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Title: Coordinated Approach to Asthma Care in Schools:
        How Connecticut and Toronto, Ontario Compare
Author: Chlo-Anne Gonsalves, MSN, RN

Date Posted:

April 28, 2011

Coordinated Approach to Asthma Care in Schools:
How Connecticut and Toronto, Ontario Compare

I have been a Registered Nurse for 25 years and for the last three years have been a school nurse at an elementary school. I love my current job and I feel like it isn’t really a “job” at all. I received my BSN degree over 20 years ago, but I recently returned to college to obtain my MSN with a focus on community and public health. I felt that the advanced degree would give me tools and strategies to develop, implement, and evaluate health programs within a community health setting, such as a school. As part of my curriculum, I recently traveled with a group of 7 peers to Toronto, Ontario with the objective of studying Canada’s Universal healthcare system with a focus on public health policy. The city of Toronto has a population of 2.48 million people which is a comparable population to the 3.5 million people who reside in the entire state of Connecticut.

The purpose of this paper is a descriptive comparison of existing guidelines of strategies for addressing asthma care for children who attend public schools in the state of Connecticut and Toronto, Ontario. It is through the lens of the public health models and community nursing models of Connecticut and Toronto, Ontario that the strategies for addressing asthma in schools are described. Both Connecticut and Toronto, Ontario recognize the severity of the health risks associated with childhood asthma in the school setting and have strategically developed asthma control programs that include assessment, surveillance, policy development, program implementation, and program evaluation within public schools to help manage childhood asthma. Each region has a somewhat different approach to managing childhood asthma in a school setting, but the overall goals are similar.

Anyone can get asthma, but children are especially vulnerable. Childhood asthma is one of the most common health problems among children in Connecticut and Toronto, Canada. In the United States, The Centers of Disease Control and Prevention (CDC) reveals that more than 32 million people living in the United States have been diagnosed with asthma at some time of their lives and 22 million currently have asthma. Each day, 11 Americans die from asthma which amounts to approximately four thousand people dying from asthma each year. In the United States, asthma is one of the most chronic diseases and leading cause of disability among children. Asthma is twice as common among children as adults. Nearly five million asthma sufferers are under the age of 18 (Centers for Disease Control and Prevention (CDC), n.d.). Asthma is the third-ranking cause of hospitalization for children and one of the leading causes of school absenteeism. Nationally, a total of 12.8 million school days are missed each year because of asthma.

The prevalence of asthma in Canada has been increasing over the last 20 years and it is estimated that currently over 3 million (8.4%) of the Canadian population over 12 years of age have asthma. Like the United States, prevalence of asthma has been increasing among Canadian children and youth and affects at least 12% of Canadian children. Childhood asthma continues to be the leading cause of hospitalization of children in Canada (Asthma Society of Canada, 2005). Asthma is the leading cause of absenteeism from school (Kohen, 2010). In Canada, over 500 people die each year from asthma and there are approximately 10 deaths per week due to asthma. Sadly, it is estimated that 80% of asthma deaths could be prevented with proper asthma management (Asthma .ca 2005).

Asthma prevalence rates among Connecticut children aged 5-18 years old, attending public schools between the period of the Fall of 2006 until the Spring of 2009, was an average of 13.1% or 28, 279 school children (Nguyen, Peng, & Hargrove, 2010). Asthma prevalence rates were highest among male students when compared to female students. In regards to asthma prevalence rates by ethnicity, Hispanic students had the highest rates of asthma followed by black students, other race/ethnicity students, and white students (Nguyen et al., 2010).

The prevalence rate of asthma of children in Toronto, Ontario is 13.65 (33,000 children). Like the United States, asthma is more prevalent among males than females (Kohen, 2010). The burden of treating asthma not only falls on the individual or their families. It also falls on schools, neighborhoods, workplaces, cities, and our state and province.

In the school setting, a healthy child is an engaged, focused student therefore a better student. Better students build better communities. Public schools have many priorities which include: teaching mandated curriculum, encouraging creative and thoughtful responses from the child to the lessons learned, promoting healthy lifestyles and social awareness, all within a safe and friendly environment. The school setting is geared for learning and children are expected to attend their classroom in optimal condition on a wellness continuum. Research has shown that children with the most severe type of asthma have the poorest outcomes in standardized reading and math scores (Kohen, 2010).

In the United States, The National Association of School Nurses (NASN) believes that every child should have access to a school nurse at a ratio 1:750. This ratio is particularly critical for children with a potentially life-threatening condition like asthma. The school nurse plays an important role in serving as a liaison between the school and child’s home and between the school and the child’s health-care provider (NASN, 2002).

