Evaluating the implementation of a community health worker-delivered intervention integrating asthma care in West Philadelphia public schools

Abstract

Objective:

Schools are an important setting because students spend much of their time in school and engage in physical activity during the school day that could exacerbate asthma symptoms. Our objective is to understand the barriers and facilitators to implementing an experimental community health worker-delivered care coordination program for students with asthma within the context of the West Philadelphia Controls Asthma study.

Methods:

Surveys (n=256) and semi-structured interviews (n=41) were completed with principals, teachers, nurses, and community health workers from 21 public and charter schools in West Philadelphia between January 2019 and September 2021. Survey participants completed the Evidence Based Practice Attitudes Scale, the Implementation Leadership Scale, and Organizational Climate Index. Semi-structured qualitative interview guides were developed, informed by the Consolidated Framework for Implementation Research.

Results:

Participant responses indicate that they perceived benefits for schools and students related to the community health worker-based care coordination program. Several barriers and facilitators to implementing the program were noted, including challenges associated with incorporating the program into school nurse workflow, environmental triggers in the school environment, and challenges communicating with family members. An important facilitator that was identified was having supportive school administrators and staff who were engaged and saw the benefits of the program.

Conclusions:

This work can inform implementation planning for other locales interested in implementing community-based pediatric asthma control programs delivered by community health workers in schools.

Asthma is one of the most common chronic conditions experienced by children in the United States (1). In 2019, 7% of children in the US had asthma. However, in some areas like Philadelphia, the childhood asthma rate is as high as 21%. Black and Latinx children in communities experiencing adversity, including poverty, bear the greatest morbidity and mortality (1-3). Reducing asthma inequities requires equitable access to quality medical care and affordable medication, as well as coordination of home and environmental assessments, trigger remediation, and patient and family education.

Community health workers (CHWs) can play an important role in the health care workforce. CHW’s can improve asthma outcomes for children and families by providing culturally-relevant care coordination and family education (4,5) and supporting the implementation of evidence-based approaches to patient-centered asthma care (6-9). However, more research is needed to understand the potential for CHWs to support youth with asthma in settings outside the home, such as in schools (5). Schools are an important setting because students spend much of their time in school and engage in physical activity during the school day that could exacerbate asthma symptoms.

The Community Asthma Prevention Program (CAPP) was developed in West Philadelphia to improve asthma knowledge, control, and quality of life by providing free asthma education at community sites (i.e. schools, daycares, community centers), home visits to address environmental concerns, and asthma resources for professionals, students, and schools by employing CHWs (6). Building on this foundation, the Children’s Hospital of Philadelphia (CHOP) established a network of partners, the West Philadelphia Asthma Care Collaborative (WEPACC), with representation from public housing, healthcare, community, and schools. After a local needs assessment and resource mapping, WEPACC designed an asthma care program with the broad objective of integrating home, school, healthcare system, and community to support school-aged children (aged 5-13) with asthma in West Philadelphia. This program includes two evidence-based interventions: 1) a primary care-based intervention with home visitation known as Yes We Can^™, and 2) two comprehensive and rigorously evaluated school-based interventions, Open Airways for Schools^® Plus (OAS Plus) and School Based Asthma Therapy (SBAT) (10-13). Through these programs, CHWs provide asthma education to students and school staff, conduct environmental assessment and remediation in homes and classrooms, and coordinate care among parents, school nurses, and primary care physicians.

An ongoing clinical trial is currently comparing the effectiveness of the primary care-based intervention, school-based intervention, and combined primary care and school interventions to usual care for improving asthma control in school-age children to explore the synergistic effect of CHW support in the home, school, and health care environments (14). The objective of the present study is to understand the implementation context, barriers, and facilitators to implementation of an experimental CHW-delivered integrated intervention, specifically aspects of the intervention implemented in the school setting, for young people with asthma in West Philadelphia to inform future scale-up efforts (15-18).

