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The free-running asthma screening test: an approach to screening for exercise-induced asthma in rural Alabama.

Vanessa, age 13, is a fish-grade student in a rural school. During asthma screening at her school through this project, a 42% decrease was noted in her post-exercise peak expiratory flow rate (PEFR). A volunteer in the school documented on Vanessa's health record that she had visited the clinic with complaints of "difficulty in breathing" and also had frequent absences. Vanessa is from a single-parent family. Her mother is employed but does not have health insurance and is like many other Americans, among the "working poor." Vanessa was referred for a medical evaluation, and her newly d diagnosed asthma is being managed with medications and preventive measures.

For many children like Vanessa, asthma represents the most common chronic illness during childhood, and it affects twice as many children as do other chronic disorders.[1] An estimated 5% to 10% of children (4 million in the United States), have manifestations of the disorder sometime during childhood.[2,3] Furthermore, asthma incidence, severity, morbidity, and mortality are increasing throughout the world.[4-6] A troubling fact is that approximately 21% of U.S. children and 24% of children in Alabama live in poverty.[7] African-American race, poverty, and living in an inner city correlate with a higher incidence of asthma in children.[8,9]

Health and the ability to learn are fundamental to the overall functioning and well-being of children and youth.[10-12] Children must be healthy to learn, and they and their parents must learn how to be healthy. Because asthma and chronic problems often are multi-faceted, it is important that professionals identify conditions such as asthma and provide education and long-term management. Also, children with asthma require substantial resources, therefore it is essential that their needs be addressed through practice, research, and multi-disciplinary partnerships.

Numerous studies addressed the incidence, socioeconomic impact, psychophysiologic dynamics, and management of asthma. However, little research using objective quantifiable pulmonary function measures has examined exercise-induced asthma (EIA) in school children. This article describes a pilot study using a Free-Running Asthma Screening Test (FRAST) and peak expiratory flow rate (PEFR) measurements in screening 437 school-age children for EIA in rural Alabama.

BACKGROUND

Children and Asthma

Between 1981-1988, the prevalence of asthma among U.S. children increased almost 40%.[13] It is a leading cause of school absenteeism, and children with asthma average 7.2 absences per year compared to the national average of 3.4 absences.[14]

The National Health Interview Survey included data from 17,110 households and compared children who had asthma with children who did not have asthma. The added burden of illness experienced by children with asthma was an additional 10.1 million days missed from school, 12.9 million contacts with physicians, and 200,000 hospitalizations. Further, almost 30% of children with asthma had some limitation in activity compared to 5% of children without asthma.[15] Asthma touches all aspects of the child's life. It impinges on learning, play activities, and psychosocial development of children as well as disrupting family life life.[3,17,18]

The economic burden of asthma also is substantial. In 1990, the cost of illnesses related to asthma was approximately $6.2 billion in direct costs with in-patient hospital services representing the largest expenditure of almost 51.6 billion. Additionally, with the loss of school days, a loss of productivity also occurs which represented indirect costs estimated to approach $1 billion in 1990.[19] Although asthma is a chronic condition that cannot be cured, it can be controlled with proper diagnosis, education, and management. Recognizing the significance of asthma as a serious public health problem, Healthy People 2000 targeted improvements in asthma care as an objective.[14]

Pathophysiology of Asthma

Asthma, sometimes referred to as reactive airway disease, is a chronic lung disease. The Expert Panel of the National Heart, Lung, and Blood Institute National Asthma Education Program 1 characterized asthma in a working definition as 1) airway obstruction that is reversible in most persons, either spontaneously or with treatment, 2) airway inflammation (edema or swelling of bronchi), and 3) increased airway responsiveness to a variety of stimuli. These pathophysiologic changes are more pronounced in younger children because of a smaller airway diameter, increased soft tissue, and vascularity of mucous membranes lining the airways which increase the child's susceptibility to airflow obstruction.

