Addressing critical barriers for sustainability of asthma stock inhaler policy implementation and resultant programming

Abstract

Background:

Asthma is a prevalent health concern among Illinois (IL) children, and management is significantly influenced by social determinants. There were 17 states who have adopted stock inhaler laws, but implementation varies widely.

Objective:

To assess critical barriers to implementation and address sustainability of stock inhaler programming in school-based asthma care in IL.

Methods:

Semistructured interviews were conducted with high asthma burden school districts in IL to assess barriers in implementing stock inhaler policies and resultant programming. Thematic analysis was performed using Atlas.ti (Scientific Software Development GmbH, Berlin, Germany) to identify and code “threats” to future sustainability. Data were synthesized and presented to stakeholders for barrier mitigation. A schematic flowchart outlining steps to support sustainability was created.

Results:

A total of 18 interviews were conducted with key community partners across 8 IL school districts, representing rural, urban, and suburban areas. Analysis revealed 25 barriers, with several identified as “threats” to future sustainability, including liability concerns, follow-up care assurance, funding/resources, pharmacy dispensing practices, district-level readiness to change, and nurse staffing. Stakeholders formed a statewide coalition to address these barriers, increase awareness, plan evaluations, and advise on state funding allocation. A national stock inhaler toolkit tailored to school administrative needs was developed to support sustainability efforts.

Conclusion:

Strategic stakeholder and community engagement are vital for establishing and sustaining stock inhaler programs that adhere to policy mandates. Many districts face challenges initiating and maintaining such programs without critical barrier mitigation and support. Collaborative solutions are necessary to ensure effective school-based asthma management and mitigate persistent pediatric asthma health disparities.

Introduction

Asthma is one of the most prevalent pediatric chronic diseases, affecting 8.1% of school-aged children nationwide.¹ Asthma affects children in many ways throughout their lifespan, and when uncontrolled, acute exacerbations can lead to respiratory failure and death.^2–6 It is the leading cause of chronic disease and missed school days in children.^2–5,7 Uncontrolled pediatric asthma is associated with more missed school days and lower education attainment, leading to reduced earning potential in adulthood compared with peers without asthma.^2,3,5–7 It is also linked to chronic, comorbid illnesses in adulthood including diabetes, cardiovascular disease, metabolic syndrome, osteoporosis, and anxiety/depression, making it essential to provide intervention to achieve asthma control within childhood.^1,3,7–9

Children of Black and/or Puerto Rican descent who are negatively affected by social determinants of health experience higher prevalence, morbidity, and mortality related to asthma. Geographically, children who reside in urban and rural settings are more likely to have a diagnosis of asthma and asthma-related morbidity and mortality when compared with other geographic settings.^9,10 Asthma among school-aged children is more likely to be uncontrolled in school districts that lack resources, particularly those in densely populated cities.^11,12 In Illinois (IL), the prevalence of childhood asthma is 9% statewide, with the highest rates found in the non-Hispanic Black population at 19%.^1,13 Unfortunately, many schools are ill equipped to handle respiratory emergencies, and most children with asthma do not have access to rescue inhalers while at school.¹⁴

School-based health policy has been found to positively affect student health outcomes, by improving student educational performances through reduced school absenteeism, when establishing school-based health centers at schools that have the space and funding.^5,8,15 When collaboratively approached, school-based health policies can result in effective and sustained programming that may improve asthma outcomes.^16–18 Although health policy can vary in its reach and approach, in the context of asthma, collaboration among these interorganizational networks facilitates the creation of school-based health policy that can provide guidelines for multilevel implementation of solutions to school-based pediatric asthma health disparities.^{11,12,16–22} School-based asthma health policy (SAHP) can be used to ensure children receive guideline-based asthma care in schools when they need it.^14,23 Schools are a trusted safety net for many families and communities, children spend a substantial portion of their day at schools, and schools harbor asthma triggers making schools a convenient setting for health policy interventions.^18–24

Moreover, SAHP can guide government and advocacy organizations, communities, medical homes, and school districts into establishing a cohesive process to support guideline-concordant school-based asthma management.^24–33 An example of SAHP can be illustrated by IL’ enacted Public Act 100–0726, which allows schools to stock rescue inhalers to be administered by trained personnel when a student experiences asthma symptoms.^30,34 Although IL has enacted various asthma health policies in recent years, evaluation of these policies has been limited.^29,31 The most recent update to stock inhaler policy requires state-mandated reporting of inhaler utilization, making it possible to track and evaluate the implementation and effectiveness of SAHP.³⁵

