More than 40% of school-aged children and adolescents in the United States have at least one chronic health condition (1). In addition to the health effects, children with chronic diseases have higher rates of school absenteeism, which is associated with lower academic achievement (2). To minimize such negative outcomes, children with chronic diseases require support in and outside of clinical settings, including in schools, where children spend the majority of their days. Research also highlights schools as optimal venues to support children's health, as they can reach a large number of children, including many who rely on schools for health services due to barriers to healthcare access (3).

School-based care is critical to enable optimal engagement for the 4.3 million school-aged children with asthma (4). Asthma is a leading cause of school absenteeism, accounting for 13.8 million missed school days annually (5). Further, research shows that children with inadequate asthma control have lower quality of life, are more likely to be bullied, and less frequently attend school activities (6–8). Inadequately controlled asthma can also interfere with students’ ability to fully engage in school, which can have detrimental lifelong consequences, such as increased disability, fewer job opportunities, and limited community interactions (3). As such, schools are integral places to promote asthma care by providing disease-specific education, supporting medication adherence, and reducing environmental exposures during the school day (9).

School-based asthma interventions are shown to positively impact affected children (10). Particularly, asthma education is a valuable tool to support disease control, reducing hospital, emergency department, and clinic visits by affected children (11). However, such asthma education typically focuses on students with asthma and does not commonly include students without asthma, who directly interact with and impact the daily experience of affected students (12). For instance, studies demonstrate that children with asthma who experience greater peer victimization have lower asthma control and self-efficacy (13). Further, research indicates lower social support is significantly associated with lower medication adherence among children with asthma (14). As such, peer support can mitigate adverse outcomes for affected students.

One effective method to encourage such peer support is asthma education for all students, including both students with and without asthma (15). To date, school-based asthma education programs for all students primarily target a small number of grade levels, with various programs that collectively span 3rd–10th grades (12, 16–23). Further, these programs are delivered over multiple sessions (12, 17–21, 23), which are led by school nurses (22), teachers (12, 17, 20, 21), or peers (18, 19, 23). Evaluation of these programs demonstrates they improve asthma knowledge (12, 16–18, 20–24). Also, few programs examine attitudes, with some demonstrating improved attitudes toward students with asthma (16, 17), while others show limited effects on attitudes (18, 21, 23). When all-student asthma education is part of a more comprehensive initiative to support asthma in schools, studies show reduced symptoms among students with asthma (25) and mixed effects on quality of life and school absenteeism of affected students (22, 24).

Although asthma education for all students has expanded in the past two decades, such programs remain limited in their intended audiences, implementation, and evaluation. First, these programs primarily focus on students in 3rd grade and higher. Few such programs are tailored to younger children (K–2nd grade) (24, 25), who have less asthma knowledge and a greater chance of bullying and victimization than older students (8, 26). In fact, research shows students in higher grades have more favorable attitudes toward peers with asthma, underscoring the importance of asthma education for younger students (27). In terms of program implementation, multi-session asthma curricula are often challenging to integrate into schools, particularly in marginalized communities most affected by asthma, given limited time, resources, and staffing (28). A one-session asthma education program may be more feasible to incorporate into schools, yet there remains a paucity of published research on such programs for all students. Further, current evaluation efforts examine effects on students with asthma, overlooking youth without asthma, who have lower disease knowledge (29). Also, despite research showing disease stigma as a key barrier to school-based care for chronic illness (30, 31), few all-student programs evaluate their impact on students’ attitudes toward children with asthma, a key metric to understand potential effects of education on peer support (16–18, 21, 23). Likewise, few programs analyze effects on self-efficacy (23), a critical component of asthma care that can improve negative attitudes toward asthma and offset perceived barriers to asthma self-management (32). Understanding programs’ impact on self-efficacy is key because children with asthma who have high self-efficacy are more adherent to treatment, leading to better asthma outcomes (32).

To fill these gaps in the reach, implementation, and comprehensive evaluation of all-student asthma education, we describe the adaptation of a one-session asthma curriculum for all kindergarten to 8th grade students and evaluate its impact on knowledge, attitudes, and self-efficacy.

This cross-sectional study was a part of a multi-component asthma intervention in three schools on Chicago's South Side that spanned Kindergarten to 8th grades. The student population is largely Black (97%) and low-income (82%) (33), and childhood asthma prevalence in this community reaches 20%–30% (34). This study was approved by the University of Chicago Institutional Review Board (IRB25-1004).

