A Presentation on Asthma Management and Prevention Asthma: A Presentation on Asthma Management and Prevention

What is Asthma? Chronic disease of the airways that may cause Wheezing Breathlessness Chest tightness Nighttime or early morning coughing Episodes are usually associated with widespread, but variable, airflow obstruction within the lung that is often reversible either spontaneously or with treatment. Asthma is a disease that affects the lungs. It causes repeated episodes of wheezing, breathlessness, chest tightness, and nighttime or early morning coughing. If someone has asthma, he or she has it all the time, but asthma attacks will occur only when something bothers the lungs. We know that if someone in the family of a person with asthma has asthma, other family members are more likely to have it too.   In most cases, we don’t know what causes asthma, and we don’t know how to cure it; however, it can be controlled. Asthma can be controlled by knowing the warning signs of an attack, staying away from things that trigger an attack, and following the advice from a healthcare provider. 2

Pathology of Asthma Asthma involves inflammation of the airways Normal This drawing from the National Heart, Lung and Blood Institute compares the normal airway on the left to the airway of a person with asthma. During an asthma episode, the airways become extremely narrow due to muscle constriction, swelling of the inner lining, and mucus production, causing very limited airflow. During severe episodes, the airways may become extremely narrow, compromising airflow and leading to unexpected fatalities. Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995 3

Asthma Prevalence in the United States June 2014 National Center for Environmental Health Division of Environmental Hazards and Health Effects

Introduction Asthma: affects 25.7 million people, including 7.0 million children under 18; is a significant health and economic burden to patients, their families, and society: In 2010, 1.8 million people visited an ED for asthma-related care and 439,000 people were hospitalized because of asthma Asthma affects 25.7 million people (2010) , including 7.0 million children under age 18 (2010); therefore, it is a significant health and economic burden to patients, their families, and society. In 2010, almost 1.8 million people visited an ED for asthma-related care and 439,000 people were hospitalized because of asthma.

Introduction Asthma prevalence is an estimate of the percentage of the U.S. population with asthma. Prevalence estimates help us understand the burden of asthma on the nation. Asthma “period prevalence” is the percentage of the U.S. population that had asthma in the previous 12 months. “Current” asthma prevalence is the percentage of the U.S. population who had been diagnosed with asthma and had asthma at the time of the survey. Asthma “period prevalence” was the original prevalence measure (1980-1996). The survey was redesigned in 1997 and this measure was replaced by lifetime prevalence (not presented in slides) and asthma episode or attack in the past 12 months. In 2001, another measure was added to assess current asthma prevalence. To describe the burden of asthma in the United States, we present two types of prevalence estimates. Asthma “period prevalence” was the original measure (1980-1996) of U.S. asthma prevalence and estimated the percentage of the population that had asthma in the previous 12 months. Beginning in 2001, current asthma prevalence was measured by the question, ‘‘Do you still have asthma?’’ for those with an asthma diagnosis and was introduced to identify all persons with asthma.

Asthma Period Prevalence and Current Asthma Prevalence: United States, 1980-2010 Asthma prevalence increased from 3.1% in 1980 to 5.5% in 1996 and 7.3% in 2001 to 8.4% in 2010. The percentage of the U.S. population with asthma increased from 3.1% in 1980 to 5.5% in 1996 and 7.3% in 2001 to 8.4% in 2010.

Current Asthma Prevalence: United States, 2001-2010 Percent Total number of persons One in 12 people (about 26 million, or 8% of the population) had asthma in 2010, compared with 1 in 14 (about 20 million, or 7%) in 2001. Year One in 12 people (about 26 million, or 8% of the U.S. population) had asthma in 2010, compared with 1 in 14 (about 20 million, or 7%) in 2001.

Blacks are more likely to have asthma than both Whites and Hispanics. Current Asthma Prevalence by Race and Ethnicity: United States, 2001-2010 Blacks are more likely to have asthma than both Whites and Hispanics. Blacks are more likely to have asthma than both Whites and Hispanics.

