academic essay on asthma

Asthma essay full guide: Introduction, outline, examples

October 24, 2023

Asthma is a chronic disease that affects a large population in the world. When assigned to write an asthma essay, you must understand the symptoms, treatment and other aspects. This article provides an overview of the essential elements of writing a fantastic essay about asthma, from researching and drafting your thoughts to formulating a thesis and ensuring the work is formatted appropriately.

What is asthma?

Chronic asthma is a lung disease that produces coughing, wheezing, and breathing difficulties. About 10-15% of people worldwide suffer from this inflammatory condition of the breathing passages, primarily affecting kids and young adults. Breathing properly becomes challenging for those with asthma because of their swollen, restricted, and mucus-filled airways.

An asthma attack, sometimes called a recurrence or flare-up, can cause symptoms to intensify, making breathing even more challenging and causing other bodily changes like tightness in the lungs or a fast heartbeat. Dust particles, strong odours, exercise, and smoking are common asthma causes. The intensity of these asthma episodes can vary, based on the person’s susceptibility to triggers, from moderate to fatal.

Causes of asthma

Allergens are substances that cause allergies and can set off asthma attacks. You might have asthma symptoms if you breathe in anything you are allergic to. Avoiding or restricting contact with established allergens is essential to lessen or avoid asthma attacks. These include pollen, dust mites, animal allergens, moulds, and rodents.

Irritants in the air

Another factor that can trigger an asthma attack is environmental irritants. While these products do not cause allergies in humans, they may irritate sensitive or irritated airways. These include;

Smoke from marijuana or tobacco products, including cigarettes
Air pollution includes ozone, smog, and other things.
Charcoal barbecues
Strong vapours, fumes, or smells (such as those from paint, fuel, perfumes, or scented soaps)
Particles and dust in the atmosphere
Physical activity and exercise

Exercise and other breathing-intensive activities may aggravate asthma symptoms. Exercise is a common asthma trigger, particularly in cold weather. Exercise can cause exercise-induced bronchoconstriction (EIB), affecting individuals with or without asthma. After prolonged exertion for many minutes, symptoms might not appear immediately. (Usually, this indicates that you need to modify your treatment if indications start earlier.) You don’t need to restrict your physical activities if you receive the proper treatment. Everyone benefits from exercise, even those who have asthma.

The weather

Occasionally, dry wind, chilly air, abrupt weather, or temperature variations might trigger an asthma attack. If a thunderstorm strikes while there is a lot of pollen and moisture, it may further aggravate someone who already has asthma. Thunder hits pollen, shattering the grains into tiny fragments. Storm-generated wind disperses these particulates, facilitating inhalation by humans.

Ways to treat asthma

After an evaluation and diagnosis of asthma, inhaled drugs are frequently utilized for daily asthma control and immediate relief during an attack. When combined with long-lasting bronchodilators, inhaled steroids assist in maintaining open airways for up to eleven hours after use by reducing airway inflammation. When inhalers are insufficient, doctors may prescribe oral medicines to manage asthma symptoms.

Writing an asthma essay

Writing an assignment on asthma can be intimidating, particularly if you don’t know much about the illness. Chronic asthma is a respiratory condition that impairs breathing, making even basic tasks such as communicating or walking difficult.

Understanding the fundamentals of asthma and its repercussions is crucial for writing a great essay about the illness
Look about the causes of asthma and the people who are susceptible to it
Learn about the available therapies for symptom management and attack prevention
Gather inspiration for your writing
Write about how the illness has affected your life or the lives of someone you care about, either professionally or personally
You might also highlight the ways that recent developments in healthcare technology have enhanced the range of treatments available to those who suffer from this illness

Asthma essay outline

Composing an asthma essay might be difficult, but it can be made much simpler with a clear framework. You can better arrange your essay and ensure you’ve covered all the essential details of the condition by creating an outline. Here are a few pointers to assist you in formulating a winning plan for your essay on asthma.

Selecting the essay’s main argument should come first. This should summarise the topics you will cover in the paper and a roadmap for your overall argument. Start classifying the material into concepts or significant points that bolster each argument. These arguments must be concise and backed up with data from dependable sources, like research papers or medical publications. List all supporting details to provide a more thorough explanation of each central point or idea. To successfully support every point or claim, use quotes and illustrations.

