School Nurses' Perspectives on Components of Asthma Programs to Address Pediatric Disparities

Abstract

Objective

To use a community engaged, collaborative approach with school nurses working within an urban community, to develop recommendations for future school-based interventions targeting pediatric asthma disparities.

Methods

Open-ended survey data were collected from 33 nurses (77% of nurses in the school district) during a face-to-face monthly health services meeting. Questions asked nurses to estimate the proportion of students with asthma with the necessary forms and medications at school and to describe perceived barriers to having such forms and medications, and potential initiatives that could be implemented. A 30-min asthma education class was also piloted with school nurses, who then rated its acceptability and feasibility. Open-ended survey data were analyzed using thematic analysis.

Results

Nurses estimated that 12% of students with asthma had an asthma action plan, 19% had a medication release form, and 15% had medications at school (i.e. inhalers). Four themes emerged regarding barriers to asthma management in schools and strategies for promoting asthma management in schools: coordination of care, asthma education, access to care, and medication adherence. Nurses noted the need for education focused specifically on teaching inhaler technique, and better communication between schools, providers, and families.

Conclusions

School nurses provided valuable information regarding specific barriers, as well as approaches to addressing these barriers in a future intervention. Findings suggest that a school-based intervention needs to address coordination among schools, parents, and medical providers, and will be optimally effective if it also addresses structural barriers.

Introduction

Pediatric asthma prevalence and morbidity rates are disproportionately higher for children living in lower-income and urban communities than children living in higher income, non-urban areas; rates are also higher among Black and Latinx children compared with non-Latinx White children (Akinbami et al., 2012). As children spend much of their day at school, efforts focused on optimizing school nurses’ abilities to coordinate care are critical to minimizing pediatric asthma disparities. Moreover, schools in lower income, urban areas serving children from predominately Black and Latinx backgrounds tend to have higher needs and fewer resources than schools serving predominately non-Latinx White children in higher-income settings (Owens & Candipan, 2019). Thus, children attending lower-resourced schools might have higher needs to begin with, further highlighting the importance of intervening in these settings. Evidence-based interventions have been implemented in school settings; however, to maximize impact, research has indicated interventions need to be adapted for different communities (Browson, Baker, Leet, Gillespie, & True, 2010). For instance, capacity and funding issues might limit feasibility, or protocol components might not be acceptable to a specific community (Lara et al., 2011).

Engaging community stakeholders (e.g. residents, school nurses, healthcare providers) is critical to ensuring that interventions fit the specific community they target and thus, are more likely to be sustained (Kilbourne, Switzer, Hyman, Crowley-Matoka, & Fine, 2006). The current study used a community-engaged approach and worked collaboratively with school nurses to enhance understanding of the ways in which school-based intervention components could be optimized in a local school district. The particular school district in which this work was conducted is comprised of older buildings, with mold and rodents present, and “substandard conditions” (Truong, 2019). These poor conditions heighten stressors within an already challenging school environment with competing priorities for staff, funding, and student learning. Moreover, the limited resources, and legacy of neglect of basic environmental and educational standards, have led stakeholders to mistrust leadership’s ability to improve conditions. Taken together, these factors suggest that the readiness of schools to integrate existing asthma programs into already under-resourced settings must be evaluated, with particular attention paid to the important perspectives of relevant local stakeholders. Moreover, our prior work has suggested that in this school district, parents have concerns about school nurses’ abilities to provide adequate asthma care (Everhart et al., 2020).

Previous research has evaluated school-based programs that aim to reduce pediatric asthma disparities. For instance, the school-based asthma therapy (SBAT) program, which targets children living in urban settings at high risk for asthma morbidity, involves school nurses administering daily preventive asthma medications (i.e. controllers). SBAT also includes a home-based environmental tobacco smoke reduction program with a motivational interviewing approach (Halterman, Borrelli, Fisher, Szilagyi, & Yoos, 2008). Elementary students in SBAT experienced more symptom-free days, compared with a control group, as well as fewer missed school days (Halterman et al., 2011). A study using the SBAT medication administration component in an urban school district found improved asthma control and reduced asthma-related healthcare utilization among participants (Allen, Arcoleo, Rowe, & Long, 2018). A limitation of SBAT, however, is that the medication administration component is only effective if the proper forms and medications are available in the school nurse’s office.