Current Asthma Prevalence by Age Group, Sex, Race and Ethnicity, Poverty Status, Geographic Region, and Urbanicity: United States, Average Annual 2008-2010 Some people are more likely to have asthma than others. Current asthma occur more in children (9.5%) than in adults (7.7%) and females (9.2%) than males (7.0%). (yellow bars) Regarding race and ethnicity, asthma prevalence was higher among black persons (11.2%) and was lower among Asian (5.2%) and Hispanic persons (6.5%) compared with white persons (7.7%). Among Hispanics, Puerto Ricans (16.1%) were more likely to have asthma compared with Mexican persons (5.4%). Current asthma prevalence increased with decreasing annual household income. As far as geographic region, current asthma prevalence was higher in the Northeast (8.8%) than in the South (7.6%) or in the West (8.0%), and was higher in the Midwest (8.7%) than in the South (7.6%). Prevalence rate did not differ between metropolitan and nonmetropolitan areas. Children, females, Blacks, and Puerto Ricans are more likely to have asthma. People with lower annual household income were more likely to have asthma. Residents of the Northeast and Midwest were more likely to have asthma. Living in or not in a city did not affect the chances of having asthma.

Child and Adult Current Asthma Prevalence by Age and Sex: United States, 2006-2010 Among children, current asthma prevalence was higher among male children aged 0 to 4 years (7.7%) and aged 5 to 14 years (12.4%) compared with female children in the same age group (4.7% and 8.8%, respectively). Asthma prevalence was similar for male and female children aged 15-17 years. Among children aged 0-14, boys were more likely than girls to have asthma. Boys and girls aged 15-17 years had asthma at the same rate.. Among adults women were more likely than men to have asthma.

From 2001 to 2010 both children and adults had fewer asthma attacks. Asthma Attack Prevalence among Children and Adults with Current Asthma: United States, 2001-2010 Children aged 0-17 years Adults aged 18 and over Both children and adults, showed a decrease in asthma attacks. In 2001, 61.7% of children and 53.8% of adults with asthma had at least one asthma attack in the previous 12 months compared with 58.3% and 49.1% in 2010, respectively. From 2001 to 2010 both children and adults had fewer asthma attacks. For children, asthma attacks declined from at least one asthma attack in the previous 12 months for 61.7% of children with asthma in 2001 to 58.3% in 2010. For adults, asthma attacks declined from at least one asthma attack in the previous 12 months for 53.8% of adults with asthma in 2001, to 49.1% in 2010.

Asthma Attack Prevalence among Persons with Current Asthma by Age Group, Sex, Race and Ethnicity, Poverty Status, and Geographic Region: Unites States, Average Annual 2008-2010 Children with asthma were more likely to have had at least one asthma attack during the previous 12 months (56.5%) than adults (49.1%). Asthma attacks occurred more often in females (52.7%) than males (49.2%) and, among those with a family income less than 100% of the federal poverty threshold (55.1%) than persons with income between 250% and less than 450% of the poverty threshold (47.9%), and among those living in South and West, than those living in Northeast. Asthma attack prevalence did not differ by race or ethnicity. From 2008 to 2010 asthma attacks occurred more often in children and women, among families whose income was below 100% of the federal poverty threshold, and in the South and West. Race or ethnicity did not significantly affect asthma attack prevalence.

Technical Notes Asthma Period Prevalence and Current Asthma Prevalence: Estimates of asthma prevalence indicate the percentage of the population with asthma at a given point in time and represent the burden on the U.S. population. Asthma prevalence data are self-reported by respondents to the National Health Interview Survey (NHIS). Asthma period prevalence was the original measure (1980-1996) of U.S. asthma prevalence and estimated the percentage of the population that had asthma in the previous 12 months. From 1997-2000, a redesign of the NHIS questions resulted in a break in the trend data as the new questions were not fully comparable to the previous questions. Beginning in 2001, current asthma prevalence (measured by the question, ‘‘Do you still have asthma?’’ for those with an asthma diagnosis) was introduced to identify all persons with asthma. Current asthma prevalence estimates from 2001 onward are point prevalence (previous 12 months) estimates and therefore are not directly comparable with asthma period prevalence estimates from 1980 to 1996 Behavioral Risk Factor Surveillance System (BRFSS): State asthma prevalence rates on the map come from the BRFSS. The BRFSS is a state-based, random-digit-dialed telephone survey of the noninstitutionalized civilian population 18 years of age and older. It monitors the prevalence of the major behavioral risks among adults associated with premature illness and death. Information from the survey is used to improve the health of the American people. More information about BRFSS can be found at: http://www.cdc.gov/brfss/.

