A Look at Asthma Care in a University Setting

Abstract
Is campus-based asthma care meeting students needs? In this study, we examined asthma severity, impact, and quality

Reviewing the Research Asthmathe most common chronic follow national asthma guidelines. Are students in university settings reillness of childhood and adolescence ceiving adequate asthma care? If not, accounts for numerous hospitalizations how do we embark on improving care while ensuring comand missed school days.5-7 Data show that ED use is highest pliance with national guideline recommendations? The stafor individuals ages 10 to 19, with asthma among the leading tistics remain grim: Asthma incidence and morbidity has causes of hospitalization.8 In the northeastern United States, increased 100% over the past 3 decades,1,2 and asthma prevaasthma morbidity from the 1960s to 1995 was twice as high lence rates in adults ages 18 to 44 were 96 and 92 per 1,000 as that for other portions of the country.9 for 1997 and 1998, respectively. This age group, among all In a survey of 2,509 adults with asthma or parents of chilothers, has experienced the greatest increase in asthma prevadren with asthma, asthma impacted school or work attenlence (up 123% from 1982 to 1996).3 Equally alarming is that dance for 25% and limited work and other activities for 22% 29% of deaths due to asthma for those younger than age 19 and 17%, respectively.7 In a comparative national sample of 4 1,000 adults who did not have asthma or asthma in the famoccur in nonhealth care settings. The Centers for Disease Control and Prevention (CDC) ily, 74% were without limitations.7 Even weekly asthma sympand the National Institutes of Health (NIH) aim to reduce toms affect quality of life, such as an individuals ability to hospitalizations, deaths, emergency department (ED) visits, walk, sleep, exercise, play with pets, and participate in social activity limitations, and work and school days missed due to and work activities.10 asthma. They also seek to increase access to quality asthma Children and adolescents with moderate and severe care and education.1 For individuals ages 15 to 34, the CDC asthma experience anxiety, depression, and restrictions on and NIH aim to reduce asthma-related deaths from 5.9 to 3 activity compared to those with mild asthma.11 Psychiatric
specific to the needs of young adults that

Susan McClennan Reece, RN, CS, DNSc Christina Holcroft, ScD Maureen Faul, RN, BS Nancy Quattrocchi, RN, ANP, MS Robert Nicolosi, PhD

of care in a sample of university students. Our research highlights the importance of designing university asthma programs

per 10,000 by the year 2010, hospitalizations from 13.8 to 8; and ED visits from 71 to 50.1

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The Nurse Practitioner December 2002 35

