Journal of Asthma, 44:449–453, 2007Copyright C© 2007 Informa HealthcareISSN: 0277-0903 print / 1532-4303 onlineDOI: 10.1080/02770900701421955

ORIGINAL ARTICLE

Providence School Asthma Partnership: School-based Asthma Program

for Inner-City Families

JUDITH D. DEPUE, ED.D., M.P.H.,1∗ ELIZABETH L. MCQUAID, PH.D.,2 DAPHNE KOINIS-MITCHELL, PH.D.,2

CHRISTOPHER CAMILLO, B.A.,3 ANTHONY ALARIO, M.D.,3 AND ROBERT B. KLEIN, M.D.3

1The Centers for Behavioral and Preventive Medicine, the Miriam Hospital/Brown Medical School, Providence, Rhode Island2Bradley Hasbro Children’s Research Center/Brown Medical School, Providence, Rhode Island

3Department of Pediatrics, Rhode Island Hospital/Brown Medical School, Providence, Rhode Island

Over 3 years, 972 families participated in an after-school asthma program at their child’s school. Parents and children attended concurrent21/2 -hour workshops. Parents were 74% Latino; 45% non-English speaking, with 77% of children on Medicaid. Asthma symptoms were significantlyreduced, from multiple times per week to less than once per week on average. Oral steroid use decreased to one third of baseline use. Hospital daysdecreased from 11% to 2%; emergency visits decreased 35% to 4%; and school days missed decreased 48% to 20%. This program has now becomesustainable with both private and Medicaid insurance coverage.

Keywords asthma, intervention, children, ethnic minority, urban schools

INTRODUCTION

Childhood asthma has become a major public health con-cern because of its increasing prevalence, particularly inethnic minority children from low-income backgrounds (1).Asthma affects over 7 million children younger than 17 yearsof age and significantly affects many of these children’s func-tioning. Children with asthma miss an estimated 10 milliondays of school each year (2). Emergency department visitsand hospitalizations for asthma have increased disproportion-ately among African American and Latino children (2).

Managing asthma can be challenging for children and fam-ilies, across home and school settings. Effective asthma con-trol involves consistent use of quick-relief and preventivemedications, avoidance of allergens or irritants from the en-vironment, and effective monitoring and response to asthmasymptoms as they occur (2). The National Asthma Educationand Prevention Program (NAEPP) (2) was initiated to addressthe growing problem of asthma in the US through education.This initiative resulted in the development of educational ma-terials and programmatic models for public disseminationthat emphasize current asthma management goals. The clin-ical and pragmatic implications of such programs extend be-yond improving asthma-specific outcomes for children to en-hancing their overall learning and school-related functioning,increasing symptom free days, decreasing absenteeism, andminimizing the amount of days caregivers miss from work be-

This work was funded by Robert Wood Johnson Foundation, Local Ini-tiatives, Rhode Island Foundation, Rhode Island Hospital Foundation, andHealth and Education Leadership for Providence.

This work was previously presented in part at American Public HealthAssociation, November 2004, Washington, DC.

∗Corresponding author: Judith DePue, Ed.D., M.P.H., Centers for Behav-ioral and Preventive Medicine, The Miriam Hospital, Coro Bldg., Suite 500,One Hoppin St., Providence, RI 02903; E-mail: JDePue@Lifespan.org

cause of the need to stay home to care for their child. Because8.8% of children have asthma (3) and school-aged childrenspend one third of their day in school, schools have beenidentified as an important point of intervention for asthmacontrol.

