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Childhood Asthma, Immigration, and Poverty Case ScenarioSara Benist, Bridgette Fox, Devika Menon, Haley GoughnourHPRB 3700Case Scenario #11Due date: 11/29/18Table of Contents TOC \o "1-3" \h \z \u CASE SCENARIO PAGEREF _Toc531210742 \h 4HEALTH ISSUE PAGEREF _Toc531210743 \h 4Definition and symptoms PAGEREF _Toc531210744 \h 4Diagnosis PAGEREF _Toc531210745 \h 5Types of asthma PAGEREF _Toc531210746 \h 5Risk factors PAGEREF _Toc531210747 \h 7Biological and genetic factors PAGEREF _Toc531210748 \h 7Environmental factors during childhood and in utero PAGEREF _Toc531210749 \h 8The hygiene hypothesis PAGEREF _Toc531210750 \h 9Medications to manage symptoms PAGEREF _Toc531210751 \h 9Triggers PAGEREF _Toc531210752 \h 11Reducing triggers PAGEREF _Toc531210753 \h 11IMPACT OF CULTURE PAGEREF _Toc531210754 \h 13Immigration PAGEREF _Toc531210755 \h 13Korean social norms PAGEREF _Toc531210756 \h 14Seeking health insurance PAGEREF _Toc531210757 \h 15Religious beliefs PAGEREF _Toc531210758 \h 15Importance of work and education PAGEREF _Toc531210759 \h 16Race and ethnicity PAGEREF _Toc531210760 \h 17School PAGEREF _Toc531210761 \h 17Governmental health programs PAGEREF _Toc531210762 \h 19NEEDS ASSESSMENT PAGEREF _Toc531210763 \h 20The case and who is impacted PAGEREF _Toc531210764 \h 20Health insurance needs PAGEREF _Toc531210765 \h 20Immigration-affected needs PAGEREF _Toc531210766 \h 21Housing needs PAGEREF _Toc531210767 \h 22School needs PAGEREF _Toc531210768 \h 23RESOURCES PAGEREF _Toc531210769 \h 24Athens Neighborhood Health Center PAGEREF _Toc531210770 \h 24School System resources PAGEREF _Toc531210771 \h 26Northeast Health District PAGEREF _Toc531210772 \h 27Children’s Medical Services PAGEREF _Toc531210773 \h 28Temporary Assistance for Needy Families PAGEREF _Toc531210774 \h 29Medicaid and CHIP PAGEREF _Toc531210775 \h 30Mercy Health Center and Athens Nurses Clinic PAGEREF _Toc531210776 \h 31Piedmont Athens Regional Hospital PAGEREF _Toc531210777 \h 32SUSTAINABILITY PAGEREF _Toc531210778 \h 33Increasing access to health care and resources PAGEREF _Toc531210779 \h 33A living wage PAGEREF _Toc531210780 \h 34Universal health coverage PAGEREF _Toc531210781 \h 34Asthmatic safe housing/environment PAGEREF _Toc531210782 \h 35Breathe Easy Home PAGEREF _Toc531210783 \h 36Purpose Built Communities PAGEREF _Toc531210784 \h 36Athens Wellbeing Project PAGEREF _Toc531210785 \h 38Safe schools PAGEREF _Toc531210786 \h 38REFERENCES PAGEREF _Toc531210787 \h 40RESOURCE HANDOUT PAGEREF _Toc531210788 \h 49REFLECTIONS PAGEREF _Toc531210789 \h 51CASE SCENARIOSun-ja came to the United States from South Korea with her parents when she was a young girl. Her son, Jun-suh, is five years old. He has asthma that can be severe. Jun-suh will begin school this year and Sun-ja is worried about how he will be helped to control his asthma when he is away from her. She is having some trouble with medical bills as Jun-suh is covered by Medicaid, and it does not cover all of his treatment. What is available at the elementary school he will attend? What is recommended for him? Are there resources for her to help with his situation?HEALTH ISSUEDefinition and symptomsAffecting 25 million people, asthma is a chronic inflammation disease which affects lung capacity by narrowing the airways (National Heart Lung and Blood Institute, 2018). Individuals with asthma will always have some inflammation in airways, but during a flare up or when symptoms appear, muscles surrounding bronchial tubes constrict, airway tissues swell, and mucus production increases (American Academy of Allergy Asthma and Immunology, 2018a; National Heart Lung and Blood Institute, 2018). The result of these biological processes is difficulty breathing which is commonly presented as wheezing, or a whistle-like sound when breathing (American Academy of Allergy Asthma and Immunology, 2018a). Other symptoms include tightness in chest, shortness of breath, and coughing in the morning or during the night (Centers for Disease Control and Prevention, 2018; National Heart Lung and Blood Institute, 2018). When symptoms persist, an asthma attack occurs and needs medicine (National Heart Lung and Blood Institute, 2018). Rarely, if symptoms are not controlled, death by asphyxiation can occur (Boehlke, 2013).DiagnosisA primary care physician or allergist can diagnose asthma through a physical exam (American Academy of Allergy Asthma and Immunology, 2018a; Centers for Disease Control and Prevention, 2018). Along with asking for the medical history of the individual and their family, individuals being tested will take a breathing test called spirometry which measures how much air the individual can breathe in and out as well as how quickly they can expel the air (American Academy of Allergy Asthma and Immunology, 2018a; Centers for Disease Control and Prevention, 2018). Another diagnostic method is a peak flow test which measures the volume of air an individual can expel quickly (National Heart Lung and Blood Institute, 2018). The maximum volume decreases for people with asthma due to airway constriction (National Heart Lung and Blood Institute, 2018). Other tests include a bronchoprovocation test which uses spirometry under different scenarios, such as while exercising or after breathing in cold air, to determine triggers or an exhaled nitric oxide test to test the level of inflammation and the effect of bronchodilator medication on lung function (American Academy of Allergy Asthma and Immunology, 2018a). Types of asthmaThere are multiple types of asthma that can be diagnosed by a physician based on triggers or circumstances surrounding asthma flare ups. One type is allergic asthma which occurs when an allergen is detected by the immune cells in the lungs and causes a systemic response (Boehlke, 2013). These cells produce antibodies that activate mast cells which produce substances such as histamine and prostaglandin D2 (Boehlke, 2013; National Heart Lung Blood Institute, 2018). Histamine and prostaglandin D2, along with other produced substances, cause increased mucus production in the lungs, narrowing the airways (Boehlke, 2013). Allergic asthma can also be inherited parent to child (National Heart Lung and Blood Institute, 2018). Cough variant asthma is another form of asthma that occasionally overlaps with allergic asthma, but the only symptom present is coughing (National Heart Lung and Blood Institute, 2018).Workers in industrial jobs are at risk of developing asthma. Asthma caused by chemicals or irritants found in the workplace is called occupational asthma; high doses of ammonia, hydrochloric acid, or sulfur dioxide can cause asthmatic symptoms that worsen while exposed at work (American Academy of Allergy Asthma and Immunology, 2018b). These chemicals are usually found in industrial jobs (American Academy of Allergy Asthma and Immunology, 2018b). In addition to serious irritants, other common irritants may trigger asthmatic symptoms at work including tobacco smoke from coworkers, cleaning products, dust, animals, and molds (National Heart Lung and Blood Institute, 2011).Lastly, nocturnal asthma is based on an individual’s lung function at night. During the day, lung function is normal, but the function decreases during night (National Sleep Foundation, 2018). The reasoning behind the reduced lung function is not known (Francisco et al., 2018). It is unclear whether a circadian rhythm factor is responsible, but one theory believes the airways might be more inflamed in the night (Francisco et al., 2018). The lungs also get more resistant with deeper sleep; the longer a person sleeps, the greater the impairment of their lungs (National Sleep Foundation, 2018). In addition to categories concerning asthmatic triggers, asthma can also be divided into four categories based of the severity of symptoms and attacks. The four categories are intermittent, mild persistent, moderate persistent, and severe persistent (American Academy of Pediatrics, 2015). Intermittent asthma is less than three days a week with no symptoms between flare ups (American Academy of Pediatrics, 2015). Mild persistent asthma can be characterized by symptoms occurring more than two days a week but less than once a day with at least 80% lung functioning (American Academy of Pediatrics, 2015). Moderate persistent asthma has symptoms occurring daily with flare ups lasting several days and lung function at 60% to 80% of normal functioning without medication (American Academy of Pediatrics, 2015). Severe persistent asthma can be characterized by more than six serious attacks each year, symptoms between attacks, more than ten missed school days or work days, and two or more hospitalizations per year (Boehlke, 2013). Attacks are usually spaced in-between non-symptomatic intervals, but people experiencing asthma may have more severe attacks following an initial attack (Boehlke, 2013). This is called the late-phase response and can occur 6-8 hours after the initial attack (Boehlke, 2013).Finally, asthma can also be categorized into extrinsic and intrinsic (Asthma and Allergy Foundation of America, 2017). People with extrinsic asthma, also known as allergic asthma, experience an allergic reaction caused by the immune system reacting to an allergen, which produces asthmatic symptoms (Asthma and Allergy Foundation of America, 2017). Intrinsic asthma, or non-allergic asthma, does not involve the individual's immune system, and asthmatic symptoms are caused by inflammation and airway blockage (Asthma and Allergy Foundation of America, 2017). Intrinsic asthma attacks can be caused by stress, anxiety, exercise, hyperventilation, or cold and dry air (Asthma and Allergy Foundation of America, 2017). Risk factorsBiological and genetic factors Although the cause of asthma is not well known, some factors in early life may contribute to the development of the disease. Family history of developing allergies and asthma, known as atopy, is a large biological contributing factor in addition to a parent having asthma (American Academy of Allergy Asthma and Immunology, 2018a). Many people with asthma also have elevated levels of immunoglobulin E, a substance that indicates an allergic reaction within the body which causes overproduction of mucus in the lungs (Boehlke, 2013). High levels of immunoglobulin E is a biological risk factor for allergic asthma (Boehlke, 2013). Environmental factors during childhood and in utero Early childhood environmental stressors may also increase the risk of developing asthma (American Lung Association, 2018). Environmental factors include exposure to allergens the child may have, severe respiratory infections, or severe viral infections during early childhood may play a role in developing asthma (American Academy of Allergy Asthma and Immunology, 2018a). Other environmental factors contributing to asthma include air pollution, psychological stress, and unsafe neighborhoods (Akinbami, Simon, & Rossen, 2016; Arthur et al., 2018). A low level of perceived community safety is associated with higher rates of diagnosed respiratory illness, and poor air quality due to air pollution is linked to the development of asthma as well as a trigger for asthma