Childhood Asthma, Immigration, and Poverty Case Scenario ...€¦ · Running head: ASTHMA,...

Running head: ASTHMA, IMMIGRATION, AND POVERTY 1

Childhood Asthma, Immigration, and Poverty Case Scenario

Sara Benist, Bridgette Fox, Devika Menon, Haley Goughnour

HPRB 3700

Case Scenario #11

Due date: 11/29/18

ASTHMA, IMMIGRATION, AND POVERTY 2

Table of Contents

CASE SCENARIO ......................................................................................................................... 4

HEALTH ISSUE ............................................................................................................................ 4

Definition and symptoms ............................................................................................................. 4

Diagnosis ..................................................................................................................................... 5

Types of asthma ........................................................................................................................... 5

Risk factors .................................................................................................................................. 7

Biological and genetic factors ................................................................................................. 7

Environmental factors during childhood and in utero ............................................................ 8

The hygiene hypothesis ............................................................................................................ 9

Medications to manage symptoms .............................................................................................. 9

Triggers ..................................................................................................................................... 11

Reducing triggers ...................................................................................................................... 11

IMPACT OF CULTURE .............................................................................................................. 13

Immigration ............................................................................................................................... 13

Korean social norms ................................................................................................................. 14

Seeking health insurance ....................................................................................................... 15

Religious beliefs ..................................................................................................................... 15

Importance of work and education ........................................................................................ 16

Race and ethnicity ..................................................................................................................... 17

School ........................................................................................................................................ 17

Governmental health programs ................................................................................................ 19

NEEDS ASSESSMENT ............................................................................................................... 20

The case and who is impacted ................................................................................................... 20

Health insurance needs ............................................................................................................. 20

Immigration-affected needs ....................................................................................................... 21

Housing needs ........................................................................................................................... 22

School needs .............................................................................................................................. 23

RESOURCES ............................................................................................................................... 24


Athens Neighborhood Health Center ........................................................................................ 24

School System resources ........................................................................................................... 26

Northeast Health District .......................................................................................................... 27

Children’s Medical Services .................................................................................................. 28

Temporary Assistance for Needy Families................................................................................ 29

Medicaid and CHIP .................................................................................................................. 30

Mercy Health Center and Athens Nurses Clinic ....................................................................... 31

Piedmont Athens Regional Hospital ......................................................................................... 32

SUSTAINABILITY ...................................................................................................................... 33

Increasing access to health care and resources........................................................................ 33

A living wage ......................................................................................................................... 34

Universal health coverage ..................................................................................................... 34

Asthmatic safe housing/environment ......................................................................................... 35

Breathe Easy Home ............................................................................................................... 36

Purpose Built Communities ................................................................................................... 36

Athens Wellbeing Project ...................................................................................................... 38

Safe schools ............................................................................................................................... 38

REFERENCES ............................................................................................................................. 40

RESOURCE HANDOUT ............................................................................................................. 49

REFLECTIONS ............................................................................................................................ 51


CASE SCENARIO

Sun-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 ISSUE

Definition and symptoms

Affecting 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).


Diagnosis

A 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 asthma

There 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 factors

Biological 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).

Triggers

Common 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 CULTURE

Immigration

Immigrants 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 norms

It 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 insurance

There 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 beliefs

One 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 education

Another 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 ethnicity

There 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 & Celedon, 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 serious

complications (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 maintain

control 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 programs

Medicaid 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 ASSESSMENT

The case and who is impacted

In 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 needs

Children 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 needs

Considering 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 needs

Another 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 needs

The 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).


RESOURCES

Athens Neighborhood Health Center

The 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 resources

School aged children may receive some asthmatic aid through their school. Each school

in the Clarke county district has at least one ¾ full time employed school nurse, meaning that

they are present at the school at least for ¾ 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 District

The 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.

http://publichealthathens.com/wp/programs/childrens-health/childrens-medical-services/

Temporary Assistance for Needy Families

Division 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

http://publichealthathens.com/wp/programs/childrens-health/childrens-medical-services/


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.

https://dfcs.georgia.gov/temporary-assistance-needy-families

Medicaid and CHIP

Medicaid 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 www.medicaid.gov. 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

https://dfcs.georgia.gov/temporary-assistance-needy-families

http://www.medicaid.gov/


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

www.medicaid.gov.

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 Clinic

Mercy 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,

http://www.medicaid.gov/


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.

http://mercyhealthcenter.net/

Athens 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

http://mercyhealthcenter.net/


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.

https://www.piedmont.org/primary-care/primary-about-us

SUSTAINABILITY

Increasing access to health care and resources

Part 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.

https://www.piedmont.org/primary-care/primary-about-us


A living wage

The 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 coverage

Another 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/environment

Many 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 Home

An 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 Communities

Purpose 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).

https://purposebuiltcommunities.org/

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.

http://www.athenswellbeingproject.org/what-we-do/#

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,

https://purposebuiltcommunities.org/

http://www.athenswellbeingproject.org/what-we-do/


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).


REFERENCES

Adamkiewicz, 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).

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https://doi.org/10.1016/j.arcmed.2017.11.009


RESOURCE HANDOUT

Case Study 11: Asthma and Immigration

ATHENS NEIGHBORHOOD HEALTH CENTER

http://www.athensneighborhoodhealth.com

Central Athens: 675 College Ave Athens GA 30601 706-546-5526

East Athens: 402 Mckinley Dr Athens GA 30601 706-543-1145

ANHC 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 CLINIC

www.athensnursesclinic.org

240 North Ave, Athens, GA 30601 706-613-6976

Athens 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 DISTRICT

Clarke.k12.ga.us

Board of Education: 440-2 Dearing ext Athens GA 30606 706-357-5239

The 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 ¾ 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 PROGRAM

www.insurekidsnow.gov/coverage/ga/index.html

Medicaid: 1-888-295-1769

CHIP: 1-877-427-3224

Medicaid 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 CENTER

www.mercyhealthcenter.net

700 Oglethorpe Ave, Athens, GA 30606 706-425-9445

Mercy 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 DISTRICT

www.publichealthathens.com

Central Athens: 345 N Harris St Athens, GA 30601 706-389-6921

East Athens: 10 McKinley Dr Athens, GA 30601 706-369-5816

The 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 FAMILIES

www.dfcs.georgia.gov

284 North Ave Athens GA 30601 706-227-7021

The 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.

.


REFLECTIONS

Sara Benist

Case 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 Fox

HPRB 3700

Dr. Hein

11/29/18

I 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 Menon

HPRB 3700

Dr. Hein

11/29/18

Reflection

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 Goughnour

HPRB 3700

Dr. Hein

29 November 2018

Reflection

Reflect 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.

Childhood Asthma, Immigration, and Poverty Case Scenario ...€¦ · Running head: ASTHMA,...

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