A recent systematic review of 32 published random-ized controlled trials of educational programs for self-management of asthma in children and adolescents (2 to18 years of age) found modest to moderate improvementsin many outcomes, including lung function, self-efficacy, ab-senteeism from school, number of days of restricted activities,visits to an emergency department, and nights disturbed byasthma (4). The relatively few studies that utilized school set-tings found improvements in a variety of outcomes, includingknowledge, self efficacy, self-care practices (5) school grades,asthma symptom scores (6, 7), school days missed due toasthma (7, 8), and in urgent health-care visits and quality oflife (8). The intervention models for these programs oftenutilize a series of classes for children during the school day(6) or they have expanded on this model to include parent,teacher, and school personnel involvement (7, 8). Because itis sometimes difficult to gain access to children’s school-dayclasses for asthma education, other intervention models areneeded. Use of after-school hours also permits opportunityfor asthma education with parents.

In Rhode Island, where approximately 18,700 childrenhave asthma, asthma-related hospitalizations in Providenceare twice the statewide rates (6.3/1000 vs. 3.6/1,000) (9).Providence is a minority majority school district character-ized by high rates of recent immigration from Latin Ameri-can and the Caribbean, especially from Dominican Republicand Puerto Rico, where asthma risk is higher than in otherLatino populations (10). In 1999, when our project was devel-oped, over 25,000 students were enrolled in the ProvidenceSchool District, and 75% were eligible for free or reduced-priced lunch. The student population was 55% Latino, 23%

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450 J. D. DEPUE ET AL.

African American or black, 11% Asian/Pacific Islander, and11 % white. The number of Latino families populating greaterProvidence is steadily growing. Median family income of stu-dents in 1999 was $28,342, and only 2% of Providence thirdgraders met the state’s writing standard.

In 1999, it was clear that an outreach program was neededfor asthma, as few families were using the hospital-basedasthma education services, even while the regional children’shospital is located in the Providence inner city. The Provi-dence School Department was also concerned about the im-pact of asthma on children’s attendance and performance andwas interested in developing ways to bring parents to theschool as part of their larger effort to increase parent partici-pation in children’s educational programs. Considering highproportions of ethnic minorities in Providence Schools, it wasimportant that outreach strategies be culturally appropriate.

Thus a partnership was formed to conduct asthma educa-tion workshops for children with asthma and their familiesin Providence elementary schools. This program is uniquefrom others reported in the literature, as it uses a school-basedmodel, offered during after-school hours; it includes parenteducation in both English and Spanish, provides concurrentparent and age-appropriate education for children, and offersan additional asthma parent support group for families. Thesingle educational workshop emphasized asthma knowledgeand behavior change strategies, including managing environ-mental triggers and appropriate use of asthma medications.Based on our prior experience, a longer single session provedto be more practical due to parents’ difficulty in attending se-rial sessions, where key content was missed with irregularattendance. As a means to reinforce education and providefurther learning opportunities, a bi-monthly asthma supportgroup was offered to all families following the workshop. Theprogram was designed to meet the needs of urban, ethnicallydiverse families with use of bicultural, certified asthma edu-cators, with provision of childcare for younger children, taxiservice, and a dinner meal. Another program feature involvedcontinuing education training for school nurses. Before andafter assessments, collected from September 2000 throughJune 2004, provided the opportunity for a naturalistic study.

METHODS

Study Design and PopulationAll families were recruited from Providence public ele-

mentary schools, with students in grades K-6. School nursesidentified children with asthma for recruitment by projectstaff. A letter was first sent home to families, giving par-ents the opportunity to refuse contact by project staff if theypreferred. Fliers promoting the asthma workshop were alsosent out to all families to alert any families not included innurse records. Registration information was collected fromparents by telephone and included demographic character-istics, along with number of family members to attend, andwith transportation and baby-sitting needs. The project useda single group design to compare asthma symptoms and uti-lization outcomes during 12 months before workshop partic-ipation, reported by parents at baseline, with the 12 monthsafter the workshop, reported at a follow-up interview.

