North Florida: Sustained Implementation Across 10 Counties

Open Airways For Schools has become a staple of the American Lung Association of Florida’s asthma education since it gained a foothold in Duval County (Jacksonville) in school year 1997-1998. Through long-term relationships with individuals in 10 counties’ health departments, the program has become established throughout the service area. With approximately 100 trained instructors teaching sessions annually, Open Airways For Schools reached 710 students during the 2003-2004 school year, despite an administrative structure that requires a school-by-school promotion and recruitment effort.

Site Background

Ten counties comprise the American Lung Association of Florida’s Northeast Region service area. This area encompasses the city of Jacksonville—also the region’s largest county, Duval County, which includes 105 public and 146 private elementary schools. In sum, 144,076 elementary students attend 457 schools throughout the 10 counties. Throughout the service area, 33,052 children have asthma.1

Beyond Duval County, which has inner-city and suburban neighborhoods, all counties present a mix of suburban, rural and inner-city schools. Each county maintains one school district overseen by a superintendent and a school board. Depending on the county size, a district may be organized into regions, each with an assistant superintendent; districts can therefore vary greatly in administrative levels, ranging from one superintendent and an assistant to up to five assistants. Each county requires unique approvals before a health program can be introduced to individual schools; Open Airways For Schools is approved in all counties, but the final decision rests with each principal for program implementation The American Lung Association of Florida offers the program to all elementary schools within the service region on an annual basis.

Program Implementation & Evolution

The first inroads were made in 1996-1997 when Open Airways For Schools was first implemented in Duval County, where the American Lung Association is a member of the Duval County Health Advisory Board. Part of the board’s work is to review programs being proposed to the school district. When Open Airways For Schools was presented to the board for approval, it was clear that the unique curriculum met the educational needs of the district’s students with asthma. During the first year of program implementation, the district’s school health nursing supervisor conducted an absenteeism study among students participating in Open Airways For Schools. The evaluation proved not only that the program is effective but that it decreases absenteeism rates, which is of paramount importance to principals and superintendents. In 1997-98, 76 volunteers taught 432 children in 30 schools. After program implementation in the schools, the Duval County Director of School Health Services compiled a report finding that the 230 students who participated in 18 area schools evaluated had a cumulative absence record of 1400 days prior to the program and 771 days after the program, reflecting a 55 per cent decrease in school days missed.

School Recruitment & Management

The school districts’ structure does not allow for district-wide mandates for asthma education or a specific program such as Open Airways For Schools. The American Lung Association of Florida, however, has secured approval to promote the program in each district, whose directors of school health distribute annual letters of recommendation to their principals. Each principal, however, maintains the authority to decide if the program will be implemented in the individual school.

Since the program has been approved for use in all 10 regional school districts, the American Lung Association of Florida sends a recruitment memo to all school health service directors or School Health Education Supervisors annually, but principals are the final decision-makers. Typically, schools most eager to implement Open Airways For Schools are at opposite ends of the spectrum: either those serving lower socioeconomic population who perhaps have the fewest healthcare resources, or those serving particularly high income populations, whose districts aspire to the highest standards for programs and services.

Through established relationships with the 10 counties’ school nurse supervisors, American Lung Association of Florida staff are on the agenda for each county’s annual nurse training sessions at the start of each school year. Through a 10-minute presentation, staff promotes Open Airways For Schools and updates nurses on any new asthma medications and devices. All program information is distributed in hard copy and is available for nurses to download through the local American Lung Association Web site as well; device information is available in hard copy only.

When approaching principals, the American Lung Association of Florida staff focuses on program benefits to the schools and a few critical facts about asthma and Open Airways For Schools. These include:

  • Program outcomes (see Evaluation, below)
  • Highlights of the 2004 Children and Asthma in America survey2—particularly on issues that shed light on children’s quality of life impacted by asthma, and communication gaps between parents and children with asthma that can impede asthma management
  • Peak flow meters and spacers, which many children would not otherwise have
  • Focus on time issues, which can be paramount to principals and superintendents. Children with asthma average four sick days per year due to asthma;3 put those children in Open Airways For Schools for less than one day’s school time, and children will have a much better chance of being back in school three additional days

While promotion is ongoing, staff makes one final push toward the end of each school year. It is a reminder to principals that many kids will be alone during summer and may be facing potential asthma crises alone. Asthma management skills learned through Open Airways For Schools could save an unsupervised child’s life. Sessions can be scheduled at the very end of the school calendar to give students that critical level of preparedness for their summers.