A Look at Asthma Care in a University Setting

DESPITE THE push from the Nasymptoms include generalized anxiety, Instruments separation anxiety, social phobia, and We developed a 26-item questiontional Asthma Education and Prevention dysthymic disorders.11 naireAsthma Screen Questionnaire Programs asthma guidelines, many clinQualitative studies on adolescents (ASQ)that asked participants about with asthma show that they have diffipast medical, and asthma history, reicians have not complied with the recculty following medication regimens. active airway disease, and asthmatic ommendations, and many patients have Adolescents also have knowledge deficits bronchitis. Seven of the questions, de12 about asthma and its treatments. rived from the guidelines,13 questioned not received health care consistent with Despite the push from the National participants on known asthma sympthe guidelines. When researchers used Asthma Education and Prevention Protoms, such as coughing, wheezing, pharmacy claims to assess treatment reggrams asthma guidelines,13 many clinishortness of breath, medications for breathing, and symptoms during the cians have not complied with the imens, they found that anti-inflammatory night, early in the morning, or after exrecommendations, and many patients drugs were underutilized and bronchoercise or physical activity. We scored have not received health care consistent 7,14 undiagnosed asthma based on the with the guidelines. When researchers dilators were overutilized, especially in used pharmacy claims to assess treatnumber of asthma symptoms or individuals with greater severity, younger ment regimens, they found that anti-inwhether the participant took asthma flammatory drugs were underutilized medications by mouth, nebulizer, or age, and longer duration of illness. and bronchodilators were overutilized, inhaler. Students who reported an especially in individuals with greater asthma diagnosis or who scored greater 15 severity, younger age, and longer duration of illness. than or equal to 3 out of 7 criteria for asthma diagnosis were Our research is an initial effort to fill the information gap the participants in this analysis (see Table 1, The Demoand address asthma severity, health behavior, and asthma graphics of Students with Asthma). We collected demomanagement among young adults in a university setting. graphic data using the Demographic Data Survey (DDS). After collecting demographic data, we asked participants to Our Study rate their health, using Likert scales of 0 (unhealthy) to 5 (exMethod cellent health), while theyve been at the university and when This cross-sectional descriptive study examined asthma and they were between the ages of 10 and 18. asthma severity through the use of interviews and written We developed the 42-item Asthma Severity/Management questionnaires. Survey (AS/MS) to assess the frequency and type of symptoms, treatments, patterns of seeking health care, participant Sample rating of his or her asthma severity, and difficulty in coping The study took place at a mid-size (13,000 students), urban, with the disease. Asthma severity was determined by 4 quesstate university in the northeastern United States. We used tions based on the guidelines,13 such as the number of dayE-mail announcements, newspaper postings, and recruiters time symptoms per week, nighttime symptoms per month, placed near dormitories, dining rooms, and libraries to invite medication use, and limitations of physical activity due to students to participate in a university health study. Our efasthma. Mild asthma was scored as 2 or less daytime sympforts resulted in a non-randomly selected convenience samtoms per week or 1 or less nighttime symptom per month, ple of 503 university students between the ages of 18 and 24. not on daily medications, and no physical activity limitaOf these, we determined that 215 students had asthma either tions. Moderate and severe asthma were scored likewise. The based on having an asthma diagnosis or on specific criteria AS/MS also contained questions specific to asthma educafrom the asthma guidelines.13 The majority (n = 170) of partion and management such as instruction on inhaler use and peak expiratory flow rate (PEFR) monitoring, symptom ticipants with asthma were Caucasian. Some 40% had a fammonitoring, and influenza vaccination. We measured diffiily history of asthma, 31% had a first-degree relative with culty and confidence in coping with asthma care using 14 asthma, 15% had a personal history of atopy, and 59% had a Likert-style questions, such as On a scale of 0 to 5 (with 0 personal history of allergies.

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A Look at Asthma Care in a University Setting

being not difficult at all and 5 being extremely difficult), how difficult is it to deal with your respiratory complaints or asthma on a day-to-day basis? We used Dartmouth COOP Charts, which measure functional health status in primary care settings to assess overall perceptions of health.16,17 Participants respond to each of ten drawings on a 1-to-5 point scale (high scores indicate low levels of perceived functioning). The chart items measure physical fitness, family connections, difficulty performing daily activities, social functioning, emotional status, pain, change in health, social support, quality of life, and overall health. The COOP has undergone content, construct, and convergent validity testing.18,19 In this study, the Cronbach alpha for

the COOP was 0.71. We added all item scores to obtain the total functional health score. The Perceived Stress Scale (PSS) is a 14-item measure of global perceived stress that focuses on self-perceptions of stress during the past month.20,21 The PSS has been psychometrically tested in studies, including those of college students.20,22 The Cronbach alpha for the PSS in this study was 0.83. Statistical Methods We used analysis of variance (ANOVA) to detect differences in mean numeric responses across three asthma severity categories. The reported P value is from an overall test of any difference among groups. We calculated all means and percentages based on nonmissing values. We used the Statistical Analysis System 6.12 for all analyses. Procedure Interested students signed the informed consent form approved by the Universitys Institutional Review Board. Next, they completed the ASQ, the DDS, the COOP Charts, and the PSS. Those with a past history of asthma or with symptom scores of three or higher completed the AS/MS.

