School Health Staff Perspectives on the Implementation of Single Maintenance and Reliever Therapy (SMART) for Children with Asthma

Abstract

Introduction:

Single maintenance and reliever therapy (SMART) uses a single inhaler for daily maintenance and as-needed relief. Despite evidence that SMART is more effective in reducing exacerbations than traditional therapy, it is not widely implemented. Successful SMART implementation requires participation from school health staff (SHS), who are a critical part of pediatric asthma management.

Methods:

Using a descriptive convergent mixed methods design and grounded in the Consolidated Framework for Implementation Research, we conducted surveys and semi-structured interviews with SHS to explore their perspectives on SMART implementation in schools. We calculated descriptive statistics for survey items and used rapid qualitative analysis to synthesize interview data.

Results:

A total of 11 SHS completed an interview and 22 completed a survey. Nearly all participants were familiar with SMART and 45% reported experience administering SMART. Most participants (59%) believed that SMART would be simpler for their students. In interviews, many participants highlighted that having one inhaler would also be simpler for them to manage. To support SMART implementation, communication with prescribing providers was highlighted as a primary need; 64% wanted a brief phone call with a provider, 59% wanted an email, and 82% wanted to receive a SMART-specific Asthma Action Plan.

Discussion:

School health staff reported familiarity with SMART and confidence in their ability to administer it. Multilevel needs include clear communication from pediatric providers when children initiate SMART and availability of SMART inhalers. Future research should explore development and implementation of strategies to address these needs while integrating perspectives of providers and families.

Introduction

Nearly 5 million children in the United States have asthma, of whom almost 40% are estimated to have had at least one asthma attack in the prior year.¹ Asthma attacks significantly impact school attendance,² parents’ work attendance, ³ and contribute to increased healthcare costs due to hospital visits.⁴ Use of two separate maintenance and reliever inhalers is the most commonly prescribed method for treating persistent and exacerbation-prone asthma.⁵ The two-inhaler approach involves an inhaled corticosteroid (ICS) for daily long-term maintenance plus a short acting beta-2-agonist (SABA- usually albuterol) as needed for rapid symptom relief. However, as of 2020, two expert organizations, the National Asthma and Education Prevention Program (NAEPP) and Global Initiative for Asthma (GINA), updated their recommendation for treatment of poorly controlled asthma to emphasize the use of single maintenance and reliever therapy (SMART).⁶ SMART is an asthma regimen that involves prescription of a single inhaler which combines an ICS for daily maintenance and formoterol, a long-acting beta-2agonist used for both daily maintenance and for as needed, immediate relief.⁷ SMART is the guideline-recommended approach for children age 4 and older based on several trials and a systematic review which showed that it reduces severe asthma exacerbations, even compared to traditional treatment with higher doses of ICS and as-needed albuterol.^8–11 However, a recent review highlighted that SMART implementation in clinical pediatric practice across the U.S. is limited.¹² To increase the adoption of SMART for children, it will be essential to engage interdisciplinary asthma care teams. With many children receiving asthma care at school, particularly for acute exacerbations, school health staff (SHS) play a critical role in the interdisciplinary team that manages a child’s asthma.^13,14 School health staff can vary across schools and include school nurses, health educators, and even advanced practice providers within school based health centers. Prior work shows that SHS have important and nuanced insights and are critical partners to facilitate the uptake of evidence-based asthma guidelines, yet to date SMART in school settings has not been investigated.¹⁵ Thus to promote more successful adoption of SMART in practice, we conducted a mixed methods study to describe SHS perspectives on SMART implementation in schools.

Methods

We conducted a convergent mixed methods study from May 2025 to June 2025 which included quantitative surveys and semi-structured interviews with SHS. In this study, all SHS were school nurses. We recruited SHS from 63 schools in Central Massachusetts participating in Asthma Link,¹⁶ a clinical program that wherein children with poorly controlled asthma receive daily SHS-supervised administration of inhaled corticosteroid medication on schooldays.¹⁷ Thus, the SHS included in our study population had experience with receiving asthma medication orders from pediatric practices and with supervising daily inhaler administration for students.

