Nurse Perspectives Regarding Implementation of an Asthma Monitoring Mobile Health Application in the School Setting

Abstract

Background: School-based telehealth (SBTH) plays a valuable role in child asthma management, although nurses have concerns with caregiver engagement. Mobile technology (m-health) has potential to improve this engagement.

Objective: We identified barriers and key desired features of an asthma m-health application as a supplement to an existing SBTH asthma program in rural settings.

Methods: Multimethod design using school nurse surveys and interviews with school and SBTH personnel to describe processes related to implementation of an m-health application.

Results: Nurses reported SBTH programs were an ideal setting to identify potential families for m-health. Benefits of caregiver education and engagement and barriers related to technology, smart phone data availability, and family buy-in were described. Desired application features included education on inhaler technique, asthma symptom, and medication adherence reports.

Conclusions: The feedback identified from nurses can be incorporated into an asthma m-health program within an SBTH program to facilitate implementation.

Introduction

Children residing in rural areas often experience barriers to asthma care.¹ Although pediatric asthma previously disproportionally affected children in urban settings, recent studies show asthma prevalence in rural areas to be similar to urban areas.^2,3 Owing to fewer primary care physicians in rural areas, children in these regions often have lower accessibility to clinicians and are less likely to receive guideline-recommended asthma care.⁴ Children living in rural areas with persistent or uncontrolled asthma are more likely to overuse rescue medications and underuse controller medications, leading to poorer health outcomes.^5,6

The school setting is ideal to address health care-related barriers that children face, particularly for children residing in rural and under-resourced areas. Through school-based telehealth (SBTH) programs, children in rural schools can receive asthma management as well as education related to health conditions during the school day. School nurses are the cornerstone to SBTH programs. They serve as frontline providers identifying students, providing asthma education, and giving rescue medications during exacerbations. SBTH services for chronic pediatric diseases such as asthma have been endorsed by the American Academy of Pediatrics.^7,8 One study showed that when an SBTH asthma program was implemented in a rural community, there was an overall decrease in emergency department (ED) visits.⁹ Another SBTH program caring for 400 children with asthma showed an increase in symptom-free days and fewer hospitalizations and ED visits.¹⁰

Although evidence has shown that SBTH asthma programs are beneficial to the children they serve as well as the community,^9,10 caregiver engagement has been demonstrated as a barrier to full uptake of these programs.^11–13 Mobile health (m-health) can potentially improve caregiver engagement and education and thus outcomes of these programs,^14–16 yet there is minimal knowledge and guidelines for the ideal approach to implement and incorporate m-health into existing SBTH programs. The objective of this study was to determine perceived acceptability of an asthma m-health application to be incorporated with an existing SBTH asthma program and key desired features and barriers to implementation of this novel application.

Materials and Methods

Study Design

This multimethod study was conducted as part of a larger study examining telehealth implementation experiences. This specific study component utilized web-based surveys of school nurses and interviews with school personnel and an academic medical university telehealth team (“telehealth team”). The study was deemed quality improvement and did not require institutional board review.

Survey Participants and Methods

Surveys were e-mailed to a total of 53 elementary school nurses in schools with a telehealth program in South Carolina. The schools were located in a variety of geographic regions, including rural areas. A subset of 26 school nurse participants at schools specifically providing asthma care telehealth services completed an additional six-item survey regarding the possible implementation of an asthma m-health application into their existing SBTH program. Surveys assessed perceptions about whether the school setting can identify families for an m-health program (yes/no), and about family technology access (cellular, Wi-Fi, and smartphone access; yes/no). Respondents also reported perceived student and family interest in six m-health application features (1 = not at all interested to 5 = extremely interested). The survey was sent to the nurses in a web-based platform using Research Electronic Data Capture. The survey was open 5 weeks (November 11–December 16, 2019) with weekly reminders sent out to nurses. A gift card valued at $10 was sent electronically to the nurses who completed the survey to compensate them for their time.

Survey Analysis

Descriptive statistics were used to report nurse characteristics and survey responses. All analyses were performed using Statistical Analysis Software (SAS version 9.4).¹⁷

Interview Participants and Methods

The Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist guided qualitative methods and report of results ((Appendix Table A1).¹⁸ A total of nine interviews were conducted with SBTH asthma program champions in nine South Carolina schools through telephone (October–December 2019). Schools with established SBTH programs for at least 1 year were purposively selected for invitation based on variability of time utilizing the SBTH program and productivity of telehealth visits (number of visits completed during current school year). All school interview participants received a $50 gift card. In addition, two in-person small group interviews were completed with the telehealth team (February and September 2019). All interviews lasted 21–89 min and were conducted by two doctoral-level female qualitative researchers not involved in SBTH program delivery.

