Notes From the Field: Diverse Partner Perspectives Improve the Usability and Equity Focus of Implementation Guides

Abstract

Context

School-based asthma programs (SBAPs) have improved health and educational disparities among youth with asthma.

Design

To support scaling out effective SBAPs, our school partners identified a need for online implementation guides that are “always available,” to meet the needs of school nurses’ demanding schedules. School nurses play a key role in the adoption and implementation of SBAPs, so it is important to ensure the implementation guide would be highly usable and acceptable to them.

Objective

Accordingly, our research team collaborated with human-centered design experts to identify the “user journeys” of school nurses and co-created our online implementation guide as a public-facing website with input from local and national school nurse partners.

Main Results

In this perspectives article, our school nurse implementation partners and human-centered design experts reflect on challenges overcome in this process of developing a tailored implementation guide to school nurses and offer lessons from the field to others seeking to co-create implementation guides with community partners.

Introduction

Six million children ages 0–17 years in the United States have asthma, which is the leading cause of pediatric hospitalizations and school absenteeism.1,2 The burden of asthma is higher for racial/ethnic minority populations and children from socioeconomically disadvantaged families.3 School nurses and health care providers play vital roles in assessing and managing asthma for children attending school; hence, it is important to engage them in addressing asthma disparities.4

School-based asthma management programs (SBAPs) are an evidence-based approach to address these disparities.5,6 We have a successful track record of implementing SBAPs in urban Colorado schools to improve asthma control and reduce school absenteeism.7–9 As we plan to test the implementation of this SBAP program in new regions across Colorado, including rural communities,9 we partnered with school nurses to understand their needs for successful implementation. In this perspectives article, our objectives are: 1) identify lessons “from the field” as we co-created the SBAP implementation guide with attention to promoting usability for nurses and equitable outcomes for students with asthma, and 2) reflect on the broader application of these lessons learned to others who seek to co-create implementation guides with community partners in either school or non-school settings.

Collaboration Processes with Our Community Partners

1. The study team convened a workgroup to co-create the implementation guide. Members of this workgroup included 2 consultants from the National Association of School Nurses (NASN), business partners from a company with human-centered design and website design expertise (Acclaro Design), and 2 school nurses from Denver Public Schools (DPS) with experience implementing our SBAP.

2. As part of the implementation planning process, the workgroup interviewed Colorado school nurses to identify their “user journeys” with a human-centered design approach that focused on their nursing goals, usual activities/workflows, and pain points for these activities. These interviews were considered exempt research by the Colorado Multiple Institutional Review Board, and nurses received compensation.

3. Over 2 years, the study team met monthly with the DPS school nurses, NASN consultants, and the Acclaro Design team to co-design the website to implement our SBAP tailored to the school nurse user journey.

Lesson Learned #1: Approaches That Worked Well in Developing a Tailored Implementation Guide

Start by Talking to a Diverse Set of Primary End-Users

Our implementation guide will ultimately serve as a resource for school nurses, program navigators, health care providers, students, and families. Our human-centered design team focused the initial efforts for the implementation guide to meet the goals and needs of the priority end-users adopting the program: school nurses; but also segmented resources for the other end-users. Interviews with school nurses identified challenges that vary from school to school, making it important to have conversations with nurses who work in varied locations and diverse economic and cultural environments. For example, in two schools in the same county, access to health care was completely different. At one school, full, uninterrupted access to health care was the norm. At the second school, there were multiple barriers to health care access.

Develop Documents That Create a Common Framework for the Team

The school nurse interviews provided us with a broad view of their roles. We learned that the opportunities and challenges of their jobs change as the school year progresses. The school nurse user journey developed from the interviews traces the seasonality of the school nurse role, including goals, challenges (“pains”) and activities over the course of a school year. This user journey also visually displayed the context for us to consider where opportunities existed to align our guide with the needs of school nurses. It was helpful to work with business partners to develop this user journey as a simple 1-page graphic (Online appendix figure, Nurse Journey).

Think About Equity from Multiple Perspectives

After developing the context of the school nurse user journey, we iteratively designed, built and tested solutions with this working group and our community advisory board partners. Our community partners suggested adding inclusive resources for multilingual students and students with varying levels of health and general literacy (e.g., how-to videos and step-by-step visual guides). Similarly, the team incorporated varied audiovisual and written content to address diverse nurse learning styles.

Highlight Local Priorities for the Implementation Setting (i.e., Schools)

It is important to describe program benefits for students in terms of both asthma and school outcomes (e.g., improved attendance) to align with school priorities and values. This unveils the “hidden healthcare system” in schools, led by the school nurse, and the critical link between supporting the health of students and their academic success. Starting this process in a state where SBAPs were successful in the past helped expand trust with school nurses.

Lessons Learned #2: Approaches to Address Barriers in the Process of Developing a Tailored Online Implementation Guide

Differentiate Resources

Similar to many implementation trials, our trial seeks to provide different resources to two distinct intervention conditions where school nurses and asthma navigators need access to standard resources only in one condition and access to enhanced resources in the other condition. Our partners advised us to include the standard resources for all school nurses in the online implementation guide, without password protection barriers. We also developed a separate website section with specific resources for the enhanced intervention condition navigators only, that they can communicate directly to their nurse partners. This approach ensured key “standard of care” asthma resources were available for all.

Conduct Web-Based Writing Workshops

The ability to convey a message simply on the website is critical, and our team was not familiar with web-based writing principles. Simple language benefits all online users because it is easiest to read quickly, supports those with literacy challenges, and translates better from English to other languages. Our Acclaro Design partners provided a “Writing for the Web” workshop to the study staff to train the team on these principles: avoid jargon; use simple language tailored to the target audience; and create scannable writing.

Use Snowball Sampling

Competing priorities caused by the pandemic made it difficult to secure interviews with school/district personnel. However, our community advisory board members encouraged nurses to speak with us and NASN representatives facilitated team conversations with nurses who had led SBAPs in Washington and North Carolina.

Find Mutually Advantageous Times to Meet

Our workgroup meetings needed to be adjusted to fit the availability of team members who spanned 3 time zones. With some effort, we identified a time that usually worked for team members and limited conflicts with our school nurse partners’ direct support of students.

Implications

Developing a visually engaging "user journey" is crucial to designing a highly usable implementation guide for key end-users -- whether in schools or in other settings. In settings other than schools, the relevant key implementer's user journey would have been identified rather than the school nurse, in partnership with thought leaders in the field. Specific to projects implementing in schools, it is important to address the academic priorities of schools, and to engage school nurses who serve as public health sentinels to expand health care access for students.10 To address equity considerations, it is key to engage a diverse sample of the target end-users who work with program recipients experiencing a broad range of social determinants of health and education.10