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Martinez A, Ye M, Hessler D, de la Rosa R, Benson M, Gilgoff R, Koita K, Bucci M, Harris NB, Long D, Thakur N. Adverse Childhood Experiences and Related Events are Associated with Asthma Symptoms in Children. Acad Pediatr 2024; 24:669-676. [PMID: 38246348 DOI: 10.1016/j.acap.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024]
Abstract
OBJECTIVE To examine the association between adverse childhood experiences (ACEs) and related events and asthma symptom burden in children. METHODS This is a cross-sectional study of baseline data from 147 participants with asthma from a cohort of children enrolled in the Pediatric ACEs Screening and Resiliency Study. Participants completed the PEdiatric ACEs and Related Life Events Screener (PEARLS) tool, a 17-item questionnaire, capturing 3 domains of childhood adversity-child maltreatment, household challenges, and social context. Asthma symptom burden was assessed using the International Study of Asthma and Allergies in Childhood core questionnaire, which asks participants to identify the presence and frequency of severe wheezing that limits speech, wheezing with exercise, nocturnal wheezing, and nocturnal cough in the last 12 months. Using multivariable logistical regression models, we examined the relationship between reported PEARLS and asthma symptoms. RESULTS Of children with asthma, 86% reported at least 1 adversity, with 48% reporting 4 or more. The odds of severe wheeze limiting speech increased by 19% with each additional reported adversity captured by the PEARLS tool (95% confidence intervals (CI) 1.01-1.41). Increasing PEARLS scores were also associated with 16% increased odds of reporting wheeze with exercise (95% CI 1.03-1.31). Wheezing with exercise was associated with the household challenges domain (odds ratio (OR) 1.34; 95% CI 1.05-1.72), while severe wheeze limiting speech was associated with the social context domain (OR 1.75; 95%CI 1.02-3.02). CONCLUSIONS Childhood adversities are associated with increased asthma symptom burden, suggesting the tool may be helpful in identifying children at risk for poorly controlled asthma.
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Affiliation(s)
- Adali Martinez
- University of California San Francisco, School of Medicine (A Martinez, Y Ye, D Hessler, R de la Rosa, and N Thakur)
| | - Morgan Ye
- University of California San Francisco, School of Medicine (A Martinez, Y Ye, D Hessler, R de la Rosa, and N Thakur)
| | - Danielle Hessler
- University of California San Francisco, School of Medicine (A Martinez, Y Ye, D Hessler, R de la Rosa, and N Thakur)
| | - Rosemarie de la Rosa
- University of California San Francisco, School of Medicine (A Martinez, Y Ye, D Hessler, R de la Rosa, and N Thakur)
| | - Mindy Benson
- UCSF Benioff Children's Hospital Oakland (M Benson and D Long), Oakland, Calif
| | - Rachel Gilgoff
- Center for Youth Wellness (R Gilgoff, K Koita, M Bucci, and NB Harris), San Francisco, Calif
| | - Kadiatou Koita
- Center for Youth Wellness (R Gilgoff, K Koita, M Bucci, and NB Harris), San Francisco, Calif
| | - Monica Bucci
- Center for Youth Wellness (R Gilgoff, K Koita, M Bucci, and NB Harris), San Francisco, Calif
| | - Nadine Burke Harris
- Center for Youth Wellness (R Gilgoff, K Koita, M Bucci, and NB Harris), San Francisco, Calif
| | - Dayna Long
- UCSF Benioff Children's Hospital Oakland (M Benson and D Long), Oakland, Calif
| | - Neeta Thakur
- University of California San Francisco, School of Medicine (A Martinez, Y Ye, D Hessler, R de la Rosa, and N Thakur).
