Sunnyside, Arizona: School Nurses’ Lessons for Native American and Hispanic Children

The Sunnyside Unified School District is one of many flourishing Open Airways For Schools communities throughout Arizona. The American Lung Association of Arizona/New Mexico services a geographically and ethnically diverse population scattered throughout a large state. The majority of the state's population lives within two metropolitan areas (Phoenix and Tucson), yet Open Airways For Schools efforts reach far beyond those cities and their suburbs into small rural areas found throughout the state, in mountains, desert areas, and on the borders of Mexico and California, serving large Hispanic and Native American populations. Open Airways For Schools has been implemented in school districts serving the metropolitan areas since 1997.

In outlying areas, Open Airways For Schools classes may be small (5-6 children), but they are reaching into communities that do not typically have immediate access to medical specialists and extensive programs. Open Airways For Schools gives school personnel, children and their families the tools they need to proactively manage asthma. Because American Lung Association staff is located so far from many of these areas, school personnel typically recruit and manage their own volunteers, who are trained by the Lung Association. School nurses, for example, then manage their programs independently, supported by their ongoing relationship and communication with the Lung Association.

In New Mexico, the American Lung Association is working cooperatively with the Albuquerque Public Schools, who are focused on implementing Open Airways For Schools in all of its elementary schools. The project is funded by a Centers for Disease Control grant to implement a comprehensive school health program for asthma. More than 40 per cent of the system's 80 elementary schools are implementing the program during the 2004-05 school year. New Mexico's Department of Health, meanwhile, has funded Open Airways For Schools training for 40 rural schools in the northern and southern areas of the states; the American Lung Association completed those trainings in Spring 2005.

Throughout Arizona and New Mexico, more than 590 volunteers have taught Open Airways For Schools to 4,505 children since 1997.

The Sunnyside Unified School District tells a unique Open Airways For Schools story, as it serves a primarily lower socioeconomic Hispanic population and has truly taken hold of the program over several year. Sunnyside is part of the Tucson metropolitan area; within the region, the Tucson Unified School District also has implemented Open Airways For Schools for many years. Sunnyside reflects the cultural priorities of its population: family-centered and family-valued. Open Airways For Schools has become ingrained in the district since 1999 and has flourished as its lessons have impacted children's families throughout the community. The program has garnered long-term relationships and support of individuals who have become overall American Lung Association of Arizona/New Mexico advocates and resources. Nurses' understanding of asthma patients' needs and the power of Open Airways For Schools have created a consistently fertile ground for the program.

Site background

Located within the Tucson metropolitan area, Sunnyside is Pima County's third-largest district of more than 15,500 students. The district, managed by a superintendent and a school board, includes 13 elementary schools. Each school has one school nurse, who is an employee of the school district.

Sunnyside's school population is primarily lower socioeconomic and diverse. The majority of students are   Hispanic or Native American. Eighty-four per cent of Sunnyside students are Hispanic; Native American students are part of the Tohono O'odham Nation. Three-quarters of the students throughout the district qualify for free or reduced meals, and 48 per cent of elementary school students are English language learners (native language other than English).[1 The region is primarily suburban but includes some limited rural areas. Throughout Pima County, more than 18,000 children under 18 are estimated to have asthma, based on national data.2

Because both the Hispanic and Native American cultures are focused on family and community, the school district is very family-oriented. Children are highly valued as family and community members. Families are typically very involved in PTA and other school functions, such as new principal meetings. The district historically has experienced a good balance of power between principals and the school board, as well as low turnover rates among principals, teachers, and school nurses. As a result, staff, faculty, the school board, as well as parents, have built an environment generally conducive to strong communication and open avenues for sharing ideas and working together to address issues.

In southern Arizona, staff support is provided by the American Lung Association of Arizona/New Mexico's asthma program manager, a registered nurse originally volunteered as an Open Airways For Schools instructor during the 1999-2000 and 2000 – 2001 school years. She is also an Open Airways For Schools Master Trainer (qualified to train instructors).

Program Implementation & Evolution

The Sunnyside Unified School District has adopted Open Airways For Schools without a district-wide mandate or other formal directive. Implementation is based on nurses' and principals' understanding of the students' asthma education needs and their willingness to invest time in the program. The American Lung Association of Arizona/New Mexico first introduced Open Airways For Schools to the district's school nurse manager in 1998. The nurse manager fully supported the program and championed Open Airways For Schools throughout the district. She enthusiastically presented the program to her school nurses. As individual nurses supported the program, they were responsible to bring it to each principal. Since 1999, when nurses began offering sessions, it has remained each nurse's decision to implement the program and to secure each principal's approval to more forward within that particular school. While the principal does have the final decision within a school, nurses are very influential; principals tend to fulfill their requests as to what they need for school health services.

As Open Airways For Schools was initiated in Sunnyside, the American Lung Association of Arizona/New Mexico offered a range of incentives to schools, as supported by a three-year grant from the St. Luke's Health Institute (see Funding, below). Nurses were supplied with nebulizers (one per participating school), peak flow meters, spacers, and t-shirts. While the incentive packages helped secure individual schools' initial participation, nurses have continued the program with only basic program and support materials, including children's t-shirts for graduation.

