Health Education Research, Vol. 17, No. 2, 181-194,
April 2002
© 2002 Oxford University Press
The prevalence and management of asthma in primary-aged schoolchildren in the south of England
1 Health Education Unit, Research and Graduate School of Education, and
2 Allergy and Inflammation Sciences, School of Medicine, University of Southampton, Highfield, Southampton SO17 1BJ,
3 NHS Portsmouth Healthcare Trust, Dunsbury Way Clinic, Havant PO9 5BG and
4 Highcliffe Junior School, Highcliffe BH23 5AZ, UK
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Abstract |
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A postal questionnaire survey of headteachers in 149 Infant, Junior and Primary schools (response rate: 63.8%) indicated poor asthma record keeping and a need for regular staff training in asthma. Dealing with an emergency was a major concern of headteachers. In 25 of the schools surveyed, an International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire was distributed to parents of children in Years 3 and 4 (7–9 years). Headteacher-reported asthma prevalence was 11.9% in these schools, while ISAAC parental reports indicated a current or previous diagnosis of asthma in 24.3% children, with 17.8% receiving asthma treatment and 18.9% reporting wheeze in the previous 12 months. Of six wheezing children per Year 3/4 class, one was receiving no treatment for asthma, three had experienced four or more attacks of wheeze in the previous year with one wheezing child per two Year 3/4 classes experiencing more than 12 such attacks. Four in six children experienced exercise-related wheeze, while only one in five schools allowed asthma medication at Physical Education lessons. A whole school policy on asthma together with some regularly updated staff education and training by an asthma-trained nurse would address many of the issues raised in this study.
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Introduction |
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School context
The last decade of the 20th century saw an increasing interest in whole school approaches to health education/health promotion both nationally and internationally (St Leger, 1999
). In Europe the World Health Organization, the European Union and the Council for Europe have supported this development through the European Network of Health-Promoting Schools (Rasmussen and Rivett, 2000). In England throughout the 1990s, numerous Local Education Authority and Health Authority schemes (Rogers et al., 1999) have resulted in the introduction of the Healthy Schools Standard (Department for Education and Employment, 1999) which uniquely enjoys the support of both the Ministry of Education and the Ministry of Health.
As the Healthy School Standard acknowledges, many schools work towards becoming a healthy school by focusing first on a particular health-related behaviour such as diet, exercise, or on the so-called sensitive issues such as drug use and misuse or sexual health or on the school environment. What healthy or health-promoting schools share in common is the commitment to a curriculum, school policies and relationship with the wider community which are tailored towards mental, physical and social well-being of the whole school community, whatever the issue under consideration. Studies have shown that where a school adopts this approach to promoting the health and well-being of pupils, achievement is higher, reports of bullying decrease and the frequency of health risk behaviours is reduced (Durlak, 1995; Moon et al., 1999; St Leger, 1999).
Rarely, however, within the framework of the health-promoting school, do mainstream schools focus on the health needs of a particular group of pupils. Nevertheless, children with chronic health problems may benefit from a whole school approach to their needs. In this paper we describe the first steps towards building such an approach to the needs of children with asthma.
Extent of the problem
Asthma is the most common cause of illness in childhood. Evidence obtained through the use of a standardized protocol, the International Study of Asthma and Allergies in Childhood (ISAAC), for the collection and international comparison of epidemiological data relating to asthma and allergies in children (Asher et al., 1995) indicates a world-wide increase in the prevalence of the disease. Reports in the medical literature also indicate that the number of children experiencing attacks of asthma is increasing (Rona et al., 1995; Kuehni et al., 1998). In the UK, nationwide surveys have reported that one in seven children aged 2–15 years may currently require treatment for asthma (National Asthma Campaign, 1999a). Furthermore, an ISAAC national survey shows that this figure may be as high as one in five amongst children aged 12–14 years (Kaur et al., 1998). Prevalence of asthma is higher in boys compared to girls (1.3:1) (Joint Health Surveys Unit, 1998a). The reported prevalence of wheeze-related problems (with or without a diagnosis of asthma) over the previous 1 year can be higher, with some national surveys reporting prevalences of 20–30% or more (Joint Health Surveys Unit, 1998a; ISAAC Steering Committee, 1998). In a class of 30 children, therefore, at least four to six children currently with or without a diagnosis of asthma may have wheeze-related problems.
