Volume 15, No.5, October 2005

Childhood Asthma: Understanding and Addressing the Public Health Problem

Contributors:
Ben Francisco, Nurse Practitioner, University of Missouri Children’s Hospital
Tanna L. Klein, Research Associate, MU Extension – OSEDA

What is Asthma?
Asthma is very common among children, teens and adults. It is a disease that causes the airways of the lungs to be too narrow for normal airflow, especially during exhalation.

Asthma causes trouble breathing that is often worse at night, during exertion, and when viruses are in the airway. The breathing difficulty of asthma might be experienced as:

• Trouble breathing
• Wheezing
• Coughing
• Chest pain
• Chest tightness

Treatment and Control of Asthma
Asthma can be controlled. For most people treatment involves four components: 1) learning about asthma, 2) monitoring symptoms and measuring changes in airflow, 3) reducing contributing factors, including allergens, airway irritants like smoke, and other illnesses that often go along with asthma, such as acid reflux disease, and 4) taking medications to reduce airway swelling and tightness.

Asthma Can Cause Disability
Despite the fact that very effective treatments are available, many school children experience disability due to asthma. Newacheck and Halfon (2000)¹ defined disabling asthma as “long-term reduction in the ability to participate in children’s usual activities, such as attending school and engaging in play.” Newacheck and Halfon (2000) reported a 232 percent increase in disabling asthma from 1960-1998 among school age children. This is far in excess of increases in asthma prevalence (70%) and increases in disability due to other chronic illness in childhood (113%).

Disabling Asthma in U.S Children
Newacheck and Halfon (2000) found that 1.4 percent of U.S. children experienced some degree of disability due to asthma. Asthma was the most common cause of childhood disability. Prevalence of asthma disability was higher among African American children. The odds ratio (OR) was 1.66 among African American children, low income (OR, 1.46), and single parent family children (OR, 1.37).

Causes of Disabling Asthma

• Not diagnosed or treated
• Poor adherence to plan of care
• Inadequate self care skills
• Lack of social support
• Impaired family functioning
• Untreated related illnesses
• Lack of monitoring
• Lack of follow-up care
• Environmental factors- smoke, mold, dust mites, cockroach, pet dander, pollen, etc

Missouri Disabling Asthma Survey
Children’s Hospital has a long history of excellence in the care of children who have asthma. In the spring of 2005 Children’s Hospital researchers developed and sent out the Disabling Asthma Survey to Missouri school nurses to evaluate the impact of asthma on school children. The survey results identified communities where school children experience disabling asthma. Follow-up interviews will be conducted in fall of 2005 with 20 rural school nurses who reported a high rate of disabling asthma among students. Interviews will identify barriers to addressing the needs of students. The purpose of this effort is to develop a long term strategy for providing resources and assistance to rural schools and communities.

In May, Francisco and Konig² surveyed 1,400 Missouri school nurses. The nurses filled out one report for each zip code in which they provided school services. Responses were received from 487 of 669 zip codes. Results were analyzed from 846 school nurses who served 520,000 of the estimated 925,000 Missouri public school students. Map 1 displays those zip codes for which data were received and analyzed. Survey results identified the rate of disabling asthma among students for reporting zip codes. Map 2 identifies 50 Missouri zip codes where the rate was 4-15 times the national average. Both urban and rural areas of high need were identified.

Survey data provided a clear indication of the numbers and location of rural children who experience disability due to asthma. The problem of urban asthma has received a great deal of attention in pediatric asthma research. Most funding for public health interventions aimed at reducing the burden of asthma has also targeted urban asthma. This survey revealed that many rural children experience disabling asthma. Map 3 illustrates the distribution of more than 3,000 rural children with disabling asthma. These data indicate the need for interventions to reduce the burden of asthma among rural children.

School Nurses Are a Key
A national survey³ reported that school nurses are very experienced dealing with asthma. However, US nurses identified the need to improve support for students with asthma at school. In 2000 a survey of Missouri school nurses⁴ found that asthma was the number one health problem for which school nurses wanted more resources. Efforts to respond to that request are paying off. Missouri school nurses are becoming a strategic group working to improve the health of children with asthma and other health problems.