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What is Epidemiology? The study of the distribution and determinants of diseases and injuries in human populations. Asthma is a highly prevalent disease that affects the quality of life of many people in the United States. Surveillance of a disease requires that public health workers have the ability to accurately identify cases, access needed data, and use adequate resources so as to collect, assess, report, and use the data. Source: Boss, Leslie; Kreutzer, Richard. The Public Health Surveillance of Asthma. Journal of Asthma, 38 (1), 83–89, 2001. Asthma is one of the most common chronic illnesses in the United States. It is therefore a significant burden to public health. In the United States, approximately 23 million people have asthma, including 6.5 million children under age 18. Without proper management, asthma can result in frequent emergency department (ED) visits, hospitalizations, and premature deaths. In 2006, almost 2 million people visited an ED because of asthma, and almost half a million of those visitors were hospitalized. Source: Mausner and Kramer, Mausner and Bahn Epidemiology- An Introductory Text, 1985. 17

Risk Factors for Developing Asthma Genetic characteristics Occupational exposures Environmental exposures Risk Factors for Developing Asthma 18

Risk Factors for Developing Asthma: Genetic Characteristics Atopy The body’s predisposition to develop an antibody called immunoglobulin E (IgE) in response to exposure to environmental allergens Can be measured in the blood Includes allergic rhinitis, asthma, hay fever, and eczema Risk Factors for Developing Asthma: Genetic Characteristics 19

Risk Factors for Developing Asthma: Environmental Exposure Clearing the Air: Asthma and Indoor Air Exposures http://www.iom.edu (Publications) Institute of Medicine, 2000 Committee on the Assessment of Asthma and Indoor Air Review of current evidence about indoor air exposures and asthma Risk Factors for Developing Asthma: Environmental Exposure 20

Clearing the Air: Categories for Associations of Various Elements Sufficient evidence of a causal relationship Sufficient evidence of an association Limited or suggested evidence of an association Inadequate or insufficient evidence to determine whether an association exists Limited or suggestive evidence of no association Clearing the Air: Categories for Associations of Various Elements 21

Clearing the Air: Indoor Air Exposures & Asthma Development Biological Agents Sufficient evidence of causal relationship House dust mite Sufficient evidence of association None found Limited or suggestive evidence of association Cockroach (among pre-school aged children) Respiratory syncytial virus (RSV) Chemical Agents Sufficient evidence of causal relationship None found Sufficient evidence of association Environmental Tobacco Smoke (among pre-school aged children) Limited or suggestive evidence of association Clearing the Air: Indoor Air Exposures & Asthma Development 22

Clearing the Air: Indoor Air Exposures & Asthma Exacerbation Biological Agents Sufficient evidence of causal relationship Cat Cockroach House dust mite Sufficient evidence of an association Dog Fungus/Molds Rhinovirus Limited or suggestive evidence of association Domestic birds Chlamydia and Mycoplasma pneumonia RSV Chemical Agents Sufficient evidence of causal relationship Environmental tobacco smoke (among pre-school aged children) Sufficient evidence of association NO2, NOX (high levels) Limited or suggestive evidence of association Environmental Tobacco Smoke (among school-aged, older children, and adults) Formaldehyde Fragrances Clearing the Air: Indoor Air Exposures & Asthma Exacerbation 23

Reducing Exposure to House Dust Mites Use bedding encasements Wash bed linens weekly Avoid down fillings Limit stuffed animals to those that can be washed Reduce humidity level (between 30% and 50% relative humidity per EPR-3) Reducing Exposure to House Dust Mites Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI, 1995

Reducing Exposure to Environmental Tobacco Smoke Evidence suggests an association between environmental tobacco smoke exposure and exacerbations of asthma among school-aged, older children, and adults. Reducing Exposure to Environmental Tobacco Smoke Evidence shows an association between environmental tobacco smoke exposure and asthma development among pre-school aged children. 25

Reducing Exposure to Cockroaches Remove as many water and food sources as possible to avoid cockroaches.

Reducing Exposure to Pets People who are allergic to pets should not have them in the house. At a minimum, do not allow pets in the bedroom. Reducing Exposure to Pets

Reducing Exposure to Mold Eliminating mold and the moist conditions that permit mold growth may help prevent asthma exacerbations.