Table 1
The Demographics of Students with Asthma*
Gender (6 missing) Male . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54% (n=116) Female . . . . . . . . . . . . . . . . . . . . . . . . . . 43% (n=93) Degree program Undergraduate . . . . . . . . . . . . . . . . . . . . 98% (n=210) Graduate . . . . . . . . . . . . . . . . . . . . . . . . . . 2% (n=5) Residence (1 missing) On-campus . . . . . . . . . . . . . . . . . . . . . . . 65% (n=139) Off-campus/commuter . . . . . . . . . . . . . . . 12% (n=26) Live at home . . . . . . . . . . . . . . . . . . . . . . 23% (n=49)

Table 2

The Results Asthma Severity We identified asthma severity among the participants: 37 (19%) had mild asthma, 116 (59%) had moderate asthma, Ethnicity (1 missing) and 45 (23%) had severe asthma. To determine agreement Caucasian . . . . . . . . . . . . . . . . . . . . . . . . 79% (n=170) between self-reported severity and severity based on scorHispanic . . . . . . . . . . . . . . . . . . . . . . . . . . 4% (n=8) ing of the AS/MS, we stratified and compared severity ratAfrican-American . . . . . . . . . . . . . . . . . . . 7% (n=16) ings (see Table 2, Comparing Students Descriptions of Southeast Asian . . . . . . . . . . . . . . . . . . . . 4% (n=9) Other Asian . . . . . . . . . . . . . . . . . . . . . . . . 4% (n=9) Severity to Survey Data). Discrepancies existed between Other . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1% (n=2) participant ratings of severity and AS/MS-determined sever* n=215 ity. Of the 94 self-reported participants with asthma, most (63%) labeled their asthma as mild followed by 34% moderate and 3% severe. Of the 59 students who defined their asthma as mild, Comparing Students Descriptions of Severity to Survey Data* only 7 (12%) had symptoms consistent with Severity by Self-Report Severity by AS/MS mild asthma.13 Of the remainder, 44 (75%) had symptoms consistent with moderate Mild Moderate Severe Mild 63% (n=59) 12% (n=7) 75% (n=44) 14% (n=8) asthma, and 8 (14%) had symptoms consistent with severe asthma. Consequently, 89% Moderate 34% (n=32) 3% (n=1) 50% (n=16) 47% (n=15) of those who thought they had mild asthma had symptom scores suggestive of moderate Severe 3% (n=3) 0% (n=0) 33% (n=1) 67% (n=2) or severe asthma. Agreement between self-re* n=94 port ratings and AS/MS scores was lowest for

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A Look at Asthma Care in a University Setting

Table 3

Asthmas Impact on Students Lives

Mild (n=37) M (range) Moderate (n=116) M (range) 0.7 (0 to 10) 1.6 (0 to 20) 1.8 (0 to 5) 1.0 (0 to 3) 1.3 (0 to 13) 0.8 (0 to 5) 0.5 (0 to 5) 0.3 (0 to 6) Severe (n=45) M (range) 2.1 (0 to 20) 4.0 (0 to 32) 5.6 (1 to 25) 5.8 (0 to 20) 1.5 (0 to 8) 1.3 (0 to 3) 1.3 (0 to 10) 0.4 (0 to 7)

Work or school days missed in 6 months due to symptoms* Days in past 6 months you had to change an activity due to symptoms* Times per week you experienced symptoms* Times per month you were up at night due to symptoms* Times per day you use your inhaler Health visits in past 6 months to monitor respiratory complaints Times in past 6 months to health care provider due to symptoms* Times to university health services because of symptoms

0.5 (0 to 10) 0.9 (0 to 10) 0.8 (0 to 2) 0.2 (0 to 1) 0.4 (0 to 3) 1.1 (0 to 11) 0.4 (0 to 3) 0.1 (0 to 2)

number of visits to University Health Services. We compared participants using ANOVA in relation to perceived functional health, present and past perceived health, global perceived stress, confidence in coping with asthma, and in difficulty with adhering to asthma care (see Table 4,Relating Students Perceived Health Status, Stress, and Coping to Asthma Severity). Those with greater severity had lower perceived functional health and higher stress scores. Greater severity was also associated with lower self-confidence and greater difficulty in coping with asthma care.