Nature of the problem
Asthma can have a serious impact on a child's physical and emotional well-being. For some children the illness can impose restrictions on their activities, particularly Physical Education and extra-curricular activities, and may result in increased absence from school (Lenney et al., 1994). Recent large surveys indicated that one in six children with asthma reported, on average, 9 days of schooling lost in one term because of asthma (Fillmore et al., 1997) and that of those children, aged 7–15 years, who had experienced wheezing attacks in the last 12 months, 48% had taken time off school (Joint Health Surveys Unit, 1998b). One in every four or five who wheeze also experience sleep disturbance on one or more nights per week while two to three of them may experience interference in their daily activities (Joint Health Surveys Unit, 1998b). There is some evidence that night-time awakenings in children and adolescents with asthma may affect school attendance and performance (Diette et al., 2000). Previous reports have suggested that poor management and control of the disease together with psychological problems are factors which may contribute to poor performance at school (Celano and Geller, 1993; Bender, 1995). There is a substantial literature reporting that children with chronic illness including asthma have increased internalizing and externalizing behaviour problems although the evidence for lower levels of self-concept and self-esteem in such children is not as clear (Lavigne and Faier-Routman, 1992; Boekaerts and Roder, 1999).
The role of staff and school in tackling the problem
Although asthma can have a major adverse effect on the health and education of a high proportion of children, reports indicate that the level of knowledge and training for school staff is low (Bevis and Taylor, 1990; Brookes and Jones, 1992; Carruthers et al., 1995). School held records on the number of children in a school or class who may have asthma are also often incomplete (Carruthers et al., 1995). Since ready access to inhaler therapy is required for the relief of symptoms and to prevent a more serious attack, the number of children reported to carry their own inhalers in schools is also lower than might reasonably be expected (Bevis and Taylor, 1990; Carruthers et al., 1995; Fillmore et al., 1997; Brown et al., 1998).
Since asthma is both common amongst school-aged children, and is reported to have considerable impact on the child's physical, mental and educational abilities, a whole school approach to asthma management seems to offer considerable opportunities for improving asthma management in schools. Such an approach could include curriculum intervention, appropriate school policy and links with families, communities and other agencies (Moon et al., 1999), and should be supported by professional development for teachers and other staff (St Leger, 1999, 2000).
Previous initiatives
A number of initiatives have already been conducted in different areas of the UK by local authorities, schools and school health personnel including the Devon Schools Asthma Project whose efforts have been highlighted in a recent National Asthma Campaign Report (National Asthma Campaign, 1999b). These initiatives have been designed to improve the care and management of asthma in schools. However, in many cases, no attempt has been made to evaluate the effectiveness of such interventions by systematically monitoring markers such as improved knowledge of asthma in teachers and pupils, decreased absence and improved levels of morbidity in children with asthma. Some reports do suggest, however, that such interventions can be valuable in increasing the knowledge and understanding of asthma in teachers (Hill et al., 1991; Coleman et al., 1995). However, a recent nationwide survey by the National Asthma Campaign (National Asthma Campaign, 1999b) suggests that little progress has been made in terms of putting in place an asthma policy in schools. Without such a policy, it is unlikely that a school could be said to be taking a whole school approach.
The present study
This paper reports on two aspects of asthma management in schools which are necessary for effective planning and implementation of a whole school approach: monitoring asthma prevalence and reviewing staff involvement. Other aspects of asthma management such as curriculum development, policy review and the involvement of outside agencies will be dealt with in another paper. Together these form part of a project, the Schools Asthma Management Project (SAM), being conducted by the GAMES group (Group for Asthma Management and Education in Schools) (Coleman et al., 1995) to evaluate a whole school approach to improve the care and management of asthma in schools.
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Methods |
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Headteacher questionnaire survey
A questionnaire relating to the knowledge, care and management of asthma in children was sent out to all 149 schools (Table I
) in the Swindon (n = 71: Infants 22, Junior 21 and Primary 28), and Basingstoke and surrounding (Hook and Fleet) areas (n = 78: Infant 29, Junior 27 and Primary 22). Two reminders were sent to those schools that had not responded within 4 weeks.
