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. Author manuscript; available in PMC: 2023 May 1.
Published in final edited form as: Pediatr Pulmonol. 2022 Feb 16;57(5):1214–1222. doi: 10.1002/ppul.25851

A response to COVID-19 school closures: the feasibility of a school-linked text message intervention as an adaptation to school-supervised asthma therapy

Juliana Arenas a,*, Sarah Becker a,*, Hannah Seay b, Christine Frisard a, Shushmita Hoque a, Michelle Spano c, Peter K Lindenauer d,e, Rajani S Sadasivam d, Lori Pbert d, Michelle Trivedi c,d
PMCID: PMC9018493  NIHMSID: NIHMS1776743  PMID: 35106970

Abstract

Background:

School-supervised asthma therapy improves asthma medication adherence and morbidity, particularly among low-income and underrepresented minority (URM) children. However, COVID-19-related school closures abruptly suspended this therapy. In response, we developed a school-linked text message intervention.

Objective:

The purpose of the study is to investigate the feasibility and acceptability of a school-linked text message intervention.

Methods:

In December 2020, children previously enrolled in school-supervised asthma therapy in Central Massachusetts were recruited into this school-linked text message intervention. We sent two-way, automated, daily text reminders in English or Spanish to caregivers of these children, asking if they had given their child their daily preventive asthma medicine. Our study team notified the school nurse if the caregiver did not consistently respond to text messages. School nurses performed weekly remote check-ins with all families. The primary outcome of the study was feasibility: recruitment, retention, and intervention fidelity. Secondarily we examined intervention acceptability and asthma health outcomes.

Results:

Twenty-six children (54% male, 69% Hispanic, 8% Black, 23% White, 93% Medicaid insured) and their caregivers were enrolled in the intervention with 96% participant retention at six-months. Caregiver response rate to daily text messages was 81% over the study period. Children experienced significant improvements in asthma health outcomes. The intervention was well accepted by nurses and caregivers.

Conclusion:

A school-linked text messaging intervention for pediatric asthma is feasible and acceptable. This simple, accessible intervention may improve health outcomes for low-income and URM children with asthma. It merits further study as a potential strategy to advance health equity.

Keywords: Asthma, school health services, medication adherence, text messaging, COVID-19, Asthma & Early Wheeze, Social Dimensions of Pulmonary Medicine, school health, under-resourced populations

Introduction

Asthma disproportionately impacts low-income and underrepresented minority (URM) populations, with most of the morbidity in these populations attributed to underuse of a daily preventive inhaled corticosteroid 1–15. School-supervised asthma therapy is a strategy which has been shown to improve adherence to this medication in research settings 16–18. The Asthma Link program is an ongoing real-world application of this strategy that predominantly serves children of low-income and URM backgrounds in Central Massachusetts and has been shown to decrease asthma-related emergency department (ED) visits and hospital admissions 19. In the spring of 2020, due to COVID-19, many schools across the United States and abroad transitioned to remote learning, with school closures disproportionately impacting children from low-income and minority backgrounds 20; 21. As a result, children in our Asthma Link program could no longer receive their asthma medication at school each day as intended, leaving many families isolated and charged with managing asthma care alone.

To fill this gap in school-supervised asthma therapy during COVID-19 school closures and to ensure access to care for the population served by the program, we developed a bilingual, school-linked text message intervention to support medication adherence. The primary purpose of this study is to evaluate the feasibility and acceptability of this school-linked text message intervention.

Materials and Methods

This was a feasibility study to assess the ability to 1) recruit and retain participants in the intervention for six months, 2) send two-way, bilingual, daily text message reminders to caregivers of children with asthma and monitor caregiver response rate to text messages, and 3) link text message responses to schools through research staff emails and school nurse remote check-ins with families. We also examined acceptability of the intervention among caregivers and school nurses as well as asthma health outcomes for children in the program. Our study was approved by the University of Massachusetts Chan Medical School Institutional Review Board. Informed consent procedures are described further below.

Intervention: Remote Asthma Link: A school-linked text message intervention

Asthma Link is an established clinical program in which children with poorly controlled asthma are enrolled by their pediatric provider to receive their inhaled corticosteroids with school nurse supervision, ensuring daily medication adherence. Detailed procedures are described previously 19. In brief, children are eligible for Asthma Link if they are 6 to 18 years old, prescribed a daily inhaled corticosteroid, have poorly controlled asthma despite optimized medical therapy and have a history of poor medication adherence. Poorly controlled asthma was defined as an Asthma Control Test score less than 19 or one emergency department visit, hospital stay, or oral corticosteroid course for asthma in the last year. History of poor medication adherence was defined as parent or child reporting missing frequent doses of the medicine or based on pharmacy information that reports an inconsistent inhaled corticosteroid refill history 19.