Recently, two school-based programs focused on children at high risk for asthma morbidity were implemented on a wider scale. In the first, a randomized controlled trial (RCT) of a school-based asthma program [the Supervised Asthma Medicine in Schools (SAMS) program] demonstrated feasibility, but failed to improve asthma control in a sample of 393 Latinx elementary age students from low-income backgrounds (Gerald et al., 2019). SAMS was originally developed and tested in African American children with asthma (Gerald et al., 2009). In this program, use of inhaled corticosteroids was observed by study staff at a regular time each day at school. Staff also ensured that children used the inhalers correctly. In the RCT, children in SAMS were compared with children with usual parent- or self-supervised medication use at home. The observed lack of effect in this RCT might be attributable to other factors (e.g. social, environmental) that differed across samples and communities (Bruzzese & Kattan, 2019).

A second study developed and tested the Building Bridges Program in a sample of 463 elementary and middle school students (approximately 70% Latinx, 20% African American) from two urban communities (Szefler et al., 2019). Building Bridges combines two existing asthma programs, the school-centered Colorado Step-Up Asthma Program (Liptzin et al., 2016) and the provider-focused Easy Breathing Program (Cloutier & Wakefield, 2011). In the Building Bridges trial, school nurses identified students at risk for poor asthma control, and provided tailored asthma education, inhaler technique coaching, and coordinated care between families and health care providers. Students in the program experienced a 22% decline in school absenteeism and improvements in asthma control (Szefler et al., 2019). This study demonstrates the potential effectiveness of implementing a comprehensive, organized program within schools.

Together, these studies suggest that school-based interventions show promise in promoting asthma management. However, little research has focused on the sustainability of these interventions once research support is withdrawn. A recent systematic review of the sustainability of public health interventions in schools, for example, has demonstrated that few evidence-based programs are sustained in their entirety (Herlitz, MacIntyre, Osborn, & Bonell, 2020). This is likely related to challenges such as limited resources, competing school priorities, and a lack of full-time (or even part-time) nursing staff that may affect the sustainment of interventions (Bruzzese, Evans, & Kattan, 2009). Moreover, programs can place a significant burden on school nurses, a group already managing multiple demands on their time with extremely limited resources. Accordingly, it is important to gauge school engagement and readiness to implement programs at the local level, especially among stakeholders most integral to their success, such as school nurses.

Translating research, such as results of existing evidence-based programs, into real-world practice, is best achieved through a community-engaged approach that highlights the perspectives of local stakeholders (Woolf, Zimmerman, Haley, & Krist, 2016). The views of local stakeholders can be gathered through focus groups, surveys, advisory board meetings, or qualitative interviews as part of the research process. A recent community needs assessment in an urban, northeastern setting identified school asthma triggers and school personnel training as key themes, based on focus group and key informant interviews that included school nurses (Bryant-Stephens et al., 2019). Surveys have also been used to assess school nurses’ perspectives in improving asthma management within schools. In an online survey, nurses in Chicago Public Schools identified time and lack of communication with providers as their greatest barriers to asthma management (Pappalardo et al., 2019). Results of a related online survey from the National Association of School Nurses indicated that nurses reporting more barriers to asthma management were also more likely to report implementing fewer asthma-specific management behaviors (Quaranta & Spencer, 2016). Despite this prior research with school nurses, there remains limited understanding of nurses’ perceptions of the feasibility and acceptability of asthma interventions in schools serving children most at risk for poor asthma outcomes.

Current Study

Given the pernicious persistence of pediatric asthma disparities, there remains an urgent need to enhance understanding of the optimal strategies to address this serious health concern (Lara et al., 2011). Our study used community engagement with key stakeholders, school nurses, as a first step in the development of an intervention to minimize asthma disparities. The current research asked school nurses their opinions about the relative feasibility of specific intervention components in their schools [e.g. SBAT, American Lung Association’s (ALA) asthma education program]. This information will inform the tailoring of existing evidence-based school interventions for students with asthma in this community. Thus, in the current study, we used a community-engaged approach to assess school nurses’: (a) experiences with children with asthma in their schools and (b) thoughts about potential strategies to improve asthma management within their school setting. We also asked their views on elements of existing interventions in order to begin developing a sustainable, school-based intervention in this district.