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Swindon and Basingstoke are large compact conurbations that are similar on a range of socio-economic and demographic census variables (Department of Health, 1996
). The percentage population under 16 is broadly the same in both areas (Swindon 21.4%; Basingstoke 22.5%). Case admission rates for asthma in children under 15 years in both district are also similar (525/100 000 in Swindon and 564/100 000 in Basingstoke) (National Health Service Executive, 1996), and are around the mean admission rates for England and Wales. Local community and hospital paediatricians and local education authority personnel expressed their support for the Project. The questionnaire contained items relating to: demography of school (four questions); school staff and roll (five questions); asthma school records (six questions); inhaler use (seven questions); occurrence of asthma attacks (four questions); education and training re asthma (six questions); liaison with school nurse (two questions); knowledge and concerns re asthma (three questions); and the occurrence of other chronic childhood conditions in the school (one question).
As part of the survey, headteachers were also invited to participate further in a study designed to improve the care and management of asthma in children. In order to enrol, schools had to have children aged 7–11 years (i.e. Junior or Primary schools) and the number on the school roll had to be greater than 200.
ISAAC asthma questionnaire survey
Following enrolment in the study, the parents of children in Years 3 and 4 in 25 volunteer schools were asked to complete the ISAAC asthma questionnaire to report on the prevalence and severity of asthma symptoms in their 7- to 9-year-old children. A number of studies have employed objective measures of asthma such as lung function, bronchial challenge and skin prick tests, and have found that the ISAAC questionnaire is a valid instrument for determining the prevalence of asthma symptoms (Jenkins et al., 1996; Ponsonby et al., 1996). Questionnaires were distributed by the schools, followed by two reminders. On completion, the questionnaires were returned to the school and forwarded on to the SAM Project office at the Health Education Unit, University of Southampton.
Statistical analysis
Data were entered using SPSS for Windows version 7.5. Differences between year groups within schools were calculated using multivariate analysis of variance and univariate t-tests. Responding and non-responding schools were compared using 
2 tests and a t-test.
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Results |
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Headteacher questionnaire
Headteacher questionnaire response
In total, 149 postal questionnaires and two follow-up reminder letters were sent to headteachers in the Swindon and Basingstoke areas. A total of 95 (63.8%) completed questionnaires were returned (Swindon 59.2%; Basingstoke 67.9%) (Table I
). Headteachers in 19 Infant schools, 23 Primary school and 12 Junior schools did not return questionnaires. No differences were found between responding and non-responding schools in school type, i.e. Infant, Junior or Primary (2 = 4.71, P = 0.1), area (2 = 1.24, P = 0.27), or in the mean number of pupils on the school roll (t = 0.50, P = 0.62) which was 237 pupils per school in responding schools and 230 pupils per school in non-responding schools. No information was available for non-responding schools in terms of geographical location. However, Table I shows differences in geographical location for responding schools with Swindon having lesser rural and more urban schools included in the survey compared to Basingstoke.
Record of asthma
Table II outlines the reported practices for the care and management of asthma in schools participating in the survey. The majority of schools had a record of pupils with asthma kept in the main by the secretarial/administrative staff but in three out four schools, also by the teacher. Nearly two in three of all schools (n = 60) reported being aware of the number of pupils using some form of inhaler therapy, 25 schools reported being unaware of this number and a further 10 schools did not respond to the question. However, when asked to provide the actual number of such pupils using inhaler therapy at school on a regular basis, just over one in three of all schools (n = 35) provided this figure. In just over one in four schools (26.6%) children are given control of their own medication when moving from infant years to Years 3 and 4. However, there is no further increase in pupil responsibility for their own medication with progress into the upper school.
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School-reported prevalence of asthma in pupils
The prevalence of asthma reported by headteachers in schools was 10.3% (11.7% boys, 9.1% girls). Figure 1
shows this reported asthma prevalence over all school years in Infant, Junior and Primary schools. The reported prevalence appears to decline between Years 2 and 3 (infant to junior transition), and then rises again in later school years. Multivariate ANOVA found a significant effect of school year [F(6,16) = 3.6, P < 0.05] with individual within-subject tests showing a significant difference between Years 2 and 3 (P < 0.05).
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Attacks of asthma
Table II
provides information on specific staff members who may have to deal with an acute asthma attack. This shows that the secretary has this responsibility in the majority of schools, followed by the headteacher and/or the teacher; 67.4% of all schools reported that they might expect any teacher to deal with an acute asthma attack, while 51.6% of schools reported that at least one teacher in the school had some training in First Aid. Only seven schools reported that everyone in the school had training in First Aid. Such training, however, is not necessarily an indicator of increased confidence and ability in dealing with an asthma attack.
