Abstract
BACKGROUND:
Asthma is one of the leading causes of school absenteeism. Schools can play an important role in coordinating asthma care. The purpose of this study was to assess the implementation of asthma-related school health policies and practices across states and how they have changed over time.
METHODS:
Data were analyzed from 36 states that conducted School Health Profiles surveys during 2008 to 2018. Trends in 6 topics were analyzed by logistic regression and JointPoint trend test.
RESULTS:
Trends in efforts to identify and track students with asthma and improve students’ and parents’ knowledge about asthma were stable or increased. Interest among lead health education teachers in receiving professional development on asthma trended downward in 35 of 36 states.
CONCLUSIONS:
Stable to upward trends suggest that a majority of schools have maintained or improved their efforts to identify and track students with asthma and increase the knowledge of students and parents about asthma. However, further improvement is needed in referral of students with asthma to health care professionals and encouraging asthma-related professional development of lead health education teachers.
Keywords: asthma education, school trend, asthma tracking
INTRODUCTION
In the United States, asthma is a common chronic health condition that affects 1 in 12 children nationwide.1 In 2019, asthma affected 8.6% (4.6 million) of school-age children (aged 5–17 years).2 Asthma is one of the leading causes of school absenteeism.3 Students with asthma missed 2.3 school days per year more than students without asthma,4 for a total of 13.8 million missed school days per year.5,6 Current guidelines for the diagnosis and management of asthma encourage expanding educational opportunities to reach patients through a variety of settings, such as pharmacies, community centers, patients’ homes, and schools to manage asthma.7
Schools can play an important role in promoting the health and safety of children and adolescents. From ages 5 to 17 years, children spend about 6 to 7 hours per day at school for nearly half the year (about 180 days per year). Schools provide physical education, counseling and psychological services, nutrition and food programs, health education, and health services. School health policies and practices that establish guidelines to create a safe learning environment are key in promoting and maintaining the health and well-being of students and ensuring disease management of students with chronic health conditions such as asthma.8
The American Lung Association’s Asthma-Friendly Schools Initiative (AFSI) is a comprehensive approach to asthma management in schools.9 AFSI is aligned with Centers for Disease Control and Prevention (CDC) strategies for addressing asthma within a coordinated school health program.10 AFSI Toolkit strategies (eg, maximize school health services, build asthma education, provide a healthy school environment, and manage physical education and activity) advance asthma management in schools and enable students to successfully manage their asthma. The strategies adopted by asthma-friendly schools were found to be very effective in improving health and quality of life of students with asthma. For instance, Clark et al. showed that providing education for elementary school children, plus educational components for principals, custodians, and other school staff members, resulted in fewer asthma episodes, improved asthma management, and decreased school absences.11 Asthma management plans including individualized asthma action plans are fundamental tools in coordinating asthma care within schools. A recent systematic review focusing on asthma in schools found that comprehensive asthma education empowers schools to provide safe school environments for children with asthma.12
Several studies11–16 show the effectiveness of asthma-friendly schools in promoting safe and healthy schools that improve the health and well-being of students and students’ academic performance. However, limited information is available to describe the extent to which asthma-related school health policies and practices are implemented, and if implementation patterns have changed over time. To address this knowledge gap, we assessed 6 asthma-related school health policies and practices in secondary schools across states by analyzing data from the 2008 to 2018 School Health Profiles,8 a state-based surveillance system developed by CDC.
METHODS
Profiles is a surveillance system developed by CDC17,18 to assess school health policies and practices in states, large urban school districts, and US territories. Profiles surveys are conducted every 2 years by education and health agencies among middle and high-school principals and lead health education teachers (LHETs). In 2018, across 43 states, the sample sizes of principals surveyed ranged from 72 to 558 and response rates ranged from 71% to 95%. The sample sizes of the LHET surveys across the states in 2018 ranged from 72 to 581 and response rates ranged from 70% to 94%.17
Participants
Profiles data for this article were limited to those obtained from state surveys conducted in 2008, 2010, 2012, 2014, 2016, and 2018. During these survey years, the participating states surveyed either all secondary schools within their jurisdiction or a selected systematic, equal-probability samples of secondary schools. For profiles, secondary schools are defined as public schools with any of grades 6 through 12, including middle schools, junior high schools, and high schools. Respondents are principals and LHETs in the selected schools. The LHET is the person at the school that the principal designates to be most knowledgeable about health education.10,17,18
Instruments
Profiles uses separate questionnaires for the principal and the LHET. We analyzed 2 questions from the principal survey and 4 questions from the LHET survey for this study. The 2 questions included asthma as a response category from the principal surveys, which were asked in 2014, 2016, 2018 only19:
Does your school routinely use school records to identify and track students with a current diagnosis of the following 7 chronic conditions? School records might include student emergency cards, medication records, health room visit information, emergency care and daily management plans, physical exam forms, or parent notes.
Does your school provide referrals to any organizations or health care professionals not on school property for students diagnosed with or suspected to have any of the following 7 chronic conditions? Include referrals to school-based health centers, even if they are located on school property.
The following 4 questions included asthma as a response category from the 2008 to 2018 LHET surveys20:
During this school year, have teachers in your school tried to increase student knowledge on each of the following 18 topics in a required course in any of grades 6 through 12?