Annual program goals are based on funding. While the Sunnyside District is willing to implement Open Airways For Schools in all 13 of its elementary schools, annual funding supports only six to eight schools, which results in approximately 100 students' attending the program. Each participating school nurse generally runs one session per year; two Open Airways For Schools volunteers recruited and trained by the Lung Association support each school nurse.  Most nurses who participated in the programs first three years have remained very faithful to Open Airways For Schools and prepare to implement it annually. In addition, the American Lung Association of Arizona/New Mexico promotes the program each fall to three or four nurses who might not automatically implement Open Airways For Schools. The time commitment can be a barrier to some schools' implementation, as nurses need to invest time to identify potential participants, distribute parent letters and process them.

American Lung Association staff contacts any new Sunnyside nurses to introduce the program personally and to establish relationships. Based on the nurse's immediate interest and experience, the American Lung Association sends her to an instructor training workshop; if none is feasible for the nurse, she is trained through one-on-one instruction. Every three years, nurses are invited to participate in an instructor training workshop again as a "complete refresher". Although CEUs are not offered, the nurses have been very open to attending the workshop for a second time to reinforce their specific program skills and to enhance their continuing education.

Open Airways For Schools is taught in English, as required by Arizona law; instructors, however, might use the (Spanish) flip-side of posters for students who are struggling with the lesson. This supports their asthma education and helps them with their English as well. Having Spanish parent sheets, however, is critical for the school-home link, as parents often do not read or speak English. Approximately five to 10 per cent of Open Airways For Schools volunteer instructors are fluent in Spanish.

Partnerships

The American Lung Association of Arizona/New Mexico has three major partners supporting Open Airways For Schools in Sunnyside: the school district, the University of Arizona College of Pharmacy, and the Pima Medical Institute. Within the district, the majority of school nurses champion Open Airways For Schools. They are willing to teach the program year after year because they have worked with it and understand its value. The nurses express that they need to educate the kids with asthma and know that Open Airways For Schools works. Most nurses proactively contact the American Lung Association of Arizona/New Mexico annually to prepare for the coming school year. Fortunately, the nurses are influential within their individual schools and are able to keep the program moving each year. The University of Arizona College of Pharmacy and the Pima Medical Institute comprise the majority of the volunteer corps working with Sunnyside schools.

Instructors

While a handful of nurses will teach their own Open Airways For Schools sessions, most nurses use two American Lung Association of Arizona/New Mexico volunteer instructors in each school. Since 1998-1999, approximately 35 volunteers have taught the program in Sunnyside schools.

The bulk of Open Airways For Schools volunteers are University of Arizona College of Pharmacy students. Each year, one pharmacy student acts as program coordinator, who works with American Lung Association of Arizona/New Mexico staff; the coordinator and the volunteer corps change annually. The college coordinator recruits volunteers from every class with first- and second-year students. Students do not receive course credit, but the volunteer role is promoted as an important part of the students' portfolio. Once students are recruited, they attend a 6-hour training held specifically for University of Arizona College of Pharmacy volunteers; approximately 25 University of Arizona students are trained through at least four workshops annually. The University of Arizona coordinator works closely with American Lung Association staff through email and some one-on-one meetings. As the American Lung Association schedules schools, the college coordinator reviews students' schedules and books two volunteers per school.

Respiratory therapy students from Pima Medical Institute are the second largest group of volunteer instructors working with the Sunnyside district. One teacher serves as the primary contact each year and promotes the volunteer project to students, who are required to participate in a community health project. Approximately 10 Pima Medical Institute are trained annually; all student instructors receive course credit for teaching complete Open Airways For Schools sessions. The American Lung Association of Arizona/New Mexico offers at least three trainings per year for these student instructors.

Evaluation

The American Lung Association of Arizona/New Mexico evaluated pre- and post-program children questionnaires in 2004. Overall, the evaluation of 257 children enrolled in the program showed an increase in self-efficacy, knowledge of disease management, asthma-related preventative behaviors, and overall good decision-making when it comes to managing the disease. Significant findings included:

  • Self-efficacy: Upon program completion, more children reported believing they could do asthma management activities without the aid of an adult than prior to the program.
  • Asthma knowledge: Upon program completion, more children reported knowing when they were experiencing symptoms of asthma than before the program.
  • Prevention behavior: Upon program completion, more students were able to choose appropriate asthma management behaviors than prior to program participation.
  • Decision-making (when to stay home, go to school, or go to the hospital based on asthma symptoms:  Upon program completion, more children chose the appropriate behavior than prior to the program.
  • Outcome expectations: Upon program completion, more children reporting post-test that they could do everything other children do than prior to program participation.

