Children with Uncontrolled Asthma from Economically-Disadvantaged Neighborhoods: Needs assessment and the development of a school-based telehealth and electronic inhaler monitoring system

Abstract

Background:

Children from economically-disadvantaged communities often encounter healthcare access barriers, increasing risk for poorly controlled asthma and subsequent healthcare utilization. This highlights the need to identify novel intervention strategies for these families.

Objective:

To better understand the needs and treatment preferences for asthma management in children from economically-disadvantaged communities and to develop a novel asthma management intervention based on an initial needs assessment and stakeholder feedback.

Methods:

Semi-structured interviews and focus groups were conducted with 19 children (10–17 years old) with uncontrolled asthma and their caregivers, 14 school nurses, 8 primary care physicians, and 3 school resource coordinators from economically-disadvantaged communities. Interviews and focus groups were audio-taped and transcribed verbatim and then analyzed thematically to inform intervention development. Using stakeholder input, an intervention was developed for children with uncontrolled asthma and presented to participants for feedback in order to fully develop a novel intervention.

Results:

The needs assessment resulted in five themes: (1) barriers to quality asthma care, (2) poor communication across care providers, (3) problems identifying and managing symptoms and triggers among families, (4) difficulties with adherence, and (5) stigma. A proposed video-based telehealth intervention was proposed to stakeholders who provided favorable and informative feedback for the final development of the intervention for children with uncontrolled asthma.

Conclusions:

Stakeholder input and feedback provided information critical to the development of a multicomponent (medical and behavioral) intervention in a school setting that uses technology to facilitate care, collaboration, and communication among key stakeholders in order to improve asthma management for children from economically-disadvantaged neighborhoods.

Asthma, the most common childhood chronic illness, disproportionately children from lower income neighborhoods and racially/ethnically minority backgrounds in the United States [1, 2]. Children from minority and economically-disadvantaged communities are found to have significantly higher rates of poorly controlled asthma and asthma-related hospitalizations compared to non-Hispanic white children and children from affluent communities [2]. Barriers faced by children from low-income neighborhoods and minority backgrounds such as a lack of reliable transportation, inconvenient office hours, and financial constraints contribute to these disparities in pediatric outcomes [3–6]. Other common factors that impact asthma outcomes include poor asthma treatment adherence and ineffective self-management behaviors [7, 8].

One approach to overcome these disparities in access to comprehensive asthma care is to deliver technology-enhanced medical care to the patient’s school using video-based telehealth [VBT] and mHealth. School-based clinics enable asthma specialists to engage with youth who are most impacted by structural and social determinants of health who might not otherwise have access to specialty care. School-based clinics have shown improvements in asthma knowledge, medication adherence, quality of life, communication between providers and caregivers, follow-up appointment attendance, and reductions in symptoms, school absences, hospitalizations, healthcare costs, and asthma morbidity for youth from historically marginalized communities [9–14]. The use of VBT has also been shown to be an effective delivery modality for addressing healthcare access barriers because it provides specialty care in schools mitigating the impact of modifiable risk factors such as access to providers (e.g., distance, availability) and financial constraints related to travel/transportation on families (e.g., availability of personal transportation, difficulties getting to specialty providers using public transportation, need to miss extended school/work for appointments). [6, 15–20] VBT has been shown to be effective because it promotes a systems approach by facilitating communication and collaboration among key stakeholders (caregivers, healthcare clinicians, and school personnel) across the different systems in which a child is expected to engage in asthma self-management behaviors [21, 22]. Further, studies suggest that the use of mHealth technologies may aid in promoting adherence to asthma treatment regimens [23]. The majority of children with asthma have used some form of health technology on their mobile device and express an interest in mHealth platforms for symptom tracking, medication reminders, and data sharing [16, 24].