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Clark K, Messineo E, Bryant-Stephens T, Song A, Marx D, Lieberman A, Beidas RS, Wolk CB. Evaluating the implementation of a community health worker-delivered intervention integrating asthma care in West Philadelphia public schools. J Asthma 2024:1-11. [PMID: 38299937 PMCID: PMC11291702 DOI: 10.1080/02770903.2024.2313146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/29/2024] [Indexed: 02/02/2024]
Abstract
OBJECTIVE Schools are an important setting because students spend much of their time in school and engage in physical activity during the school day that could exacerbate asthma symptoms. Our objective is to understand the barriers and facilitators to implementing an experimental community health worker-delivered care coordination program for students with asthma within the context of the West Philadelphia Controls Asthma study. METHODS Surveys (n = 256) and semi-structured interviews (n = 41) were completed with principals, teachers, nurses, and community health workers from 21 public and charter schools in West Philadelphia between January 2019 and September 2021. Survey participants completed the Evidence Based Practice Attitudes Scale, the Implementation Leadership Scale, and Organizational Climate Index. Semi-structured qualitative interview guides were developed, informed by the Consolidated Framework for Implementation Research. RESULTS Participant responses indicate that they perceived benefits for schools and students related to the community health worker-based care coordination program. Several barriers and facilitators to implementing the program were noted, including challenges associated with incorporating the program into school nurse workflow, environmental triggers in the school environment, and challenges communicating with family members. An important facilitator that was identified was having supportive school administrators and staff who were engaged and saw the benefits of the program. CONCLUSIONS This work can inform implementation planning for other locales interested in implementing community-based pediatric asthma control programs delivered by community health workers in schools.
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Affiliation(s)
- Kayla Clark
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elizabeth Messineo
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Darby Marx
- Joan & Sanford I. Weill Medical College of Cornell University, New York, NY
| | - Adina Lieberman
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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3
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Rogers HE, Hershey JA, Morone J, Lipman TH, Wilson-Hall L, Anderson K, Hawkes CP. Perspectives of Pediatric Community Health Workers: Roles, Successes, and Challenges. Health Promot Pract 2023; 24:1206-1214. [PMID: 35876335 DOI: 10.1177/15248399221112866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This multicenter qualitative study described the roles of 10 pediatric community health workers (CHWs) in their own words through exploration of the role features, successes, and challenges in pediatric health care settings across three urban U.S. cities (Philadelphia, New York City, and Cincinnati). Individual, semi-structured telephone interviews were conducted. Interviews described prominent features of the pediatric CHW role, which included taking a family-centered approach to goal setting and determining support needed, ensuring family goals stayed at the center of the work, and acting as a trusted figure for families to talk openly with. CHWs described their role as rewarding, believing in the work, and feeling a sense of fulfillment, and felt successful when families had positive outcomes, including when barriers were eliminated, resources were obtained, or independence was demonstrated by families. Challenges CHWs faced in their roles included establishing trust with families, managing the ever-changing family circumstances many families experience due to socioeconomic barriers, and managing limitations of protocol and restrictions within their roles. This study demonstrated numerous considerations for CHW practice in pediatric health care settings, in addition to considerations for pediatric-specific CHW program development and management. The primary policy implication of this study included a basis for increased funding for CHW programs in pediatric health care settings. This study also demonstrated a need for further research on the change CHWs effect within child and family systems outside of health care, such as schools and child welfare agencies.
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Affiliation(s)
- Hanna E Rogers
- Evaluation Strategies, Ypsilanti, MI, USA
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Jennifer Morone
- Yale University School of Medicine, New Haven, CT, USA
- Veterans Administration Health Services Research & Development, Washington, DC, USA
| | - Terri H Lipman
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- University of Pennsylvania School of Nursing, Philadelphia, PA, USA
- University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | | | - Colin P Hawkes
- Children's Hospital of Philadelphia, Philadelphia, PA, USA
- University College Cork, Cork, Ireland
- University of Pennsylvania, Philadelphia, PA, USA
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Nelin TD, Scott KA, Just AC, Burris HH. Place-Based Strategies Addressing Neighborhood Environments to Improve Perinatal and Preterm Infant Outcomes. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1646. [PMID: 37892309 PMCID: PMC10605196 DOI: 10.3390/children10101646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 09/21/2023] [Accepted: 09/30/2023] [Indexed: 10/29/2023]
Abstract
Preterm birth (defined as birth <37 weeks of gestation) is a significant health concern globally, with lasting implications for individuals, families, and society. In the United States, high preterm birth rates among Black and low-income populations likely result from differences in environmental exposures. Structural racism and economic disadvantage have led to unequal distribution of polluting industrial sites and roadways across society as well as differential access to health-promoting resources which contribute to preterm birth risk. Once born, preterm infants remain at risk for numerous environmentally responsive adverse health outcomes that affect growth and development throughout childhood and adulthood. In this commentary, we describe associations of neighborhood environments with pregnancy and preterm infant health outcomes and propose strategies to address harmful exposures that affect families across the lifespan.
