, and accepted for publication November 30, 1998.

asthma self-management and school grades for participating children while decreasing the frequency and duration of their asthma episodes5

The ultimate objective of Awesome Asthma School Days (AASD) was to improve the health and well-being of children with asthma in Milwaukee. Specific aims of AASD were:

1) to identify children with asthma in the Milwaukee (Wis.) Public Schools;

2) to assess the functional and emotional impact of asthma and home management approaches among these children;

3 ) to improve the child's understanding and self- management of asthma;

4) to better control the symptoms and effect of asthma on them; and,

5 ) to establish effective community partnerships in addressing childhood asthma.

The primary premise of this project was that children in Milwaukee (Wis.) Public Schools were adversely affected by asthma and had limited knowledge of asthma self-care. This study tested this hypothesis. A secondary premise was that improved understanding and self-management of asthma would result in improved school attendance and reduced medical care costs. This study did not assess the validity of these assumptions. Overall, AASD planners believed that these problems could be addressed through educational efforts and community partnerships.

This article describes a unique process of teaching children with asthma and the results of surveys of these participating children. The specific roles of community partners in addressing childhood asthma also are addressed. For schools and communities facing similar challenges, this educational approach and strategic plan may be replicated to improve the quality of life of children with asthma and their families.

PROJECT DEVELOPMENT The project was a series of cross-sectional studies.

Seventy-four of 116 elementary schools in the Milwaukee (Wis.) Public School district participated. Students in grades three to five were targeted but some from first through middle school enrolled. Public health nurses in schools identified students with asthma by reviewing emergency cards submitted by parents and other caregivers for

Journal of School Health February 1999, Vol. 69, No. 2 63

school registration. During the 1997-1998 school year, more than 1,400

students participated in the Awesome Asthma School Days education program. Because of an inability to survey all children who participated, and for convenience, the first 488 children enrolled between October 1997 and January 1998 were selected for a series of surveys. This group represented 35% of all participating students and a geographically random sample of all participating schools.

Parents of potential student participants received written information about the program and consent forms for release of Milwaukee (Wis.) Public School medical records and participation in Awesome Asthma School Days. With parental approval, survey results of what the individual children learned in the program were mailed to their primary physicians.

During a regular school day, 60 to 100 students, some school staff, and a few parents attended a three-hour asthma education session at the Primecare Health Education Center. Center construction was supported by Primecare Health Plan, a subsidiary of United Hea l thca re Corporation. Volunteer teachers were recruited from the American Lung Association of Wisconsin, Children’s Hospital of Wisconsin Respiratory Care department, the

Table 1 Functional Impairment

Due to Asthma Reported by 488 Children

Function Impaired by Asthma Children (N) Children (%)

Play or exercise

Sleep disrupted by asthma during most nights 185 38

interrupted by asthma 21 0 43

Table 2 Prevalence of Asthma Activators

or Triggers as Reported by 468 Children

Asthma Activators or Triggers Children (N) Children (%)

Smoke 41 7 Dust 367 Strong smells 279 Cold, dry air 249 Laughing, yelling, or crying 241 Cold or flu symptoms 236 Polluted air 22 1 Animal dander 208 Trees or grass 136

Mold 136 Nervous feelings 99

Exercise 1 a1

89

60 53 51 50 45 44 41 39 29 21

78

Health Education Center, Marquette University School of Nursing, the Medical College of Wisconsin Pediatric Pulmonary Medicine section, and the Sinai Samaritan Medical Center Outpatient Asthma Program.

The program taught children about the definition and pathophysiology of asthma, early warning signs of an exac- erbation, monitoring methods of asthma health, environmental controls, and the roles and use of asthma medications. For example, students were taught that a cough clears mucus, “control” medicines such as inhaled steroids decrease inflammation, and relief medicines such as inhaled albuterol reduce bronchospasm. Students engaged in high technology, interactive learning methods at the Health Education Center. The technology included use of electronic keypads by students providing immediate aggregate analysis of survey responses for display on a multimedia screen. The learning methods included an asthma rap song and an asthma jeopardy game.

Students were surveyed within one week before and immediately after the education session about their experience of asthma symptoms and activatordtriggers, knowledge of monitoring methods such as peak flow meters, environmental controls, and use of asthma medications and spacers. Adults assisted children who had difficulty reading or understanding questions. Public Allies Milwaukee, a team of young volunteers dedicated to community service, also administered surveys to students about three months after the education program.