In Connecticut, The Connecticut State Department of Education (CSDE) supports school health services by providing on-site Registered Nurses. School nurses promote adherence to a child’s asthma management plan by performing surveillance, maintaining individual care plans, and administering medications as ordered by the child’s Primary Care Physician (PCP) while they are in school, and supports education of the child for self-management. This is especially important to children with asthma in order to maintain their level of wellness, prevent asthma “attacks”, and promote participation in all school activities (Lorentson, 2010). The school nurse in each school of Connecticut is required to complete an annual asthma survey of children attending school based on Health Assessment Records of children entering Kindergarten, 6th grade, and 9-11th grade, and submit their findings to Connecticut’s DPH. The Connecticut School-based Asthma Surveillance Report, established in 2003-04, continues to provide a measurable means of ongoing surveillance of asthma rates and trends within the state.

School nurses are first responders to all emergencies that may occur during the school day. Unfortunately, children who have asthma are at risk for attacks from various “triggers” while attending school. For example, one child at my school collapsed during his physical education class while exercising. Upon my arrival, the child had a panic stricken look on his little face, was breathing at a rapid rate, and had audible wheezes. This was a terrifying experience for the child but also for the P.E. teacher and the other children attending the class. The children also wondered out loud if he was going to die! Of course, the little boy heard these comments and wondered this too! As an experienced R.N. with expert skill in asthma management, I quickly assessed the child’s respiratory status, determined the level of intervention required, offered medication according to the PCP management plan, and provided support and reassurance to the child and the entire school community. If the child’s condition had worsened, I knew who to call and how to support the child until additional help arrived. Fortunately, the outcome was positive and the child stabilized without any further worsening of his condition.

The strategy for addressing asthma in schools is quite different in Toronto. There is no on-site school nurse to provide direct care to children with asthma. It is up to the schools’ Principal, administrative staff, and teachers to support a child with asthma during the school day including delivering direct care such as medication administration.

The Public Health School Asthma project was initiated in response to the increasing burden of childhood asthma in Ontario. A coroner recommended that schools provide asthma education to children with asthma after a teen-age boy had died from asthma. (Cicutto et al., 2006). Each school relies on public health nurses to assess the needs of the school, provide resources and programming to make the school asthma friendly, and to establish partnerships among public health units and the school community. In Ontario, a public health nurse visits approximately 25-30 schools a month (Cicutto et al., 2006). Research has shown that the school staff is appreciative of the education they receive regarding asthma management but express they do not feel confident enough in their skill if a true asthma emergency arose.

Children with asthma can live healthy, normal lives with proper management and adherence to their PCP recommended regimes. It is important for schools to be asthma friendly and deliver appropriate care and support to these children while they are in school

The purpose of this paper is to provide awareness of existing guidelines for public policy, surveillance, prevalence, and strategies for addressing asthma care for children who attend public schools in the state of Connecticut and Toronto, Canada. There are noted similarities in asthma prevalence rates among the two regions but the biggest contrast is the direct care provided to children while they are in school. Currently, there is a Toronto based public health nurses’ council promoting the presence of onsite school nurses but this action is still in the formative stage of planning.

About the Author: Chlo graduated with her BSN in 1986 and will receive her MSN on May 15th, 2011. She dedicates her advanced degree to her wonderful and supportive family - her husband, Joe, of 21 years and her three daughters who "keeps things real".


Asthma .ca website. (2005).

Centers for Disease Control and Prevention (CDC). (n.d.).

Cicutto, L., Conti, E., Evans, H., Lewis, R., Murphey, S., Rautiainen, K., & Sharrad, S. (2006, August). Creating asthma- friendly schools:a public health approach. Journal of School Health, 76, pp.252-258.

Kohen, D. E. (2010, December). Asthma and school functioning (Research article Catalogue no.82-003-X). Retrieved from Statistics Canada:

Lorentson, M. (2010, November 1). Health services program information survey report (Annual report). Retrieved from The Connecticut State Department of Education:

Mason, D. J., Leavitt, J. K., & Chaffee, M. W. (2007). Policy and politics in nursing and health care (5th ed.). St. Louis, MO: Saunders.

National Association of School Nurses. (2002). Asthma management in the school setting (Issue Brief). Retrieved from

Nguyen, K., Peng, J., & Hargrove, S. (2010). Connecticut school-based asthma surveillance report 2010, School years: Fall 2006-Spring 2009. Connecticut Department of Public Health, Health Education, Management and Surveillance Section, Hartford CT. Retrieved from

Turnock, B. J. (2009). Public health: what it is and how it works (4th ed.). Sudbury, MA: Jones and Bartlett.

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