Participants and Recruitment

Quantitative Survey:

We recruited SHS during our routine end-of-year check-ins for Asthma Link. The Asthma Link team reached out to all SHS (n=70) at the 63 schools currently participating in the program (n=70) via email to ask about their interest in participating in a study on their experiences with SMART. The team received responses from 62 invitees of whom, 27 indicated interest in completing the survey and were sent a survey link via email. The research team followed up with a maximum of two email reminders to prompt survey completion, with 22 SHS completing the survey.

Qualitative Interviews:

We used a purposive sampling approach for recruitment to ensure we reached participants with familiarity with SMART and a broad range of perspectives. We started by inviting SHS who were known to be supervising medication administration for a child who was prescribed SMART (n=3), then we reached out to SHS who had multiple children enrolled in Asthma Link or who had been engaged with the Asthma Link team throughout the year (n=8). Throughout data collection, our team met regularly and monitored progress towards thematic saturation or the point at which new data was emerging in interviews and concluded interviews when we determined this had been met.¹⁸

Measures

We used the Consolidated Framework for Implementation Research (CFIR) to ground and develop the survey questions and interview guide for this convergent mixed methods study. CFIR is a widely used determinant implementation science framework that is designed to help identify and organize the factors that influence implementation.¹⁹ Our goal for both surveys and interviews was to explore and describe barriers and facilitators to SMART implementation across the five CFIR domains of: (1) innovation (SMART), (2) process (what is needed to implement SMART), (3) inner setting (what is happening within school settings that affects SMART implementation), (4) outer setting (what is happening external to school settings that affects implementation), and (5) individuals involved (SHS, families, and pediatric practices and providers). Survey items focused on specific barriers and facilitators within each domain, and the interview guide was designed to provide exploratory data while eliciting nuance and context for the quantitative results.

Study procedures

Quantitative Surveys:

We used RedCap to collect survey data; an individualized link was sent to each participant. The questions on SMART were designed to take approximately 7-10 minutes to complete.

Qualitative Interviews:

We conducted all interviews using web-conferencing software, recorded the conversation, and used an automatic transcription feature to generate initial transcripts. The interviewer reviewed and edited the initial transcript for accuracy.

Analysis

Quantitative Surveys:

We calculated frequencies and descriptive statistics for all survey items.

Qualitative Interviews:

We used rapid qualitative methods to analyze the interview data,²⁰ an analytic approach with high concordance to traditional thematic analysis methods.²¹ In this rapid qualitative analysis we created a template to summarize data from each interview within domains that map back to interview guide questions and CFIR domains. The analysis team started by using the template to each summarize the same three interviews. The team then met to review completed templates of the same three interviews to ensure each team member adequately captured pertinent data with consistent breadth and depth of summary. After confirming consistent summarization across team members, we divided the remaining transcripts between the team so that each remining interview would be summarized by a single team member. Finally, we used the summaries to create a matrix to compare responses across participants and generate themes and sub-themes within domains.

Mixed Methods Triangulation:

The analysis team met to synthesize quantitative and qualitative results which included a thorough examination of areas of concordance and differentiation between both data sources.

Ethical approval:

The University of Massachusetts Chan Medical School Institutional Review Board approved all study procedures (Study Identification Numbers: STUDY00001015; H00012920) in compliance with US Federal Policy for the Protection of Human Subjects. Both the interviews and surveys were designated as minimal risk studies and therefore we received approval to use an IRB-approved Factsheet which was provided to study participants ahead of time and participants were given time to review and ask questions. For interviews, we verbally confirmed consent ahead of the interview and received verbal consent to record interviews.