Asthma essay introduction

Bringing the reader’s focus should be the first goal of the opening. Utilize fascinating information or thought-provoking questions about asthma to draw readers into your writing. Giving readers some background knowledge on asthma will help them comprehend this problem’s importance. Ensure you incorporate trustworthy information, such as morbidity or prevalence numbers for various populations.

Essay body paragraphs on asthma

Identifying your significant ideas and the order in which you want to convey them in the main body of the paper is the first stage in creating a body paragraph for an asthmatic essay. After you’ve decided on this, you will need to learn more about these points through investigation and data collection. This might encompass pertinent papers, research, statistics, or other sources.

It’s critical to arrange your ideas rationally to flow well together when composing the body paragraphs. Each paragraph should begin with an introduction summarizing the viewpoint covered in that section.

Subsequently, furnish proof and corroborating particulars for your claim derived from the preliminary investigation conducted. Lastly, summarize each paragraph by restating the key ideas and connecting them to a coherent thesis or argument.

Asthma essay conclusion

An asthma essay conclusion should primarily summarize your main ideas, support your conclusion with evidence, and give the reader a sense of completion. First, provide a succinct overview of every topic you raised in your article. Then, concisely describe your general conclusion regarding the subject in a few words.

Here, it would help if you offered your concluding thoughts or viewpoint on the topic you covered throughout the central portion of the paper. Put a thought-provoking comment or concept at the end to get readers to consider how they feel about asthma, its effects, and possible solutions.

Asthma essay topic ideas

What is the impact of asthma on daily activities?
Discuss the various treatment methods for controlling the effects of asthma
Discuss the different types of asthma and the different symptoms
Explain the effects of asthma on the human body
Discuss air pollution as a causative agent of asthma
What are the new devices and advances in technology available to help manage asthmatic conditions
Discuss the current knowledge about asthma, research, technologies, emerging treatments, and management strategies
What is the impact of better asthma diagnosis and medications
Discuss the impact of poverty on access to quality health care for patients with asthmatic conditions
How does the society view those who have asthma?

Some pointers for composing a reflective essay about asthma

Writing an essay for nursing about asthma might be enlightening for many people. The author will be able to express their perspective with other people and think about how their daily life has been affected by their experiences with asthma. The following advice can help you create a thoughtful essay about asthma:

To successfully describe an asthma attack in literature, one must have a thorough understanding of the sensation and consequences of the attack. Think about the areas you would like to highlight from your encounter with asthma. Are there specific occasions that jump out as being significant? Would you like to talk about the effects of having this illness? Or perhaps investigate how chronic asthma has affected your way of life.

Consider carefully any feelings you may have regarding this subject. Writing down your bodily and emotional reactions to an attack can be helpful in creating a more intimate narrative of the encounter. Consider looking at different asthma essay examples before writing such an assay.

Throughout the writing process, attempt to keep an account where you may jot down any thoughts or ideas on asthma. Look for therapy or treatments that have been successful for other people with asthma. This will help readers gain insight into various therapy options and help them learn more about how to cope with their symptoms.

Asthma is a severe respiratory illness affecting a large population in the world. The illness is characterized by difficulty breathing, wheezing, chest tightness, and cough. This guide contains information about the condition and how to write an asthma essay in college or university. If you are a student and need help writing an asthma essay, contact us at medicalessaywritingservice.com . We provide medical essay-writing services to students at affordable rates.

Asthma Management: Asthmatic Adult Patient Essay

To find inspiration for your paper and overcome writer’s block
As a source of information (ensure proper referencing)
As a template for you assignment

Introduction

After reviewing the patient’s medical records and conducting a physical examination, the diagnosis of ongoing asthma with worsening symptoms is determined. It appears that the patient’s asthma symptoms have intensified due to possible exposure to triggers and an increase in physical activity. The International Classification of Diseases tenth revision (ICD10) classifies asthma as chronic obstructive with acute exacerbation or chronic obstructive asthma with status asthmaticus (“ICD-9-CM to ICD-10-CM conversion”, 2019). The ICD ten provides two types of asthma, of which Cynthia’s case is chronic obstructive.

