Commencement of Global Dissemination and Implementation of a School-Based Academic Asthma Education and Counseling Program

Background, Purpose , Aims: One of the most critical issues impeding improvement in public health is the gap between what we know can optimize health and what gets implemented. Dissemination and implementation science seeks to address this gap by understanding how best to transfer efficacious and effective programs into real world settings. The purpose of this presentation is to share the commencement phase of our dissemination and implementation study. We seek to facilitate increased dissemination and implementation of an innovative and effective theory-guided, evidence-based academic asthma health education and counseling self-management program into schools and community settings. We are using the program to challenge an existing paradigm that condition-specific asthma self-management programs are inappropriate for academic settings and to address a critical school barrier to progress in the field of asthma self-management. The novel program, Staying Healthy-Asthma Responsible & Prepared™ (SHARP) has two components: a school component for older school age students with asthma aged 9–14 years enrolled in grades 4–7 delivered by trained certified elementary school teachers in schools during instructional time and a community component for invited members of the students’ social networks delivered by public health educators during scheduled evening and weekend events [1–3]. The specific aims of the dissemination and implementation study were formulated to (a) assess the acceptability, integration, and adaptation of SHARP within schools and community settings that serve diverse populations, (b) evaluate the degree of fidelity in whether SHARP’s core components are faithfully transported to real world settings, (c) address issues of SHARP’s complexity, adoption, sustainability, and cost-effectiveness, and (d) determine the impact of SHARP on community-wide outcomes related to school absenteeism and use of healthcare services.

Framework: The Transdisciplinary Dissemination and Implementation of SHARP Model (TDISM) used to guide the study integrates concepts and processes of three related frameworks: (a) the Consolidated Framework for Implementation Research (CFIR) that provides structure for implementing complex, interacting, and multi-level interventions in real world settings [4], (b) the Logic Model of School-based Asthma Interventions (LM-SAI) that provides structure for implementing asthma health education and counseling programs in school settings [5], and (c) the Acceptance of Asthma Model (AAM) that served as the basis for development and evaluation of the SHARP program.

Participants: We used outreach, engagement, and marketing efforts to launch dissemination and implementation across the United States and around the globe. We contracted with site principal investigators to identify and recruit targeted users as study participants; specifically, program champions who in turn identify and recruit school liaisons, certified elementary school teachers, and public health educators. Champions such as school nurses are responsible for promoting the program within school districts and community settings. School liaisons such as school personnel with access to district-wide databases are responsible for recruiting students with asthma and their caregivers into the program. Certified elementary school teachers identified by the district are responsible for delivery of SHARP’s school component. Public health educators are responsible for delivery of SHARP’s community component. We orient, train, monitor, and evaluate targeted users in their respective roles and provide them with user-specific packaged program materials.

School-based Intervention: When the National Asthma Education and Prevention guidelines recommended expanding asthma self-management education to schools and community settings to address high morbidity and mortality outcomes in diverse older school age students; schools were reluctant to adopt programs that were not academically-focused. Using a transdisciplinary and community-based participatory approach, we collaborated with health professionals, school personnel, and community partners to develop SHARP as a comprehensive and developmentally-appropriate academic asthma health education and counseling self-management program [1–3]. SHARP has features that appeal to school administrators because the program complements existing curricula by integrating biology, psychology, and sociology content with related spelling, math, reading, writing, and art assignments as an elective course that meets benchmarks for grades 4–7 and performance-based assessment activity consistent with grade 5. A series of randomized clinical trials confirmed SHARP’s feasibility, benefits, efficacy, and effectiveness on improving cognitive, psychosocial, and behavioral factors that impact condition control, quality of life, and use of health care service outcomes in racially-diverse, medically-underserved, inner-city, lower socioeconomic families.

Method: We used the TDISM to guide the commencement phase of dissemination and implementation. During the commencement phase, we partnered with technology and education specialists to transfer our orientation, training, and certification modules as well as monitoring checklists and evaluation surveys to an online format. The online format has the capacity for (a) a public platform to promote and market the program, (b) an individual login platform with a series of eLearning modules for training and certification of targeted users, (c) a user group survey platform for monitoring and evaluating ongoing dissemination and implementation efforts, and (d) a secure platform for ordering program materials, supplies, and products. We created the public platform for advertisement and marketing at the individual, district, community, state, national, and international levels using all forms of communication such as social media, face-to-face, email, pamphlets, presentations, and bulleted-talking-point handouts. In addition, space on the public platform was allocated for sharing students’ competitively-selected creative and written expressions of what it is like for them to live with asthma. We created the individual login platform to streamline time and effort invested in training and certification of individually-targeted users. For example, school teacher training was streamlined from 12 face-to-face hours to six online hours while retaining important content and allowing for review using a series of four eLearning modules. We created the user group survey platform to respond to participant feedback in real time and to post responses to frequently asked questions. We contracted to use the university’s secure payment platform for ordering, downloading, and/or purchasing SHARP materials and products including: (a) curriculum manuals, student workbooks, community handouts, invitation notecards, and certificates, (b) teaching flip charts for the school component and PowerPoint slides for the community component, and (c) peak flow meters, expandable sponges, stethoscopes, spacers, refrigerator magnets, asthma stat cards, mugs, pins, and stickers.

Evaluation: We chose to use a hybrid, blended, type III implementation design. Study participants include the targeted users; specifically program champions, school liaisons, school teachers, and public health educators. We chose not to include students with asthma and members of their social networks enrolled in the SHARP program as participants in this study because no data will be collected directly from students or members of their social networks. Targeted users will report student participation and progress in aggregate format. We evaluated the commencement phase and will continue to evaluate every phase of dissemination and implementation using online surveys. The user group platform sends emails to targeted individuals and/or groups with links to the online system at preset intervals. We selected reliable and valid measures as well as pragmatic open-ended and guided interview items that map to CFIR domains and constructs to assess and address our dissemination and implementation aims. We modified our existing session-specific checklists to evaluate the degree of fidelity in delivery of SHARP’s core components. We integrated reliable and valid scales and sub scales used in our previous studies into program training and ongoing monitoring. We partnered with epidemiologists to obtain public data to determine SHARP’s impact on two major health outcomes over time: (a) district-wide school absenteeism rates and (b) community-wide healthcare services utilization rates such as emergency room visits. We determined a multiple-group pre-post interrupted time series analysis, where one group consists of districts that receive the SHARP program and a matched control group of districts not receiving the SHARP program would be appropriate. A matching process based on propensity scores was established and power estimates for sample size were based on minimum detectable effect sizes. We are using the aims to guide analyses of quantitative and qualitative data.

Implications: Findings will be used to advance dissemination and implementation science, guide dissemination and implementation of other efficacious and effective school- and community-based health education and counseling programs, uncover further direction for dissemination and implementation science, and inform health policy related to delivery of asthma self-management programs in schools and community settings.