New York, NY: Battle Plan for a City's Asthma Epidemic

The nation’s largest school system has embraced Open Airways For Schools as its primary asthma education program since 1996. New York City schools, with a student population of nearly 1.1 million among nearly 1400 schools, continue to deal with an asthma epidemic that affects the spectrum of its students—ethnically diverse, and representative of children living in a range of socioeconomic conditions.1

Driven to address its critical asthma situation by intensive media coverage, New York City Public Schools has trained more than 1,570 Open Airways For Schools instructors, and graduated 31,361 students from 1996-2004. A longstanding partnership among the public, corporate and nonprofit sectors remains the crux of this successful system-wide Open Airways For Schools implementation. It has withstood major changes within the school system and its structure within the city government.

Site Background

The New York City Department of Education functions with myriad levels of management responsible for every aspect of education that school systems nationwide manage, yet given the incredible student population, its language and diversity realities, coupled with a faculty of 91,390 teachers that work is much more cumbersome.

The system is responsible for more than 542,000 elementary school students.2 System-wide, 82 per cent of students are eligible for free or reduced lunch; 13.7 per cent of students are categorized as Limited English Proficient students.3

The Department of Education and a Chancellor head the system, followed by several divisions managed by a Vice Chancellor, one of whom is responsible for Teaching & Learning. The 1400 schools within the system are divided into ten regions, each of which has a regional superintendent, who oversees a variety of educational elements, including curriculum and instruction, which is directed by local instructional superintendents, who oversee individual school principals. All health issues are managed through a completely separate division not under the auspices of the regional superintendents. Parent groups are involved through school-specific Parent Coordinators, PTAs and Communitywide and Citywide Educational Councils who provide input to the Department of Education. School nurses, for the most part, are employed by the New York City Department of Health and Mental Hygiene; some are employees of the Department of Education. Politically, school issues are impacted by a host of individuals and bodies, including the Mayor, City Council, Department of Education, and Department of Health and Mental Hygiene.

An estimated 383,361 New York City children under age 18 had asthma in 2002 (based on national rates).4 In 2000, children in New York City were almost twice as likely to be hospitalized for asthma as children in the country overall, and children aged 0-4 from low-income areas were more than four times as likely to be hospitalized for asthma than those from high-income areas. In 1999, school-based asthma prevalence among children 4-5 years old was more than twice as high among children from low-income areas than among those from high-income areas.5

Program Implementation & Evolution

While early efforts by the American Lung Association of New York resulted in limited implementation through work with the Department of Public Health, Open Airways For Schools was catapulted as a major strategy heralded by the Mayor, Board of Health, and Board of Education in response to a scathing, week-long series in the New York Daily News, Asthma: The Silent Epidemic, in March 1998. Front-page and special report headlines in the tabloid-style newspaper screamed, “Why Too Many Die,” “Gasping For Good Care,” “Kids In Danger: Why Students Don’t have Lifesaving Medicine,” and “Is your Child’s School Equipped to Deal with Asthma?” among others. The in-depth report illustrated the reality of asthma throughout the city, and particularly among children and in schools. It also presented basic information about asthma from the American Lung Association of New York and spotlighted Open Airways For Schools as an effective tool.6

The news coverage forced public officials to respond. In the midst of the Daily News series, key players in the city government began working for change. Since the American Lung Association had existing relationships within the Department of Public Health, those individuals approached staff to create expanded opportunities. The Association’s former president, Dr. Robert Mellins, who was one of the architects of Open Airways For Schools at Columbia University, became the catalyst for a city-wide partnership by leveraging his relationships within the schools to bring all key stakeholders together. The city quickly assessed asthma education programs, and soon thereafter selected the American Lung Association of New York as its program vendor. Within five weeks of the news series, the Daily News reported that the ’City Forms a Battle Plan,’ highlighting New York City’s four-step plan, including efforts to train teachers, better equip school nurses to work cooperatively with parents and physicians of students with asthma, launch a public education campaign, and create a hotline for people with asthma and their families.7

Partnership Structure & Funding

Following the Daily News expose in March 1998, the Department of Health and Board of Education committed themselves to solving the asthma problem in schools. They formed the Partners In Asthma Education, with original members’ being their two bodies, GlaxoSmithKline (Glaxo Wellcome at that time), and the three American Lung Association constituents serving New York City at that time (now consolidated as American Lung Association of the City of New York). At the time, Glaxo was already involved with Open Airways For Schools in Florida and wanted to expand its sponsorship into New York. As the work of the partnership evolved, other members were added, including an anonymous foundation and the New York City Council, both of whom supported the partnership financially.