Most survey questions were developed by a collaborative team of local experts in health education and asthma. Survey contents are noted in the results and tables. Questions specifically about the emotional impact of

Table 3 Lack of Asthma Self-Management Tools

as Reported by 468 Children at Time of Education

Asthma Children Children Self-Management Tools (N) (“/o)

Did not have a spacer for inhaler@) at school Did not use a spacer for inhaler($ at home or at school Did not have a spacer for inhaler@) at home Did not use a “low-allergy’’ pillow cover Did not have a written asthma action plan Did not have a peak flow meter Exposed to someone smoking in the home Did not use an anti-inflammatory inhaler (control for daily symptoms) Did not use a beta-agonist inhaler (relief for acute symptoms)

42 1 90

337 72

239 51

365 78

223 69 304 65

276 59

314 67

94 20

64 Journal of School Health February 1999, Vol. 69, No. 2

asthma were derived from the Feeling Thermometer which provides a good estimate of the value that children place on their asthma health status.6 Children at 7 to 10 years of age likely yield valid information when surveyed about their asthma symptoms and health-related quality of life.’

More than 100 physicians identified by parents as primary care providers for their children received a letter describing the program from four local asthma experts and results of the surveys of their individual patients. For example, the mailing included their specific patient’s responses to questions about play interruption, sleep disturbance, smoke exposure, use of control and relief medications, and use of spacers, peak flow meters, and action plans.

Children’s reports about their knowledge and experience with asthma were measured immediately after education when the response rate was highest and their understanding of the question was most likely to be reliable. For the 20 children who did not complete a survey immediately after education, their responses to the pre-education survey were included in the immediate posteducation survey data set. SAS software was used for statistical analyses. Chisquare test for association was used to analyze the data and to calculate p values for comparisons.*

PROJECT RESULTS Most children completed surveys before and immedi-

ately after education. Within the week before the education program, 454 students completed a preintervention survey. Immediately after the education program, 468 students completed a postintervention survey. Twenty children completed the preintervention survey only and six children completed the postintervention survey only. About three months after the education program, 303 (62% of the 488 analyzed children) completed another postintervention survey.

About two of every five children reported play interrupted and sleep disturbed by asthma (Table 1). During most programs, some students were coughing. Up to one- third of children were emotionally affected by asthma during the week prior to the survey. About one-half of children whose asthma was activated by emotions also experi- enced significant stress in the previous week.

Most children were aware that they were sensitive to smoke (Table 2) and 55% of children reported exposure to

Table 4 Lack of Inhalers as Reported by Children

with Functional Impairments Due to Asthma

Play Sleep Interrupted Disrupted

Asthma by Asthma by Asthma Inhaler Not Used (n = 199) (n = 177)

No anti-inflammatory inhaler (control for daily symptoms) 58% 66%

No beta-agonist inhaler (relief for acute symptoms) 16% 25 %

tobacco smoke in their home. One fifth-grade boy said that he occasionally smoked cigarettes with his parents.

Most children reported they lacked asthma self-management tools that should be made available by a health care provider, especially for children with persistent symptoms (Table 3). Two-thirds of children did not use an anti-inflammatory medicine, the mainstay of asthma control, and some lacked a beta-agonist, the quick relief medication. Most lacked a spacer or holding chamber for medication delivery at home and most had no spacer at school. About two-thirds lacked a written asthma action plan and a peak flow meter to measure lung function. About two-thirds of children with persistent symptoms did not use an anti-inflammatory inhaler which is recommended by a panel of asthma experts convened by the National Institutes of Health (Table 4).’

The educational program improved students’ expectations about normal play and sleep despite asthma (Table 5). It also improved their understanding of asthma medications. In general, Public Allies staff observed that surveyed children enjoyed the educational program and better under- stood asthma self-care. Three months after the program, about one-third of students claimed to have changed their behavior because of Awesome Asthma School Days. Some used anti-inflammatory medicines, others avoided triggers such as smoke, and still others used peak flow meters. For example, after the program, one boy asked his physician for a control medicine that reduced subsequent visits to the school nurse for asthma symptoms. Classmates without asthma and teachers seemed to become more aware of the impact of asthma on the well-being and learning of affected children.

Twenty-seven adults who attended Awesome Asthma

Table 5 Effect of Education on Knowledge

of Asthma as Reported by 350 Children

Knowledge Before After P of Asthma Education Education Value

Students knew they should be able to sleep through the night without

Students knew they should be able to exercise 48% 78% 0.001 Students knew the role of beta-agonist (relief for acute

Students knew the role of anti-inflammatory medicine (control for daily symptoms) 30% 55% 0.001

symptoms 45% 80% 0.001

symptoms) 39% 68% 0.001

Journal of School Health February 1999, Vol. 69. No. 2 65

Table 6 Program Collaborators, Provided Components, and Suggested Components

Program Collaborators Components Provided Suggested Future Components

Health Education Center Led Tandem Efforts for Asthma of Wisconsin, Inc.