During this school year, did your school provide parents and families with health information designed to increase parent and family knowledge of each of the following 9 topics?
During the past 2 years, did you receive professional development (eg, workshops, conferences, continuing education, any other kind of in-service) on each of the following 18 topics?
Would you like to receive professional development on each of the following 18 topics?
Procedures
Self-administered questionnaires were sent to the principal and LHET at each selected school and returned to the agency conducting the survey, either by mail or using a web-based system. Participation in the Profiles surveys was confidential and voluntary. Follow-up telephone calls, emails, and written reminders were used to encourage participation. Data were included in this article only if the state provided appropriate documentation of methods and obtained a school response rate ≥ 70% for each survey year. Results were weighted to adjust for non-response in all states and were adjusted for the likelihood of selection in states that chose to administer questionnaires to a sample of schools.
Data Analysis
Weighted data from the 2014 to 2018 surveys of principals from 36 states (Table 1) and from the 2008 to 2018 surveys of LHETs from 36 states (Table 2) were used for the analyses. We included states that had at least 5 of the 6 data points from 2008–2018 in the trend analysis. Trends were assessed using logistic regression analyses and JoinPoint statistical software to determine inflection points.21 The statistical significance of linear time effects was determined at p < .05. We also calculated the median percentage of schools across states for each variable. Statistical software SUDAAN 11.1 was used to account for the sampling design and unequal weights.
Table 1.
Percentage of Schools Identifying Students with Asthma and Providing Referrals to Health Care Services, by State, 36 States, 2014 to 2018
| State | Routinely Use School Records to Identify and Track Students with a Current Diagnosis of Asthma | Provide Referrals to Any Organizations or Health Care Professionals for Students with a Current Diagnosis of Asthma | ||||||
|---|---|---|---|---|---|---|---|---|
| 2014 % (CI)* | 2016 % (CI)* | 2018 % (CI)* | Linear trend† | 2014 % (CI)* | 2016 % (CI)* | 2018 % (CI)* | Linear trend† | |
| AL | 96.6 (94.8–97.8) | 97.0 (95.2–98.1) | 97.6 (96.0–98.5) | No | 48.8 (44.7–52.8) | 29.9 (26.3–33.8) | 40.2 (35.8–44.7) | Decreasing |
| AR | 96.3 (93.9–97.8) | 94.6 (92.4–96.1) | 95.6 (93.6–97.0) | No | 54.9 (49.8–59.9) | 53.2 (48.6–57.8) | 57.8 (52.7–62.6) | No |
| CA | 98.4 (96.7–99.3) | 97.3 (95.3–98.5) | 97.6 (95.5–98.7) | No | 66.9 (62.3–71.1) | 57.3 (52.9–61.6) | 56.0 (51.1–60.7) | Decreasing |
| DE | 96.7 (93.1–98.4) | 100 (—) | 93.0 (89.0–95.6) | No | 69.5 (62.8–75.4) | 57.5 (50.8–63.9) | 78.2 (71.9–83.4) | Increasing |
| FL | 94.4 (91.8–96.2) | 96.8 (94.7–98.1) | 95.3 (92.9–97.0) | No | 45.8 (40.9–50.6) | 40.2 (36.0–44.6) | 44.6 (40.4–48.9) | No |
| GA | 96.8 (94.5–98.1) | 94.2 (91.6–96.0) | 93.2 (89.5–95.6) | No | 44.6 (40.0–49.2) | 39.8 (35.4–44.3) | 47.5 (41.8–53.3) | No |
| HI | 96.2 (93.8–97.7) | 95.1 (93.1–96.5) | 100 (—) | Increasing | 31.2 (27.0–35.6) | 28.0 (24.5–31.7) | 29.2 (25.2–33.6) | No |
| ID | 91.5 (88.4–93.8) | 90.5 (87.2–93.0) | 95.5 (92.9–97.1) | No | 42.9 (38.2–47.8) | 39.5 (35.0–44.2) | 46.0 (41.0–51.1) | No |
| IL | 96.9 (94.7–98.2) | 97.5 (95.4–98.6) | 99.1 (97.5–99.7) | No | 51.1 (46.1–56.2) | 49.4 (45.1–53.7) | 46.4 (41.6–51.3) | No |
| KS | 92.9 (90.6–94.7) | 93.4 (90.6–95.4) | 94.7 (92.2–96.4) | No | 43.9 (39.8–48.1) | 38.4 (33.9–43.1) | 55.8 (50.6–60.8) | Increasing |
| KY | 97.4 (95.4–98.6) | 97.2 (95.2–98.4) | 94.9 (92.4–96.7) | No | 57.9 (53.1–62.6) | 56.4 (52.2–60.4) | 56.8 (52.3–61.2) | No |
