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Keywords:

  • asthma;
  • cognition;
  • school connectedness;
  • school absenteeism;
  • child and adolescent health;
  • coordinated school health programs;
  • academic achievement;
  • achievement gap;
  • socioeconomic factors

Abstract

  1. Top of page
  2. Abstract
  3. OVERVIEW AND DISPARITIES
  4. CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES
  5. WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?
  6. PROVEN OR PROMISING APPROACHES
  7. SUMMARY
  8. REFERENCES

OBJECTIVES: To outline the prevalence and disparities of asthma among school-aged urban minority youth, causal pathways through which poorly controlled asthma adversely affects academic achievement, and proven or promising approaches for schools to address these problems.

METHODS: Literature review.

RESULTS: Asthma is the most common chronic disease affecting youth in the United States; almost 10 million youth under 18 (14%) have received a diagnosis and 6.8 million (9%) have active asthma. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs. 8.8%), as were average annual estimates of asthma attacks (8.4% vs. 5.8%). Urban minority youth have highly elevated prevalence of poorly controlled asthma as evidenced by overuse of emergency departments and under-use of efficacious medications. Poorly controlled asthma has functional consequences on cognition, connectedness with school, and absenteeism. Exemplary asthma programs include management and support systems, school health and mental health services, asthma education, healthy school environments, physical education and activity, and coordination of school, family, and community efforts.

CONCLUSIONS: Asthma and, more importantly, poorly controlled asthma are highly and disproportionately prevalent among school-aged urban minority youth, has a negative impact on academic achievement through its effects on cognition, school connectedness, and absenteeism, and effective practices are available for schools to address this problem. To reduce the adverse effects of poorly controlled asthma on learning, a multifaceted approach to asthma control and prevention in which schools can and must play a central role is essential.


OVERVIEW AND DISPARITIES

  1. Top of page
  2. Abstract
  3. OVERVIEW AND DISPARITIES
  4. CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES
  5. WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?
  6. PROVEN OR PROMISING APPROACHES
  7. SUMMARY
  8. REFERENCES

Asthma is a chronic respiratory disease causing transient episodic attacks of wheezing, coughing, and shortness of breath. Mild asthma has minimal functional consequences to daily life and activity, but severe asthma is characterized by frequent attacks and symptoms that can cause sleep disruption, necessitate urgent medical care, lead to hospitalization, and, in rare cases, death. Poor urban minority youth experience disproportionately high rates of severe asthma and are dramatically harmed by this disease. Asthma adversely affects quality of life for youth and their families and is associated with inefficient and ineffective use of health care resources. Asthma undermines the mental-emotional and physical health of youth and has harmful effects on educational outcomes through multiple pathways.

Asthma is thought to be the result of complex interactions between genetic and environmental factors.1–5 Its etiology is not clearly understood, thus populationwide approaches to primary prevention are not yet feasible.6 Many cases of mild or moderate asthma resolve with age, but, to the extent that the disease persists and is severe, more harmful long-term consequences accrue.1–3,5 This fact underscores the importance of minimizing poorly controlled disease among youth. Effective educational and public health approaches include controlling symptoms through medications that reduce susceptibility to asthma attacks and minimization of exposure to environmental allergens and irritants that may cause and exacerbate symptoms.6

The 2006 National Health Interview Survey indicated that 9.9 million youth under 18 years old (14%) had ever been diagnosed with asthma and 6.8 million (9%) still had asthma.7 Compared with girls, boys were more than 45% more likely to have ever been diagnosed with asthma (11% vs 16%) and more than 35% more likely to still have asthma (8% vs 11%).7 Both lifetime and current asthma prevalence disproportionately affect non-Hispanic Black youth, particularly those from poor families. Compared with youth under 18 years old not in poor families, youth in poor families had prevalence rates that were almost 40% higher for ever having asthma (13% vs 18%) and almost 45% higher for current asthma (9% vs 13%).7 Urban minority youth not only experience higher prevalence of lifetime and current asthma, but also worse health-related consequences, both of which adversely affect educational outcomes.

The following data describe average annual numbers and/or rates of asthma during 2001–2003 for youth between the ages of 5 and 14.6 There were 3,878,000 youth with current reported asthma and 111 deaths. Average annual prevalence estimates were approximately 45% higher for Black versus White children (12.8% vs 8.8%) (Figure 1), as were average annual estimates of asthma attacks (8.4% vs 5.8%). The estimated annual rate of emergency department visits with asthma as the primary diagnosis was 3 times greater for Black versus White children (18.3% vs 6.1%). Average annual prevalence estimates for children of Puerto Rican descent were 21.5%, compared with 5.4% for children of Mexican descent (Figure 1). Reasons for higher prevalence of asthma among children of Puerto Rican versus Mexican decent6,8,9 are not well understood,10 but the discrepancy has implications for directing limited resources to the populations with the greatest needs.

image

Figure 1. Asthma Prevalence for Youth in the United States, Ages 5–14, by Race/Ethnicity Source: National Center for Health Statistics, 2001–2003 data.