attacks (Arthur et al., 2018). Without safe and secure neighborhoods, individuals are not able to participate in outdoor activities and exercise and experience a greater amount of stress from lack of security, increasing their risk of health issues such as asthma (Arthur et al., 2018).In addition to exposure to environmental irritants during young childhood, exposure to air pollution in utero may affect how fetal lungs develop (Bose et al., 2018). During gestational time period where lung development occurs, maternal exposure to nitrate (NO3-) air pollution may affect how well an infant’s lungs develop, with male infants more affected by the air pollution (Bose et al., 2018). This disparity between sexes may be an explanation for higher prevalence of asthma in male children compared to female (National Heart Lung and Blood Institute, 2018). Other prenatal factors can affect the risk of developing asthma. Vitamin D deficiency within the womb can lead to improper development and maturation of fetal lungs (Miraglia del Giudice, 2014). Additionally, the levels of vitamin D from umbilical cord blood are inversely correlated with the risk of respiratory infections and wheezing in children (Miraglia del Giudice, 2014).The hygiene hypothesis One explanation for high rates of asthma as well as allergies and eczema in developed countries is the hygiene hypothesis (American Academy of Allergy Asthma and Immunology, 2018a; Food and Drug Administration, 2018). Due to an emphasis placed on sanitation and sterile conditions a newborn experiences post birth, the immune system develops differently in response to the lack of germs. Certain commensal relationships with bacteria act to orient an infant’s immune system and activate defense responses (Haapakoski et al., 2013). TLR4, a receptor found on T cells which helps to mediate innate immune responses, respond to bacterial endotoxins by reducing innate inflammatory responses (Haapakoski et al., 2013). Due to the overly clean environment, the T cell response to a virus called respiratory syncytial virus (RSV), which serves a similar purpose to the bacterial endotoxins, may trigger asthma (Food and Drug Administration, 2018). There is scientific support for and against this hypothesis. For example, the hygiene hypothesis does not explain the incidence of asthma in developing countries (van Tilburg Bernardes & Arrieta, 2017).Medications to manage symptoms Since there is no cure for asthma, treatments focus on managing the symptoms. The Asthma Action Plan, created by a doctor and the person with asthma, is a personalized directory of how and when to take daily medicine as well as when to seek treatment for more serious situations (National Heart Lung and Blood Institute, 2018). An important action for managing symptoms is to avoid triggers (National Heart Lung and Blood Institute, 2018). While the medications described below are vital in managing asthma symptoms, access to them can be an issue for people who are underinsured or uninsured. There are two types of medications to treat asthmatic symptoms: long-term and quick-relief or rescue. Long-term medicine, such as Advair and Symbicort, is taken every day and helps reduce airway inflammation and prevent asthma symptoms (National Institutes of Health, 2018). Lower doses of inhaled corticosteroids are the preferred and most effective option for long-term relief (American Academy of Allergy Asthma and Immunology, 2018a). Some side effects of inhaled corticosteroids include a mouth infection called thrush, cataracts, and osteoporosis (National Institutes of Health, 2018). These side effects are present after continuous use of inhaled corticosteroids taken long-term (American Academy of Allergy Asthma and Immunology, 2018a). Other long-term control medicines include anti-inflammatory medicine, such as cromolyn, and immunomodulators, such as omalizumab (National Institutes of Health, 2018). Quick-relief medicine or rescue medicine relieve asthma symptoms that have already flared up (National Heart Lung and Blood Institute, 2018). The most common quick-relief medication for asthma is bronchodilators (American Academy of Allergy Asthma and Immunology, 2018a). There are three types of bronchodilators: beta-adrenergic bronchodilators, anticholinergic bronchodilators, and xanthine derivatives. (National Health Service, 2016). Bronchodilators relax the muscles surrounding airways and widen the airways (American Academy of Allergy Asthma and Immunology, 2018a). Beta-adrenergic bronchodilators, such as albuterol, are the most commonly prescribed asthma medication (National Health Service, 2016). Albuterol is the most common quick-relief medicine and is provided in steroid inhalers or available as a liquid to vaporize using a nebulizer (National Health Service, 2016). TriggersCommon asthmatic triggers, which cause asthmatic flare ups, include dust, mites, pet dander, cockroaches, mold, air pollution, and tobacco smoke (Centers for Disease Control and Prevention, 2018; Asthma and Allergy Foundation of America, 2017). These substances usually act as allergens and cause an immune response in the lungs to produce asthmatic symptoms (Asthma and Allergy Foundation of America, 2017). Since these triggers, specifically mold, can be found more prevalently in poor housing or low income areas with unsafe housing, people living in poverty or with low socioeconomic status are more likely to have asthma attacks as well as develop asthma (Akinbami et al., 2016). Exercise, cold dry air, and pool air may also trigger asthma attacks (Centers for Disease Control and Prevention, 2018). Exercise-triggered asthma, also known as exercise-induced bronchoconstriction, can occur during physical activity (American Academy of Allergy Asthma and Immunology, 2018a). Athletes that frequent ice rings or very cold environments can experience asthmatic symptoms due to the cold air; in these environments, the lungs tend to lose heat and water which then narrows the airways (Centers for Disease Control and Prevention, 2018). Indoor pool air is usually warm, humid and has high amounts of chlorine which changes the airway structure and causes difficulty in breathing (Centers for Disease Control and Prevention, 2018). Reducing triggers While medication is key in reducing symptoms of asthma in individuals, reducing triggers in the community and home can reduce the overall prevalence of asthma attacks (Centers for Disease Control and Prevention, 2018). Healthy housing is essential in reducing triggers (Georgia Healthy Housing, 2018). Homes and other frequently accessed buildings, such as schools for children, need to be dry, clean, ventilated, pest and contaminate free, maintained, and temperature controlled (Georgia Healthy Housing, 2018). Using dust proof covers on bedding and washable linens such as curtains can reduce the amount of dust in close contact with the individual with asthma (Georgia Healthy Housing, 2018). Mold may be reduced using dehumidifiers in the home as well as drying bathrooms and kitchens (Georgia Healthy Housing, 2018). Air filters, mobile air purifiers, and in home air conditioning units, can reduce dust and mold by filtering the air (Georgia Health Housing 2018). Although these guidelines for asthmatic-safe housing can be completed by the resident of the home, many housing problems that are harmful to people with asthma cannot be fixed by residents due to the overall poor quality of housing, specifically for low income residents (Adamkiewicz et al., 2014). According to The State of the Nation’s Housing report, approximately 1 in 10 U.S. low-income families live in inadequate housing (Joint Center for Housing Studies of Harvard University, 2018). Much of the low income housing has environmental hazards and structural issues that the residents cannot afford to fix (Adamkiewicz et al., 2014) Construction design, building materials, maintenance of building, multiple family households, and surrounding pollutants all negatively affect people with asthma and cannot be changed or controlled by the resident (Adamkiewicz et al., 2014). A community wide intervention would be necessary to thoroughly manage asthmatic triggers as they relate to housing. Asthma attacks can also be reduced by maintaining healthy behaviors such as a healthy weight, a nutritious diet, and exercise (National Heart Lung and Blood Institute, 2018). Avoidance of tobacco smoke, both active smoking as well as second-hand smoke, can also reduce asthma symptoms (Asthma and Allergy Foundation of America, 2017). Although 21% of individuals living with asthma in the United States also smoke, tobacco smoke can irritate lung tissue and produce asthmatic symptoms (Asthma and Allergy Foundation of America, 2017; Centers for Disease Control and Prevention, 2016). Young children are particularly sensitive to secondhand smoke, causing asthma attacks and increasing the risk of developing asthma (Asthma and Allergy Foundation of America, 2017). Impoverished areas have higher rates of smoking as well as more housing in which tobacco smoke has permeated the building, lowering the quality of housing and increasing the prevalence of tobacco smoke which increases asthma triggers (Adamkiewicz et al., 2014).IMPACT OF CULTUREImmigrationImmigrants make up approximately 17% of the total United States workforce (United States Department of Labor, 2018). Compared to non-immigrants, immigrants are less likely to work in management or professional jobs and are more likely to work in jobs related to agriculture, construction, food business, or cleaning jobs (Orrenius & Zavodny, 2009; United States Department of Labor, 2018).Immigrants tend to work riskier jobs or less safe working conditions than non-immigrants (Orrenius & Zavodny, 2009). This occurrence may be due to lower English comprehension, lower level of education, or have a lack of other options (Orrenius & Zavodny, 2009). Compared to non-immigrants, immigrants are more likely to work in worse or hazardous conditions in order to receive a higher wage (Orrenius & Zavodny, 2009). This trade-off of wealth for health may increase the risk for developing occupational asthma (Centers for Disease Control and Prevention, 2018). Since there is a fear of having no other job opportunities, immigrants may continue to risk their health in order to continue working, increasing the health disparity between immigrants and the general population (Orrenius & Zavodny, 2009).Immigration status also impacts access to healthcare. There are several laws and policies that prohibit and restrict undocumented immigrants from accessing health services, including emergency care (Martinez, 2015). The laws and policies explicitly state that undocumented immigrants cannot seek health service and mandate that health professionals must report documentation status to officials (Martinez, 2015). Although some medical care does not require citizen status of people using the services, the fear of being asked citizen status can deter immigrants seeking primary care and emergency care (Fernández, A., & Rodriguez, R. A., 2017). Perceived fear of deportation and harassment from authorities correlates to lack of access to a wider range of health services (Martinez, 