| ME | 97.8 (96.7–98.6) | 99.1 (98.4–99.5) | 97.1 (95.6–98.0) | No | 70.0 (67.1–72.8) | 63.5 (60.8–66.1) | 64.2 (60.7–67.5) | Decreasing |
| MI | 92.8 (89.6–95.0) | 94.4 (91.4–96.4) | 91.0 (87.3–93.7) | No | 41.9 (36.8–47.1) | 40.7 (36.0–45.6) | 37.2 (31.6–43.2) | No |
| MN | 97.6 (95.8–98.6) | 96.2 (94.2–97.5) | 95.3 (93.1–96.8) | No | 70.3 (66.3–74.0) | 57.4 (52.9–61.7) | 56.5 (52.2–60.8) | Decreasing |
| MO | 97.9 (95.8–98.9) | 97.6 (95.5–98.7) | 95.6 (93.1–97.3) | No | 56.2 (51.4–61.0) | 52.2 (47.1–57.1) | 47.7 (42.7–52.8) | Decreasing |
| MS | 95.8 (93.4–97.4) | 98.7 (97.0–99.4) | 92.1 (89.4–94.2) | No | 44.4 (40.1–48.9) | 60.4 (55.9–64.8) | 45.1 (40.5–49.9) | No |
| MT | 94.1 (92.8–95.2) | 95.5 (94.6–96.2) | 93.5 (92.5–94.5) | No | 57.8 (55.2–60.3) | 50.4 (48.6–52.3) | 53.3 (51.2–55.3) | Decreasing |
| NC | 98.1 (95.7–99.2) | 98.5 (96.9–99.3) | 96.4 (94.2–97.8) | No | 62.3 (56.4–67.8) | 54.7 (49.7–59.5) | 53.0 (48.6–57.4) | No |
| ND | 89.1 (86.8–91.1) | 88.4 (85.8–90.5) | 84.1 (81.8–86.1) | Decreasing | 43.9 (40.5–47.4) | 38.0 (34.5–41.6) | 42.3 (39.4–45.2) | No |
| NE | 98.7 (97.4–99.4) | 99.1 (97.8–99.6) | 96.4 (94.3–97.7) | No | 54.2 (50.0–58.3) | 56.9 (52.7–61.1) | 57.3 (52.8–61.7) | No |
| NH | 99.0 (98.4–99.3) | 98.4 (97.5–99.0) | 97.7 (96.5–98.5) | Decreasing | 72.1 (70.2–74.0) | 72.2 (69.5–74.6) | 67.2 (64.2–70.1) | Decreasing |
| NJ | 99.3 (97.9–99.8) | 96.5 (94.3–97.9) | 99.0 (97.3–99.6) | No | 73.2 (68.3–77.7) | 63.6 (59.0–68.0) | 69.2 (64.4–73.6) | No |
| NV | 97.0 (95.1–98.2) | 98.0 (96.4–98.9) | 95.7 (93.4–97.2) | No | 61.6 (57.2–65.8) | 47.5 (43.4–51.8) | 49.5 (44.9–54.1) | Decreasing |
| NY | 96.4 (93.8–97.9) | 96.5 (94.2–97.9) | 94.7 (91.5–96.7) | No | 70.2 (65.4–74.7) | 74.7 (70.4–78.6) | 69.3 (64.5–73.7) | No |
| OH | 94.4 (91.8–96.2) | 97.5 (95.3–98.7) | 95.3 (92.6–97.0) | No | 51.8 (47.0–56.5) | 43.1 (38.1–48.4) | 46.8 (42.1–51.4) | No |
| OK | 92.6 (89.6–94.8) | 91.8 (88.8–94.1) | 92.8 (89.9–94.8) | No | 41.5 (36.7–46.4) | 42.4 (37.7–47.2) | 43.3 (38.6–48.1) | No |
| OR | 93.5 (90.9–95.4) | 94.4 (91.9–96.1) | 93.8 (90.7–95.9) | No | 66.5 (62.5–70.4) | 57.6 (52.9–62.2) | 60.5 (55.6–65.3) | No |
| PA | 97.4 (95.5–98.5) | 96.6 (94.2–98.1) | 98.2 (96.1–99.2) | No | 62.2 (57.8–66.4) | 56.5 (51.5–61.4) | 63.0 (58.0–67.7) | No |
| SC | 97.8 (96.2–98.7) | 97.7 (96.1–98.6) | 96.0 (93.7–97.4) | No | 59.6 (55.7–63.3) | 56.2 (52.4–60.0) | 47.7 (42.8–52.7) | Decreasing |
| TN | 97.2 (95.4–98.3) | 97.2 (95.6–98.3) | 96.7 (95.2–97.8) | No | 48.3 (43.9–52.7) | 48.7 (45.1–52.4) | 44.2 (40.7–47.7) | No |
| UT | 95.9 (94.4–97.0) | 96.5 (95.0–97.5) | 93.5 (91.5–95.1) | Decreasing | 32.8 (29.7–36.0) | 26.0 (23.0–29.1) | 25.2 (22.1–28.5) | Decreasing |
| VA | 98.8 (97.2–99.5) | 98.3 (96.4–99.3) | 98.5 (96.7–99.3) | No | 56.0 (51.2–60.8) | 38.8 (34.0–43.9) | 44.9 (40.4–49.6) | Decreasing |
| VT | 97.6 (96.1–98.5) | 95.6 (94.4–96.5) | 96.7 (95.1–97.8) | No | 78.9 (75.7–81.8) | 80.2 (78.0–82.2) | 82.2 (79.2–84.8) | No |
| WA | 98.6 (96.8–99.3) | 97.3 (95.3–98.5) | 97.8 (95.8–98.8) | No | 63.6 (59.0–68.0) | 59.7 (55.5–63.8) | 60.7 (55.8–65.4) | No |
| WI | 96.5 (94.1–97.9) | 97.6 (95.4–98.7) | 96.0 (93.7–97.4) | No | 53.5 (48.9–58.0) | 48.0 (43.2–52.9) | 50.5 (45.8–55.2) | No |
| WV | 97.3 (95.7–98.3) | 97.6 (95.8–98.7) | 100 (—) | Increasing | 68.1 (64.4–71.5) | 70.8 (66.6–74.7) | 61.8 (57.2–66.2) | No |
| Median | 96.8 | 97.2 | 95.6 | 56 | 52.2 | 50.5 | ||
| Minimum | 89.1 | 88.4 | 84.1 | 31.2 | 26 | 25.2 | ||
| Maximum | 99 | 100 | 100 | 78.9 | 80.2 | 82.2 | ||
| Range | (89.1–99.0) | (88.4–100) | (84.1–100) | (31.2–78.9) | (26.0–80.2) | (25.2–82.2) | ||
95% confidence intervals (CI) for teacher question’s percent estimates with finite population correction.