Methods

This study was approved by the Institutional Review Board and was part of a larger community needs assessment focused on refining evidence-based interventions in developing an asthma program for an urban community in the southeastern United States (Everhart et al., 2020). This study includes findings from school nurses from the public-school system targeted in the needs assessment. This city was selected given its high rates of both asthma prevalence and child asthma hospitalizations. This school district serves over 25,000 students: 66% identify as African American/Black, 17% as Latinx, and 75% of students receive free or reduced lunch. Most schools in this district (85%) are Title 1 and receive federal funding.

Stakeholder building

In order to support nurses’ future engagement with school-based interventions, it was important to first build a relationship with the local school board and its health services department. Initial stakeholder building involved a series of meetings with the school district’s leadership team. In these meetings, the research team presented the study’s focus to leadership and worked collaboratively with the district to determine the optimal implementation approach to maximize benefit for both school nurses and students with asthma. Following approval from the leadership team, the researchers met with the health services department to develop a partnership that would allow the research team to attend school nurse meetings and interact individually with school nurses across the district. This collaboration evolved over a series of regular meetings and phone calls and has enabled a sustainable partnership focused on addressing asthma in the school district.

Procedures

This study used a two-step methodological approach. First, survey data (including open- and closed-ended questions) were collected from school nurses during a face-to-face monthly health services meeting. This district engages school nurses through a pre-established monthly meeting. All nurses (43 in total), across the district are invited to attend this meeting. Nurses in attendance that day (33 of the 43) completed a 15-item questionnaire. Eleven items from the questionnaire were relevant to the current study and asked nurses to estimate the percentage of students with asthma who had the necessary forms and medications at school, and to describe perceived barriers to students having the appropriate forms and medications at school. Nurses also responded to questions about the relative feasibility (for their school environment) of initiatives such as the medication component of SBAT, asthma education programs, and standardized asthma protocols for school nurses. Open-ended items asked nurses to describe perceived barriers to students having appropriate forms and medications at schools, ways in which they believed they could be helped to ensure students had the appropriate forms and medications, and what parents should know about improving their child’s asthma care at school.

The community-engaged team (asthma and health disparity researchers, a pediatric pulmonologist, a school nurse, and a parent advisory group) developed the survey items using a socio-ecological framework (McLeroy, Bibeau, Steckler, & Glanz, 1988; see Supplementary Table 1 for included items). Moreover, we tailored the open-ended items to focus on barriers to “appropriate forms and medications at school” as this was consistently identified by community stakeholders as a major challenge for nurses in this school district (Everhart et al., 2020). Doing so provided a more nuanced understanding of barriers to this specific component of school nurse care and ways to minimize such barriers. Nurses completed the questionnaire anonymously; no demographic information was collected about respondents to protect confidentiality further. Most nurses in this school system are Registered Nurses. When completing the survey, nurses were asked to think about the school in which they spend most of their time.

After administering the questionnaire, we piloted a 30-min asthma education class based on ALA’s Asthma Basics course (ALA, 2019). This brief intervention was delivered by a pediatric pulmonologist and included a basic overview of asthma and its triggers, as well as an overview of asthma symptoms and medications. The ALA’s course was selected because it is one of the most commonly used curriculums addressing the components of asthma education as outlined by the National, Heart, Lung, and Blood Institute (NHLBI, 2007) and has been shown to decrease school days missed (Coffman, Cabana, & Yelin, 2009). In our study, it was important to determine whether school nurses would find the education useful in increasing their asthma knowledge, and be receptive to receiving more asthma education. Asthma education is linked to increases in nurses’ self-confidence regarding the provision of effective asthma care for students (Winkelstein et al., 2006). Post-test data consisting of an additional four items (see Supplementary Table 1) were collected to ascertain the acceptability of using components of an asthma education course, such as Asthma Basics, with nurses in this school district. Nurses rated how informative they found the class from 1 (not informative) to 10 (very informative), what new information they had learned, and whether they thought this education would be beneficial for nurses, other school personnel, and students. Nurses were compensated $25 for their time.

