“Getting in and doing it personally”: Engagement strategies for rural school asthma programs

Abstract

Background:

Asthma is a common pediatric lung disease in the United States. Children in rural schools face unique environmental asthma triggers and longer distances to medical services than do urban children. Although Illinois law permits schools to carry undesignated rescue inhalers for respiratory distress, few rural schools participate.

Objective:

To develop a rural school engagement strategy for stock inhaler programming.

Methods:

An initial engagement strategy was derived from a rural qualitative inquiry through semi-structured interviews and presented for feedback. A two-hour focus group was conducted with eight partners who work within or with rural schools related to school health. Participants were identified through purposeful and snowball sampling. The discussion was transcribed, and key themes were identified using rapid qualitative analysis.

Results:

Three themes emerged from the analysis: Building Policy Awareness and Assessing Local Needs, Building Rapport and Support for Rural School Programming, and Unique Considerations for Rural Schools. Engagement strategy suggestions included working with a community health champion and conducting a needs assessment before proposing an intervention. Communication suggestions included concise top-down messaging tailored to rural communities with personal storytelling. Unique rural school characteristics identified were isolation, strong sense of community, insularity, and generosity. Barriers such as communication, liability concerns, and lack of school nurses and physicians were described. This feedback refined the rural engagement strategy.

Conclusion:

A carefully selected focus group with diverse perspectives helped elucidate the best engagement and implementation strategies for rural school health interventions. Addressing the unique challenges faced may improve health outcomes for rural children.

Introduction

Asthma is a prevalent chronic disease nationwide, affecting 6.5% of children in the United States.¹ Approximately 60 million people in the United States live in rural areas, but there are few data on American rural asthma prevalence.² Although urban areas have been believed to have disproportionately high pediatric asthma prevalence, several studies have found rural pediatric asthma prevalence is similar to that in urban and suburban areas.^2–5 When comparing their social determinants of health with those living in urban areas, people living in rural areas also have a lower-than-average income, receive more public insurance, and have reduced access to health care facilities.^2–6 Children in rural regions encounter significant barriers to effective asthma management, complicated by lack of access to asthma subspecialists and asthma screenings.^2–5 Reduced health care access exacerbates these challenges, with rural children experiencing greater rates of Medicaid enrollment, delays in care, and greater outof-pocket costs than do urban children.⁶

Rural environmental landscapes amplify asthma triggers. Exposures are related to both small- and large-scale farming, such as pesticides, ragweed and other pollens, dust, increased firsthand and secondhand tobacco exposure, and housing conditions (ie, woodburning stoves and mold).^3,7–10 These environmental factors contribute to the exacerbation and severity of asthma symptoms. This potential for worse asthma symptoms coupled with rural children’s limited access to care significantly augments the negative effects children may experience.

School-based health policies can improve rural school-based asthma management by providing necessary infrastructure and support.^11–13 Illinois’ Public Act 100–0726 allows trained personnel to administer undesignated rescue asthma inhalers to anyone with asthma symptoms.^14–16 This policy allows children to return to class after an asthma incident, avoids unnecessary 9-1-1 calls to schools for asthma, and supports follow-up asthma care.^11–16 However, implementation of this policy in rural schools has been slowed by limited school health resources and other factors.^13,17

The purpose of this manuscript is to explore the viewpoints of rural schools and affiliated partners regarding health policy, stock inhaler programming, and rural school engagement to inform subsequent policy implementation. Through focus groups conducted in partnership with rural school community leadership, we developed an engagement strategy tailored to rural schools. By focusing on rural schools in Illinois, this research seeks to provide understanding and strategies for overcoming the unique challenges faced by rural communities.

Methods

Study Design

This study adopted a community-engaged qualitative approach using focus group methods to identify strategies for rural school engagement in school-based asthma management, specifically stock inhaler programs. An initial rural school engagement strategy was drafted in the previous months based on 21 one-on-one semistructured key informant interviews with rural school partners. Those interviews identified barriers, facilitators, and engagement recommendations. A single focus group was then held to refine the strategy. For this manuscript, we are reporting the thematic analysis of the focus group data and the refined engagement strategy for rural schools.

