Orange County, Florida: County-Wide Success through Partnerships

Sustained Open Airways For Schools implementation in Orange County, Florida is the result of long-term partnerships as well as focused school recruitment and instructor recruitment, training, and maintenance. American Lung Association of Florida Central Area staff has created and continue to work through a comprehensive strategy of program planning and implementation, paying attention to the details that keep schools and volunteers engaged and create a fun learning experience for children.

The Orange County experience reflects an approach married to the program standard but extended beyond the basic curriculum to best support all constituents involved in county-wide success. Efforts incorporate a working, evolving knowledge of key contacts within schools and educational partners so that promotion and implementation are based on needs of those groups and their perceived value of Open Airways For Schools.

Site Background

The Orange County School District is the nation’s 12th largest and the fifth largest in Florida. It serves 78,467 elementary school students attending 108 schools1 and has a school board with a district superintendent. The district is divided into five Learning Communities. Each Learning Community includes 25-35 schools; principals in these communities report to an area superintendent, who reports directly to the district superintendent. Learning Communities differ by racial and socioeconomic elements. This structure provides a more direct line of communication between principals and the superintendent.

While nearly 28 per cent of the student population is categorized as Black, this includes a large Haitian community, with many cultural and language (Creole, French) differences. The county’s Spanish population includes primarily Puerto Rican children, as well as Mexican (children of migrant workers), who have a higher incidence of asthma. These families in the region tend to be quite transient, as they move within the region, and some move back and forth to New York. Other areas within the county serve homeless populations, which also are transient and are at high risk for asthma. The severe 2004 hurricane season also contributed to transience and turnover, as one school reported that 30 percent of students did not return one month after the hurricanes. Some schools experience up to a 70 percent annual student turnover rate. These children do not have the benefits and consistency of having a primary care physician or consistent asthma management.

A 2002 survey by the Central Florida Asthma Initiative (American Lung Association of Florida and the Central Florida Asthma Consortium) in 2002 targeted three high-minority zip codes in the Central and East Learning Communities and identified physician-diagnosed youth asthma rates ranging from 12 to 17 per cent. In addition, 16 per cent of households surveyed had children with symptoms consistent with asthma but no physician  diagnosis. The survey revealed the following asthma-related hospitalizations rates in Orange County: 35 per cent African American; 41 per cent White; and 20 per cent Hispanic.2

Individual school principals are powerful stakeholders within this structure, which results in the American Lung Association of Florida’s needing to approach decision-makers on a school-by-school basis. Although Open Airways For Schools has been mandated in one Learning Community (West Learning), compliance is not assured within that community; school-by-school marketing and recruitment must continue. Each Learning Community, however, has one nurse supervisor who oversees health issues and health room staff of all the schools within the region. The nurses work very closely with their principals and do impact principals’ decisions on health issues and programs. Every school employs specially-trained health assistants; some also have a school nurse. While no statewide mandate for asthma education exists, the Florida State Department of Health in 2005 published Nursing Guidelines for the Delegation of Care for Students with Asthma in Florida Schools. The new guidelines provide up-to-date information on asthma, legal requirements for addressing students with special needs, guidelines for safe delegation, recommendations for staff training and monitoring of direct caregivers.

Program Implementation & Evolution

The American Lung Association of Florida began implementing Open Airways For Schools during school year 1997-1998. Due to the district’s decentralized structure, staff faced initial challenges working through the system to identify the true decision-makers who could commit to the program and actually ensure that it would be implemented. As a result, staff personally met or called every principal during summer vacation to introduce Open Airways For Schools. Eventually, the Lung Association worked through layers of gatekeepers until  connecting with the district’s medical director (a subsequently defunct position) in 1999. The medical director championed the program by endorsing Open Airways For Schools and writing to the principals about it.

The district’s medical director launched a long-term trusting relationship between the Learning Communities’ nurses and the American Lung Association of Florida, which became the foundation for Open Airways For Schools implementation throughout the county. The Lung Association of Florida began building relationships with individual nurses and worked to establish itself as a dependable resource. As individual relationships were solidified, the Lung Association of Florida began conducting staff in-services for school staff. Open Airways For Schools was ready to take off throughout the district and has matured into an efficient, well-coordinated program that leverages long-term school relationships and community partnerships.

Program Recruitment & Implementation

While Open Airways For Schools received approval as a health program by the Orange County School Board in 1996, principals decide annually whether or not each school will participate. The American Lung Association of Florida constantly works to recruit and confirm schools. While some particular schools consistently commit to the program, others require ongoing effort. A recruitment packet is faxed to the year’s targeted schools at least once, during the most opportune times for principals. Information incorporates results of a 2003 American Lung Association survey of National Association of School Nurses members.

