Asthma: School-Based Self-Management Interventions for Children and Adolescents with Asthma

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Snapshot

Summary of CPSTF Finding

The Community Preventive Services Task Force (CPSTF) recommends school-based asthma self-management interventions to reduce hospitalizations and emergency room visits among children and adolescents with asthma. Evidence shows interventions are effective when delivered by trained school staff, nurses, and health educators in elementary, middle, and high schools serving diverse populations.

When implemented in schools in low-income or minority communities, interventions are likely to promote health equity.

Intervention

School-based self-management interventions for asthma control provide education or counseling to help children and adolescents with asthma learn to do one or more of the following:

Recognize and manage asthma symptoms
Use medications and inhalers properly
Avoid asthma triggers

Interventions may also provide instruction on the following:

Monitoring asthma signs and symptoms
Stress management
Implementing an asthma action plan

Interventions may be delivered to students with asthma in group or individual sessions. Trained facilitators may include nurses, teachers, health educators, or peers, and sessions may be provided at school during or outside of regular school hours. Self-management interventions may be combined with additional asthma control activities directed at school staff, parents, or healthcare providers.

CPSTF Finding and Rationale Statement

Read the full CPSTF Finding and Rationale Statement for details including implementation issues, possible added benefits, potential harms, and evidence gaps.

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What the CPSTF Found

About The Systematic Review

The CPSTF uses recently published systematic reviews to conduct accelerated assessments of interventions that could provide program planners and decision-makers with additional effective options. The following published review was selected and evaluated by a team of specialists in systematic review methods, and in research, practice, and policy related to asthma.

Harris KM, Kneale D, Lasserson TJ, McDonald VM, Grigg J, Thomas J. School-based self-management interventions for asthma in children and adolescents: a mixed methods systematic review. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD011651. DOI:10.1002/14651858.CD011651.pub2

The review included 33 studies (search period through August 28, 2017). The team examined each of the studies included in the systematic review and abstracted supplemental information about study, intervention, and population characteristics.

The CPSTF finding is based on results from the published review, additional information from the included studies, and expert input from team members and the CPSTF.

Context

Schools provide a unique opportunity for asthma control activities. They can educate students, parents, and staff about asthma prevention and control, take steps to remove or reduce asthma triggers, and offer students healthcare services. School-based interventions are an important component of a comprehensive community and health system approach to asthma control.

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement.

The published systematic review included 33 randomized controlled trials. Three of these studies did not measure any of the review’s outcomes of interest and were not included in the CPSTF analysis.

A meta-analysis of 19 studies reported the following effects of school-based self-management interventions:
- Reductions in asthma-related emergency department visits (13 studies)
- Reductions in asthma-related hospitalizations (6 studies)
- Reductions in unplanned visits to a medical provider (5 studies)
- Increases in self-reported asthma-related quality of life (7 studies)
- Mixed results for all causes of school absences (10 studies)
Studies also measured intervention effects on asthma control outcomes. Compared with controls, students in self-management intervention groups reported the following:
- Less need for the use of asthma reliever medications (6 studies)
- Fewer activity limitations (6 studies)
- Little or no change in self-reported day-time or night-time symptoms (12 studies) or measures of lung function (6 studies)

Summary of Economic Evidence

An economic review has not been conducted.

Applicability

Based on results from the review, the finding should be applicable to U.S. school children and adolescents with asthma.

Evidence Gaps

The CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

How effective are these interventions with high school students who have asthma?
How does effectiveness vary between programs set in urban and rural schools? Future studies could inform and provide additional evidence on programs and program components in rural settings.
Does teaching students how to use inhalers and following up with them to ensure proper use have an effect on asthma-related outcomes?
Do additional school policies (e.g. child inhaler possession and use policies, requirements for asthma action plans) improve student self-management practices and overall asthma control?
How does effectiveness vary by asthma severity?

Study Characteristics

Included studies were conducted in the United States (19 studies), Canada (4 studies), Australia (2 studies), the United Kingdom (2 studies), China (1 study), Jordan (1 study), and Spain (1 study).
The published systematic review included 33 randomized controlled trials that assigned groups by student (6 studies) or school (26 studies); one study did not report this information.
Studies included students aged 5 to 10 years (20 studies), 11 to 15 years (14 studies), and 16 years and older (1 study). Most studies were conducted in elementary schools and/or middle schools (21 studies).
Studies most often recruited students by using surveys or announcements (50%), or health records (27%).

Supporting Materials

Analytic Framework

Effectiveness Review

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Logic Model [PDF (Print Only) - 309 kB]
Text Description [PDF - 59 kB]

Summary Evidence Table

A summary evidence table for this Community Guide review is not available because the CPSTF finding is based on the following published systematic review:

Included Studies

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Al-sheyab N, Gallagher R, Crisp J, Shah S. Peer-led education for adolescents with asthma in Jordan: a cluster-randomized controlled trial. Pediatrics 2012;129(1):e106–12.

Atherly A, Nurmagambetov T, Williams S, Griffith M. An economic evaluation of the school-based “power breathing” asthma program. Journal of Asthma 2009;46(6):596–9.