Pharmacological Measures

To manage symptoms and prevent exacerbations, asthma treatment typically consists of a combination of medications, including bronchodilators and corticosteroids. Prescription medication consists of bronchodilator, such as albuterol, to use as needed to relieve asthma symptoms the dispensation is through inhalation whenever there is experience of an asthma attack (“Asthma medications”, 2019). In addition, a prescription will be made for a long-acting bronchodilator, such as salmeterol, to take on a daily basis to control her asthma. In addition, fluticasone, an inhaled corticosteroid, is prescribed to reduce airway inflammation and prevent asthma exacerbations (Habib et al., 2022). Over-the-counter medication medications that can help the patient include ephedrine, racepinephirine, epinephirine (HealthMatch Staff, 2022). All of these medications are bronchodilators which means that relax the muscle bands responsible for tightening the airways.

Non-Pharmacological Measures

The patient is advised to avoid triggers that exacerbate her asthma symptoms and to regularly monitor her asthma control using a peak flow meter. Additionally, she should adopt a healthy lifestyle, including proper diet and exercise. Overall, with proper care and regular monitoring, patients with asthma can lead a healthy and active lifestyle. The patient is scheduled for follow-up appointments to assess the effectiveness of the management plan and ensure optimal asthma control (Song et al., 2019). The patient is advised to avoid known triggers such as pet dander, dust, and pollen. In addition, she should avoid exercising in cold or dry weather. She should use a peak flow meter to monitor her asthma control and adjust her medication as needed. To promote overall health and prevent aggravations, the patient is also advised to live a healthy lifestyle by eating a balanced diet and engaging in regular exercise.

Health Maintenance and Counseling

During scheduled appointments, the patient’s asthma control is monitored, and medication is adjusted as needed, requiring asthma patients to schedule regular check-ups with their healthcare providers to ensure proper management of their condition (Licari et al., 2020). The healthcare provider will also instruct the patient on proper inhaler use and remind them to refill their prescriptions. It is also recommended to get a flu shot every year to avoid respiratory infections, which can trigger asthma attacks. As a result, regular check-ups and preventative measures are critical to effectively managing asthma.

The individual is taught about asthma management, which includes the importance of using inhalers correctly, tracking symptoms, and avoiding triggers. In addition, the patient is advised to use a peak flow meter and how to adjust medications based on readings. In addition, the individual is taught how to recognize signs of an asthma flare-up and when to seek immediate medical attention. Educating the patient on asthma management, symptom tracking, and recognizing signs of an asthma flare-up is emphasized as a crucial aspect of her care. The importance of adhering to medication schedules and seeking prompt medical assistance when needed is also stressed.

Asthma medications: Know your options . (2022). Mayo Clinic. Web.

Habib, N., Pasha, M. A., & Tang, D. D. (2022). Current understanding of asthma pathogenesis and biomarkers . Cells , 11 (17), 2764. Web.

HealthMatch Staff. (2022). Over the counter medicine for asthma: What you need to know . HealthMatch. Web.

ICD-9-CM to ICD-10-CM conversion . (2019). Centers for Disease Control and Prevention. Web.

Licari, A., Votto, M., Brambilla, I., Castagnoli, R., Piccotti, E., Olcese, R., Tosca, M. A., Ciprandi, G., & Marseglia, G. L. (2020). Allergy and asthma in children and adolescents during the COVID outbreak: What we know and how we could prevent allergy and asthma flares . Allergy , 75 (9), 2402-2405. Web.

Song, D. J., Choi, S. H., Song, W., Park, K. H., Jee, Y., Cho, S., & Lim, D. H. (2019). The effects of short-term and very short-term particulate matter exposure on asthma-related hospital visits: National health insurance data. Yonsei Medical Journal , 60 (10), 952.

Ullmann, N., Mirra, V., Di Marco, A., Pavone, M., Porcaro, F., Negro, V., Onofri, A., & Cutrera, R. (2018). Asthma: Differential diagnosis and comorbidities . Frontiers in Pediatrics , 6 (2). Web.