A recent school nurse survey in IL reveals that, although 65% of school nurses want a stock inhaler program at their school, only 15% of those surveyed had one.³⁰ According to the most recent IL State Board of Education tracking of stock inhaler utilization from the 2022 to 2023 school year, only 112 actuations of stock inhalers were reported statewide. Of 857 districts (852 of those are IL State Board of Education-run schools), only 11 reported usages, totaling a mere 1.3%.^31,32 It is unclear why reported usage of inhalers is low despite the asthma prevalence in school districts and SAHP that allows schools to stock rescue inhalers. What is clear is that having rescue inhalers readily available can provide lifesaving interventions for a child in respiratory distress and can address medication access concerns for historically marginalized children.^{23–25,36,37} Barriers to implementation are crucial to evaluate to ensure the adoption and sustainability of stock inhaler programming guided by SAHP in IL.^{30,33,36–38} Our study aimed to provide data that can facilitate collaborative, sustainable stock inhaler programming to assist schools in appropriately responding to a student in respiratory distress.^38,39 This manuscript evaluates the relationship between SAHP and the sustainability of programs aimed at equitable implementation of these policies in the setting of pediatric asthma in IL. We are specifically interested in identifying critical barriers influencing the adoption of existing stock inhaler policy and providing potential solutions to common barriers to sustainment of current stock inhaler programming in IL.^40,41

Methods

Study Design and Participant Interviews

This mixed methods study investigated the barriers associated with statewide stock inhaler implementation. We collected our data through the purposeful sampling of semistructured interviews with key stakeholders. Stakeholders were a diverse group of individuals involved in school-based asthma care, including school administrators, teachers, school nurses, advocacy agencies, and government organizations. Two categories of stakeholders were identified and interviewed. The first stakeholder category was represented as internal school health personnel and included school/district administrators, nurses, and staff in counties located across urban, suburban, and rural areas totaling 10 interviews. The second stakeholder category comprised state and national advocacy groups in IL represented as external advocacy and government agencies totaling 8 interviews.

During the primary qualitative data analysis, stakeholder interviews were recorded and transcribed using Atlas.ti, a qualitative data-coding software. Interview codes were generated by an interdisciplinary team of medical and public health personnel using descriptive statistics and labeling of patterns that emerged from the data. These data were synthesized and presented to stakeholders for barrier mitigation. A schematic flowchart outlining steps to sustainability was created. The study protocol received approval from the Institutional Review Board before data collection commenced. Informed consent was obtained from all survey participants and key informants. The study achieved a 100% participation rate, as all individuals who were invited agreed to take part, with 1 exception in which an individual had retired, and their replacement was interviewed instead.

Qualitative Data Collection

Using a map of key stakeholders and community-engaged research methodologies from our previous pilot study, we identified key informants with varying levels of influence and interest in stock rescue inhaler policy.^22,42,43 Qualitative data were collected using semistructured key informant interviews. These interviews were conducted with stakeholders representing governmental organizations, advocacy groups, and school districts within high asthma burden counties in IL. Key informants were selected based on their expertise and involvement in asthma management and policy development. The interviews aimed to explore in-depth insights into the barriers and facilitators of stock inhaler implementation. Participants were invited on a rolling basis until the research team obtained a representative sample and no further novel insights emerged in subsequent interviews, thereby indicating thematic saturation had been reached.^44–46

Primary Qualitative Data Analysis

Coding of interviews and data analysis was performed using Atlas. ti software, which followed a systemic process of data familiarization, initial code generation, and identifying, reviewing, defining, and naming themes. An interdisciplinary team of researchers from various health fields convened to develop a preliminary codebook and complete the first phase of qualitative analysis. The initial analysis resulted in codes that were grouped as barriers, facilitators, or process considerations.