The American Lung Association taps key school contacts as program coordinators. Of these, 60 percent are school health staff; others are guidance counselors, curriculum resource teachers, as well as a limited number of principals, assistant principals, physical education teachers and coaches. The coordinators are assigned by the school principal manages logistics within a given school; the American Lung Association gives school coordinators a detailed checklist with step-by-step reminders for scheduling classes, distributing pre- and post-tests and parent materials, and communicating with the Lung Association staff. The process ensures consistent program delivery between the school and the Lung Association. This streamlined approach to recruitment and school-specific program management results is based on customer service-focused program set-up and delivery. Coordinators and principals receive small thank-you gifts to acknowledge the time they donate to the program. Each school’s physical education teacher also receives a clipboard imprinted with emergency warning signs and information about what to do during an asthma episode.

Partnerships & Volunteers

In the program’s infancy, volunteer recruitment had been challenging, yet local rivalry among hospitals became one of the American Lung Association of Florida’s leveraging points. Nurses and respiratory therapists are the majority of Open Airways For Schools instructors—the result of long-term educational partnerships with the five major hospitals in Orange County (Florida Hospital East Orlando, Florida Hospital Celebration Health, Florida Hospital Orlando, Orlando Regional Healthcare System, and Osceola Regional Healthcare System, as well as the Health Central Foundation, which funds school nurses in the West Learning Community, in conjunction with the Orange County Public Schools. The American Lung Association of Florida also recruits nursing and respiratory therapy students through partnerships with the University of Central Florida School of Nursing and University of Central Florida Department of Cardiopulmonary Sciences. These partners promote the program internally, recruit instructors, and in some cases pay for staff volunteer timer. Staff maintains very close contact with the universities’ preceptors and hospitals’ clinical coordinators who are primary contacts for recruiting instructors.

Current instructors are the program’s best recruiters for additional volunteers, as they network among colleagues. Respiratory therapists are drawn to the program as staff promotes it as an opportunity to interact with children with a chronic condition with the goal of patient wellness. Many respiratory therapists have limited opportunities for getting to know patients, as they work in acute care, life support systems and emergency hospital-based situations, but teaching Open Airways For Schools can be very rewarding for these health care professionals.

The American Lung Association of Florida uses several strategies to support and maintain instructors, including positioning individuals as part of elite team of people serving and impacting the community; making volunteering fun and convenient (pairing instructors or assistants, picking up and dropping off supplies to volunteers as needed); creating continuity by returning instructors to “alma maters” where they have taught previously; and sharing program and student outcomes via an email newsletter.

In addition to standard forms of recognition (lapel pins, recognition during annual board meeting, thank-you notes and gifts, letters of commendation to employers), creative forms recognition play a critical role in maintaining instructors. These include: Happy Respiratory Care Week “Have lunch on us” card and Subway gift certificate (donated); Volunteer Hall of Fame (instructors are added to plaque after 3 consecutive years of service); and Volunteer of the Year award at annual board meeting.

Training

The American Lung Association of Florida conducts four-hour trainings for individuals who have committed to a school, which eliminates time and costs spent on volunteers who do not teach classes in the long run. Trainings are scheduled as needed but tend to occur near the beginning of semesters so that the information is fresh in the instructor’s mind. Instructors receive four CME’s for completing the Open Airways For Schools training; certificates are distributed after teaching a complete session of six classes at a school. Instructors are encouraged to be retrained through a refresher course periodically. Staff also pairs instructors who have recently completed training (new or refresher) with instructors who have not recently participated in training, which helps keep instructors fresh and updated.

Funding

Since 1996-1997, the American Lung Association of Florida has secured several grants and other funds, some of which are multi-year agreements and/or have been renewed annually. Funders for 2004-2005 include the Florida Healthcare Coalition, Childhood Asthma Management Grant, Community Foundation of South Lake, and Community Health Charities (Heart of Florida United Way). Past funding has included GlaxoSmithKline grants, American Lung Association Childhood Asthma & IAQ grant, and varied level of support from individual physicians and group practices (pulmonologists, allergists). Funds support program staff (1 FTE), volunteer training and support, and all program materials and add-ons. Materials include: placebo inhaler and discus; puppets; lung model; growth chart; peak flow meters and magnets; t-shirts; party boxes (refreshments, goodie bags, disposable cameras).

Evaluation

In addition to the curriculum’s student pre- and post-program questionnaires, the American Lung Association of Florida conducts a six-month follow-up phone survey among parents and analyzes school coordinator and instructor evaluations. This optional parent survey is handed out (in an envelope) in Lesson 1 and delivered to the parent via the student. Incentives are offered to students for returning the survey by Lesson 6. Parents who agree to participate in a six-month post-program evaluation are called and interviewed by senior nursing and respiratory students. Six months post program, participating parents are called by senior nursing and RT students who conduct the survey. In addition to answering the survey, parents have the opportunity to ask the nursing and respiratory therapy students questions about asthma. All evaluation results are subsequently sent to the American Lung Association’s national office.