Methods

Intervention overview

The full details of the larger trial are published elsewhere (14). Briefly, WEPACC partnered with 8 charter schools and 28 public schools across West Philadelphia. Eligible children were aged 5-13, living in West Philadelphia, receiving primary care services from a participating clinic, had a diagnosis of asthma, and experienced at least one asthma flare requiring a course of systemic steroids over the 12 months prior to study enrollment. Eligible children were identified through medical records review or emergency department referral. Families were randomized to a primary care-based CHW or usual clinical care, as well as to a school-based CHW for OAS Plus and SBAT interventions in the school setting or usual school operations. OAS Plus involved school CHWs leading: 1) asthma education classes for students, 2) environmental assessment and remediation of classrooms, and 3) yearly asthma education for school staff (19). SBAT involved coordination with primary care to obtain MED-1 asthma care forms (i.e., the documentation required to authorize the administration of medication in school, which must be signed by a healthcare provider and the child’s guardian) and provide daily dosing of asthma controller medications at school (11). CHW’s worked across multiple schools.

Implementation evaluation overview

We conducted surveys and qualitative interviews with school partners to understand the context of implementation in participating schools and learn about experiences with the implementation of OAS Plus and SBAT. The procedures were approved by the University of Pennsylvania Institutional Review Board (protocol number 830021). The study is sponsored by the National Heart, Lung, and Blood Institute (NHLBI). All participants provided informed consent prior to engagement in surveys and interviews.

Survey procedures

Surveys were distributed either in person or electronically using REDCap, a secure, web-based application that supports online data collection between January 2019 and June 2019. Participants received a $10 gift card for participating in the survey.

Semi-structured interview procedures

Interviews were conducted by trained bachelor’s and master’s level interviewers. Interviewers were not blinded to the participant’s role; however, interviewers received training and ongoing supervision in qualitative interviewing to ensure bias was not introduced during interviews.

Interviews were approximately one hour in length and were conducted in two rounds, with the first occurring from February 2020 through May 2020 (i.e., pre-COVID-19 pandemic) and the second from March 2021 through September 2021 (i.e., following onset of the pandemic, or peri-COVID). Interviews were conducted over the phone and audio recorded. Participants received a $50 gift card. Interviews were transcribed verbatim, de-identified, and checked for accuracy.

Study population and recruitment

Surveys

We collected survey data from 256 participants within 21 schools during the 2019-2020 school year to understand the school context. Participants represented a range of groups including teachers, nurses, principals, and primary care providers.

Semi-structured interviews

We recruited school and clinic CHWs and other school staff (nurses, administrators, and teachers) from schools participating in the experimental arm of the trial and research coordinators to participate in qualitative interviews. Inclusion criteria were having an affiliation with a school or clinic receiving CHW services, OAS Plus, and SBAT (or involvement as a member of trial staff) for at least one semester. Eligible participants were contacted in-person or by phone, and those willing to participate completed a one-time, semi-structured interview. A total of 45 stakeholders were interviewed (see Table 1); seven of these 45 individuals were interviewed both pre- and peri-COVID.

Table 1.

Qualitative Participant Demographic Characteristics (N = 45)

Variable	No (%)
Mean Age (SD)	43.5 (13.2)
Sex
Male	4 (9)
Female	41 (91)
Ethnicity
Hispanic/Latino	1 (2)
Non-Hispanic and/or non-Latino	43 (96)
Missing	1 (2)
Race
Asian	1 (2)
Black or African American	33 (73)
White	9 (20)
Multiple races	1 (2)
Missing	1 (2)
Role
CHW (Clinic)	4 (9)
CHW (School)	4 (9)
Clin Research Coordinator	1 (2)
Nurse	12 (27)
Parent (of student at a school)	6 (13)
Parent Liaison	1 (2)
Primary Care Provider	5 (11)
Principal	4 (9)
Teacher or Teaching Assistant	6 (13)
Vice-Principal	2 (4)

Measures

Surveys

Demographic questionnaire.

Participants self-reported their age, gender, ethnicity, race, professional title/school role, years in current job/role, and years at current school.

Evidence based practice attitudes scale (EBPAS).