Missouri School Health Initiative
Missouri has a longstanding commitment to improve the health of school children. In 1993 50 percent of Missouri school districts had no school health program. More than 300,000 children did not have access to basic health services at school. However, over the last 12 years the Missouri Department of Health and Senior Services (MDHSS) provided salary support and training to address the lack of health services. Today only seven school districts in Missouri – 680 children – are without school nurses. School nurses are playing a critical role in reducing the burden of asthma.

Nurses’ Role in Asthma Care
With good care, children can avoid serious risks associated with asthma. A high level of functioning is possible. To help children stay well and in the classroom Missouri school nurses monitor the condition of children who have asthma, help children take their medications correctly, promote indoor air quality at school, recognize undiagnosed asthma, and teach children, families, and the school community about asthma. To aid nurses in their efforts, the University of Missouri (MU) has assisted the Missouri Department of Health and Senior Services in the development of nationally recognized resources for school asthma services. Funding has been provided by the Centers for Disease Control and Prevention (CDC).

Asthma Disability & Health Risk
A focus group of Missouri school nurses suggested that some children with disabling asthma are at higher risk for adverse health effects. They recommended addition of a health risk item to the disabling asthma survey to help identify children needing more urgent assistance. (Other children miss school or can not participate in sports, choir, or band due to breathing problems. However, they do not experience serious episodes of asthma that require emergency care or stays in the hospital.) A priority score was calculated for each reporting zip code. Data from the survey allows evaluation of priority scores for disabling asthma by region. Map 4 indicates the location of 40 zip codes in Mid-Missouri with the highest priority scores. These data will guide efforts to improve services for Missouri children with asthma. Some barriers to asthma care at school can be readily addressed; others take time and the coordinated effort of parents, teachers, school administrators, clinicians, and others.

Barriers at School

• Delayed access to quick relief medications
• Lack of a policy for self-administration of breathing Rx
• Environmental – mold, pets, diesel smoke in the classroom
• Lack of asthma awareness among school staff
• Lack of peer education and support for asthma
• Inadequate communication with parents
• Lack of communication with clinicians

Better Local Asthma Resources
Schools are a critical focus of efforts to reduce the burden of childhood asthma. However, other settings are important as well. Asthma Ready Communities™ is an MU strategy for closing service gaps in schools, daycare, primary care, ERs and hospitals, and specialty care. The IMPACT Asthma Development and Outreach Office, Department of Child Health, MU School of Medicine is currently working to inventory county-level asthma resources as part of a statewide effort of the Missouri Asthma Coalition. Schools, hospitals, health departments, and community health coalitions are being contacted to determine how asthma is currently being addressed in 30 rural Missouri counties. Communities have unique strengths, as well as risk factors related to asthma. The asthma inventory will inform efforts to support counties in their efforts to address asthma. Local community efforts will be strengthened by a statewide network for sharing asthma resources. Asthma Ready Communities™ will provide resources and help train asthma educators to meet the needs of Missouri children in a variety of settings.

Community Asthma Factors

• Air quality
• Social support systems
• Disparities
• Cultural factors
• Economic trends
• Health as a shared value

Resources for Day Care Providers An important aspect of social support in communities involves the care of young children. About half of ER visits in Missouri for childhood asthma are for infants and pre-school children under age 5. Many parents and day care workers lack knowledge about asthma. CDC funding, through the MDHSS, will help improve asthma care for these young children. MU staff are developing resources to meet this need. Basic educational materials will be delivered to day care centers by public health nurses who serve as Child Health Consultants (CHC) across the state. CHC already provide training for daycare operators and staff for a range of health topics. A “train-the-trainer” curriculum will equip Missouri CHC to also address asthma.