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Affiliation(s)
- Timothy D. Nelin
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (K.A.S.); (H.H.B.)
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Center of Excellence in Environmental Toxicology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA 19104, USA
| | - Kristan A. Scott
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (K.A.S.); (H.H.B.)
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Allan C. Just
- Department of Epidemiology, School of Public Health, Brown University, Providence, RI 02912, USA;
| | - Heather H. Burris
- Division of Neonatology, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA; (K.A.S.); (H.H.B.)
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Center of Excellence in Environmental Toxicology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
- Leonard Davis Institute of Health Economics, Philadelphia, PA 19104, USA
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Harries MD, Xu N, Bertenthal MS, Luna V, Akel MJ, Volerman A. Community Health Workers in Schools: A Systematic Review. Acad Pediatr 2023; 23:14-23. [PMID: 36223871 PMCID: PMC9951773 DOI: 10.1016/j.acap.2022.08.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 07/28/2022] [Accepted: 08/21/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Community health workers (CHWs) are trusted community members who provide health education and care. However, no consensus exists regarding whether community health worker-based interventions are effective within the school setting. OBJECTIVE To determine outcomes and best practices of school-based community health worker interventions. DATA SOURCES PubMed, CINAHL, and SCOPUS databases. STUDY ELIGIBILITY CRITERIA This systematic literature review examined articles that described an intervention led by community health workers, targeted children and/or parents, and took place primarily within a Kindergarten-12th grade school setting. Articles were excluded if they described an intervention outside the United States. PARTICIPANTS Community health workers, children, and/or their parents INTERVENTIONS: School-based community health worker programs RESULTS: Of 1875 articles identified, 13 met inclusion criteria and were included in the final analysis. Of these, 5 described a statistically significant primary outcome. Seven articles provided details regarding community health worker recruitment, training, and roles that would enable reproduction of the intervention. LIMITATIONS This review focused on interventions in the United States. Bias of individual studies had a wide range of scores (9-21). Heterogeneity of studies also precluded a meta-analysis of primary outcomes. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS The utilization of Community health workers in school-based interventions for children and/or parents is promising. This review identified a lack of detail and uniformity in program presentation, specifically with Community health worker recruitment, training, and roles. A standardized reporting mechanism for Community health worker interventions in schools would better allow for reproducibility and scalability of existing studies.
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Affiliation(s)
- Michael D Harries
- Department of Pediatrics (MD Harries, M Bertenthal, A Volerman), University of Chicago, Chicago, Ill.
