A large, urban school district in Oakland, CA, and its community partners, was able to demonstrate a large-scale system to effectively identify and recruit adolescent students with asthma into appropriate services. The proportion of all middle school students in the targeted schools who took the case identification survey was notably high (92%), as was the proportion of eligible students who participated in the school-based services (83%).
Detailed health outcomes of the Kickin’Asthma
© education program are presented in a separate paper.26
It is worth noting that students who participated experienced significantly fewer symptoms, days with activity limitation, nights of sleep disturbance, and emergency department visits. These results are stronger than those previously published for adolescents participating in school-based asthma programs.19,27
Truly effective public health programs must not only improve outcomes among participants, they must also be able to efficiently identify and engage large numbers of the targeted population.
Schools are logical places to conduct large-scale public health activities because they offer a structured environment for locating and working with a large proportion of a community’s children. Schools often have resources (e.g., meeting space, parental contact information, and nursing staff) not necessarily available elsewhere, and previous studies have found that school-based health education garners higher attendance rates compared to clinic-based programs, particularly in urban settings.28,29
Many school districts have additional interest in addressing asthma, as poorly controlled asthma can impact school attendance, academic performance, and general well being of students.28
Several studies have reported the results of school-based programs aimed at finding students with asthma (case identification) and/or students with asthma symptoms but no asthma diagnosis.4,30–36
However, few studies have investigated the link between school-based case identification and an actual asthma intervention.37
Likewise, few studies have focused on the identification of students with asthma in the secondary schools, an age group with whom many perceive to be more difficult to work compared to elementary school-aged children.17,38
Factors that likely contributed to the success in Oakland include the allowance of flexibility for the schools in the survey completion process, minimization of the burden on teachers, and identification of volunteer school liaisons to help with all facets of the process. Scheduling of classes during nonacademic times facilitated support from school staff. Persistent marketing and recruitment contributed to our success at getting over 83% of eligible students to come to the classes. An engaging curriculum and enjoyable environment likely played a role in retaining students for multiple sessions—nearly 75% of students who enrolled in classes attended at least three out of the four sessions. Self-administration of the surveys by students during school contributed to the high completion rate of the surveys. Furthermore, OUSD administrators allowed a “partial waiver” of parental consent, such that signature was required only if the parent did NOT want the student to participate. If parental consent to take the survey had been required by the UCB Review Board or OUSD, it would have made the estimates of asthma occurrence too imprecise to be useful and would have missed many children who would have participated in the classes. Lastly, the collaborative nature of this community-based undertaking brought in the necessary skills, manpower, expertise, and volunteers to make it possible.
One limitation to the system is that some children at participating schools were not captured by the surveys, including those students who were absent on the survey date and whose teachers did not provide the make-up, and students who transferred into school after the survey date. Those children in the community who are home-schooled, attend private or charter schools, or were not in school at all are not captured.
Some misclassification is to be expected, as is the case with most surveys that rely on self-report. The question as to whether the respondent had ever been diagnosed by a physician with asthma is nearly identical to that used in several other school-based surveys, including the validated asthma prevalence survey developed for the International Study of Asthma and Allergies in Childhood, which is administered to 13- to 14-year-old children.24
The OUSD asthma surveys as well as similar ones done in other settings demonstrate good or very good concordance between adolescent and parental reporting of asthma diagnosis.25,39,40
Children tended to report more symptoms than the parents. Reliability studies have shown mixed results for asthma surveys among children younger than middle school age.41–43
One other limitation of an annual asthma survey, as with any variable disease or condition, is that measures of asthma control vary according to time, particularly with regard to season. The main criteria for initially identifying students with asthma—ever receiving an asthma diagnosis and the experience of symptoms during the previous 12 months—are minimally subject to this natural variation. The variability is most likely to influence which students are designated as higher risk and referred for the more intensive services, although additionally the nurse or health educator had the opportunity to further assess students over a period of 4 weeks.