All interviews initially briefly described the m-health intervention as a smart phone application for children and families with specific features, including symptom tracking, medication management, education on proper inhaler technique, asthma reports, and the ability for families to join school-based visits through their smart phone. The discussion then probed for ways to identify families for this application and potential benefits and barriers. All interviews were audio-recorded and field notes were taken by the interviewers to track observations and reflections on theme saturation.¹⁹ Interviews were transcribed verbatim and NVIVO qualitative software was utilized for analysis.²⁰

Interview Analysis

A qualitative description approach^21–23 was used for this study following principles of thematic analysis²⁴ to identify, categorize, and contextualize patterns. Two independent coders read and re-read each interview transcript, assigning codes to text and grouping related concepts to reach thematic salience based on four a priori established code domains related to ways to identify families to utilize the application, potential barriers, and benefits to the application, and perceptions of acceptability of each family for utilization of the application. Rigor was assured using prolonged engagement with the data, debriefing across coders, an audit trail of the coding process, and team discussion to resolve discrepancies.^25,26

Results

Survey Results

Twenty-six respondents (49%) completed the survey (Table 1). Seventy-five percent of respondents felt the SBTH program was an ideal setting to identify families for an m-health asthma care program. Eighty-eight percent of nurses stated that most families and caregivers had cellular access, yet 46% of nurses reported that families were limited in their access to home Wi-Fi (Fig. 1). Nurses felt families would be extremely or very interested in the following mobile application features: video education on proper inhaler technique (40%), medication adherence tracking (36%), asthma symptom and medical adherence reports (32%), in-home assessment on proper inhaler technique (31%), and symptom tracking (31%) (Fig. 2).

Table 1.

Survey and Interview Participant Demographic Characteristics

VARIABLE	CATEGORY	STATISTIC	VALUE
Survey participants (n = 26)
Gender	Female	N (%)	25 (96)
Race/ethnicity	White, non-Hispanic	N (%)	21 (81)
	White, Hispanic, or Latino		0 (0)
	Black		5 (19)
Age	25–34	N (%)	4 (15)
	35–44		7 (27)
	45–54		10 (39)
	55–64		4 (15)
	65+		1 (4)
Time as a nurse	Years	Mean (range)	19.9 (2–40)
Time as a school nurse	Years	Mean (range)	8.2 (0–24)
Time in current school as nurse	Years	Mean (range)	5.4 (0–14)
Average number of asthma telehealth visits per month	0	N (%)	10 (39)
	1–5		12 (46)
	6–10		41 (15)
No. of students at school		Mean (range)	427 (90–860)
No. of students with asthma at school		Mean (range)	41 (5–150)
No. of students with asthma that nurse treats at school		Mean (range)	16 (1–50)
School interview participants (n = 12; 9 nurses; 2 teachers; 1 principal)
Gender	Female	N (%)	11 (92%)
Time in current position	Years	Mean (range)	6.0 (<1–10)
No. of students at school		Mean (range)	441 (196–646)
No. of students with asthma at school		Mean (range)	38 (5–60)
No. of students with asthma that school nurse treats at school		Mean (range)	23 (3–50)
No. of asthma telehealth visits; previous 6 months		Mean (range)	19 (0–42)
Telehealth team interview participants (n = 7; 3 physicians, 2 nurses, 1 respiratory therapist, 2 program coordinators)
Gender	Female	N (%)	7 (100%)
Time in current position	Years	Mean (range)	5.5 (1–7)

Fig. 1.

School nurse perception of students' internet capabilities.

Fig. 2.

School nurse perception about caregivers' interest in features for an asthma monitoring mobile application.

Interview Results

Nine schools in South Carolina already participating in the SBTH asthma program were included in interviews (Tables 1 and 2). Four of these schools were classified as rural.²⁷ Interviews with school participants ranged from 1 to 3 total participants. All interviews included the school nurse, two interviews included an elementary-level teacher, and one school interview included the principal, a total of 12 participants. There were two small group interviews with telehealth team members that included four and three participants, respectively. These telehealth team small group interviews included three physicians and one nurse program leader, respiratory therapist, and two program coordinators, a total of seven participants (Table 1).

Table 2.