Download figure to PowerPoint

The most recent estimates from a nationwide probability sample of high school students11 indicate that 20.3% had ever been told they had asthma. Lifetime asthma prevalence estimates were more than 22% higher for Black (24.0%) than White (19.6%) students. Lifetime asthma prevalence for Hispanic students (18.5%) must be interpreted with caution due to the extreme heterogeneity of asthma among Hispanic students.6,8,9 Almost 11% of high school students reported current asthma, and the prevalence rates of current asthma were 40% higher for Black (14.7%) than White (10.5%) students. The rate for Hispanic students was 9.5%.

If national prevalence estimates indicate a very substantial magnitude of asthma, statewide and local prevalence estimates among urban minority youth have been even higher. The most recent data indicate that lifetime asthma prevalence among high school students across 34 participating states ranged from 15.4% to 28.7%. Estimates of current asthma ranged from 8.4% to 14.2%. Surveys in selected local areas demonstrate considerable variation in current asthma prevalence: from 6.8% in Houston to 19.9% in Baltimore.11 In Detroit, 1 study in 14 elementary schools identified approximately 25% of children from approximately 4600 participating families as having asthma,12 another conducted with 35 Head Start centers found probable asthma reported by 30% of parents responding.13 A study of children of Puerto Rican descent from samples collected in 2 urban areas of Puerto Rico and in the South Bronx estimated that 38.6% and 35.3%, respectively, had current asthma.8 A statewide surveillance project conducted in Massachusetts, which included one half of K-8 schools (n = 958 schools), found that prevalence based on nurse reports was, on average, 9.2% across all participating schools, but as high as 30.8% in individual schools.14 A survey of more than 8000 middle school students in Oakland, CA, indicated that 17.5% had active asthma.15 Additional studies could be outlined. The evidence that poor urban minority children are disproportionately harmed by uncontrolled asthma is not controversial.

Poor urban minority youth not only have higher rates of asthma and more severe forms of the disease, but are much less likely to receive contiguous high-quality medical care and to consistently use appropriate, efficacious medications. They are also more likely to be exposed to noxious environmental “triggers.” Consequently, they are more likely to experience severe asthma that adversely affects their quality of life, including their motivation and ability to learn in school.

Current knowledge exists to control asthma effectively and to minimize its harmful consequences. The 3 main asthma control methods are (1) access to contiguous high-quality medical care, (2) medications to control clinical sequelae (eg, asthma attacks), and (3) avoidance or minimization of environmental triggers. Poor urban minority youth experience extreme and consequential disparities with respect to all 3 of these highly effective secondary prevention methods.

Emergency department visits for asthma increased dramatically from 1980 (79.1/10,000) to 2004 (155.1/10,000), with a more than 4-fold disparity in emergency department use between Black (195.0/10,000) and White (43.6/10,000) children.6 Conversely, in 2001–2003, the estimated average rate (per 100 persons with current asthma) of physician office visits was almost 150% higher for White (74.9) than Black (30.2) children.6 Intervention programs have sought to reduce asthma-related emergency department visits because of cost and because, while emergency care addresses the acute problem (ie, an asthma attack), it does not tend to foster continuity of medical care or effective disease management.

Gaps in health insurance coverage affect a significant proportion of children in the United States and limit their access to quality medical care.16,17 This is particularly a problem for poor urban minority youth, in general,18–21 and youth with asthma, in particular.19,22–25 Given that access to consistent and high-quality medical care can help prevent morbidity from asthma,26–29 disparities in access are likely to be one of several key factors accounting for disparities in asthma morbidity.17,19,30 Medical access disparities are evidenced by greater dependence on emergency departments, as opposed to consistent primary care,31 by more severe acute exacerbations,32 and by inappropriate overuse of medications.24

Adherence to asthma medications (eg, budesonide inhalation suspensions) can prevent asthma morbidity.27,31,33–37 Appropriate use of inhaled corticosteroids has been associated with improved chronic airway inflammation and course of the disease,34 decreased use of emergency departments,31,33,35,37 and decreased hospitalization.27,31,33,37 But adherence to effective medications has been found to be much lower among poor urban minority youth.24,30,31,38,39 Medication adherence problems have been found to affect both younger26,40 and older41 children, and to disproportionately affect Black and Latino children, independent of income.42 In some inner-city families, children rather than parents, are responsible for medication adherence.43 Nonadherence to medication has been associated with more frequent asthma exacerbations, emergency department visits, and hospitalization.31,40