2015). Not only will this deter individuals who need help, but it can also deter the places that provide the care for the fear of breaking the law (Fernández, A., & Rodriguez, R. A., 2017).Korean social normsIt is known that Korean immigrants have densely connected social networks and ties that link them to other Korean immigrants (Oh & Jeong, 2017). In closely connected social networks, the players in these networks, in this case being Korean immigrants, tend to lack diversity and are less likely to bring new knowledge into their network from outside (Oh & Jeong, 2017). People interact with other individuals they have social ties with and learn from them. When people are seeking information from others in their network, they may not get exposed to the most current, updated information (Oh & Jeong, 2017). The influence of social networks translates to the sharing of health information (Oh & Jeong, 2017). First generation Korean immigrants are positioned with a transnational health care structure; they have access to information surrounding health systems from both their home country and their host country (Lee et al, 2010). The health information being shared in their social networks is a combination of perceived and actual differences in health system practices between their home and host countries (Lee et al, 2010). Seeking health insuranceThere are many levels of influence that impact health resources and health care access for immigrants (Yang, 2010). Many Korean immigrants are uninsured which has directly impacted their ability to access health care (Choi, 2013). This lack of insurance has been influenced by their culture; Korean immigrants seek health information from people who are in a similar context as them (Choi, 2013). A qualitative study reported that immigrants from Korea hesitated to seek health-related information from both non-Korean immigrants and English information sources (Choi, 2013). When individuals buy health insurance, it is important for them to learn about costs and benefits, know the vocabulary, understand various policies, and know the process for accessing health care using insurance. If immigrants are mainly relying on what their peers know about insurance, with no one in their social network really having the most accurate, updated information, people are not going to have the entire basis of knowledge to make decisions surrounding health insurance (Choi, 2013). Immigrants must make adjustments from what they knew in their home country in order to effectively navigate the health system of the country that they now reside in (Yang, 2010). Religious beliefsOne aspect impacting health behaviors is religion. South Koreans predominately practice Confucianism and thus hold many Confucian values (Cho & Sillars, 2015). Though views are shifting and becoming slightly more progressive, these values are still held in varying degrees today (Park, I. Y., 2016). South Koreans are very family centered and have much solidarity with their kin (Cho & Sillars, 2015). They display more kin collectivism than they do kin individualism (Cho & Sillars, 2015). This means they consult with their families prior to making decisions rather than making decisions and announcing them to their family. Family generally takes precedence over other social groups or individual family members (Cho & Sillars, 2015). They protect and guide members of their group and do not feel the same allegiances to people out of the group, meaning non-family members (Cho & Sillars, 2015). The strength of these group boundaries is seen surrounding family health information; it is not shared unless it is required because they do not want stigmatizing information shared outside of their family circle (Cho & Sillars, 2015). This decision to keep health information within the family may also impact the decision to seek care.Importance of work and educationAnother aspect that influences culture is education. South Koreans heavily emphasize hard work and education in their society (National Center on Education and the Economy, 2016). There is high value on being highly educated, and stellar performance in school is expected, as well as high aspirations (National Center on Education and the Economy, 2016). South Korea has the fourth highest proportion of adults with a post-secondary education (National Center on Education and the Economy, 2016). Parents often make personal sacrifices in order for their child to have these educational opportunities (Diem, R., Levy, T., & VanSickle, R., 2013). Schooling is competitive, test-driven, and highly pressured: performance in school can determine career prospects, marriage prospects, general social prestige, and many other various opportunities (National Center on Education and the Economy, 2016). Parents work to make sure their child can be successful in school, and children work equally hard in school to impress their parents (Diem, R., Levy, T., & VanSickle, R., 2013). Students and parents alike have a drive to achieve (National Center on Education and the Economy, 2016).Race and ethnicityThere are significant disparities within minority populations living in the United States compared to the majority population (Dai, 2014). Racial and ethnic disparities persist among the top ten leading health indicators identified in the 2010 National Health Objectives (Healthy People 2020, 2018). Socioeconomic factors, lifestyle behaviors, social environment, and access to clinical prevention contribute to these disparities (Dai, 2014). Minority children are less likely to be properly diagnosed and prescribed regular medication (American Lung Association, 2008). Minority children also miss more school due to asthma symptoms accounting for 10.5 million missed school days in 2008 (American Lung Association, 2008). This can be contributed to limited access to healthcare, lack of asthma self-management education, lower health literacy, and fragmented care (Forno & Celedo?n, 2012).School On average, 3 students in a 30-person classroom has asthma or asthmatic symptoms with minorities, low income, and inner city students at higher risk for more seriouscomplications (Centers for Disease Control and Prevention, 2017). In order for a school to be asthma-friendly, teachers, administration, and other personnel must make an effort to begin and maintain an asthma program. Asthma programs include care clinicians specialized in treating asthma, identification of at-risk students, receiving administrative support, employing a full-time nurse, training and educating students and staff about asthma, providing health services for students, and creating a safe environment that avoids asthmatic triggers (Centers for Disease Control and Prevention, 2017).Asthma is one of the leading causes of school absenteeism, and the rates are higher among children who come from low-income families (Meng, 2012). This is due to the fact that those who are from low-income areas tend to have more frequent and severe asthma symptoms, therefore missing more school (Meng, 2012). School-based asthma education and management is important in addressing asthma within schools (Massey, 2018). Schools that serve low-income areas often do not have these programs or someone designated to take care of children who have asthma during the school day (Meng, 2012). Attending public school with asthma involves much preparation in order to maintaincontrol over asthmatic triggers (Walker & Reznik, 2014). Before beginning the school year, symptoms and triggers must be identified and reviewed in case a change has occurred (American Lung Association, 2018). An Asthma Action Plan should be designed with a doctor and shared with the student, teacher, coach, and school nurse to in case an emergency occurs (American Lung Association, 2018).In addition to preparing the adults surrounding the student, the child, who is usually five years old and entering school for the first time, needs to learn to administer their inhaler by themselves (American Lung Association, 2018). This action can be hard for young children recently diagnosed with asthma, but large distances away from their rescue inhaler can be dangerous (Walker & Reznik, 2014). Being able to afford multiple inhalers for home, to carry with the child, and to keep with the nurse may exhibit a health disparity for low income students; they are more likely to visit emergency departments or die from asthma (Centers for Disease Control and Prevention, 2017). By lacking the resources to have a rescue inhaler as needed, low income students could be more at risk for severe complications related to asthma. Parents of students who experience hospitalization due to asthma attacks will also lose work hours to care for their child (American Lung Association, 2018).Governmental health programsMedicaid is the federal and state program which provides a measure of health insurance for populations in the United States, including low income families (Centers for Medicare and Medicaid Services, 2018b). After the changes made by the Affordable Care Act of 2010, eligibility for Medicaid was set at 133% of the federal poverty level (Centers for Medicare and Medicaid Services, 2018a). Income eligibility is determined by the federal government using Modified Adjusted Gross Income (MAGI) which does not differ between states or different groups of people served by Medicaid (Centers for Medicare and Medicaid Services, 2018b). Recipients must also be residents of the state they are getting Medicaid from and either a citizen or “lawfully present” (Centers for Medicare and Medicaid Services, 2018b). These requirements are set to exclude undocumented immigrants. Health services covered by Medicaid differ between states with several mandatory services that must be provided to recipients. Hospital services, physician services, and pediatric services are some health care benefits that must be covered by Medicaid (Centers for Medicare and Medicaid Services, 2018b). Respiratory care and prescription drugs have optional coverage; states do not have to cover these services (Centers for Medicare and Medicaid Services, 2018b). Children may also be covered by the Children’s Health Insurance Program (CHIP) in addition to Medicaid coverage. Uninsured children up to 19 years old living above the income requirement of Medicaid are the main recipients of CHIP (Centers for Medicare and Medicaid Services, 2018a). The level of income covered by CHIP is left to states’ discretion, with most covering up to and above 200% of the federal poverty level (Centers for Medicare and Medicaid Services, 2018a). Children must be “lawfully present” to receive benefits from CHIP (Centers for Medicare and Medicaid Services, 2018a). In 2010, the Affordable Care Act allowed states the option to include children of public employees (Centers for Medicare and Medicaid Services, 2018a).CHIP covers the mandatory benefits of Medicaid as well as other services which varies state by state (Centers for Medicare and Medicaid Services, 2018a). States can choose standard governmental health insurance coverage, such as Blue Cross Blue Shield services, or other equivalent approved coverage (Centers for Medicare and Medicaid Services, 2018a). Vaccines must also be covered