Asthma Status MeasuresAsthma Functional Severity Scale. The registration inter-

view also assessed the impact of asthma on the child’s dailyfunctioning over the past year, with the Asthma FunctionalSeverity Scale (AFSS) (11). The scale examines four compo-nents of children’s asthma morbidity, including episode fre-quency, frequency of symptoms between episodes, intensityof impairment during an episode, and intensity of impairmentduring intervals between episodes. The functional morbidityindex score is calculated by computing a mean across allcompleted items, with higher scores indicating greater im-pairment (range 0-4). The AFSS was developed on a sampleof more than 10,000 children; the index score is significantlycorrelated with school absences, medical visits for asthma,and medication use (11). Additional questions were addedregarding oral steroid use.

Utilization data. Parent interviews also assessed asthma-related emergency department (ED), overnight hospital uti-lization, and school days missed due to asthma in the pastyear.

InterventionThe primary intervention consisted of a single 21/2-hour

workshop to parents and children at each of 24 Providenceelementary schools. Each school hosted four workshops overa 3-year period to increase access to families and offer oppor-tunities for repeat attendance. The workshop curriculum wasbased on National Institutes of Health recommendations (2),tailored to low-literacy parents, in both English and Span-ish languages. These recommendations included describingcontrast between asthmatic and normal airways, understand-ing what happens to airways in an asthma attack, under-standing how asthma medications work (quick relief versuslong-term control), demonstrating use of inhalers, spacersand peak flow meters, and identifying environmental trig-gers. Intervention emphasis was on knowledge and prac-tical behavioral strategies, such as identifying early warn-ing signs for asthma attacks, managing asthma triggers, andappropriate use of asthma medications. Asthma peak flowmeters and spacers were provided to parents. English andSpanish-speaking workshops were held concurrently in dif-ferent rooms (no translation) by certified asthma educators.Project staff represented the cultures in the community, in-cluding African American, Latino, Native American, andCaucasian residents. Also, three of five project staff wereparents of children with asthma.

A separate children’s workshop, based on the same in-formation described above and tailored in an age-appropriatemanner, was simultaneously conducted. The children’s work-shop was taught by a child psychologist who focused on be-havioral strategies and used interactive games and hands-onactivities to show asthma’s effects on the lung and to identifyenvironmental triggers. They also used a rhyme, “Asthma’sMagic Number,” to help the children remember importantinformation. At the end of the evening, the children gavea brief performance—in rhyme—to their parents, to demon-strate what they had learned. To address needs of low-incomefamilies, transportation was provided, along with babysittingfor any younger siblings, and dinner for the family.

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PROVIDENCE SCHOOL ASTHMA PARTNERSHIP 451

After workshop participation, parents were invited to at-tend ongoing bi-monthly asthma support groups, in Englishor Spanish, for further learning and reinforcement of educa-tion content. Both groups used a bi-cultural staff member ascoordinator. The meetings typically hosted a guest speaker,with opportunity for group discussion. Refreshments, on-sitebaby sitting, and transportation were also provided for thesesessions. The project also offered two 1-hour training ses-sions on asthma management for school nurses, on the firstand third years of the project, to provide an update on asthmamedications and practice guidelines, with continuing educa-tion credit.

Statistical AnalysisWe examined whether bias was introduced by response rate

at follow-up by comparing follow-up responders and non-responders on baseline characteristics, using t-tests for con-tinuous variables and chi-square for categorical variables. Wealso examined characteristics of those who repeated work-shop attendance and those who utilized support groups bycomparing each of these subgroups, respectively, with allothers, on key demographic and asthma-related variables. Foranalyses regarding changes in asthma morbidity, we utilizedANOVA models. Because the parents attended workshops ineither English or Spanish language and families were clus-tered within 24 schools, the analysis design used analysisof variance (ANOVA) models with type of class (English vs.Spanish) nested within school and the 24 schools were nestedwithin the total sample. For our other primary outcomes, (i.e.,changes in asthma-related emergency room and overnighthospital utilization and changes in school days missed due toasthma), we utilized the McNemar test of proportions, as thedata were not normally distributed.