Data Analysis

Coding of the open-ended responses followed six steps for thematic analysis as described by Braun and Clark (2006) and was embedded within a socio-ecological framework (McLeroy et al., 1998). First, we became familiar with the data by reading and re-reading the open-ended responses and taking notes. Second, we developed initial codes from the data using open-coding. Third, we examined initial codes and searched for themes. Next (step 4), we reviewed the themes to ensure that they captured the data/initial codes and in step five, we further defined themes and created a thematic map (see Figure 1). The sixth step is to write up the findings. The first, second, and third authors (“analysts”) participated in this coding process and met weekly to discuss coding. Trustworthiness in this process was achieved through analyst triangulation, documentation of thoughts and notes, use of a coding framework, and team consensus (Nowell, Norris, White, & Moules, 2017). SPSS was used to generate descriptive statistics from the survey data. Results were synthesized by the research team to determine the optimal manner in which to tailor school-based interventions, with an emphasis on the needs of school nurses.

Figure 1.

Thematic analysis map: Emergent themes are circles and initial codes are in boxes. Note. Missing responses for the open-ended questions ranged from 0 to 5 depending on the item.

Results

Over half (58%) of the 33 school nurses completing the survey worked in elementary schools (see Table I). When asked to estimate the percentage of students at their school with asthma, the average response was 28% of students. Five nurses reported that 50% or more of students in their school had asthma. Nurses reported that on average, 12% of students with asthma had an asthma action plan, 19% had a medication release form, and 15% had their necessary medications at school. Almost half (n = 16, 48%) indicated that an SBAT-like program (i.e. administering preventive medications daily) would be feasible at their school and an additional 7 nurses responded “maybe.” Of the 10 respondents who answered “no,” two nurses commented, “parents should be doing this” and “parents need to be responsible for their child’s maintenance medication.” Other nurses stated, “only if they are chronic and need it daily, otherwise they miss too much time from class” and “sometimes students take inhalers and don’t need it.” With respect to the question about whether there should be a standardized protocol (i.e. set guidelines and procedures) for nurses to follow in response to asthma symptoms, 76% of nurses agreed. Three indicated that a set protocol was already in place at their schools.

Table I.

School Nurses’ Survey Responses

	N (%)
Nurse school level
Elementary	19 (58%)
Middle	5 (15%)
High	5 (15%)
More than one	3 (9%)
No response	1 (3%)
Estimated percentage of students
Have an asthma action plan?	M = 11.48% (SD = 11.71%); Median = 11.60; Range 1–50% No response: 2
Have a medication release form?	M = 16.71% (SD = 17.13%);Median = 16.92; Range 0–100% No response: 2
Have an inhaler at school?	M = 14.00% (SD = 14.36%); Median = 14.18; Range 1–50% No response: 4
Possible to administer daily controller medications at school?
Yes	16 (48%)
No	10 (30%)
Maybe	7 (21%)
Helpful to have a standardized asthma protocol to follow?
Yes	25 (76%)
No	0 (0%)
Maybe	2 (6%)
“Already in place”	3 (9%)
No response	3 (9%)

Open-Ended Survey Findings

Open-ended responses provided a more nuanced understanding of the reasons why so few students (less than one-fourth) with asthma were reported to have asthma action plans, medical release forms, or medication at school. Four themes emerged from the coding of the open-ended responses including: (a) coordination of care; (b) asthma education; (c) access to care; and (d) medication adherence. Open-ended questions specifically asked the nurses to describe barriers they encountered and what could help them ensure proper asthma management at school. Representative quotes are presented within the description of themes that follow and additional quotes are in Supplementary Table 2. Finally, the thematic map (Figure 1) illustrates which codes were included in themes and how each theme connects to others.

Coordination of Care

The most frequently reported barriers fell into the theme coordination of care (reported by 97% of nurses). This theme identifies points at which coordination of care breaks down, such as school nurses not having signed forms and medication, parents not having access to forms, forms with missing signatures, not seeing the doctor regularly, and communication breakdowns. For example, one nurse said that a barrier is, “Parents not following through and taking child to physician and not bringing signed form to school and giving it to nurse” Another nurse noted, “Forms are not available to them [parents] when they see a physician.” Overall, although nurses primarily identified barriers at the parent/family level, they shared strategies that parents, school nurses, and doctors could implement to coordinate care more effectively and ensure that children’s asthma is well managed at school. With respect to what nurses can do, one nurse said, “If aware of appointment date, I would provide the student the forms or instruct parents to get forms.” Some nurses also shared that being able to communicate directly with doctors could help ensure signed forms and medications were at school. One nurse noted, “I get a lot of forms with parent signature but no physician signature, which seems to be half of my battle. Being able to email a physician’s office the information and they being able to email us back.” Finally, nurses also shared strategies that doctors might be able to implement. A nurse shared, “Have doctor always write prescriptions for multiple inhalers, having the doctors’ offices already in possession of the various forms to do it, doesn’t require parent actually bringing the form in.”