Key Themes and Exemplary Quotes

KEY THEME	DEFINITION	TELEHEALTH TEAM QUOTES	SCHOOL NURSE QUOTES
Identification of families appropriate for mobile application	Suggestions for optimal strategies to identify students to use the mobile application	“I think it would just be wrapped up in this enrollment process [for the telehealth program], but it does require a little technical assistance.”	“…come from school nurses. When we have a lot of students—we have health information forms that are filled out at the beginning of every year …if students have any kind of medical diagnoses, so that's the start. You can see from those forms who has asthma, and so then you figure out who's having issues because they will come to you if they're having trouble. Then…start figuring out, this child has asthma but they don't have an asthma pump at home or they're not seeing their doctor….”
Mobile application benefits	Perceived benefits to implementing mobile application in school-aged children	“I've had some families that were fabulous and they popped right on and we talked to the kid and mom's in the background waving and it went very well…I love the idea of families being able to stream into the visit.”	“I think that would be awesome. I think that would be a really good way to involve the parents so they know what's going on…Most everybody has a smart phone now, and I think that would be a really good idea.”
Mobile application barriers	Perceived barriers and challenges to implementing mobile application in school-aged children	“I know that sometimes what they say is they don't have [cell phone] data…and maybe they don't have internet at home…” “That may be a challenge for people that aren't super technology-savvy. And we are finding a large number of our students are living with older relatives now and that's been an issue with senior citizens… navigating through an app into a chatroom has been something they couldn't do.”	“The population out here, there's a lot of older people…So, they're limited. It's kind of mix and match with who's going to have a smart phone, or even be able to get a signal on their phone. There are some young people that are young parents but they're going to work, so I don't know if they would even use it [the mobile application]. They pretty much get everybody else to take care of their kids when they drop them off at school. That's just the beast out here.”
Mobile application family acceptability	Impressions of family openness to taking on and using mobile application	“I mean after working with [similar programs] for a couple of years, I haven't had to convince anybody [to use it]. They are all excited about managing care where they are, being able to open their phone and text a question or be able to have somebody call them back.”	“I think it'll work…That's what they're using now. Technology is a big thing now; cell phones, iPads, iPods or anything with technology would be good because that's what they're using now. Anything that we could use that would relate to the children would be very helpful.” “Whether they would use it is up in the air, I don't know. When they tried to set up something similar for the parents to be getting grades sent to their smart phone, there was minimal parents that signed up for. Maybe they think that health is more important, so maybe it would be worth it, I don't know. I don't want to say it wouldn't work.”

Identification of Families for Program

Interviews highlighted the acceptability of utilizing an m-health application to engage families in school-based asthma care. Participants from schools and the telehealth team agreed that it was feasible to identify families for the mobile application program from existing school records (health history forms and students currently accessing care in the school setting).

Mobile Application Benefits

Primary benefits perceived by nurses included that an m-health application could help families and caregivers become more involved in asthma care by having a role in the patient visit and being able to receive more hands-on education for treatment modalities and medications. In addition, nurses reported families would have high comfort with technology as they typically utilize electronic devices in a routine manner at home so this type of mobile application would be a way to accommodate preferences of patients and families.

Mobile Application Barriers

Although the majority of potential families and caregivers were reported to own cell phones, limited cell phone data and lack of internet access were cited multiple times as potential barriers to participation. In addition, nurses reported that some potential student participants are primarily cared for by grandparents or older guardians, who may not be as technology-savvy, hence creating a barrier for participation.

Mobile Application Family Acceptability

There were mixed responses and perceptions from both the school champions and telehealth team on whether the families and caregivers would demonstrate buy-in and adoption of this application. Participants believed that some caregivers would download and participate with application activities to help support their child's medical needs. However, some families are continually challenging to interact with and are not engaged in school-based activities; thus, lack of participation by some families was believed to be a potential significant barrier to ongoing implementation (Table 2).

Discussion

SBTH programs have the benefit of providing health care to children in rural or underserved areas that may not otherwise receive care, although family involvement and engagement in telehealth services has been identified as a barrier to optimal uptake.^11,13 m-Health applications that can be utilized by patients and caregivers in the home can improve caregiver involvement in their child's health care, with the potential to improve asthma-related health outcomes.¹⁴ This study found that key stakeholders of SBTH were enthusiastic and supportive about the potential benefits of incorporating m-health to existing SBTH asthma programs.

Specifically, this study revealed ways to identify children for m-health program participation in schools, potential barriers to implementation of this program within the school setting, and key features to include in the m-health application. It was evident that m-health programs were considered acceptable to nurses based on their convenience and potential to benefit patients and families. However, without addressing caregiver and family buy-in and rural connectivity issues, these types of programs are unlikely to lead to widespread improvement in health outcomes, specifically in rural and underserved areas. There is a clear need to continue to design and test patient and family-centered interventions for common chronic disease, while simultaneously working to improve family engagement and connectivity and technological barriers. Redesigning health care interventions based on identified barriers and facilitators will aid in reaching as many patients as possible to address existing health disparities related to access to care.