Results

The total sample for this mixed methods study included 31 SHS (22 completed surveys and 11 completed interviews; 9 participated in both survey and interview). The 11 interviews ranged in length from 21 to 32 minutes (IQR 6.5 minutes). All SHS were female with time working as SHS ranging from 2 to 36 years (IQR 9 years). Most worked within elementary schools and had a bachelors’ level degree. (Table 1)

Table 1.

Participant demographics for survey (n=22) and interviews (n=11)

Demographic	Survey (n=22)*	Interviews (n=11)*
	n (%) or range (IQR)	n (%) or range (IQR)
Sex
Female	22 (100%)	11 (100%)
Time as school health staff
Years	2 - 36 (9.75)	5 - 30 (14.5)
Highest degree held
Associate’s	4 (18.2%)	0 (0.0%)
Bachelors	12 (54.5%)	9 (72.7%)
Masters	5 (22.7%)	3 (27.3%)
RN	1 (4.5%)	0 (0.0%)
School Type
Elementary	17 (77.0%)	9 (82.0%)
Middle	1 (5.0%)	1 (9.0%)
High	1 (5.0%)	0 (0.0%)
Elementary/Middle/High	1 (5.0%)	0 (0.0%)
Middle/High	0 (0.0%)	1 (9.0%)

^*Note: Of the 11 SHS who completed interviews, 9 also completed a survey. We report demographics for participants in each data collection separately.

Overview of results.

Data are presented as follows, Table 2 presents quantitative survey data with individual items aligned with corresponding CFIR domain, Table 3 presents qualitative themes, sub-themes, and relevant quotations from interviews also organized by CFIR domain. Finally, Figure 1 illustrates triangulation of quantitative and qualitative data highlighting the needs to support successful implementation of SMART in schools.

Table 2:

Participant survey responses by CFIR domain (N=22)

CFIR Domain	Survey Responses	n	%
Innovation	Extremely familiar with SMART	2	9.1
	Very familiar with SMART	6	27.3
	Somewhat familiar with SMART	7	31.8
	Slightly familiar with SMART	6	27.3
	Not at all familiar with SMART	1	4.6
	Yes, I have given SMART as quick relief to a student	10	45.5
	No I have not given this for quick relief	12	54.5
	SMART offers a simpler one-inhaler regiment for my students	13	59.1
	SMART is more in line with what my patients are actually doing	4	18.2
Process	Brief phone call from a pediatric office when a patient is prescribed SMART	14	63.6
	Brief email from pediatric office when a patient is prescribed SMART	13	59.1
	Receipt of a SMART Asthma Action Plan when a patient is prescribed smart	18	81.8
	Access to brief, online videos to help understand SMART	10	45.4
	Access for students to brief, online videos to help understand SMART	10	45.5
	An online repository of SMART resources for your patients	14	63.6
Inner setting	I have questions and concerns about using SMART in school	2	9.1
	I am concerned that SMART will not work for a child in an acute asthma attack	2	9.1
Outer Setting	I am concerned that insurance may not cover 2 inhalers for children prescribed SMART	13	59.1
	I have concerns that my students on SMART are receiving albuterol in other locations (i.e., hospital, urgent care)	2	9.1
Individuals Involved	I am concerned that my students on SMART are still using albuterol for rescue use at home	6	27.3
	I am concerned that SMART is confusing for my students and families	9	40.9
	I have never received physician orders for SMART to be given to any my students	9	40.9
	I have received physician orders for SMART and I was easily able to administer SMART to my student	11	50.0
	I have received SMART medication orders, but then did not receive the correct inhaler from the family to be able to use SMART for rescue use	2	9.1
	I have received SMART medication orders, but then did not receive SMART action plan	4	18.2

^*Response rate 31%, table include responses of 22 participants from 70 invited SHS.