Asthma Education

Many nurses expressed a need for more asthma education for children and parents (44% of nurses). Nurses emphasized the importance of both children and parents learning about the child’s asthma triggers and early warning signs. One nurse shared, “The importance of being able to pick up on early signs of an asthma attack” and another noted, “Know their child and know their triggers. So they can plan with us, so we know what to look for and tell administration and staff.” When nurses were specifically asked if children would benefit from instruction regarding proper inhaler use, 100% agreed. Nurses shared that children don’t often know how to use inhalers or spacers correctly (e.g. “Yes, they inhale too quickly. Do not wait between puffs.”). Moreover, nurses noted that education can help ensure medication is getting to the lungs and also emphasized that teaching children how to use inhalers/spacers properly is important because they likely see/feel the warning signs before others.

Access to Care

Although nurses primarily placed the responsibility of ensuring that signed forms and medication are taken to school on the parents, other barriers emerged that can contribute to a breakdown in coordination of care; this breakdown, in turn, can make it harder for school nurses to manage a child’s asthma effectively at school. For instance, an emergent theme was access to care (e.g. language, transportation, financial barriers; 38% of nurses). A nurse described, “language barriers (lots of Spanish-speaking students and even though I speak Spanish, the forms are not always in Spanish).” Parents also face transportation and financial barriers to accessing care that can make coordination of their child’s care difficult. For example, one nurse noted, “Parents have to pay doctors to complete forms and Medicaid doesn’t want to pay for the second inhaler.” Another shared, “parents with limited transportation to the doctor’s office.” Strategies to help address access to care barriers included having stock medication at school, decreasing financial costs to parents, ensuring forms are available in different languages, and a dedicated liaison to help get forms from home to school. For instance, one nurse shared, “If we had standing orders for asthma at school and also if students were provided medication at school via stock medication.” Another nurse shared, “Have doctors waive 10–20$fee and Medicaid to approve 2 inhalers at each refill, and spacers also available for home and school.”

Medication Adherence

Finally, nurses highlighted the importance of prevention and medication adherence (34% of nurses) in managing children’s asthma at school. For instance, one nurse noted, “Parents need to follow physicians’ orders more consistently at home to reduce episodes at school.” Another nurse shared, “Children need to follow the care plan provided especially if they need controller medication. It needs to be taken daily as ordered.”

Reactions to the Asthma Education Pilot

In the post-intervention survey, school nurses rated the informativeness of the presentation based on ALA’s Asthma Basics course as an 8.6/10. Specifically, nurses noted that they learned new information about using spacers and triggers of asthma symptoms. All but one nurse (96%) responded that asthma education would be useful for school nurses; 100% reported that it would be useful for students, and 93% reported that it would be useful for other school personnel. Five nurses did not respond to these asthma education questions.

Discussion

Our goal was to learn directly from nurses about the ways in which asthma management within schools could be improved to minimize asthma disparities, particularly among children living in low-income settings and in a school district with high rates of asthma morbidity. We used a two-step, community-engaged approach, which allowed us to identify both specific barriers to optimal care provision within schools, and factors causing and maintaining these barriers, from school nurses’ perspectives. Findings identified parent, nurse, and provider actions that could be implemented to improve coordination of care and minimize disparities. We also assessed nurses’ views about components of existing evidence-based interventions to identify the perceived acceptability and feasibility of specific approaches that could be implemented in future school-based asthma care programming.

Consistent with prior research (see Hanley Nadeau & Toronto, 2016, for a review), barriers to asthma management within schools that emerged in this study included challenges with coordinating and accessing care, a lack of asthma education, and poor medication adherence. The primary barrier that emerged was difficulty coordinating care, including nurses’ inability to provide appropriate care because they do not have the child’s medication and/or the signed required forms (e.g. asthma action plans, medication release forms). Importantly, nurses noted that parents were not solely to blame for this breakdown in care coordination. For example, school nurses noted that factors such as providers not writing a second inhaler prescription, providers charging for forms to be completed, providers not signing required forms, insurance companies not covering a second inhaler for schools, and forms not translated into Spanish for parents, further impeded optimal treatment in the school setting.