Other Asthma Triggers Air pollution Trees, grass, and weed pollen

Clinical Management of Asthma Expert Panel Report 3 National Asthma Education and Prevention Program National Heart, Lung and Blood Institute, 2007 An expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP) Coordinating Committee (CC) developed the 2007 EPR 3 Guidelines on Asthma. The National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health coordinated the effort. Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf 30

2007 NAEPP EPR-3 Treatment recommendations based on: Severity Control Responsiveness Provide patient self-management education at multiple points of care Reduce exposure to inhaled indoor allergens to control asthma-multifaceted approach The expert panel used the 1997 guidelines and the 2004 update as the framework to organize the literature review, and the final guidelines report for four essential components of asthma care: assessment and monitoring, patient education, control of factors contributing to asthma severity, and pharmacologic treatment. Here are a few highlights. Source: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf 31

What is GIP? Guidelines Implementation Panel Report for Expert Panel Report 3 Recommendations and strategies to implement EPR-3 Six key messages The Guidelines Implementation Panel (GIP) Report presents recommendations and strategies for overcoming barriers to the acceptance and use of the updated NHLBI clinical practice guidelines for asthma. At the heart of the GIP Report are six key messages to address the issues that are likely to significantly affect asthma care processes and outcomes if the broader asthma community were to focus its attention and resources on them. The GIP Report is a call to action by the full range of guideline end-users, including medical professionals, office support staff, educators, administrators, policy makers, purchasers, and payors of healthcare services in both the private and public sectors. Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf 32

GIP’s Six Key Messages Inhaled Corticosteroids Asthma Action Plan Asthma Severity Asthma Control Follow-up Visits Allergen and Irritant Exposure Control Inhaled Corticosteroids Inhaled corticosteroids are the most effective medications for long-term management of persistent asthma, and they should be used by patients and clinicians as recommended in the guidelines for controlling asthma. Message: Asthma Action Plan All people who have asthma should receive a written asthma action plan to guide their self-management efforts. Message: Asthma Severity Message: All patients should have an initial severity assessment based on measures of current impairment and future risk to determine type and level of initial therapy needed. Message: Asthma Control Message: At planned follow-up visits, asthma patients should review the level of control with their health care providers on the basis of multiple measures of current impairment and future risk; this review can guide clinician decisions to either maintain or adjust therapy. Message: Follow-up Visits Patients who have asthma should be scheduled for planned follow-up visits at periodic intervals to assess their asthma control and to modify treatment if needed. Message: Allergen and Irritant Exposure Control Clinicians should review each patient’s sensitivity to allergens and irritants and provide a multipronged strategy to reduce exposure—i.e., avoid exposures that make the patient’s asthma worse. Source: http://www.nhlbi.nih.gov/guidelines/asthma/gip_rpt.pdf 33

Diagnosing Asthma: Medical History Symptoms Coughing Wheezing Shortness of breath Chest tightness Symptom Patterns Severity Family History Diagnosing Asthma: Medical History 34

Diagnosing Asthma Troublesome cough, particularly at night Awakened by coughing Coughing or wheezing after physical activity Breathing problems during particular seasons Coughing, wheezing, or chest tightness after allergen exposure Colds that last more than 10 days Relief when medication is used Diagnosing Asthma 35

Diagnosing Asthma Wheezing sounds during normal breathing Hyperexpansion of the thorax Increased nasal secretions or nasal polyps Atopic dermatitis, eczema, or other allergic skin conditions Diagnosing Asthma

Diagnosing Asthma: Spirometry Test lung function when diagnosing asthma Diagnosing Asthma: Spirometry 37

Medications to Treat Asthma Medications come in several forms. Two major categories of medications are: Long-term control Quick relief Medications to Treat Asthma

Medications to Treat Asthma: Long-Term Control Taken daily over a long period of time Used to reduce inflammation, relax airway muscles, and improve symptoms and lung function Inhaled corticosteroids Long-acting beta2-agonists Leukotriene modifiers Medications to Treat Asthma: Long-Term Control

Medications to Treat Asthma: Quick-Relief Used in acute episodes Generally short-acting beta2agonists Medications to Treat Asthma: Quick-Relief