The 15-item EBPAS (20) measures attitudes toward evidence-based practices (EBP), in this case asthma interventions in schools. Four subscales can be calculated.(20) Appeal (Cronbach’s α = .80) refers to the extent to which a staff person will adopt a new practice if it is intuitively appealing. Requirements (Cronbach’s α = .90) refer to the extent to which a staff person will adopt a new practice if required by the organization or legally mandated. Openness (Cronbach’s α =.78) is the extent to which a staff person is generally receptive to using new interventions. Divergence (Cronbach’s α = .59) is the extent to which a staff person perceives research-based treatments as not useful clinically (20). The EBPAS demonstrates good internal consistency (21) and validity is supported by its relationship with both staff and organizational characteristics (20). The EBPAS has been previously used in school settings (22).

Implementation leadership scale (ILS).

The 12-item ILS (23), which has previously been used in the school context (24), measures leadership around evidence-based practice implementation. Four subscales are calculated and range from 0-4, including: proactive leadership (i.e., the degree to which the leader anticipates and addresses implementation challenges), knowledgeable leadership (i.e., the degree to which a leader has a deep understanding of EBP and implementation issues), supportive leadership (i.e., the leader’s support of clinicians’ adoption and use of EBP), and perseverant leadership (i.e., the degree to which the leader is consistent, unwavering, and responsive to EBP implementation issues).

Organizational climate index (OCI).

The 27-item OCI (25) measures the dimensions of school climates at the student, teacher, principal, and community levels; these constructs have been identified as impactful in school-based dissemination and implementation efforts (26). The institutional vulnerability subscale evaluates the relationship between the school and community. Professional teacher behavior captures the relationships among teachers. Collegial leadership measures the relationship between principals and teachers. Achievement press measures teacher, parental, and principal press for achievement. Standardized scores are computed to facilitate comparison to national norms (mean = 500, range = 200-800).

Semi-structured interviews

We used the Consolidated Framework for Implementation Research (CFIR)(27,28), a comprehensive framework detailing contextual factors that require consideration when planning for the implementation of a health service intervention, to inform the development of semi-structured qualitative interview guides (one guide was developed for each role: CHW, school personnel, caregivers). Interview guides included questions about individual experiences with the program and asthma intervention, and factors that influenced implementation of these interventions before and during the COVID-19 pandemic.

Data analyses

Quantitative analyses

Subscale and standardized scores and descriptive statistics were computed as appropriate for each measure. ILS and OCI scores were aggregated at the school level as is customary for these measures.

Qualitative analysis

Interviews were transcribed verbatim. Analyses were supported by use of an NVivo database. Coding was conducted by three graduate students and one research assistant; coders received extensive training and supervision in qualitative coding. Analysis was guided by an integrated approach (29) that included identification of a priori attributes of interest (i.e., constructs from CFIR) and modified grounded theory (30). This integrated approach used an inductive process of iterative coding to identify recurrent themes, categories, and relationships. An initial codebook was generated and optimized through the process of iterative recalibration into the final codebook. A subset of transcripts (20%) were double-coded to ensure inter-coder reliability of all team members. Coders reached and maintained reliability at κ ≥ .85.

Results

Quantitative results

Survey participants were predominantly female and reported diverse racial and ethnic identities (see Table 2). Mean EBPAS total scores ranged from 1.01 to 2.56. School staff reported that they would adopt a new practice if it was appealing or required to a moderate extent, openness to using new interventions to a great extent, and that they see research-based treatments as not useful to a slight extent on the EBPAS (see Table 3).

Table 2.

Survey Participant Demographic Characteristics (N = 253)

Variable	No (%)
Mean Age (SD)	41.2 (12.3)
Sex
Male	31 (12)
Female	218 (86)
Prefer not to disclose	2 (1)
Missing	2 (1)
Ethnicity
Hispanic/Latino	8 (3)
Non-Hispanic and/or non-Latino	233 (92)
Prefer not to disclose	5 (2)
Missing	7 (3)
Race
American Indian or Alaska Native	3 (1)
Asian	4 (2)
Black or African American	146 (56)
Native Hawaiian or other Pacific Islander	0 (0)
White	93 (35)
Other/Missing	10 (4)
Prefer not to disclose	6 (2)
Missing	4 (2)
Other Specified
Indian	1 (0.4)
Spanish	1 (0.4)
Role
Teacher or Teaching Assistant	152 (60)
Non-teaching assistant	15 (6)
Nurse	15 (6)
Office staff	16 (6)
Parent (of student at this school)	1 (0.4)
Other	47 (19)
Prefer not to disclose	1 (0.4)
Missing	6 (2)

Table 3.

