Stamford, Connecticut: City Health Department's Commitment to Addressing Asthma in its Schools

The Stamford, Connecticut Public Schools have completely embraced Open Airways For Schools, to the point where the program is deeply-rooted in the school nurses’ annual responsibilities. Nine hundred thirty-one students have graduated from the program since 1996. This success story is the result of the public health commitment of the city, well-cultivated relationships among collaborators, school staff continuity, and a city structure whereby school nurses work for the health department.

With a health department committed to addressing asthma in its city’s schools, Stamford had not just the support but the direction it needed from within its municipal leadership. The Director of Health and Director of Nursing Services understood the urgency of asthma in the schools. They learned about the program and worked with the American Lung Association of Connecticut to move Open Airways For Schools through the city’s school system, convincing leaders that schools must make time for this critical program.

Site Background

Stamford, Connecticut’s fourth-largest city with 117,000 residents, is a diverse community with both urban and suburban neighborhoods. Its close proximity to New York City and corporate business growth is reflected in several affluent areas of the city, yet Stamford also faces the challenges of a lower socioeconomic inner-city population. Among the 6,704 students in its 12 public elementary schools, 45.6 percent of children are eligible for free/reduced-price meals. Approximately 8.5 percent of children in Stamford have asthma, which is 35 percent higher than the rate for Fairfield County as a whole1. In Fairfield County, an estimated 19,686 children under age 18 had asthma in 2002 (based on national rates).2

The City of Stamford Department of Health employs all school nurses throughout the city, including those working in public, private and parochial schools. Their work is directed by the Director of Health, whose department maintains a cooperative relationship with the Stamford School District, as the School Medical Advisor. Staff within both departments has continued to work well together, despite turnover among both superintendents and health directors.

Even with changing Directors of Health, mid-level managers have been progressive and very public health-oriented, which has resulted in the school nurses remaining on the cutting edge of students’ health education opportunities.

Program Implementation Evolution

The city’s Director of Health began focusing on asthma in 1992 with an assessment of incoming students. Based on the alarming rate of asthma seen in a private and a public elementary school during a one-year pilot, the department developed a questionnaire for all incoming students. The questionnaire was intended to highlight potential asthma symptoms so that nurses could pay particular attention to these students and any symptoms they experienced during the school year.

Over the years, nurses were experiencing more students with asthma in crisis. Calls to 911 from schools were not rare. The Director of Health had a standing order for nurses to provide nebulizer treatments for any child with asthma. The children generally did not have much standardized asthma management (in 1992) for a variety of reasons, including, high numbers of uninsured and underinsured children, denial of the diagnosis by some parents, and the fact that care for children with asthma varied between pediatricians, family practice physicians, nurse practitioners and physician assistants.

Within a year, the city created an Asthma Management Planning Council (in 1993) to address a community-wide response to the burgeoning health crisis. The council’s diverse membership was comprised of influential physicians from local hospitals and private practice, and representatives of community organizations, business, education, and the Connecticut Thoracic Society.

The American Lung Association of Connecticut introduced Open Airways For Schools to the council and the city’s school and community nurses as part of a nursing in-service at the end of 1995. While the vast majority of school nurses endorsed the program, the Health Department also sought support from the Board of Education. American Lung Association staff continued to cultivate relationships within the city and worked closely with the schools and health department to maximize program adoption because the Health Department was 100 per cent supportive of Open Airways For Schools.

With the school program in hand, the Health Department presented the reality of the asthma crisis in schools to Board members: the 911 calls from the nurses, ambulances pulling up to schools, the resulting disruption for the entire school, and of course the health crisis for so many students. The school superintendent, whose designee was part of the Asthma Management Planning Council, endorsed Open Airways For Schools and directed each public elementary school principal to work with their school nurse to plan the program in each school. In 1996, the city began working with Open Airways For Schools and had completely embraced the program by the start of the 1996-1997 school year.

Open Airways For Schools has become institutionalized in the Stamford Public Schools. The program has become an annual, ongoing part of every school nurse’s job. They implement the program every year—just like immunizations or vision and hearing screenings. After several years, the nurses have seen themselves that the program has made a significant difference in their students’ health. They do not routinely see Open Airways For Schools graduates visiting the nurse’s office in crisis. Principals, too, are acutely aware of the decreased crises, which would result in an ambulance pulling up outside the school office window.

Two issues have had tremendous effect on the program’s maintenance and growth: the structure of school nurses’ being part of the health department, and staff continuity. As part of the health department, school nurses’ work is public health-focused and is not directly impacted by factors such as political issues from the Board of Education, for example. Their work is directed by the city’s Health Director, rather than the superintendent or other school administrators. The health department looks for cutting-edge programs to benefit students, and its nurses implement them within the schools. Stamford also has experienced negligible school nurse turnover, and principals also have not changed significantly. As a result, principals and their school nurses have worked side-by-side for years and have long-term, respectful relationships. While superintendents and medical directors have turned over, the front-line staff has continued to work in partnership.

School nurses were initially trained by the American Lung Association of Connecticut during a regularly scheduled nursing in-service during the 1995-96 academic year. The Lung Association was in close contact with the nurses during the first year of the program and quickly responded to concerns and questions. The program, therefore, moved forward smoothly. Since there is minimal school nurse turnover, new training needs are rare. When a new nurse begins the program, she is paired during her first year with a mentor nurse who has implemented the program for several years.

School nurses serve as the program managers and instructors in all elementary schools. While nurses plan to implement the program annually, the only reason an elementary school would not be running Open Airways For Schools is if not enough parents gave their children permission to participate. In those cases, nurses strategize and plan to catch these students sometime within the three grades/years (3rd-5th) for which it is designed.