| | - Nuo Xu
- Department of Medicine (N Xu, V Luna, MJ Akel, A Volerman), University of Chicago, Chicago, Ill
| | - Michael S Bertenthal
- Department of Pediatrics (MD Harries, M Bertenthal, A Volerman), University of Chicago, Chicago, Ill
| | - Viridiana Luna
- Department of Medicine (N Xu, V Luna, MJ Akel, A Volerman), University of Chicago, Chicago, Ill
| | - Mary J Akel
- Department of Medicine (N Xu, V Luna, MJ Akel, A Volerman), University of Chicago, Chicago, Ill
| | - Anna Volerman
- Department of Pediatrics (MD Harries, M Bertenthal, A Volerman), University of Chicago, Chicago, Ill; Department of Medicine (N Xu, V Luna, MJ Akel, A Volerman), University of Chicago, Chicago, Ill
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Akinbami LJ, Bryant-Stephens T. Increasing the Resolution and Broadening the Focus on Childhood Asthma Disparities. Pediatrics 2022; 150:188584. [PMID: 35871698 PMCID: PMC9377684 DOI: 10.1542/peds.2022-057206] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Affiliation(s)
- Lara J. Akinbami
- National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
| | - Tyra Bryant-Stephens
- Children’s Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, Pennsylvania
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Trivedi M, Pappalardo AA, Udoko M, Garg A, Phipatanakul W, Szefler SJ, Nyenhuis SM. Social Determinants of Health in Asthma Through the Life Course. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:953-961. [PMID: 35033702 DOI: 10.1016/j.jaip.2021.12.032] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/29/2021] [Accepted: 12/30/2021] [Indexed: 10/19/2022]
Abstract
There is strong evidence supporting the influence of social determinants of health (SDOH) on the development and progression of asthma. SDOH are defined as conditions in which people are born, grow up, live, work, and age, which influence their opportunity to be healthy, risk of illness, and life expectancy. The goal of this article was to describe 2 case-based approaches (pediatric and adult) to assessing and addressing SDOH in asthma across the life course and in community settings. As asthma providers and specialists, the role of SDOH is complex in our clinical care; however, it is critical to address social needs identified through clinical care for our patients with asthma. Clinical-community partnerships, through grant and cost-sharing mechanisms with resource agencies, are necessary to ameliorate social needs for patients and their communities and have the potential to improve asthma outcomes. Although this is a unique and exciting time in health care to promote individual and population health, knowledge gaps remain, including best practices to integrate holistic SDOH care into the care of patients with asthma.
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Affiliation(s)
- Michelle Trivedi
- Division of Pediatric Pulmonology, University of Massachusetts Chan Medical School, Worcester, Mass; Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Mass; Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, Mass
| | - Andrea A Pappalardo
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Ill; Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Mfonobong Udoko
- Department of Pediatrics, Anschutz Medical Campus, Children's Hospital Colorado Breathing Institute, University of Colorado, Denver, Colo
| | - Arvin Garg
- Department of Pediatrics, University of Massachusetts Chan Medical School, Worcester, Mass
| | - Wanda Phipatanakul
- Division of Asthma, Allergy, and Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Stanley J Szefler
- Department of Pediatrics, Anschutz Medical Campus, Children's Hospital Colorado Breathing Institute, University of Colorado, Denver, Colo; Anschutz Medical Campus, Adult and Child Consortium for Outcomes Research and Delivery Science (ACCORDS), University of Colorado, Denver, Colo
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Busse WW, Kraft M. Current unmet needs and potential solutions to uncontrolled asthma. Eur Respir Rev 2022; 31:31/163/210176. [PMID: 35082128 PMCID: PMC9488919 DOI: 10.1183/16000617.0176-2021] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 09/28/2021] [Indexed: 12/16/2022] Open
Abstract
Despite the availability of effective inhaled therapies, many patients with asthma have poor asthma control. Uncontrolled asthma presents a significant burden on the patient and society, and, for many, remains largely preventable. There are numerous reasons why a patient may remain uncontrolled despite access to therapies, including incorrect inhaler technique, poor adherence to treatment, oversight of triggers and suboptimal medical care. Shared decision-making, good patient–clinician communication, supported self-management, multidisciplinary patient education, new technology and risk stratification may all provide solutions to this major unmet need in asthma. Novel treatments such as biologics could benefit patients’ lives, while the investigations into biomarkers, non-Type 2 asthma, treatable traits and disease modification give an exciting glimpse into the future of asthma care. Despite effective therapies, many patients with asthma have poor asthma control, which is preventable. The benefits of shared decision-making, supported self-management, risk stratification and novel treatments in transforming patient care are reviewed.https://bit.ly/3A386Nm
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Affiliation(s)
- William W Busse
- Dept of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Monica Kraft
- University of Arizona College of Medicine, Tucson, AZ, USA
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Bryant-Stephens T, Williams Y, Kanagasundaram J, Apter A, Kenyon CC, Shults J. The West Philadelphia asthma care implementation study (NHLBI# U01HL138687). Contemp Clin Trials Commun 2021; 24:100864. [PMID: 34926863 PMCID: PMC8649219 DOI: 10.1016/j.conctc.2021.100864] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 10/05/2021] [Accepted: 11/09/2021] [Indexed: 11/28/2022] Open
Abstract
Asthma is the most common chronic condition among children, with low-income families living in urban areas experiencing significantly higher rates. Evidence based interventions for asthma are routinely implemented in either the home, school, or primary care setting. However, even when caregivers of poor children are engaged in asthma interventions in one setting, they often have to navigate challenges in another setting, such as an under-resourced home, non-supportive school, or disengaged health care provider. The West Philadelphia Asthma Care Implementation Plan aims to compare the effectiveness of a primary care-based intervention, school-based intervention, and combined primary care and school intervention to usual care for improving asthma control in school-age children to explore if the synergistic effect of Community Health Worker (CHW) support in the home, school, and health care environments will result in improved asthma control. Children ages 5-13 with uncontrolled asthma from four West Philadelphia recruitment sites will be eligible for enrollment. The families of school age children interested in participating will be randomized to receive a primary care CHW or usual care. Those identified as attending a participating school will have a CHW-led school intervention or usual care in school. If proven effective, this care coordination program will assist caregivers in assessing resources, improving self-management skills, and ultimately reducing asthma-related ED visits and hospitalizations as well as provide additional information for healthcare systems and policy makers to inform their decisions about how and where to focus additional resources and investments in childhood asthma care to improve health outcomes.