Education and training in asthma
Twenty-six of 95 (27.4%) headteachers reported that they were `very confident' and 64 of 95 (67.4%) reported that they were `fairly confident' about the care of pupils with asthma. However, `coping with an emergency' was a concern expressed by two-thirds of headteachers (n = 63) with the majority quoting this as their only principal concern, followed by `treatment administration' (n = 21), curriculum access, i.e. Physical Education (n = 10), and safety of or disruption to other pupils (n = 4). The majority of headteachers (n = 69) also reported that they would like to see asthma training as a regular component of staff development with 75 of 95 schools (78.9%) having already received useful information in the past aimed at educating teachers and other members of staff in the care of pupils with asthma. A Health Promotion Unit (n = 26 schools) and the National Asthma Campaign (n = 24 schools) were quoted as sources of information but the majority of schools (n = 56) received this information from the school nurse, with this being the only source of information for nearly one half of these schools. It should be pointed out that school nurses in UK primary schools are not based in a particular school but are allocated a number of schools in which they carry out periodic health checks and provide education and lessons on matters such as general health, hygiene and sex.
ISAAC questionnaire responses in headteacher survey schools (n = 25)
ISAAC questionnaire response
Of the 95 headteacher survey questionnaires returned, 57 schools expressed a wish to participate further in the study (19 Infant, 19 Primary and 19 Junior). For the purposes of continuity and follow-up over a longer period, only Junior and Primary schools with children of the target age (7–9 years) were invited by the SAM Project to participate in the study. Of the remaining 38 Junior and Primary schools, five Primary schools were not invited to participate because of a low school roll (less than 200 pupils) and eight schools later declined to participate (three Junior and five Primary). A total of 25 schools were thus enlisted to the project (10 Primary and 15 Junior).
A total of 3081 ISAAC questionnaires were distributed via the schools to the parents of children in Years 3 and 4 in the 25 schools. After 4 weeks, a reminder letter and a further copy of the questionnaire were sent to the parents. A further reminder letter was sent out 2 weeks later. A total of 1732 questionnaires were returned to the schools (response rate: 56.2%) and passed on to the Project office.
ISAAC-reported prevalence of asthma in pupils
The prevalence of asthma in Years 3 and 4 in the 25 schools as reported in the headteacher survey was 11.9%. Visits to these schools indicated that this school-reported asthma prevalence figure was derived in a number of ways. The number of inhalers held in the office was used as an indicator in some schools and the individual teacher's knowledge of her own pupils with asthma was also a further source. Other schools kept a record, usually in the school office. This was sometimes acknowledged as being out of date through a lack of information from parents or for other reasons. A number of schools used a combination of such sources to compile a figure reflecting the number of children with asthma.
Responses to the ISAAC questionnaire from parents of children in the 25 schools showed a different picture in terms of prevalence of asthma and wheeze to that found in the headteacher survey responses. Table III shows the ISAAC-recorded prevalence and severity of wheeze-related problems based on parental report for Year 3 and 4 children at the same schools. Parents reported that almost one quarter of pupils (24.2%) had a current or past diagnosis of asthma and that just less than one in five pupils (17.8%) had received asthma treatment in the previous year. This latter figure provided by parents is half as much again as the asthma prevalence figure derived from the headteacher survey in these schools (11.9%).
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Slightly more children (18.9%) were reported by parents to have wheezed in the same period. This indicates that approximately one in five of all children in Years 3 and 4 had experienced symptoms of wheeze in the last year, and suggests that for every class of 30 children, therefore, approximately six children per class experienced wheeze in the last 12 months. Table III
also shows that of those children who had ISAAC parental reports of wheeze in the last 12 months, only four in five of these children (79.3%) were reported by parents to also have a diagnosis of asthma with about the same number having received asthma treatment in that period. Of those six wheezing children per class of 30 in Years 3 and 4, approximately one child with reported symptoms of wheeze, therefore, may not have received a diagnosis or treatment for asthma and will not be using inhaler therapy.
Attacks of asthma
ISAAC responses covering the previous 1-year period suggest that of the six children per class who wheeze, all experienced at least one to three attacks of wheeze in the last year while three of these children experienced four or more attacks with just over one in 10 children, representing one child with wheeze in every two Year 3/4 classes, experiencing 12 or more attacks of wheeze. The severity of such attacks cannot be determined from ISAAC responses but responses show that one child per class experienced wheezing severe enough to limit the child's speech to only one or two words at a time between breaths.