Nurses plan program schedules with their individual principals, and they coordinate with both the health department’s Director of Nursing Services as well as the American Lung Association of Connecticut program staff as needs arise. Nurses have expanded the curriculum as published by creating fun events for students, family and the school community.

Stamford’s first year of Open Airways For Schools was a rousing success upon which the ongoing implementation grew. Many children, for the first time, realized they were not alone and that their own classmates and schoolmates were experiencing the same health issues. Students became very empowered both by what they were learning and by the end of their previously-perceived isolation as a person with asthma. They became ambassadors within their schools to recruit other students with asthma. School nurses took advantage of their students’ enthusiasm and planned festive graduations that actively involved principals. In one case, the nurse turned the graduation ceremony into an Academy Awards-style event. By the time each group of students graduated, they had bonded into a group empowered by their knowledge and confidence.

Momentum created by Open Airways For Schools has extended to other efforts within the city and state. For example, referrals to the American Lung Association of Connecticut’s Camp Treasure Chest (asthma camp) have increased, the city produced award-winning Natalie Says videos (English and Spanish versions) to complement Open Airways For Schools, and a city-wide asthma and environment program, Breath of Fresh Air, was created (see below).

Funding

Oxford Health Plans, a member of the original Asthma Management Planning Council, provided initial funding for Open Airways For Schools in the Stamford Public Schools. Since the program became institutionalized, ongoing costs include peak flow meters and t-shirts for students, which are provided by the American Lung Association of Connecticut. The Association supports its Open Airways For Schools maintenance needs for ongoing school systems through an annual golf tournament called the NTS Charity Challenge This tournament is sponsored by New Technology Systems, an East Hartford, CT based firm specializing in high-end hardware and software products. (The American Lung Association of Connecticut’s work to establish the program in new school districts is supported by specific grants and other dedicated funding sources.)

Challenges

For the City of Stamford, the major challenge remains implementing Open Airways For Schools in the city’s private and parochial schools. This might have been accomplished at the beginning of the program had representatives of these schools been involved in the early stages of the Asthma Management Planning Council. Current issues pertaining to private and parochial schools are increased program costs, fewer cases among this student population and a shortage of private and parochial School nurses to do this job.

Impact

Stamford’s school nurses report a significant drop in school absenteeism due to un/undermanaged asthma. According to the city, fewer ambulances have had to be called because of asthma attacks in schools, and the hospital reports fewer emergency department visits due to asthma attacks. The program has increased students’ involvement.  In some schools the children act as ambassadors for Open Airways For Schools and encourage other children who they know have the diagnosis.

The success of Open Airways For Schools has impacted the City of Stamford, the State of Connecticut and the work of the American Lung Association of Connecticut several ways.

First, as the City of Stamford Asthma Management Planning Council strengthened and Open Airways For Schools took hold, council members began building a program that would reach into the home environments of children with asthma living in low-income or multi-family housing. Children are referred by school nurses (private, public, parochial schools) and Stamford hospital.

Breath of Fresh Air, developed by the City of Stamford Department of Health, focuses on environmental asthma triggers in the home. Environmental assessments are conducted by a team of a housing code inspector and a bilingual nurse educator. The nurse educator assesses parents’ or caregivers’ understanding of asthma, their child’s treatment regimen, and compliance issues; the nurse works with families on these issues and provides educational resources. The housing inspector, meanwhile, assesses environmental asthma triggers and works with the family to remove them. Depending on the physical situation of the home, the inspector may require remediation by the landlord, and/or replacement of household items (upholstered furniture, bedding, and carpeting), which is funded through the program. The city also recruited a pediatric pulmonologist to see each child in the program at least once, gratis.

With all facets of the city involved in asthma, Stamford’s health department has become involved as a lead agency working with other towns under the State of Connecticut’s Asthma Action Plan, established in 2003. The state plan, developed with the support of the American Lung Association of Connecticut, organizes regions responsible for implementing asthma education through community coalitions, which are being formed in 2005.

For the American Lung Association of Connecticut, the strong success of the Open Airways For Schools program in Stamford served as a model for other school districts to follow.  The American Lung Association of Connecticut was also able to attract more funders to support the program in other school districts in the state based on the successful outcomes of Stamford’s implementation. Currently, approximately one-third of Connecticut’s elementary schools are now participating in Open Airways For Schools.

As an increasing number of schools began implementing the Open Airways For Schools program, the American Lung Association of Connecticut recognized the need to address indoor air quality issues in schools as the next step to manage asthma in schools and began implementing IAQ Tools for Schools. The Association joined the Connecticut School Indoor Environment Resource Team, which is a consortium comprised of 23 agencies and organizations dedicated to improving the air quality in schools. This partnership has become a critical link in recruiting schools to implement both IAQ Tools for Schools and Open Airways For Schools, as the programs are cross-marketed during program trainings.

The City of Stamford’s experience with Open Airways For Schools is the result of a community response to a critical health issue, as well as the springboard for a more expansive city and state plan to address asthma. The City of Stamford reaped the rewards of well-cultivated relationships between health and education staff. In this case, the strong relationship allowed the health department an opportunity to demonstrate the impact of Open Airways For Schools: that children would be empowered personally, do better academically, and have improved health; and that schools would be calmer places of learning with decreased asthma crises.

For the American Lung Association of Connecticut, the Stamford experience reinforces the need to secure district-wide program support initially. It also validates the time and effort spent cultivating and maintaining relationships with decision-makers and those who work closely with them within school and health departments, coalitions, and potential funders. Open Airways For Schools also continues to play a major role in the Association’s expanding indoor air quality work throughout the state.


  1. City of Stamford Department of Health. 2002 data.
  2. American Lung Association. Estimated Prevalence & Incidence of Lung Disease by Lung Association Territory. September 2004.