The child's perception of physical symptoms related to these airway changes is an important first step in recognizing early stages of asthma. However, research has indicated a high degree of variability when comparing symptom perceptions of the child with pulmonary function measures and peak expiratory flow rate.[20] Consequently, children may have acute attacks that go unnoticed by parents and teachers.

Although the exact etiology of asthma is complex, hypersensitivity to various "triggers" or stimuli may be a cause of an allergic reaction or exacerbation of asthma. In the school-age child, inhalants appear to be major allergens or triggering factors.[21] The allergic reaction cannot only precipitate an immediate response leading to bronchial obstruction, but may cause a later bronchial obstruction within several hours after the initial stimuli exposure. Further, the child may not be aware of the stimuli that triggered the attack. Because of variation in etiology and onset of episodes, asthma may go undiagnosed.

Exercise-induced asthma (EIA). Exercise is a major non-inhalant trigger of bronchospasm in approximately 90% to 95% of children with asthma.[9] The primary pathophysiological change associated with EIA is smooth muscle constriction rather than airway inflammation. Exercise-induced asthma, also called exercise-induced bronchospasm (constriction or narrowing of the smooth muscle wrapped around the bronchi and bronchioles), occurs minutes after the onset of vigorous activity, and a corresponding decrease occurs in lung function. Bronchospasm reaches its peak approximately 5-10 minutes after the child has ceased the activity and will usually resolve in another 20-30 minutes (Figure 1). It is believed that heat and water loss during exercise cause changes in airway osmolarity with subsequent constriction of airways and bronchospasm.[1] Also, manifestation of a latent phase of EIA occurring 4-12 hours after the initial exacerbation has been addressed in the literature.[9,22]

[Figure 1 ILLUSTRATION OMITTED]

Because children with asthma characteristically have airway irritability, they are predisposed to EIA. In many children, exercise may be the only trigger for an exacerbation of asthma. EIA is characterized by a history of cough, feeling of chest tightness or pain, and decreased endurance during exercise.[1,23]

In a study by Wiems et al,[23] the incidence of EIA was evaluated from a symptom perspective in 88 patients (mean age 12.4 [+ or -] 3.2 years) without heart disease or known asthma who were referred to a pediatric clinic for chest pain. Pulmonary function was assessed before, during, and at intervals after treadmill exercise. EIA, defined as a decrease in FEV[2] or peak expiratory flow rate of [is equal to] 15%, was found in 36 (4%) of the children.

SCHOOL HEALTH SERVICES AND ASTHMA

In the school setting, asthma is of great concern. A national survey conducted by the Office of School Health, University of Colorado Health Sciences Center, revealed that chronic health problems such as asthma ranked as the second most significant problem by elementary school districts.[24] In a recent Iowa study, Williams and McCarthy[25] reported on the frequency of chronic conditions encountered by school nurses in 92 communities. Although nurses cared for a range of chronic conditions, 108 of 109 school nurses identified asthma as the most frequently occurring chronic condition.

The benefits of asthma management in school children are numerous. Studies demonstrated that asthma education in schools can improve the child's health, school attendance, and school performance.[26-28] Schools are accessible to families, have large numbers of children congregated in one site, and therefore are logical cost-effective sites for identification of children with asthma through screening and health history.

Health screening for asthma became popular in the 1950s and 1960s as a means of detecting health problems in schoolchildren without doing a complete history and physical examination. Valinis[29] described screening as the "presumptive identification of unrecognized disease or defect by the application of tests, examinations, or other procedures that can be applied rapidly and inexpensively to populations". Presently, screening for illness is the major component of most school health programs, although health screening requirements vary by state. Because well children are being screened and a potential economic and psychological cost exists, the benefits versus the costs to both child and society should be weighed and consideration given to scientific, social, ethical, and cost benefit issues.

An issue to be addressed is whether a screening program for asthma in general populations or even high-risk populations is justifiable. Although the importance of asthma management and education is receiving increased attention, asthma is not included in most screening programs, for school systems and school nurses already are burdened with many expectations and few resources. However, timely recognition of early indicators of asthma is basic to reduction of asthma morbidity.