To support program implementation, funding and volunteer efforts, the American Lung Association of Florida has developed several long-term partnerships. These include the school health offices of the health departments in all 10 counties served; the United Way of Northeast Florida; local hospitals; four local colleges/universities (Florida Community College of Jacksonville, Jacksonville University, University of North Florida and University of Florida). (Additionally, other coalition-based partnerships are described below; see Impact.)

Volunteers & Training

The large geographic area covered in 10 counties requires a pool of trained instructors available throughout the region. At times, up to nine schools request sessions on the same day. In five counties, nursing and respiratory therapy students are the primary program instructors. Volunteers in the balance of the counties are recruited and trained by an AmeriCorps volunteer and school nurses. Those nurses are part of a mentoring program through which they recruit their colleagues, including retired teachers, to teach the sessions on days when they, themselves will be present in a given school. That way, school nurses are comfortable knowing that dependable volunteers are presenting in their schools.

Under a current grant, the American Lung Association of Florida will train at least 80 volunteers (instructors and school nurses) annually. Nurses can earn contact hours; respiratory therapists earn CEUs; and anyone else not needing license hours receive community service hours. Staff maintains a data base of all trained volunteers and contacts them annually to confirm their availability for the coming school year. Throughout the year, as schools schedule sessions, volunteers are assigned to those elementary schools. To ease scheduling logistics, some university programs, such as University of Florida nursing students, are assigned to specific Open Airways For Schools’ participating schools, which creates consistency from year to year. In addition, some professors have attended training workshops along with their students.

In some rural areas, where no base of college student instructors exists, the American Lung Association of Florida has used some additional techniques to maintain the program in schools. For example, the Association has contracted with a respiratory therapist to conduct sessions on a stipend basis, which has filled a void when needed. Some districts are beginning to hire respiratory therapists as emergency personnel for bioterror attack response. The American Lung Association of Florida is working toward training these individuals, as well as schools’ health aides and other local respiratory therapists, to manage the program in outlying areas.

Required volunteer criminal background checks can become a scheduling problem, as well as adding to program costs. Most colleges, however, are running background checks on students before sending them into hospitals to do clinical work, so they have absorbed those costs ($25 per person). Adding time for background checks to be completed can hamper scheduling with schools, so an additional layer of planning is added to program management.

After completing Open Airways For Schools sessions, all instructors provide feedback to the American Lung Association regarding the teaching experience and logistics. Instructors are tracked against the success of the students in their Open Airways For Schools sessions. That data is used to improve instructors’ performance and ultimately increase effectiveness of the program for students.

Evaluation

Open Airways For Schools results in the Northeast Florida 10-county service area, based on 2003-2004 pre- and post-tests data from students and parents, as well as six month follow-up parent data4:

  • 43% of the students increased school attendance
  • 57% of the students reduced their physician visits due to asthma
  • 29% of the parents reduced their work days missed because of their child’s asthma
  • 57% increase in peak flow meter usage
  • 100% of the parents felt their child was better able to manage asthma because of OAS
  • 100% of the parents felt OAS was beneficial to their family

Funding

Annual funds sought are based on maximum program goals, which is 800 students proposed for 2005-2006. Funding for 2004-2005 came from an American Lung Association National Headquarters’ Childhood Asthma & IAQ grant in five counties of the service area. The other five counties are funded through a United Way grant. For school year 2004-2005, for example, the United Way grant proposal set program goals as reaching at least 580 children and training at least 70 new volunteer instructors. Short-term program objectives defined in the grant are based on students’ increased knowledge regarding the mechanics of asthma, their own personal triggers and handling situations with them, how to avoid an attack before it begins, and understanding the need to take medications as prescribed, regardless of symptoms. Long-term objectives are based on students’ decreased school absenteeism due to asthma, and students’ better understanding of asthma, including the use of their peak flow meter, a spacer device, and breathing techniques.

Challenges

Maintaining a consistent volunteer base requires much recruitment and energy. Since the majority of instructors are students teaching the session as part of clinical requirements, there is annual turnover. This results in yearly recruitment and training efforts of a large portion of the volunteer base. Should a nursing director or other clinical contact change within the universities, staff invests more time developing new relationships within that institution to keep that volunteer pool valid.

In addition to logistical issues related to volunteers and school demands, the biggest challenge currently facing the program is the competition for time with schools’ focusing on the Florida Comprehensive Assessment Test. During certain months (February, March and August), schools provide no access for outside programs. Prime months for Open Airways For Schools sessions have become September or soon thereafter or April and May at the conclusion of the school year.