The Home Environment
The home and family can be a source of great support for children who have asthma. Unfortunately, indoor air quality is sometimes poor. Exposure to tobacco smoke, mold, dust mites, cock roaches, pet dander and other things can make a child’s asthma much worse. A home health visitor trained to identify and remediate these problems and to provide asthma education is sometimes needed. The National Safety Council provides funding and technical assistance to communities who are interested in developing this service.

http://www.nsc.org/ehc/asthma/asthma.pdf

Barriers at Home

• Difficulty establishing treatment routines
• Struggle between households over care
• Disagreement over asthma management
• Smoking, pets, mold, and other triggers
• Cost & complexities of medications and devices
• Family strain - ill caregivers, siblings
• Competing needs and priorities

Assisting Health Care Providers
Most children with asthma receive care in a primary care setting. Basic supplies and routines must be in place to support best practices for asthma care. Excellent training materials are available to help prepare Asthma Ready™ clinics, emergency rooms, pharmacies, and hospitals. Evidence-based curriculum has been developed to: 1) help local health care providers manage asthma by national expert guidelines, 2) improve communication with children and families, and 3) use appropriate billing procedures to ensure fair reimbursement for services.

Health System Barriers

• Inadequate use of anti-inflammatory Rx
• Lack of inhalation instructions
• Infrequent monitoring & visits
• No planning for periodic exacerbations
• Failure to use spirometry to assess airflow
• Allergens not identified, no avoidance plan
• Little education and support for self care, caregiver roles
• Poor phone support, no access during crises

Conclusion
Childhood asthma is a public health problem. Rural and urban children are significantly affected. Many Missouri school children experience disability due to asthma. However, asthma can be controlled and disability can be eliminated. Many community settings are important in efforts to reduce the burden of asthma. Excellent resources are available or under production at MU to support a public health approach to reducing the burden of asthma in Missouri.

Special thanks to: Peggy Gaddy, Missouri Asthma Program Coordinator and Marjorie Cole, State School Nurse Consultant, Missouri Department of Health and Senior Services.

Technical assistance provided by: Daryl Hobbs, Professor Emeritus of Rural Sociology and Senior Research Associate, and Lance Huntley, Research Associate MU Office of Social and Economic Data Analysis (OSEDA).

Funding: The disabling asthma survey and this report were funded in part by: The 2005 Barbara J. & Kenneth L. Levy Nursing Fellowship in honor of Dr. and Mrs. Richard Wallace

References
¹ Newacheck, P. W., & Halfon, N. (2000). Prevalence, impact, and trends in childhood disability due to asthma. Archives of Pediatrics & Adolescent Medicine., 154(3), 287-293
² Francisco, B. D., & Konig, P. (2005). School nurse appraisal of disabling asthma among Missouri school children: University of Missouri. Unpublished study. IRB project 1048936.
³ Report on the results of the asthma awareness survey. ORC by Macro. (2003). Retrieved October 15, 2005 from http://www.nasn.org/resources/asthma_survey.pdf.
⁴ Bachman, J. A., Brennan, P. F., Patrick, T. B., & Cole, M. (2000). A world wide web-based health resource. Survey of Missouri school nurses to determine priority health information resources for schoolhealthlink. Journal of School Nursing., 16(1), 28-33.

Asthma Resources Developed at MU

Caring for Kids with Asthma© Curators University of Missouri, 24 fact sheets for parents and school age children
http://info.muhealth.org/ptedindex/

Evidence-based computer assisted, multimedia instruction for children ages 6-12, IMPACT Asthma Kids CD© Curators University of Missouri
http://impactasthma.missouri.edu/homestuff/demos2.html

Missouri School Asthma Manual (MSAM)
http://www.dhss.mo.gov/asthma/Publications.html

Multimedia Tutorial for the MSAM
http://www.dhss.mo.gov/asthma/Publications.html

Asthma video for Missouri Schools
http://www.dhss.mo.gov/asthma/Publications.html

Missouri School Asthma Kit & Tutorial
franciscob@health.missouri.edu

Notable National Asthma Resources

Best Practices for Health Care Providers
http://www.aaaai.org/members/resources/initiatives/pediatricasthmaguidelines/default.stm

Consumer Information
http://www.aanma.org

Asthma in Children and Adolescents: Knowledge Path; Maternal Child Health, US Department of Health & Human Services
http://www.mchlibrary.info/KnowledgePaths/kp_asthma.html

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