While VBT and mHealth technologies appear to be promising tools for addressing access and self-management barriers, there are limited data examining stakeholders’ requirements for utilizing these technologies to within school-based interventions for children from economically-disadvantaged communities. Findings from a recent systematic review provide preliminary evidence of the benefits of VBT asthma interventions provided in schools [25]. However, two common limitations of these interventions was a lack of primary care physicians’ (PCP) engagement in the intervention and varying levels of asthma control at enrollment [25]. The omission of a key care provider (PCP) in comprehensive asthma management highlights the importance of capturing all stakeholder perspectives in the planning and implementation of interventions to help ensure continued engagement and intervention effectiveness. Therefore, the purpose of this study was two-fold: 1) to gain a better understanding of the experiences, challenges, and treatment preferences for asthma management from children with uncontrolled asthma living in economically-disadvantaged neighborhoods, caregivers, school nurses, resource coordinators, and primary care physicians and 2) to develop a novel care delivery model based on the needs assessment and stakeholder feedback regarding barriers, intervention components, and implementation methods.

Method

Participants and procedures

The overall method included a needs assessment with stakeholders, intervention design by a multidisciplinary team, critique by stakeholders, and a final design of a novel school-based telehealth and electronic inhaler monitoring system (for a detailed description of the method please see the electronic supplement). First, a qualitative research strategy was used to elicit a needs assessment from five distinct stakeholder groups: children with uncontrolled asthma from economically-disadvantaged neighborhoods (age 10–17 years), caregivers, school nurses, school resources coordinators, and primary care physicians. Nineteen children with uncontrolled asthma recruited from their schools in economically-disadvantaged neighborhoods (age 10–17) and their caregivers participated in focus groups (i.e., 14 parent/child dyads in 2 patient groups, 2 parent groups) or individual interviews (5 patient interviews, 5 parent interviews) which took place following clinical appointment with a pediatric pulmonary asthma specialist or at the patients’ school. Professionals (i.e., 14 school nurses, 8 PCPs, 4 school resources coordinators) were recruited from the same schools as the children and participated in role-specific focus groups).

Semi-structured question guides related to the experience and challenges of managing pediatric asthma were developed by interdisciplinary team members following a review of the literature. The question guides also presented an image and described potential components of school-based solutions (e,g., VBT, electronic adherence monitoring devices connected to an associated app via blue tooth) for care and asked participants about their feedback regarding these potential solutions (see electronic supplement for intervention description). An experienced focus group moderator used the question guides to ask similar stem questions to each stakeholder and then further elucidated responses to expand the discussion. Question guides and the intervention solutions were revised in an iterative fashion to refine unclear questions, add questions about unanticipated issues, and best understand optimal intervention and implementation components. The focus group and interviews were audio-taped and transcribed verbatim by an outside vendor. Transcripts were stripped of identifiers and reviewed for accuracy. This study was approved by the IRB, and consent was waived.

The analysis team read transcripts and discussed initial concepts to create a preliminary codebook for each stakeholder group. Line-by-line open coding by the analysis team was employed to define the actions and events in the data in an inductive manner which limited the imposition of a single investigator’s beliefs on the interpretation of the data [26]. Upon completion of initial coding, the raters met again to further define individual codes and identify emerging themes. Transcripts were then independently coded and discrepancies were resolved via consensus. Final data and themes were utilized in a series of study team meetings to fully develop a novel asthma management intervention.

Results

The needs assessment of stakeholders resulted in five major themes: (1) barriers to receiving and providing quality asthma care, (2) poor communication across care providers, (3) family difficulties with identifying and managing symptoms and triggers, (4) difficulties with adherence to asthma regimen, and (5) patient-perceived stigma. Results include a description of the themes along with representative participant quotes, the initial intervention that was presented to the stakeholders for feedback, and the feedback regarding the proposed content and implementation. Please see Table 1 for a detailed mapping of the themes, specifics of the iterative process of feedback, and proposed solutions and final interventions.

Table 1.