Due to the COVID-19 pandemic, schools in Massachusetts closed starting on March 13, 2020, forcing an abrupt cessation of school-supervised asthma therapy. Therefore, during clinical visits, providers in the Pediatric Pulmonary Clinic at the University of Massachusetts Memorial Children’s Medical Center (UMMCMC) asked caregivers of children that had been enrolled in Asthma Link during the 2019-2020 school year about their preferences on how to receive medication reminders. All caregivers reported to their providers that they preferred to receive a text message reminder rather than use an app, website, video, or phone call to aid with daily medication adherence. Caregivers preferred to receive a text message in the early evening rather than other times of the day. All caregivers reported owning a text-enabled mobile phone with the ability to receive free text messages. Efficacy and acceptability of text message reminder interventions for asthma medication adherence have been well established 22–27 Therefore, we developed a school-linked text message intervention, called “Remote Asthma Link”, described below.

Text Messaging Content, Frequency, Language

We designed the content of the text messages based on tenets established in previous text message intervention studies showing the efficacy of two-way communication 28 as well as participant preference for concise messages 29. Caregivers of children enrolled in Remote Asthma Link were sent automated daily text messages, in English or Spanish depending on their preference, at 5pm on Monday-Friday asking: “Has your child taken their daily asthma inhaler today? Please respond: “Yes or No”.

School Linkage

Text message responses were linked to the schools. If the caregiver’s response to the text message was “No” or there was no response on more than two out of five days each week, the research team sent an email to the child’s school nurse stating, “medication adherence is a concern.” School nurses agreed to conduct weekly remote check-ins with all child-caregiver dyads to ask about medication adherence and discuss the importance of daily preventive asthma medication. These weekly school nurse check-ins were performed via phone or video chat based on the caregiver’s preference. If the school nurse received an email from the research team stating, “medication adherence is a concern”, the school nurse would review strategies to improve medication adherence during the weekly check-ins with child-caregiver dyads.

Patient Population

Children were eligible for Remote Asthma Link if they were (1) enrolled in Asthma Link during the 2019-2020 school year, (2) able and willing to provide informed assent, and (3) English or Spanish speaking. Caregivers were eligible to participate if they were (1) >18 years old, (2) English or Spanish speaking, (3) able and willing to provide informed consent, and (4) owned a text-enabled phone. School nurses of the children enrolled were eligible to participate in the study if they were (1) able and willing to provide informed consent.

Recruitment

Between March 13, and November 30, 2020, providers in the Pediatric Pulmonary Clinic at the UMMCMC asked caregivers of children already enrolled in Asthma Link about their interest in learning about Remote Asthma Link during clinical visits. Providers documented in the medical record whether the family was interested in the remote intervention. Starting in December 2020, research staff contacted those caregivers who reported interest in learning about the intervention to assess eligibility and enroll them in the study (Figure 1). School nurses of children enrolled in Remote Asthma Link were then contacted to determine their interest in participating. Informed consent/assent was obtained from all participants to enroll in this school-linked text message intervention.

Figure 1:

Figure 1:

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Enrollment and follow-up: text message intervention for asthma medication adherence

Assessments

The research team monitored the response rates to text messages each week. Caregivers completed a baseline and six-month follow up survey to collect demographic information and assess asthma medication adherence, acceptability of the intervention, and asthma-related health outcomes. School nurses were sent a survey at the end of the study period to assess the acceptability of the intervention. Caregivers were sent a survey via email or called via phone. The survey was available in the caregivers’ primary language, Spanish or English. Data was collected using REDCap, a secure data collection tool.

Analysis

The primary outcome of the study was feasibility, defined as recruitment, retention, and intervention fidelity. This was assessed based on (1) the ability to recruit and retain 25 child-caregiver dyads and their school nurses in the intervention for six months, (2) the ability to send bilingual two-way text messages (number of weeks the texts were sent/number of weeks in the study period), and monitor caregiver response rate to text messages (number of text message responses/number of text messages sent to caregivers), and (3) the ability to link text message responses to schools through research staff emails (number of weeks an email was sent to school nurse when medication adherence was a concern/number of weeks an email was intended to be sent) and school nurse remote check-ins with families (calculated as the number of school nurses that conducted remote check-ins/number of school nurses recruited into the study as well as the number of child-caregiver dyads receiving remote check-ins from the school nurse/number of child-caregiver dyads enrolled in the study).