Attitudes, Implementation Leadership, and Organizational Climate Scale Scores (N = 253)

Variable	Variable Definition	Overall Sample Mean (SD)	National Mean1	Difference between National Mean and Sample Mean
Evidence Based Practice Attitudes Scale (EBPAS) (31) 1
EBPAS Total		2.53 (0.65)	-	-
EBPAS Requirements	The likelihood of adopting EBP given requirements to do so (36)	2.31 (12)	2.41	−.10
EBPAS (Appeal)	The intuitive appeal of EBP (36)	2.42 (0.91)	2.91	−.49
EBPAS (Openness)	Openness to new practices (36)	2.56 (0.87)	2.76	−.20
EBPAS (Divergence)	The perceived divergence of one’s usual practice with research-based/academically developed interventions (36)	1.01 (0.86)	1.25	−.24
Implementation Leadership (ILS)
ILS Total		1.76 (116)	-	-
ILS (Pro)	Proactive leadership: the degree to which the leader anticipates and addresses implementation challenges (37)	1.82 (124)	-	-
ILS (Know)	Knowledgeable leadership: the degree to which a leader has a deep understanding of EBP and implementation issues (37)	1.57 (12)	-	-
ILS (Support)	Supportive leadership: the degree of the leader’s support of followers’ adoption and use of EBP (37)	1.7 (1.2)	-	-
ILS (Persev)	Perseverant leadership: the degree to which the leader is consistent, unwavering, and responsive to EBP implementation (37)	2.03 (1.27)	-	-
Standardized Organizational Climate Index Scores (SOCI) 2
OCI (SCL)	Collegial Leadership s directed toward both toward meeting the social needs of the faculty and achieving the goals of the school (25).	538.83 (110.95)	500	38.83
OCI (SPTB)	Professional Teacher Behavior is marked by respect for colleague competence, commitment to students, autonomous judgment, and mutual cooperation and support (25).	528.8 (144.88)	500	28.8
OCI (SAP)	Achievement Press describes a school that sets high but achievable academic standards and goals (25).	471.46 (121.64)	500	−28.54
OCI (SIV)	Institutional Vulnerability is the extent to which the school is susceptible to a few vocal parents and citizen groups (25).	441.59 (86.28)	500	−58.41

¹National norms are available for the EBPAS, obtained from Aarons et al (2010).

²Scores are standardized such that If the score is 200, it is lower than 99% of the schools. If the score is 300, it is lower than 97% of the schools. If the score is 400, it is lower than 84% of the schools. If the score is 500, it is average. If the score is 600, it is higher than 84% of the schools. If the score is 700, it is higher than 97% of the schools. If the score is 800, it is higher than 99% of the schools.

Aggregated ILS total scores ranged from 0.8 - 2.89 across schools (see Supplemental File for scores by school). At most schools, participants reported that their leader was proactive (i.e., anticipated and addresses challenges), knowledgeable, supportive, and perseverant, to a moderate extent on the ILS (see Table 3).

On the OCI, school staff at the majority of schools reported that their organizational climate had moderate collegial leadership, professional teacher behavior, achievement press, and institutional vulnerability (see Table 3; see also Supplemental File for scores by school). For the OCI Collegial Leadership (CL) subscale, values for 10% of schools were >1 standard deviation (SD) below the mean, 55% schools were ±1 SD of the mean, and 35% of schools >1 SD above the mean. For Professional Teacher Behavior (PTB), values for 30% of schools were >1 SD below the mean, 45% schools were ±1 SD of the mean, and 35% of schools >1 SD above the mean. For Achievement Press (AP), values for 30% of schools were >1 SD below the mean, 55% schools were ±1 SD of the mean, and 15% of schools >1 SD above the mean. For Institutional Vulnerability (IV), values for 30% of schools were >1 SD below the mean, 65% schools were ±1 SD of the mean, and 5% of schools >1 SD above the mean.