Asthma management concerns from all stakeholders and developed intervention solutions

Qualitative data from stakeholders			From team	Qualitative data from stakeholders	Finalized by Intervention Team
General Concern Themes	Stakeholder(s) concerned	Intervention Solution	Proposed Component	Stakeholder(s) Preference/Concerns regarding proposed component	Intervention Component/Implementation
Logistical barriers to asthma specialty care – Concerns with time, travel to clinic, and missed work and school	Parents Children PCPs	School-based intervention visit with asthma specialist	Intervention location – School setting with use of video-based telehealth visits	Parents and most children preferred visits in the school nurse’s office, however some children preferred visits at their primary care clinic Children preferred visits during non-core classes Most nurses and resource coordinators endorsed school setting over other settings, however some expressed concerns about feasibility PCPs expressed concerns about time commitment and interruption of clinic flow	Medical and self-management telehealth visits to occur in school nurse’s office Intervention visits to occur during non-core classes A intervention coordinator to aid nurse with duties and pilot study will specifically assess feasibility Medical visits will be documented in the EMR and made accessible to PCPs to improve efficiency of understanding intervention visits
			Type, structure, and frequency of intervention visits – Medical visits	PCPs expressed concerns about their role in care and decisions about medication changes PCPs and parents saw benefit in having visits every few weeks Some school nurses reported uncertainty about low adherence to visits	Medical telehealth appointments will include a physical exam and assessment of asthma control, medication changes will be documented in EMR, decision open for communication Monthly medical appointments with an initial in-person visit and follow-up telehealth visits Recommended visits will be conducted on days when children are present, make-up visits will be scheduled
Barriers to care – Hard to reach patients	PCPs School nurse Resource coordinator	Targets students attending school in a disadvantaged neighborhood	Target population – Children	Some PCPs felt the intervention was an opportunity to better serve high need youth with uncontrolled asthma and/or no established medical home, other PCPs did not think patients with uncontrolled asthma should be included in the intervention School nurses and resource coordinators indicated that given how hard it is for them to track down who needs what, even when seeing youth daily, it must also be difficult for specialty care providers to reach them and that school-based care could aid with this.	Children attending low-income schools with uncontrolled asthma will be targeted as they stand the most to gain from a school-based intervention
Communication – Poor communication among families, providers, and schools	Parents PCPs School nurses Resource coordinator	Use of telehealth and other forms of electronic communication	Digital Communication Strategies – to facilitate communication	PCPs expressed concerns about families’ comfort using telehealth Most children preferred text messaging Most parents preferred phone calls for intervention visits and text messaging for intervention measures Most school nurses and resource coordinators indicated better success with texting parents Most PCPs preferred the EMR and phone calls	Medical follow-up and self-management visits will be conducted via telehealth and a school nurse/coordinator will be available to assist Individualized text messaging will be utilized to promote adherence to behavior plans Phone calls will be utilized for intervention measures outside of telehealth communication EMR will be utilized to document visits
Identifying and managing symptoms and triggers – Difficulties identifying and managing asthma triggers, symptoms, and treatments among families	Parents Children School nurses Resource coordinator	Asthma education Individualized asthma self-management intervention	Type, structure, and frequency of intervention visits – Self-management sessions	Parents expressed a desire for frequent visits individualized to the patient’s needs Parents, nurses, and resources coordinators were split on the benefits of individual versus group sessions Nurses highlighted the need for asthma education for children, families and teachers Most children preferred to receive adherence reminders/tips 1–3x/week	Biweekly, individualized self-management sessions including education, goal-setting, problem-solving and motivation for change Individual sessions will be provided to better accommodate school schedules and to provide individualized intervention Electronic inhaler data used to guide adherence discussions and education Text messages tailored to promote adherence to individual behavior plans will be delivered 1x/week
Adherence to asthma medication and regimen – Adherence to asthma regimen	Parents Children PCPs School nurses Resource coordinator	Electronic inhaler monitors used to track adherence School delivery of medications Individualized self-management intervention	Technology – for assessment of asthma and adherence monitoring	Parents and most children expressed interest in electronic inhaler monitors, however a few children reported concerns about privacy Some nurses and resource coordinators expressed concern about children losing/leaving electronic inhaler monitors at home and potential discomfort with using a tracking device PCPs felt electronic inhaler monitors would be valuable, but expressed concerns about patients having multiple inhalers PCPs expressed concerns about the accuracy of computer-based tool for asthma control assessment	Asthma team contacts PCP to confirm agreement with diagnosis and treatment after each visit Electronic inhaler monitors will be used to track inhaler adherence, privacy concerns will be directly discussed during consent Replacement electronic inhaler monitors will be provided for lost electronic inhaler monitors, potential discomfort will be discussed Children will be provided electronic monitors for all inhalers
Stigma – Stigmatization in school, sports, and social activities	Parents Children School nurses	Private medical and self-management visits Self-management sessions teach skills to improve asthma management and reduce exacerbations in front of others/need for albuterol	Type, structure, and frequency of intervention visits – Private medical and self-management visits	Parents and children expressed interest in use and format of medical and self-management visits	Children will transition to medical and self-management visits between class rather than being called out of class Self-management sessions will teach skills to reduce exacerbations in front of others/need for albuterol and improve asthma management including plans for symptom management and addressing questions/concerns from others at school and extracurriculars