One current strategy to overcome the time availability in school issues leverages a twice-monthly early release schedule in some areas. The half-day early release, the result of contractually-guaranteed professional education time for teachers, creates logistical and financial problems for parents, particularly working parents and those who may not have regularly scheduled child care. The American Lung Association of Florida has made a recommendation to the Duval County Health Advisory Board to keep students in school during those times but assign that time for all approved health programs (Open Airways For Schools, dental, eye/ear, violence prevention, mentoring programs, etc.) This would create dedicated time for health programs without affecting after-school care issues and teachers’ professional development time.

Impact

From 1999-2004, 3353 children from 264 schools participated in Open Airways for Schools program; 174 volunteer instructors taught the program. In 2002-2004, 100 volunteers were trained annually across the 10- county service region.

Legislative changes first impacted Open Airways For Schools directly in 1997, when the state’s self-carry legislation was passed; now Open Airways For Schools’ track record supports and informs asthma and environmental efforts by illustrating effective program initiatives. The 2005 legislative docket includes a bill to allow students to carry their own EpiPens, which is supported by the asthma community, including Open Airways volunteers and school contacts. Issues being considered for the following legislative agenda include a no-idling policy for school buses and school bus driver asthma education, which link directly to both Open Airways For Schools and IAQ Tools for Schools.

Delivering the proven Open Airways For Schools program to schools in its 10-county service area spotlighted the American Lung Association of Florida as a credible voice bringing a unique program to the schools. It created a corps of impassioned volunteers who have become an extension of the American Lung Association’s extensive work on asthma coalitions, which has expanded its funding base and Open Airways For Schools penetration.

One example of focused coalition work is Healthy Jacksonville 2010, which includes interconnected sections on asthma, tobacco control and the environment; American Lung Association of Florida is involved in strategic planning and issues-specific community programs for all three sections. Working as part of the Healthy Jacksonville 2010 Asthma Coalition, the Lung Association has become involved in a major asthma data collection project with cooperation from all local hospitals and related institutions. This work ultimately will inform and impact every element of asthma education in the community. Additionally, the Healthy Jacksonville 2010 Asthma Coalition created an asthma resource guide so that day care providers and others in the community can access asthma education programs; the coalition also is creating a brochure that lists all the potential environmental hazards in the home, including common asthma triggers.

In the seven years since Open Airways For Schools became part of its program offering, the American Lung Association of Florida has experienced two critical changes affecting the program: staffing restructuring, and the advent of the comprehensive Asthma-Friendly Schools approach to school-based asthma management and education. The latter has resulted in a more holistic, student-focused effort because schools are addressing myriad issues that impact students with asthma, including staff training and their physical environments. In the meantime, staff changes in 2003 resulted in one individual being responsible for the related Open Airways For Schools and IAQ Tools for Schools programs. This has streamlined promotion and recruitment, as well as tracking and budgeting. This change has maximized opportunities throughout the spectrum of the American Lung Association’s work by creating synergy within the organization to the benefit of fundraising and volunteer development.

Open Airways For Schools’ success over seven years has impacted the American Lung Association of Florida’s Northeast Area activities in coalition work, advocacy, and expanded school asthma efforts. Staff restructuring over the years also has affected related program work and maximized school and community contacts for greater impact.

The Open Airways For Schools experience has informed other program efforts by the American Lung Association of Florida’s North area, as well as having providing insight and contacts into other funding areas.

Volunteers, students and others involved in Open Airways For Schools are tied into other American Lung Association activities and opportunities. To build relationships with parents, any parent who returns Open Airways For Schools pre-program surveys received information about asthma camp, Asthma Busters, Asthma Walk, and Living With Asthma Nights.

Although countywide mandates were not attempted when program promotion began nearly 10 years ago, Open Airways For Schools staff and volunteers continue to maximize opportunities to secure ongoing program implementation and funding. The proposed early release health programming, for example, would create that dedicated school time for Open Airways For Schools that has been elusive.


  1. American Lung Association’s Estimated Prevalence and Incidence of Lung Disease by Lung Association Territory. September 2004.
  2. Asthma and Children In America Survey. Asthma Action In America, GlaxoSmithKline. December 2004. www.asthmainamerica.com. Accessed on March 12, 2005
  3. Ibid.
  4. 2003-2004 Open Airways For Schools General Report. American Lung Association of Florida