Participants in the focus group were identified as key influential figures who are part of, or interact frequently with, rural schools, including school administrators, nurses, community researchers, and health care providers. Collaboration between researchers and all participants in real time allowed a larger number of collective qualitative data not possible by other methods.^18,19 This community-engaged approach evaluates ways policy can be effectively translated into practice and offers a model for successful health policy implementation in rural schools.^20,21

Participant Selection

Overall, 25 individuals with experience in rural health and/or community settings who had previously completed an interview about stock inhalers in rural schools, or those known to participants who had, were invited to the focus group on the basis of availability; eight individuals were available and participated in the study. Participants represented three of six Illinois Department of Public Health regions in Northern and Central Illinois; two of the eight individuals had duties in multiple rural communities statewide, whereas the rest represented separate communities.

Focus Group Facilitator Guide

A comprehensive semistructured focus group interview guide was developed, featuring questions aimed at refining the rural engagement strategy initially formulated from one-on-one interviews.²² These questions aimed to explore participants’ experiences and perspectives on raising health policy awareness, assessing community needs, building rapport and support for school-based programs, and unique characteristics of rural schools (Table 1). Participants viewed each question on a Microsoft PowerPoint slide during the focus group.

Table 1.

Focus Group Questions and Main Points

Interview question	Main points
What are your experiences with engaging rural schools to participate in school-based health interventions?	Rural schools value community trust and relationship-building. Engaging local health champions (eg, school nurses, administrators, or respected community members) is essential for initiating programs. Challenges include limited resources, staff shortages, and competing priorities within the school environment.
If you work within a rural school, what have your experiences been with engaging outside people on school health issues?	Outside entities need to build credibility and demonstrate understanding of local context. Collaboration is more effective when outside partners work through existing community leaders. Resistance can occur if initiatives are perceived as being imposed without input from locals.
We developed a strategy for schools based on your key informant interviews. We are going to share this strategy with you now. We would like you to share your reactions on how you feel about this strategy.	Participants emphasized importance of conducting a needs assessment first. Suggestions included simplifying communication materials and ensuring flexibility in the framework to accommodate diverse school environments.
What do you like about it, and what do you think we should change?
What are the best ways to disseminate health policy information in rural areas?	Personal storytelling is highly effective for connecting with rural audiences. Use direct communication channels. Simplify messaging to focus on relevance and urgency, avoiding overly technical language or excessive reliance on data.

Data Collection

A total of eight rural school partners participated in a two-hour audio-recorded focus group interview conducted through Zoom (Zoom Communications, Inc.) on March 16, 2024. Participants included school nurses, community-based researchers, and school administrators. Graphic recording with an experienced health equity-focused graphic recorder was used to provide qualitative analysis themes (Fig 1).²³ The focus group interview was facilitated by the principal investigator of the study (A.P.) and a research assistant (P. H.).

Figure 1.

Focus group graphic recording.

Data Analysis

The focus group was audio-recorded through Zoom and sent to a paid service for human transcription. Each facilitator guide question and its associated responses were extracted from the transcript, and separated by respondent. Each answer was then summarized by a single coder, and a group of four coders collaboratively reviewed the summary; next, they developed and assigned qualitative codes to each response in Microsoft Excel.^24,25 Any new discussion points that emerged were added to the spreadsheet, detailing each participant’s contributions. This document formed the basis for a thematic analysis meeting involving 4 researchers from the project team. During this meeting, the team reviewed the responses to the semistructured interview guide, in addition to the new discussion items, and collectively coded each participant’s response to each question. Over three subsequent meetings with the same researchers, these codes were reviewed and thematically analyzed using Dedoose Version 9.2.7 to identify overarching patterns.^24,25 This process aided in the refinement of the engagement strategy, addressing comments and feedback from the focus group.