Secondary outcomes included acceptability of the intervention according to caregivers and school nurses, utilizing adapted acceptability rating scales 30; 31. Furthermore, children’s asthma health outcomes were assessed at baseline and six months: maximum symptom days (a validated composite measure of two weeks’ specific nighttime and daytime asthma symptoms) 32, emergency room visits and hospital admissions due to asthma, oral steroid courses, and seven-day recall of medication adherence 31.

Statistical Analysis

Summary statistics were calculated to analyze demographic data, caregiver response rates and intervention fidelity described above, as well as caregiver and school nurse survey responses. Means and standard deviations (SD) were used to describe health outcome measures with a Wilcoxon Signed Rank Test to compare baseline and follow-up distributions for paired subjects using STATA 33.

Results

Demographics

Of the 48 Asthma Link patients who were seen in the Pediatric Pulmonary Clinic at the UMMCMC between March 13, 2020, and November 30, 2020, thirty-eight reported interest in learning about Remote Asthma Link (the school-linked text message intervention). Of the 38 caregivers identified and contacted, 26 (68%) were enrolled to receive the text message intervention. Those not enrolled included four caregivers who could not be reached, one who was excluded due to language (non-English or Spanish speaking), and seven who were not interested in participating (Figure 1). Of the seven caregivers who were not interested in participating, two reported that it was because their child was able to take their daily asthma medication without issue, and one reported that their child was able to receive medication at school in the school’s hybrid model. The remaining four caregivers stated that they were not interested in participating without further explanation. All caregivers initially contacted owned a text-enabled phone and therefore none were excluded from the study based on this criterion.

The children included in the study were in grades 1 through 10 (mean of grade 4) and ages ranged from 7 to 16 years old (mean age of 11 years old). For the 26 children enrolled, 17 caregivers (65%) were primarily English-speaking, compared to nine (35%) primarily Spanish-speaking. Of the children enrolled, 14 (54%) were male, 18 (69%) were Hispanic/Latino, two (8%) were Black/African American, and six (23%) were White/Caucasian. Most children included in the study (n=24, 92%) were enrolled in Medicaid. Twenty children (77%) were prescribed fluticasone propionate as their daily inhaler and six (23%) were prescribed fluticasone propionate-salmeterol.

Primary outcome: Feasibility

Recruitment and Retention of Study Participants

1a. Child-caregiver recruitment and retention:

We recruited 68% (26/38) of child-caregiver dyads contacted and retained 96% (25/26) through the follow-up assessment conducted approximately six months after enrollment.

1b. School nurse recruitment and retention:

We recruited 100% (22/22) of school nurses into the study. Three school nurses were assigned two students and one school nurse was assigned three students because the students attended the same school. Seventeen school nurses were assigned one student each. Thirteen of the 14 (93%) school nurses who participated in check-ins completed a follow-up survey at study completion. One school nurse who participated was on medical leave and unable to complete the follow-up survey.

Intervention Fidelity

2. Feasibility of sending text messages and monitoring response rate:

Two-way bilingual text messages were sent to caregivers every weekday for 24 out of the 25 (96%) weeks in this study. During one week, the intervention text messages were sent just two out of five days due to a technological error with the text messaging system. Caregiver response rate to the daily text messages (number of text responses received from all caregivers/number of texts sent to all caregivers) over the six-month study period was 81%. Most caregivers (81%, n=21) had a response rate over 70%, and 50% of caregivers (n=13) had a response rate over 90% over the study period. Weekly caregiver response rate remained consistent over the study period and was not affected by school vacations (Figure 2).

Figure 2:

Figure 2:

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Response rate by week among all caregivers; * indicate school vacation weeks

3. Feasibility of school linkages:

The research team was able to send emails to the school nurses stating “medication adherence is a concern” for 24 of the 24 (100%) weeks that caregivers had text responses of “No” or no responses on two or more days out of the five days of the week. This email was intentionally not transmitted to schools on the one week when daily text messages were unable to be sent due to the technological error. Of the 22 school nurses, 14 (64%) participated in remote check-ins with participants. The remaining eight school nurses were not able to contact their designated students despite multiple attempts. This was due to child-caregiver dyads not answering their phones or not logging into video chats. Therefore 18 of the 26 (69%) child-caregiver dyads received remote check-ins. Of the eight dyads (31%) that did not receive any school-nurse check-ins during the study period, one dyad had a response rate less than 50% to text messages and the remaining seven dyads (88%) had a response rate greater than 70%.