Qualitative results

The main themes from qualitative interviews, organized by CFIR domains, are presented below. See Table 4 for exemplary quotations from qualitative interviews, organized by theme.

Table 4.

Exemplar Quotations from Qualitative Interviews

Theme	Subtheme	Quotations
Outer Setting	External Policies	“But there are so many impediments to getting the inhalers. Too many of them only have one inhaler, they have to keep it at home. Too many of them lose them. Or their brother used it. There are so many impediments, let alone getting the forms filled out. The school district requires that every student who keeps an inhaler in the building must have a form filled out by the doctor. That’s an impediment on its own because many doctors require a fee to fill out these forms if the parent forgets to get the form filled out at their yearly appointment.” - School Nurse
	Home Environment	“When you have to weigh the pros and the cons, we would rather have it [controller medication] here and administer it because we know our children…like I mentioned before, a lot of these kids are being raised by grandparents and they’re with their moms and their dads, and they’re not going to get three Flovents or three Advairs or Qvar so chances are these kids could be missing it, and they have a horrible day in school, where I’d rather have it here.” – School Nurse “And to date, we still kinda struggle with getting the meds in…Some of these children don’t have PCPs we can refer to, but that’s the biggest struggle, is getting the meds here and the MED-1 forms here…” - School Nurse “Well I think a lot of it stems from the clinical site, when they go in to the doctor, a lot of them [parents] don’t know the difference between Flovent and albuterol… And a lot of parents don’t understand the basics, like the triggers, and what’s going on, and that they even should have an albuterol inhaler in the house.” - School Nurse
Inner Setting	Barriers	“Yeah. I had a nurse that swore her school shouldn’t even be open. She was taking pictures, saying she knows there’s asbestos in the school. She had like a hole in the ceiling.” - School CHW “… the school water can’t be used because there’s lead in it.” – School CHW “At one school I had three kids, so all three kids are in the nurse’s office at once. And this is a tiny nurse’s—most of the nurse’s offices are small.” – School CHW
	Facilitators	“But the other main priority is providing a safe environment for the children and that’s where the asthma care program comes in. You know these parents depend on us to take care of their children from the time they arrive to the time they leave so having a program like this helps us to do that and helps us to make sure that the children are safe because we can’t learn if the environment isn’t safe and if it’s not supportive. And so this program definitely fits into one of our top two priorities.” – Vice Principal “We have a lot of people in place to make things work around here. We were able to adjust the schedule so that students can get the education piece. We have an amazing nurse who does what she needs to do to get the students what they need and where they’re supposed to be. Our teachers are very easy-going, we don’t have a lot of teachers who give a lot of push-back about anything. So I haven’t seen barriers.” – Principal “[New ideas] are embraced. Our principal, she’s very caring, she’s very engaged with the kids and she wants to see them healthy. If there is anything that is happening that help them do better in school, if it’s something with their health, she’s all for it. She’s very open to that.” – School Nurse
CHW Characteristics	Benefits to Students and Staff	“Yes, oh my gosh. They said they were going to do this. I didn’t have to—as soon as they said they were going to do this, I had the paperwork, I had the medication delivered to me. It was smooth. It was as smooth as pie, I couldn’t believe it.” – School Nurse “So we had [Other 01] who came. She came quite a bit, which was great. And it was very well received by the scholars. They really enjoyed, and as a matter of fact, they requested more classes, so they really enjoyed and took a lot away from classes and the time with [Other 01] that she spent.” – School Nurse
	Important Traits	“As long as the facilitator is comfortable working with a varied age group of students and have experience with those age groups, the challenges that they can present, and flexible, I think the facilitator will have an enriching time; but if it’s somebody that gets really frustrated by little distractions, it could get frustrating for them, so just people that have some experience and patience with student behaviors.” – Teacher “But, you know, to her credit, she was consistent in her expectations. And she was also diligent explaining what the importance of the program was to the scholars, and so slowly I could definitely see the difference in her rapport with them and their willingness to just listen to what it is she had to say…” – Vice Principal
Implementation Process	OAS Plus-Specific	“They suggested doing [the asthma lessons] during recess or lunch, which I am totally against. I feel like that’s their time, their little social time. But sometimes math is a child’s favorite subject, or science, or English. So you never really know, so I think that’s a little challenging too, picking the right times for it.” - School CHW