Table 3:

Qualitative themes, sub-themes and representative quotations by CFIR domain (n=11)

CFIR Domain	Themes	Sub-themes	Representative quotations
Innovation	School health staff experience with SMART	• Familiarity with SMART • Mixed experiences with children on SMART	SN5: “[The student] was having a really tough time breathing and [SMART] didn’t seem as effective as the albuterol for her. But I don’t know if that’s just for her or if that’s for other students, so I’m not sure the effectiveness yet.” SN8: “so it makes it real nice and easy for me when I just have to keep [one] inhaler for them instead of having [both] their daily and… a rescue as well.”
	Perceived benefits of SMART	• Convenience of less inhalers • Perceived improvement in asthma symptoms Fewer medication errors	SN2: “I guess it would be beneficial to parents not having to buy so many different inhalers, and knowing which ones are what” SN3: “[The one child I have on SMART…] He doesn’t worry me as much now that he’s using the SMART Therapy as before when we just needed that albuterol.” SN8: “And I just noticed a complete change as soon as we started the therapy with her…. She’s been able to stay in class” SN6: “Not getting confused between which inhaler to use. - I just think that’s the biggest [benefit]” SN10: “It just cuts down all that like potential error or like confusion that like families, especially families would have that like don’t have like a, a medical background or anything like that.”
	Perceived drawbacks of SMART	• SHS confusion about changing inhaler regimen • Issues with inhaler loss with SMART	SN4: “I don’t understand the science behind smart therapy versus the dual therapy…how does a Med that you’ve known for so many years being a controller now can also work as a rescue? Like what’s the what’s the science behind that?” SN7: “The issue would be that if the, if the student is taking it regularly that they might run out of the medication faster since it’s just, it’s used as a daily and a rescue.”; “If they had the SMART therapy at [home] …if they lost the inhaler, it would be, it would be taking away their preventative and their rescue”
Process	School health staff’s needs for supporting SMART implementation in schools	• Education • Clear asthma action plans for SMART • Clear orders from providers • Direct phone call with practice	SN9: “I’m always happy to get extra information on things. To review it, like, understand it More, just, you know, just for my knowledge. I don’t think, like, a formal training would be necessary” SN2: “You know, they could come and educate everybody, and just showing them, like, I think showing them, like, this is the Symbicort inhaler, You know, the colors and how confusing it can be” SN4: “I think a […] video explaining [SMART] because you know, everybody, everybody’s on their phones nowadays, like explaining the physiological benefits of SMART therapy” SN1: “I’d love to have it in the Asthma action plans. I think those are helpful” SN10: “I think just like maybe like clear instructions from the doctor, like on the orders that say […] if there’s like a difference in puffs or…anything like that, like take like 2 puffs in the morning and then two to four as needed. Like just something very clear”
Inner setting	Barriers to SMART in schools	• Parents may need help getting refills to school • Color of inhaler tops is similar which may make workflow changes harder	SN7: “The biggest challenge is when the parent doesn’t bring in the inhaler because they think it’s uhm, you know, it’s, it’s only to be used at home if it were to be the SMART therapy instead” SN3: “Maybe if it was a different color. Like, the Ventolin is blue, and the albuterol is red, but then my Symbicort is also red, so parents will say to me, the red one or the blue one? Yeah, so maybe they didn’t have to choose between the red one and the blue one. That would be easier”
	Facilitators to SMART in schools	• Education for parents • Identifying a natural time point to make the switch (i.e., when traditional therapies “run out”)	SN4: “The process can be confusing for both parents and nurses due to lack of communication, including the doctor’s office. Providers should clearly communicate and educate families on the reasoning of why student is prescribed SMART to prevent misunderstandings and defaulting back to albuterol use.” SN6: “I think the time to switch would be when the new inhaler is due…. So when the inhaler’s expired and they offer a refill, would be a good time to switch them over.”
Outer setting	Barriers to SMART outside schools	• Cost • Insurance coverage issues • Pharmacy stock	SN5: “Insurance has been an issue with a lot of families, but not only like them covering the inhalers, but some families are not realizing they need to reapply if they have MassHealth or so. We have a lot of families that don’t have insurance at all.” SN10: “Because if it’s all one inhaler, I mean, maybe that would be the barrier then I guess. Because then then insurance, insurance could argue like, oh, well, you just filled this, this day.” SN8: “I get a lot of calls or conversations with the parents. ‘Hey, I called the pharmacy. They didn’t have this medication.’ So maybe making sure that it’s covered by that individual’s like insurance and that it would be easy to get, you know, the refill.”
Individuals involved	Parental receptivity to SMART	• Perception of positive reaction from families • Health literacy challenges could make it difficult for some families	SN2: “I think they probably, some of them would probably be thrilled, because again, they don’t have to have all these inhalers with them….” SN4: “I think if parents understood that financially and clinically SMART therapy would work better for their child, I think they’d be more on board with it.” SN9: “We’ve had many situations where parents were confusing the Flovent and the albuterol, and giving the wrong medication at the, you know, at the wrong time so having just one would alleviate that.” SN8: “I think there’s a lot of health literacy challenges.”
	Child acceptability	• Children strongly accept SMART at school • Age of child could affect how much they accept SMART	SN1: “I think children usually will do whatever their parents tell them, or the doctors tell them.” SN9: “If we’re going the opposite way, from 1 to 2, I think that would be more difficult. I think going from 2 to 1, is much easier for everyone” SN5: “Like they’re younger, everybody’s kind of managing everything for them. So that’s why they don’t really care.”; “I think maybe as they get older it’ll be harder to understand..”
	Communication with providers	• SMART could require more communication with providers to manage • SMART could lead to less communication with providers	SN7: “I think [communication] would improve just because just because we’re like tracking something new. And, you know, if if it wasn’t, if it wasn’t working, then we could just communicate” SN8: “[If kids were on SMART the pediatrician’s office] might be more involved. It might be more like individualized maybe.” SN10: “it might increase just because like like maybe maybe the doctor might be interested in seeing how the kid is doing more often on on on SMART versus like the, you know, traditional like albuterol treatment” SN11: “I think definitely less communication”…” That would be due to the… the effectiveness of the medication, and the compliance level.”