Medications to Treat Asthma: How to Use a Spray Inhaler The health-care provider should evaluate inhaler technique at each visit. Medications to Treat Asthma: How to Use a Spray Inhaler Source: “What You and Your Family Can Do About Asthma” by the Global Initiative for Asthma Created and funded by NIH/NHLBI

Medications to Treat Asthma: Inhalers and Spacers Spacers can help patients who have difficulty with inhaler use and can reduce potential for adverse effects from medication. Medications to Treat Asthma: Inhalers and Spacers 42

Medications to Treat Asthma: Nebulizer Machine produces a mist of the medication Used for small children or for severe asthma episodes No evidence that it is more effective than an inhaler used with a spacer Medications to Treat Asthma: Nebulizer

Managing Asthma: Asthma Management Goals Achieve and maintain control of symptoms Maintain normal activity levels, including exercise Maintain pulmonary function as close to normal levels as possible Prevent asthma exacerbations Avoid adverse effects from asthma medications Prevent asthma mortality Managing Asthma: Asthma Management Goals

Managing Asthma: Asthma Action Plan Develop with a physician Tailor to meet individual needs Educate patients and families about all aspects of plan Recognizing symptoms Medication benefits and side effects Proper use of inhalers and Peak Expiratory Flow (PEF) meters Managing Asthma: Asthma Action Plan

Managing Asthma: Sample Asthma Action Plan Describes medicines to use and actions to take The Asthma Action Plan summarizes the doctor’s instructions for self-management of asthma. The plan contains places in which the doctor can fill in directions for medication, peak flow numbers, asthma triggers, and actions to take in case of an asthma attack or an emergency. The written Asthma Action Plan specifies details for patients’ daily management (medications and environmental control strategies) and outlines steps to take to recognize and handle an asthma attack. A written Asthma Action Plan is recommended for all patients. National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007. 46

Managing Asthma: Peak Expiratory Flow (PEF) Meters Allows patient to assess status of his/her asthma Persons who use peak flow meters should do so frequently Many physicians require for all severe patients

Managing Asthma: Peak Flow Chart People with moderate or severe asthma should take readings: Every morning Every evening After an exacerbation Before inhaling certain medications Managing Asthma: Peak Flow Chart Source: “What You and Your Family Can Do About Asthma” by the Global Initiative For Asthma Created and funded by NIH/NHLBI

Managing Asthma: Indications of a Severe Attack Breathless at rest Hunched forward Speaks in words rather than complete sentences Agitated Peak flow rate less than 60% of normal Managing Asthma: Indications of a Severe Attack

Managing Asthma: Things People with Asthma Can Do Have an individual management plan containing Your medications (controller and quick-relief) Your asthma triggers What to do when you are having an asthma attack Educate yourself and others about Asthma Action Plans Environmental interventions Seek help from asthma resources Join an asthma support group Managing Asthma: Things People with Asthma Can Do

A Public Health Response to Asthma A call to action for organizations and people with an interest in asthma management to work as partners in reducing the burden of asthma within our nation’s communities. A Public Health Response to Asthma

A Public Health Response to Asthma: Surveillance Over time… How much asthma does the population have? How severe is asthma across the population? How well controlled is asthma in the population? What is the cost of asthma? A Public Health Response to Asthma: Surveillance

A Public Health Response to Asthma: Uses of Surveillance Data Basis for planning and targeting intervention activities Evaluating intervention activities A Public Health Response to Asthma: Uses of Surveillance Data

A Public Health Response to Asthma Education Education programs can be targeted to: People with asthma Parents of children with asthma Medical care providers School staff Public A Public Health Response to Asthma Education

A Public Health Response to Asthma: Coalition Successful asthma campaigns need the cooperation of committed partners. A Public Health Response to Asthma: Coalition

A Public Health Response to Asthma: Advocacy Asthma needs to be addressed comprehensively by multiple government and non-government agencies.

