Ensuring Access to Albuterol in Schools: From Policy to Implementation. An Official ATS/AANMA/ALA/NASN Policy Statement

Addressing critical barriers for sustainability of asthma stock inhaler policy implementation and resultant programming

BACKGROUND

Asthma is a prevalent health concern among Illinois (IL) children, and management is significantly influenced by social determinants. There were 17 states who have adopted stock inhaler laws, but implementation varies widely.

OBJECTIVE

To assess critical barriers to implementation and address sustainability of stock inhaler programming in school-based asthma care in IL.

METHODS

Semistructured interviews were conducted with high asthma burden school districts in IL to assess barriers in implementing stock inhaler policies and resultant programming. Thematic analysis was performed using Atlas.ti (Scientific Software Development GmbH, Berlin, Germany) to identify and code "threats" to future sustainability. Data were synthesized and presented to stakeholders for barrier mitigation. A schematic flowchart outlining steps to support sustainability was created.

RESULTS

A total of 18 interviews were conducted with key community partners across 8 IL school districts, representing rural, urban, and suburban areas. Analysis revealed 25 barriers, with several identified as "threats" to future sustainability, including liability concerns, follow-up care assurance, funding/resources, pharmacy dispensing practices, district-level readiness to change, and nurse staffing. Stakeholders formed a statewide coalition to address these barriers, increase awareness, plan evaluations, and advise on state funding allocation. A national stock inhaler toolkit tailored to school administrative needs was developed to support sustainability efforts.

CONCLUSION

Strategic stakeholder and community engagement are vital for establishing and sustaining stock inhaler programs that adhere to policy mandates. Many districts face challenges initiating and maintaining such programs without critical barrier mitigation and support. Collaborative solutions are necessary to ensure effective school-based asthma management and mitigate persistent pediatric asthma health disparities.

Advocacy and Health Equity: The Role of the Pediatric Pulmonologist

Pediatric pulmonologists have the expertise to be advocates in many areas that affect the respiratory health of children. This article provides an overview of selected advocacy topics related to health equity and provides key examples that can improve child respiratory health in the clinical encounter and beyond.

Safe Administration of Medication in School: Policy Statement

Many youth with acute and chronic health conditions require medication to be administered during the school day. This policy statement offers guidance to school physicians, community prescribers, school nurses, other school health professionals, and groups providing oversight to school health activities and ensures patient safety and equity lenses are applied to administration of medications during school and for school-related activities. The American Academy of Pediatrics supports a robust collaborative model that allows all those involved in student health, including the student and family, to communicate, participate in effective medication management, inform delegated medication responsibilities, and promote safe medication storage and administration. School medication administration protocols are developed to help prevent medication administration errors specific to potential risks in the school setting and are responsive to the maturing students' evolving understanding of their health needs, growing autonomy, and responsibility. All protocols involving school nurses, unlicensed assistive personnel, and prescribers must be consistent with state and federal regulations on scope of practice, student privacy laws, and professional nursing organization guidelines. Consistent policies and messaging on safety of the patient and the entire school community enable school health teams to ensure equitable treatment of students prescribed therapeutic agents newly regulated by the US Food and Drug Administration, over-the-counter medications, or products that are currently not regulated by the US Food and Drug Administration.

How Schools Can Help Address Social Determinants of Health in Asthma Management

Schools are in a unique position to address social determinants of health (SDOHs) in pediatric asthma management because of their potential to provide resources and facilitate collaboration with health care providers and services for children at risk within their community. SDOHs include economic factors, educational attainment and health literacy, neighborhood factors and the built environment, social and community aspects including discrimination and racism, and health care access and quality. These factors have a significant impact on asthma health in children, and certain populations such as minoritzed populations and those living in high-poverty environments have been shown to be at greater risk for adverse effects of SDOHs on asthma outcomes. School-based asthma programs address several SDOHs including health literacy, the built environment, and health care quality and access and have been shown to improve asthma outcomes. Key components include connection between the school and the health care team, self-management education, and directly observed therapy. School nurses play a key role in directing and managing effective programs because they can evaluate and support a student's health while considering the effect of SDOHs at interpersonal, institutional, community, and policy levels.

Pharmacists' perspectives on school stock inhaler access for children

Several states in the United States (U.S.) have laws permitting stock inhalers, including short-acting beta-agonist inhalers, such as albuterol, and spacers to be prescribed to, dispensed to, and stocked in schools for use in students in respiratory distress, based on a protocol. This survey study assessed Arizona pharmacists' (1) levels of comfort for dispensing a short-acting beta-agonist inhaler to an individual child versus a stock inhaler to a school, and (2) awareness of the related Arizona state law. Researchers surveyed pharmacists licensed in Arizona who self-reported practicing in an outpatient pharmacy setting. Among 251 pharmacist participants, 62% practiced in a chain community pharmacy. About 80.8% felt comfortable filling a prescription for an albuterol inhaler in a pediatric patient case, whereas only 26.7% felt comfortable filling a prescription for albuterol inhalers to be used as stock inhalers for a given school. Among those who would not fill the stock inhaler prescription, only 5.5% reported awareness of the state law compared to 42.6% of those who would fill it (p < 0.0001). This survey identified a lack of pharmacist awareness of state laws pertaining to stock inhalers for schools.