Bartholomew KL, Sockrider M, Abramson SL, Swank PR, Czyzewski DI, Tortolero SR, et al. Partners in school asthma management: evaluation of a self-management program for children with asthma. Journal of School Health 2006;76(6):283–90.

Bruzzese JM, Unikel L, Gallagher R, Evans D, Colland V. Feasibility and impact of a school-based intervention for families of urban adolescents with asthma: results from a randomized pilot trial. Family Process 2008;47(1):95–113.

Bruzzese JM, Stepney C, Gallagher R, Wang J, Petkova E, Evans D. Reducing morbidity and urgent healthcare utilization in urban pre-adolescents with asthma: results of a randomized control trial of asthma: it’s a family affair. American Journal of Respiratory and Critical Care Medicine 2010;181:A2250.

Bruzzese JM, Sheares BJ, Vincent EJ, Du Y, Sadeghi H, Levison MJ, et al. Effects of a school-based intervention for urban adolescents with asthma. A controlled trial. American Journal of Respiratory and Critical Care Medicine 2011;183(8):998–1006.

Cicutto L, Murphy S, Coutts D, O’Rourke J, Lang G, Chapman C, et al. Breaking the access barrier: evaluating an asthma center’s efforts to provide education to children with asthma in schools. Chest 2005;128(4):1928–35.

Cicutto L, To T, Murphy S. A randomized controlled trial of a public health nurse-delivered asthma program to elementary schools. Journal of School Health 2013;83(12):876–84.

Clark NM, Brown R, Joseph CL, Anderson EW, Liu M, Valerio MA. Effects of a comprehensive school-based asthma program on symptoms, parent management, grades, and absenteeism. Chest 2004;125(5):1674–9.

Clark NM, Gong M, Kaciroti N, Yu J, Wu G, Zeng Z, et al. A trial of asthma self-management in Beijing schools. Chronic Illness 2005;1(1):31–8.

Clark NM, Shah S, Dodge JA, Thomas LJ, Andridge RR, Little RJ, et al. An evaluation of asthma interventions for preteen students. Journal of School Health 2010;80(2):80–7.

Gerald LB, Wittich AR, Erwin S, Hains C, Hemstreet MP, Redden D, et al. Outcomes for a comprehensive school based asthma management program. Journal of School Health 2006;76(6):291–6.

Gerald LB, McClure LA, Mangan JM, Harrington KF, Gibson L, Erwin S, et al. Increasing adherence to inhaled steroid therapy among schoolchildren: randomized, controlled trial of school-based supervised asthma therapy. Pediatrics 2009;123(2):466–74.

Henry RL, Gibson PG, Vimpani GV, Francis JL, Hazell J. Randomized controlled trial of a teacher-led asthma education program. Pediatric Pulmonology 2004;38(6):434–42.

Horner SD, Fouladi RT. Improvement of rural children’s asthma self-management by lay health educators. Journal of School Health 2008;78(9):506–13.

Horner SD, Brown A, Brown SA, Rew DL. Enhancing asthma self-management in rural school-aged children: a randomized controlled trial. Journal of Rural Health 2015;32(3):260–8.

Howell KJ. “Quest for the Code”: A Study of a Computer Based Education Program for Children With Asthma [dissertation]. Syracuse University (Thesis). Syracuse: Syracuse University Libraries, 2005.

Kintner EK, Sikorskii A. Randomized clinical trial of a school-based academic and counseling program for older school-age students. Nursing Research 2009;58(5):321–31.

Levy M, Heffner B, Stewart T, Beeman G. The efficacy of asthma case management in an urban school district in reducing school absences and hospitalizations for asthma. Journal of School Health 2006;76(6):320–4.

McCann DC, McWhirter J, Coleman H, Calvert M, Warner JO. A controlled trial of a school-based intervention to improve asthma management. European Respiratory Journal 2006;27(5):921–8.

McGhan SL, Wong E, Jhangri GS, Wells HM, Michaelchuk DR, Boechler VL, et al. Evaluation of an education program for elementary school children with asthma. Journal of Asthma 2003;40(5):523–33.

McGhan SL,Wong E, Sharpe HM,Hessel PA,Mandhane P, Boechler VL, et al. A children’s asthma education program: Roaring Adventures of Puff (RAP) improves quality of life. Canadian Respiratory Journal 2010;17(2):67–73.

Monforte SE, Gleason M, Covar R, Cicutto L, Szelfer SJ. Reducing health disparities for asthma with a school based asthma education program [Abstract]. Journal of Allergy and Clinical Immunology 2012;129:AB41 [156].

Patterson EE, Brennan MP, Linskey KM, Webb DC, Shields MD, Patterson CC, et al. A cluster randomised intervention trial of asthma clubs to improve quality of life in primary school children: the School Care and Asthma Management Project (SCAMP). Archives of Disease in Childhood 2005;90(8):786–91.