Secondary Outcomes: Acceptability, Asthma Health Outcomes

Acceptability of Intervention

Caregiver perceptions:

Of the 25 caregivers that completed a six-month follow-up survey, all (n=25, 100%) agreed that the text-messaging program was acceptable and easy to use. All were satisfied with how often they received the text messages, and the majority (n=24, 96%) were satisfied with the timing of the daily text message (Figure 3). Forty-four percent (n=11) of caregivers found that the daily text messages alone were the most helpful aspect of the intervention for promoting their child’s asthma medication adherence, while 56% (n=14) found both the daily text messages and school nurse check-ins most helpful. All (n=25, 100%) caregivers stated this program took less than ten minutes above and beyond their daily routine; 68% (n=17) stated this program took no time above and beyond their daily routine (Figure 4). Ninety-two percent (n=24) of caregivers responded they preferred to receive text messages every day, versus 4% (n=1) that preferred to receive text messages three days out of the week, and 4% (n=1) that preferred to receive text messages once per week.

Figure 3:

Figure 3:

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Caregiver acceptability of school-linked text message intervention

Figure 4:

Figure 4:

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Caregiver and school nurse perceptions of school-linked text message intervention

School nurse perceptions:

The majority (85%, n=11) of school nurses that completed the follow-up survey found this to be an acceptable program in their everyday practice. Most (85%, n=11) agreed that there was a benefit to them in having their students participate in this program (Figure 5). All nurses (n=13, 100%) who completed the survey said participating in this program took less than 25 minutes above and beyond their daily routine per student; 77% (n=10) stated this program took less than ten minutes per student (Figure 4).

Figure 5.

Figure 5.

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School nurse acceptability of school-linked text message intervention

Asthma Health Outcomes

All asthma health outcomes significantly improved for children in the study from baseline to six-month follow-up (Table 1). Maximum Symptom Days decreased from a mean of 6.5 [SD=4.6] to 3.6 days [SD=5.0]. Asthma-related emergency department visits and hospital admissions decreased from 2.8 [SD=3.6] to 0.2 visits [SD=0.7] and from 1.6 [SD=3.0] to 0.1 admissions [SD=0.4], respectively. Frequency of prescribed oral steroids courses decreased from 3.0 [SD=3.4] to 0.4 courses [SD=0.8] at six-month follow-up, and seven-day medication adherence increased from 5.1 [SD=2.3] to 6.4 days [SD=0.4].

Table 1.

Asthma health outcomes for participants in the school-linked text message intervention

Baseline 6 Month Follow-Up
N Mean SD Range N Mean SD Range P-Value
Maximum Symptom Days 26 6.5 4.6 14 25 3.6 5.0 14 0.004
Asthma-related ED visits 26 2.8 3.6 11 25 0.2 0.7 2 0.003
Asthma-related hospital admissions 26 1.6 3.0 11 25 0.1 0.4 2 0.008
Oral steroid courses 26 3.0 3.4 11 25 0.4 0.8 2 0.001
7-day medication adherence 26 5.1 2.3 6.5 25 6.4 0.4 2 0.008
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Discussion

This pilot study demonstrated the feasibility and acceptability of a school-linked text message intervention in a diverse population of children at risk for significant asthma morbidity. We demonstrated successful recruitment and retention of participants for up to six months. We observed a high caregiver response rate of 81% to daily text messages which remained consistent over the study period. Caregivers perceived this intervention to be acceptable, reporting it was easy to use and helped remind them to give their child their daily asthma medication, corroborating findings in other studies investigating the acceptability of text message programs to assist with pediatric asthma 22; 23. The majority of caregivers responded that the program added less than five minutes above and beyond their daily routine, suggesting that this program may be easily incorporated into families’ busy schedules, a common barrier to successful intervention implementation 34 The high response rate and acceptability of this intervention by caregivers of children from largely low-income and URM backgrounds demonstrates the potential of this intervention to help advance asthma health equity for these high-risk populations.