Funding

A three-year grant from St. Luke's Health Institute enabled the American Lung Association of Arizona/New Mexico to establish Open Airways For Schools in Sunnyside. The matching grant of $180,000 required the American Lung Association of Arizona/New Mexico to match the funding level through other sources and provided resources for 150 schools throughout Arizona to implement the program with full support, including incentives described above. That grant supported Sunnyside through school year 2001-02. Funding continued through a 2003-04 Childhood Asthma & IAQ grant from the American Lung Association's national office. Open Airways For Schools is currently funded at a lower level in Sunnyside through a one-year (2004-2005) grant from the U.S. Environmental Protection Agency Region 9.

Challenges

The Sunnyside Unified School District has consistently implemented Open Airways For Schools for six years, yet nurses and the local Lung Association staff face some ongoing challenges.

Nurses and the American Lung Association of Arizona/New Mexico face two hurdles within the schools. In all schools, nurses implementing Open Airways For Schools compete for time against students' preparation for the state's standard testing, Arizona's Instrument to Measure Standards (AIMS). As with other states grappling with requirements of No Child Left Behind, teachers and principals are held accountable for students' test scores and generally will not release students from class time for health curricula. Many Open Airways For Schools classes, therefore, are scheduled in blocks at the end of September and early October or in January and February. Overcrowding is a problem in some schools, where nurses have to scramble for space in which to teach Open Airways For Schools sessions

For the Lung Association, funding has decreased since 1999, resulting in fewer schools' participating in the program annually. At its height, 10 schools implemented Open Airways For Schools in Sunnyside, while only 5 completed sessions during the 2004-2005 school year. Staff turnover is less of a challenge, yet any changes in nurse staffing require additional training support, which impacts a limited budget. The American Lung Association of Arizona/New Mexico continues to pursue expanded funding but within a very competitive fundraising and grant market. Funding that would provide for financial incentives for schools to provide additional resources to the program would increase school participation. Incentives could allow for peak flow meters and spacers, additional program classroom supplies, or perhaps help supplement school personnel time invested in Open Airways For Schools.

Impact

In six years, Open Airways For Schools has reached more than 450 students in 12 schools; more than 35 college students have worked as volunteer instructors during that time. This ongoing implementation has been achieved with the support of very limited staff time; one staff services Open Airways For Schools for approximately half of Arizona's schools, during a 10-hour work week. The program's impact, however is far-reaching beyond the school district.

Immediate impact is demonstrated among Open Airways For Schools students' extended families. Within the Hispanic community, extended family members are very involved in school events. Often, a grandparent, aunt, uncle or great-grandparent is a care provider. Many family members typically attend Open Airways For Schools graduations, and family members express deep gratitude to people who are clearly helping their young child. They see first-hand how the nurse, volunteers, and American Lung Association of Arizona/New Mexico are improving that child's health care.

Being involved in Open Airways For Schools can affect school faculty and staff, as well as volunteer instructors, long after their sessions are completed. The ongoing relationship between school nurses and the local Lung Association staff has resulted in the Association's becoming a reliable resource of information for school nurses. Individuals who have taught only one or two classes have become long-term champions of the American Lung Association of Arizona/New Mexico. Volunteers have become great advocates through their professional networks and have increased awareness of the American Lung Association, its asthma work, as well as Open Airways For Schools. They also have become involved in development projects, including Asthma Walk.

While a statewide mandate for asthma education in schools does not exist in Arizona, a statewide asthma program is in development; it is anticipated to be finalized mid-year 2005. The plan is being developed by the Arizona Asthma Coalition working with the governor's office and is part of Arizona's comprehensive chronic disease plan. The American Lung Association of Arizona/New Mexico is involved in the plan's development and is a member of the coalition. The plan, to be managed by the State of Arizona's Department of Health, Department of Chronic Diseases, will incorporate objectives for epidemiology and research; treatment and management; patient education; secondary prevention; school/child care issues; recommendations for asthma education; disparity; collaborative efforts; advocacy; and public awareness. ALA of Arizona/New Mexico has recommended that Open Airways For Schools be implemented statewide under the plan, as well as Asthma 101 for school district personnel and a clean indoor air program. While the state plan may not name any specific programs, staff anticipates that it will recommend that schools incorporate asthma education.

Despite ongoing challenges, including the school district's financial constraints, Open Airways For Schools has taken hold in the Sunnyside Unified School District. Its success is a tribute to persistence, in part, but also to the value of the program heralded by the district's nurses.

They continue the program because they have seen what an invaluable tool it can be for children. While physicians can prescribe powerful medications for children, asthma education can be a huge gap for parents and children. Open Airways For Schools teaches both the children and parents a wealth of basic information they never knew they were missing. It continues to put the children in control—particularly children who often feel left out or different because of their asthma. As Open Airways For Schools was originally designed, that control, instead, empowers those children to take on anything.

 


1. About Our District. Sunnyside Unified School District web site. http://www.sunnysideud.k12.az.us/about-us, accessed 3/29/05

2. American Lung Association Estimated Prevalence and Incidence of Lung Disease by Lung Association Territory. September 2004.