Logistic regression was used to test statistical significance of the trends. “Increasing” is significant increased trend; “Decreasing” is significant decreased trend; “No” no statistically significant trend.
Table 2.
Percentage of Schools with Health Education on Asthma by Topics - 36 States, 2016 or 2018
| State | The Most Recent Available Data Year | School Tried to Increase Student Knowledge on Asthma in a Required Course for Students in Grades 6 through 12 during this School Year % (CI)† | School Provides Health Information Designed to Increase Parent and Family Knowledge of Asthma during this School Year % (CI)† | Lead Health Education Teacher Received Professional Development* on Asthma during the Past 2 years % (CI)† | Lead Health Education Teacher Would Like to Receive Professional Development* on Asthma % (CI)† |
|---|---|---|---|---|---|
| AL | 2018 | 65.0 (60.4–69.3) | 34.7 (30.1–39.6) | 39.1 (34.6–43.7) | 47.0 (41.9–52.2) |
| AR | 2016 | 75.7 (71.6–79.3) | 35.0 (31.1–39.0) | 41.7 (37.3–46.2) | 57.7 (53.7–61.7) |
| AZ | 2016 | 25.8 (21.7–30.5) | 16.9 (13.7–20.7) | 17.0 (13.8–20.8) | 47.5 (43.1–52.0) |
| CA | 2018 | 38.1 (33.4–43.1) | 20.8 (17.0–25.2) | 16.1 (12.9–19.9) | 44.0 (39.0–49.2) |
| DE | 2018 | 49.2 (42.4–55.9) | 35.5 (29.1–42.4) | 16.9 (12.3–22.8) | 48.9 (41.9–56.0) |
| FL | 2018 | 56.8 (52.2–61.4) | 24.1 (20.1–28.6) | 31.3 (27.0–36.0) | 52.3 (47.6–56.8) |
| GA | 2018 | 61.0 (55.9–65.8) | 25.3 (21.0–30.1) | 25.5 (21.1–30.4) | 43.6 (38.0–49.5) |
| HI | 2018 | 44.0 (39.3–48.8) | 12.6 (9.7–16.0) | 11.9 (9.1–15.4) | 51.1 (46.3–55.9) |
| IL | 2018 | 69.2 (64.6–73.4) | 20.7 (17.0–25.0) | 43.1 (38.6–47.8) | 47.2 (42.6–51.9) |
| KS | 2018 | 41.5 (36.8–46.4) | 12.2 (9.2–16.0) | 11.0 (8.6–13.9) | 41.3 (36.4–46.4) |
| KY | 2018 | 64.7 (60.3–68.8) | 22.8 (18.9–27.3) | 20.6 (16.8–25.1) | 41.1 (36.3–46.0) |
| ME | 2018 | 43.2 (39.8–46.6) | 15.0 (12.7–17.6) | 9.8 (8.0–12.1) | 26.6 (23.6–29.7) |
| MI | 2018 | 44.0 (38.6–49.6) | 14.1 (10.6–18.5) | 18.1 (14.1–23.0) | 46.1 (40.9–51.5) |
| MN | 2018 | 48.3 (44.7–51.9) | 17.2 (14.4–20.5) | 15.8 (13.0–19.1) | 31.3 (27.7–35.0) |
| MO | 2018 | 68.7 (64.1–72.9) | 28.3 (24.1–32.8) | 27.8 (23.5–32.4) | 41.5 (36.7–46.4) |
| MS | 2018 | 71.3 (66.8–75.4) | 38.1 (33.4–42.9) | 44.2 (39.6–49.0) | 61.8 (56.9–66.5) |
| MT | 2018 | 59.7 (56.9–62.5) | 15.1 (13.3–17.3) | 18.4 (16.4–20.7) | 46.7 (43.9–49.5) |
| NC | 2018 | 69.9 (65.1–74.4) | 29.0 (24.7–33.6) | 36.0 (31.5–40.7) | 53.4 (48.4–58.4) |
| ND | 2018 | 52.9 (49.7–56.1) | 13.9 (11.8–16.2) | 16.1 (13.8–18.6) | 39.6 (36.5–42.8) |
| NE | 2018 | 51.7 (47.1–56.2) | 31.7 (27.6–36.2) | 40.8 (36.8–45.0) | 31.1 (27.3–35.3) |
| NH | 2018 | 53.0 (49.3–56.7) | 22.3 (19.4–25.6) | 21.7 (18.8–24.9) | 47.2 (43.5–51.0) |
| NJ | 2018 | 75.1 (70.7–79.0) | 44.8 (40.1–49.6) | 58.7 (54.0–63.3) | 53.2 (48.2–58.2) |
| NV | 2016 | 67.7 (63.4–71.6) | 17.0 (14.0–20.6) | 18.3 (15.1–21.9) | 48.8 (44.4–53.2) |
| NY | 2018 | 54.6 (49.0–60.1) | 23.1 (18.4–28.5) | 17.3 (13.5–21.8) | 55.1 (49.5–60.5) |
