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Asthma agents: monitoring asthma in school.


* To develop an interactive computer-based asthma education program designed to teach children proper inhaler technique, peakflow meter (PFM) use, symptom recognition, and asthma triggers

* To develop an Internet-based asthma monitoring system designed to increase children's daily use of the PFM and to monitor symptoms and school absences


Children enrolled in grades 1-4 at 2 elementary schools with a combined enrollment of 738 students participated in the program with the written consent of their parents or guardians. The schools are located in 2 urban, low-income, predominantly minority school districts each has 1 elementary, 1 middle, and 1 high school. Each district employed 1 full-time nurse for a 37.5-hour workweek. Although both nurses were based at the program schools, they were responsible for student health in all schools within their district, resulting in a nurse to student ratio of 1:1219 in 1 district and 1:1467 in the other district.


The presence of nurses at their schools, computer access in individual classrooms and libraries, and prior participation in a school-based asthma case detection procedure were the criteria for inviting these districts to participate. Although both school districts had participated in a study to assess the validity of a school-based asthma case detection program that determined the prevalence of asthma to be 12.5% within one district and 16.2% within the other, (1) neither school district had ongoing asthma case detection or education programs.


Although the Pediatric Asthma Guidelines recommend daily peakflow monitoring, (2) few children use their PFMs as recommended. To increase children's daily use of a PFM and build children's self-management skills, collaborators developed a computerized educational program and Internet-based monitoring system using constructs from social cognitive theory, principles of self-management, and principles of recognition and reward. The theme "Asthma Agents: Patrolling and Controlling Asthma" was chosen and a prototype educational CD-ROM and Internet monitoring system was developed.

A single, largely minority, urban elementary school agreed to test the prototype program for 4 weeks in May 2002. Twenty children in grades 1-4 participated in this feasibility study. Of these children, 95% were black and 55% were female. The children were identified through a study conducted in 4 urban schools (NHBLI IR01HL65529). Six children had a diagnosis of mild intermittent asthma, 4 were classified as mild persistent asthma, and 10 were classified as moderate persistent asthma. (1)

Two study coordinators worked with the school nurse, the librarian, 13 teachers, and 2 office staff members to implement the program. All staff involved in the project attended a 60-minute coordinator- and investigator-led in-service before program implementation. The in-service provided basic asthma education, instruction in the proper use of the PFM, and asthma action plans. The in-service also included a review of school asthma policies and a demonstration of the computerized education program and Internet-based monitoring system.

Coordinators directed the children through the educational program, set the PFM for each child, and communicated regularly with school staff to answer questions and resolve technical problems. Teachers were responsible for supervising the children's use of the Internet monitoring system using classroom computers and for verifying PFM results. Since computers were also available in the library, the librarian provided backup for absent or busy teachers. The nurse assisted the coordinators with guiding the children through the educational program, helped children who had yellow and red PFM readings follow asthma action plans, and logged in to the computer once a week to report follow-up for low PFM readings. Office staff served as the backup for the nurse when she needed to go to other schools in the district.

Children first viewed a 20-minute, interactive, computerized educational program on a CD-ROM that incorporated clip art, written text, and interactive voice-over of program content. The program explained asthma, its triggers, and proper use of a metered dose inhaler in one module and the use and interpretation of a PFM in a second module. Children responded to a 5-item quiz upon completion of the first module and a 6-item quiz at the end of the second module. Both quizzes provided the children with feedback on their responses and an opportunity to review key points related to incorrect answers. After completing the program, children demonstrated their PFM and inhaler skills to the nurse and received an "asthma agent" badge with stickers representing the educational program concepts of "symptom sleuth," "inhaler certified," "expert meter reader," and "certified agent" (asthma triggers). Each child received a PFM to use in school and a second PFM to use at home. Parents and guardians received educational booklets that communicated and expanded upon the information provided to their children.