for the age-related vaccines of the recipient.NEEDS ASSESSMENTThe case and who is impactedIn this case scenario, the boy, Jun-suh, is a five year old asthmatic that is underinsured through Medicaid and is about to enter public school. The mother, Sun-ja, emigrated from South Korea when she was younger and is having trouble paying her son’s medical bills. Those affected by this scenario include people experiencing poverty and unable to pay medical bills, immigrants and barriers they experience through the healthcare system, and asthmatic children in school. This case occurs in Athens, Georgia.Health insurance needsChildren in the United States are often insured through Medicaid or CHIP, which works closely with the state Medicaid program (Centers for Medicaid and Medicare Services, 2018a). About half the children with asthma are covered by Medicaid or CHIP, but the insurance may not fully cover all charges associated with asthma medical care (Centers for Disease Control and Prevention, 2012). Currently, the treatment Jun-suh is receiving is not fully covered by Medicaid. The mother needs access to more affordable health care that accepts Medicaid insurance or health insurance that covers all costs associated with Jun-suh’s asthma. Another possible need for people using Medicaid as insurance is access to medical care which accepts Medicaid insurance. If people cannot use primary or acute care doctors for medical checkups, they are likely to use emergency rooms (ERs) in non-emergency situations (Uscher-Pines, Pines, Kellermann, Gillen, & Mehrotra, 2013). This ER use is associated with high copayments and expensive bills which would increase cost for both the insured and the insurance company (Uscher-Pines et al., 2013). In 2015, 62% of under 18 year olds using the ER used Medicaid, showing a disparity in ER use based on income (Sun, Karaca, & Wong, 2018). This disparity shows the need for accessible medical care which accepts federal health insurance. If there were primary care physicians that accepted federal health insurance and were easily accessible, it would decrease the need for emergency room visits in order to treat various health issues (Uscher-Pines et al., 2013). In this case, someone with asthma would be able to manage their symptoms with their primary care physician and treat the symptoms before having to go to the emergency room. Immigration-affected needsConsidering that Sun-ja came to the United States when she was a young girl, English is most likely not her first language. The two main problems that she would have to deal with are a lack of health communication and low English proficiency (Betancourt, Green, Carrillo & Ananeh-Firempong, 2016; Kreps & Sparks, 2008). Immigrants represent a population at risk for being unable to communicate with doctors, health care workers, and insurance officials because of a language barrier or low education levels (Kreps & Sparks, 2008). Health literacy is the ability to understand and access relevant health information (Kreps & Sparks, 2008). Her low English proficiency puts her at risk to have a low health literacy. Doctor-patient communication without an interpreter, even when there is a minimal language barrier, is a major challenge to effective health care (Betancourt et al., 2016). Those who are not English-speaking are less likely to understand their diagnosis, prescribed medications, special instructions, and plans for follow-up care (Betancourt et al., 2016). A multilingual medical professional or translator would increase medical care access for Sun-ja. The translator would be able to efficiently translate the asthma action plan for her son. Other barriers that Sun-Ja may face are the laws and policies regarding undocumented immigrants and health services. She may feel that she cannot seek service for her son, even though he is documented, due to fear regarding her own immigration status. It is mandated that health professionals must report documentation status to officials and that could come up when discussing treatment options for her son (Martinez, 2015). While some medical care does not require the citizen status of people using services and she is not the one seeking care, the fear of being asked of her own status could deter her from seeking primary care and emergency care in certain settings, thus reducing the access to care that Jun-Suh has (Martinez, 2015). This fear of deportation and harassment from authorities highlights another need; policy change regarding immigrants and their access to health services. People living in this country should not be denied access to or have a fear of utilizing health services if they are truly in need. Housing needsAnother important factor to assess is where Jun-suh will be spending the most of the time. Being a 5 year old, he will either be in school or at home. Maintaining air quality in both areas is of utmost importance. Children living in poor conditions are more likely to have respiratory problems and to be at risk for infections (Barnes, Cullinane, Scott, & Silvester, 2013). The housing that is within their price range is most likely not the safest and healthiest option for a child with asthma. Cheap housing is notorious for having dust, mold and cigarette smoke residue, which all contribute to developing asthma symptoms (Bryant-Stephens, Kurian, Guo, & Zhao, 2009). This is especially the case for mold because the presence of mold and early exposure in childhood can lead to the development of asthma or worsen symptoms already present (Centers for Disease Control and Prevention, 2018). To alleviate these risk factors, there needs to be affordable, healthy housing. Healthy housing means that the house needs to be checked for mold and leaks, as well as, roach and/or other bug infestations and be cleaned regularly to maintain healthy air quality (Georgia Healthy Housing, 2018). School needsThe school that Jun-suh is zoned for likely encounters similar issues of air quality. School districts with lower income families do not receive enough funding for school, so the structural issues that lead to poor air quality are difficult to control and hard to address (Sampson, 2012). The schools do not have funds to upkeep the school, so this calls for a policy measure that increases funding. Many schools that are located in medically underserved areas do not have school nurses available for students. The main barrier that schools face when it comes to hiring a nurse is the “Free Care Rule” (Malcarney, Horton, & Seiler, 2016). The Free Care Rule prohibits Medicaid from paying for services that can be used by the public for free (Malcarney, Horton, & Seiler, 2016).This is an issue because the students most likely to benefit from the presence of a school nurse are ones that are eligible for Medicaid and CHIP (Malcarney, Horton, & Seiler, 2016). RESOURCESAthens Neighborhood Health CenterThe Athens Neighborhood Health Center (ANHC) was founded with the intention of providing healthcare to underinsured individuals in Athens. Populations at-risk of being underinsured or have no insurance includes children in poverty, people experiencing poverty, elderly individuals, people experiencing homelessness, and the chronically ill. Various insurance plans are accepted at the Health Center. Medicare, Medicaid, and CHIP are accepted as well as BlueCross BlueShield and other plans. ANHC uses a sliding payment scale to determine how much an uninsured individual will pay for services. The fee scale is dependent on income and family size. In addition, ANHC staffs insurance navigators to work in their Health Care Financial Counseling and Insurance program. They have certified and licensed health plan navigators on staff that can provide counseling on enrollment services for the Affordable Care Act, Medicare, Medicaid, and Children’s Insurance Program (CHIP). This is helpful for those who are unsure of what each plan covers and talking to an expert can ease the process of navigating health insurance. Services offered by ANHC includes acute care and chronic illness care, behavioral health needs, and immunizations and laboratory testing. Different sections of the Health Center are dedicated to different medical clinics. The general practice clinic provides a primary care provider for adults 18 years old and higher and treats basic medical concerns along with coordinating care with different clinics. The family practice clinic provides children primary care for ages 2 and higher with an emphasis prevention. Pediatrics provides primary care for infants and adolescents, birth to age 18. The acute care clinic treats sudden, acute illnesses or injuries. The chronic care clinic treats chronic conditions such as asthma, diabetes, heart disease, and depression. The medication program services provide prescription fulfillment at reduced prices, and the laboratory services can conduct diagnostic testing on site. All CDC-recommended immunizations are available. The ANHC also provides mental health services through the mental health clinic. Athens Neighborhood Health Center offers severely discounted prices for certain asthma medications. For $3 for 30 day and/or $8 for 90 day supplies, individuals can receive Advair Diskus (100/50, 250/50, 500/50 only), FLovent (44, 110, 220 mcg only), Proair 108 HFA, Spiriva HandiHaler, and Proventil HFA. These are all inhaler type medications. Montelukast/Singulair (all strengths) is provided for free by their pharmacy service. Nebulizers are not provided at a reduced cost through the clinic; however, it is covered under Medicaid and CHIP under durable medical equipment. Doctors will also work the individual and family on creating an action plan to maintain asthma symptoms. Athens Neighborhood Health Center is not to be used for emergency services. To access the services provided for asthma at ANHC, initially a primary care provider would need to be seen. The primary care provider would conduct a clinical exam, discuss current signs and symptoms of asthma, perform a basic spirometry test, and conclude a diagnosis. They would also prescribe medications to the individual. The prescriptions could be filled on site at the ANHC pharmacy for a reduced cost. Once diagnosed, the individual’s case would then be moved to the chronic care clinic at ANHC, as it is an ongoing medical condition. The Athens Neighborhood Health Center has three locations in Athens. One location is administrative while two locations provide medical care. The Central and East medical care clinics are located at 675 College Avenue and 402 McKinley Drive, respectively. The Eastside medical care clinic can be accessed by Athens Transit routes 2 and 3. The Central location is located near downtown Athens and is located on Athens Transit route 8.A potential issue of the Athens Neighborhood Health Center includes possible barrier to access through business hours. Since the business hours follow a normal working day, 8:00 AM to 5:00 PM on Mondays, Wednesdays, and Thursdays and 8:00AM to 7:00 PM on Tuesdays, individuals working all day may find it difficult to access care because the offices are not open after the working day ends. Also, there is an hour break at noon where the office is not open, furthering impeding