Engagement Strategy Creation

The rural engagement strategy was created over an eight-month period and was initially drafted on the basis of findings from one-on-one interviews with 21 rural school health partners. The strategy was iteratively reviewed by three researchers with expertise in asthma policy and implementation science, along with two medical students involved in the project. The focus group served as a key refinement step to ensure the strategy reflected community priorities, confirm its feasibility, and identify gaps. The goal was to create a practical, community-centered framework for asthma policy implementation.

Results

A total of eight participants attended the focus group including three clinicians, one school nurse, one rural academic researcher, one regional school superintendent, and one government representative, and three themes emerged from the focus group analysis: Building Policy Awareness and Assessing Local Needs, Building Rapport and Support for Rural School Programming, and Unique Considerations for Rural Schools. These helped identify important characteristics and factors for the rural engagement strategy, which were iteratively modified real-time during the focus group, and subsequently during thematic analysis. Themes, subthemes, corresponding codes, and indicative quotes are listed in Table 2.

Table 2.

Focus Group Rapid Thematic Analysis

Theme	Subthemes	Codes	Indicative quote(s)
Building policy awareness and assessing local needs	Needs assessment	Needs assessment Education needs	“Is it possible that a needs assessment comes first or are we going to make the assumption that rural equals need?”
	Leadership	Top-down messaging	“I think the most effective way to demonstrate disseminate information has always been from the top down from a leadership position or another word I’m thinking of − responsibility.”
	Champions/Trusted official	Found a champion Community buy-in	“Having someone the community already trusts was key—they became our champion in pushing the program forward.”
Building rapport and support for rural school programming	Storytelling as a method to express need	Personal stories Facilitates follow-up	“Sharing a story about a student who avoided an ER visit because of a stock inhaler really resonated with them.”
	Trust-building	Facilitator to school engagement Facilitates education	“When you trust, it makes a big difference.”
	Listening	Effective communication	“Not that you’re going to necessarily do everything everybody wants, but you got to listen.”
	Avoiding communication pitfalls	Communication difficulties Lack of perceived need	“Sometimes schools don’t fully understand the need for these programs until you explain it in very practical terms.”
Unique considerations for rural schools	Strengths	Tight-knit community Distance to EMS	“We’re miles from the nearest pharmacy or hospital, so it’s not just a school issue—it’s a rural issue.”
	Barriers	No health care workers in the school Time constraints Too overwhelmed Isolation Lack of access to pharmacy/provider Lack of access to PCP/specialists Liability concerns	“Schools are dealing with so much, and they don’t see how they can take on one more thing;” “In these small communities, there’s a lot of hesitation to let outsiders in.”

Abbreviations: EMS, Emergency Medical Services; PCP, Primary Care Provider.

Theme: Building Policy Awareness and Assessing Local Needs

The focus group discussed strategies that worked in their own communities or in their work within rural communities. Participants suggested identifying a community health champion, conducting a needs assessment before any proposed intervention, elucidating local needs and intervention goals, and leveraging any existing relationships within rural schools and communities to facilitate trustbuilding. One rural school nurse shared ways they engaged with a local health champion to implement a program:

“We have one provider in our community, one nurse practitioner in [town]. .. Many of our students go to her as their provider. And so, for me, that was just the most natural person to go to. She already has a vested interest in our community, in our students’ lives. .. she was very, very open and just very willing to come alongside me as I figured it out and to make it possible.”

Participants also stressed the importance of conducting a needs assessment before intervention implementation. A rural school nurse described how a needs assessment can be challenging in rural schools owing to the lack of health infrastructure. They explained identifying gaps in knowledge and resources among school staff, many of whom are not medically trained, is often helpful:

“It may even be difficult though for a school to even know that this is a need, especially if there is not a school nurse on site. Secretaries or those school health aides, as we would call them, the secretaries that would be there caring for students, they’re not going to know about albuterol being a necessity for those who are needing it, you know, in an emergency. I think it also goes a little deeper too, that maybe there’s a need that they don’t even know that it’s a need.”

Understanding gaps allows engagement strategies to focus on training and supporting nonmedical school staff, ensuring confidence in recognizing respiratory distress, and administering inhalers. By assessing local challenges through a collaborative approach, programs can meet the needs of rural schools.