Asthma Management We evaluated asthma manageTime seen in ED because appointments 0.1 (0 to 2) 0.4 (0 to 4) 0.6 (0 to 4) not available with primary care clinician* ment in relation to health supervision, tertiary care use, Means as calculated from non-missing values. n=198. * P < .05 asthma education and monitoring, and influenza prevention (see Table 5, Relating Health Supervision and Students participants with self-reported mild asthma and highest for Health Behaviors to Asthma Severity). More than 70% of participants with self-reported severe asthma. participants saw their health care providers for routine health care. Those with greater asthma severity used EDs more ofAsthma Impact ten than those with less severe asthma, as they could not obWe combined data of those with moderate and severe asthma (n = 161). Of these, 89 (58%) reported taking daily medicatain immediate appointments with their primary care clinician. Participants with moderate and severe asthma were tions for asthma, 93 (62%) said their physical activities were more likely than participants with mild asthma to have relimited at times because of asthma, and 31 (22%) had used the ED within the past 2 years. None of the participants clasceived education on inhaler use. Use of the PEFR for monitoring asthma was well below sified with mild asthma responded affirmatively to these questions. Only one student with mild disease had ever been guideline recommendations.13 Only 22% had been told by their clinician to measure PEFRs, only 26% had been inhospitalized for asthma. structed how to measure PEFRs, and only 4% reported daily All participants with asthma, especially those with severe measurement. Of participants with moderate and severe asthma, believed the disease impacted various activities, such asthma, only 4% and 8%, respectively, measured their daily as missing work or school, altering activities, and seeking PEFRs, and only 10% and 15% measured their PEFRs when health care because of illness (see Table 3, Asthmas Impact ill. Of the total number of participants, only 22% had reon Students Lives). Students with severe asthma reported ceived the influenza vaccine in 2000/2001, as is recomsleep interruptionsbecause of asthma symptomsapproxmended.23 imately 6 times a month. Asthma severity didnt affect the

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A Look at Asthma Care in a University Setting

Limitations Limitations of our study include the nonrandom sample from one university, the cross-sectional nature of the research, and the use of written questionnaires to estimate asthma severity. Longitudinal research combined with interview and physiological indicators, such as pulmonary function studies including spirometry, would have provided greater precision in severity classification. Better estimates of asthma diagnosis might have included physiological testing for hyperresponsiveness to exercise or methacholine.24 Ideally, asthma research in the university setting should be augmented with qualitative research that uses interviews and focus groups.

Table 4
Relating Students Perceived Health Status, Stress, and Coping to Asthma Severity*
Mild (n=37) Perceived functional health Health while at the university Health between ages 10 and 18 Global perceived stress Confidence in coping with asthma || Difficulty with asthma care || 2.1 (0.5) 3.7 (0.9) 4.0 (1.0) 1.5 (0.5) 3.5 (1.2) 0.3 (0.5) Moderate (n=116) 2.3 (0.5) 3.4 (1.0) 3.8 (0.9) 1.8 (0.6) 2.7 (1.2) 0.9 (0.9) Severe (n=45) 2.4 (0.6) 3.1 (1.0) 3.3 (1.0) 1.9 (0.6) 2.5 (1.0) 1.6 (1.0)

* n = 198; P < .05 for each row variable, overall ANOVA COOP Charts (high scores indicate low levels of perceived function) Demographic Data Survey Perceived Stress Scale || Asthma Severity/Management Survey

Implications for Clinicians Asthma-related morbidity, mortality, and ED visits in individuals ages 15 to 34 have increased substantially in the northeastern United States.9 Death due to asthma per million population increased from 2.9 to 3.7 between 1987 and 1995, emergency department visits increased from 53 to 69 per 10,000 population between 1992 and 1995, and hospitalizations due to asthma increased from 9.5 to 10 per 10,000 population. Our studys results suggest that undiagnosed asthma and poorly controlled asthma existed on the campus studied. Because of the large number of students that had moderate or severe disease and the infrequency of inhaler use, we determined that inadequate asthma control existed. Many students with moderate or severe asthma either didnt use their inhaler or used it more than 4 times per day, and neither extreme is consistent with recommended asthma care.13 Students classified with moderate and severe asthma tended to underestimate their diseases severity. Discrepancies between self-reported severity and scores on the AS/MS further suggest poorly controlled asthma. Adherence behaviors of individuals with asthma include difficulty managing their illness because of denial and lack of environmental control. Frustrated by asthma-induced limitations, many neglect their control medications or fail to measure PEFRs.12,24 In our study, those with moderate and severe asthma had difficulty coping with the disease. They had low perceptions of functional health and health ratings both during childhood and while attending the university. Living at a

