Asthma OpEd Mindful Breathing

A Breath of Fresh Air: Utilizing Community Health Advocates and Student Educators to Combat the Asthma Epidemic in Southeast Washington, DC Schools

  • Savanna Vidal, Therese Bueno, Hannah Kralles, Carolina Rivera
  • Clinical Public Health Summit on Childhood Asthma
  • GW School of Medicine and Health Sciences, MD Class of 2025

There is no justifiable reason why the children in our communities should not be able to breathe. The culprit of this suffocation, you ask? Asthma. As if this prospect is not startling enough, the roles of race/ethnicity, poverty, and urban dwelling as risk factors for higher asthma-related morbidity only exacerbate this reality (Milligan et. al, 2016). In the context of our local community, Wards 7 and 8, located in SE Washington, DC have endured this disease burden of childhood asthma for far too long. Ankoor Shah, the medical director of the asthma clinic at Children’s National Hospital in DC, states that childhood asthma “disproportionately affects poor, urban minority children. And the severity is worse, specifically when you think about Wards 7 and 8,” (Baskin, 2019). Additionally, children ages 4-15 in Wards 7 and 8 have some of the highest Emergency Department visit rates for asthma in the district (Children’s National, 2017). Challenged by a multitude of gaps, notably in healthcare access and education, the tool we propose to address this is bestowed in the power of community health workers (CHWs) as community health advocates (CHAs) and supportive student educators (SEs). The implementation of a hybrid model of individualized care helps breathe life back into the asthmatic children in our community.

Our innovative two-pronged approach sits at the heart of meeting patients and caregivers where they are at — combining education, resources, and community in a holistic model to improve care for children with asthma. The first part of this model is centered on the implementation of permanent, full-time CHAs in high-need schools in Southeast Washington, DC. Such CHAs will serve as a powerful tool to link families to resources and educate students on all-things asthma. CHAs will engage the entire school community in ongoing education surrounding asthma: triggers, medication technique and adherence, and exacerbation protocols. With introductions made at parent-teacher meetings, CHAs will serve as a trusted point-person to assist caregivers in obtaining health insurance, help with assistance programs applications, and connect with legal aid for housing concerns. As a permanent employee, CHAs will follow up with caregivers to ensure their successful connection to resources. As asserted by researchers authoring “Community Health Workers: Connecting Communities and Supporting School Nurses,” CHAs are the leaders needed to help schools address complex health challenges (Boldt et. al, 2021).

The hallmark of successful leaders, though, are their support networks, which alludes to the second part of our model: volunteer SEs. The vital work of CHAs will be supplemented by student volunteers and interns lecturing on various educational topics or assisting with resource connection and logistics. Both new CHAs and volunteers will receive training from the Association of Asthma Educators, which organizes their training modules into a high-quality CHA curriculum and Asthma Educator Certification Courses (AAE, 2022).

Furthermore, compensation for full-time CHAs can be paid through governmental grants such as the DC Preventive Health and Health Services Block Grant that funds program areas such as Pediatric Asthma Outcomes and Community Health Improvement Planning (DC DOH, 2021). If additional support is needed, program directors can look toward alternative private and public grants for asthma initiatives as well as appeal to philanthropic foundations.

The final recommendation includes implementing a protocol for continuous evaluation of the proposed two-pronged model. Such evaluative tools can include, but are not limited to, surveys to be filled out by students and families, data gathered on asthma exacerbation rates before and after program implementation, and assessments that accompany each educational module during CHA and SE training.

Fortunately, the CHA model has been widely implemented and proven successful in countless health sectors nationwide. This demonstrates promise in the expansion of the CHA role to reach schools where students suffer the consequences of inadequate asthma healthcare. In fact, according to data posted by the U.S Bureau of Labor Statistics in May 2020, Washington DC had one of the highest Location Quotients of CHWs in the country (U.S. Bureau of Labor Statistics, 2020), indicating that this industry is already deeply established in DC (Emsi Burning Glass, 2020). 

Moreover, the need for CHWs in high-need schools is supported by data and research. In a Public Health Nursing study, 72% of 160 Chicago Public School nurses felt that time and communication were the greatest barriers to improving outcomes in pediatric asthma cases. A majority of participants supported the use of web-based applications and assistance from CHWs as effective interventions (A. Pappalaro et. al, 2018). In our model, the CHA will be available both in person or virtually, making them easily accessible and adaptable to student/caregiver preference.

Furthermore, evidence has shown that CHW intervention in the management of asthma, specifically, is highly effective in creating meaningful improvements. This impact is further amplified when implemented in minority and low-income populations. In a 2016-2019 comparative effectiveness trial conducted amongst Hispanic and low-income children in Cook County, Illinois, participants assisted by CHWs reported a 42% reduction in days of activity limitation caused by asthma (M. Martin et. al, 2021). Thus, the role of CHAs in schools, especially within underserved communities, not only lessens the stress and demand placed on school staff but also introduces sustainable asthma management for affected students.

CHWs have been deemed as health advocates, social justice warriors, and a precious resource for underserved communities. School-based CHWs are responsible for bridging the gap between community and cultural barriers as well as contact tracing, infection control, health education, and screenings (Boldt et. al, 2021). Although CHAs might alleviate the burden placed on school nurses, to address increased CHW burnout rate, the supplemental volunteer program would help alleviate the workload while also promoting greater program success (Gunderson et. al, 2018).

Currently, our model mainly focuses on asthma. However, we acknowledge that it is not sustainable to employ a health advocate solely for asthmatic students. Therefore, while the initial focus will be on asthma, our program will require CHAs and SEs be accredited by a renowned association in lecturing and will also allocate resources for additional diseases over time. This will only promote growth within the role and broaden the scope of impact.

Finally, the adaptable hybrid system in which students can schedule virtual meetings with their CHA and attend Zoom lectures hosted by SEs is tailored to the ever-changing school environment during the COVID-19 era. Although digitalization of these services may pose certain technology-based challenges, implementing virtual options have been found to be financially beneficial, improve quality of services, and increase training efficiency and organization of both volunteers and paid workers (Mishra et. al, 2019). Therefore, despite inherent challenges to the proposed model, each can be addressed with innovative approaches that keep the program adaptable and community centric.

The two-pronged Asthma Health Advocates program is vital in addressing the inequitable access to quality healthcare and education by children and their caregivers living in Southeast Washington, DC. This program seeks to mobilize CHWs as student advocates as well as volunteers as community educators. The program builds off prior evidence showing the efficacy of such an approach. The flexibility of the program allows a personalized approach for each child with asthma and their caregivers, living in Washington, DC — effectively making it the breath of fresh air our local communities deserve.

Acknowledgements

The completion of this project could not have been done without the consultation and advice of Ariel Berry. We would also like to thank Dr. Dawes as well as all of the GW and local community members that shared their insights, stories, and expertise to us during the 2022 Asthma Summit.

Refrences

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Pappalardo, A. A., Paulson, A., Bruscato, R., Thomas, L., Minier, M., & Martin, M. A. (2018). Chicago Public School nurses examine barriers to school asthma care coordination. Public Health Nursing, 36(1), 36–44. website

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