| OH | 2018 | 54.4 (49.5–59.2) | 18.3 (14.6–22.6) | 20.9 (17.2–25.2) | 36.8 (32.2–41.6) |
| OR | 2018 | 46.7 (42.0–51.4) | 7.8 (5.5–10.9) | 12.4 (9.5–16.0) | 35.1 (30.3–40.2) |
| PA | 2018 | 54.0 (49.3–58.6) | 17.3 (13.6–21.7) | 17.2 (14.0–21.1) | 39.8 (34.9–44.9) |
| SC | 2018 | 57.1 (51.7–62.3) | 22.3 (18.1–27.3) | 24.3 (20.0–29.3) | 49.8 (44.3–55.4) |
| TN | 2018 | 59.1 (55.5–62.6) | 33.5 (30.2–36.9) | 42.4 (38.7–46.2) | 49.0 (45.1–52.9) |
| UT | 2018 | 54.1 (50.3–57.9) | 11.1 (8.9–13.7) | 18.1 (15.4–21.2) | 47.3 (43.5–51.1) |
| VA | 2018 | 65.4 (61.0–69.5) | 31.5 (27.0–36.3) | 42.8 (38.2–47.6) | 50.0 (45.0–55.0) |
| VT | 2018 | 31.9 (28.7–35.3) | 21.9 (19.1–25.0) | 16.2 (13.7–19.0) | 27.1 (24.1–30.4) |
| WA | 2018 | 46.1 (41.0–51.3) | 24.2 (19.9–29.0) | 33.4 (28.6–38.6) | 32.0 (27.7–36.7) |
| WI | 2018 | 50.2 (45.7–54.7) | 14.5 (11.9–17.5) | 13.0 (10.4–16.2) | 34.0 (30.1–38.1) |
| WV | 2018 | 76.0 (72.3–79.4) | 27.9 (24.1–32.0) | 15.7 (12.8–19.2) | 44.0 (39.9–48.2) |
| WY | 2016 | 44.0 (39.9–48.3) | 11.0 (8.5–14.1) | 7.4 (5.4–10.1) | 28.5 (24.7–32.6) |
| Median | 54.3 | 22.1 | 18.3 | 46.4 | |
| Minimum | 25.8 | 7.8 | 7.4 | 26.6 | |
| Maximum | 76 | 44.8 | 58.7 | 61.8 | |
| Range | (25.8–76.0) | (7.8–44.8) | (7.4–58.7) | (26.6–61.8) |
Professional development, such as workshops, conferences, continuing education, or any other kind of in-service.
95% confidence intervals (CI) for teacher question’s percent estimates, with finite population correction.
RESULTS
Table 1 shows results for the 2 questions from the 2014 to 2018 principal questionnaires. The median percentage of schools that routinely use school records to identify and track students with a current diagnosis of asthma was 96.8% in 2014, 97.2% in 2016, and 95.6% in 2018. The percentage ranged from 89.1% in North Dakota to 99.0% in New Hampshire in 2014, from 88.4% in North Dakota to 100% in Delaware in 2016, and from 84.1% in North Dakota to 100% in Hawaii and West Virginia in 2018. Among the 36 participating states, the percentage of schools identifying and tracking students with a current diagnosis of asthma did not change significantly over time in 31 states but significantly decreased in 3 states and significantly increased in 2 states (Figure 1).
Figure 1.
Summary of Linear Time Effects of Percentage of Schools Identifying and Tracking Students with Asthma and Providing Referrals to Health Care Services - 36 States, 2014 to 2018
The percentage of schools that referred students with a current diagnosis of asthma to any organization or health care professional during the 2 years preceding the survey varied widely across states. The median percentage was 56.0% in 2014, 52.2% in 2016, and 50.5% in 2018. The percentages ranged from 31.2% in Hawaii to 78.9% in Vermont in 2014, from 26.0% in Utah to 80.2% in Vermont in 2016, and from 25.2% in Utah to 82.2% in Vermont in 2018. Among the 36 participating states, the percentage did not change significantly over time in 23 states but significantly decreased in 11 states and significantly increased in 2 states (Figure 1).