When considering screening for asthma in the school setting, a question often arises: "Does asthma screening meet essential criteria for a school screening program?" Criteria for screening suggested by Nadar[30] and Valanis[29] offered a useful framework for preliminary dicision-making in this project. Table 1 shows a comparison of EIA screening with basic criteria for screening. From a scientific perspective, quantitative pulmonary function measures are available for screening. An exercise-challenge using a free-running exercise screening test and peak expiratory flow rates are valid measures of exercise-induced asthma.' However, the issue is not only a matter of identification of asthma, but appropriate referral and management.

Table 1 A Comparison of Exercise-lnduced Asthma with Essential Criteria for Screening[29,30]
Criteria                                    Exercise-Induced Asthma (EIA)
1. Disease: Must have high prevalence       Incidence, morbidity,
of undetected disease, high morbidity,      and cost of asthma on the
mortality, cost.                            increase.

2. Screening test: Test has high            Peak expiratory flow rate (PEFR)
detection rate and specificity. Test        is accurate, timed-volume
should detect disease at early stage        measure of pulmonary function.[1]
before child is symptomatic.

3. Screener: Individual doing screening     Screening device is
must be well-trained and experienced.       user-friendly. Accuracy
                                            contingent on screener's ability

4. Treatment: Available treatment will      Effective asthma treatment and
effectively prevent or reduce morbidity     control regimen are available.
of disease and is acceptable to clients.

5. Population being screened: Screening     Asthma incidence in school
should be directed to groups with high      population is high (6% to
prevalence of disease.                      10%, 4 million in United
                                            States)

6. Referral and treatment: Follow-up        Availability of services for
diagnosis and treatment for those           referral and treatment varies
positive on screening.                      dependent on locale.

7. Cost/benefit ratio: Costs include all    Screening with peak flow meters
screening, referral, treatment, and         is relatively inexpensive (actual
administrative costs, and emotional         cost per child in numbers >100 =
costs associated with false positives.      $.20 per child). Benifits is great
Benifits refers to reduction in morbidity.  from reduced morbility.

8. Quality/efficacy of program: Systematic  Additional research is needed
review and research determines              on referral and treatment to
screening effectiveness.                    validate effectiveness.
$.20 per child). Benefit is great
from reduced morbidity.




The cost-benefit criterion is of importance. Peak flow meters and disposable mouthpieces will need to be purchased. Pharmaceutical companies may donate or sell the equipment at a discounted rate. There also are costs related to time and personnel involved in screening. However,pulmonary function screening of children in the school setting offers numerous benefits which include: 1) early identification and management of EIA, 2) facilitation of the child's participation in sport activities by using a FRAST or exercise-challenge and peak expiratory flow rate (PEFR) measurements to determine need for treatment, 3) provision of guidance for school personnel when a child has episodes of asthma at school, 4) education of families in monitoring respiratory status and initiating prompt treatment, and 5) collection of research data relative to EIA in the school setting.

THE ASTHMA SCREENING PROJECT

A major factor prerequisite to an effective asthma screening program involves availability of professionals to coordinate the program. School sites selected for this screening project were located in Alabama where school nurses are not mandated. There were two school nurses for 18,103 students in the county selected for this study. Time constraints are immense, therefore screening is limited to vision, hearing, and scoliosis programs which are required by the state.

The primary aim of the project was to identify children with or at risk for EIA using an exercise-challenge and peak expiratory flow rate measures as a screening test. The children attended schools located in a medically underserved area. For the purpose of this project, exercise-induced asthma was defined as a [is greater than or equal to] 2 15% decrease in PEFR following a four-minute free-running exercise.Three questions were posed: What percentage of children screened experience a decrease ([is greater than or equal to] 15%) in peak expiratory flow rate (PEFR) measurements following a free-run exercise challenge? Does a relationship exist between demographic variables of poverty, school absences, and exercise-induced-asthma (EIA)? Can a free running asthma screening test (FRAST) identify children with exercise-induced asthma (EIA)?