Currently, Open Airways For Schools is managed under a three-year contract between the American Lung Association of the City of New York and the New York City of Department of Health. The American Lung Association’s deliverables are: training of school nurses (up to 175 per year, according the 2004 contract); providing all technical support; procuring and assembling materials needed for lessons; answering nurses’ questions on an as-needed basis; and providing parent and instructor newsletters.

School nurses are responsible for coordinating Open Airways For Schools and teaching all of the sessions. Each trained nurse is required to teach tat least one complete Open Airways For Schools program per semester. The program is managed from a top-down structure. The Department of Health alerts the American Lung Association as to the number of new nurses to be trained, arranges the site and delivers the nurses to the training. Nurses also are encouraged to teach single 60-minute “Refresher Course” to program graduates, concentrating on a few of the important health messages of the complete Open Airways For Schools program. All lessons are taught in English.

Managing the partnership has evolved both as the relationships deepened and as political changes have impacted school health. Long-term relationships have minimized formal meetings, although meetings do occur as city staff turns over, such as the director of nursing. A shift in city structure in 2004 impacted school nurse staffing, which in turn affects Open Airways For Schools delivery. The (former) Board of Education, which had been an independent entity within the city government, became a city agency as the Department of Education. The merging of roles still presents a challenge in the training as well as the implementation phases of the program. For example, some schools have two school nurses while others have none. Very recently, the New York City Council authorized hiring more nurses, which will benefit the program when staffing issues and assignments settle.

Instructors

The Department of Health recruits new school nurses for one-day trainings. Trainers include American Lung Association staff and volunteers who present Asthma Pathophysiology. School nurses who have implemented Open Airways For Schools for many years present the didactics of the program curriculum. Nurse trainers pay particular attention to individual lessons and focus on each lesson’s health message to ensure that nurses understand what the children need to get out of each session. On two occasions, the Lung Association conducted a refresher “re-orientation” for the nurses who assist in the training.

Under its current contract, American Lung Association of the City of New York staff is required to drop in on sessions to critique nurses. While the nurses are trained in the curriculum, they are teaching the children in environments that may not be conducive to effective learning. Some nurse offices may hold a maximum of three or four children, and nurses are often interrupted, as most do not have any back-up coverage.

Evaluation

Open Airways For Schools was evaluated locally in 1997-1998 by Columbia University to determine if the evaluation conducted for the original study could be validated, since the program reach became citywide and involved a larger number of schools and students than the original study. The evaluation focused on absenteeism and self-management skills. Absenteeism was based on review of attendance records of 649 children who participated in Open Airways For Schools; self-management was based on pre- and post-questionnaires completed for 1,226 children. The findings supported the original Open Airways study; specifically:

  • Children who participated in Open Airways For Schools had nearly two less absences per year (22.01 days in baseline year vs. 20.09 days in follow-up year)
  • Children who participated in Open Airways For Schools were more often taking positive steps toward self-management after the program

Additionally, the American Lung Association of the City of New York currently is analyzing participants’ pre- and post-program questionnaires for 2002-2003

Challenges

Prior to the citywide partnership, the major program challenge was trying to secure implementation in schools. Although schools began taking on Open Airways For Schools, it required an extreme amount of legwork, with no assurances that implementation would actually take place.

A major challenge within the partnership structure is the inherent conflicts between principals and school nurses, where two sets of priorities among individuals working for separate agencies, collide. This has become an increasingly pressing issue, as emphasis on state testing has become paramount. Failing schools, in particular, are extremely reluctant to allow students to miss any test preparation time in the classroom.