Table 2 shows the percentage of schools with affirmative responses to the 4 questions from the LHET questionnaire, by state, using the latest available data (2016 or 2018). For all 4 topics, the percentage varied across states. Table 3 shows the trend analysis results for the 4 questions, by state, during 2008–2018. The median percentage of schools that tried to increase student knowledge on asthma during the school year was 54.3%, ranging from 25.8% in Arizona to 76.0% in West Virginia (Table 2). During 2008 to 2018, among the 36 participating states, the percentage did not change significantly over time in 24 states, significantly decreased in 1 state, and significantly increased in 11 states (Table 3, Figure 2).
Table 3.
Linear Time Effects in the Percentage of Schools with Health Education on Asthma by Topics - 36 States, 2008 to 2018
| State | Years Available | School Tried to Increase Student Knowledge on Asthma in a Required Course for Students in Grades 6 through 12 during this School Year | School Provides Health Information Designed to Increase Parent and Family Knowledge of Asthma during this School Year | Lead Health Education Teacher Received Professional Development* on Asthma during the Past 2 years | Lead Health Education Teacher Would Like to Receive Professional Development* on Asthma |
|---|---|---|---|---|---|
| AL | 2008–2018 | No† | No† | Increasing† | Decreasing† |
| AR | 2008–2016 | No | No | Increasing | Decreasing |
| AZ | 2008–2016 | No | No | No | Decreasing |
| CA | 2008–2018 | No | No | No | Decreasing |
| DE | 2008–2018 | No | Increasing | No | Decreasing |
| FL | 2008–2018 | Increasing | No | No | Decreasing |
| GA | 2010–2018 | No | Decreasing | No | Decreasing |
| HI | 2008–2018 | No | No | Decreasing | Decreasing |
| KS | 2008–2018 | No | No | No | Decreasing |
| KY | 2008–2018 | No | No | No | Decreasing |
| ME | 2008–2018 | Increasing | No | Decreasing | Decreasing |
| MI | 2008–2018 | No | No | No | Decreasing |
| MN | 2008–2018 | Increasing | No | Decreasing | Decreasing |
| MO | 2008–2018 | No | No | No | Decreasing |
| MS | 2008–2018 | Increasing | Increasing | Increasing | Decreasing |
| MT | 2008–2018 | Increasing | No | No | Decreasing |
| NC | 2008–2018 | Increasing | Increasing | No | Decreasing |
| ND | 2008–2018 | Increasing | No | No | Decreasing |
| NE | 2008–2018 | No | No | Decreasing | Decreasing |
| NH | 2008–2018 | Increasing | Increasing | Increasing | No |
| NJ | 2008–2018 | Increasing | Increasing | Increasing | Decreasing |
| NV | 2008–2016 | Increasing | No | No | Decreasing |
| NY | 2008–2018‡ | Decreasing | No | Decreasing | Decreasing |
| OH | 2008–2018 | No | No | No | Decreasing |
| OR | 2008–2018 | No | No | No | Decreasing |
| PA | 2008–2018 | No | No | No | Decreasing |
| SC | 2008–2018‡ | No | No | Decreasing | Decreasing |
| TN | 2008–2018 | No | No | No | Decreasing |
| UT | 2008–2018 | Increasing | No | No | Decreasing |
| VA | 2008–2018 | No | Increasing | Increasing | Decreasing |
| VT | 2008–2018 | No | No | Decreasing | Decreasing |
| WA | 2008–2018‡ | No | No | Decreasing | Decreasing |
| WI | 2008–2018 | No | No | No | Decreasing |
| WV | 2008–2018 | No | No | No | Decreasing |
| WY | 2008–2016 | No | No | Decreasing | Decreasing |
Professional development, such as workshops, conferences, continuing education, any other kind of in-service.
Logistic regression was used to test statistical significance of the trends. “Increasing” is significant increased trend; “Decreasing” is significant decreased trend; “No” is no statistically significant trend.
No data for 2012.
Figure 2.
Summary of Linear Time Effects in the Percentage of Schools with Health Education on Asthma by Topics - 36 States, 2008 to 2018
The median percentage of schools that provided health information designed to increase parent and family knowledge of asthma during the school year was 22.1%, ranging from 7.8% in Oregon to 44.8% in New Jersey (Table 2). During 2008 to 2018, among the 36 participating states, the percentage did not change significantly over time in 29 states, significantly decreased in 1 state, and significantly increased in 6 states (Table 3, Figure 2).
The median percentage of schools in which LHETs received professional development on asthma during the past 2 years was 18.3%, ranging from 7.4% in Wyoming to 58.7% in New Jersey (Table 2). During 2008 to 2018, among the 36 participating states, the percentage did not change significantly over time in 21 states, significantly decreased in 9 states, and significantly increased in 6 states (Table 3, Figure 2).
The median percentage of schools in which LHETs would like to receive professional development on asthma was 46.4%, ranging from 26.6% in Maine to 61.8% in Mississippi (Table 2). During 2008 to 2018, among the 36 participating states, the percentage did not change significantly over time in 1 state and significantly decreased in 35 states (Table 3, Figure 2).
