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Open Airways for Schools (OAS) is a major American Lung Association (ALA) [external link] initiative to help children in elementary schools better manage their asthma. The program is school-based, designed by physicians, and operates in a variety of elementary school settings throughout the United States. OAS is an extension of the Open Airways program, which was originally designed for delivery in health care settings with Black and Latino children from under served communities. While Open Airways is an educational program for parents and their children, OAS was designed to be a child-centered educational program.

OAS is based on the premise that a clinic-based educational program would increase parents’ and children’s ability to manage asthma and thus reduce the number of emergency room visits, hospitalizations, missed school days, and disruptions in family life that are caused by asthma.

In recognition of the lack of asthma education for children with asthma who are not involved with pediatric specialty clinics, the validated clinic based Open Airways was transferred to an elementary school setting. To insure that Open Airways would be effective in a school setting, two separate studies were conducted, using an experimental research design. For a more detailed discussion of this transfer process, refer to the September 1986 publication by D. Kaplan, J.L. Rips, N.M. Clark and others titled “Transferring a clinic based health education program for children with asthma to a school setting” in volume 56 of the Journal of School Health.

In the first study, a pilot study, parental participation remained a key feature of the intervention; however, in response to the low attendance of parents, researchers made the decision to reduce the level of parent participation in favor of a more child-centered program. As a result, the materials and format for OAS were revised to be developmentally appropriate for children in third through fifth grades, based on Piaget’s model of cognitive development in children. According to Piaget, children in grades 3 through 5 have reached the stage of concrete operations and are able to understand the concepts of causation and prevention. OAS also utilizes the concept of self-efficacy, derived from Bandura’s Social Cognitive Theory. Self-efficacy refers to one’s belief in his or her ability to perform a task effectively as a prerequisite to undertaking that task. A common method of instilling and reinforcing that belief is through repeated demonstration and practice of that specific task.

In 1984, the revised intervention was implemented in 12 schools in New York City to determine its effectiveness. The following sections discuss the goals, educational content, and evaluation design and results of the intervention as well as important characteristics of the study population. This discussion is based on an article by D. Evans, N.M. Clark, C.H. Feldman and others titled “A school health education program for children with asthma aged 8-11 years” that was published in 1987 in volume 14 of Health Education Quarterly.

According to Dr. David Evans, one of the lead researchers, OAS was conceived to address a goal set forward by the National Heart, Lung, and Blood Institute to increase the availability of asthma education programs. A school-based intervention provides the opportunity to reach a larger, more diverse group of children with asthma than in a traditional clinic setting.

In addition to this overarching goal, the intervention hoped to achieve several specific objectives:

• increase a child’s ability to recognize asthma symptoms
• increase self-efficacy with respect to managing asthma
• increase children’s positive influence over their parents’ asthma-management decisions
• improve school attendance and performance.

Educational Content of the Intervention
The educational sessions focused on the child’s role in asthma management and emphasized tasks children could complete without parental participation or supervision. Each session used physical, hands-on activities and allowed children to practice their newly acquired skills in class.

The intervention consisted of six 60-minute educational sessions with groups of eight to twelve children. The sessions were held during the school day and were offered over a 2-to3-week period. The six sessions covered the following topics:

• basic information and feelings about asthma
• recognizing and responding to symptoms
• using asthma medicines and deciding when to seek help
• keeping active
• identifying and controlling triggers
• handling problems related to asthma and school

Additional printed materials were designed for and provided to parents to keep them abreast of what their child was learning. Homework assignments also allowed children the opportunity to practice exercises and techniques and to share information that was learned in class with family members. For instance, one homework assignment instructed children to teach a family member a belly breathing exercise learned in class.

An experimental research design was used to evaluate OAS. Twelve elementary schools in New York City were chosen to participate in the study. Each school was paired with a comparison school selected on the basis of ethnic composition and size. One school in each of the six pairs was randomly selected to receive the intervention. Evaluation results were collected in the year following the intervention. After the study was completed, the comparison schools also received the intervention.

To detect changes in children’s knowledge, attitudes, beliefs, and skills with respect to asthma self-management, data were collected on the following outcome measures through the stated mechanisms:

Self-management skills: An index of 36 self-management activities performed by the child to prevent the occurrence of symptoms, to communicate information about current symptoms and the need for treatment to parents, and to manage asthma symptoms at home and at school

Self-efficacy: An index to measure the child’s perceived self-efficacy with respect to 13 asthma management behaviors

Influence on parental decision-making: An index of the parent’s rating of the child’s influence on parental decisions regarding school attendance and emergency room visits

School attendance and performance: School attendance (number of days absent) and performance (grades in 11 subjects or skills and performance on standardized mathematics and reading achievement tests) measured using school records and teacher-provided behavioral assessments of classroom performance