	SBAT-Specific	“Students play in the yard, gets a busted knee and then I already have a child in my office getting a covid test. And then a student needs an asthma treatment. I cannot accommodate this in my room.” - School Nurse “The time it takes to call kids down, to get them in here, to get them settled, have them take the inhaler, have them rinse their mouth out, make sure they get back to class. So I can’t imagine, if somebody had ten or fifteen kids like that, how they could get the screenings or case manage other students with other issues.” - School Nurse
	Communication Between Staff and with Parents	“Having this program now is helping him a lot. I just want them to communicate more and send information out to me, to let me know if they’ve said anything to him so I can stay updated what going on with him.” - Parent “The best experience, for me, is always when it’s just kind of the most organized, so when everybody kind of knows that I’m coming. Because I’ve gone to some places where they’re not really sure why I’m there, and that can take some time. So when they’re organized, when there’s maybe a set person in charge that I can report to, that can help bring the kids to me, or take the kids back.” - School CHW “We actually had a list. And that way we knew if children were walking in the hallway, you know which children are supposed to be walking in the hallway. Who’s heading to the library, who’s supposed to be- just making sure everybody was on the same page so we knew as the children were transitioning where they were going, who needed to be there, and things like that…” - Vice Principal
	COVID-19	“I had … some familiarity with virtual platforms in general from just… I guess growing up in 2020 **laughs** … but I quickly realized that it was a large stressor for the community health workers working on this project, so I think I want to say, I’ve at least done 4 or 5 one- to two-hour trainings with them on different platforms - Zoom, Google Meet, BlueJeans– how to share on everything, how to share videos…” – Clinical Research Coordinator “So they were actually nine third and fourth graders. But only six attended regularly. All of them attended at some point, but only six attended regularly… I think it’s really hard for these kids to be doing school on laptops.” – School CHW “We found a really good video which was really focused on the ages we’re working on. So we kept most of the curriculum but just instead of when we would use poster boards, we would insert videos instead. Which I really like. I hope we keep. Because the kids really seem to like that too.” – School CHW
Intervention Characteristics	Perceptions of OAS Plus	“Well, the classes I think was beautiful, because I saw the difference in the kids after they had the classes. My asthmatics that I would see often that were in the class. Once they had the class, you could see that their knowledge grew as far as how to actually administer the medication and some of them are like, ‘Oh, I remember this was how we’re supposed to do it,’ or they’ll tell me things that I didn’t necessarily know, so I thought that was pretty cool. So it is pretty effective, the classes.” - School Nurse “I do think that you have some kids that are mature enough to sit through the classes, and then you have some kids that aren’t mature enough to sit though the classes. I believe that the classes should mainly run from maybe fourth to sixth grade, because second and third grade—third grade they’re too young. Seventh and eighth grade is not suitable for them—the booklet is not like at their age level.” - School CHW “I think that they—because, okay, number one, I’m teaching in schools… so it’s mainly minorities, from what I see, and with the posters, they [the students] don’t see themselves replicated.” - School CHW
	Perceptions of SBAT	“My, because a couple of my chronic illness scholars are on the plan, and they have not gone to the hospital, not once this school year, and that’s so rare. And it’s my fourth year with them. And I feel like them getting that—at least the controller med, if they’re only getting it once a day, it’s definitely helping them.” - School Nurse “Well, I almost resent… if the parents who sign up are the parents who manage the children at home, so why should I be giving a medication in school, a prevention med? That should be given at home. I just don’t understand. For the life of me, and many of the other nurses are saying, “Why are we giving prevention medications in school? This really belongs at home.” Who is going to do it when we’re not here in the summer? And Easter? And Christmas?” - School Nurse

Outer setting

The outer setting includes the social, political, and economic context in which a school exists. The prevalence of asthma is high in the communities served by the study schools. Policies at the school district and city levels, as well as those related to insurance, impact the integration of asthma interventions in school. Examples include the requirement that every child have a MED-1 form filled out by a doctor and brought to the nurse’s office before they can receive asthma medication in school, the practice of sharing nurses between schools in the event of absences or nursing staff shortages, and insurance companies covering only one inhaler per child.