An effective way to increase awareness is targeting leadership to relay key messages. Three participants agreed that gaining a leadership buy-in is a helpful initial strategy so messages about policies and health concerns come from trusted leadership sources; one government organization representative stated:

“I think the most effective way to demonstrate disseminate information has always been from the top down from a leadership position or another word I’m thinking of—responsibility… So, instead of starting with the, let’s say, worker bees, let’s go up to the top and like the doc was saying, can we start with the superintendents? Can we start at the health department?”

To summarize, knowledge dissemination can be difficult in rural areas, partly owing to reliance on nonmedical staff for health responsibilities. Therefore, it is important to leverage existing relationships and understand local needs to identify unrecognized gaps and tailor support accordingly, especially for school staff who have not received clinical training.

Theme: Building Rapport and Support for Rural School Programming

Establishing a trusting relationship with rural school representatives and/or community members is essential when building rapport and support for rural school programing. Although building trust de novo is possible, it can be time consuming and requires persistence. An academic researcher shared their experience:

“I just like personal relationships, and I would hope that could be incorporated somehow … it’s time consuming. It can get there, but I really think it’s getting in and doing it personally … that is the key to getting that done, is that they trust, they begin to trust you. Anybody could write an email, anybody can text, but where is it really making that hit?”

Building trust involves personalized, empathetic communication that shows respect for local values. The researcher continued:

“I think what had always worked for me is to really personalize it … In rural areas, they’re very sensitive to, I think, the feelings of others … when you trust, it makes a big difference.”

Participants agreed personal storytelling is a powerful method to express need because this can resonate more deeply with partners than presenting a case for programming on the basis of data alone.²⁶ It also serves as a dual purpose of trust-building by showing up consistently and indicating the need with persistence. A government representative described the power of storytelling compared with sharing statistics:

“If there is a story, not that you want to bring in negativity, but if there’s an urgent problem, sometimes they relate best to a story… they were going to throw data out to a lot of the different districts and communities, but data isn’t going to strike the heart as much as a story.”

Another key component of building support is listening. Even if all suggestions cannot be acted on, respectful acknowledgment of different viewpoints sustains collaboration:

“The key point for me is … collaboration, teamwork, and getting everybody’s thoughts together… not that you’re going to necessarily do everything everybody wants, but you’ve got to listen. That’s what pushes forward rather than just ignoring or sending them off like that’s not important. You have to hear everybody.”

Lastly, participants identified common communication pitfalls to avoid, particularly making assumptions of shared knowledge. School personnel may not initially see the relevance of health programs until clearly framed:

“Sometimes schools don’t fully understand the need for these programs until you explain it in very practical terms.”

Trust-building, storytelling, active listening, and clear education can help gain long-term support for rural school health programs.

Theme: Unique Considerations for Rural Schools

Rural schools have unique characteristics that both facilitate and hinder the implementation of asthma management programs. Participants described these schools as tightly knit communities with a strong sense of responsibility to students. One government representative noted:

“They feel even more concerned about the welfare of their students, they most likely have to address the issue on site.”

However, participants also discussed that rural schools may exhibit a degree of insularity and resistance to change, which can be challenging for external interventions. One academic researcher stated:

“The relationship building in rural [communities] is an absolute. There’s a lot of hesitancy for change.”

Another consideration for rural schools is limited health infrastructure. Many rural areas are a long distance from hospitals and have limited primary care and subspecialist physician access. This reveals the urgent need for school health programs such as stock inhalers. As 1 rural clinician explained:

“In our community, there definitely is a need. And part of that need comes from the fact that … there are fewer physicians, and so fewer nurse practitioners, fewer health centers. So even if a child was diagnosed accurately by the school nurse, getting them into a physician, whether it’s a primary care doctor or specialist, takes months.”

Next, focus group participants discussed ways stock inhaler programming could feasibly function in rural schools, which have been classically slow to implement these programs. One of the most common barriers was the lack of health care workers in schools (n = 4), specifically the absence of school nurses:

“Some very small school districts don’t have school nurses at all, but they rely on health aides, which often are the school secretary or other people who have to give their consent to perform these sorts of medical procedures.”