Poor urban minority youth have high levels of exposure to indoor pollutants (eg, environmental tobacco smoke) and allergens (eg, in the northeast, cockroach allergens).44,45 They also exhibit heightened sensitivity to these allergens.46 The combination of exposure and sensitization is thought to be one of several key causes of asthma morbidity.47 In the Inner City Asthma Study, compared with children who were not exposed or sensitized to cockroach allergen, children who were both exposed and sensitized experienced more days of symptoms and missed more school. Once sensitized, even low levels of exposure can trigger an allergic response,48 underscoring the value of preventing sensitization and avoiding exposure to allergens among those already sensitized. Outdoor pollutants in the inner city (eg, diesel exhaust particulates) may interact with allergens to exacerbate allergic reactions among susceptible youth, thereby increasing the extent of morbidity.49,50

There are regional variations in the nature and extent of indoor allergen exposure in the United States. In northeastern inner cities (eg, New York and Boston), cockroach allergen exposure appears to influence asthma morbidity more than pet allergens or dust mites. In the south and northwest, there are higher levels of exposure and sensitivity to dust mites. Inner-city communities are vulnerable to specific kinds of exposures at high concentration levels.51 Type of dwelling (eg, public housing apartments) and specific features of the household have also been found to be associated with the presence of particular kinds of allergens.52 These local variations in the kinds of allergen exposure and sensitivity have important implications for planning prevention programs. Tailoring interventions to the relevant allergens and pollutants of specific populations will likely have a strong influence on their effectiveness.53

The home is a primary exposure source of indoor allergens and pollutants.49,53 For youth, the school environment is also important.54,55 In a Minneapolis study of 2 elementary schools serving poor urban minority youth, the school environment was found to be an important source of fungi and cat allergen.56 A southeast Texas study of 60 urban elementary schools (385 rooms) included extensive environmental assessment in 20 schools. Cockroach allergen was found in all of the schools and the observed levels were above recommended limits in 10% of the rooms. Mold spores exceeded recommended limits in more than half of the classrooms.57 In the most recent nationwide School Health Policies and Programs Study, approximately one third of districts and approximately one half of schools had an indoor air quality program, approximately one third had a bus idling reduction program, approximately one quarter of the states required schools to adhere to a pest management program.58 These data illustrate both positive current initiatives and the need for increased environmentally relevant policies and programs. (It should be noted that respiratory infections and exercise in cold weather may also trigger symptoms.)

In addition to the 3 risk factors outlined above, poor urban minority youth often have other risk factors that affect moderate to severe persistent asthma morbidity. These include household and outdoor environmental exposures, behavioral or emotional concerns, lack of parental support regarding medication, poor medication adherence, and poor medical care43 as well as multiple risks of a psychosocial or sociocultural nature.59,60 In addition, lower levels of parental literacy have been associated with greater use of emergency departments, hospitalization, rescue medications and school absenteeism; parents had less knowledge about the disease and their children were more likely to have more severe persistent asthma.61 Although the disproportionate prevalence of asthma among poor urban minority populations is of great concern, of even greater concern are the disparities in asthma severity, emergency department utilization and hospitalization, and behavioral and environmental factors.62 These disparities all have consequences for quality of life in general and educational outcomes in particular.

CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES

  1. Top of page
  2. Abstract
  3. OVERVIEW AND DISPARITIES
  4. CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES
  5. WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?
  6. PROVEN OR PROMISING APPROACHES
  7. SUMMARY
  8. REFERENCES

The significance of asthma for closing the educational achievement gap lies in its functional consequences on multiple educational outcomes: cognition, connectedness with and engagement in school, and absenteeism, and the effects of comorbidity such as sleep disruption and multiple risk factors on ability to succeed in school.