RESULTS

Program AttendanceSince families were given multiple opportunities to attend

the workshops, our database featured data associated withthe first attendance for each child, while any additional at-tendance was also noted. Thus, the following data reports arebased on unique individuals who attended over the course of3 school years. Attendance totaled 972 children, with first-time attendees decreasing from 415, to 323, to 234 over theconsecutive years, respectively. Attendance across schoolsranged from 15 to 56, over the 3 years. All children were ac-companied by at least one parent, but the child’s attendanceis used for family participation counts. Twenty-five percentof families chose to repeat attendance of the workshop (range1–6 times). Twenty-six percent of parents attended a supportgroup at least once (range 1–20 times). Repeat workshop andsupport group attendees were more likely to be Latino thanother ethnic groups (X 2 = 31.32, p < 0.001), however, therewere no differences in baseline asthma severity by singleversus multiple attendances. The professional nurse trainingcomponent was attended by 100% of nurses; 81% of nursessat in on after-school family workshops.

Demographic Characteristics of ParticipantsFamilies who attended were predominantly Latino and

45% of parents did not speak English. Usually mothers at-

tended (90%), although sometimes both parents attended theworkshop. Most children had health insurance (97%), includ-ing a large proportion with RIte Care (77%), the Rhode Islandmanaged Medicaid program (see Table 1). Over the 3 years,the percentage of Latino and non-English speaking parents in-creased, and parents’ education levels decreased significantly(data not shown). Approximately 69% of children had moresevere asthma symptoms on functional morbidity scores (fmsscore ≥ 1). Approximately 35% of parents reported that theirchild was prescribed an oral steroid for asthma treatment inthe previous year. Thirty-five percent of the sample at base-line had one or more ED visits due to asthma and 11% hadat least one asthma-related hospitalization in the past year.Almost half (48%) had one or more school days missed dueto asthma.

Changes in Asthma OutcomesAsthma outcomes were analyzed on 559 participants with

data at both baseline and follow-up. Response rates at the12-month follow-up averaged 60% for the first 2 years, butdecreased to 51% in the third year. We examined differencesin demographic and key asthma variables at baseline betweenthose who completed follow-up and those who did not. Par-ticipants without follow-up data were not different from thosewith data in terms of child age, child gender, or whether thefamily had health insurance. Latino families demonstrated atrend toward higher follow-up participation (60.5% overall,with other ethnic groups ranging from 20–51%) (X 2 = 11.77,p < 0.07). Accordingly, follow-up rates were also higher(63.2%) in families where Spanish was the language spokenmost often in the home (X 2 = 22.21, p < 0.001), comparedto homes where English was the primary language (48.1%).Children lost to follow-up also appeared to have slightly moresevere asthma, with higher functional morbidity scores, F(1, 87) = 10.33, p < 0.001, greater frequency of hospital-izations, X 2 = 5.61, p < 0.05, and marginally higher EDutilization, X 2 = 3.54, p < 0.07, at baseline.

Changes in asthma morbidity were significant over time,while controlling for type of class (English vs. Spanish) andschool, in the model, F (1, 428) = 183.77, p < 0.001. Al-though significant variability between schools was noted,

TABLE 1.—Participant characteristics.

Total sample at baselinen = 972

Child’s age, mean (SD) 8.1 (3.0)Child’s gender, % male 57.1Parent’s education, %

8th grade or less 13.6Some high school 25.7High school or GED 29.9Some college/vocational training 13.8College graduate 4.5Post grad training 7.7Refused/missing 4.7

Parent speaks English 55.0Race/ethnicity, %

White 7.2Latino 73.5African American 9.1Other 3.7Refused/missing 6.6

Medicaid (RIte Care), % 76.7Children < 18 living at home, mean (SD) 2.8 (1.3)Children at home with asthma, mean (SD) 1.8 (1.0)

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452 J. D. DEPUE ET AL.

TABLE 2.—Change in asthma-related outcomes from 12 months before school-based workshop to 12 months after (per parent report).