university, away from family support, while coping with the unpredictability of college life may further impede adherence to asthma plans. We found a positive association between stress and asthma severity. This finding is consistent with the literature describing psychological symptoms and discomfort among individuals with moderate and severe asthma.11 Students who live away from their support system may experience heightened anxiety and concern. In this study, students with greater asthma severity had less confidence and greater difficulty coping with their illness than students with less asthma severity. Recommendations state that clinicians should aim treatment toward asthmas physiologic and psychological manifestations.11 We identified deficiencies in asthma care and asthma management. Although all students had access to the University Health Service, many didnt use it. For example, the University Health Service offered free influenza shots that targeted students with asthma, but only 31% of our studys participants with severe asthma received the vaccination. Implications for University Students Results from this study provide preliminary insights into asthma in one university. Study outcomes highlight the deficiencies in self-care and in professional management of asthma. Results also call into question the adequacy of current mechanisms for identifying and caring for college stu-

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A Look at Asthma Care in a University Setting

Table 5
Relating Health Supervision and Students Health Behaviors to Asthma Severity*
Mild (n=37) Sees clinician for regular checkups Has been in ED within past two years Has been hospitalized Instructed by clinician on inhaler use Clinician recommended measuring PEFR

Moderate (n=116) 80% (n=93) 17% (n=17) 14% (n=14) 74% (n=67) 26% (n=26) 33% (n=32) 4% (n=4) 10% (n=9) 47% (n=50) 22% (n=23)

Severe (n=45) 89% (n=40) 33% (n=14) 27% (n=11) 75% (n=24) 33% (n=13) 38% (n=15) 8% (n=3) 15% (n=6) 48% (n=19) 31% (n=12)

70% (n=26) 0% (n=0) 3% (n=1) 50% (n=12) 11% (n=4) 17% (n=5) 3% (n=1) 0% (n=0) 38% (n=14) 22% (n=8)

Instructed by clinician on how to measure PEFR Measures daily PEFR Measures PEFR when ill Clinician recommended receiving influenza vaccine Received influenza vaccine during this academic year
PEFR = Peak expiratory flow rate. * n = 198; Percentages as calculated from non-missing values.

dents who may be living with asthma. We must determine the role of university health services and where students with asthma receive treatment for their exacerbations. Partnerships between patients and clinicians are key to successful asthma management.13 The partnership begins with education about the illness, its triggers, pharmacological treatments, and environment assessment and control. Management plans should include symptom monitoring, environmental control, contingency plans for rescue actions, and written instructions for medications. Patients may also find a treatment and symptom diary helpful.13 We must develop new approaches to asthma care in university settings, such as creating Internet-based asthma education programs, asking students to keep asthma symptom diaries in password-protected computer files, maintaining communication with students by E-mail, and scheduling visits at student-friendly times. Further, our study highlights asthma research needs. Detailed health surveys completed upon admission may identify students who have asthma, including those unaware of their condition. We must also fine tune severity categorization, develop mechanisms to improve clinical approaches to asthma management, substantiate evidenced-based asthma care, and improve treatment.25 Ideally, research will

guide the design of interventions that meet the health needs of college students, providing quality of care and improving functional health outcomes.
REFERENCES
1. U.S. Office of Disease Prevention and Health Promotion: Healthy People 2010. Respiratory diseases, Washington, D.C.: U.S. Office of Disease Prevention and Health Promotion <http://www.health. vog/healthypeople/Document/HTML/ Volume2/24Respiratory.htm_TOC489764825. [21 October 2002]. 2. National Institutes of Health: Data Fact Sheet. Available: http://www.nhlbi. nih.gov/health/prof/lung/asthma/asthstat.pdf. [21 October 2002]. 3. American Lung Association: Trends in asthma morbidity and mortality, January 2001. <http://www.lungusa.org/data/asthma/asthmach_1.html> [24 September 2002]. 4. Hefflin BJ, Etzel RA: Out of hospital deaths due to asthma in North Carolina, 1980-88. Am J Prev Med 1995;11:66-69. 5. Adams PF, Marano MA: Current estimates from the National Health Interviews Survey, 1994. Vital Health Stat. 1995;193 (10):1-52. 6. Taylor WR, Newacheck PW: Impact of childhood asthma on health. Pediatrics 1992;90:657-62. 7. Asthma in America: Executive summary. <http://www.asthmainamerica.com/ execsum_over.htm> [24 September 2002]. 8. U.S. Department of Health and Human Services: Adolescent health chartbook. Washington, D.C.: U.S. Department of Health and Human Services, 2000. 9. Mannino DM, Homa DM, Pertowski CA, et al.: Surveillance for asthma United States, 1960-1995. MMWR 1998;47(SS-1):1-27. 10. Juniper EF, Guyatt GH, Ferrie PJ, et al.: Measuring quality of life in asthma. Am Rev Respir Dis 1993;147:832-38. 11. Vila G, Nollet-Clemencon C, de Blic J, et al.: Asthma severity and psychopathology in a tertiary care department for children and adolescents. Eur Child Adolesc Psychiatry 1998;7(3):137-44.