This study builds upon and extends our prior work, conducted in the same community (Everhart et al., 2020), which suggested that parents have concerns about the asthma care their children receive from school nurses. These data also extend existing literature on asthma management within schools by: (a) directly asking school nurses about the feasibility and acceptability of specific strategies in this community and (b) highlighting the need to implement comprehensive programs that facilitate partnerships across multiple sectors of a child’s daily life. Current findings suggest that systemic changes by multiple stakeholders (i.e. school nurses, parents, providers) are needed to facilitate better coordination of care, reduce access issues, and increase parent and student asthma education. Thus, even when an intervention is primarily school-based, current results suggest comprehensive interventions and policy changes that target multiple drivers of asthma disparities are necessary.

Given coordination of care emerged as the primary barrier, a necessary component of a developed intervention is an asthma liaison or navigator to help families navigate the healthcare system, connect nurses with primary care providers, and ensure that the proper signed forms and medications are accessible to nurses. Efforts of health navigators and liaisons have been shown to reduce health disparities (Rohan, McDougall, & Townsend, 2018). Bryant-Stephens et al. (2019) used a similar model with CHWs in their school-based pilot. Leveraging community partnerships might help in creating navigator positions that can coordinate care among family, school, and health settings.

Moreover, Hanley Nadeau and Toronto (2016) suggested that nurses might be in a unique position to serve as a liaison to coordinate care. However, school nurses in this role would need support from schools, families, physicians, and public health officials as they are already often overloaded with their existing responsibilities. Some nurses in this study shared that being able to communicate directly (e.g. phone, fax, email) with providers could help them ensure that the appropriate signed forms and medications are at school. Mobile technology or shared electronic platforms might also facilitate care coordination by making forms more accessible and more easily sharable across parents, nurses, and providers (Perry et al., 2016). Future research should consider directly evaluating school nurses’ perspectives on the feasibility and acceptability of integrating an asthma navigator or liaison into the school. It also seems important to assess nurses’ views about whether they are able and willing to serve in this role with appropriate support and funding. A model that uses existing school nurses as navigators might also lead to a more sustainable program within schools.

In this study, school nurses also identified the need for students to receive more education on proper inhaler technique. Children are typically taught how to use an inhaler at their prescribing provider’s office; however, this training is insufficient to meet the true educational need, according to the nurses in the current study. This finding is not surprising given that proper inhaler use is an ongoing challenge for many children, limiting the effectiveness of inhaled medication and negatively impacting asthma control (Roman-Rodriguez, Metting, Garcia-Pardo, Kocks, & van der Molen, 2019). A recent pragmatic trial of the Easy Breathing Program for Schools, a school nurse-led adaptation of the Building Bridges Program (Szefler et al., 2019), demonstrated that school nurses are in an ideal position to identify and target improper inhaler use (Simoneau et al., 2020). As part of the program, school nurses provided asthma education related to inhaler technique, which was then measured using the 5-item Inhaler Technique Checklist (ITC) (Cicutto, Dingae, & Langmack, 2014). The study found improvements in ITC scores over the intervention period; also, the inhaler technique component was the program element most liked by school nurses (Simoneau et al., 2020). Findings from the current study suggest that integrating inhaler technique teaching into school nurses’ current interactions with students might similarly benefit students in this school district. In fact, nurses might consider using the ITC with students and sharing results with providers; this would allow both providers and school nurses to continue to work with children as needed to improve inhaler technique and ensure the effectiveness of prescribed medications.

Nurses’ responses also reflected their own desire for additional education about asthma management. Specifically, most agreed that more asthma education for both nurses and school personnel would be useful. Most nurses also found the education provided in this study informative, and thought it would be of interest to other school nurses and personnel. Furthermore, over three-quarters of nurses thought a standardized asthma management protocol should be in place; (another 9% said such protocols were already in place in their schools). A standardized protocol is, in itself, a form of education, as it guides service providers in proper procedures. Given this relatively high level of interest in additional education, and in light of past research demonstrating the effectiveness of school nurse training on asthma management (Simoneau et al., 2020; Szefler et al., 2019), these areas seem like promising targets for future interventions. Future research is needed, however, to determine how best to implement and sustain asthma education in schools for nurses, students, and other personnel.