Project Participants

A descriptive design was used to address the preceding questions. A convenience sample consisted of 437 children, ages 10-13 (M = 11.2 years), representing diverse populations who attended three rural Alabama schools. Protocol for use of human subjects was followed, and the project was reviewed and approved by the university institutional review board. Permission for screening was obtained from the school board, superintendent of schools, principals, and parents. Asthma screening was conducted during the physical education time period, but teachers did not participate. Data were collected outdoors in similar environmental conditions with the exception of one school where screening was conducted in the gymnasium due to inclement weather. Children with abnormal peak flow results were rescreened, and were referred to physicians for further evaluation.

Screening Instrumentation

A four-minute free running asthma screening test was used to assess the child's response to exercise. Pulmonary function was measured with a peak flow meter.

Free-running asthma screening test. An exercise challenge, in the form of a four- to eight-minute free running test, provides a reliable measure and screening tool to identify EIA, because ventilation during exercise produces airway thermal changes conductive to obstruction of the bronchial airway. Exercise of four to eight minutes can lead to a 50% or greater increase of the individual's predicted oxygen consumption.[1] The exercise challenge may be formal or informal and indoors or outdoors depending on the circumstances.

Peak expiratory flow measurement. In analyzing lung function, the vital capacity (VC) is the most important volume measure to assess the child's effort and the presence of a restrictive component to the disease. The peak expiratory rate (PEFR) measure correlates with forced expiratory volume (FEY) measured by spirometry.[1] The peak flow meter is a small hand-held device calibrated in liters per minute to measure maximum air flow velocity produced with a short forced expiration. The PEFR is the maximum flow rate that can be generated during a forced expiration.

The peak flow meter offers a simple and quantifiable measure of airway obstruction during an exercise challenge. Additional advantages of the peak flow meter are portability and low cost. However, a limitation is that it measures only large airway obstruction. As a result, children with mild asthma whose pathophysiologic abnormalities are linked to small airways may go unrecognized.

Screening Procedures

A "train the trainers" model was implemented to prepare college of nursing faculty and nursing students for the screening initiative. A registered nurse from the Comprehensive Asthma Center conducted an afternoon workshop for faculty on PEFR measurement. Faculty then taught students the procedure for PEFR measurement in the college laboratory. Six faculty, one graduate student, 104 nursing students, and one school nurse participated in the screening project which extended over seven months in 1994- 1995.

Written guidelines including steps of the screening process were provided for each faculty and nursing student. Immediately prior to actual screening, faculty and students collected demographic data. Additionally, children were asked 1) how they felt on the day of screening, 2) whether they had a history of asthma, and 3) if they used an inhaler or took medications. Health records also were searched for additional information related to the child's history. Any child not feeling well or having a respiratory problem was excluded from the testing to increase specificity of data. For infection control, children had their own disposable mouthpieces.

A four-minute free-running asthma screening test (FRAST) then was initiated. Children were coached in proper use of the peak flow meter to obtain their personal best effort and also to ascertain that they exhaled rather than inhaled into the peak flow meter. Additionally, they were monitored carefully by nursing students during the exercise challenge. A nursing student was stationed at each end of the course to observe for any signs of respiratory distress during the free running.

Three forced expiratory measurements were taken on a peak flow meter both prior to and immediately following the free running exercise challenge. The peak expiratory flow rate measurements were recorded on a flow sheet. A major consideration during data collection was that the measure was effort-dependent, for the child must be willing and able to exhale as hard as possible in a short exhalation each time to obtain valid measurements.

Predicted values of PEFR were based on the height, age, and gender of the child. An abnormal value was determined by a percentage decrease [is greater than or equal to] 15% in the personal best post-exercise measures. The use of 15% as a criterion for an abnormal PEFR was a conservative measure, for any value over 12% is considered indicative of EIA.[1] Parents of children with abnormal screening results were notified by the school nurse. Health records also were searched for additional information related to these children. Two make-up dates were scheduled for rescreening.