workers who can leave their job during a lunch break.School System resourcesSchool aged children may receive some asthmatic aid through their school. Each school in the Clarke county district has at least one ? full time employed school nurse, meaning that they are present at the school at least for ? of the school day or school week (Massey, 2018). Each school also has albuterol vials available for anybody present in the school who is having an asthma attack or is having a hard time breathing (Massey, 2018). This is important because having a nebulizer and albuterol can make a difference when it comes to the severity of the symptoms and can prevent using an ambulance and/or emergency care services. Students with asthma are also red flagged in their school system, so that each care provider knows that that student will potentially need some kind of care (Massey, 2018). On an elementary level, schools do store inhalers in the clinic, and students can come and use them when the nurse is present (Massey, 2018). This can potentially be a problem because if the nurse happens to not be present, the student does not have access to their inhaler. One component that differs between schools is the education that is offered to parents and families of the child that has asthma. Each school also uses the Children’s Healthcare of Atlanta Action Plan (Massey, 2018). This lists all the individual’s medications and how often they need to use them. This also provides an accurate scale for how well the individual is doing during and after the symptoms arise. These are presented in zones. The green zone means the individual is doing well and is not coughing or wheezing, has no chest tightness, and no shortness of breath (Children’s Healthcare of Atlanta, 2014). The yellow zone means that there is coughing, wheezing, chest tightness, and shortness of breath present (Children’s Healthcare of Atlanta, 2014). The individual is also is waking up at night due to asthma symptoms and has to limit certain activities that they can usually do when symptoms are not present (Children’s Healthcare of Atlanta, 2014). In this zone, the recommended treatment is to either take puffs from a steroid inhaler or use a nebulizer with albuterol in it (Children’s Healthcare of Atlanta, 2014). The red zone usually means that the individual is having an asthma attack. The individual is very short of breath, continually coughing, skin between the ribs is pulling inwards, has difficulty speaking, and quick-relief or steroid medications is not working (Children’s Healthcare of Atlanta, 2014). This is when emergency services needs to be called (Children’s Healthcare of Atlanta, 2014). The nurse and other staff members are trained to deal with asthma attacks and other issues that arise with asthma. Northeast Health DistrictThe Northeast Health District is made up of 10 counties in northeast Georgia. Underneath the district level, county public health departments that provided a multitude of services. These services include DOHC (Diabetes, Obesity, Hypertension, and Cardiovascular Disease), immunizations, WIC supplemental food, Tuberculosis testing and treatment, HIV/AIDS services, sexually transmitted infections testing, high blood pressure control, and breast and cervical cancer screenings. Children’s Medical Services The NE Health District also provides medical services for children. To qualify for Children Medical Services, the children must have certain conditions or chronic disease, be a Georgia resident, and under 21 years old. Services are always provided no matter if the family has health insurance or not. The NE Health District accepts insurance; however, if families do not have insurance, they operate on a sliding scale system based on income and how much the individual or family can pay for the service. Some of the services provided include physical assessments, diagnostic testing, development of medical plan, referrals, case management/coordination of care, corrective surgery, health education, nutrition services, physical therapy, financial assistance, medical devices and equipment (wheelchairs, braces, inhalers), and ongoing healthcare supervision. Medical eligibility conditions include burns, cardiac conditions, chronic lung disease, craniofacial anomalies, diabetes mellitus, gastrointestinal disorders, hearing disorders, spina bifida, neurological and neurosurgical conditions, epilepsy and hydrocephalus, orthopedic and/or traumatic amputations of limbs, cerebral palsy, and vision disorders.The NE Health District accepts health insurance with Medicaid. They also work with different Medicaid care management organizations such as Amerigroup, CareSource, Peach State, and Wellcare. For children, this is very important because they have specialized care for when their parents cannot afford health care insurance. At the public health department, the clinic will only take cash or debit/credit cards for payment. The Clarke County Health District has two locations: the main health department at 345 North Harris Street and the East Athens Clinic at 410 McKinley Drive, which is the center for Children’s Medical Services. Athens Transit routes 2 and 3 service the East clinic. Assistance for Needy FamiliesDivision of Family and Children Services provides a monthly cash assistance programs for low income families with children under 18 years old or if children are attending school full time. TANF is only available to families with children under 18 or 19 and attending school full time and applicants who have applied for and accepted benefits available to them, through unemployment compensation, workman’s compensation, or other programs applicable to the recipient. An applicant’s income must be below the limit for their number of family members. Applicant must work at least 30 hours per week, with training on finding a job and becoming self-sufficient. Receiving benefits from TANF is dependent on cooperating with Office of Child Support Services. Applicants and all members of family unit must also be a citizen, have a social security number, and have a child who experiences absences from the home of at least one parent, physical or mental incapacity of at least one parent, or the death of a parent. Children must attend school if between the ages of 6 and 17 or must have all immunizations if preschool aged. The child’s paternity must be confirmed and filed with DFCS. Applicants may only receive aid for 48 months in their lifetime, unless extensions are granted. The DFCS office is located at 284 North Avenue. Since this program is only offered to citizens or documented immigrants, undocumented immigrants will not be able to access this resource. Even if the family unit applying for TANF are all citizens, there may still be fear about using this program due to its strict regulations on citizenship and interacting with Child Services. Also, the family may be worried about revealing undocumented neighbors or friends which risks deportation. Depending on the citizenship status of the family in the case, this resource would not be available for them. Medicaid and CHIPMedicaid is a federal program that supplies health insurance for low income individuals. Because Georgia did not expand Medicaid with the Affordable Care Act, individuals below 100% FPL are covered if they also fit the inclusion criteria (Centers for Medicare and Medicaid Services, 2018b). Participants must also be residents of their state and citizens or documented immigrants (Centers for Medicare and Medicaid Services, 2018b). Mandatory services that must be required by states include inpatient hospital stays, outpatient hospital services, diagnostic screenings, physician services, laboratory and x-ray services, pediatric services, and transportation to medical care (Centers for Medicare and Medicaid Services, 2018b). Asthmatic services for children are covered under Medicaid using pediatric services (Centers for Medicare and Medicaid Services, 2018b). However, as an adult, respiratory care may not be covered in some states, and prescription drugs, such as Singular or inhalers, also do not have to be covered by states (Centers for Medicare and Medicaid Services, 2018b). Medicaid can be applied for online at . For help signing up, users can call support numbers, or Athens Neighborhood Health Center can help applicant enroll. CHIP is a state program which covers low income children up to 19 years of age that cannot be covered through Medicaid (Centers for Medicare and Medicaid Services, 2018a). In addition, pregnant women not covered by Medicaid may be covered through CHIP, and the Affordable Care Act extends benefits to children of public employees (Centers for Medicare and Medicaid Services, 2018a). Most states cover up to 200% FPL and about half cover up to 250% FPL (Centers for Medicare and Medicaid Services, 2018a). Georgia covers up to 247% FPL and does not require a waiting period after November 2016 before receiving benefits. Children must also be documented citizens to enter program (Centers for Medicare and Medicaid Services, 2018a). CHIP covers all mandatory Medicaid benefits, which includes asthmatic services (Centers for Medicare and Medicaid Services, 2018a). CHIP can also be applied for through . The Georgia CHIP program is called Peachcare for Kids. For children under six, Peachcare is free but can vary from $0 to $36 per month per child older than six (Centers for Medicare and Medicaid Services, 2018a). The maximum premium amount is $72 for two or more children (Centers for Medicare and Medicaid Services, 2018a). Co-payments range from $0.50 to $12.50, with $2-3 on average (Centers for Medicare and Medicaid Services, 2018a). Families will only pay 5% of their yearly income at most per year (Centers for Medicare and Medicaid Services, 2018a). Piedmont Healthcare, which includes all the physician offices that offer primary care, accept both Medicaid and Peachcare for Kids.Mercy Health Center and Athens Nurses ClinicMercy Health Center was founded on the principles of Christianity and has been in operation since 1999. Their mission is “through a community of volunteers, Mercy provides quality, whole-person healthcare in a Christ-centered environment to our undeserved neighbors”. They provided services for those who live in Athens that have low income (at or below 150% of the Federal poverty level) and are uninsured. Only people with no insurance may use Mercy medical services. They require picture identification, proof of income, and proof of residency, which can be hard for those are undocumented or do not have a proof of residence. Services are provided free of charge, although every person is given the opportunity to contribute to their care either through financial donations or volunteering. The center is located on Oglethorpe Avenue and is on the Athens Transit bus 5 and 7 line. Nurses Clinic (ANC) is focused on providing care for uninsured individuals with low or no income in Athens. Established in 1988, ANC is located on North Avenue as part of the Athens Resource Center for Hope and is open five days a week. The main populations served by ANC include people experiencing homelessness, people experiencing poverty, and people who are uninsured. ANC