Children’s attitudes: Students were asked about their feelings about school, about asthma, and if friends or other children did anything to help them during their most recent asthma episode at school

Parental report on the frequency, duration, and severity of child’s asthma episodes: Parents’ report of the number of asthma episodes and average duration (number of days) in the past year, the number of episodes treated at home, and the number of episodes requiring treatment in emergency departments

To recruit participants for the study, teachers sent a letter, in both Spanish and English, home with all third through fifth grade students. The letter described the symptoms of asthma and the purpose of the intervention. Interested parents were interviewed by a bilingual phone interviewer to determine whether the child met the criteria for participation in the program. Children were eligible to participate in the study if a) they were enrolled in the third, fourth, or fifth grade, b) parents reported at least three episodes of asthma in the past year, and c) parents provided written consent for participation.

The study population consisted of 239 students from 237 families with 134 children in the experimental group and 105 in the control group. The children were mainly from low-income families with 71% receiving Medicaid. Seventy percent were Hispanic, 28% were non-Hispanic Blacks, 2% were non-Hispanic whites. Fifty-nine percent were male, with an average age of 9.1 years . Ninety-three percent of the children’s parents stated that a physician had previously diagnosed asthma in their child. An additional 6% of parents reported that their child experienced wheezing, coughing, or shortness of breath, and 1% reported two or more symptoms in absence of a physician diagnosis.

The intervention was effective in increasing children’s self management skills and self-efficacy and the child’s influence on parental decision making. Results also showed a decrease in the annual frequency and average duration of self-reported asthma attacks. During the year, the number of symptom days decreased by 43% in the intervention group and 7% in the control group. Children in the intervention group also increased the number of actions they took to manage their asthma compared with children who did not receive the intervention.

In addition, children in the intervention group reported more positive feelings about school and fewer negative feelings about asthma and were more likely to receive help from others (e.g., nurses or parents) during an attack than were children in the control group. Children in the intervention and the control groups both had fewer absences in the follow-up year than in the base year, though the difference between groups was not statistically significant. However, children in the intervention group received higher grades, especially in math and oral expression.

OAS research was supported by Grant R18-HL-28907 from the Division of Lung Diseases, National Heart, Lung and Blood Institutes (NHLBI) and a gift from the Spunk Fund.

Similar to the goals of the intervention research, the overarching goals for Anne Arundel County’s OAS program are to improve children’s understanding of asthma and proper medication use and to teach children how to better manage their asthma. The specific objectives of the Anne Arundel County program are as follows.

• Know personal asthma triggers
• Prevent asthma episodes
• Recognize personal asthma symptoms
• Have fewer absences due to asthma related illness
• Conduct asthma management steps
• Have fewer nurse and hospital visits
• Discuss asthma problems with adults
• Have fewer unscheduled medical visits

In fact, the Anne Arundel County goal of reducing the number of nurse, hospital, and emergency room visits extend beyond the goals for the intervention research, which translated OAS to a school setting.

OAS is offered to all students in third through fifth grades identified with asthma by their school nurse. Students are identified as having asthma if they are currently taking asthma medications, they have a physician’s diagnosis on file, or their parents indicate the child has needed a physician visit for asthma in the last year. The school nurse sends a letter home with students, based on the sample letter provided in the kit, that describes the program and requests permission for the student to participate in the program. Similar to children in the intervention research, many of the children in Anne Arundel County do not have regular access to medical care.

Since 1998, 709 students have participated in OAS in Anne Arundel County.

In Anne Arundel County elementary schools, OAS is usually offered as a series of six 40-minute group sessions. All classes are held during the school day; however, the timing, number, and format of the sessions vary depending on a number of factors, such as the school nurses’ perceptions of students’ cognitive abilities, willingness to let a child miss a scheduled class, or preference for the length of sessions. Classes are usually stratified by grade; however, nurses report that when only a few children sign up for the sessions, nurses mix grades as appropriate.

All nurses conducting the OAS program are trained by a health educator from the state ALA office. Although length of training may vary across the country, it is typically 1 full day. The ALA sends a certified educator to train the nurses at a location convenient to them. In Anne Arundel County, nurses meet with the trainer at a centrally located school. The ALA instructor describes the program and reviews the components of the OAS kit. Additionally, the instructor demonstrates the uses and functions of different types of asthma medical devices, such as peak flow meters and inhalers. In Anne Arundel County, the training occurs when a new group of nurses is hired.

OAS in the county is funded as a component of the AMP by the County Health Department as part of the county’s allocation for school health and nursing. This arrangement makes it difficult to identify funds used exclusively for the operation of OAS. An alternative way to gauge the resources required to operate OAS in Anne Arundel County is to estimate the labor involved with operating the program. The school nurses estimate that OAS requires 12 hours for each set of the OAS classes: 4 hours to conduct six 40-minute classes; 3 hours for planning and preparation; 2 hours for copying and sorting; 1 hour to write and distribute informational letters to parents; and 2 hours to communicate with parents, teachers, and principals.