Secondary Qualitative Data Analysis to Identify Critical Threats to Sustainability

Using results from the primary analysis, we conducted a secondary analysis of the 25 coded barriers across and within interviews. Code frequency between interviews with internal and external influence groups was compared using a Fisher’s exact test using SAS OnDemand for Academics (SAS Institute, Cary, North Carolina). We compared specific parameters such as the frequency of barrier codes across interviews, the level of influence a coded barrier represented, and recurrent patterns and trends among codes. Codes that were identified as similar were regrouped, and subthemes were created using several correlation and reliability statistical tests. Final codes and subthemes were determined using interrater reliability among our team of reviewers, creating codes that were defined as critical to sustainability.

Results

Secondary Analysis: Critical Sustainability Barriers

A total of 18 unique interviews were conducted with a diverse group of key stakeholders involved in school-based asthma care, including 10 interviews with school health staff and 8 interviews with IL advocacy and government organizations (Table 1). Interviews with School Health Staff were defined as internal stakeholders that are directly involved in school-based asthma care and included personnel from schools in urban, suburban, and rural districts. Advocacy and Government Organizations were defined as external stakeholders that have a high influence on school-based asthma care. Our primary qualitative analysis identified the frequency of each barrier coded across the 18 interviews and grouped codes into school-, regional-, and policy-level themes. Of the 25 barrier codes identified in our primary analysis, 21 codes with the highest internal consistency reliability (α = 0.81) were compared using item analysis with a discrimination cutoff of 0.5 and reclassified into subthemes outlined in Figure 1. Using the frequency of each barrier coded within and across interviews, we identified 10 critical sustainability barriers. Critical sustainability barriers were defined as obstacles that would impede the core functioning of stock inhaler programming. The codes “Too expensive,” “State/district has no funds,” “Had to pay for order,” and “Feels like an unfunded mandate” represented barriers at the school/district, regional, and policy levels. These codes were consolidated into their respective internal or external themes and subclassified under Funding. This process was repeated for each code until thematic saturation was reached (Fig 2).

Table 1.

Demographics of Stock Inhaler Stakeholder Interviews

Context	Stakeholder category	Subclassifi cation	Interviews (N = 18)
Internal stakeholders	School health staff	Urban	3
		Suburban	5
		Rural	2
External stakeholders	Advocacy and government organizations	Illinois government organizations	2
		Illinois advocacy group	2
		Other state or national advocacy group	4

Figure 1.

Frequency of barrier codes within and across stakeholder interviews: primary and secondary analysis.

Figure 2.

Codes and themes identified from thematic analysis of interviews with stock inhaler stakeholders.

Theme: Internal Barriers

Internal barriers reflect barriers reported by stakeholders at the individual schools and districts. Internal stakeholders included school health staff in rural, suburban, and urban districts. Barriers include those related to district funding, stock inhaler medication availability, liability concerns, and assurance of follow-up care. Each of these barriers was further subclassified into subthemes based on our evaluation of stakeholder interview trends.

Subtheme: Education

Education presented as a recurring subtheme across both internal and external contextual barriers. Education was represented by the code “Liability concerns” as an internal barrier. One stakeholder discussed training more personnel in the event the school nurse is unavailable to mitigate liability and address risk management:

“… our administrators are the backup to the nurse [if] the nurse is not there, or on an emergency or at lunch, that administrator might be the second one to be trained.”

Subtheme: Funding

The subtheme of Funding was characterized by the codes “Too expensive” and “State has no funds” as internal critical barriers. Lack of funding poses a serious challenge to the implementation of stock inhaler programming. Our data revealed that funding was mentioned 4 times as a concerning barrier and 9 times as facilitators across 18 interviews. Schools in economically marginalized areas reported having difficulty locating a consistent supply of medication due to limited capacity:

“Funding is tight … probably for the low-income school buildings which is a whole other issue because obviously those are the schools most in need to have the undesignated albuterol.”

Subtheme: Supplies and Resources

The subtheme of Supplies and Resources was used to encompass the internal codes “Do not have stock albuterol” and “Too overwhelming.” Having access to medication was a critical concern for stakeholders. Stakeholders mentioned barriers to obtaining a supply of stock inhalers or not enough inhalers for students with diagnosed asthma:

“We have 3289 students, right now, who have a given [to us] medical diagnosis of asthma and we have 1785 inhalers.”