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12. van Es SM, le Cop EM, Brouwer AI, et al.: Adherence-related behavior in adolescents with asthma: Results from focus group interviews. J Asthma 1998;35(8):637-46. 13. U.S. Department of Health and Human Services, National Institutes of Health: National asthma education and prevention program, expert panel report II: Guidelines for the diagnosis and management of asthma. Bethesda, Md.: U.S. Department of Health and Human Services, National Institutes of Health, 1997, Publication 97-4051. 14. Finkelstein JA, Lozano P, Shulruff R, et al.: Self-reported physician practices for children with asthma: Are national guidelines followed? Pediatrics 2000;106(4):886-96. 15. Jatulis DE, Ying-Ying M, Elashoff RM, et al.: Preventive pharmacologic therapy among asthmatics: Five years after publication of guidelines. Ann Allergy Asthma Immunol 1998;81:82-88. 16. Beaufait DW, Nelson EC, Landgraf JM, et al.: The COOP measures of functional status. In: Stewart M, Tuiver F, Bass MJ, et al., eds. Tools for primary care research. Newbury Park, Ca.: Sage, 1992. 17. Nelson EC, Wasson JH, Johnson DJ, et al.: Dartmouth COOP functional health assessment charts: Brief measures for clinical practice. In: Spilker B, ed. Quality of life and pharmacoeconomics in clinical trials. Philadelphia, Pa.: Lippincott-Raven Publishers, 1996;161-68. 18. Nelson E, Wasson J, Kirk J, et al.: Assessment of function in routine clinical practice: Description of the COOP Chart method and preliminary findings. J Chron Dis 1987;40(suppl):55S-62S. 19. Bronfort G, Bouter LM: Responsiveness of general health status in chronic low back pain: A comparison of the COOP Charts and the SF-36. Pain 1999;83:201-09. 20. Cohen S, Kamarck T, Mermelstein R: A global measure of perceived stress. J

Health and Soc Behav 1983;24:(3)85-96. 21. Cohen S, Williamson G: Perceived stress in a probability sample in the United States. In: Spacapan S, Oskamp S, eds. The social psychology of health. Newbury Park, Ca.: Sage, 1988;31-67. 22. Gwele N, Uys LR: Levels of stress and academic performance in baccalaureate nursing students. J Nursing Education 1998;37(9):404-07. 23. Centers for Disease Control and Prevention: Updated recommendations from the advisory committee on immunization practices in response to delays in supply of influenza vaccine for the 2000-01 season. MMWR 2000;49:888-92. 24. Randolph C, Fraser F: Stressors and concerns in teen asthma. Current Problems in Pediatrics 1999;29:82-93. 25. Bauchner H, Steinbach S: Research and asthma: Where do we go from here? Pediatrics 2000;106(4):897-98.

ACKNOWLEDGMENT
This research was supported by a grant from the Massachusetts Department of Public Health.

ABOUT THE AUTHORS

At the University of Massachusetts Lowell, Susan McClennan Reece is a professor and coordinator of Family Health Nursing, College of Health Professions; Christina Holcroft is a biostatician Work Environment, College of Engineering; Maureen Faul is a program manager for the Center for Health and Disease Research, Clinical and Laboratory Sciences, College of Health Professions; Nancy Quattrocchi is director, University Health Services; and Robert Nicolosi is a professor, Clinical and Laboratory Sciences, and director of the Center for Health and Disease Research, College of Health Professions.

Educational Offerings
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