Created multimedia components

Entered survey data

Teach school personnel, social service workers, and others in the community about asthma.

Management (TEAM)

of program

Milwaukee Public Schools TEAM member Request action plans from students. Excused students with asthma from Encourage use of asthma tools at school for program. school.

from school to Health Education Center Coordinated transportation of students Study effect of asthma and education

on school absence, grade failure, and sDecial education enrollment.

Public health nurses TEAM member Identified more than 1,400 students with asthma

Parents Approved their child's participation

American Lung of Association of Wis. Children's Hospital of Wisconsin Respiratory Care Health Education Center Marquette University School of Nursing Medical College of Wisconsin Pediatric Pulmonary Medicine Sinai Samaritan Medical Center

TEAM members Volunteer teachers

Teach parents, school teachers, and outreach workers about asthma care

Public Allies Milwaukee TEAM member Volunteered to survey 303 students three months after the program

Center for the Advancement of Urban Children and Health Policy Institute at Medical College of Wisconsin

Analyzed survey data Analyze both parent's and child's knowledge and management of asthma

Community Collaboration for Healthcare Quality

Reviewed findings Improve clinician knowledge about asthma diagnosis and management

Healthy Communities Initiative Reviewed findings Pool resources for more efficient primary care and community-based interventions.

Milwaukee Health Department Reviewed findings Reduce exposure to environmental

Promote asthma action plans Analyze community data about asthma

triggers

Sixteenth Street Community Health Center Reviewed findings

TEAM member Lead community campaign to address environmental triggers of asthma

Primecare Health Plan Supported construction of the Health

Reviewed findings

Educate primary care clinicians about Health Education Center asthma practice guidelines.

Fight Asthma Milwaukee TEAM member Reviewed findings

Sponsor a parent advocacy group, community forums, and camps about asthma care.


School Days at the Health Education Center also completed surveys. Their occupations included teachers, nurses, coun- selors, and aides. They especially valued learning about asthma medications, spacers, and inhaler techniques.

PROJECT IMPLICATIONS Awesome Asthma School Days succeeded in identifying

children with asthma in the Milwaukee (Wis.) Public Schools. It was confirmed that children were adversely affected by asthma and had limited knowledge of asthma self-management. The educational program improved students’ understanding and self-management of asthma.

The reported survey results were consistent with information from other national and local sources that inner city children with asthma need special attention. Children living in central city areas have higher rates of asthma than children living in more affluent areas.’” In Milwaukee, annual asthma hospitalization rates for residents of all ages range between 6 and 20 per 1,000 residents in areas of high childhood poverty and between 2 and 7 per 1,000 residents in areas of low childhood poverty. The federal Healthy People 2000 goal i s 2 as thma hospitalizations per 1 ,000 Americans. l 2

Under-treatment is a major contributor to asthma morbidity. Children not receiving adequate asthma care have poorer development of lung function and more rapid decline in adult lung function than children receiving appropriate treatment.” Most hospitalizations due to asthma are preventable or avoidable if patients receive appropriate primary medical care and specialty care, when indicated.” The quality of ambulatory care, including choice of preven- tive therapies and thresholds for admission, likely plays a key role in determining community hospitalization rates for childhood asthma.I5

The project had some limitations. Survey responses of children were not confirmed by their parents. Qualitative analyses of responses to open-ended questions were not performed. The effect of asthma education on student school absence and parent work absence as well as on emergency department and hospital use was not measured. Studies should be performed to compare school absence, grade failure, and special education enrollment of children with asthma and those without asthma. Such research would be useful to understand if poor health is a reason for academic problems at Milwaukee (Wis.) Public Schools.

COMMUNITY RESPONSE Organizations that collaborated in planning, implement-

ing, or evaluating the educational program are listed in Table 6. Both the major components provided by the participating organizations, a s well a s components suggested by those groups for addition to future educational endeavors are noted in the table.

On June 18, 1998, representatives of community organizations responded to the Awesome Asthma School Days survey findings at a conference with invited guests. Milwaukee (Wis.) Public Schools, public health agencies, health plans, parents and other family members, clinics and hospitals, physicians and other clinicians, and other community leaders were encouraged to use this survey knowledge to help children with asthma to “Breathe Free in Milwaukee.” Their presenters provided a strategic plan for

Milwaukee to improve the health of children with asthma. This plan could be modified and implemented in other communities.