Subtheme: Risk Management

The Risk Management subtheme was characterized by the internal codes “Liability concerns” and “Follow-up care assurance.” Liability concerns were coded in 20% of stakeholder interviews, and 3 providers stated their refusal to write a prescription because of the concern of liability. Having follow-up care posed a barrier for schools/districts and further added to liability concerns:

“It is a struggle for us. One of the things that we deal with on a daily basis in the nurse’s office is getting these kids access to [follow-up] care.”

Theme: External Barriers

External barriers reflect barriers related to external organizations outside the school system, including finding a prescriber, obtaining medication and supplies, accessing follow-up care, and funding. Key external stakeholders included advocacy and government organizations. These external barriers included the codes “State has no funds,” “Follow up care hard,” “No provider,” and “Pharmacy refusal to fill prescriptions.”

Subtheme: Education

Education was represented by the codes “No provider” and “Pharmacy refusal to fill prescription” in the context of external barriers. Stakeholders mentioned access barriers surrounding local policy:

“Even with the adoption of a local policy for undesignated asthma medication would be the access to having a physician … that in and of itself is a barrier.”

Subtheme: Funding

The subtheme of Funding was characterized by the code “District has no funds” as an external barrier. Lack of funding poses a serious challenge to the implementation of stock inhaler programming. Stakeholders expressed concern over access and availability of external funding:

“I do not know where the room is at a federal level, other than something like an incentive program … [where] a state is more likely to get federal funding if that has this law in place.”

Subtheme: Supplies and Resources

In the context of external barriers, Supplies and Resources were defined by codes “Follow up care hard,” “No provider,” and “Pharmacy refusal to fill prescriptions.” External barriers to obtaining supplies presented as critical barriers to a school’s desire to implement stock inhaler programming:

“I did not sign on for the undesignated inhalers because of the challenges that it presented trying to get in touch with a doctor that would give orders.”

Subtheme: Risk Management

The Risk Management subtheme was characterized by the external codes “No provider” and “Pharmacy refusal to fill prescriptions.” Select quotes from stakeholder interviews are outlined in Figure 3 and further underscore the development and classification of each subtheme.

Figure 3.

Select stakeholder interviews on critical sustainability barriers.

Solutions

Our analysis revealed that most of the interviewees (94%) provided valuable suggestions for improving the implementation of stock inhaler programs. For example, despite bringing up funding often, select stakeholders provide insight into potential solutions to “funding” concerns (Fig 3). In addition, finding and identifying a school or district champion to advocate was mentioned across the interviews. Several key individuals in different districts had invested interests in funding and finding funding for stock inhaler programming. Using stakeholder feedback, we further researched solutions to critical sustainability concerns outlined in Figure 4.

Figure 4.

Themes and subthemes of critical threats to sustainability with potential solutions. Q/A, question/answer.

On the basis of synthesized findings and stakeholder input, a schematic flowchart was developed (Fig 5) outlining steps toward the future sustainability of stock inhaler programs. This flowchart visually represents the recommended strategies, interventions, and collaborations needed to overcome barriers and ensure the long-term effectiveness of stock inhaler programs in schools.

Figure 5.

Schematic flowchart of proposed steps to sustainability of stock inhaler pilot programs. PI, Principal Investigator.

Discussion

Through community collaborations with various stakeholders, we were able to obtain perspectives from real-world high asthma-burden school districts, counties, and related community representatives in IL to evaluate interprofessional parameters that affect the sustainability of stock inhaler programs. We assessed critical sustainability barriers and mitigation strategies to create guidelines for schools to use in the enhancement of sustainable stock inhaler programming. These barriers include difficulty finding providers and pharmacies to fill stock inhaler prescriptions, inadequate funding, liability concerns, and the hurdle of schools feeling overwhelmed when implementing a new program.