While trained nurses do teach at least one complete Open Airways For Schools course per semester, some sessions pull together only three or four students, given the time conflicts with test preparation. Overall, nurses are very supportive of the program and the American Lung Association, but they are limited by the realities of bureaucracy and principals’ directives. As a result, fewer students are graduating from the program in 2004-2005 compared with rates in 2002.

Securing timely or regular reporting on the reach of the program, i.e., the number of schools that implemented the curriculum and how many children graduated, also has been a challenge. As forms are revised and updated, adherence to protocol subsequently becomes problematic. If the program is extended by a new contract, partnership members would address strategies for maximizing the program’s reach and improving reporting mechanisms.

Impact

Partners in Asthma Education has impacted both New York City and the American Lung Association offices working within the city. It has created a unique situation through which city departments have found ways to work together on a citywide health program. Clearly, the program has made an impact on children with asthma, as 31,361 students have participated in Open Airways For Schools from 1996-2004. Furthermore, the 2000 New York City asthma hospitalization rate (3.36 per 1,000) was the lowest rate in 10 years; while the underlying reason for the decline is not understood, the New York City Department of Health and Mental Hygiene indicates that it may signal success of city-wide asthma program efforts, including Open Airways For Schools.8

Open Airways For Schools has catapulted the American Lung Association of the City of New York within health, education and business arenas. The organization is more clearly viewed as the leading organization in asthma, providing a critical resource for individuals, agencies and others who need information about asthma. From an advocacy perspective, the American Lung Association now carries the reputation of an organization able to bring together and work cohesively with New York City, other nonprofit agencies, and private funders. This has been not only a source of pride for the organization but a tool toward accomplishing its lung health goals.

Given the scope and success of the program, the American Lung Association of the City of New York plays a more prominent role within its relationships with the Department of Health and Mental Hygiene’s Commissioner’s Health Advisory Council, the City Council’s Asthma Task Force, and the New York City Asthma Partnership (of which the Association is Co-Chair). In addition, the Open Airways For Schools partnership was recognized through the New York City Department of Health and Mental Hygiene’s Public Health Partnership Award in 2001.

New York City’s Open Airways For Schools’ success is the result of key decision-makers within a bureaucratic system pushing the program forward through a creative partnership, which has been at the crux of the program’s achievements. The partners have the power to mandate the program and to carry it through. They have provided needed support and have stood behind the program as structure and politics have shifted. Such high-level support is invaluable when implementing a multi-session program such as Open Airways For Schools, as that structure is not easily accepted and adopted by school personnel.

Leveraging established relationships throughout the city and bringing a nationally-implemented program available are two factors that greatly influenced the city to adopt Open Airways For Schools. City officials were comfortable and quick to accept a program whose development was originally funded by the National Institutes of Health, that was being used nationwide, and whose creator was an eager catalyst in bringing diverse parties together to plan a city-wide plan to deal with asthma in the schools.


  1. New York City Department of Education Statistical Summaries. Available at http://schools.nyc.gov/AboutUs/data/stats/default.htm. Accessed January 13, 2010.
  2. Ibid.
  3. “The State of Learning” In New York: An Annual Snapshot with Comparisons of Select Counties Around the State (Key Findings from the 2003 State of Learning “655 Reports” issued by the Regents and the State Education Department). 2003. Campaign for Fiscal Equity.
  4. American Lung Association. Estimated Prevalence & Incidence of Lung Disease by Lung Association Territory. September 2004.
  5. Garg R, Karpati A, Leighton J, Perrin M, Shah M. Asthma Facts, Second Edition. New York City Department of Health and Mental Hygiene, May 2003.
  6. New York Daily News. Asthma: The Silent Epidemic. February 22-26, 1998.
  7. “City Forms a Battle Plan/Schools are Key in Fight Against Disease,” New York Daily News. March 30, 1998. pg. 7.
  8. Garg R, Karpati A, Leighton J, Perrin M, Shah M. Asthma Facts, Second Edition. New York City Department of Health and Mental Hygiene, May 2003. Accessed April 26, 2005 at http://www.nyc.gov/html/doh/downloads/pdf/asthma/facts.pdf.