Asthma: School-Based Self-Management Interventions for Children and Adolescents with Asthma
Findings and Recommendations
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.
The full CPSTF Finding and Rationale Statement and supporting documents for Asthma: School-Based Self-Management Interventions for Children and Adolescents with Asthma are available in The Community Guide Collection on CDC Stacks.
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.
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.
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%).
Summary of Results
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
There was not enough economic evidence to determine cost-effectiveness or cost-benefit for school-based asthma self-management interventions.
The economic review included 8 studies (search period 1995 through May 2020). All monetary values are reported in 2019 U.S. dollars.
Intervention Cost
- The median cost per person was $44 (IQI: $40 to $131), based on eight estimates from seven studies.
- The variation in intervention cost is partly explained by differences in the size of intervention groups, with smaller intervention costs associated with larger groups.
Economic Benefit
- The changes in healthcare cost per person were -$208, $0, and $62, based on estimates from three studies.
Return on Investment
- The return on investment was -1 and -2.5, based on two studies that reported both intervention cost and change in healthcare cost. The negative values indicate intervention cost exceeded the healthcare cost averted.
Applicability
Based on results from the review, the finding should be applicable to U.S. school children and adolescents with asthma.
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?
Implementation Considerations and Resources
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.
- 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.
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.
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 2030 includes the following objectives related to this CPSTF recommendation.