The following data are based on school year 2003-2004 evaluations and reflect activity throughout Central Florida, including Orange County.3 The data were collected via pre- and post-tests administered to the students before and after the six-week program. Additionally, pre/post surveys were collected from the parents. The post-program parent surveys were collected six months after program implementation via telephone. The data represents a sample size of 68 and accounts for 12 per cent of all participants.

  • 83% of the students showed improved confidence in their ability to take steps to manage their asthma
  • 41% increased their use of Peak Flow Meters
  • 56% of the students increased school attendance
  • 60% of the students reduced their ER visits for asthma
  • 41% of the students reduced their unplanned physician visits for asthma
  • 64% of the parents reduced their missed workdays due to their child’s asthma
  • 98% of the parents felt Open Airways was beneficial to their family

The following summarizes 2003-2004 School Coordinator/Instructor Evaluations4. (Sample size = 28, or 63% of the school coordinators responding.)

When asked, “Generally speaking, has asthma management improved in your school(s) because of Open Airways For Schools?”

  • 60 % answered yes
  • 0 % answered no
  • 40 % answered don’t know

When asked to “rate how effective you think Open Airways For Schools has been in teaching children with asthma how to prevent asthma episodes and emergencies, using a scale of 1 to 5 where “5” means “extremely effective” and “1” means “not at all effective”:

  • 60 % answered extremely effective
  • 26 % answered very effective
  • 14 % answered effective
  • 0 % answered not at all effective
  • 0 % answered don’t know

Challenges

Although the American Lung Association of Florida is one of only a handful of organizations allowed to bring an outside program into the Orange County Public Schools, finding time for Open Airways For Schools is a major challenge as schools prepare for the annual Florida Comprehensive Assessment Test (FCAT). As a result, several schools conduct their Open Airways For Schools sessions as soon as testing and spring break end in March, and staff and volunteers need to juggle a hectic schedule.

Space limitations also present challenges in overcrowded schools. Depending on the school, instructors may bounce among various locations throughout the six sessions. The severe 2004 hurricane season created scheduling difficulties for schools who lost up to three weeks at the beginning of the school year, which resulted in some Open Airways’ sessions’ being cancelled or rescheduled.

The American Lung Association of Florida incorporates a large bank of volunteers and electronic scheduling to overcome the challenge of coordinating schools’ requests with volunteer availability. Schools contact American Lung Association staff to schedule sessions, and volunteers are alerted to openings through constant email updates (both informal and a regular email newsletter).

Impact

In its first seven years, Open Airways For Schools reached over 4500 students with asthma in Central Florida, including 2500 in Orange County. Nearly 300 volunteers have taught the program in Central Florida from 1997-2004.

While the state’s self-carry inhaler law did not involve Open Airways For Schools contacts per se, the program does create a platform for educating schools about the law and why allowing students to carry their inhalers is critical.

The success of Open Airways For Schools has created a fertile ground for the work of the Florida Asthma Consortium, which is focused on helping the community understand the severity of asthma and finding ways to ease the burden of asthma locally. This group of stakeholders now implements the Asthma 101 staff education program among 12 schools in Orange County, as a result of contacts established through Open Airways For Schools. Additionally, members of the Consortium participated in an American Lung Association advocacy workshop in 2003, during which the team met with Florida legislators on Capitol Hill to discuss asthma issues.

The vibrancy of Open Airways For Schools in Orange County is the product of staff’s flexibility, resourcefulness in funding, and ability to engage volunteers into the overall work of the American Lung Association. Lessons learned through Open Airways For Schools have impacted other program areas as well as fundraising. Ongoing work is based on the philosophy that staff responds to constituents’ need and individual protocols and remain flexible to meet them. This is also accomplished by being attentive to feedback and making revisions to approaches and/or details based on individuals’ input.

Open Airways For Schools volunteers have been integrated into other program aspects and special event fundraising as specific opportunities have arisen. Volunteers are highly valued as a critical component to not only this program but to overall education and funding efforts. Students and their families also participate in other Lung Association sponsored activities, including Better Breathers Clubs, Asthma Walk, and speaking at symposia and Asthma 101 programs, for example.

Finally, the trusting relationships built through Open Airways For Schools have become the foundation for extended work. These relationships have established the American Lung Association of Florida as the leader in asthma education and resources and a liaison and referral source for community- and home-based asthma intervention programs. The Association has become the first call for school personnel, families, corporations, and school administrators seeking asthma information and support.


  1. Orange County Public Schools. Pocket Fact Sheet 2004-2005. www.ocps.k12.fl.us, accessed March 8, 2005.
  2. Uncovering Childhood Asthma in Central Florida. Central Florida Asthma Initiative,  March 2002.
  3. American Lung Association of Florida 2003-2004 Open Airways For Schools Report.
  4. Ibid.