In the home setting, school staff members highlighted that many families served by their schools experience poverty, housing insecurity, parental separation or frequent guardianship changes, and may not have access to regular primary care. Finally, school personnel reported concerns about adherence to treatment in the home and limited parental knowledge about asthma. For example, participants expressed concern for children who are not given their controller medication as prescribed at home, or whose parents may not know the difference between rescue and controller medication.

Inner setting

Inner setting refers to the culture, climate, and other characteristics of the environment in schools. Participants reported high rates of asthma among students in their schools. Most schools never had asthma-related education or programming before this study. While participants were generally supportive of asthma programming, some participants expressed concern about students missing class or recreation time for asthma education classes.

The physical school environment was also a barrier cited by many participants. Environmental challenges included a lack of updated HVAC systems and presence of asbestos as potential asthma triggers and lead in school water as a limiting factor to administering controller medication for SBAT, as these medications require the child’s mouth be rinsed after administration. Some schools reported nurse’s offices were too small for the demands of SBAT or that there was inadequate space to hold asthma education classes.

Despite these challenges, most participants believed the school asthma programs were congruent with their school’s mission and values. Participants reported their schools to be generally supportive of innovation, and specifically supportive of asthma programming. Ample communication, clear workflows, and organization in schools contributed to program success. Participants overwhelmingly mentioned supportive school staff as a facilitator to implementation of the school-based interventions. The following roles were highlighted specifically as instrumental to program success: a receptive principal to organize programming; teachers who received the program positively, engaged with the program, and understood its benefit to students; a CHW who was pleasant, flexible, and connected well with students; and a school nurse who was organized and competent.

CHW characteristics

CHW characteristics refers to the characteristics of school CHWs that impacted implementation. Nurses largely found CHWs to be very helpful, both in educating students about asthma and in coordinating with clinics to get MED-1 forms and controller medications to school. The following characteristics were described as most important for an effective CHW: consistency, longitudinal relationship with students, good with children, patient, and flexible.

Implementation process

Implementation process refers to factors relevant for the process of implementing the interventions, including scheduling, coordination, and execution of activities. The importance of communication was frequently highlighted, including the value of clear and frequent communication between school staff members and the CHW and between school staff and parents. For example, some school nurses noted the importance of being informed about the CHW’s role and the SBAT program prior to initiation. School personnel also noted the importance of having a point person to direct and support the CHW. Parents wanted to be informed about the intervention, its component programs, or the people interacting with their children as part of the intervention in the school setting. Multiple participants stated they wished parents could be included in the educational components of the intervention to improve parent understanding of asthma.

Participants also cited OAS Plus and SBAT-specific barriers to implementation. OAS Plus -specific barriers included challenges scheduling asthma education classes for students without disrupting their school day. SBAT-specific barriers included adding responsibilities for already-overburdened nurses, logistical challenges getting children from their classrooms to the nurse’s office, and struggles obtaining MED-1 forms and controller medications.

Participants mentioned that COVID-19 presented several unique barriers. Technology issues included lack of familiarity among CHWs with virtual learning applications and a lack of reliable access to technology and/or the internet among students. CHWs had more difficulty building relationships with students and school staff virtually. Additional barriers included a decline in student attendance rates and concerns about confidentiality for students in the virtual setting; inability to translate educational materials to the virtual setting; and fear of COVID-19 preventing families from attending primary care visits to obtain the necessary paperwork and medications for SBAT.

While COVID-19 presented challenges, participants noted that there also were helpful innovations that resulted. For example, educational videos about asthma for the OAS Plus courses were developed and received favorably. Some participants noted an ability to conduct more asthma classes for students during the pandemic as opposed to pre-pandemic because of the efficiency of transitioning between virtual spaces. Participants noted it was easier to schedule asthma education for staff in a virtual environment.