Participants also described the difficulties in obtaining a standing order from a physician (n=3) and obtaining stock inhalers from a pharmacy (n=3). A school nurse described:

“A barrier, as [Speaker] mentioned, for me and implementing the albuterol in our school was finding someone to sign the prescription for us to be able to implement.”

Liability concerns were raised by school administrators and health care providers (n=3). A superintendent described the issue:

“The other thing that my administrators are going to ask is, has anybody talked to my lawyers or my liability insurance?. .. if rookies are administering something medical, what liability am I stepping into?”

A rural clinician emphasized the systemic challenges of implementing such policies, citing resource constraints and lack of detailed guidance:

“It’s not so much that physicians are not willing … when we implement laws like this, you’re asking everyone to do more with less … it doesn’t get into the very detailed specificity of exactly what you’re saying. Who’s going to write the prescriptions? Who’s going to provide it? Is there a grassroots organization that we can pair with, which in this case with the inhaler there is, which is fantastic. Who’s going to help us implement these in schools? Who’s going to educate? Who’s going to farm out the time at each individual school to do this?”

These findings show a comprehensive support system is needed to address the human and resource-related challenges of starting a stock inhaler program. The lack of health care workers in schools, along with the scarcity of physicians, is of ongoing concern in rolling out a new school health program.

Rural School Engagement Strategy

The rural school engagement strategy (Fig 2) was developed to address the unique challenges of implementing health policies in rural communities. This focus group-informed strategy outlines six key steps, each ensuring successful implementation through community collaboration and trust-building.

Figure 2.

Rural engagement strategy. EMS, Emergency Medical Services; ER, emergency room.

Step 1. Identify Key Local School Health Champions

Focus group participants shared external interventions often face resistance in rural communities unless efforts are rooted in trusted relationships. This step responds to those concerns by identifying school health champions who already have strong credibility within their communities. Their involvement helps legitimize and align policies with the local context.

Step 2. Engage and Partner With the Local Health Champion(s)

This step formalizes collaborative conversations with the health champion. Participants shared schools are more receptive when approached by someone they already trust. Therefore, it is important program representatives build authentic partnerships with champions. Engaging them in coplanning helps make the intervention a local effort and not an external imposition. It may also change the intervention entirely so that it best aligns with community needs. Lastly, this step leverages the champion’s status and relationships by having them lead outreach to schools.

Step 3. Conduct a Community-Led Needs Assessment

Participants agreed rural schools differ widely in staffing, infrastructure, and readiness to implement health policies. They emphasized the need for flexibility and data that reflect each community’s priorities and capabilities. This step ensures engagement is datadriven, appropriate, and not based on assumptions.

Step 4. Create a Tailored Approach Based on Specific Rural School Barriers and Resources

The focus group highlighted the importance of addressing a new policy’s relevance, benefits, and local challenges. This step creates trust and transparency with school personnel by showing a shared understanding of the community and offering solutions for specific barriers. For example, the absence of health care workers in schools can be mitigated through flexible, online training programs. Challenges obtaining prescriptions can be resolved by partnering with local pharmacies or health departments. Providing solutions helps school personnel understand the practicality and feasibility of the program.

Step 5. Guided Implementation of Health Policy and/or Protocol

Participants indicated school personnel often feel overwhelmed by new program implementation, especially given limited time and staffing. They stressed the value of having a clear, step-by-step implementation framework. This step addresses this finding by providing schools with toolkits, templates, and flexible protocols to reduce burden and promote action while also welcoming collaboration to finalize key aspects.

Step 6. Ongoing Support and Evaluation

The final step addresses the importance of sustainability in school health policies. A key focus group finding was the importance of building long-term relationships and revisiting community needs over time. Beyond initial implementation, better sustainability can be achieved by continuing to foster close relationships with the community and providing continuous support. This includes regular checkins, provides space for schools to voice new challenges or priorities, and includes a plan for continuous evaluation and adaptation with the program representative(s).