PROJECT FINDINGS

Data were analyzed descriptively. There were 216 females and 221 males in the sample population. The pre-exercise and post-exercise personal best measures were noted. From the data it was determined that 25 (5.7%) of the 437 children screened had exercise intolerance as evidenced by a [is greater than or equal to] 15% decrease in personal best PEFR measures during post-exercise testing. Of the 25 children, 3 (12%) had reported a diagnosis of asthma and seven had a history of asthma according to the school nurse.

Although the project focused only on the exercise-induced manifestations of asthma, findings were consistent with the incidence of asthma from all causes/triggers.[2,3] More females (n = 14) than males (n = 11) had post-exercise PEFRs consistent with EIA. However, a salient finding was that 17 (68%) of the 25 students in the exercise intolerance group lived in poverty (determined by Medicaid eligibility), as compared with 81 of 412 (19.7%) of the children with normal screening results (Table 2). Absences for the children with EIA was higher. They had missed 6.2 days per school year which is a higher incidence than the national mean of 3.4 days per year.
Table 2
Description of Sample

                          Gender
                Size   Female   Male      Age
Subjects        (N)    f(%)     f(%)   M       SD
Total sample    437    216      221    11.08   1.37

Exercise-
intolerance
group            25     14        11   11.36   1.47

                  Asthma
                  Diagnosis   Inhaler Use
                  By Report   By Report
Subjects          f(%)        f(%)
Total sample      24 (5.49)   14 (3.2)

Exercise-
intolerance       3 (12.0)    3 (12.0)
group




Examining data from a less conservative measure of a [is greater than] 12% mean change in PEFR revealed that 35 (8.0%) of children had results indicative of EIA. This finding represents an increase of 10 (40%) with EIA using the less conservative measure (Table 3).

Table 3 Children with PEFR Decreases (Exercise-intolerance) in FRAST
                                                  Subjects Size (N)
Measure                                                f(%)
Pre-exercise to post-exercise personal best
decrease [is greater than or equal to] 15%            25 (5.7)

Pre-exercise to post-exercise personal best
decrease [is greater than or equal to] 12%            35 (8.0)

                                                     Gender
                                                Female     Male
Measure                                         (f)        f(%)
Pre-exercise to post-exercise personal best
decrease [is greater than or equal to] 15%      18(72.0)    7(28.0)

Pre-exercise to post-exercise personal best
decrease [is greater than or equal to] 12%      24(68.0)   11(31.4)




However, project findings must be interpreted cautiously because data were collected by a large number of individuals leading to potential reliability flaws during the procedure. Another confounding variable is that children are not always the best historians in relating their health histories relative to asthma, allergies, and treatment. Also, there was both conflicting data and a paucity of information on the student's health record in the school office. Further, data collectors had to rely on the child's ability to use a peak flow meter for the screening procedure. Additional factors included difficulty in obtaining permission slips from parents and guardians for the rescreening, and inability to locate children for rescreening when they transferred to other schools or left the state.

Prevalence of asthma. Although findings mirrored an incidence of asthma consistent with national statistics,[2,3,14,17] several factors should be considered when interpreting results. First, the screening was limited to asthma induced by exercise, because it can easily be identified through quantitative measurement. The incidence of asthma would most likely be higher if the many other triggers that precipitate an episode of asthma were investigated. Second, a conservative measure for abnormal PEFR results was set to allow for possible error in measurement. A secondary analysis of data using a less conservative but acceptable value for abnormality revealed a higher incidence of EIA. Third, if screening were targeted to high-risk populations, inner-city African Americans and children from low-income groups, the incidence most likely would be greater. With few provisions in school district budgets for elective screening of general populations for asthma, a cost-effective first step would be to screen high-risk populations.

Poverty, absenteeism, and asthma. A finding consistent with asthma research reported in the literature was the high percentage of children with exercise-induced asthma who were living below the federal poverty level. Further, children with EIA had more absences than the national average. This finding also supports the correlation of absences with a history of asthma found in the literature. These findings offer a compelling argument for school-based health services that include identification, education, and management of asthma.

