Slide 46: A Public Health Response to
Asthma
As you can see, asthma is a complex disease which requires a coordinated
and multifaceted response from many organizations to effectively combat
it. I'd like to take some time to discuss the components of a public
health response to asthma. You can think about where you and the
organizations or interests you represent fit into this response.
Slide 47: Surveillance
Surveillance, the process by which the distribution and occurrence of
asthma in a population is understood over time, is the first step to
addressing a health problem from a public health perspective. The size
of the problem is important to know. This might be assessed in a number
of ways--for example, the number of people with a disease or the number
of people dying of the disease. With asthma, we do not yet know how to
prevent or cure the disease, but we do know how to decrease its
severity. As a result, monitoring the number of people with asthma who
receive care in an emergency department or are hospitalized can be
important.
Severity is decreased primarily through disease control. Knowing how
people with asthma take care of their disease is helpful. For example,
how many people have asthma-management plans and take appropriate
medications? Asthma is costly to the medical care system and to society.
Although disease management is costly, emergency care, hospitalizations,
and deaths are costly as well. Monitoring cost over time provides useful
information.
Slide 48: Uses of Surveillance Data
Knowing about the disease means little if we do not act on the knowledge
and intervene in a manner that improves the health of people with
asthma. Data are crucial to defining where and what kind of programs are
needed, as well as providing information for educational purposes.
Finally, data are essential to program evaluation. Good data help
determine whether we are doing the right thing with our interventions
and whether we are doing things right.
Slide 49: Education
Asthma education can be a component of a larger intervention or a
stand-alone activity. Educational programs can be targeted to people
with asthma, parents of children with asthma, medical-care providers,
school personnel, and the general public. Asthma education needs to
cover the spectrum from mass public education using a variety of media
to one-on-one education in a provider's office. At this time, asthma
education in the clinical setting is not reimbursable by most
third-party payers. However, we can look at diabetes and see the
positive effect of patient education. We can use diabetes as a model for
targeting the issue of reimbursement for education sessions.
Slide 50: Coalitions
For an asthma campaign at any level to succeed, it needs the cooperation
of a coalition of committed partners. On the national level, federal
organizations such the National Institutes of Health, the Centers for
Disease Control and Prevention, and the Environmental Protection Agency
are working together to address asthma. On the state level, health
departments can coordinate with organizations like the American Lung
Association, insurance companies and managed-care groups, school
districts, universities, housing authorities, and medical providers.
In addition, national and state agencies can help support local
coalitions with modest start-up grants, educational sessions and
materials, scientifically sound intervention protocols, and
opportunities to network.
The former Executive Director of the Arizona Asthma Coalition has stated
that "The beauty of a coalition is that it fosters collaboration by
providing the strategic direction, structure, process and the safety for
like-minded partners to dissolve barriers and build the support
necessary to achieve its goals." She also acknowledges that coalitions
are hard work and time consuming and can cause a great amount of stress
as different groups with different agendas come together. Perhaps some
of you already have worked with a coalition and can relate to the
challenges they provide. However, given the complexities of asthma and
the number of different aspects that its effective management requires,
a coalition is a virtually essential element of a public health
response.
Slide 51: Advocacy
All public health activities require both advocates and resources. A
well-conceived approach to addressing the asthma problem in your
jurisdiction, one based on sound data and grounded in science, will help
you obtain these essential elements. Asthma has numerous risk factors,
and it needs to be addressed comprehensively by multiple government
agencies responsible for the environment and schools. The private
sector, including voluntary organizations, health maintenance
organizations, and hospitals, also needs to be involved. In addition,
appropriate legislation can contribute to asthma control through means
such as ensuring access to asthma medication in school or third-party
payment for asthma-education activities. Clearly, a broad range of
policy advocacy is required.
Slide 52: Interventions
Addressing asthma will require intervention activities not only within
federal, state, and local governments, but also within communities,
neighborhoods, and homes. Interventions can be simple, focusing on a
specific element of asthma, or they can be complex and integrated to
address asthma issues on several fronts. Much depends on the level of
funding, staff resources, and commitment by partners. There are many
types and combinations of possible asthma interventions. Three major
types to be discussed here are medical-management, environment, and
schools. Active groups to facilitate these activities must be formed on
all levels, but particularly on the local level. Important local-level
activities include reducing the level of asthma triggers in homes and
schools and ensuring that all people with asthma receive the medical
help necessary to manage their asthma.