Appropriate inhaler use in children with asthma: barriers and opportunities through the lens of the socio-ecological model

Objective: Proper use of inhaled medications is essential for management of asthma, as inhaled therapies are recommended as first-line for both prevention and treatment of asthma symptoms. Optimizing adherence requires identifying and understanding multiple layers of systemic complexity to obtaining and using these therapies and offering specific solutions to address these barriers. Bronfenbrenner's socio-ecological model provides a framework for examining multilevel systems - both internal and external - that contribute to the management of childhood asthma. The four levels in this model consist of factors related to the individual, interpersonal relationships, organizational entities, and societal structures and rules. This narrative review identifies influences and factors related to asthma inhaler adherence by each level and offers evidence-based solutions to each obstacle.Data Sources: We conducted PubMed searches to identify relevant articles for barriers and solutions impacting asthma control at each level of the socio-ecological model.Study Selection: Common barriers to asthma control at each model level were identified. Pertinent studies for each barrier were identified and reviewed by the writing group for inclusion into the narrative review.Results: For each level of the socio-ecological model, three primary issues were identified based on the literature review. Approaches for addressing each issue in an evidence-based, systematic fashion are presented.Conclusion: Understanding the obstacles and potential interventions to achieve proper use of inhaled medications is a critical step necessary to develop and implement systematic solutions aimed at improving asthma control and morbidity for the more than 6 million affected children in the United States.

Updates in school-based asthma management

PURPOSE OF REVIEW

School-based asthma management is an important component of pediatric asthma care that has the potential to provide more universal evidence-based asthma care to children and mitigate asthma-related health inequities. The purpose of this review is to highlight relevant developments in school-based asthma management over the past 2 years.

RECENT FINDINGS

There have been considerable recent scientific advances in school-based asthma management including robust clinical trials of environmental interventions in the classroom setting, school-nurse led interventions, stock albuterol policy changes, school-based telemedicine approaches and innovative methods to engage community stakeholders in research that have pushed the frontiers of school-based asthma care.

SUMMARY

Recent scientific work in school-based asthma management demonstrates the potential power of schools in providing access to guideline-based asthma care for all children with asthma and in improving their health outcomes. Future work should focus on the evaluation of methods to promote the adoption of school-based asthma management strategies in real-world practice and support evidence-based policy change and strategic partnerships to improve asthma health outcomes and produce meaningful public health impact for diverse children and families.

Ensuring equitable access to guideline-based asthma care across the lifespan: Tips and future directions to the successful implementation of the new NAEPP 2020 guidelines, a Work Group Report of the AAAAI Asthma, Cough, Diagnosis, and Treatment Committee

The most recent recommendations from the 2020 National Asthma Education and Prevention Program Update and Global Initiative for Asthma 2021 guide evidence-based clinical decision making. However, given the present state of health disparities by age, income, and race, the equitable implementation and dissemination of these guidelines will be unlikely without further guidance. This work group report reviews the current state of the new asthma guideline implementation; presents updated evidence-based therapeutic options with attention to specific patient populations; and addresses barriers to the implementation of these guidelines in minoritized, historically marginalized, and underresourced communities. Allergists and immunologists can use practical ways to accomplish the goals of improved asthma care access and advanced asthma care across the life span, with specific considerations to historically marginalized populations. Modifiable barriers to guideline implementation include financial barriers, environmental factors, and allergy subspecialty access and care coordination. Various programs to improve access to guideline-based asthma care include community programs, school-based asthma programs, and digital health solutions, with an emphasis on reducing disparities by race.

Asthma medications in schools: a cross-sectional analysis of the Asthma Call-back Survey 2017-2018

CONTEXT

Asthma is the most common chronic disease affecting children in the United States. Goals for asthma management include symptom control, the ability to maintain a normal activity level, and minimizing adverse events.

OBJECTIVES

The objective of this study is to analyze the number of children with asthma that are permitted to carry medications at school and without an asthma action plan.

METHODS

In this study, we analyzed the Center for Disease Control and Prevention (CDC) Asthma Call-back Survey (ACBS) to assess the prevalence of children in school allowed to carry medication and with asthma action plans. Utilizing the sampling weights provided, we estimated population prevalence by age group and urbanicity.

RESULTS

Results showed that, overall, 34.8% of students reported they were not allowed to carry asthma medications in school. Specifically, nearly 51% of children ages 5 to 9 and 33% of children ages 10 to 14 were reported not to be allowed to carry medications at school. Further, 58.2% of children did not have a written asthma action plan. Reported urbanicity was not significantly associated with access to medication at school (p=0.46) or having an asthma action plan (p=0.57).

CONCLUSIONS

In our study, more than one-third of students were not permitted to carry asthma medications and nearly three-fifths did not have a written asthma action plan. Therefore, we recommend partnerships between schools, healthcare professionals, students, and osteopathic family physicians to increase access to asthma action plans and medication in schools.