Note. EMR – electronic medical record

Theme 1: Barriers to care

An initial theme identified by stakeholders was the plethora of barriers (e.g., time, travel, schedule/responsibility conflicts) to receiving and providing quality medical care for pediatric asthma. For example, children and caregivers reported several structural barriers to attending clinic appointments. One parent reported, “…it’s a serious commitment [clinic appointments], And I’m lucky that I work with my family, but, you know, that’s a serious time commitment. And so I don’t get a lot, as much flexibility in other times.” Further, PCPs and school nurses identified barriers to facilitating access to care for many patients. One PCP noted, “… to just rely on primary care in the doctors’ office; there are a lot of patients who are not reachable for so many reasons.”

Theme 2: Poor communication across care providers

Stakeholders also raised concerns about poor communication across care providers among families, clinicians, and schools. Many PCPs and school nurses noted that the inability to contact families was a key barrier to providing quality asthma care. One PCP stated, “[Not having] Working phone numbers are an obstacle.” School nurses also reported varied success with contacting PCPs. On the other hand, caregivers shared the ongoing challenges of keeping doctors and schools updated about their child’s medical status and regimen. One parent shared, “...if we do have an issue, and I call over here [to the asthma clinic] and speak to the nurse, then we come back to the appointment, and you’ve got to repeat everything. Then when you go see somebody else. And then . . . you got to try to keep the school in the loop if something is wrong...”

Theme 3: Identifying and managing symptoms and triggers

Caregivers and school nurses both highlighted the need for increased knowledge and skills for managing asthma symptoms and triggers. For example, many caregivers and children reported difficulties managing symptoms with changes in seasons. One parent reported, “I’m finding I’m using it (nebulizer) more as the weather changes, and I know the spring is going to be rough, and we already ahead of it because last year we had a lot of problems.” School nurses also noted concerns about the lack of asthma knowledge among children and teachers. One nurse indicated, “I just think educating the kids is key because they really don’t understand their asthma. They don’t know that waking up at night coughing is a part of their asthma. Finding ways to educate them.”

Theme 4: Adherence to asthma medication and regimen

Another theme that arose among stakeholders was concern about regimen adherence. Many caregivers expressed difficulties maintaining good medication adherence while navigating the transition of self-management responsibilities to children. One parent indicated, “…he’s on a lot of different medicine, and he misses his medicine more than he should, but I don’t always remind him either, but to me, at his age, he should know that he has to take it like this is something I must do.” Similarly, a child reported, “…if you wait until you out the door and be like, oh, I got to take my medicine, then you be like, forget it. I’m just going to school without it.” School nurses also noted challenges with helping students who fail to share their asthma regimens or do not store medication in the nurse’s office. A nurse shared, “Or maybe they should be getting it [medication] at lunch, and the parent hasn’t signed the form, so they don’t have the medicine at school.”

Theme 5: Stigma

Stakeholders also reported concerns about perceived stigmatization around having asthma. For example, one child reported, “Some people like might look at you funny and stuff, because they don’t have asthma, so they never like experience like the equipment you use to help you get back on track.” Similarly, a nurse shared, “I think with the high-schoolers, they don’t want people to know that they have a problem... or asthma.”