Children started using the Internet-based, daily-monitoring program the day after completing the educational program. With each log-in, children reported whether they had used their PFM the previous night and again prior to coming to school. If they answered "yes," they were asked to report whether the zone was red, yellow, or green. The monitoring program then asked the children, "How is your breathing today?" Response choices included fine, coughing, wheezing, or tightness in chest. The program allowed children to report more than one symptom. Children were then prompted to blow into their PFM and record the reading. When a child reported a green zone, the system replied with the message, "Great! Go and play today." When a child reported a yellow or red reading, the system instructed the child to "Stop and talk to an adult." Yellow- and red-zone results generated automatic e-mails to the nurse and study coordinator with PFM results and symptoms. Teachers received training to permit children to log in to the system at the same time once a day to prevent diurnal variation in PFM readings. Children and school staff earned prize points for logging in to the system and completing their respective tasks. Children could exchange points earned over a 10-day period for prizes worth $1-2 or prizes worth $3-5 for 20 days. School staff incentives were mall gift certificates of varying values according to the responsibilities involved and the number of children assisted.

The average educational program test score for the children was 89%. Monitoring program log-ins across all users were steady throughout the project. The percentage of days users logged on averaged 85% for the children, with a range of 51-100%, and 75% for the teachers. Sixty-six percent of children reported using their PFM that morning and 63% the evening before. Ninety-three percent of PFM readings at school were in the green zone, 5% in the yellow, and 2% in the red. Readings taken the previous evening and before coming to school yielded similar results.

Two focus groups conducted with the children indicated that the Asthma Agent theme was popular. Children easily identified monitoring system icons, and they could operate the monitoring system with little assistance. Group members' ability to correctly answer questions about information received during the educational program 4 weeks earlier demonstrated good retention of information. Children also described social networking related to program participation. They reported identifying others in their class or grade who also had asthma, making friends with those schoolmates, and watching out for each other during outdoor activities. Children also reported that the slowness of the Internet-based daily-monitoring system was a frequent problem.

Feedback solicited through one-on-one interviews with school staff indicated that the system was easy to use and caused little interruption during the school day. The nurse appreciated the system's capacity to allow off-site review of daily PFM data. Since she was in the school only a few hours each day, this review cued the nurse to obtain information from office staff for weekly computer reports describing follow-up actions. Teachers and the nurse reported that the Asthma Agent program increased their communication with each other, with the children, and, in some cases, with the child's parent. Teachers and staff also reported increased knowledge about asthma and asthma action plans and increased confidence in responding to an asthma exacerbation. Teachers' recommendations focused on streamlining the Internet monitoring system. For example, the system required teachers who had more than 1 student enrolled in the program to reenter the system to report information for each individual child. Teachers also requested the incorporation of the paper system used to report red- or yellow-PFM reading follow-up into the computer system. In addition, the teachers pointed out that they did not earn prize points when a child was absent and suggested awarding points for reporting absenteeism.

The 80% average rate of student and teacher log-ins was a major problem from the research team's perspective. There were no efforts to encourage teachers and students to log in after the initial training. Theoretically, the prize-point system, developed by human performance management consultants, should have provided sufficient encouragement. High teacher and student absenteeism during the last month of school, partly due to the number of out-of-school field trips and other planned activities, interfered with regular log-ins. Placing the school nurse in the supervisory role also seemed to contribute to the less-than-ideal log-in rate. Since asthma is a health condition, we felt the nurse would be the appropriate person to monitor system use and provide feedback to teachers and students who were not using the system consistently. However, the nurse felt uncomfortable directing teachers to complete program responsibilities because she did not have a supervisory role within the school system.

Following this feasibility study, the program team made a number of modifications, including implementing the teacher recommendations described above. A program revision allowed teachers to monitor absenteeism by logging in to report why a child had not completed a daily log-in. When a child returned to school following an absence, teachers received a prompt requesting a reason for absence. Categories for absences were respiratory or asthma illness, other illness, school activity or field trip, or other. Since confirmation of the validity of children's before- and after-school PFM readings was not possible, those questions were eliminated; questions for children related only to their PFM readings and asthma symptoms while at school. Modification of nurses' reports of PFM follow-up allowed the capture of more details, such as use of rescue medication and emergency services. Finally, the introduction of streaming video into the educational piece offered modeling PFM and inhaler skills for the children. Additionally, children had the option of choosing an African-American male or Caucasian female as their training agent. The synchronization of voice-overs with text addressed the needs of children with lower literacy skills.