While the School Health Services program pays for the nurses’ time, many school nurses indicated that additional funding is needed to cover such “extras” as pizza, other food and refreshments, prizes, and stickers. Often these items are purchased by the nurses themselves, or in some cases, by the Parent Teacher Association (PTA).

The implementation of OAS in Anne Arundel County has had no formal or structured evaluation. However, in December of 2000, the Anne Arundel County Department of Health applied for a grant from the Maryland Department of Health and Mental Hygiene, and was awarded $19,000 to begin analyzing outcome data for its Asthma Management Program, of which OAS is a part.

Pre-Packaged Open Airways for Schools Kit
Using the OAS Kit enables session leaders to follow a previously evaluated format for teaching asthma self-management. This practice is especially beneficial for the nurses who do not have a teaching background. Nurses report that the prepared seminars and curriculum provide them a kind of “safety net” and an opportunity to focus on teaching the children instead of having to focus on developing teaching tools and activities.

Solid School Foundation
OAS operates in a county with solid experience with school health programs. The county has both a framework for school health and a network of people interested in its success.

Part of a Larger Initiative
In Anne Arundel County, OAS operates within the context of AMP and the school nursing program. In this way the program has a “home” and can flourish. AMP offers school nurses a set of guidelines and resources to facilitate monitoring students with asthma, while OAS offers nurses the tools to educate elementary schools students about how to manage their asthma. Not only does AMP result in improved coordination of services but it also promotes consistency in asthma management in the county school system.

Flexibility
Nurses in Anne Arundel County have indicated how important it is that instructors have the flexibility to alter the delivery of the OAS program to either better meet the needs of students with different learning styles or maximize limited resources. However, in the absence of a formal evaluation, it is unclear how altering the format and/or delivery of the program affects its effectiveness.

Time missed from regularly scheduled class: Students participate in educational sessions during school hours. As a result, they often have to miss a regularly scheduled class. Nurses report that some parents and teachers are reluctant to have a child miss classroom instruction and possibly fall behind his or her peers. In addition, OAS is one of many activities in the schools with which teachers have to compete with for their students’ time. Nurses report that, whenever possible, they try to hold class during the lunch break to avoid causing the student to miss class. When students must miss class, nurses communicate with both parents and teachers to explain how teaching children with asthma to better manage their disease results in benefits not only for students but for parents and teachers as well. In fact, the amount of time that a child spends out of class is less than or equal to one school day missed due to asthma, which he or she will easily make up for in learned asthma management skills. Healthier students learn better and have lower rates of absenteeism.

Community Outreach
Although OAS in Anne Arundel County is part of a larger county-wide initiative, neither AMP nor OAS partners with other sectors of the community besides the Department of Health. As a result, very little advertisement exists of the program’s availability or success. Staff members report that greater visibility would facilitate efforts to raise funds to purchase “extras” the program needs, such as peak flow meters and nebulizers. It is important to note that the State Department of Health and Mental Hygiene now has an asthma coordinator responsible for building community partnerships.

Staff Turnover
Currently, the annual turnover rate among school nurses in Anne Arundel County is 30%. In addition, the county and state experienced a general nursing shortage last year that led to staff shortages for OAS as well.

Because developing and evaluating a program is resource intensive, using an already developed and pre-packaged validated program is easier and more cost effective. OAS staff indicate that the program has been successful in Anne Arundel County in large part because it is an already developed and validated program and thus easily replicable.

It is important to have a school nursing program which enables nurses to be in schools daily to operate the program and monitor students. School nurses are the backbone of OAS in Anne Arundel County; they are the educators, champions, marketers, and facilitators. They operate the program day-to-day and provide the most informed feedback on its implementation. It is also important to have health assistants to relieve nurses when they teach the OAS classes. Not all schools have school nurses, however, and trained community volunteers can serve well as instructors. Although school nurses play a pivotal role in the Open Airways for Schools program in Anne Arundel County, the program is designed to be delivered by a variety of instructors including health educators and teachers.

OAS nurses stress the importance of small classes with no more than five to eight students. One nurse stated that she once had 22 children in a class, which made it difficult to give children individualized attention and ensure that each student was comprehending the information on asthma management.

Prior to program implementation, the preliminary work of developing relationships with principals, parents, and the community is critical. Principal support is key to making school-based programs work. The nurses who have principal support generally receive faculty support; such support makes it easier to remove students from their regularly scheduled classes. Working closely with faculty is also important. To involve school faculty and staff, school nurses in Anne Arundel County have conducted OAS awareness sessions with them. This strategy has proven particularly effective with physical education teachers.