Asthma and Attendance in Urban Schools

Sara B. Johnson, PhD, MPH; Paul Spin, PhD; Faith Connolly, PhD; Marc Stein, PhD; Tina L. Cheng, MD, MPH; Katherine Connor, MD, MSPH


Prev Chronic Dis. 2019;16(10):e148 

In This Article

Abstract and Introduction


Introduction: Asthma is linked to student absenteeism, a risk factor for poor achievement and school dropout. Studies of asthma and absenteeism have common limitations, including relying on parent-reported asthma, which may be unreliable and prone to selection, and inadequately accounting for confounding health and social risks. Therefore, the rate of absenteeism attributable to asthma and the extent to which better asthma control would translate into better attendance remain unclear.

Methods: Participants were 1,194 students in 2 large urban US schools (1 elementary, 1 middle) in 2016–2018. Student asthma was assessed based on parent report on health forms, student-reported asthma-related emergency department/hospitalization or medication use, and school health center record of asthma. Multiple imputation was used to reduce selection from missing asthma reports. The relationship between asthma and school district–reported days absent was estimated using Poisson random intercept regression, accounting for health and demographic covariates.

Results: Parent-reported ever asthma (27%) was not associated with absenteeism in adjusted models. Student-reported asthma health care or medication use (16%) and school health center record of asthma (17%) were associated with higher absenteeism (incidence rate ratio [IRR], 1.16; 95% confidence interval [CI], 1.01–1.35 and IRR, 1.21; 95% CI, 1.09–1.34, respectively). Student-reported asthma and school health center record of asthma were associated with 1.9 and 1.5 absences per year, respectively.

Conclusion: Student-reported and school health center record of asthma explained 14% to 18% of student absenteeism, even after accounting for other health and social risks. When possible, student reports should supplement parent reports to ensure that students with asthma are identified and obtain access to care.


Approximately 1 in 101 schoolchildren in the United States has asthma.[1] Forty-nine percent have missed 1 or more days of school due to the condition.[2] Absenteeism, in turn, is associated with lower grades and assessment scores.[3]

Asthma is more prevalent among low-income and racial/ethnic minority children and children in urban areas.[4–6] Disparities in asthma control are related to access to and quality of health care, adherence to medication use, and social factors such as segregation and psychosocial stressors.[7] These factors also contribute to absenteeism.[8] However, many studies of asthma and attendance have not accounted for factors such as poverty, access to transportation, and comorbid health conditions.[8,9] It is unclear, therefore, whether improved asthma management alone would meaningfully improve attendance among low-income and racial/ethnic minority students with asthma.[9]

Many studies of asthma and attendance have relied on parent reports,[9] which may be unreliable in settings with high asthma prevalence,[10,11] and may underestimate asthma among low-income children because of difficulty reaching parents.[11,12] Thus, to characterize the public health burden of asthma in urban schools for planning and intervention, supplements to parent reports are needed.

We examined asthma and attendance in 2 large urban schools. First, we investigated schoolwide prevalence of 3 asthma indicators based on 1) parent reports; 2) student reports of asthma-related emergency department (ED) visits, hospitalization, or use of asthma medication; and 3) school health center record of asthma. We expected prevalence would be highest based on parent reports, which were expected to be most inclusive. Second, we investigated the relationship between each asthma indicator and attendance, accounting for health and sociodemographic factors. We hypothesized that the relationship would be strongest for student reports and that all relationships would be attenuated after accounting for health and social factors.