DISCUSSION
Profiles is a system of surveys assessing school health policies and practices in states, large urban school districts, and US territories. We analyzed Profiles data to assess the extent to which the asthma-related school health policy and practices were implemented across states and if use patterns changed over time. In 2018, the majority of schools (95.6%) identified and tracked students with a current diagnosis of asthma; however, only about half of schools referred students with a current diagnosis of asthma to health care professionals. Improving schools’ referrals of students with asthma to health care professionals could strengthen linkages and coordination of care for these students, and boost students’ access to effective asthma management and encourage regular follow-up visits. Those students might then obtain an up-to-date written asthma action plan and quick and easy access to prescribed medications. Action plans can be used in schools to provide instruction for medication use, control of asthma triggers, and to recognize and handle worsening asthma symptoms.22 Effective asthma management leads to better long-term asthma control and prevents asthma attacks. It also can reduce school absenteeism and improve learning and academic success.9,22
Trends in implementing 4 asthma education policies and practices were mostly stable across states from 2008 to 2018. One exception was that fewer LHETs expressed interest in receiving professional development on asthma in nearly all states. The Profiles dataset did not provide sufficient information to determine reasons for the decline. Educating students, their parents and families, and school staff members about asthma can raise awareness about the disease, improve knowledge of the basics of asthma care, and help students and families improve asthma self-management skills.10,23 The study findings suggest further improvement is needed in educating students, their parents and families, and school staff about asthma, considering that across states, a median of 54.3% of schools increased students’ knowledge on asthma, a median 22.1% of schools increased parents’ and family’s knowledge on asthma, and a median 18.4% of LHETs received professional development on asthma. CDC has publicly available tools which can help students, families, and schools learn more about asthma and how to control it.24,25
Tracking these school health policies and practices is important in assessing state-level efforts to create safe learning environments, improve the health and well-being of students, and ensure disease management of students with chronic health conditions such as asthma.8 Identifying and tracking students with a current diagnosis of asthma, increasing students’ and parents’ knowledge about asthma, and professional development of school staff on asthma could foster partnerships among families, clinicians, and school nurses centered on the child, and assist in establishing a circle of support for asthma care.10,12,14–16
School policies and practices can provide the support and infrastructure needed for chronic disease management of students and professional development of staff members. Those steps are crucial in reducing school absenteeism, increasing academic success, and promoting and maintaining the health and well-being of students, including those with asthma.10–13 School districts with a policy requiring schools to provide health services to address chronic health conditions of students also are more likely to provide funding for or offer professional development on health services.25 Having a school nurse on-site and easy access to a school-based health center for consultation could improve health services offered at schools. Such services might include identification or school-based management of health conditions, tracking, case management, and referrals for chronic health conditions, such as asthma or diabetes.25,26
CDC provides guidance on addressing asthma management at schools through coordinated school health programs.10,23,24 CDC’s National Asthma Control Program established strategies to help people with asthma achieve better health and improved quality of life. The program also funds states and non-government organizations to help them improve surveillance of asthma, train health professionals, and educate persons with asthma and their families.24
The findings in this report are subject to at least three limitations. First, the cross-sectional design and data used were school-based and not at the individual level. Therefore, the effects of implemented school policies and practices on students’ health and safety could not be established. Second, data were self-reported and thus are prone to response or recall bias because of inaccurate recall or social desirability of providing positive responses. However, the reporting bias might be minimal because school principals and LHETs are more likely to know more about the school health policies and professional development opportunities for asthma than are other school staff members. Finally, the study population included schools in only 36 of the 50 states. Although the number of states represent the majority, the findings cannot be generalized to the states that did not participate in Profiles during the study period.
IMPLICATIONS FOR SCHOOL HEALTH
We assessed the implementation of 6 asthma-related school health policies and practices in participating schools across 36 states and how use has changed over time. The study findings indicate that use of 6 asthma-related school health policies and practices varied across states. The stable to upward trends in use across states suggest that many schools have maintained and improved their efforts to identify and track students with a current diagnosis of asthma and increase students’ and parents’ asthma knowledge. Because of low implementation and mixed trend results among states, further improvement is needed in referral of students with a current diagnosis of asthma to health care professionals and encouraging LHETs receiving professional development on asthma. School policies can benefit the overall health and academic performance of students. Results from this study can help states in the study to further improve adaptation of asthma-related school health policies.
Human Subjects Approval Statement
As a surveillance system, School Health Profiles has been determined to be exempt from review by the Centers for Disease Control and Prevention institutional review board. However, some individual states and school districts have chosen to submit their Profiles surveys for review; approval has been granted in all these cases.
Acknowledgments
The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. We thank Dr. Zanie Leroy, MD, MPH and Ms. Holly Hunt from School Health Branch, Division of Population Health, CDC for their review and useful suggestions.
Footnotes
Conflict of Interest
The authors declare they have no conflicts of interest.
REFERENCES
- 1.Zahran HS, Bailey CM, Damon SA, Garbe PL, Breysse PN. Vital signs: asthma in children-United States, 2001–2016. MMWR Morb Mortal Wkly Rep. 2018;67:149–155. 10.15585/mmwr.mm6705e1externalicon. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Centers for Disease Control and Prevention. National Health Interview Survey (NHIS) Data. 2021. Available at: https://www.cdc.gov/asthma/most_recent_national_asthma_data.htm.