Figure 1:

Mixed methods summary of school health staff reported needs to support SMART implementation

Innovation (SMART as a new approach).

In surveys, all but one participant reported that they are at least somewhat familiar with SMART and 45.0% had administered SMART as quick relief therapy at least once. Similarly, most SHS were familiar with SMART, though their experiences with SMART use in schools varied and only a couple SHS reported that they had more than one student currently using SMART. More than half of survey respondents (59.0%) agreed that SMART would be a simpler regimen with a single rather than a two-inhaler approach. In interviews, SHS recognized several key perceived benefits of SMART as a new approach, including the convenience of managing only one compared to two inhalers, their perception that SMART could improve children’s asthma symptoms, and several noted that having a single inhaler could lead to fewer medication errors. On the other hand, SHS noted that there could be some confusion in changing medication routines when transitioning from two-inhaler therapy to SMART and potential problems that could be caused by logistical challenges such as if a child lost their single inhaler and did not have a backup.

Process (Activities and strategies to implement SMART).

Survey participants reported that communication from providers via a phone call (63.6%) or a brief email (59.0%) when a child is first prescribed SMART would be helpful for SMART implementation. Nearly all (81.8%) reported that they would need a SMART-specific Asthma Action Plan. Additionally, 45.4% of SHS agreed that brief online videos for both them and for students would be helpful to understand SMART. When discussing the process of implementing SMART in schools, SHS described their specific needs to help increase its adoption in more detail. In interviews, many SHS described clear and specific asthma action plans as critical for implementation success. They also emphasized the importance of receiving explicit provider orders that specify which inhaler to use and under what conditions, as well as having a direct line of communication with prescribing providers. While many felt confident in managing SMART, SHS suggested the use of accessible resources such as visual aids, videos, and weekly newsletters could support adoption.

Inner Setting (Setting in which SMART is implemented: home, clinical, school setting).