12 months 12 months Significantpre-workshop follow-up Statistic time effect

Asthma morbidity, mean 1.63 .62 F (1, 428) = 183.77 p < 0.001Score range 0-4 (infrequent to daily symptoms)

Oral steroid use in past year, percent “yes” 35 12 X 2 = 84.9 p < 0.001Any emergency department visit in prior year, % 35 4 X 2 = 135.01 p < 0.001Any hospitalizations in prior year, % 11 2 X 2 = 35.21 p < 0.001Any school days missed in prior year, % 48 20 X 2 = 84.1 p < 0.001

F (23, 428) = 2.32, p < 0.001, no significant main effector interaction was noted by whether the class was given inEnglish or Spanish. On average, the pretest functional mor-bidity score was 1.63, which represents asthma symptomsoccurring approximately 1 to 2 times per week. At follow-up, the average functional morbidity score had decreased to0.62, which corresponds to symptoms occurring less thanweekly.

All medication and utilization outcomes showed signifi-cant improvements over time. The drop in oral steroid usewas one-third what it was at baseline, from 35% of sampleto 12% of sample (X 2 = 84.9, p < 0.001). Reductions inED and hospitalizations were dramatic, from 35% to 4% forED visits (X 2 = 135.01, p < 0.001) and 11% to 2% for hos-pitalizations (X 2 = 35.21, p < 0.001). School days misseddropped by more than half that of the year before the asthmaeducation workshop, decreasing from 48% to 20% of chil-dren missing any school days due to asthma (X 2 = 84.1,p < 0.001) (see Table 2).

DISCUSSION

This intervention model focused on a single 21/2-hourafter-school workshop with parents, with a concurrent chil-dren’s session. Additional components included the oppor-tunity to repeat the workshop, which was utilized by 25% ofparents, and a bi-monthly support group with asthma expertspeakers, which was attended by 26% of parents. Thus, thesingle workshop was the primary opportunity to reach mostparents. Overall, asthma symptoms were significantly im-proved, with symptoms reported at multiple times per weekat baseline to less than once per week on average at follow-up, while controlling for language of parent workshop andfor school in nested analysis. There was significant varia-tion across schools, which was not surprising, with variableprincipal and school nurse support. Schools with more activeschool nurse involvement, including more active recruitmentof families and attendance at workshops, had higher familyparticipation rates and better outcomes. While 45% of parentswere non-English speaking, there was no significant main ef-fect or interaction effect on language in which the class wasdelivered.

Other outcomes also improved significantly. Oral steroiduse decreased from 35% to 12% who reported any oral steroiduse in the previous year. Hospital days due to asthma droppedfrom 11% to 2%, emergency visits dropped from 35% to 4%,and school days missed due to asthma decreased from 48%to 20% from the year before the workshop to the year afterthe workshop.

We were especially successful recruiting families in theLatino community, beyond the proportion of Latino chil-dren in the schools. There are few reports in the literature

on asthma interventions in this population. This success maybe because of a greater need among recent Latino immigrantsfor this service. Recruitment was through the efforts of schoolnurses, as well as word of mouth in the community. Our staffalso participated in many community events (health fairs,cultural festivals) and media opportunities (Spanish news-paper stories, talk shows). We observed a higher propor-tion of single parents and more frequent household movesamong African American families. However, the impact ofsuch observations on family asthma management would bespeculative.

The intervention plan purposely created multiple offeringsin the same school to increase opportunities for families toattend to accommodate busy families who sometimes cannotattend at the last minute and families who want a review ofthe content. We found that Latino families more likely uti-lized these extra workshop opportunities than other ethnicgroups, while there was no difference in asthma severity be-tween multiple and one-time workshop attendees. These mul-tiple opportunities were apparently appreciated and offeredfamilies in need an opportunity to connect with a culturallyfamiliar resource.

