Detroit, Michigan: Extensive Team Effort throughout an Urban System

Open Airways For Schools was originally designed for and pilot-tested with inner-city children. More than 10 years after its development, it is making major impact in one of the nation's toughest urban school systems, the Detroit Public Schools. Open Airways For Schools in now one element of a comprehensive asthma management and education program following the Asthma-Friendly Schools model. The success of the program within Detroit is attributable to a well-coordinated effort among aggressive school health services staff who have formed an extensive team, including student educators, to combat asthma in their schools. Since 2001, more than 1000 Detroit students from 33 elementary schools have participated in Open Airways For Schools.

School system leaders, furthermore, continue to work with the American Lung Association of Michigan and the  Detroit Alliance Against Asthma to effect statewide asthma education change. Their work, in fact, was part of a successful effort to create a school asthma management plan published in January 2005 by the Michigan State Board of Education, which is anticipated to impact asthma education district-by-district.

Site Background

The Detroit Public Schools are economically challenged and have experienced great tumult over the past several years. In 2001 the State of Michigan took over school administration, which was returned to the city in November 2004 as the result of a public referendum. A community-based transition team began work in January 2005 in partnership with Detroit Public Schools to achieve governance by an elected school board and to establish itself as financially sound. This underfunded urban school system is home to approximately 142,000 students[1] and faces potentially overwhelming challenges for faculty, staff and students. Ninety-one per cent of the students are African-American, and 70 percent of students live below the national poverty level.[2] The district has a $150 million fiscal deficit for 2004-2005.

Within Detroit, 8.7 percent of adults have asthma, compared with the national 7.5 percent average.[3] Based on Detroit Public Schools School Nurse Monthly Reports, 18 percent of students have physician-diagnosed asthma, and an estimated 7-10 percent of students have undiagnosed asthma. During the 2003-2004 school year, nurses handled three to five life-threatening asthma episodes per month.

Fifteen school nurses manage the entire elementary school population of 98,200 spread among 130 schools. While state law requires schools to administer students' medication during the day, it is the responsibility of the principal or his or her designee, to do so. In reality, many Detroit schools rely on the office assistant to administer students' medication.

Program Implementation & Evolution

Open Airways For Schools was introduced to the Detroit Public Schools in 1998 when the University of Michigan piloted the program in 14 elementary schools as part of a program evaluation. The research team managed the program, which reached 835 children and was taught by graduate students, health educators, and members of the Zeta Phi Beta service sorority. Twenty-four month follow-up interviews with parents showed that participating children had significant improvements, particularly children with persistent asthma. These included declines in symptoms, and parents reported fewer absences from asthma.

The positive pilot results led directly to the system's adoption of the program when funding was secured for 2001. Since that time, the Detroit Public Schools has secured successive funding, and the program continues to flourish as part of a comprehensive Asthma Education Program set in place in 2004. The overall asthma program, which includes Open Airways For Schools, is administered through the Detroit Public Schools Office of Health, Physical Education, and Safety.

Under the comprehensive asthma education program, Asthma Education Planning Teams of administrators, teachers, and parents attend a day-long asthma workshop; the individual responsible for administering medication within a given school and one administrator must be team members. The workshop addresses the basics of the disease, triggers, asthma-friendly school elements, and review of the system's required school asthma management plans. At the conclusion of the workshop, each team must create a plan and return to their schools to identify their students with asthma and begin implementing their plans. By March 2005, 116 of Detroit's 242 schools had participated in the asthma education workshops.

The required asthma management plan follows the CDC-DASH Asthma in Schools Logic Model and presents a five-year activity plan to reach the overall goal of reducing the burden of asthma among Detroit Public Schools students in grades 2-5, including a reduction in the number of hospitalizations and emergency room visits.

Open Airways For Schools sessions begin for after November 1 annually and are run throughout the remainder of the school year. Students who have previously participated join a refresher session, which includes a review of all six Open Airways For Schools lessons.