There are numerous existing m-health applications related to health, yet research has identified that uptake of some programs has not been successful.²⁸ It is vital to identify patient and family m-health feature preferences to promote uptake and subsequent improved health outcomes.^29,30 Thus, when introducing the asthma care m-health application, providers can stress benefits of these features to patients and families to promote acceptability and utilization.

This was the first study to examine key stakeholder's perceptions of how mobile applications may integrate into school-based health care. Previous studies have shown the value of m-health in the care of pediatric asthma, also identifying similar barriers as this study.^14–16 Some of the key features that participants in this study noted for the m-health asthma care application: medication tracking, symptom tracking, video education of inhaler technique, and home assessment of inhaler technique, have been successfully utilized in other m-health applications to improve asthma-related outcomes.^31–33 In addition, a prior study identified that parents of children who receive school-based asthma care valued communication from the school and using a mobile application for asthma care may achieve this goal.³⁴ Finally, clinicians have previously noted similar concerns to implementation of mobile health regarding access to technology and smart phones.³⁵

There were a few limitations to this study. The study population was limited to nurses in South Carolina and a telehealth provider team at a medical university so results may not be generalizable across other states. Also, the perspectives of families and children were not included in the study, which may be important for next implementation steps.

Conclusion

This study combined perspectives of school nurses and the telehealth provider team to describe preferences about key features for an m-health application and implementation barriers for delivery within an SBTH setting. Asthma-based m-health applications may be a promising supplement for existing SBTH programs by potentially improving family engagement in school-based care while also improving access to care for populations in need.

Appendix

Appendix Table A1.

Consolidated Criteria for Reporting Qualitative Studies: 32-Item Checklist

		COMPLETED
DOMAIN 1: RESEARCH TEAM AND REFLEXIVITY
Personal characteristics
Interviewer/facilitator	Which author/s conducted the interview or focus group?	X
Credentials	What were the researcher's credentials? e.g., PhD, MD	X
Occupation	What was their occupation at the time of the study?	X
Gender	Was the researcher male or female?	X
Experience/training	What experience or training did the researcher have?	X
Relationship with participants
Relationship established	Was a relationship established before study commencement?	X
Participant knowledge of the interviewer	What did the participants know about the researcher?	X
Interviewer characteristics	What characteristics were reported about the interviewer/facilitator? e.g., bias, assumptions, reasons, and interests in the research topic	X

DOMAIN 2: STUDY DESIGN
Theoretical framework
Methodological orientation and theory	What methodological orientation was stated to underpin the study?	X
Participant selection
Sampling	How were participants selected?	X
Sample size	How many participants were in the study?	X
Nonparticipation	How many people refused to participate or dropped out? Reasons?	N/A
Setting
Setting of data collection	Where was the data collected? e.g., home, clinic, or workplace	X
Presence of nonparticipants	Was anyone else present besides the participants and researchers?	X
Description of sample	What are the important characteristics of the sample? Demographic data, date	X
Data collection
Interview guide	Were questions, prompts, guides provided by the authors? Was it pilot tested?	X
Repeat interviews	Were repeat interviews carried out? If yes, how many?	X
Audio/visual recording	Did the research use audio or visual recording to collect the data?	X
Field notes	Were field notes made during and/or after the interview or focus group?	X
Duration	What was the duration of the interviews or focus group?	X
Data saturation	Was data saturation discussed?	X
Transcripts returned	Were transcripts returned to participants for comment and/or correction?

DOMAIN 3: ANALYSIS AND FINDINGS
Data analysis
No. of data coders	How many data coders coded the data?	X
Description of the coding tree	Did authors provide a description of the coding tree?	X
Derivation of themes	Were themes identified in advance or derived from the data?	X
Software	What software, if applicable, was used to manage the data?	X
Participant checking	Did participants provide feedback on the findings?
Reporting
Quotations presented	Were participant quotations presented to illustrate the themes/findings? Was each quotation identified?	X
Data and findings consistent	Was there consistency between the data presented and the findings?	X
Clarity of major themes	Were major themes clearly presented in the findings?	X
Clarity of minor themes	Is there a description of diverse cases or discussion of minor themes?	X

Authors' Contributions

All authors have met the four criteria for authorship, as described by the journal.

Disclosure Statement

No competing financial interests exist.

Funding Information

This publication was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) as part of the National Telehealth Center of Excellence Award (U66 RH31458). The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by HRSA, HHS, or the U.S. Government.