services include acute care, such as seasonal illnesses, chronic disease management, such as heart disease, asthma, or high blood pressure, laboratory work, education or counseling on health concerns, dentistry services, women’s services, prescription assistance programs, such as providing inhalers or insulin, over-the-counter medications, and prescription fulfillments through a partnership with Walgreens on Prince Avenue. The services provided by ANC are free to the services user, but it should be clearly indicated that ANC is only available for people with no insurance. The Athens Nurses Clinic is located northeast of downtown Athens. Piedmont Athens Regional Hospital Piedmont Athens Regional Hospital is a local hospital in Athens, Georgia and is located on the Athens Transit Bus route. Although the hospital should not be used for long-term and regular care for a chronic disease, such as asthma, it is a great resource when it comes to emergency care. Severe asthma attacks need to have emergency care. The emergency room will be able to provide immediate care despite health insurance status and citizen status. The emergency room is the best place to get tertiary preventative care. On a bigger scale, the use of the emergency room by individuals who do not have a citizen status or are without health insurance can cause costs to rise and their care will often go unpaid. Despite this, the emergency room is often the only option for many people. Many ER visits are avoidable, but when it comes to asthma and the severity of the disease, the emergency room can make a difference. Piedmont Athens Regional Hospital does not have a primary physician’s office; however, they do have licensed physicians located around Athens that can provide primary care. The primary care physicians are a multi-specialty group with more than 230 primary care physicians and 65 specialists practicing throughout the surrounding communities. Although there is not a lack of care in the area, this system is not the best option for those who do not have insurance or are insured through a federal health insurance plan such as Medicaid or Medicare due to the associated cost of medical care. access to health care and resourcesPart of the issue experienced by low income children with asthma is the unavailability of primary health care and health resources (Song et al., 2015). Primary health care includes screenings and doctor visits necessary for diagnosing and managing asthma, while health resources include consistent health care professionals, which the person can establish history and trust with, and asthma inhalers (Boulet et al., 2015). The main solution to eliminating the barriers to primary health care is by having a living wage and universal health coverage.A living wageThe issue surrounding wages begins with the fact that the people receiving minimum wage are not able to remain healthy (Leigh, 2016). People that are working low skill jobs and receiving minimum wage tend to be uninsured, meaning that it is highly unlikely that they are having regular checkups which is essential to maintaining their health (McCarrier et al., 2011). There is also the issue of having many unmet medical needs due to cost (McCarrier et al., 2011). If the minimum wage was raised to $12 that would lead to increase in wage for over 35 million workers all across the United States (Leigh, 2016). An increase of minimum wages to a living wage would result in an increase to healthcare access and a reduction in negative health outcomes (Lenhart, 2017). Universal health coverageAnother way to increase access to health care is universal health insurance. Lack of health insurance is a large part of why uninsured individuals use emergency services over primary care or do not seek primary care (Uscher-Pines et al., 2013). By instituting universal health insurance, national spending on health care would decrease due to decreased use of emergency services while also allowing uninsured individuals access to primary health care (Atun et al., 2013; Thornton & Rice, 2008). Health outcomes also improve due to primary health care access, access to needed medications, and consistent care (Atun et al., 2013; Thornton & Rice, 2008). Universal health care can also be used to improve equity by removing the financial burden of health care cost from impoverished and low income populations (Atun et al., 2013). Universal health insurance can also address the disparity between immigrant and non-immigrant health. Immigration status is correlated with less preventative care, contact with physicians, and spending on healthcare (Siddiqi, Zuberi, & Nguyen, 2009). This relationship applies across multiple races, including Hispanic and Black individuals (Siddiqi et al., 2009). The health insurance disparity between immigrant and non-immigrant is strong enough to exist at low income and continue to persist as income increases; this relationship is unique because many health-related aspects improve with income (Siddiqi et al., 2009). By improving access to health insurance, mortality and other health outcomes will improve (Thornton & Rice, 2008).Asthmatic safe housing/environmentMany triggers of asthma are household or environmental substances, such as pollen,tobacco smoke, dander, or mold. By building and maintaining safe housing, the incidence of asthma attacks can be reduced along with the symptoms accompanying the attacks. Current building codes and requirements can include asthmatic safe building material and precautions to lower the risk of future development of asthma (Adamkiewicz et al., 2014). Other actions to maintain a safe environment around asthmatic homes would include smoke-free zones or caution signs that indicate that there are children present that are at risk from secondhand smoke (Lin et al., 2015). In many cases, the implementation of smoke free legislation is shown to have a reduction in the number of pediatric hospital admissions for asthma-related issues (Faber et al., 2016). This shows the importance of creating smoke-free zones so that children with asthma do not have to worry about potentially having an asthma attack (Lin et al., 2015). Another environmental hazard that can be an asthmatic trigger is pollution (Gaffin & Phipatanakul, 2009). An asthmatic child’s home can be invaded by indoor allergens in many different ways, so it is important to create safe areas where pollution is kept to a minimum (Gaffin & Phipatanakul, 2009). Removing or lowering environmental hazards could include a no-idling zone in a neighborhood, reduced emissions from a local factory, or regulations on dumping of trash or waste. One way that people could avoid these environmental hazards would be through the use of personal protective equipment, specifically respirators (Johnson, 2016). The respirator is essential to stopping the trigger/allergen from getting inside the body (Johnson, 2016). They do reduce exposure to such agents but are not recommended as a method of complete protection (Casey & Mazurek, 2017). Individuals that choose to use respirators must also be educated on whether a respirator fits in their asthma management plan (Casey & Mazurek, 2017). Several interventions have attempted to improve the issue of unsafe environments for asthmatic individuals including Breathe Easy Home, Purpose Built Communities, and Athens Wellbeing Project. Breathe Easy HomeAn intervention known as the Breathe Easy Home was developed to create an asthma friendly home for individuals (Takaro et al., 2011). The intervention started by seeking out public housing that was infested with mold, insects, or moisture (Takaro et al., 2011). These housing units were then developed into energy efficient homes that were well ventilated, moisture proofed, cheap to upgrade (Takaro et al., 2011). The data showed that families living in these homes did not have to deal with any triggers such as mold and insects, which greatly improved their quality of life (Takaro et al., 2011). However, it is still important that the families receive education on how to manage asthma and avoid triggers (Takaro et al., 2011). Ideally, this is the type of model home that families need to have the best quality of life. Purpose Built CommunitiesPurpose Built Communities is a non-profit program which focuses on holistic revitalization of communities (Purpose Built Communities, 2018b). The initiative focuses on conducting a needs assessment of the community, mobilizing the community and identifying leaders, and revitalizing community resources, such as creating mixed income housing, educational opportunities, and health resources. The main goal of Purpose Built Communities is to stop generational poverty (Purpose Built Communities, 2018b). Each program is specific to the area of focus and interventions are tailored to specific needs of the community. Community interventions have been based in areas in Midwest and Eastern United States with Atlanta’s East Lake community as the first successful program (Purpose Built Communities, 2018b). Built environment improvements included sidewalks, street repairs, YMCA amenities, high-quality grocery stores, and economic stability programs (Purpose Built Communities, 2018b). Long term outcomes for East Lake community include lower asthma rates, as well as reduced obesity and increased physical activity (Purpose Built Communities, 2018b). To bring Purpose Built Community to Athens, a “community quarterback” or a nonprofit that is established to improve Athens area must become a Network Member (Purpose Built Communities, 2018a). The community needs to be mobilized and ready to begin work to improve the area, with community leaders and partners already talking and on a board (Purpose Built Communities, 2018a). Applications include questions about the community, what the community’s goal is, what obstacles the community has encounters, and what fundraising the community conducts (Purpose Built Communities, 2018a). Network Members must also commit to the four goals of community revitalization: mixed income housing, cradle-to-college education, wellness services, and economic sustainability (Purpose Built Communities, 2018b). Network Members will join Purpose Built Community for annual meetings as well as in-person meetings with Purpose Built directors, and they must support other Network Members through teamwork, shared resources, and shared knowledge (Purpose Built Communities, 2018a). This program shows a vital resource which addresses the fundamental issue contributing to asthma. Poor housing with mold and unsafe environmental factors greatly contribute to childhood asthma (Adamkiewicz et al., 2014). By providing clean and safe housing to low income families, asthma prevalence and asthma attack incidence will decrease (Adamkiewicz et al., 2014). It is also important to note that many environmental health hazards cluster around poor housing and communities; poorer health outcomes correlate with more environmental hazards, partially stemming from the surrounding neighborhoods since there is constant interaction between the residents, their homes, and the environment surrounding the neighborhood (Adamkiewicz et al., 2014). Athens Wellbeing Project Athens Wellbeing Project is