With their internal support and grant funding, the Detroit Public Schools manages its Open Airways For Schools program without need of ongoing direct support of the American Lung Association of Michigan. Local Lung Association staff remain point persons for supplies and data collection annually. Staff continues to collaborate beyond Open Airways For Schools, however, on the Detroit Alliance Against Asthma Coalition and through development and future implementation of new programs like Asthma 101, designed to teach all school staff about asthma management, awareness, and response.

Instructors & Training

School nurses are the primary Open Airways For Schools instructors, and all 10 nurses on staff are trained. Nurses participated in a refresher training course in 2004; new nurses attend an American Lung Association instructor training. Each nurse is responsible for implementing the program in at least three schools. Students are selected from district health appraisal forms; classroom teachers also refer students into the program.

Detroit Public Schools began an innovative training program in 2001, which continues throughout the life the program, by incorporating "student educators" into Open Airways For Schools. Eleventh and 12th grade high school students from the Detroit Public Schools' Allied Health Academy of Science and Technology, are trained to work one-on-one with Open Airways students. The student educators, who are preparing for careers in health care, work under the supervision of school nurses. Each student must have a minimum of a 3.0 grade point average and attend a three-day training conducted by the school system. Their participation meets the Academy's non-paid health-related practicum requirement. Through school year 2004-2005, 14 student educators have participated in Open Airways For Schools as supplemental instructors.

Funding

The Detroit Public Schools has secured CDC funding under a Health Risk Reduction Through Education—Asthma (HRRTEP) grant since 2001. The initial grant was supplemented by an unrestricted grant from Merck and included participation by several local organizations including the Greater Detroit Area Health Council. A subsequent five-year HRRTEP grant began in the 2003-04 school year and supports a comprehensive Asthma Education Program, including Open Airways For Schools as the grades 2-5 curriculum.

Evaluation

Under its current grant, the Detroit Public Schools are measuring short-term outcomes (2004, 2005), intermediate outcomes (2006, 2007) and long-term outcomes (through 2008), which are tracked through its logic model.

Additionally, an internal evaluator is collecting students' 2004-2005 baseline data (attendance, grade point average, test scores) and will analyze those compared with the students' data at the end of 2005-06.

Program outcomes were evaluated in May 2004 for the first year of the grant cycle. During that year, 511 students participated. The program was evaluated with input from students, nurses, and parents.

Summary data based on student questionnaires (administered by the nurse) follows:

  • 70% attended all six sessions
  • 92% reported better understanding of their asthma triggers
  • Approximately 60% indicated they knew what to do if they are going to have an asthma attack
  • 73% reported they knew the name of their asthma medication, and students in grades 4 and 5 were more likely to know the name of their medication (77%) than students in grades 2 and 3 (69%)
  • 80% reported talking with parents about asthma triggers, but only 50% did so with teachers (with concerns of embarrassment, the teacher's being busy, or fear of being excluded from physical activities)
  • 91% would like to know more about their asthma

Eighty per cent of nurses completed a self-administered questionnaire. Highlights of results are:

  • The Open Airways For Schools curriculum was effective and helpful, as nurses believed most students had increased understanding of how to manage their asthma
  • Younger students need more help and reinforcement, while materials also were appropriate for older students.
  • Materials sent home were important in getting parents involved with Open Airways For Schools.
  • Most nurses conducted six separate weekly sessions, but some had to make schedule adjustments to accommodate other school activities such as testing dates.
  • Most building staff were supportive of the program, but some teachers were reluctant to release students from class for six sessions.
  • Parent involvement was low but is needed to help reinforce what students learn in class.

Challenges

Detroit continues to grapple with a few challenges to Open Airways For Schools, including some that are universal in American education in 2005, and some that are unique to the city's schools.

Like school systems nationwide, school nurses in Detroit are challenged to find creative ways to work around class time focused on the state's standardized testing. Competing against time focused on core academics, nurses have taught sessions during lunchtimes or scheduled Open Airways For Schools during classroom time that is not focused on a state-tested topic. The program is not taught during testing periods.