In surveys, few participants (9.1%) endorsed items related to inner setting barriers. However, when asked about this domain in interviews, SHS identified several inner setting barriers and facilitators that influence the implementation of SMART in school environments. One significant challenge mentioned included the potential of not having a second combination asthma inhaler for school use, either due to confusion about SMART being intended for both maintenance and rescue, or due to difficulties obtaining multiple inhalers from insurance. SHS emphasized the need for parent education to clarify how SMART differs from traditional regimens and to ensure consistent and accurate use. Moreover, SHS suggested that the ideal time to initiate SMART may be when students are due for a medication refill, serving as a natural transition point.

Outer setting (External influencers on implementation: Cost, insurance).

Nearly 60% of survey participants reported concern about insurance coverage for two inhalers. In interviews, SHS highlighted more outer-setting factors that they perceived to influence SMART implementation, including cost and pharmacy access. SHS noted that from their experience financial concerns play a significant role in families’ ability to obtain the medications for SMART. Examples of these barriers observed and described by SHS include families facing gaps in insurance coverage, lack of insurance altogether, limited insurance coverage for SMART (i.e., needing multiple inhalers for both school and home settings), or confusion over refill timing. SHS also shared that families have reported pharmacies not having SMART treatment in stock or of being aware of details about SMART. To support broader adoption of SMART, SHS emphasized ensuring affordability, clarifying insurance processes, and improving pharmacy available as being essential for broader adoption of SMART.

Individuals involved (Parents, children, providers, SHS).

Nearly half, 40.9% of survey participants were concerned that families would be confused by SMART with 27.3% reporting they believed the family would continue to use albuterol. In interviews, SHS reinforced this point, noting that health literacy challenges could affect families’ ability to fully understand the rationale and correct use of SMART (i.e. stopping traditional albuterol). SHS highlighted the importance of multiple individuals to support a child in initiating SMART including parents, children, providers and SHS. Overall, SHS generally perceived that families would accept and be receptive to SMART due to its convenience, its simplified regimen and the potential that SMART could reduce asthma exacerbations as well as medication errors. SHS reported their observation that generally, younger children were more likely to follow adult instruction for their asthma management and therefore were more likely to accept and adhere to SMART. In contrast, SHS noted older children or adolescents may struggle more with the transition from multiple inhalers to one due to increased independence.

In relation to providers, SHS survey participants were split as 40.9% reported never receiving orders from a physician for SMART and 50.0% reported receiving physician orders for SMART (8.9% of respondents did not report either receiving or not receiving orders) . Similarly, in interviews, perceptions varied among SHS regarding communication with healthcare providers. Some SHS anticipated that SMART could lead to more frequent and meaningful interactions with providers, due to their monitoring of the new therapy. Others conversely suggested that in reducing asthma attacks, SMART may also decrease communication needs between SHS and providers.

Discussion

To our knowledge, this is the first study to explore SHS perspectives on SMART implementation in schools. This work highlights the experience of a critical healthcare partner in the adoption of current pediatric asthma guidelines and identifies strategies to promote SMART uptake. This mixed-methods study revealed that SHS are familiar with, accepting of, and willing to implement the SMART approach to asthma management in the school setting. However, to do so, they need clear medication orders, asthma action plans, communication with pediatric providers, and a second combination inhaler. These critical resources are essential for real-world use of SMART. Additionally, SHS thought that educational resources for parents along with improved accessibility of SMART inhalers (i.e., cost, insurance coverage, availability) would support SMART use in practice. To date, literature on SMART implementation has focused on pediatric clinics and described best practices and recommendations for prescription and management to support providers.^12,22,23 Here, we focus on a unique aspect of SMART implementation by exploring perspectives of SHS working in schools where children with asthma spend a third of their day.

