A team of CU researchers is making strides to advance health equity by reducing pediatric asthma disparities. Their research is part of the Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease Risk (DECIPHeR) Alliance. This Alliance is a set of seven programs funded by the National Heart, Lung, and Blood Institute (NHLBI) to eliminate cardiopulmonary health disparities.
The Colorado DECIPHeR team, led by Stanley Szefler, MD, professor of pediatrics, Amy Huebschmann, MD, MSCS, associate professor of medicine at the University of Colorado School of Medicine, and Lisa Cicutto, PhD, RN, director of community research at National Jewish Health, is the only team to focus on pediatrics and asthma.
“Lisa and Stan both have expertise in the management of pediatric asthma and addressing health disparities by managing asthma within schools. Over the past two decades, they have developed the school-based asthma program that we're evaluating together in this trial, with Lisa bringing additional expertise from working in rural settings,” says Huebschmann, an implementation scientist with the Adult and Child Center for Outcomes Research and Delivery Science (ACCORDS).
Building on local success
The DECIPHeR study is a seven-year grant that included a three-year planning period that ended in August 2023. The researchers are in the first year of a four-year pragmatic trial.
The Colorado study, Reducing Asthma Attacks in Disadvantaged School Children with Asthma, focuses on improving asthma disparities for children ages 5-12 years in low-income communities in Colorado. They are currently testing their clinical trial, the Better Asthma Control for Kids (BACK) Program, an evidence-based program for addressing pediatric asthma disparities, in four new regions of the state. The purpose is to determine whether they can replicate the positive findings of their longstanding program developed in the Denver area. Rather than using a one-size fits all approach to scale BACK, the team has worked with a community-advisory board in each of the four regions to tailor the implementation approach to local contextual priorities, resources, and needs.
Szefler has directed the original version of the BACK program, the Colorado Comprehensive School-Centered Asthma Program (AsthmaCOMP), in Denver Public Schools since 2006. It began with a grant from the Colorado Department of Public Health and Environment (CDPHE), which continues funding the program today. The aim of the new study is to compare the reach to students and families when implementing two separate BACK program strategies, and to compare the effectiveness of BACK and usual care on asthma exacerbations. Working with their advisory boards, the BACK team is making plans to sustain the program in the participating schools beyond the project phase and hopes to work with other partners to further scale it to other locations in Colorado and nationally.
Addressing disparities through community engagement
A special DECIPHeR Issue of the journal Ethnicity & Disease released in April included three publications from the Colorado DECIPHeR team. In these articles, the researchers discuss selected findings from the initial three-year planning period.
Sarah Brewer, PhD, MPA, assistant professor in the Department of Family Medicine and ACCORDS Education Program director, is lead author of two publications in the special issue.
In the first paper, “Understanding Core Community Needs for School-Based Asthma Programming: A Qualitative Assessment in Colorado Communities,” the researchers worked with community advisory boards to interview community members to understand their needs.
“What we found were three tiers of things that our communities needed,” says Brewer, a mixed methodologist leading the qualitative research on the DECIPHeR study. “The foundational pieces were buy-in from stakeholders and asthma prioritization. Next was relational — we need to have people at the table talking about each child’s needs and supporting their asthma management, including school nurses, asthma navigators, social service resource agencies, and parents. Lastly, we could think about functional needs like making sure kids had their inhalers at school, that they had care plans in place, and that people had education about asthma. Those things had to build on each other to bring this program to new places.”
Development of tools
Brewer says that through these community interviews, the researchers learned of concerns about social needs screening. In the second publication, “Developing a Social Determinants of Health Needs Assessment for Colorado Kids (SNACK) Tool for a School-Based Asthma Program: Findings from a Pilot Study,” the researchers developed a new screening tool they felt was a better fit than existing tools for asthma navigators to use with families.
“One component of the BACK program is helping people deal with their social needs, whether that's food insecurity, access to medication, or transportation to their medical appointments to manage their asthma,” Brewer says. “We heard that there was a need for a more tailored tool to do that. Many of the tools were tailored for clinical settings, but we need something that works in a school-based program with community-based navigators supporting families.”
To help scale the school-based asthma program, the team has also created an online implementation guide. Huebschmann shares lessons from the field when building the implementation guide in a third article, “Notes From the Field: Diverse Partner Perspectives Improve the Usability and Equity Focus of Implementation Guides.”
“We created the website with sections to fit the needs of everyone who is part of the BACK program. For example, school nurses have a resource library that is based on the phases of the school year, as their day-to-day work varies seasonally. We also made a portion of the website with tabs for resources that would be useful for families of children with asthma, which can be translated into over 100 languages to serve diverse communities. Health care providers have their own section to explain how the BACK program works and to access resources. The asthma navigators, who are key implementers of BACK, can access information they need on the back end,” Huebschmann says. “The article explains our process and how we worked with the end users and developed this with them in mind.”
Expanding school-based asthma support
The researchers say the trial only works due to the high levels of engagement at all levels. They cite the support of the community advisory boards, schools, school districts, nurses, and primary care providers who are interfacing with the intervention as key components.
The trial also relies on partnerships with a variety of working groups, a state advisory board, a scientific advisory council, Trailhead Institute, and the National Association of School Nurses to implement the school-based program. The trial has also benefitted from the input provided by the National Heart Lung and Blood Institute including their technical advisory panel and Research Coordinating Center.
The four regions currently in the trial are Lower Arkansas Valley, Greeley/Weld/Morgan, Pikes Peak/Colorado Springs, and Mesa/Delta/Montrose.
“We’ve repeatedly observed reduction in asthma hospitalizations and exacerbations or urgent care visits by about 80% in the first year when we work with students in the schools through AsthmaCOMP. Our goal with DECIPHeR is to see if we can replicate the success in the large urban setting into settings outside of Denver, including rural areas,” Szefler says.