Cognition

Children with asthma appear to be at a disadvantage for school readiness,63 which may have great significance for perpetuating a continuing cycle of academic struggle.64,65 Compared with children who do not have asthma, children who do have asthma have been shown to perform worse on some tests of concentration and memory66 and on task orientation (ie, concentrating well).67

This may be explained, at least in part, by sleep disruption. Children with asthma are more likely than children who do not have asthma to have disturbed sleep.66 Underlying causal circadian factors, such as inflammation, bronchial hyper-responsiveness, and airway resistance at nighttime may exacerbate asthma symptoms and cause children with asthma to experience coughing, breathlessness, and wheezing that disturb sleep.68 Children with asthma may have delayed and less consistent time falling asleep and total sleep time.69 Wheezing, a common asthma symptom, has been associated with reduced quality of sleep due to nocturnal awakenings and restlessness.70 Nocturnal asthma is associated with severity of the disease, but even youth with “stable asthma” experience considerably more sleep problems than children who do not have asthma. These problems include wheezing, coughing, breathlessness, and difficulty maintaining sleep during the night. As a consequence, children with asthma may also experience more daytime sleepiness, tiredness, and other disturbances.71 Nocturnal asthma is associated with difficulty falling and staying asleep, restlessness, daytime sleepiness, and tiredness.68

An emerging literature supports the importance of sleep for cognitive functioning.72–77 Disturbed sleep is associated with decreased ability to learn and with educational outcomes.72–77 Several recent studies in adolescents have observed associations between too little sleep and learning difficulties and compromised academic performance.77–79 Students with marginal academic performance reportedly experienced less sleep on school nights and greater daytime sleepiness than children with better academic performance.80 Greater daytime sleepiness has been associated with lower mathematics and language grades.81

Connectedness

There has been little research on asthma and connectedness with school, but several plausible relationships between the 2 warrant investigation. For example, adolescents with higher levels of sleepiness were reportedly less involved in extracurricular activities.73 This lack of involvement may be indicative of less connectedness and engagement with school. In another study in inner-city children, youth with more severe (persistent) asthma had more problems with peers and more anxious and shy behaviors.67

Connectedness with school may also be affected by emotional comorbidity of asthma. Compared with children who do not have asthma, children who do have asthma, especially those with more severe asthma, are more likely to exhibit psychological problems,66,82,83 depression,82,84–87 and anxiety.67,86–88 In a recent cross-sectional study of 102,353 randomly selected children under 18, Blackman and Ghurka82 characterized the nature and extent of asthma comorbidities. They report dose-response gradients between asthma severity and key developmental, behavioral, and emotional outcomes that dramatically affect educational outcomes. These outcomes include absenteeism, depression, learning disabilities, and behavioral disorders.

Absenteeism

Despite inconsistencies across studies in the operational definition of asthma, in the ages of the study populations, and in data collection methods, the fact that children with asthma miss school because of the disease is well established.82,89,90 Sleep disturbances associated with more severe and persistent symptomatic asthma, in particular, affect absenteeism.91 In a review of all 66 studies examining asthma and school attendance, Taras and Potts-Datema89 reported that virtually every study found a positive association between the disease and school absenteeism. In 2003, youth with current asthma (experiencing at least 1 attack in the previous year) missed a total of 12.8 million school days directly attributable to asthma.92

Asthma can result in absenteeism in numerous ways: as a result of symptoms, the need to attend doctor visits, hospitalization, the need to avoid environmental triggers at school, sleep deprivation due to nocturnal attacks, comorbidity (eg, respiratory illness) associated with increased susceptibility, among others. The extent to which each of these contributes to the overall rate of absenteeism is not well understood.89 Youth with more severe and chronic symptoms (eg, sleep disturbance and hospitalization) have higher rates of school absenteeism.90,91,93 Nonadherence to medication is also associated with higher levels of morbidity and absenteeism among inner-city elementary level children.40 Poor Black children have higher levels of asthma morbidity,22 and poor children and Black children have been shown to have high levels of disability and school absenteeism due to asthma94 and high levels of activity limitations.22,94

WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?

  1. Top of page
  2. Abstract
  3. OVERVIEW AND DISPARITIES
  4. CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES
  5. WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?
  6. PROVEN OR PROMISING APPROACHES
  7. SUMMARY
  8. REFERENCES

Leading experts in asthma control have developed a well-conceived and comprehensive policy action blueprint for improving childhood asthma control.95 The nation's schools play a prominent role. The blueprint emphasizes a multifaceted approach encompassing both provision of contiguous quality medical care and control of the physical aspects of the environment that exacerbate symptoms. The overarching policy objective is to increase the extent to which communities are “asthma-friendly,” as exemplified by early detection and treatment, and to minimize environmental exposures to allergens and irritants.95 Schools throughout the nation have made strides with policies and programs to minimize the harm caused by asthma,96 but persistent disparities in poorly controlled asthma indicate the need for a greater emphasis on this widespread and educationally consequential chronic disease.