Proposed intervention

In order to address the aforementioned themes, we proposed a school-based VBT intervention with asthma specialists targeting students attending schools in an economically-disadvantaged neighborhood. Components included: 1). the use of technology and electronic communication including video-based telehealth visits, electronic medical record notes, computer-based assessment of asthma control [27], and text messaging to mitigate accessibility barriers and to facilitate communication between families, clinicians, and schools 2) integration of asthma education to increase knowledge and skills for asthma management 3) the use of electronic inhaler monitors to track adherence and identify adherence barriers in order to deliver individualized behavioral interventions to address adherence concerns expressed by all stakeholders, 4) school delivery of medication refills, 5) ensuring the privacy of visits and study data and allowing students to attend visits between classes to reduce stigma. See electronic supplement for a full description of proposed VBT intervention.

Stakeholder feedback

Study location.

Generally, all stakeholders expressed approval of a school-based intervention. For instance, one child shared, “It [seeing a doctor via VBT at school] is easier than going to the doctor and getting out early because we’re here, and we don’t have to go there too, it would give you another way to the doctors.” Similarly, a parent expressed, “I think it would benefit because we wouldn’t have to miss work, and it is in school, we could get to it, and she is already here. So, that would benefit her.” However, PCPs and school nurses expressed concerns about the feasibility of the VDT intervention given the existing responsibilities and demands of their current jobs. For instance, one PCP stated, “…so if this [VDT intervention] would be expanded to all our patients or a large portion of the patients, taking that time to call you guys would probably be a time barrier.”

Medical visits.

Stakeholders largely agreed that telemedicine visits with the asthma specialist every few weeks would be beneficial; however, some nurses expressed concerns about adherence between sessions. Several PCPs also expressed concerns about their role in care and decisions about medication changes. One PCP indicated, “…I think the PCP should be the one who actually makes the changes, like in their medical record and pharmacy.” All stakeholders expressed a desire to include asthma education as a part of the visit to help children identify their personal asthma symptoms and triggers and to facilitate better asthma self-management. For instance, one parent shared, “Something so they would notice their symptoms a lot sooner or notice a situation.” Additionally, children expressed interest in greater knowledge about their symptoms, “What’s the symptoms of it kind of stuff, because I don’t know nothing about the symptoms.”

Target population.

Some PCPs expressed concern that the VBT intervention was not equipped to manage children with uncontrolled asthma and/or no established medical home, while others saw it as an opportunity to better serve this high-need population. One PCP stated, “…you don’t want to have somebody in the study with a severe asthma as a start,” and another responded, “I think you do… We really need to be – it is the ones who are the worst that we need to find if we are going to make an impact. I would kind of challenge that maybe that is the thinking we need to have – it IS the most severe and most disconnected that are the most at risk, and they are exactly who we should target.” In addition, all stakeholders, including children with uncontrolled asthma, indicated that symptom control was a very important outcome of an asthma management intervention (e.g., “Me not having to stop running and playing to use an inhaler”), highlighting the need to direct the intervention toward children with poorly controlled asthma.

Digital communication strategies.

While the majority of families and clinicians were open to the use of technology for communication, feedback differed regarding the specific mode of technology. For example, children preferred text messaging whereas caregivers preferred some information be communicated by phone and other information collected/communicated via text message and/or email. PCPs tended to prefer use of the electronic medical record (EMR) or phone calls for receiving information but also acknowledge the advantage of using families’ preferred platform for communicating information. One PCP expressed, “So technology-wise, I think that would be a huge strive forward if, as clinicians, we have the ability to text any phone directly versus voice message. I just think it is the direction that as a society and the younger generation is totally going to.”

Behavioral self-management intervention.

Caregivers and children also expressed that a specific aim of the VBT intervention should be the inclusion of personalized self-management intervention content specific to a child’s needs at that time. One parent shared that the goal of the study should be “ways to deal with it when he has his attacks. Instead of him panicking, you know, he needs to figure out ways, you know, how he can tell somebody what’s going on…” Children and their caregivers also expressed interest in content that addressed ways to reduce stigma and handle questions/concerns from peers and adults when at school and in extracurricular activities. For instance, one parent expressed, “…I think managing the daily medications and being prepared for things you can’t anticipate, you know, when you’re traveling or being with friends, overnights, school activities, it does force a strong level of responsibility for it. It’s probably something that maybe not all your friends are having to deal with, you know.” When discussing desired intervention outcomes, one child shared, “Me not having to stop running and playing to use an inhaler.”