The Detroit Public Schools' fiscal situation also impacts Open Airways For Schools, as there are not enough human resources for all schools. The system's Coordinated School Health Council, however, plans to provide Open Airways For Schools training for teachers in buildings without nurses. Through the annual school team trainings, individuals will be identified for Open Airways For Schools training. They may include teachers, support staff and possibly parents.

Detroit experiences a 40 per cent transient school population within a typical school year, which hampers nurses' working with students with asthma (and other chronic diseases) and their ability to pull them into Open Airways For Schools sessions. Nurses and other school administrators, however, can continue to track the transient populations through Detroit's comprehensive student information system.

Continuing parental involvement is a major challenge. Nurses typically get a good response to Open Airways For Schools' students' permission slips and lessons sent home. Expanding that involvement, however, has been difficult, even with incentives for parents to complete follow-up questionnaires.

Impact

Since 1998, more than 1000 Detroit Public Schools students have participated in Open Airways For Schools, and the program is expanded through long-term grants.  Detroit's involvement in Open Airways For Schools has furthered community- and statewide asthma education and management effort, from both the schools' and the American Lung Association of Michigan's perspectives. One of Michigan's asthma community's major achievements was the 2005 passage of the Michigan State Board of Education Policy on the Management of Asthma In Schools. The model policy will be reviewed by local boards who decide independently to adopt or modify the policy. If the policy does not have major impact on asthma education in schools statewide, the American Lung Association and coalition partners would consider a legislative action to mandate asthma education.

School health administrators are actively involved in the State Asthma Advisory Committee, as well as the former Detroit Asthma Coalition, a former city-wide professional education group. The coalition has been replaced by the CDC grant-funded Detroit Alliance Against Asthma, created by the Detroit Department of Health & Promotion to implement comprehensive asthma interventions in communities and schools, and to target the uninsured asthma population.

Open Airways For Schools has increased awareness among Michigan school staff of the need for asthma education and asthma management in the school system. As districts become more aware of triggers within their facilities, support for policy changes has built. Individual districts in Michigan are tackling school bus idling times, as well as conversion to cleaner burning fuels. Cognizant of asthma triggers, districts are improving ventilation systems and making indoor air quality improvements within their individual financial constraints.

The success of Open Airways For Schools in Detroit and other school systems has paved the way for the American Lung Association of Michigan to secure funding for other school-based asthma programs, such as Asthma 101 (in-service for school staff). This program reached 1500 school staff in 2004 with basic asthma education for faculty and staff and is funded in one county for 2005, with the goal of making it a statewide program, pending funding.

The American Lung Association of Michigan has leveraged Open Airways For Schools' success and contacts into support for other ongoing advocacy work to effect legislative and policy changes throughout the state. Michigan's self-carry inhaler bill passed in 2000, due, in part, to the advocacy efforts of Open Airways For Schools' instructors who worked with coalitions to support the legislation. In turn, these volunteers have become advocates on many related lung health issues, including two clean indoor air bills being reintroduced in 2005—one of which is specific to bars, restaurants and private clubs, and the other to worksites.

Detroit's Open Airways For Schools experience is reflective of the support of the district administrators who recognize the major problem that asthma has become in the schools. The schools' CEO, for example, attends asthma team workshops and welcomes staff teams from individual schools to the program. The message is clear: the schools are committed to asthma education, and that message impacts staff and parents in individual schools who create and implement their own asthma management plans.

The program is passionately championed by the system's Program Supervisor, Coordinated School Health, who has sought funding and expanded asthma management to CDC's asthma-friendly schools expectations. The Detroit Public Schools and the American Lung Association of Michigan focus on why the schools need Open Airways For Schools: a proven curriculum that helps students meet national standards by enabling them to be healthy so that they can spend their time in school.



[1] A Letter form Our COO. Detroit Public Schools Web site, www.detroit.k12.mi.us. Accessed March 6, 2005

[2] Kids Count in Michigan (2000 Data Book)

[3] Epidemiology of Asthma in Michigan  Asthma Initiative of Michigan (AIM), Michigan Department of Community Health (MDCH)