While CDC recommends school-based case identification
approaches to find students with diagnosed and active asthma, the benefits of population-based case detection
cases of asthma—are unproven.20,31,44
Although previous studies have shown that asthma case detection surveys have high reproducibility, the American Thoracic Society Working Group on Asthma Screening (ATS-WGAS) determined that case detection in schools and other community settings is currently not recommended, citing the inevitable impact of false positives, the lack of evidence of cost-effectiveness, uncertain benefit, and inconsistent access to follow-up clinical care, among other concerns.45
However, surveys administered for asthma case identification purposes, such as those administered at the OUSD, inevitably produce information that can be used to identify individuals with undiagnosed asthma. The ATS-WGAS did not provide recommendations for this particular circumstance. The OUSD and its partners believed it was ethically obligated to inform the parent/guardian of those students who did not report a diagnosis but whose survey responses suggested a particularly high likelihood of having asthma (i.e., “possible asthma”) based on a conservative physician-designed algorithm.
It should also be noted that three OUSD high schools participated during the first 2 years of the program. The survey methodology and curriculum were the same as for the middle schools. Whereas survey response was similar to that of the middle schools, attendance to the onsite asthma education program was substantially lower. It was very difficult to schedule asthma classes in these high schools at a time other than lunch because of increased pressure to have students attend academic classes. We attribute the lower attendance to the observation that many high school students leave campus during lunchtime to eat and socialize and are unwilling to voluntarily attend asthma classes during this time. Although we were able to obtain high attendance during physical education at one high school, we decided to focus on middle schools exclusively.
Several criteria should be considered when deciding whether to implement a survey-based asthma case identification system in a school system.46
The added time and cost of such a system may be most appropriate in school settings with high asthma prevalence and poorly organized, incomplete, or otherwise inaccessible school health records. We suspect that these criteria are true of many school districts around the U.S. It is also crucial that school-based asthma services and/or off-site linkages with asthma case managers or medical providers exist for those students identified as having poorly controlled asthma. Lastly, to effectively optimize local resources, schools and school districts should consider opportunities for partnerships in their communities.47
As a result of the success of this program, and with help from the Coalition, the OUSD has taken steps toward institutionalization of the asthma case identification process. The OUSD School Board passed an asthma policy that requires that the District to maintain an unspecified system for identifying students with current asthma and to designate a nurse to be responsible for asthma-related activities.
As a first step toward improving the existing system, the OUSD Forms Committee added additional asthma questions to the emergency contact forms that are required to be completed by parents during school registration. These new forms allow school personnel to determine whether any student has asthma, whether it is active, and what asthma medications she/he currently uses. Additional questions could not be included because of space considerations and competing priorities. Concurrently, the OUSD has been able to increase parental completion of the emergency contact forms, asthma management plans, and other health forms by improving the appearance and readability of the forms, emphasizing to parents the importance of completing the forms during the registration process, and instructing school nurses and front-office staff to aggressively follow-up with parents who do not complete them. The emergency forms are now being used for asthma case identification at all elementary schools in the OUSD—over 85% of the enrolled students in a random sample of seven schools had an emergency contact form on file at the end of the 2006–2007 school year. Although many of the marginal benefits of the surveys remain, these steps have increased the viability of a sustainable asthma case identification system that the OUSD is able to implement without additional resources or outside support. These efforts have also improved school–parent communication in general and student health surveillance for other conditions besides asthma.
One remaining drawback of the administrative-based case identification system, compared to a survey-based system, is that it does not get the same amount of information about each child’s asthma. Unless additional questions can be added in the future, identifying children with the most poorly controlled asthma will be quite difficult. It is very important for schools to be able to prioritize higher-risk children, particularly in schools with limited resources and high asthma prevalence. Less detailed information also means a greater probability of misclassification. Another drawback is that the information exists in hard copy only and is not centralized in one location. Neither a computerized system, nor the staff to enter the data currently exists, making the information greatly more time consuming to access and to produce reports, such as lists of students or asthma prevalence. Furthermore, it remains to be seen if a nonsurvey-based system will be sufficient for large-scale case identification in the secondary schools where timely completion of the health forms can still be low at many schools. The OUSD continues to make improvements to its administrative infrastructure and will monitor the benefits of both survey-based and administrative-based asthma case identification systems to balance the need for sustainability with the need for high coverage, detailed information, and accessibility.