Exercise-related wheeze
Wheezing with exercise is a common feature of asthma and Table III shows that four in six wheezing children in a class experience wheeze during/after exercise in the 25 schools. While two in three of these schools allow at least some children to take their inhalers to Physical Education lessons, only five schools allowed all children to take their inhaler therapy to Physical Education. Table III also shows that over half of all wheezing children experienced wheeze which may not be triggered by exercise but triggered by other factors such as dust, temperature change, cold air, pollution and stress. Since 17 of the 25 schools allow medication to be taken in one location only, results indicate that the majority of children with asthma may not have ready access to their inhaler therapy in school hours when needed.
Sleep disturbance and interference in daily activities
According to the ISAAC questionnaire results, about four in six wheezing children had some sleep disturbance in the last year with one in four such wheezing children having experienced disturbance on one or more nights per week. It is important to note that this problem of sleep disturbance may not be confined to children whose parents reported problems with wheeze. Night-time cough, apart from that associated with a cold or chest infection, was reported by a quarter of all pupils. Therefore, just over eight pupils per class experienced such a symptom in the last year while only four of these children experienced problems related to wheeze. Nearly four in six children with wheeze (73.1%) had some wheeze-related interference in their daily activities, with parents reporting that one in five such children experiencing this at a moderate to high level.
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Discussion |
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Asthma prevalence
Overall, the asthma prevalence rate reported by schools in this study must be viewed with some caution. An asthma prevalence of one in 10 children (10.3%) aged 7–9 years is generally lower than would be expected for this age group. A number of reports suggest that school reported prevalence of asthma morbidity may be underestimated (Bevis and Taylor, 1990
; Brookes and Jones, 1992; Carruthers et al., 1995; Fillmore et al., 1997) and this also appears to be the case in this study. On the other hand, the ISAAC parental survey of 25 schools showed that almost one in four children (24.2%) had a current or previous diagnosis of asthma, nearly one in five children (18.9%) had wheezed in the last year and one in six children had received asthma treatment in the last year (17.8%). This latter figure was half as much more when compared both to the 10.3% asthma prevalence reported for all schools (n = 95) participating in the headteacher survey and to the 11.9% headteacher-reported prevalence found for the 25 schools participating in the current SAM study.
The response rate for the ISAAC questionnaire was rather low (56.2%) and no information was available for non-responders to determine if our sample was representative. However, similar prevalence rates were found when the ISAAC questionnaire was used in another recent survey in Sunderland in the north east of England (Shamssain and Shamsian, 1999). This study had a very high response rate (80%) due to the assistance of the Local Education Authority officials. Parents of 3000 children aged 6–7 years reported that 22.7% had a diagnosis of asthma and that 18.0% had wheezed in the last 12 months. The frequency of reports of wheeze in the last year found in this study are similar to those found in the Sunderland study (Table IV) and are also similar to those found in a smaller ISAAC study of 220 schoolchildren aged 8–9 years carried out in Wales (Fielder et al., 1999). It is likely, therefore, that headteachers in this study had underestimated the number of children with asthma in their schools.
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Asthma record keeping
Poor maintenance of asthma record-keeping systems in schools may account for differences in prevalence reports. While just over half of all headteachers of Infant Schools reported on the number of children receiving inhaler therapy, this number dropped to one in five headteachers in Junior Schools. The headteacher survey suggests a dip in school-reported asthma prevalence in Years 3 and 4 in Primary schools. This coincides with the finding that one in four children take on sole responsibility for their medication around the age of 7–8 years. This is not to suggest that schools do not have concerns about the use of asthma medication. The majority of schools monitor children when taking their therapy. However, at this transitional stage, teachers may become less aware of which children have asthma particularly if the child carries their own inhaler or, indeed, chooses to leave it at home. Results of a previous nationwide survey indicated that some children feel embarrassed about taking their medication (Lenney et al., 1994
) and such children may simply choose not to make their illness `visible' either to staff or to their peers once they have left the infant classes. However, this should not be taken as an argument for preventing children from taking responsibility for their asthma medication. Most children of this age are generally considered capable of taking on such a responsibility (National Asthma Campaign, 1998b). Of course, not all children may be considered ready to carry their own therapy but under such circumstances the medication should be kept within easy access for the teacher and/or child.