A large body of research informs the programmatic needs to control and prevent asthma symptoms within the nation's schools and in other community institutions. The emphasis is on better control among youth with known asthma as opposed to populationwide screening.97,98 Six strategies for addressing asthma within a coordinated approach to school health have been identified by the Centers for Disease Control and Prevention.99 These, along with other consensus recommendations (eg, National Asthma Education and Prevention Program),100 can be used by individual schools and school districts.

  • 1
    Establish management and support systems for asthma-friendly schools.
  • 2
    Provide appropriate school health and mental health services for students with asthma.
  • 3
    Provide asthma education and awareness programs for students and school staff.
  • 4
    Provide a safe and healthy school environment to reduce asthma triggers.
  • 5
    Provide safe, enjoyable physical education and activity opportunities for students with asthma.
  • 6
    Coordinate school, family, and community efforts to better manage asthma symptoms and reduce school absences among students with asthma.

Specific actions that are recommended under these strategies include:

  • 1
    Have on file an asthma action plan for all students with known asthma.
  • 2
    Use a variety of data sources to identify students with poorly controlled asthma.
  • 3
    Provide intensive case management for students with poorly controlled asthma at school.
  • 4
    Minimize asthma triggers in the school environment.
  • 5
    Implement a policy to permit students to carry and self-administer asthma medications.
  • 6
    Train school staff on recognizing and responding to severe asthma symptoms that require immediate action.
  • 7
    Have a full-time registered school nurse on site during school hours to provide needed care.
  • 8
    Provide parents and families of students with asthma information to increase their knowledge about asthma management.

These school-based initiatives can apply current knowledge to control asthma effectively and minimize its harmful consequences by helping to ensure increased access to high-quality medical care, increased adherence to effective medications, and decreased exposure to environmental triggers.

PROVEN OR PROMISING APPROACHES

  1. Top of page
  2. Abstract
  3. OVERVIEW AND DISPARITIES
  4. CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES
  5. WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?
  6. PROVEN OR PROMISING APPROACHES
  7. SUMMARY
  8. REFERENCES

The quality of evaluative research assessing school-based asthma programs varies greatly across studies, as does the consistency of program effects on variables relevant to education outcomes. Collectively, however, these studies leave little doubt that well conceived and implemented programs can achieve beneficial health and educational outcomes for poor urban minority youth. Various approaches to asthma education and medical management have been conceptualized and demonstrated to have favorable effects on educational and health outcomes. These outcomes include attendance,89,101–104 grades,105 medication use,106 physiological functioning and restricted activity days,89,101,104 asthma management by caregivers,107 daytime and nighttime symptoms,108 emergency department use,102,109,110 and hospitalization.102,109

SUMMARY

  1. Top of page
  2. Abstract
  3. OVERVIEW AND DISPARITIES
  4. CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES
  5. WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?
  6. PROVEN OR PROMISING APPROACHES
  7. SUMMARY
  8. REFERENCES

To reduce the effects of asthma on learning, a multifaceted approach to asthma control and prevention, in which schools can and must play a central role, is essential. Coordinated school health programs can exert a dramatic influence on asthma morbidity and its educational and quality of life consequences among poor urban minority youth. Schools provide an effective context for engaging youth with asthma in asthma education and control programs. School-based programs can reach a large proportion of the at-risk population with tailored educational programs for groups and individuals and can provide social and emotional support and address mental and emotional needs that may be associated with persistent and severe asthma. Schools can assist with medications and provide an avenue to educate parents or caregivers in ways to support improved asthma outcomes. School staff must have the necessary knowledge and skills to respond appropriately if students with asthma have attacks during the school day or during after-school sports.

Among the many aspects of the physical environment that warrant attention are particulate air pollution and adequacy of ventilation systems, misuse of paints, pesticides and cleaning solutions, water leaks and associated molds,secondhand smoke (many schools do not have policies prohibiting smoking on school grounds), the availability of clean cold water and of good hand-washing facilities (both of which are extremely important for communicable disease prevention and control). Aspects of the biological environment that warrant attention include the presence of cockroaches or rodents, and furry or feathered pets within the classroom. It is not surprising that many school-based programs have demonstrated effectiveness for improving educational and health outcomes associated with asthma. The priority now is to increase the extent to which these programs are implemented in the nation's schools serving urban minority youth.

REFERENCES

  1. Top of page
  2. Abstract
  3. OVERVIEW AND DISPARITIES
  4. CAUSAL PATHWAYS AFFECTING EDUCATIONAL OUTCOMES
  5. WHAT CAN SCHOOLS DO TO ADDRESS ASTHMA SYMPTOMS?
  6. PROVEN OR PROMISING APPROACHES
  7. SUMMARY
  8. REFERENCES