Our project’s emphasis on increasing school attendanceand on realistic expectations of staff/district involvementwere important in building a working relationship with theschool department. In Rhode Island and nationwide, urbanschools strive to become community centers with “out ofschool time” activities, making them good sites for healthintervention projects. In working with schools, project staffmust work to develop the trust of school staff. While supportfrom the school district needs to be articulated at the out-set of a project, their trust is earned by ensuring that projectstaff will respect their space—leaving classrooms the waywe found them, by starting and ending on time, and by show-ing that families will come and give positive feedback. Weprovided annual reports to principals and school nurses, withschool-specific attendance and reductions in school absencesfound in our 12-month follow-ups.

Our efforts have subsequently focused on how to sustain(maintain and expand) services. Based on success in Prov-idence, we have negotiated with the three main RI healthinsurers to add a member benefit for asthma education. Themodel has now been expanded into other areas of RhodeIsland.

We would like to comment on some limitations in ourstudy. Our design did not include randomization or a con-trol group. It is therefore not possible to determine whetherthere was regression to the mean or if there were impor-tant trends in the community to account for the observedchanges, such as changes in medical reimbursement thatwould affect utilization rates for ED and hospitalizations.

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PROVIDENCE SCHOOL ASTHMA PARTNERSHIP 453

However, asthma healthcare utilization surveillance datafrom RI RIte Care (RI Managed Medicaid program) is avail-able for 1998–2002, and this showed a fairly constant inpa-tient rate (50–75 admissions for asthma per 10,000) duringthis period; there was more variation in ED rates, but witha repeating seasonal pattern (low of 100 asthma visits per10,000 in July-September quarters to high of 200–225 vis-its per 10,000 in October-December quarters) (12). Sinceour data were collected year-round, one-year apart for eachchild, any seasonal effects were collapsed. Medical reim-bursement policies would not likely affect other outcomes,such as school days missed due to asthma. Furthermore, therewere no changes in overall school absences in the ProvidenceSchools during this time period. We were limited to parentreport on outcomes, which may have been biased by social de-sirability factors or Hawthorne effect. However, others havefound parents’ reports of symptoms, functional health sta-tus, and health care utilization to accurately define asthmastatus in children (13). We experienced a loss to follow-up,where non-Latinos were significantly less likely to be rep-resented at follow-up, as were children with more severeasthma. Others have reported low follow-up rates in school-based programs with low-income ethnically diverse families(41%–23%), with lower Latino rates (14). Our participantswere not enrolled in a formal research study, with fiscal in-centives to complete assessments. Therefore, this bias mayhave resulted in overstating our outcomes. However, 65%of children in our analysis sample had more severe asthmasymptoms at baseline. Thus, our outcomes were represen-tative of a large proportion of children with severe asthma.At the same time, inclusion of families with children whohad mild as well as more severe asthma symptoms may haveminimized the degree of impact on the sample as a whole.

CONCLUSIONS

Our naturalistic study has an important strength in its abil-ity to reach a predominately Latino population at high risk forasthma complications and provide needed asthma manage-ment strategies. This program generated significant improve-ments in asthma symptoms, oral steroid use, asthma-relatedemergency department visits, overnight hospital stays, andschool days missed due to asthma. Our program results havealso allowed us to negotiate reimbursement from the state’sthree major health insurers, including the state’s managedMedicaid provider, to add a member benefit for asthma ed-ucation, allowing us to expand and sustain this service. Thisnew coverage represents a major change in the system ofcare for children and families with asthma in Rhode Island.This success can be cited by other programs/states lookingto achieve similar change.

ACKNOWLEDGMENT

The authors wish to acknowledge Catherine Mansell,R.N., M.S., for her work in developing this program for the

Providence schools. The authors are grateful for her visionand diligence in launching the program. The authors also wishto acknowledge their program staff, Catherine Kempe, ArelisValerio, Pastora Medina, and Lisa Letang, as well as to theProvidence School Department and its school nurse teach-ers, whose dedication to the health of Providence families isappreciated by all.

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