In total, 603 K–8th grade students participated in a 45-minute education session, with a total of 28 sessions in April/May 2024. We received post-session surveys from 485 students (version 1: n = 335, version 2: n = 150) (Table 2). Participants were 50% male. Student-reported asthma prevalence was 19% (n = 93/485), which aligns with prior studies in these schools (51); of note, 16% of students indicated they were unsure if they had asthma. Table 3 shows results for asthma knowledge, attitudes, and self-efficacy for all participants and by subgroups based on grade and asthma diagnosis.

This study is the first, to our knowledge, to evaluate a novel one-session asthma education program for K–8th grade students in urban schools, demonstrating positive outcomes post-curriculum in terms of students’ asthma knowledge and self-efficacy, despite mixed impact on attitudes. This study demonstrates such an intervention is feasible and beneficial for schools to promote asthma awareness and can influence school culture around chronic diseases.

In our study, most students answered asthma knowledge questions in each topic area correctly post-curriculum. This high level of asthma knowledge post-curriculum aligns with literature on asthma education programs developed for similar settings, including for student populations in grades 1–10 (12, 16–20, 22, 24, 25), who are predominately Black (12, 24), and with high asthma prevalence (17, 18, 20). All of these studies involved programs with multiple educational sessions (12, 17–21, 24, 25), while our study involved one session; thus, we demonstrate it is feasible to impact knowledge with a one-session asthma education program. Notably, in our study, knowledge varied by topic area with fewer students answering correctly in episode management and triggers. These findings suggest opportunities to further revise content to optimize student knowledge. Such curriculum refinement is important as high asthma knowledge can be beneficial in building a positive school culture around asthma, with literature providing compelling evidence that health education promotes healthy behaviors among youth and open communication about their condition with peers and parents (47, 52).

When examining asthma knowledge by subgroups, students with and without asthma had similar knowledge across all topic areas, while older and younger students had similar understanding of the transmission of asthma, its symptoms, and triggers. These findings underscore our curriculum's ability to effectively engage all students, regardless of age or asthma diagnosis. However, more older students demonstrated understanding of pathophysiology, medication use, and episode management than younger students, which may result from differences in baseline knowledge, medication familiarity, and curriculum content/delivery. For instance, research indicates that older adolescents with asthma are more knowledgeable about asthma than younger adolescents (26, 29). While our study did not focus solely on students with asthma, these age-related differences in asthma knowledge may translate to all students. Similarly, the discrepancies in knowledge about medication use may reflect that younger students are less familiar with medications, due to fewer encounters through personal experience or observing family members (53). Further, research highlights most healthy children under eight years do not understand how medications work (54). Hence, these results suggest the need to revise content to optimally engage younger students, including as related to asthma medication use. The curriculum should be adapted to better account for different educational strategies needed as children develop skills in self-management, for example by incorporating more interactive play as well as cooperative learning for younger students, which are the most effective methods in chronic disease management education interventions for this age (47).

In addition to knowledge, our study revealed mixed outcomes for attitudes. Our findings mirror prior all-student education programs that report limited impact on students’ attitudes (18, 21, 23). However, our findings differ from two prior studies that show positive effects of asthma education on students’ attitudes (16, 17), a discrepancy that may be explained because they differed from ours in regard to curriculum design (i.e., booklet, multi-lesson program) and study population [i.e., older students in 6–8th grade, predominantly white (17) or high socioeconomic status (16)]. Various factors may explain the limited impact we observed, for instance, a ceiling effect, as literature suggests students without asthma generally hold positive attitudes toward students with asthma (16, 23, 29, 31, 55). Further, the 3-point Likert scale used may have limited the ability to differentiate attitudes, whereas similar all-student asthma education programs use a 4-locus attitudes scale, which is more comprehensive but may impact understanding by younger students (21, 31). Finally, the mixed attitudes about asthma we observed were surprising given the high asthma knowledge in our study population, as studies show positive correlation between asthma knowledge and asthma attitudes (29, 55).

Regarding asthma attitudes by age group, older and younger students reported similar attitudes about children with asthma participating in physical activity. However, more older students reported positive attitudes about the cause of asthma episodes, which may reflect research that outlines older students being more accepting of classmates with asthma than younger ones (27, 29). When analyzing attitudes by asthma diagnosis, we found a greater proportion of students with asthma reported positive attitudes about participating in physical activity than students without asthma, while there were no differences in attitudes about the cause of asthma episodes. Our results echo prior studies assessing students’ attitudes toward asthma, including one study that reported students without asthma had less tolerance toward children with asthma and their limitations on activity as compared to children with asthma (29). Given these findings, future curriculum refinements, such as peer teaching, role-playing, and repeated asthma education, may have greater potential to impact asthma attitudes of all students.