Free-running asthma screening test. Findings supported use of an exercise-challenge with peak expiratory flow rate measurements as an approach to screening for asthma. This project identified a 6% incidence of asthma induced by exercise which is consistent with national averages.

PROJECT IMPLICATIONS

Because asthma is a reversible airway disease, and effective treatment regimens are available, it is incumbent upon health professionals to focus more effort on case-finding and follow-up. From a school health perspective, evidence supports expanding school health services to include asthma screening, especially in high-risk populations.

Use of a free-running asthma screening test (FRAST) with peak expiratory flow rate (PEFR) measurement offers a simple quantifiable approach for identifying children with EIA and initiating early treatment, education, and management. From a research perspective, data would be more informative if repeat PEFR measures were done at five-minute intervals for 15 minutes after the exercise challenge. Repeat measures were not feasible in this project because of the large numbers of children and time constraints.

It is important that additional research be conducted to validate sensitivity and specificity of the screening test. Further, data relative to indoor and outdoor environmental factors such as tobacco smoke exposure, cockroach infestation, pesticide use, and pollutants should be collected and analyzed to assist in guiding educational and asthma management programs. Likewise, a social and ethical concern associated with asthma, as well as other screening programs involves follow-up, referral, and treatment of children ineligible for Medicaid who do not have health insurance.

The screening and data collection process confirmed a need for more school nurses and support personnel for school health programs. School nurses often travel great distances in rural settings, and they have difficulty recruiting health assistants to perform the basic required screening. Use of trained volunteers and nursing students provide excellent resources for a systematic approach to facilitating and expanding health screening, but cost-benefit aspects should be more closely examined in future studies.

Likewise, data obtained through screening and in the maintenance of health records provide a compelling argument for more a comprehensive, accurate, and streamlined approach to managing information. The introduction of technology, and the education of school nurses and support personnel in use of computer information systems, are fundamental to increasing preventive health services in schools. A computerized information system provides comprehensive and accurate record keeping as well as efficient follow-up and treatment. Both school nurses and teachers could facilitate the child's participation in activities, if current, accurate, and complete health records were maintained relative to asthma. Premedication before exercise may avert an exacerbation of asthma and even hospitalization. Family education is a vehicle for controlling the asthma and promoting normalization of the child's life. Also, a screening program in high-risk populations could reduce morbidity, hospitalizations, visits to physicians, and absenteeism.

CONCLUSION

Traditionally, school health programs have been poorly defined, fragmented, and inadequately funded. Changes in the policy environment and reconfiguration of health services are needed to increase preventive services to children. As Igoe[31] asserted, "It is crucial that schools remain a central location for providing population-focused prevention and health promotion instruction, services, and events for all students" (page 34). Further, it is imperative that school nurses and school personnel be advocates for school health, keeping in mind that schools are optimal locations for promotion and delivery of affordable preventive care to children.

Screening programs for asthma provide strategies for attaining the Healthy People 2000 objectives[32] and can play a significant role in accomplishing the objective, "Achieve access to preventive services for all Americans."[31] Although school-age children are relatively healthy. problem identification and follow-up of asthma are integral to optimizing school functioning. Health promotion through screening and appropriate referral are powerful forces for achieving healthy children and empowering them for their educational journey.

References

[1.] National Heart, Lung, and Blood Institute National Asthma Education Program. Expert panel report: Guidelines for the diagnosis and management of asthma. J Allergy Clin Immunol. 1991 ;88:427-534.

[2.] Murphy S, Kelly W. Asthma, inflammation, and airway hyper-responsiveness in children. Current Opinion in Pediatrics. 1993;5:255265.

[3.] Newacheck PW, Taylor WR. Childhood chronic illness: Prevalence seventy, and impact. Am J Public Health. 1992;82:364-370.

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[6.] Ryan-Wenger N, Walsh M. Children's perspectives on coping with asthma. Pediatr Nurs. 1994;20:224-225.

[7.] Anne E Casey Foundation. Kids Count Data Book. Baltimore, Md: Anne E Casey Foundation; 1995.