A key finding in our study is that the mere passage of stock inhaler legislation does not guarantee the successful implementation of these programs. Successful implementation of sustainable programming requires active and ongoing support for schools to build the infrastructure to adopt stock inhaler policies.^47–49 As a solution, we propose adopting an implementation science and community-engaged approach.^50,51 Implementation science can provide a structured approach to developing strategies and identifying interventions to barriers.^51–53 In addition, a community-engaged approach will engage stakeholders in the implementation process, which ensures that methods and interventions align with a community’s priorities. Together, these approaches can improve policy implementation and reduce prevalent disparities.^47–53

Our study found education and training for stakeholders to be a recurring subtheme for successful implementation and overcoming barriers. This calls attention to the role of community-engaged efforts to improve health outcomes. Risk management, a critical barrier identified, can be addressed under this theme. More specific examples of risk management include liability concerns, follow-up care assurance, difficulty finding providers, and pharmacy refusal to fill prescriptions. Educating health care providers, pharmacies, school administration, and other faculty about stock inhaler policy is therefore essential to successful implementation. Education can take form through workshops, training programs, and toolkits that provide comprehensive information about state policies, documentation requirements, and best practices for asthma care in schools.^{16,17,27,35,54–56} Another form of education is through collaboration among stakeholders. Through the formation of a stock inhaler coalition, stakeholders can share both information and resources while also addressing challenges together. These findings confirm that community involvement and comprehensive stakeholder engagement are essential to ensure successful implementation.

Another critical challenge observed was resource disparities. This challenge is especially pronounced in districts with limited funding and fewer resources, in which asthma prevalence is higher. This poses a significant barrier to equitable policy implementation and poorer health outcomes for underserved populations. Identifying areas with a high burden of asthma cases and targeting interventions in these regions can help to achieve more equitable outcomes. Our study highlights several strategies that can be used to overcome this challenge. Solutions include policy and advocacy for state/county-level funding, public insurance reimbursement, fundraising events, and the creation of funding programs. In terms of resource and supply issues, such as difficulty finding follow-up care and stocking inhalers, we suggest insurance reimbursement and institutional support for telehealth, mobile care, resource allocation training, statewide and national toolkits, National Association of School Nursing, and Community Health Workers support for schools.^57,58

Partnerships with external organizations can create long-term solutions to accessing supplies and securing medication. For example, we created partnerships with the Asthma and Allergy Foundation of America, a national advocacy organization, to create stock inhaler kits for schools through their RESCUE program. Local state health departments can also be a resource for obtaining stock inhaler supplies. In IL, Winnebago, Cook, and Lake County health departments offer free stock inhaler prescriptions, alleviating the need to search for a provider and allowing lower-income schools access to lifesaving medication. Through these solutions, schools can ensure that resource barriers do not limit successful implementation.^17,58–60

We acknowledge the limitations of our study. The small sample size and the focus on early adopters and willing participants might limit the generalizability of our findings. Our study design was focused on in-depth qualitative interviews to explore specific themes related to stock inhaler sustainability. The inclusion of only 2 rural school staff members partially reflects the dearth of rural school involvement in stock inhaler initiatives. This might be associated with a larger access problem that we have noticed and hope to address in future manuscripts as we continue to work with legislation and sponsors to increase stock inhaler reach into rural school districts.

Each interview provided rich and personable insights into the role of stock inhalers allowing us to attain diverse perspectives within this population. In addition, qualitative research often prioritizes depth over breadth, and the saturation point was reached within each step of our analysis.^6,9,45,46,60 Furthermore, our study was conducted in IL, which might not fully represent the challenges faced by schools in other states. Despite these limitations, our study provides valuable insights into the barriers and opportunities for sustainability in stock inhaler programs, laying the groundwork for future research and advocacy efforts.

By actively engaging diverse stakeholders with specific purposes in mind of addressing critical barriers with stakeholder-driven solutions, our findings for sustainability can be applicable nationwide.^61–64 Difficulties in implementation are more likely to reinforce health disparities, disproportionately affecting school districts and underserved populations with limited access to resources. Barriers identified are not unique to stock inhaler implementation and have been found in other school-based health initiatives such as in the management of anaphylaxis and substance use disorders in the school setting.^65–67 These findings echo our key finding that the mere passage of health policy is just the beginning of a desired health outcome.

There is a crucial need for active support, collaboration, and resource allocation to successfully implement school-based health policies, such as stock inhaler programs. Not only does our study identify barriers, but it also offers solutions. To ensure legislation is equitably implemented, policy implementation must be an active process that leverages implementation science and community-engaged research methodologies. This ensures that schools are adequately equipped with the resources necessary to sustainably use crucial school health programming and reduce asthma health disparities. This study serves as a call to action for researchers and as inspiration for stakeholders to pursue more equitable asthma health for all children.