a project that is looking to work with local community leaders and institutions to provide comprehensive information of Athens’ unique needs and assets (Athens Wellbeing Project). They look for problems within five different domains: education, health, housing, community safety, and civic vitality (Athens Wellbeing Project). They retrieve information through a survey and other data collection methods, although their main purpose is to educate and to collect data (Athens Wellbeing Project). Their information can be used to create better housing situations within Athens-Clarke County by providing data for projects and interventions as well as mapping what problems occur in different areas. Safe schools School-age students spend the majority of their time in schools, so it is essential that they are in a clean and healthy environment. Not only are clean schools essential for healthy children, they are better able to focus on their academic performance if they do not have to worry about the cleanliness of the school. There are multiple measures that schools can take to ensure that their students are learning in clean environments (National Education Association).One thing that schools can put into place is a year-round comprehensive cleaning program (National Education Association). A comprehensive cleaning program focuses on addressing certain issues that the school faces (National Education Association). School have a variety of problems that aggravate asthma symptoms such as mold, bad air quality, and being near a roadway (Hauptman & Phipatanakul, 2015). This makes an implementation of a program even more important. With a program, they can locate the problem and allocate resources to fix the issue at hand (Hauptman & Phipatanakul, 2015). A program would also allow for the collection of data, so healthcare providers and schools can know their own needs and how to achieve them (Hester et al., 2013). REFERENCESAdamkiewicz, G., Spengler, J. D., Harley, A. E., Stoddard, A., Yang, M., Alvarez-Reeves, M., & Sorensen, G. (2014). Environmental conditions in low-income urban housing: Clustering and associations with self-reported health. American Journal of Public Health, 104(9), 1650-1656. doi:10.2105/AJPH.2013.301253Akinbami, L. J., Simon, A. E., & Rossen, L. M. (2016). Changing trends in asthma prevalence among children. Pediatrics, 137(1).American Academy of Allergy Asthma and Immunology. 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Journal of Immigrant and Minority Health, 12(3), 340-353. doi:10.1007/s10903-008-9173-zRESOURCE HANDOUTCase Study 11: Asthma and ImmigrationATHENS NEIGHBORHOOD HEALTH CENTER Athens: 675 College Ave Athens GA 30601 706-546-5526East Athens: 402 Mckinley Dr Athens GA 30601 706-543-1145ANHC is a non-profit organization that serves uninsured and underinsured individuals and families. The services they provide include acute care, chronic illness care, behavioral health needs, immunizations and laboratory testing. They also offer an insurance navigator service to assist uninsured individuals with ACA, Medicaid, Medicare, and CHIP enrollment. They accept insurance or payment on a sliding scale that is dependent on income and family size.ATHENS NURSES CLINIC240 North Ave, Athens, GA 30601 706-613-6976Athens Nurses Clinic is a non-profit agency that provides evaluation, treatment, and education for acute or chronic medical conditions to uninsured individuals with no or low income. They provide acute care, chronic disease management, lab work, women’s health services, and prescription assistance. The services are free but are only offered to people who are uninsured.CLARKE COUNTY SCHOOL DISTRICTClarke.k12.ga.usBoard of Education: 440-2 Dearing ext Athens GA 30606 706-357-5239The Clarke County school district encompasses 21 schools and has more than 13,000 students enrolled; it is a public entity. Their primary goals is providing educational opportunities to students but they also ensure the health of their students. Each school employs a nurse that is at the school ? of the week. These nurses follow the Children’s Healthcare of Atlanta Action Plan to provide non-emergency medical services and medications to students while they are at school. MEDICAID/ CHILDREN’S HEALTH INSURANCE PROGRAMcoverage/ga/index.htmlMedicaid: 1-888-295-1769CHIP: 1-877-427-3224Medicaid and the Children's Health Insurance Program (CHIP) provide no or low cost health coverage for eligible children in Georgia. If a child’s family income does not allow them to qualify for Medicaid, they might still qualify for CHIP. A child cannot be enrolled in both programs. These programs provide insurance coverage for children so they can receive routine check-ups, immunizations and dental care to keep them healthy.MERCY HEALTH CENTER700 Oglethorpe Ave, Athens, GA 30606 706-425-9445Mercy Health Center is a non-profit agency that provides health services and resources at no cost to people who are uninsured and are living at or below 150% of the poverty line. They require picture identification, proof of income, and proof of residency to access their services. NORTHEAST GEORGIA HEALTH DISTRICTCentral Athens: 345 N Harris St Athens, GA 30601 706-389-6921East Athens: 10 McKinley Dr Athens, GA 30601 706-369-5816The Northeast Georgia Health district offers a variety of public clinic services and health programs. The services relate to DOHC (Diabetes, Obesity, Hypertension, and Cardiovascular Disease), immunizations, WIC supplemental food, Tuberculosis, HIV/AIDS, STI testing, and breast and cervical cancer screenings. They also offer programs that specifically serve children who are plagued with chronic health conditions. Children's Medical Services is a program that provides physical assessments, diagnostic testing, development of medical plans, referrals, case management, and financial assistance to children with chronic diseases and conditions. The health department accepts insurance or payment on a sliding scale.TEMPORARY ASSISTANCE FOR NEEDY FAMILIESdfcs.284 North Ave Athens GA 30601 706-227-7021The Division of Family and Children Services provides a monthly cash assistance program, Temporary Assistance for Needy Families, for low income families with children under 18 years old. .REFLECTIONSSara BenistCase Study Reflections In our case study, we researched how to help a mother with a child experiencing severe asthma get the resources she needs. The family emigrated from South Korea when the mother was young and currently experiences poverty. This case study was interesting to work on since I did not understand the problems an undocumented immigrant would have getting basic necessities like a reliable job, health care, or governmental aid if needed. Finding information, specifically regarding immigration, was extremely hard. Not much research has been conducted involving undocumented immigrants or South Koreans. It was difficult to find information for the culture section that was relevant to our case. Finding information on asthma was easily accessible, but I was not expecting the root of asthma as a community issue to stem from poverty through poor housing and environmental pollution. It was interesting to find out exactly why asthma is a community health issue and where the health disparities concerning asthma stem from. It was also interesting to find most care for asthma is simply managing symptoms and triggers rather than focusing of reducing risk factors as a preventative measure. The resources were very frustrating to find and get into contact with. Even though I am well-versed in using the internet to find information, there is a startling lack of information readily and easily available. Even if you find a resource that is relevant to the case, the website does not have the information you are looking for, and the phone number may or may not be useful. For example, trying to reach the Athens Neighborhood Health Center feels like pulling teeth. Even after multiple emails and phone calls to both clinic locations, we could not reach anyone to talk to until weeks after we first expressed interest in performing a site visit. Even over the phone, the supervisor was not forthcoming with information on if we could meet. However, the school district nurse for Clarke County school district was very helpful and able to answer our questions over email. As a person with asthma concerned with getting care, it would be difficult to access the resources. Most of the resources are open during work hours, which leads to the need to take off work to use their services. In addition, there are not many resources that can help clinically with low income individuals experiencing asthma with insurance other than the Athens Neighborhood Health Center and the Northeast Georgia Health District. To add on undocumented immigration, there are many challenges trying to find both health insurance and care for you or your child. There would also be the challenge for the individual needing services of having the necessary English skills and computer skills to find the resources that would be able to help them. Since I am used to looking up the information I need online as well as having professors to turn to for assistance, it would be exponentially harder to find what you need, especially with a close social circle like Koreans that may not have the answers you need and may be the only people you interact with. I have gained skills on working with other groups of people that I may not share much with that I can use in my future career. Even though I was born in the United States and do not currently have a child with asthma, I have learned how to find what kind of issues someone experiencing this case might encounter and what kind of resources may be available to them. I will be able to transfer this skill to other groups of people and other areas of the United States that I might encounter. I have also learned what kind of resources are present in most places, such as a low income clinic or a local health district, which I can use to find other resources in the area I am working in. Finally, I have learned how to write a professional-type paper alongside multiple people which will be essential if I work anywhere involving community assessments, grant writing, or other research.Bridgette FoxHPRB 3700Dr. Hein11/29/18I initially was interested in this case study because my younger brother has asthma and it has caused him a multitude of problems since early childhood; he’s 18 years old now and I still remind him to keep an inhaler in his backpack because I know he can experience problems at any time. I had previous experience with asthma because of my brother, but I had no clue how much it really takes to manage the symptoms. This initially came to my attention in the first individual draft. The shear number of medications available and all the different triggers were overwhelming. I felt for the mother in the case study and my mother as well knowing she once had to navigate this. Recognizing individual triggers is very important to addressing asthma and its detrimental effects and I watched my family struggle with this for years. This personal experience caused me to have some difficulty with this case study; I wanted more