Access to inhaler therapy
Another reason for the apparent reduction in prevalence on transfer from infant to junior education could be that parents have learned that, as infants, their children have not been given ready access to reliever inhalers. Some parents, therefore, may choose not to disclose that their child has asthma so that the child can have their inhaler therapy close to hand. Results do suggest that the majority of children in this study do not have access to their medication when they need it. Whatever the trigger, a deterioration in a child's condition can occur quite quickly and immediate administration of the reliever therapy should result in the child recovering in a matter of minutes. Accessibility to medication is an important issue for such children whether this may be in the classroom, lunchroom, playground or gym.
Exercise-related wheeze
Only eight schools reported that medication was taken in the playground. This is surprising since exercise-related wheeze is such a prominent feature of asthma and cold air can trigger a wheezing episode, as well as laughing and running around in the playground. According to the ISAAC data children in this study frequently experienced wheeze during or after exercise. It has been reported elsewhere (Coleman et al., 2001) that exercise-related wheeze was reported by the majority of children at all levels of asthma severity as determined by medication use in the previous year. However, almost one-half of schools reported that pupils did not take their inhalers with them to Physical Education lessons. Access to inhaler therapy before and, if necessary, during a period of continued exercise would enable these children to participate fully in physical activities.
Night-time cough, sleep disturbance and interference in daily activities
Many children with wheezing problems experience night-time cough. In this study four in six wheezing children reported this symptom, while a further three to four non-wheezing children experienced the same symptom. Parents of four in six wheezing children also reported sleep disturbance with one wheezing child per class experiencing sleep disturbance on one or more night per week. Similarly, four children per class of 30 experienced wheezing which interfered with their daily activities and for one child this will have been at a moderate to high level of interference. These findings are consistent with other reports in the literature (Joint Health Surveys Unit, 1998b), and with reports that children with asthma may feel sleepy in lessons the next day (Lenney et al., 1994) and lose schooling due to increased levels of absence because of asthma (Fillmore et al., 1997) which may of course impede the child's academic progress.
Asthma school policy
Only two of the 25 schools participating in the SAM study reported having a policy specifically related to the care and management of asthma in their school. The Department for Education and Employment together with the Department of Health have issued Circular 14/96 `Supporting Pupils with Medical Needs in School' (Department for Education and Employment, 1996) setting out the legal framework for mainstream schools and Local Education Authorities in supporting pupils with medical needs. It is recommended in this Circular that schools draw up policies and procedures for supporting pupils with medical needs which should include provision of health care plans and medication arrangements for such pupils. A whole school policy on asthma involving a well-maintained record of children with asthma and the occurrence of asthma attacks, provision of health care plans, medication arrangements and regularly updated training for all staff would address all of the concerns previously raised in this report. Such a policy would encourage more teacher–parent dialogue, awareness about the child's therapy, periods of illness, attacks of asthma and their causes, absences from school, tiredness in school, and possible learning difficulties encountered because of these factors.
Regularly updated records may also enable school staff to feel more confident about allowing children to carry their own medication, thus allowing ready access to their reliever therapy which can lead to improvements in school attendance and a reduction in symptoms (Colver, 1984). The general development of skills related to asthma management could enable children with asthma, their relatively healthy peers and school staff to identify symptoms when they occur as well as situations which may give rise to such symptoms and to take appropriate action. This is so in the case of exercise-related wheeze occurring in the playground but particularly so in the gym where predosing with inhaler therapy and gentle warm-up activities can have a significant impact in the reduction of symptoms, and thus allow children with asthma equal access and participation in this aspect of their education. Such a coordinated whole school approach may also help to reduce children's concerns about the `visibility' of their illness and increase their perceived self-competence and self-esteem in relation to the disease and it's management. An improvement in management of the physical aspects of the disease as well as the psychological well-being of the child may then result in improved school performance.
A whole school policy may thus lead to improved school performance not only through improvement in the physical management of the disease but also through improvement in the psychological well-being of the child. An increase in perceived self-competence and self-esteem in relation to the illness and its management brought about by a coordinated whole school approach may help reduce children's concerns about the `visibility' of the disease and allow both children in school and their parents in the community more voice in the treatment and management of this chronic childhood disorder.