Intervention characteristics

Intervention characteristics refers to perceptions about intervention quality, complexity, and cost. Some participants reported OAS Plus educational materials were not as engaging, age-appropriate, or representative of the racial and ethnic makeup of the student body as they could be. Many nurses felt SBAT was burdensome given their other responsibilities and limited office space. Some nurses also believed that administering controller medication should be a responsibility of parents at home rather than nurses at school.

Participants reported asthma classes were both enjoyable and educational for students, improving their knowledge about asthma and autonomy in managing their diagnosis. SBAT was seen as beneficial for improving rates of medication use and asthma control. Many administrators, teacher, and nurses felt their students were experiencing less frequent exacerbations and requiring less rescue medication than they were prior to the initiation of school-based asthma care. Overall, however, school asthma programming was generally thought of as effective and beneficial for students.

Discussion

Our multi-method evaluation of implementation in West Philadelphia schools indicates that schools that implemented evidence-based asthma services supported by a CHW were satisfied with the programs, though challenges and areas for potential refinement were also identified. On a validated measure of attitudes prior to the launch of asthma interventions, school staff reported some openness to evidence-based practices but also a reluctance toward research, with mean EBPAS subscale scores slightly lower than would be expected based on national norms (31). When scores on organizational measures were aggregated at the school level, moderate support for implementation leadership emerged and adequate organizational climate, consistent with national norms within and across subscales. While we explored whether variations on these quantitative measures were associated with different patterns of qualitative responding, no clear patterns emerged. Future mixed methods work related to the implementation of asthma interventions for youth is encouraged.

Qualitatively, school administrators and nurses largely described OAS Plus and SBAT as beneficial to their students and schools. Overwhelmingly, participants believed asthma care was aligned with their school’s mission. It is possible that the high rates of asthma in the Philadelphia community contributed to participant’s perspective on the importance of asthma care for students. Participants’ also reflected on their professional and personal experiences with asthma; personal experiences with asthma may also have contributed to perceptions of the importance of school-based supports for pediatric asthma. Participants reflected favorably on their experiences working with CHWs and study team members, and described positive benefits for both students and staff that they directly attributed to the study. In particular, the support CHWs provided in helping schools obtain necessary paperwork and medications and in delivering educational content was highly regarded. This adds to a broader literature demonstrating the value of CHWs in improving health outcomes and reducing health disparities (32-34).

Barriers to implementation of OAS Plus and SBAT reported by participants were primarily related to structural and resource limitations in the school system that were beyond the capacity of an individual school to address. This is not surprising. Previous work has demonstrated the challenges associated with implementing mental health interventions and public health programs in settings where basic needs are not adequately met (e.g., Maslow’s hierarchy of needs) (35). Some of the noted structural barriers included environmental insults, like asbestos, in school buildings or insufficient nursing personnel to meet demand in schools. Funding for the school nurse role and remediation of environmental toxins in under-resourced schools are needed in order to maximize the potential of school-based asthma interventions.

The importance of communication between home, school, and clinic, as well as among school personnel was frequently noted. Communication is important in ensuring that all staff, parents, and other professionals can adequately support the relevant programmatic components and so students can optimally benefit. Researchers and policy makers considering implementing similar programs should ensure that communication before and during implementation is clear, frequent, and includes all relevant stakeholders. Schools may be able to leverage existing parent and community engagement mechanisms, such as school advisory councils, to support communication around the implementation of asthma interventions. Additionally, hiring CHWs who are from the community and familiar with the local school system is recommended (32).

This work is situated in a single area of one major Mid Atlantic city, which may limit generalizability. The implementation context in one public school system does not necessarily represent the experience of all urban public schools. Future work in other geographic areas and school districts will be important. Additionally, this work builds on years of community partnered research and practice. While this is a strength that likely contributed to the successes of the current implementation, it may also be hard for others to replicate. Ongoing work to understand how OAS Plus and SBAT are sustained in these schools following active study supports is planned and will be important to understanding sustainment of EBPs for youth asthma.