of a clinical diagnosis with tangible ways to solve the health problem because that was what I had been apart of before. Instead assumptions had to be made since we did not know some of the specifics of the case itself. I struggled to look at the case in a broad way and was initially pretty focused on the specific people involved. After a lecture in class about what the paper should entail and which sections could specifically mention the case, I had a much clearer understanding of what was required of us to do. I definitely had to take a step back to have a less clinical viewpoint of the case. I was then able to look at it as more of a problem with various solutions. Once I shifted my mindset from clinical to analytical, I was able to have a clearer understanding of what sustainable solutions would look like. The sustainable solutions were difficult for me to imagine at first because I was getting overwhelmed with the specific health issue. These solutions could not simply be ensuring a child has an inhaler and a primary care physician or making sure the teachers at school are aware of students’ condition. Solutions needed to be more focused on ways to increase health status and improve a multitude of the social determinants of health. I do not know why it took me so long to be able to process the case study like we were supposed to (as health promotion and not just health) but it finally clicked for me and I was able to assess the case like we do with examples in class. Hopefully the insight that this case study provided for me will carry over to work that comes after graduation; if something isn’t clear to me I need to take a step back and look at it in a broader sense. This case study also required me to do much more “real life research” than I have ever had to do. I believe that I am pretty well versed in internet research, but throughout the paper we struggled to find readily available information. This was especially true when trying to find healthcare and insurance resources. There was no easy way to find out exactly what an individual could qualify for as far as public assistance. It was very difficult to navigate some of the government websites and I’m a pretty tech savvy individual. I can only imagine the difficulty someone might have doing their own research if they were not familiar with using some of the websites. The difficulty also extended to getting in touch with providers. We had the most difficult time getting in contact with and getting responses from Athens Neighborhood Health Center, which was frustrating because we felt we were following all the necessary steps. Overall this case study taught me a lot about having to do things in a “real life” context as opposed to a school context, and it made me so much more excited to start to work. It required me change my ways of looking at health issues and learn to navigate using health resources I was not previously familiar with. Devika MenonHPRB 3700Dr. Hein11/29/18Reflection Our case study was about a mom who immigrated from South Korea to the United States, she has a son that had asthma that needs treatment. We made the assumption that she was undocumented and that her son was born here since he has Medicaid. Though I knew basics about asthma, I learned quite a lot while researching for the health and culture sections.The main concept that I got the chance to understand more about was how asthma is tied to low SES. I found that people living in poverty had higher rates of asthma due to their living conditions. The housing that is in the price range that is “affordable” tends to be ridden with dust, cockroach droppings, and mold. People can’t just up and move if their house isn’t up to standard, is isn’t as easy as some people like to think. I also learned that since children spend the majority of their time at home or schools those are the two main places that need to be clean. If someone is living in poverty there a high possibility that the school district, they are in is also not in good shape. This made me realize that not everything is controllable. There are things that people can do to alleviate issues caused by low SES but the only real thing that will help is institutional change. Things like affordable housing, more PCP’s, and universal health care would be the best way to solve the issue.There were multiple factors that my group and I had to consider when looking for resources for our case. We had to look for immigrant friendly, asthma centered and Medicaid accepting resources available in Athens. The only resource that fit all of the criteria that were required was the Athens Neighborhood Health Center, which has two locations. One of my group members found the contact information of the secretary of the Eastside location and sent an email. After few days of no response, she tried calling them but couldn’t get through because no one was picking up the phone. Then, another group member sent another email to both of the locations and still did not hear back. She tried calling both of the locations but also could not get through to either locations. After a week of no response to either of my group members, I called the location on College Ave. They ended up picking up my call and I received an email address that I could email to schedule a site visit. I sent the email and got a call back the day after asking what I wanted out of a site visit. After explaining what we wanted to learn about their center, I never heard back from them.The most worrying aspect of this entire process was that we were only students looking for information, we weren’t even patients. This is upsetting to think about what patients go through if this is their only resource that they can afford/fits their own criteria. If they can’t even get through to a resource how are they supposed to get the treatment, they need. Not only that, but it’s also important to consider that not everyone can just show up in person to ask questions. People have to take off of work, find childcare, get transportation to even get to the health center. After looking at some google reviews, I found that there are others that had trouble getting in contact with the health center. This is a big issue if you’re providing a service that is necessary for the health of some people but don’t answer the phone or have any other way to get in contact.This case study was a great opportunity to understand the intersection between immigration and health. Though I have knowledge on immigration, it is limited to South Asian immigration. It was very interesting to see the immigrant narrative of South Koreans and how they react to health problems. Along with that, looking for resources and contacting them gave me real world insight into what health promotion specialist have to do. Though we did not end up getting in contact with our main resource, health promotion specialists don’t have that option. If they don’t get in contact with a resource their patient might not receive the urgent care that they need. Overall, working on the case study was quite interesting because it was a real-world example that had very real barriers and figuring out the solutions was good experience for my future career in health care. Haley GoughnourHPRB 3700Dr. Hein29 November 2018ReflectionReflect on the process of gathering information from community agencies. Describe where problems were encountered and specify challenges faced by the individuals in the case studies. Note any insights you have learned that may be of benefit to you in your career. Our case study involved researching resources and solutions to assist a mother with a child with severe asthma. The child is starting school and his mom is worried about the resources he would have at school. The mother and her parents emigrated from South Korea when she was young, so we assumed that she does not have citizen status and is currently experiencing poverty. This case study was enjoyable to work on because many of the things we had to research were things that I did not have a lot of knowledge on. It was also really interesting for me because I do have asthma, so a lot of the general health information and the medications were already something I had years of experience with and I understand how severe asthma can get when resources are not available or the environment that you live in is not suitable for something with asthma. For the culture section and the resources section, it was really fun to research on the topics of how South Koreans approach health care and how they view family roles and responsibilities. Although it was easy to research the disparities concerning health, finances, and access experienced by minorities in America, specifically looking at South Koreans in America was very difficult. The fact that Asian Americans are also the least likely ethnic group to experience asthma made information on the internet scarce. I also thought that the hardest thing to find information on was immigration. There were not a lot of research done about immigration in the United States and various statistics about their health and access to quality food and housing. This also made me realize that we will not be able to get accurate statistics on the prevalence and incidence of asthma in specific populations because citizenship is most likely considered. Getting into contact with resources deemed quite difficult. When we were able to find a resource online, their website often did not offer the information we needed. At most, we would know that they provided asthma prevention and treatment service, but no details about what they did exactly. When we ran into this problem, we often called the location and asked some simple questions to learn more about what they could provide and that offered a lot of information. We chose Athens Neighborhood Health Center for our site visit and we were looking forward to getting to know more about their practice and what resources they had, but after weeks of emails and calling both clinics multiple times, we received very little reception. We got very close to getting some information on whether we could visit them, but they never actually got back to us. To combat this loss of opportunity, we emailed the school district nurse for Athens-Clarke County schools, Molly Massey. Mrs. Massey offered a lot of information on what the schools had to offer in relations to asthma control and treatment. She was a great resource considering our case study had to do with asthma care in schools. This case study project really pushed me to go beyond the internet and reach out to real life resources within our community. I felt like this was the most beneficial aspect of the project to me because it made me get out of my comfort zone and expand my research. I also enjoyed getting to delve into someone else’s experience with asthma and learn about all the factors that contribute to the severity of the condition. I also enjoyed working with my group and it was great to work on such an involved and long project. This really pushes group work to a whole new level and that is exactly what we will be experiencing out in the health promotion field. ................
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