Technology.

Most families and clinicians were open to the use of electronic inhalers to monitor adherence. One parent highlighting the benefits of receiving these data indicated, “Keeping track of it [the medication]. Just so we know. ‘Cause I mean, I know, all of us work, and my daughter doesn’t come home and say, ‘I was out of breath today and had to use my inhaler’… and she doesn’t need it every day. So that would be good to know, oh okay, what did you do today that you had to take your inhaler?” Children also expressed interest in receiving adherence reminders via text message a few times per week. However, some PCPs voiced concerns about the accuracy of a computer-based tool for assessment of asthma control.

Discussion

Results of this assessment revealed a clear need for improved asthma care among children with asthma living in economically-disadvantaged neighborhoods. Specifically, patients, caregivers, school nurses, PCPs, and resource coordinators indicated an effective asthma management intervention would need to address and overcome: (1) barriers to receiving and providing quality asthma care, (2) poor communication across care providers between physicians, schools, and families, (3) problems identifying and managing symptoms and triggers among families, (4) difficulties with adherence to asthma regimen, and (5) stigma. To develop this intervention, our multidisciplinary study team developed an initial intervention proposal that included patient and multidisciplinary team-derived solutions consistent with each theme including school-based VBT to address barriers to care, use of electronic communication such as EMR and text to address communication concerns, inclusion of objective adherence data from electronic monitoring devices in behavioral interventions to improve adherence through individualized interventions based on patient specific barriers. Feedback regarding the proposed intervention content and implementation was largely positive; however, participants provided invaluable, specific feedback on both the intervention content and implementation that is paramount to the development of the final intervention, such as differences in communication preferences and a need for all aspects of the intervention to be personalized.

Based on stakeholder feedback specific to the proposed intervention, our interdisciplinary team iteratively developed a final six-month school-based asthma management intervention in which children with asthma from economically-disadvantaged neighborhoods would receive VBT medical visits with an asthma specialist, VBT self-management sessions, and adherence monitoring devices. With specific feedback regarding the logistical barriers to receiving asthma specialty care, the school-based VBT intervention will make visits easier for families to attend and prevent them from missing school and work. Based on feedback regarding the frequency of visits, we decided upon an intervention consisting of seven medical visits with an asthma specialist physician. Each medical visit is designed to include a review of symptoms and medications, a physical exam with an electronic stethoscope, an assessment of the level of asthma control, determination of required medication, and asthma education. All VBT visits will be completed in a private room at school on a laptop using HIPAA-compliant video-conferencing software (Cisco Jabber ^®, San Jose, CA) with the assistance of the school nurse and/or resource coordinator based on stakeholder input regarding existing demands of school nurses. Visits will be conducted during lunch, extracurricular classes, or after school to reduce the stigma of being called out of class and to minimize effect on academic concerns. To address stakeholder feedback regarding adherence measurement, monitoring, and behavioral training, adherence will be monitored using FDA-approved electronic medication sensors that monitor inhaler usage via mobile-phone Bluetooth. The adherence data (i.e., percentages, patterns) will be incorporated into the five VBT self-management visits. These visits will be conducted with a master’s level psychologist specializing in adherence and three of these visits will coincide with medical visits to improve feasibility. The focus of these sessions will be to review adherence data, identify and discuss barriers to adherence, discuss the links between medication adherence and asthma control, and engage in problem-solving around select strategies to improve adherence. A manual has been developed for the sessions, and as requested by the stakeholders, these visits will be personalized to address patients’ individual regimens, symptoms, and barriers. Finally, to address feedback regarding communication among asthma specialists, PCPs, and school nurses, a visit note for all sessions will be written in the participant’s electronic medical record. This note will be sent to the PCP and is accessible to all healthcare team members including the school nurse.

