Putting Guidelines to Use: Evaluation of the Connecticut School-Based Asthma Surveillance System

BACKGROUND:  Evaluation is an essential component of any surveillance system. In 2001 the Centers for Disease Control and Prevention (CDC) published the Updated Guidelines for Evaluating Public Health Surveillance Systems. Surveillance of chronic diseases, such as asthma, can be used to guide public health programs and interventions.  Asthma affects 7.1 million children and accounts for 14.4 million lost school days annually in the United States. In 2004, as required by state law, Connecticut initiated its state-wide School-based Asthma Surveillance System (SBASS). Our objective is to conduct the initial evaluation of SBASS using CDC guidelines.

METHODS:  We engaged stakeholders at Connecticut Department of Public Health (CDPH) to assist with describing SBASS and focusing the evaluation. Document review and key informant interviews were used to assess SBASS usefulness and system attributes. Key informants included four CDPH staff, one Connecticut State Department of Education staff, three school nurse supervisors, and six school nurses. Interview transcripts were reviewed independently by two researchers using the Constant Comparative Method to identify common key words and themes. 

RESULTS:  Eighty-five percent participation by Connecticut public schools suggests representativeness and acceptability; however, nurse interviews indicated low understanding of the purpose of reporting, decreasing acceptability.  SBASS child asthma prevalence (13.1%) is similar to Behavioral Risk Factor Surveillance System prevalence (13.4%) and SBASS data are available at a finer geographic scale (e.g., school, district) — providing evidence of sensitivity. Difficulties in updating the reporting and data entry systems indicate moderate flexibility. SBASS data drive public health programs such as Putting on AIRS and Healthy Homes Initiative, indicating usefulness. However, it is unclear how the State Legislature uses SBASS reports. Paper-based reporting and a well-developed database indicate stability. Manual data entry of 21,000 records annually is burdensome, but CDPH is currently installing optical character recognition software to reduce data entry burden. Dissemination of SBASS data every three years is timely, but reporting deadlines are poorly designed for school nurses. Weaknesses include data quality (24% missing asthma severity, 7% missing race/ethnicity) and simplicity (redundant and confusing data collection tools).

CONCLUSIONS: SBASS provides useful asthma prevalence data not available currently from other surveillance systems. However, the following improvements are recommended:  increase communication with nurses to improve acceptability; engage nurses to improve data collection tools (simplicity), data quality, and timing; and follow-up with State Legislature to determine usefulness of SBASS reports.  CDC guidelines are a beneficial tool for rapid and thorough surveillance system evaluation.