Legal implications
Such recommendations have implications for school staff acting in loco parentis. There appears to be some ambiguity in the UK Government's guidance to teachers regarding the administration of asthma medication. As pointed out in the NAC School Pack (National Asthma Campaign, 1998) and in Circular 14/96, there is no legal or contractual duty on school staff to administer asthma medication or to supervise a pupil taking it unless they have been specifically contracted to do so. However, in an emergency situation such as the occurrence of an acute asthma attack in school or possibly on a school outing, Circular 14/96 states that school staff `have a common law duty to act as any reasonably prudent parent would to make sure that pupils are healthy and safe' which may extend in exceptional circumstances to `administering medicine and/or taking action in an emergency'. Nevertheless, this Circular goes on to suggest that the Local Educating Authority or governing body should ensure that their insurance policies provide appropriate cover for staff `willing to support' pupils with medical needs. It seems somewhat inappropriate that, at present, particular staff members, namely secretarial/administrative staff, may be more likely to have to deal with such situations as shown in this study and elsewhere (Brookes and Jones, 1992).
Our results show that of the six children per class of 30 who have problems with wheeze, one child may not have a diagnosis of asthma. Other analyses (Coleman et al., 2002) indicate that approximately one in 20 children with wheeze experience these symptoms at a moderate to severe level but are not currently receiving treatment. These children will have no reliever therapy and clearly `coping with an emergency' in such a child would be of concern to staff. Such emergencies may involve a child without a diagnosis of asthma, a child with a diagnosis of asthma but without inhaler therapy at school or a child whose asthma is being undertreated and thus is not currently receiving therapy. For these reasons, some initiatives have encouraged an asthma policy which involves the school keeping a spare inhaler which can be used safely with children in the event of such emergencies, as in the Southampton schools GAMES initiative (Coleman et al., 1995) and those in other areas (Sadler, 1994; Brown et al., 1998; Summerfield, 1998) including the Devon Schools initiative. Teachers' concerns about their rights and responsibilities could be addressed if the Local Education Authority or governing body provided indemnity for school staff who not only administer the child's own reliever therapy but also for those who administer reliever therapy from an emergency inhaler.
Circular 14/96 also states that `school staff should not, as a general rule, administer medication without first receiving appropriate information and/or training'. Sources of help and support for teachers have been identified by headteachers in this study. School nurses are the major source of asthma information, and can play an important role in the education and training of school staff in the care and management of asthma, particularly if asthma-trained themselves. If not asthma-trained, the school nurse can introduce the staff to a specialist nurse who can provide staff training and education for children about asthma but, more importantly, can assist in setting up a whole school policy on asthma, a practice which has been encouraged by the NAC in the UK over the last decade with some limited success (National Asthma Campaign, 1999a).
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Conclusion |
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The results of this study suggest asthma management is a major issue for health promotion in schools. Schools can and should be more proactive in asthma management and education. A whole-school approach, based on the healthy schools model, and involving policy development, curriculum intervention, links with families and outside agencies, could lend itself well to the needs of pupils, staff and parents identified by these two questionnaire surveys. Schools embarking on a whole school approach would first need to establish the prevalence of asthma amongst the pupils in their schools, recognizing that for various reasons their existing records may not be complete. School staff would also need to be aware that some children who wheeze may have significant problems despite not having a diagnosis of asthma or not currently receiving treatment for asthma. A survey of the training teachers and all other staff have received would also inform action to improve staff knowledge and confidence, especially in dealing with emergencies. The support of the school nurse and the Local Education Authority/governing body are key factors in enabling appropriate policies to be developed and implemented in schools. Regularly updated records and policies would ensure that current and new staff would be aware of the needs of children with this common, chronic disorder. An evaluation of such an approach in 24 of the 25 schools participating in these surveys is ongoing.
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Notes |
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All authors with the exception of I. D. are with the Schools Asthma Management (SAM) Project being conducted jointly at the University of Southampton, UK, by Child Health, Southampton General Hospital and the Health Education Unit, Research and Graduate School of Education
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Acknowledgments |
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Our thanks go to all headteachers participating in the asthma survey, and particularly to the parents, pupils and staff in the 25 participating schools in the Swindon and Basingstoke, Hook and Fleet areas of the South of England for their ongoing assistance in the SAM Project despite pressure of work and the many other demands on their time. This study was funded by a National Health Service Research and Development Grant (Project AM1/08/008) administered by the National Asthma Campaign.
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Received on June 19, 2000; accepted on July 29, 2001
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