While other studies have demonstrated the feasibility of text message interventions for daily asthma medication adherence for pediatric patients 22–27, to our knowledge none of these prior interventions have linked with the school systems. Moreover, there has not been an explicit focus on utilizing these interventions to address existing health inequities for low-income and minority populations, who have the highest asthma morbidity. School linkages play a vital role in optimizing pediatric health and add a component of accountability with a trusted partner 16–19. Our results from this feasibility study demonstrate an excellent response rate among caregivers enrolled in the study up to six months (a study duration longer than the majority of other pediatric asthma text message interventions 22–27). This connection to a trusted health professional in the school system may have allowed us to reach, engage and retain families from low-income and minority families who are at highest risk of asthma morbidity. At a time when school resources were largely inaccessible and many avoided healthcare visits due to COVID-19, we were able to engage both caregivers and schools, providing access to preventive health care guidance for children with poorly controlled asthma.

While the objective of this study was to assess feasibility and acceptability of the intervention, we conducted a preliminary assessment of asthma health outcomes which demonstrated an improvement in outcomes from baseline to six-months. These findings are exploratory, and results should be interpreted in the context of the limitations of a pilot study without a control group, conducted amid the COVID-19 pandemic. Past studies evaluating the impact of text message reminders on pediatric asthma health outcomes have been mixed with some showing no impact on health outcomes 22; 23; 26 and others showing significant improvements in medication adherence and asthma control 24; 25; 27 Our findings of improvements in health outcomes may be related to seasonal changes in asthma symptoms 35 and/or to the COVID-19 pandemic (with increased mask use, stay-at-home orders, etc.) as other studies have shown decreases in pediatric asthma health care utilization during the pandemic 36; 37 However, our baseline and follow-up assessment of asthma health outcomes were both conducted after the onset of the pandemic, mitigating the impact of pre- to post-pandemic changes in asthma morbidity.

A significant strength of this study was our inclusion of a large percentage of Hispanic and low-income children, demonstrating feasibility of this intervention for these populations which experience not only high asthma morbidity but also were disproportionately impacted by COVID-19 school closures 20; 21. The substantial percentage of Hispanic children in our study may have been a result of our development of text messaging content and study materials in both English and Spanish, as half of the Hispanic children in our study came from primarily Spanish-speaking households. We recommend future studies of text messaging interventions include multi-lingual text content and study materials to reach diverse populations. Both the school-linkage and the high-risk study population highlight the potential power of this school-linked text message intervention to serve a group of children and families that suffer disproportionately from asthma morbidity.

We recognize several limitations in our study. While we were able to successfully transmit information about text message response rates to school nurses, the remote school nurse check-ins with families were not feasible for all the study participants due to nurses not being able to connect with families over the phone or through video chats. Future studies should qualitatively assess caregiver and school nurse preferences on more effective communication as well as understand and address barriers to engagement. Alternatively, given the challenges with fidelity to the school-nurse remote check-ins, development of a similar two-way, multilingual text message intervention for pediatric asthma without school staff or with linkage to a different third party for accountability (e.g., pediatric clinic staff, community health workers, or care managers supported by value-based contracts) may be considered. Participation bias in survey responses must also be acknowledged, as those most willing to participate may look more favorably on the program. Finally, we would like to emphasize that the nature of this pilot study was to assess feasibility and acceptability of this school-linked text message intervention. Larger, randomized, controlled trials are necessary to formulate conclusions on clinical impact.

The results of this study indicate the feasibility and acceptability of a school-linked text message intervention, particularly to serve a population of children from low-income and URM families who are at significant risk for asthma morbidity. If future randomized controlled trials demonstrate a positive impact on clinical outcomes, this intervention may be used to support medication adherence when school-supervised asthma therapy is not available, including during remote school conditions, summer breaks, weekends, and school vacations. In addition, it may provide support to children for whom school-supervised therapy is not an option, either due to a child or parent not wanting to participate in daily medicine at school or due to lack of school or clinical resources to support school-supervised therapy. Importantly, this intervention could provide critical support for low-income and URM families that may face other barriers to pediatric asthma care, such as lack of transportation to visits, through providing a simple, accessible school-linked text-message service to aid with medication adherence. A school-linked text message intervention merits more in-depth study, particularly given its potential to mitigate health inequities for children with asthma.

Funding:

Dr. Trivedi was supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under Award Number K23HL150341. Dr. Lindenauer was supported by grant K24 HL132008. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funding sources played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Footnotes

Declaration of competing interest: For the remaining authors no conflicts of interest were declared.

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