Most SHS in our study were familiar with SMART and some were already administering it in schools. These SHS provided insights into what will need to happen to support implementation of SMART in schools. First, the importance of strong communication with the prescribing provider was noted. Specifically, SHS believe it will be critical to have asthma action plans, clear orders, and easy communication with children’s practices to support SMART implementation, especially when children first transition from traditional therapy. This finding is aligned with previous literature demonstrating that asthma action plans and communication between providers and SHS are vital to support successful asthma management.²⁴ Secondly, nearly all SHS reported that some level of education for either themselves, families, or both, would be needed. Many indicated that a repository of online educational resources could be a simple way to accomplish this. Importantly, SHS noted that these educational materials must be accessible to parents with varying levels of health literacy. Both of these documented needs emphasize that SHS, providers, and parents will need to work together to support SMART implementation.

Beyond what will need to happen in schools to support SMART, SHS also noted the importance of ensuring affordability, insurance coverage for inhalers for school and home, and availability of SMART inhalers from pharmacies. This is consistent with a prior findings of clinicians perspectives of SMART implementation, ²⁵ though not focused on pediatric populations as well as a review which highlighted how insurance, cost and accessibility may be barriers to SMART implementation in pediatric populations.¹² Our findings show SHS are cognizant of these barriers and describe how these external barriers not only delay access to needed medications but also have the potential to create confusion among families about SMART use. Future work will need to focus on developing multilevel approaches to support implementation of SMART that incorporate perspectives of other implementers and stakeholders including insurances and pharmacies to address the needs and barriers identified by SHS.

SMART represents a significant paradigm shift in asthma treatment which requires that SHS, parents, children, and pediatric providers accept the change, see its benefits, and have the ability and resources needed to make the transition. Findings from both interviews and surveys with SHS reiterate that they are key partners in children’s asthma management who recognize the potential benefits of SMART. However, SHS identified barriers that must be overcome to support their ability to smoothly transition to using SMART in school settings. The barriers identified by SHS suggest that implementation of SMART may be supported by current best practice models used for other forms of asthma treatment. Based on this, in Figure 1 we highlight potential strategies to overcome SMART barriers. However, since the barriers and solutions are related to families and pediatric providers understanding these additional perspectives will be key to successful implementation. In seeking to promote SMART implementation, we can also look to lessons learned from other school-based asthma programs which include families and providers.²⁶ Obtaining understanding from all parties involved in pediatric asthma management is key to supporting effective selection of implementation strategies to support SMART uptake. ²⁷

Strengths and Limitation

This study fills a knowledge gap on the perspectives of SHS on SMART implementation in schools and the use of mixed methods to reach a critical community partner in asthma management adds important nuance and context to these results. These study results may not generalize to other groups, and may specifically reflect different views from those who declined to participate or from the general population of SHS. Though our sample size was limited, we conducted interviews until thematic saturation was reached (i.e. stopped interviews when further data collection was unlikely to yield new insights) and there was a high level of agreement between our qualitative and quantitative findings. Our use of mixed methods enhances the credibility of our findings. Notably, our study population was a highly engaged group of SHS who were more likely to be early adopters of new guidelines like SMART, positioning us to elicit substantive feedback from SHS who were familiar and had experience with SMART. Most also worked within Elementary schools which is reflective of schools that participate in Asthma Link (46 of 63 participating schools). As such, their perceptions may may differ from the general population of SHS and future work should aim to explore perceptions of SHS from schools of different educational levels.

Conclusion

Guideline-concordant SMART represents a significant paradigm shift from the traditional two-inhaler asthma management approach. While SMART has potential to improve asthma care for children while offering a simpler single inhaler regimen, there has been limited adoption in pediatric practice. School health staff are a critical partner to support more widespread implementation of SMART for children. This study provides insights into the needs of SHS for SMART implementation. These needs include clear asthma medication orders, SMART-specific asthma action plans, clear communication with providers when students are prescribed SMART and educational resources for SHS as well as families to support SMART adoption. Future research should focus on the development of strategies that can address these SHS needs and elicit perspectives from providers and families on SMART implementation.