Slide 53: Medical Management
Interventions
Although guidelines exist for state-of-the-art treatment of people with
asthma, only a small percentage of people with asthma benefit from these
guidelines. Ensuring that people with asthma know about their disease
and are empowered to demand appropriate management is a role of the
public health system. Disseminating management guidelines; developing
curricula for medical-care providers about asthma management; and
ensuring appropriate management of people treated for asthma in public
health clinics or public hospitals or with Medicaid dollars are all
important public health activities.
Slide 54: Environmental Interventions
The public health system can help people create and maintain a healthy
home and work environment. Homes need to be pest-free because allergens
from cockroaches, mice, rats, and other vermin can cause asthma
episodes. Mold and mildew, which can result from structural problems in
the home, also can make asthma worse. People living in rented or public
housing may need assistance in convincing landlords to solve these sorts
of problems. Other sources of allergens and irritants or a dirty
household may relate to individual behavior. General educational efforts
through the public health system may help people understand the
importance of removing these sources from their homes, particularly if
they or their children have asthma. The public health system can also
help people obtain low-cost asthma-proofing products such as dust
mite-impermeable covers for bedding.
Programs also can be established where people work to improve air
quality. Smoking cessation, declaring areas off-limits to smoking,
improving air circulation, avoiding or eliminating industrial chemicals
or other substances with strong odors, and improving cleaning procedures
can all improve air quality.
Slide 55: School Interventions
School-based asthma education is essential. Asthma is the leading cause
of school absenteeism caused by a chronic illness. Education goes
hand-in-hand with modifying the school environment and improving asthma
awareness in schools. Finally, the nature of asthma and its management
raises issues that need to be resolved through a partnership between
school officials, parents, health-care providers, and students with
asthma.
Slide 56: Schools: Absences
Asthma is a major concern of parents, teachers, and school
administrators. However, asthma is not just an issue because of school
absences. Many children with asthma have to take medication during
school hours, and medication must be available at all times in the event
of an attack. Children need access to medications in the school, on the
playground or sport field, on school buses, and during field trips.
Schools provide an ideal situation for children to learn about asthma
management in small groups with other children who also have asthma.
Numerous research efforts have demonstrated the value of such
activities. School boards and administrators also should seek out asthma
information from state or local agencies that could be used as
in-service training for school staff.
Because children spend a considerable amount of time in school, the
physical environment of the school is important in the prevention of
asthma episodes. Let's look closer at things that can affect the indoor
quality of a school building.
Slide 57: Schools: Harmful Exposures
As in a home, water leaks in a school can result in mold and mildew
growth. Carpet can increase the mold problem and also expose children to
dust mites when they sit or lie on the floor. Cockroaches may be common
in food-preparation areas, and air quality may be an issue if air
circulation is inadequate. Animals in the classroom can expose children
to pet dander and its related allergens.
Tools for Schools is a program developed at the Environment
Protection Agency that focuses on developing and maintaining a healthy
school environment. Although not specially targeted to asthma, it
addresses the important environmental factors needed for a safe
environment for children with asthma.
Slide 58: Schools: Actions
Children face many challenges with asthma while they are at school.
Drug-free school policies have made medications illegal to carry in some
school districts. Most schools do not have a full-time nurse, so a
variety of medications, including those for asthma, are stored and
dispensed by the school's administrative personnel. Because the asthma
episodes of some children are more likely to occur with increased
physical activity, teachers and staff members should be particularly
aware of the condition of a child with asthma during gym class and
recess. In addition, many students spend extra hours on the school
grounds when the school nurse and administrative personnel may not be
present. Providing access to medications during these after school
periods is an added challenge. For every child with asthma, an
up-to-date management plan should be on file in the school, along with
the medications needed to respond to that plan. Medications also need to
be available during sporting events, field trips, and other off-campus
events.
Slide 59: Evaluation
With all intervention programs, evaluation is necessary to provide
answers to two questions. First, "Are we doing the right thing?"--in
other words, are we applying approaches that have been demonstrated
through scientific research to improve the health of those to whom the
intervention is applied? And second, "Are we doing things right?"--in
other words, as we apply this proven approach, are we applying it
correctly? A well-designed surveillance system coupled with appropriate
process measures will provide the answers to these evaluation questions.
Slide 60: Summary
Thank you for considering the challenges of asthma management and
control. I hope this discussion gives you and your organizations a
better idea of steps you can take to become a part of a Public Health
Response to Asthma.
Slide 61: Resources 1 and
Slide 62: Resources 2
These are some organizations that serve as asthma resources. All of
these organizations have established asthma information and prevention
programs to help people manage their asthma. Contact any of these
organizations when establishing your own asthma management program.