In January 2003, a modified 17-week pilot-test program was reintroduced to the school that had participated in the feasibility study and expanded to a second largely minority, urban elementary school. Students whose school health records indicated they had a current physician diagnosis of asthma were identified as participants. Forty-two children in grades 1-4, of which 69% were black and 48% female, participated in the program. Of the 42 children, 20% had participated in the feasibility study. Twenty teachers, 2 nurses, and 6 support staff participated. Children were more likely to choose the agent of their same gender, with 43% of children choosing the black male and 41% choosing the white female. No choice was recorded for 16%. Completion time for the educational program ranged from 15-35 minutes with a median of 20 minutes. Younger students generally took longer. Test scores, based on a child's first attempt to answer questions correctly, ranged from 40-100% with an average of 87.8%.

Figure 1 shows the average weekly log-in rate for the 2 schools, adjusted for children's absences. Children had an overall average weekly log-in rate of 91.3% with a median of 93% and a range of 77-98%. On average, 91.5% of teachers logged on to the system weekly with a median of 86% and a range of 72.5-98.5%. The 2 nurses' combined average was 3.1 log-ins/week. During the 17 weeks, a total of 2695 PFM readings were recorded, of which 94% were in the green zone, 5% yellow, and 1% red. School nurses or school staff verified the accuracy of yellow and red readings, which averaged 10 yellow- or red-zone reports/week. In response to verified low readings, school staff followed the school's asthma policy, which included physician orders and parent or guardian instructions. When the nurses were not in the building, staff reported their actions to the nurse. They used e-mail to notify the nurses of red- and yellow-PFM results, or, the child's teacher contacted the nurses directly.


Overall, 97.4% of PFM readings were accurate. Nurses reported follow-up for 90% of the yellow and red PFM readings. The child's parent or guardian was contacted 15% of the time, medication was given at school 55% of the time, and emergency services were called 2.5% of the time. In other instances, the children rested in the school office or returned to the classroom. All participants remained enrolled in the schools for the duration of the study. The Internet monitoring system documented an average monthly attendance rate of 92.3%. Among the 42 children, there were 290 absences. Children's absences ranged from 0-54 days with a mean of 6.9 (SD = 9.4) and a median of 4 per child. A teacher reported a reason for 45% (n = 131) of the absences. Of these, 24% were due to asthma or respiratory illness, 35% were due to another type of illness, and the remaining 41% were categorized as "other." This program is now being implemented in 35 schools in 5 school systems.


* Limited time for nonacademic programs can hinder implementation of multisession programs in low-income schools.

* A streamlined educational program with a complementary monitoring system that fosters students' development of self-management habits may be a viable alternative to traditional asthma education programs.

* Daily-monitoring systems can be used to obtain information regarding absences but must accommodate school day time constraints.


(1.) Gerald LB, Grad R, Turner-Henson A, et al. Validation of a multistage asthma case-detection procedure for elementary school children. Pediatrics. 2004;114(4):e459-e468.

(2.) National Asthma Education and Prevention Program Expert Panel Report. Guidelines for the Diagnosis and Management of Asthma: Update on Selected Topics. Bethesda, Md: National Heart, Lung, and Blood Institute; 2002.

Joan M. Mangan, PhD, MST, Research Assistant Professor (jmangan@, Lung Health Center, University of Alabama at Birmingham, 618 20th Street South, OHB-Room H138, Birmingham, AL 35233-7337; and Lynn B. Gerald, PhD, MSPH, Associate Professor/Assistant Director (, Lung Health Center, University of Alabama at Birmingham, 618 20th Street South, OHB-Room H138, Birmingham, AL 35249-7337. This study was funded by Blue Cross, Blue Shield of Alabama. First and foremost, the authors would like to thank Sue Envin, CRT, for her insight and dedication as well as the faculty and staff of Midfield and Tarrant Elementary Schools, especially Susan Harvill, Joanne Cain, Valissa Beavis, Shelby Hayes, RN, and Philip Plemons, RN. In addition to implementing the Asthma Agents program, school staff provided constructive feedback to enhance the program. The authors would also like to thank The Blue Cross and Blue Shield of Alabama Caring Foundation; Edward Harris, Jane Maloch, and Jane Yarborough of Blue Cross and Blue Shield of Alabama for their leadership and enthusiasm; Art Roper and Holli Graham of Blue Cross and Blue Shield of Alabama for their creativity and technical support; and Tom Spencer, PhD, of Snowfly, Inc.
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Author:Mangan, Joan M.; Gerald, Lynn B.
Publication:Journal of School Health
Geographic Code:1USA
Date:Aug 1, 2006
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