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Monday, December 8, 2014

Introducing an environmental assessment and intervention program in inner-city schools

Few studies have comprehensively examined the role the school environment plays in asthma and how effectively changing the environment may reduce morbidity, when adjusting for exposures in the home. In their review, Huffaker and Phipatanakul summarize the importance and common challenges of school-based environmental assessment and intervention studies linked to health effects (J Allergy Clin Immunol 2014; 134: 1232-1237). They discuss the challenges and potential benefits of comprehensive environmental assessment and health outcomes in inner-city schools.

The school environment has been shown to be a significant reservoir for allergens and pollutants. Indoor allergens known to be important in urban home environments may also be important in schools, including cockroach, cat, dog, mouse, dust-mite, and molds. Studies have identified children with asthma in inner-cities have markedly higher levels of mouse allergen in their schools compared to levels in their individual bedrooms. Given the paucity of comprehensive data on school-based environmental interventions and health outcomes, successful home-based strategies currently serve as the model for school-based interventions. For example, practical interventions to reduce environmental exposures at home such as the use of air filtration systems and integrated pest management can be utilized in schools. 

Despite the challenges associated with implementing environmental interventions in schools, evidence supports the importance of school and classroom exposures and health outcomes. School-based interventions have the potential to reduce exposures for many symptomatic children, in contrast to the individual families impacted by home-based interventions. If effective, results from school-based interventional studies could inform public policy change, funding and initiatives. If it can be demonstrated that reduction of classroom-specific exposures leads to improved asthma outcomes, then findings can be translated into efficient and cost-effective strategies to benefit communities of children through improvement of the school environment, where children in America spend the majority of their day.

Establishing School-Centered Asthma Programs

Approximately 36,000 children miss school each day due to asthma which ultimately affects a child’s ability to learn. In fact, according to a U.S National Interview Survey, children with asthma missed three times more school and had a 1.7 times greater risk of having a learning disability compared to well children. Moreover, students attending schools with the highest proportions of low income students are more likely to miss school because of asthma. In their review article, Cicutto et al discuss how asthma and associated causal pathways can have interactive and synergistic effects that result in a complex situation that must be addressed collectively through a coordinated and partnered approach (J Allergy Clin Immunol 2014; 134: 1223-1230). School-centered interventions are thus directed at improving asthma control and reducing asthma-related absenteeism.

Asthma management at schools is important for pediatric pulmonologists and allergists, primary care providers and the whole interdisciplinary team working alongside them to provide quality asthma care. Several studies and systematic reviews demonstrate that students with asthma when supported through school-centered asthma care programs can have improvements in asthma knowledge, confidence in and actual practice of asthma management skills, regular use of preventive asthma medications, reduced school absenteeism, better school performance, and the use of urgent and emergent asthma care. Collectively, available research demonstrates that programs that either provide asthma care directly at-school and/or ensure adequate links between school, family and asthma care provider have achieved a reduction in asthma morbidity. The authors indicate that the synergy created by collaborative and coordinated efforts of schools and asthma care providers assists students and their families to achieve asthma control and reduce associated morbidity.

Future research is needed to determine the cost effectiveness of school-centered asthma programs and how to sustain program implementation once research funding no longer exists. Nonetheless, community asthma care providers are essential to successful asthma management across home and school settings.

Question for the authors:

You emphasize that clinicians must be advocates for appropriate services within inner city schools. What approaches can you suggest clinicians utilize to educate local school administrators?

Schools, especially inner city schools, are very limited in resources that they can devote to health care. Therefore, clinicians can provide a valuable service by partnering with schools in varying ways. The first step would be for the clinician to set up a dialogue with the school nurse that is responsible for a high proportion of the children in their practice.

A multitude of things can be done once this step is taken. First, an understanding of the challenges the nurse faces in delivering medications in school would be a start to the conversation. Many school action plans are not provided to the school nurse and many are not written for the school nurse. Also, availability of and access to rescue medications at school can be a challenge. A dialogue between the school nurse and clinician can help resolve these problems at the core level. Next, steps could be taken to assist the school nurse with education of school staff around medication administration and recognizing symptoms of asthma. The rest will depend on the clinician’s time and interest in improving asthma care in the school setting and developing a sense of community engagement.

Once you do get involved, it is a very rewarding experience. The school nurses really appreciate it, and the clinician will understand the challenges in managing care in the real world setting.