In order to consider replicating an intervention model similar to this, it would be helpful to apply the learnings from the stakeholders in this study, build relationships with school-based nurses, principles, and resource coordinators, and obtain feedback regarding an intervention consistent with the one outlined above. It would be important to consider that this intervention will likely be most beneficial or cost effective for children who have uncontrolled asthma and have barriers consistent with those outlined in our needs assessment (e.g., logistical barriers to receiving asthma specialty care, poor communication among care providers, adherence concerns) hat an intense intervention such as this may not be necessary for all patients with asthma. Additionally, forming relationships between asthma specialty providers and school personnel in schools with school-based health centers would be central to the successful implementation of VBT school-based programs given that space is needed at the schools and that some states require that telehealth visits take place in a school based health clinic in order to be reimbursed for the visit.

Although the themes and the resulting intervention in this study have been formed inductively through interviews with five distinct stakeholder groups and are supported by the literature[28], the findings should be interpreted within the context of methodological limitations. First, despite the richness and diversity of qualitative data obtained, the sample size was fairly modest; however, we reached saturation in the qualitative data, and the consistency across participants suggests sufficient sampling. Second, this was a single-site study conducted in a clinic specific to uncontrolled patients. As such, patients and families in this study may have been more receptive to intensive health technology interventions due to a higher burden of disease. Third, although a diverse set of patients and professionals were recruited from a school system in an economically-disadvantaged neighborhood, we did not gather personal, self-reported data regarding race or SES. Further research is needed to generalize findings to families of all racial and ethnic backgrounds, those living outside urban areas, and patients with less severe forms of asthma.

Future research should test the feasibility and efficacy of this novel school-based care delivery model that incorporates VBT medical and self-management visits with electronic inhaler monitoring to improve asthma outcomes. Finding an effective way to deliver high-quality healthcare to this underserved population has the potential to improve health outcomes, reduce morbidity and mortality, and reduce healthcare utilization and is of the utmost importance. To our knowledge, this is the first intervention that has been developed to utilize a multi-component medical and behavioral intervention program delivered by VBT in a school-based setting to improve asthma care in an underserved, economically-disadvantaged population. Recent data for our children with asthma have demonstrated that 60% to 70% of missed outpatient visits are due to transportation barriers and parental resource constraints leading to uncontrolled symptoms and healthcare utilization, suggesting that an intervention such as this has the potential to improve health outcomes, asthma symptoms, and adherence outcomes [2, 29–33]. This intervention is innovative because it would increase access to care at the community level and reduce disparities for children from underserved neighborhoods who have poor health outcomes by leveraging mobile technologies and by providing care using standardized, evidence-based guideline assessment of asthma severity, control, and treatment [34, 35]. Technology solutions such as VBT visits and electronic inhaler monitoring systems will likely continue to become more widely adopted following the COVID-19 pandemic as willingness to use telehealth for medical appointments has increased particularly in Black Americans and those with less than a high school education[36] which may substantially reduce health disparities [34, 35, 37]. Additionally, leveraging technology at centralized locations such as schools allows specialty asthma care to more universally deliver optimal healthcare.

Table 2.

Intervention components, frequency, and personnel

Intervention component	Frequency	Who will execute	Details
Medical VBT visits	7 visits, monthly, on days when children are at school, make-ups will be scheduled	Pediatric pulmonologist or allergist at clinic with electronic stethoscope; Intervention coordinator to aid school nurse	Physical exam and assessment of asthma control, symptoms, healthcare utilization medication changes documented in EMR, private room, assessment symptoms
Self-management VBT visits	5 sessions, biweekly during months 2–3 (3 sessions immediately following a medical visit)	Adherence psychologist at clinic; Intervention coordinator to aid school nurse;	Individual sessions to improve feasibility and to provide individualized review of electronic monitoring data, identify barriers, discuss link to asthma control, engage in problem-solving
Documentation in EMR	Following each medical and self-management VBT visit	Pediatric pulmonologist or allergist and adherence psychologist	All documentation in EMR will be made accessible to PCPs and school nurses
Individualized text messaging	Several days prior to each visit	Intervention coordinator or adherence psychologist	Will be utilized to promote adherence to appointments and behavior plans
Electronic inhaler monitoring	Continuous data collection via wireless Bluetooth	Smartphones with data plans will be provided	Adherence will be examined in medical and self-management VBT visits