Interestingly, about half of the nurses in this study (48%) thought that the medication component of SBAT would be feasible in their schools and an additional 21% thought it might be feasible. Reasons given for the perceived infeasibility of SBAT in local schools (30% of nurses) included nurses’ beliefs that parents should be responsible for administering preventive medications. Responses also suggested that some nurses might not understand that controller medications are prescribed to be taken daily. Thus, more education might be needed for school nurses regarding how this specific component of SBAT would benefit students and allow them to receive optimal asthma treatment. This would likely be necessary prior to implementing an SBAT-like program for this school district. As previous work has highlighted (Bryant-Stephens et al., 2019), understanding the current needs of local stakeholders is important in building capacity for future, sustainable interventions.

Finally, it is important to note that in our sample, nurses estimated that about 28% of the students in their schools had asthma, which is higher than published asthma prevalence rates among children less than 18 years in the United States. Lifetime prevalence rates suggest that about 13% of all children have asthma, and approximately 17% of African American/Black children, with higher lifetime rates (16%) also prevalent among children living in poverty (Centers for Disease Control, 2017). Notably, about 15% of school nurses estimated that at least half of their students have asthma. This result might suggest that school nurses are seeing a lot of students with symptoms consistent with upper respiratory or breathing problems. Future school-based efforts might suggest policies for following up with parents if a school nurse notices breathing difficulties in a student without any health forms indicating an asthma diagnosis.

A few limitations of this study should be noted. First, while a strength of this study is hearing directly from nurses, it is also important to acknowledge that parent and provider perspectives are also needed in developing a comprehensive asthma program. In addition, some nurses in this district work in multiple schools. To reduce response burden on nurses, they were not asked to provide separate answers for each school but rather reported on the school in which they spend the majority of their time. Thus, we cannot determine if barriers varied by school. Moreover, we relied on school nurse estimates of the percentage of students with asthma and the appropriate forms/medications at school. Future work should use data gathered from school records in providing these estimates. Questionnaire data were also collected via free-text in a survey which did not allow the opportunity to clarify statements or ask relevant follow-up questions, as can be done in interviews or focus groups. Furthermore, to maintain nurse confidentiality, we did not gather any demographic information from school nurses. Thus, we are not able to place our results within the context of school nurses’ backgrounds, such as their degrees or familiarity with asthma. Although the participation rate was high, there may be a selection bias in that those nurses who participated might give different responses regarding feasibility of various interventions than those who did not attend the meeting that day.

Additionally, our study is limited by the open-ended items included on the school nurse survey that were primarily focused on medication access. Future surveys should include items related to other aspects of asthma care that could be the responsibility of school nurses. Moreover, our study did not address environmental factors within schools that can exacerbate asthma symptoms. Within the school environment, and especially in this school district with older buildings, children can be exposed to allergens, such as mold or dust. Interventions that reduce allergens within schools are an important future direction for many school districts (Jhun et al., 2017) and the ALA provides a toolkit to help schools create an asthma-friendly environment. For older schools, however, budgetary support from the local government might be needed to remediate allergens in certain built environments. Results of the current study are also specific to the urban school district that was sampled and, therefore, may not generalize to other urban settings.

Despite these limitations, this study has several strengths, including the inclusion of the vast majority of school nurses in this district (77%). Also, this district serves a student population at extremely high risk of asthma and its complications (Asthma and Allergy Foundation of America, 2019); thus, determining strategies to address these challenges within this population could have significant public health impact. Finally, this research was conducted in accordance with best principles for community-engaged scholarship (Israel, Eng, Schulz, & Parker, 2005), and investigated local stakeholders’ perspectives on the most important issues that need to be addressed to facilitate effective school-based asthma management. District-specific perspectives should be used to optimize implementation of future intervention efforts within this locality and in other urban settings. It is likely that components of existing interventions, such as SBAT (Halterman et al., 2008) or the Easy Breathing Program for Schools (Simoneau et al., 2020), could be refined and adapted to meet the needs of schools and their available resources.

Supplementary Data

Supplementary data can be found at: https://academic.oup.com/jpepsy.

Funding

Research reported in this publication was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number U34HL130759 to R.S.E. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Conflicts of interest: M.S.S. reports personal fees for a Data Monitoring Board from Astra-Zeneca, honorarium from GlaxoSmithKline, and research support from Mylan Pharmaceuticals and Translate Bio, Inc. No other authors have financial interests to disclose.