Discussion

The results of this qualitative study on rural school engagement in the context of school-based asthma management and stock inhaler programming show the necessity of tailored approaches in rural school health policy implementation, when unique barriers and community characteristics can influence the effectiveness of such programs. First, we identified three areas as crucial to successful engagement: identifying local needs and raising awareness, building community trust and support, and addressing the unique structures of rural school systems through collaborative multilevel programming. Second, this study indicated the best methods to communicate and engage successfully with rural schools to ensure programs can be implemented and function successfully in high need areas.

Often, rural communities operate within a context of limited health care access, geographic isolation, and resource constraints, which complicate asthma management efforts.^27,28 The focus group revealed substantial barriers including the shortage of healthcare workers in schools and resource constraints. Rural schools may lack school nurses and rely on nonmedical staff to handle health-related issues. This presents challenges for stock inhaler programs, in which administering inhalers requires training, confidence, and liability coverage. Despite barriers, multi-level approaches that address policy, school-level infrastructure, and community partnerships can provide solutions.^28,29 These include flexible training options, access to resources, legal protections for school staff, and collaboration with local healthcare providers.³⁰ Programs such as the School-Based Asthma Management Program and Resources for Every School Confronting Unexpected Emergencies are examples of successful multifaceted approaches.^31,32 These programs, which provide resources and guidance, have increased stock inhaler program implementation in high-need participating schools and show potential in improving asthma health outcomes for rural children.

Engagement with rural schools begins with understanding awareness and local needs. Conducting an initial needs assessment helps identify context-specific barriers, facilitators, and engagement strategies. Several participants also suggested working with community health champions, individuals who already hold influence and trust in the community, is effective. Supporting research has previously found community-based interventions are more successful when local leaders advocate and lead efforts.³⁰ Champions bridge communication gaps and frame the programs on the basis of community needs. Participants also recommended top-down messaging so health policy information is shared by trusted leadership figures. Many participants also shared how important flexibility is in program implementation, given many rural school leaders juggle multiple responsibilities and face time constraints. A thoughtful engagement approach respects these constraints and provides clear guidance, technical assistance, and scheduling flexibility.

Another important component of successful policy implementation is the way support and rapport are built with rural schools. Trust-building and relationships were described as essential and often required time and consistency. Moreover, pairing storytelling with data was identified as an effective way to build support for the program. Hearing personal stories about students with asthma, especially when rescue inhalers were not available, gave emotional weight, and often were more effective than presenting statistics. This is supported by studies reporting the impact of storytelling in the health policy-making process.^26,33 Participants also noted actively listening to community concerns, even if not all can be addressed, is effective in building rapport. Finally, participants gave suggestions to avoid common communication pitfalls. They shared school leadership may not always be aware of the need for programs until it is clearly explained. Offering direct explanations and being respectful in communication help build support for policies such as stock inhaler programs.

This study has several limitations. First, because only a single focus group was conducted, the sample size is small and may not represent the full range of rural school perspectives. Opinions from parents, students, and school board members were not included. Second, in a group setting, it is important to acknowledge the possible bias in participant responses. Given snowball sampling was used and some participants knew each other, responses may have been shaped by social desirability or specific personal experiences. Future research should include a larger sample across different rural regions and school roles. Moreover, quantitative data on engagement strategy outcomes can help validate and expand on the findings of this study.

This study provides a strategy for identifying solutions to overcome structural and resource-related barriers challenging rural school program implementation using a tailored, community-centered approach. School health programs can be better designed and sustained by beginning with local needs assessments, building trust and rapport, and addressing unique constraints of rural schools. Next steps will evaluate our rural engagement strategy’s effectiveness through pilot programs and assess long-term outcomes of asthma management initiatives in rural schools. Policymakers may consider implementing structured training for nonmedical school staff, legal protections for school personnel, and funding resources to address the shortage of health care professionals. This contributes to the growing literature on adaptable community-based solutions to address health disparities in rural schools and offers solutions for sustainable policy implementation.