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Key Words
- ACQ, Asthma Control Questionnaire
- Asthma
- Asthma in children
- CAPP, Communitiy Asthma Prevention Program
- CHOP, Children's Hospital of Philadelphia
- CHW, Community Health Worker
- Community research
- EBI, Evidence-based intervention
- ED, emergency department
- EHR, electronic health record
- IRB, institutional review board
- Implementation science
- OAS, Open Airways for Schools
- SAMPRO, School-based Asthma Management Program
- SBAT, School-based Asthma Therapy
- WEPACC, West Philadelphia Asthma Care Collaborative
- pCHW, primary care community health worker
- sCHW, school-based community health worker
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Affiliation(s)
- Tyra Bryant-Stephens
- Community Asthma Prevention Program, Sr Director, Center for Health Equity, Associate Professor of Pediatrics, United States
| | | | | | - Andrea Apter
- Perelman School of Medicine at the University of Pennsylvania, United States
| | - Chén C. Kenyon
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States
| | - Justine Shults
- Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, United States
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Everhart RS, Corona R, Mazzeo SE, Dempster KW, Schechter MS. School Nurses' Perspectives on Components of Asthma Programs to Address Pediatric Disparities. J Pediatr Psychol 2020; 45:900-909. [PMID: 32524136 PMCID: PMC7828575 DOI: 10.1093/jpepsy/jsaa039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 02/29/2020] [Accepted: 05/02/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE To use a community engaged, collaborative approach with school nurses working within an urban community, to develop recommendations for future school-based interventions targeting pediatric asthma disparities. METHODS Open-ended survey data were collected from 33 nurses (77% of nurses in the school district) during a face-to-face monthly health services meeting. Questions asked nurses to estimate the proportion of students with asthma with the necessary forms and medications at school and to describe perceived barriers to having such forms and medications, and potential initiatives that could be implemented. A 30-min asthma education class was also piloted with school nurses, who then rated its acceptability and feasibility. Open-ended survey data were analyzed using thematic analysis. RESULTS Nurses estimated that 12% of students with asthma had an asthma action plan, 19% had a medication release form, and 15% had medications at school (i.e. inhalers). Four themes emerged regarding barriers to asthma management in schools and strategies for promoting asthma management in schools: coordination of care, asthma education, access to care, and medication adherence. Nurses noted the need for education focused specifically on teaching inhaler technique, and better communication between schools, providers, and families. CONCLUSIONS School nurses provided valuable information regarding specific barriers, as well as approaches to addressing these barriers in a future intervention. Findings suggest that a school-based intervention needs to address coordination among schools, parents, and medical providers, and will be optimally effective if it also addresses structural barriers.
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Affiliation(s)
| | - Rosalie Corona
- Department of Psychology, Virginia Commonwealth University and
| | | | | | - Michael S Schechter
- Division of Pulmonary Medicine, Department of Pediatrics, Children’s Hospital of Richmond at VCU
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