The Awesome Asthma School Days Program: Educating Children, Inspiring a Community

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<ul><li><p>The Awesome Asthma School Days Program: Educating Children, Inspiring a Community John R. Meurer, Sue McKenzie, Elaine Mischler, Steve Subichin, Marsha Malloy, Varghese George </p><p>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) </p><p>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 chil- dren. Among low-income families, children with asthma have twice the odds of school failure compared with chil- dren 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 </p><p>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 </p><p>John R. Meurer, MD, MM, Assistant Professor, Pediatrics, Medicnl College of Wisconsin, 8701 Wutertown Plank Road, Milwaukee, WI 53226. or ; Sue McKenzie, MEd, former Director of Education, Health Education Center of Wisconsin, Inc., 1533 N. Rivercenter Drive, Milwaukee. WI 53212-3913, or : 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 develop- ment of Awesome Asthma School Days. This article was submitted September 17, 1998, and accepted for publication November 30, 1998. </p><p>asthma self-management and school grades for participat- ing children while decreasing the frequency and duration of their asthma episodes5 </p><p>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: </p><p>1) to identify children with asthma in the Milwaukee (Wis.) Public Schools; </p><p>2) to assess the functional and emotional impact of asthma and home management approaches among these children; </p><p>3 ) to improve the child's understanding and self- management of asthma; </p><p>4) to better control the symptoms and effect of asthma on them; and, </p><p>5 ) to establish effective community partnerships in addressing childhood asthma. </p><p>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. </p><p>This article describes a unique process of teaching chil- dren with asthma and the results of surveys of these partici- pating 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. </p><p>PROJECT DEVELOPMENT The project was a series of cross-sectional studies. </p><p>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 emer- gency cards submitted by parents and other caregivers for </p><p>Journal of School Health February 1999, Vol. 69, No. 2 63 </p></li><li><p>school registration. During the 1997-1998 school year, more than 1,400 </p><p>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. </p><p>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. </p><p>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, Childrens Hospital of Wisconsin Respiratory Care department, the </p><p>Table 1 Functional Impairment </p><p>Due to Asthma Reported by 488 Children </p><p>Function Impaired by Asthma Children (N) Children (%) </p><p>Play or exercise </p><p>Sleep disrupted by asthma during most nights 185 38 </p><p>interrupted by asthma 21 0 43 </p><p>Table 2 Prevalence of Asthma Activators </p><p>or Triggers as Reported by 468 Children </p><p>Asthma Activators or Triggers Children (N) Children (%) </p><p>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 </p><p>Mold 136 Nervous feelings 99 </p><p>Exercise 1 a1 </p><p>89 </p><p>60 53 51 50 45 44 41 39 29 21 </p><p>78 </p><p>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. </p><p>The program taught children about the definition and pathophysiology of asthma, early warning signs of an exac- erbation, monitoring methods of asthma health, environ- mental 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. </p><p>Students were surveyed within one week before and immediately after the education session about their experi- ence of asthma symptoms and activatordtriggers, knowl- edge 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. </p><p>Most survey questions were developed by a collabora- tive 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 </p><p>Table 3 Lack of Asthma Self-Management Tools </p><p>as Reported by 468 Children at Time of Education </p><p>Asthma Children Children Self-Management Tools (N) (/o) </p><p>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) </p><p>42 1 90 </p><p>337 72 </p><p>239 51 </p><p>365 78 </p><p>223 69 304 65 </p><p>276 59 </p><p>314 67 </p><p>94 20 </p><p>64 Journal of School Health February 1999, Vol. 69, No. 2 </p></li><li><p>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. </p><p>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 exam- ple, the mailing included their specific patients 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. </p><p>Childrens 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.* </p><p>PROJECT RESULTS Most children completed surveys before and immedi- </p><p>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. </p><p>About two of every five children reported play inter- rupted 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 chil- dren whose asthma was activated by emotions also experi- enced significant stress in the previous week. </p><p>Most children were aware that they were sensitive to smoke (Table 2) and 55% of children reported exposure to </p><p>Table 4 Lack of Inhalers as Reported by Children </p><p>with Functional Impairments Due to Asthma </p><p>Play Sleep Interrupted Disrupted </p><p>Asthma by Asthma by Asthma Inhaler Not Used (n = 199) (n = 177) </p><p>No anti-inflammatory inhaler (control for daily symptoms) 58% 66% </p><p>No beta-agonist inhaler (relief for acute symptoms) 16% 25 % </p><p>tobacco smoke in their home. One fifth-grade boy said that he occasionally smoked cigarettes with his parents. </p><p>Most children reported they lacked asthma self-manage- ment 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-inflam- matory 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). </p><p>The educational program improved students expecta- tions about normal play and sleep despite asthma (Table 5). It also improved their understanding of asthma medica- tions. 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. </p><p>Twenty-seven adults who attended Awesome Asthma </p><p>Table 5 Effect of Education on Knowledge </p><p>of Asthma as Reported by 350 Children </p><p>Knowledge Before After P of Asthma Education Education Value </p><p>Students knew they should be able to sleep through the night without </p><p>Students knew they should be able to exercise 48% 78% 0.001 Students knew the role of beta-agon...</p></li></ul>