- 3.Akinbami LJ, Moorman JE, Liu X. Asthma prevalence, health care use, and mortality: United States, 2005–2009. Natl Health Stat Report. 2011;12(32):1–14. [PubMed] [Google Scholar]
- 4.Nurmagambetov T, Kuwahara R, Garbe P. The economic burden of asthma in the United States, 2008–2013. Ann Am Thorac Soc. 2018;15(3):348–356. [DOI] [PubMed] [Google Scholar]
- 5.Hsu J, Qin X, Beavers S, Mirabelli MC. Asthma-related school absenteeism, morbidity, and modifiable factors. Am J Prev Med. 2016;51(1):23–32. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Centers for Disease Control and Prevention. Asthma-Related Missed School Days among Children Aged 5–17 Years. 2015. Available at: https://www.cdc.gov/asthma/asthma_stats/missing_days.htm
- 7.National Asthma Education and Prevention Program, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. 2007. Available at: https://www.nhlbi.nih.gov/sites/default/files/publications/08-5846.pdf.
- 8.Centers for Disease Control and Prevention. School Health Services. 2019. Available at: https://www.cdc.gov/healthyschools/schoolhealthservices.htm..
- 9.American Lung Association. Asthma-Friendly Schools Initiative Toolkit. 2020. Available at: https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/asthma-education-advocacy/asthma-friendly-schools-initiative/toolkit.
- 10.Centers for Disease Control and Prevention. About CDC Healthy Schools. 2019. Available at: https://www.cdc.gov/healthyschools/about.htm.
- 11.Clark NM, Brown R, Joseph CL, Anderson EW, Liu M, Valerio MA. Effects of a comprehensive school-based asthma program on symptoms, parent management, grades, and absenteeism. Chest. 2004;125(5):1674–1679. [DOI] [PubMed] [Google Scholar]
- 12.Kakumanu S, Lemanske RF Jr. Asthma in schools: how school-based partnerships improve pediatric asthma care. Immunol Allergy Clin North Am. 2019;39(2):271–281. [DOI] [PubMed] [Google Scholar]
- 13.Trivedi D Cochrane review summary: asthma education for school staff. Prim Health Care Res Dev. 2019;20:e149. 10.1017/S1463423619000860. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Langton CR, Hollenbach JP, Simoneau T, Cloutier MM. Asthma management in school: parents’ and school personnel perspectives. J Asthma. 2020;57(3):295–305. [DOI] [PubMed] [Google Scholar]
- 15.Kew KM, Carr R, Donovan T, Gordon M. Asthma education for school staff. Cochrane Database Syst Rev. 2017;4(4):CD012255. 10.1002/14651858.CD012255.pub2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Centers for Disease Control and Prevention. Strategies for Addressing Asthma in Schools 2015. Available at: https://www.cdc.gov/asthma/pdfs/strategies_for_addressing_asthma_in_schools_508.pdf.
- 17.Centers for Disease Control and Prevention, School Health Profiles 2018: Characteristics of Health Programs among Secondary Schools 2018. Available at: https://www.cdc.gov/healthyyouth/data/profiles/pdf/2018/CDC-Profiles-2018.pdf.
- 18.Brener ND, McManus T, Wechsler H, Kann L. Trends in professional development for and collaboration by health education teachers-41 states, 2000–2010. J Sch Health. 2013;83(10):734–742. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Centers for Disease Control and Prevention 2019. 2018 School Health Profiles School Principal Questionnaire. Available at: https://www.cdc.gov/healthyyouth/data/profiles/pdf/2018/2018_questionnairep.pdf.
- 20.Centers for Disease Control and Prevention 2019. 2018 School Health Profiles Lead Health Education Teacher Questionnaire. Available at: https://www.cdc.gov/healthyyouth/data/profiles/pdf/2018/2018_questionnairet.pdf. Accessed March 23, 2021.
- 21.Centers for Disease Control and Prevention. Conducting Trend Analyses of YRBS Data 2020. Available at: https://www.cdc.gov/healthyyouth/data/yrbs/pdf/2019/2019_YRBS_Conducting_Trend_Analyses.pdf.
- 22.National Institutes of Health. Managing Asthma. A Guide for Schools, NIH Publication No. 14–2650. 2014. Available at: https://www.nhlbi.nih.gov/files/docs/resources/lung/NACI_ManagingAsthma-508%20FINAL.pdf. [Google Scholar]
- 23.Centers for Disease Control and Prevention. EXHALE Guide for Schools 2020. Available at: https://www.cdc.gov/asthma/exhale/documents/EXHALE_Guide_Schools-508.pdf.
- 24.Centers for Disease Control and Prevention. EXHALE Guide for People with Asthma, their Families, and their Caregivers 2020. Available at: https://www.cdc.gov/asthma/exhale/documents/EXHALE-Guide-People-with-Asthma-Families-Caregivers-508.pdf.
- 25.Jones SE, Brener ND, Bergren MD. Association between school district policies that address chronic health conditions of students and professional development for school nurses on such policies. J Sch Nurs. 2015;31(3):163–166. 10.1177/1059840514547275. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Knopf JA, Finnie RK, Peng Y, et al. School-based health centers to advance health equity: a community guide systematic review. Am J Prev Med. 2016;51(1):114–126. 10.1016/j.amepre.2016.01.009. [DOI] [PMC free article] [PubMed] [Google Scholar]