A Public Health Response to Asthma: Interventions Medical management Education Environment Schools A Public Health Response to Asthma: Interventions

A Public Health Response to Asthma: Medical Management Interventions Ensure people with asthma know about their disease and are empowered to demand appropriate management A Public Health Response to Asthma: Medical Management Interventions 58

A Public Health Response to Asthma: Environmental Interventions Help people create and maintain healthy home, school, and work environments. Environmental interventions may consist of: Assessments to identify asthma triggers Education on how to remove asthma triggers Remediation to remove asthma triggers A Public Health Response to Asthma: Environmental Interventions 59

A Public Health Response to Asthma: School Intervention Science-Based Guidance Management and support systems Health and mental health services Asthma education for students, staff, and parents Healthy school environment Physical education and activity School, family, and community efforts The six strategies for addressing asthma within a coordinated school health program are [read bullets]. If you open the Strategies document, you will see that each one is accompanied by action steps. The strategies and action steps are based on research evidence and on expert opinion and evidence from exemplary practice in school asthma management, health education, and public health. The publication can be downloaded for free at this Web site. Source: www.cdc.gov/HealthyYouth/asthma/strategies 60

Key Aspects Require team effort Coordinate health, including mental and physical health, education, environment, family, and community efforts Assess needs of school and prioritize (every action step is not feasible to every school or district) Focus on students with frequent asthma symptoms, health room visits, and absenteeism The beginning of the Strategies document provides some overall guidance for programs, specifying that a team effort is required with school nurses, administrators, classroom teachers, PE teachers, and others working together to ensure that students with asthma can participate safely in school. Every action step is not going to be feasible for every school or district. For example, not every school can provide a full-time nurse. Schools should establish priorities on the basis on their needs, and they should focus first on students with frequent symptoms, health room visits, and/or absenteeism. These students will need the school and school district’s support the most. 61

Coordinated School Health Program Health Services Family/Community Involvement Strategies for Addressing Asthma 1. Management & Support Systems 6. School, Family, & Community Efforts 2. Health & Mental Health Services Counseling, Psychological, and Social Services Physical Education 5. Physical Education & Activity 3. Asthma Education Health Education Nutrition Services 4. Healthy School Environment This graphic shows how the six strategies for addressing asthma fit within the eight components of a coordinated school health program. A successful school asthma program is a team effort—it involves school nurses, administrators, classroom and physical education teachers, building maintenance staff, families, and students. Healthy School Environment Health Promotion For Staff 62

A Public Health Response to Asthma: School A leading chronic disease cause of school absence Common disease addressed by school nurses Affects teachers, administrators, nurses, coaches, students, bus drivers, after school program staff, maintenance personnel A Public Health Response to Asthma: School

On average, 3 children in a classroom of 30 On average, a typical classroom of 30 students is likely to have 3 with asthma.* According to the 2004 National Health Interview Survey, parents reported that 9.6% (5.1 million) of their school-aged children (ages 5-17) had been told by a doctor that they have asthma (“lifetime asthma”) and still had asthma (“current asthma”). are likely to have asthma.* *Epidemiology and Statistics Unit. Trends in Asthma Morbidity and Mortality. NYC: ALA, July 2006. 64

A Public Health Response to Asthma: What can make asthma worse in the school? Mold and mildew Animals in classroom Carpeted classrooms Cockroaches Poor air quality Poor air quality can include fumes and vapors and the presence of tobacco smoke.

Asthma-Friendly School DVD and Toolkit Objectives Personal stories to relate to viewer Aspects of an asthma-friendly school Six strategies for addressing asthma in a coordinated school health program Potential impact of asthma-friendly schools The DVD was developed to help lay people understand what asthma-friendly schools are and to help asthma advocates market asthma-friendly schools; CDC developed a video called Creating an Asthma-Friendly School. The purpose of the video is to show the face of an asthma-friendly school. The video has a broad target audience—pretty much all the people whom asthma health advocates may want to convince that asthma is an important issue for them to address. This target audience includes teachers, school board members, school business leaders, school administrators, school health councils, school nurses, community members, and community asthma coalitions. 66

A Public Health Response to Asthma: School Actions Establish policies and procedures to support children with asthma. Keep students’ asthma action plans at the school. Make medications available During school hours Before physical activity and sports During before- and after-school programs On field trips or when away from campus Train school staff to recognize signs of an asthma attack and to use appropriate medications. A Public Health Response to Asthma: School Actions

