Asthma has a greater negative impact on poor and minority children than on others, partly because of undertreatment and poor adherence to medication regimens in these groups. Community-based interventions, including intensive case management, educational programs, and multimedia programs aimed at educating patients and monitoring asthma, have demonstrated inconsistent results. Directly observed treatment has been shown to be effective. Direct observation could be used to provide daily preventive medications for asthma during school hours, which would assure that children receive these medications at least on school days. Halterman and associates assessed the impact of school-based provision of inhaled corticosteroids on asthma severity in urban children with mild to severe persistent asthma.

Children aged three to seven years who met the National Heart, Lung, and Blood Institute guidelines for mild to severe persistent asthma and whose primary care provider agreed that their asthma required daily doses of inhaled corticosteroids were included in the study. Patients were randomly assigned to a school-based group (daily inhaled corticosteroids provided through the school) or a usual-care group (inhaled corticosteroids not given through the school).

Patients in the school-based care group received two metered-dose inhalers of corticosteroid preparation, with one dose administered by the school nurse each day the child was in school. Follow-up assessments were performed on a monthly basis, with the main outcome measure being the number of symptom-free days. Other outcome measures of asthma severity included daytime and nighttime asthma symptoms, the need for use of rescue inhalers, absenteeism, use of the health care system, and quality of life of parents and caregivers.

There were 180 children who participated in the study. Children in the school-based care group had more symptom-free days during the winter months and missed fewer days of school than children in the usual-care group. The parents of the children in the school-based care group showed a greater improvement in quality of life than the parents of children in the usual-care group.

The authors assessed the impact of the school-based program on children who were or were not exposed to secondhand smoke and found that those who were not exposed to secondhand smoke and were in the school-based program had significantly more symptom-free days, were less likely to require rescue medications, and were less likely to have three or more acute visits for asthma treatment. Patients who were exposed to secondhand smoke did not receive any significant benefit from the school-based program.

The authors conclude that school-based programs providing inhaled corticosteroids on school days significantly improve symptoms, quality of life, and absenteeism in urban children with mild to severe persistent asthma. They add that the impact of this program is only noted in children who are not exposed to secondhand smoke. This program served poor and minority children and may become a model for the management of childhood asthma in underserved communities.