Persaud DI, Barnett SE, Weller SC, Baldwin CD, Niebuhr V, McCormick DP. An asthma self-management program for children, including instruction in peak flow monitoring by school nurses. Journal of Asthma 1996;33(1):37–43.

Praena-Crespo M, Fernandez-Truan J, Gálvez-González J, Murillo-Fuentes A, Castro-Gómez L, Cenizo-Benjumea J. Randomised controlled trial of educational intervention directed by physical education teachers in high schools. European Journal of Allergy and Clinical Immunology 2010;65:190–1.

Shah S, Peat JK, Mazurski EJ, Wang H, Sindhusake D, Bruce C, et al. Effect of peer led programme for asthma education in adolescents: cluster randomised controlled trial. BMJ 2001;322(7286):583–5.

Splett PL, Erickson CD, Belseth SB, Jensen C. Evaluation and sustainability of the Healthy Learners Asthma Initiative. Journal of School Health 2006;76(6):276–82.

Srof BJ, Velsor-Friedrich B, Penckofer S. The effects of coping skills training among teens with asthma. Western Journal of Nursing Research 2012;34(8):1043–61.

Velsor-Friedrich B, Pigott T, Srof B. A practitioner-based asthma intervention program with African American inner-city school children. Journal of Pediatric Health Care 2005;19(3):163–71.

*Bruzzese JM, Bonner S, Vincent EJ, Sheares BJ, Mellins RB, Levison MJ, et al. Asthma education: the adolescent experience. Special Issue: Educating and Counseling Children about Physical Health 2004;55(3):396–406.

*Mosnaim GS, Li H, Damitz M, Sharp LK, Li Z, Talati A, et al. Evaluation of the Fight Asthma Now (FAN) program to improve asthma knowledge in urban youth and teenagers. Annals of Allergy, Asthma and Immunology 2011;107(4):310–6.

*Pulcini J, DeSisto MC, McIntyre CL. An intervention to increase the use of Asthma Action Plans in schools: a MASNRN study. Journal of School Nursing 2007;23(3):170–6.

* Three of the studies included in the review conducted by Harris et al. did not measure any of the outcomes of interest to the CPSTF and were excluded from this analysis.

Search Strategies

Refer to the existing systematic review for information about the search strategy:

Considerations for Implementation

The following considerations for implementation are drawn from studies included in the existing evidence review, the broader literature, and expert opinion.

Related CPSTF Recommendation

The CPSTF also recommends school-based health centers based on evidence of effectiveness for a range of student education and health outcomes, including reduced asthma-related emergency department visits and hospitalizations. School-based health centers can provide a useful location for asthma self-management instruction and may be used to identify students with asthma.

Implementation Guidance

Guidance is available to inform implementation of school-based asthma self-management interventions and help schools select from a range of strategies.

The Centers for Disease Control and Prevention (CDC), National Asthma Control Program (NACP) provides resources and tools to foster asthma-friendly schools .
- Strategies for Addressing Asthma in Schools describes actions schools can take [PDF - 6.27 MB] to identify barriers and address environmental triggers.
- Success stories feature ways schools have worked to prevent and control asthma
- The EXHALE technical package [PDF - 760 kB] provides an evidence-based group of strategies to help improve asthma control and inform decision-making in communities, organizations, and states.
CDC Healthy Schools provides information specific to managing asthma at school.
The American Lung Association provides resources based on real-life activities that have been used in U.S. schools, including step-by-step instructions for a long-term asthma management plan in the Asthma-Friendly Schools Initiative Toolkit .
Examples of school-based asthma self-management programs include Open Airways for Schools (OAS) and the Roaring Adventures of Puff . These programs provide educational and interactive approaches (e.g., group discussion guides, stories, games) to promote and improve asthma control.
The American Academy of Allergy Asthma & Immunology offers guidance on components for a comprehensive school-based asthma management program .
The National Asthma Education and Prevention Program offers Managing Asthma: A Guide For Schools [PDF - 1.04 MB]

Asthma Action Plans

Implementing a personalized asthma action plan involves the student, family, and asthma care provider. Encouraging students to work with their healthcare providers to develop an asthma action plan is a common element of self-management instruction. Schools may want to establish policies or practices that encourage or require students with asthma to submit an asthma action plan.

Example actions plans that can be personalized:

Asthma Action Plan resources available on the CDC website provide tools for asthma control that were created following evidence-based guidelines published by the National Institutes of Health . Forms can be printed and completed for immediate use or tailored.
Asthma Action Plan for Home & School [PDF - 68 kB] from the American Academy of Allergy, Asthma, and Immunology.

Additional Considerations

School resources and staff time will likely be required to recruit students with asthma to participate. Schools may send notices to parents or students (e.g., email, fliers), recruit students through school-based health centers, or start with students who have asthma action plans.

Parental consent and provider prescription requirements for self-management training, asthma action plans, and rescue medications vary by school district and can be barriers to full participation.

School-based interventions can be an important component of a comprehensive community and health system approach to asthma control.

Crosswalks

Healthy People 2020

Healthy People 2020 includes the following objectives related to this CPSTF recommendation.

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