A Public Health Response to Asthma: Evaluation The systematic investigation of the structure, activities, or outcomes of asthma control programs. Are we doing the right thing? Are we doing things right? We have all heard the word evaluation. A whole range of things can be evaluated, from how well our partnerships work, how effective our administrative systems and policy development activities are, to how well our specific interventions work to improve the lives of persons with asthma. What is evaluation? Evaluation is the systematic investigation of the structure, activities, or outcomes of the asthma control programs. Note that evaluation is “systematic,” meaning that the process is disciplined, structured, and objective. The core of the word is “value”, and evaluation cannot be done without judgments and context. Evaluation answers how and why questions and provides a full understanding of what is happening in a specific program and why. The process helps to identify program strengths and builds on them. It is not a fault-finding process, but it does help identify areas that can be improved or things that can be done better. Even the best programs can improve. Through this process, we learn to become better at what we do! Program staff who are new to this process will build assessment skills and capacity as they conduct evaluations. There are no prerequisites for beginning an evaluation. Novices should draw on resources like this presentation and other materials to guide them along the way. 68

Benefits of Program Evaluation Evaluations help asthma programs Manage resources and services effectively Understand reasons for current performance Build capacity Plan and implement new activities Demonstrate the value of their efforts Ensure accountability There are several basic uses and reasons to evaluate your program so that you Manage resources and services effectively—Evaluation provides information for better decision-making. For example, it may offer data concerning the practicality of a new approach to contact investigations, or it may examine case management practices in detail to make sure that staff members are following protocols. Understand reasons for current performance—Evaluation provides us with a means to understand why we achieved our successes, or why we did not meet our objectives. Evaluation requires that we examine factors objectively, both inside and outside our program, to assess our performance. Understanding these factors allows us to make better decisions, implement change where appropriate, and improve upon what we have accomplished. Build capacity—We can also use evaluation for self-directed change, such as to increase funding, develop skills, and/or to build the infrastructure needed for a successful program. For example, evaluating an intervention in a community of recent immigrants might reveal a need to translate informational materials into a new language to enhance the program’s capacity to serve this emergent group. Evaluation also builds on itself—as we learn and gain experiences in conducting evaluations, we also build evaluation capacity for our program and increase program capacity for self-directed improvements. Plan and implement new initiatives—Evaluation helps us assess where we are in program development and accomplishments, and it helps us identify information we need to plan for our next steps. It tells us what we are lacking and where we need to focus our efforts. It provides us with information we need to strategize, plan, and implement initiatives that enhance the effectiveness of our asthma control program. Evaluation helps demonstrate the value of our efforts—It documents what each of us does and systematically shows how each has added value toward accomplishing our goals. This information can help decision-makers at all levels understand the benefits and consequences of what they are doing. At crucial times, findings from evaluation help us advocate for the cause and leverage support. Finally, evaluation can strengthen accountability—Evaluation is part of good management. It allows us to demonstrate that we are responsible stewards of the program’s funding and resources. 69

Using Evaluation to Improve Programs Highlight effective program components Recognize achievements Replicate successes Assess and prioritize needs Target program improvements Advocate for the program Evaluation is an important tool to help us improve asthma control programs. Evaluation helps highlight effective program components. Many important things require our attention. Evaluation helps us prioritize needs and identify areas that require the most attention and can make the most impact. Evaluation is also a great tool for targeting program improvements. In a world where evidenced-based decision-making is important, evaluation results can be used to demonstrate program need and its value in advocacy efforts. 70

Framework for Program Evaluation

A Public Health Response to Asthma: Summary Asthma is a complex disease that is not yet preventable or curable. Asthma can be managed with medication, environmental changes, and behavior modifications. By working together, we can ensure that people with asthma enjoy a high quality of life. A Public Health Response to Asthma: Summary

Resources National Asthma Education and Prevention Program http://www.nhlbi.nih.gov/about/naepp/ Asthma and Allergy Foundation of America http://www.aafa.org American Lung Association http://www.lungusa.org American Academy of Allergy, Asthma, and Immunology http://www.aaaai.org Allergy and Asthma Network/Mothers of Asthmatics, Inc. http://www.aanma.org Resources

Resources American College of Allergy, Asthma, and Immunology http://www.acaai.org American College of Chest Physicians http://www.chestnet.org American Thoracic Society http://www.thoracic.org The Centers for Disease Control and Prevention http://www.cdc.gov/asthma Resources