[8.] Mak H, Johnston P, Abbey H, Talamo RC. Prevalence of asthma and health service utilization of asthmatic children in an inner city. J Allergy Clin Immunol. 1982;70:367-372.

[9.] Murphy SJ, Kelly WH. Advances in the management of acute asthma in children. Pediatrics Rev. 1996;17:227-234.

[10.] Center for Health Economics Research. Access to Health Care: Key Indicators for Policy. Princeton, NJ: Robert Wood Johnson Foundation; 1993.

[11.] Klerman L. School absence - a health perspective. Pediatr Clin North Am. 1988;35:1253-1269.

[12.] National Health Education Consortium. Creating Sound Minds: Health and Education Working Together. Washington, DC: National Health Education Consortium; 1992.

[13.] Weitzman M, Gortmaker SL, Sobol AM, Perrin JM. Recent trends in the prevalence and severity of childhood asthma. JAMA. 1992;268:2673-2677.

[14.] Taggart VS, Fulwood R. Youth health report card: Asthma. Prev Med. 1993;22:579-584.

[15.] Taylor WR, Newacheck PW. Impact of childhood asthma on health. Pediatrics. 1992;90:657-662.

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[17.] Fowler ML, Davenport JG, Garg R. School functioning of US children with asthma. Pediatrics. 1992;90:939-944.

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[19.] Weiss KB, Gergen, MPH, Hodgson, TA. An economic evaluation of asthma in the United States. N Engl J Med. 1992;326:862-866.

[20.] Fritz, GK, Klein, RB, Overholser, JC. Accuracy of symptom perception in childhood asthma. Develop Behav Pediatr. 1990;11:69-73.

[21.] Nelson HS. The atopic diseases. Annu Allergy. 1985;55:441-447.

[22.] McFadden ER. Exercise and asthma. N Engl J Med. 1987;317:502-504.

[23.] Wiens L, Sabath R, Ewing L, Gowdamarajan R, Portnoy J, Scagliotti D. Chest pain in otherwise healthy children and adolescents is frequently caused by exercise induced asthma. Pediatrics. 1982;90:350353.

[24.] Davis M, Fryer GE, White S, Igoe, JB. A Closer Look: A Report of Select Findings from the National School Health Survey. Denver, Colo: University of Colorado School of Nursing, Office of School Health; 1995.

[25.] Williams JK, McCarthy AM, School nurses' experiences with children with chronic conditions. J Sch Health. 1995;65:234-236.

[26.] Capen CL, Dedlow ER, Robillard RH, Fuller BM, Fuller CP. The team approach to pediatric asthma education. Pediatr Nurs. 1994;20:231-237.

[27.] Evans D, Clark NM, Feldman CH, Rips J, Kaplan D, Levison MJ, et al. A school health education program for children with asthma aged 811 years. Health Educ Q. 1987;(Fall):267-269.

[28.] Mellins RB. Patient education is key to successful management of asthma. J Rev Respir Dis. 1989;(suppl):547-552.

[29.] Valanis B. Epidemiology in Nursing and Health Care. Norwalk, Conn: Appleton-Century-Crofts; 1986:327.

[30.] Nadar PR. School Health Policy and Practice. Elk Grove Village, III: American Academy of Pediatrics; 1993

[31.] Igoe JB. School health: Designing the policy environment through understanding. Nurs Pol Forum. 1995;1(3):10-13,30-36.

[32.] US Dept of Health and Human Services. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: US Dept of Health and Human Services publication PHS 91-50212; 1991.

Doris J. Heaman, DSN, RN, Associate Professor; and Jenny Estes, EdD, RN, Assistant Professor, College of Nursing, The University of Alabama in Huntsville, Huntsville, AL 35899. This research project was funded in part by a University of Alabama in Huntsville Mini-Grant. This article was submitted July 15, 1996, and revised and accepted for publication December 23, 1996.
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Publication:Journal of School Health
Date:Mar 1, 1997
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