In contrast to mixed attitudes, our study demonstrated that post-curriculum, a majority of all students had positive self-efficacy about helping a classmate with an asthma episode. This finding was unanticipated in light of the results about attitudes, given prior research highlights higher self-efficacy is associated with more positive attitudes about asthma (56). Such research underscores that the mixed attitudes we observed could be a consequence of our evaluation methods rather than the content of the curriculum. Taken together with asthma knowledge, the students’ positive self-efficacy emphasizes the potential of the curriculum to encourage peer support for students with asthma, similar to other research revealing that asthma education increases peer support (15). Hence, our curriculum can help schools cultivate a supportive environment for students with asthma and even serve as a model for schools to incorporate education for other common chronic illnesses at school, such as food allergies. Notably, we must acknowledge that developing self-efficacy is an ongoing process requiring support from many individuals, including students’ families, healthcare professionals, teachers, and school nurses (57). For this reason, in addition to our curriculum, schools must offer regular opportunities for children to discuss and apply these concepts, as well as promote collaboration from all groups involved with asthma care (i.e., caregivers, healthcare professionals, peers).

In evaluating self-efficacy by subgroups, we found that a greater proportion of younger students indicated positive self-efficacy than older students. This result was unexpected considering that children develop increasing autonomy for asthma self-management as they mature (26). Our findings may differ because younger children in our study may have been overly confident, as suggested by literature that highlights children are more likely to report self-efficacy than objective measures of preparedness (58). Nevertheless, our curriculum shows early asthma education can support all students in feeling confident to help a classmate with an asthma episode. Further, in analyzing by asthma diagnosis, there were no differences in self-efficacy to help a classmate in the event of an episode, reinforcing the program's value to all students and potential to cultivate supportive school environments for students with asthma. While few prior all-student education programs measure effects on self-efficacy, one study that included students with asthma documented significant improvements in mean self-efficacy post-intervention (23). Along with these findings, our study emphasizes the importance of all-student education programs to promote increased self-efficacy among children, with the goal of supporting better asthma care in schools.

Following the curriculum, majority of all students indicated that they are more likely to help a classmate with asthma and understand asthma better because of the curriculum. There were no differences by grade or asthma diagnosis. As such, this result emphasizes the ability of our curriculum to be broadly accessible across all developmental stages, regardless of asthma diagnosis. Further, we provide evidence that school-based education can be an effective method to promote chronic disease awareness among school-aged children and should be considered for broader school or district-wide implementation.

For limitations, participants only completed surveys post-curriculum, and this study did not have a control group, limiting our ability to attribute asthma knowledge, attitudes, and self-efficacy directly to the curriculum. Similarly, not all participating students completed the post-survey. Also, surveys were distributed immediately after the session and did not assess medium or long-term effects. Despite these limitations, our study design represents real-world application that accounts for the pragmatic considerations of implementation in school classrooms. While the curriculum objectives and content were the same across the three schools, the survey underwent revisions in mid-stages of implementation (i.e., only one school received the revised survey) to refine questions for the students’ literacy level in K–2nd grade students. Thus, the survey tool and changes mid-implementation may have limited our ability to fully capture the effects of the curriculum on younger students. Further, the survey tool had a limited number of questions in each domain, particularly attitudes and self-efficacy, to support its completion within the timeframe in the classroom and also dichotomized the results. These measurement-related factors may have introduced biases, impacted internal validity, and limited the ability to detect meaningful changes or differences between subgroups. Lastly, our study was conducted in a high-prevalence, urban community, potentially limiting its generalizability to other populations.

Our one-session asthma curriculum was delivered to all K-8th grade students in three schools, and participating students had high asthma knowledge and self-efficacy post-curriculum; attitudes about asthma were mixed. Future research should examine pre and post-session asthma knowledge, attitudes, and self-efficacy as well as use a control group or a delayed intervention group to understand changes due to the curriculum, alongside individual-level effects. In addition, future work should evaluate the curriculum's longitudinal impact on knowledge, attitudes, and self-efficacy, as well as the impact of recurrent asthma education for all students (e.g., annual curriculum implementation) and its effect on self-management, quality of life, asthma control, and absenteeism among students with asthma. Our curriculum suggests school-based asthma education is feasible and beneficial for all K–8th grade students in classrooms, underscoring that such educational programs may promote inclusive environments for chronic disease management.