The Chairperson of the Asthma Workgroup for the Community Collaboration for Healthcare Quality, a unique partnership of local hospital systems and health plans led by the Medical Society of Milwaukee, described an initiative to improve provider knowledge about asthma management. The collaboration simplified the National Asthma Education and Prevention Program guidelines 16 and distributed them in May 1998 to more than 2,000 physicians who provide care for patients with asthma in the Milwaukee metropolitan area.

Physicians and other clinicians must address patient’s concerns about their asthma, prescribe daily anti-inflammatory medications for persistent asthma, and provide written action plans for patient self-care at both home and school. Tobacco users must be advised to quit and assisted with a plan to quit.” Clinics and hospitals should conduct asthma education sessions for clinicians, school teachers, and patients about methods to control environmental triggers and techniques for proper use of inhalers and peak flow meters.

A representative of the Healthy Communities Initiative presented the views of an existing civic partnership which has been comprised of hospital systems, the city health department, medical schools, large clinics, and health and social service agencies. The Initiative intends to pool resources to reduce fragmentation and duplication in primary care and in community-based interventions focused on asthma. They may expand Awesome Asthma School Days, fund outreach workers who serve families in partnership with clinicians, sponsor asthma camps for families, and create written information about asthma for Spanish- and Hmong-speaking Milwaukeeans.

The deputy superintendent of Milwaukee schools presented the views of a major urban elementary, middle, and high school system. Students must be healthy to succeed academically. The school system plans to ask students with asthma, with help from their parents and health care providers, to develop action plans with daily and emergency care arrangements. They also will encourage students to bring inhalers, spacers, and peak flow meters to school. School staff will work collaboratively with health professionals to develop teacher-friendly information about asthma recognition and first aid for asthma episodes. The school system will continue to coordinate transportation of students to Awesome Asthma School Days and will provide in-school opportunities for students to participate in follow-up programs such as the American Lung Association Open Airways.

The acting commissioner of the city health department presented the agency’s three major goals to address asthma. The department will reduce exposure to environmental triggers by promoting smoke-free environments, by reducing contamination of homes by cockroaches and dust mites, and by decreasing local contributors to air pollution. They will help families, day care providers, and schools to understand and use individualized asthma action plans with safe self-medication policies. The department also will collect and analyze data needed for community-based continuous quality improvement of asthma care.

The director of environmental health at Sixteenth Street

Journal of School Health February 1999, Vol. 69, No. 2 67

Community Health Center discussed an asthma project led by the major, urban primary care provider. With support from the Environmental Protection Agency, the health center will guide a community-based, sustainable campaign to coordinate asthma self-management plans for children at home, school, and clinics.

A medical director for P r imeca re Health Plan, a subsidiary of United Healthcare Corporation, presented the strategy of a large payer and utilization manager of asthma care providers. The health plan identifies members with asthma who are diagnosed in clinics, referred to specialists, or treated in hospitals. The health maintenance organization arranges home-based education for families affected by asthma. The health plan provides asthma action plan cards with patient-specific information about doctors, nurses, asthma medications, allergies, and peak flow meters. Medical directors of the plan will directly educate primary care clinicians about the Community Collaboration for Healthcare Quality asthma practice guidelines.

Health plans might include spacers, nebulizers, and peak flow meters for use at home(s) and school in durable medical equipment benefits and facilitate asthma equipment distribution through pharmacies, clinics, and emergency departments. They might also offer intensive smoking cessation programs and nicotine replacement ther- apy to families of children with asthma.

The coordinator of Fight Asthma Milwaukee, a family- centered, community-based advocacy group, represented the important perspective of parents and other family members. Fight Asthma Milwaukee will continue to sponsor community forums to teach every family caretaker about care of childhood asthma. A parent advocacy group offers interpersonal support and the power to promote solu- tions to common barriers to care. An advisory committee provides asthma insights and raises public awareness about asthma issues. At Fight Asthma Milwaukee educational programs, family members are encouraged to adhere to medication use prescribed by the child’s doctor or nurse and to visit their clinician at least every six months and soon after every emergency department visit and hospital stay. Family members are urged to prohibit smoking in the home. Smokers are advised to inform friends, family, and coworkers of plans to quit and to ask for emotional support.

CONCLUSION The Awesome Asthma School Days project represents a

relevant initiative for schools and communities. The educational program, survey design, community partnerships,

and strategic plans can be replicated in other locales. These collaborative endeavors require visionary leadership and long-term commitment but the potential benefits for children with asthma and their families are tremendous. H

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