Chronic Obstructive Pulmonary Disease: Concept Map
The Asthma and Allergies Relationship
Overall Health and Pathophysiology
Intubation and Mechanical Ventilation of the Asthmatic Patient in Respiratory
Asthma's Diagnosis and Treatment
The History of Tuberculosis
Asthma Exacerbation in Pregnancy
The Gap in Quality Care of Chronic Obstructive Pulmonary Disease
Automated Cough Sound-Centred Analytic System
Social Determinants of Chronic Obstructive Pulmonary Disease and Inequalities in the UK
Chicago (A-D)
Chicago (N-B)

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The Role of Climate Change in Asthma

Affiliations.

1 Stanford School of Medicine, Stanford, CA, USA.
2 Sean N. Parker Center for Allergy and Asthma Research at Stanford University, Palo Alto, CA, USA.
3 Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, CA, USA.
PMID: 37464115
DOI: 10.1007/978-3-031-32259-4_2

Human activity and increased use of fossil fuels have led to climate change. These changes are adversely affecting human health, including increasing the risk of developing asthma. Global temperatures are predicted to increase in the future. In 2019, asthma affected an estimated 262 million people and caused 455,000 deaths. These rates are expected to increase. Climate change by intensifying climate events such as drought, flooding, wildfires, sand storms, and thunderstorms has led to increases in air pollution, pollen season length, pollen and mold concentration, and allergenicity of pollen. These effects bear implications for the onset, exacerbation, and management of childhood asthma and are increasing health inequities. Global efforts to mitigate the effects of climate change are urgently needed with the goal of limiting global warming to between 1.5 and 2.0 °C of preindustrial times as per the 2015 Paris Agreement. Clinicians need to take an active role in these efforts in order to prevent further increases in asthma prevalence. There is a role for clinician advocacy in both the clinical setting as well as in local, regional, and national settings to install measures to control and curb the escalating disease burden of childhood asthma in the setting of climate change.

Keywords: Air Pollution; Asthma; Climate Change; Heterogeneity; Mold; Pollen; Wildfires.

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The Relationship Between School Absence, Academic Performance, and Asthma Status

2008, Journal of School Health

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Asthma Essay

Type of paper: Essay

Topic: United States , Asthma , Environment , Environmental Issues , Family , Nursing , Medicine , Children

Words: 1700

Published: 11/14/2019

ORDER PAPER LIKE THIS

Introduction

Asthma is one of the common respiration complications which are known to affect a substantial number of people all over the world. It is a chronic inflammatory complication which is known to affect the patient’s air channels within the respiratory chambers. It is usually characterized by diverse symptoms which may be persistence or recurring in nature. According to scientific and other medical researches which have been carried out in a number of developed countries, they have shown that asthma is not linked to any parasitic element emanating from the external environment (WHO. 2008). However, it is a general complication which develops as a consequence of tissue or cell inflammatory responses. Two main factors are known to cause or induce the occurrence of asthma to any individual. They include the environment under which a person has been operating together with the genetic links to parents or family members who had a history of asthma. Consequently, since these causative factors have been in existence since time immemorial, asthma has lived with man for a long period of time. In the ancient Egypt, history of asthma has been identified but proper documentation of asthma was done by Greek philosophers who identified the most prone group to be affected by this condition as tailors and those who worked in metal work industries (Wollan, Bertram & Yawn, 2008, p 67).

Types of asthma

Various types of asthma have been identified and clustered according to the level of their severity, complexity and diversity of symptoms linked to this complication. According to medical reports and practices, the classification of asthma is based on the frequency at which symptoms manifest themselves in any given patient. Another form or platform through which classification of Asthma is based is the client’s forced respiratory volume a process which is usually clinically carried out. This forced respiratory volume is based on a specified period of one second a process which is used to generate or develop the peak expiratory flow rate for that individual patient. Consequently, Asthma can be grouped as either atopic also known as extrinsic or as a non-atopic also termed as intrinsic form of asthma. Such classifications are based on whether the given form or class of asthma under question is based on allergen induction or not. Despite asthma being a chronic obstructive health state, medical researchers have not classified it as a subject of chronic obstructive pulmonary ailment since by subjecting asthma under this group; it literally combines asthma under other irreversible respiratory complications such as bronchiectasis, emphysema and chronic bronchitis among others of which their occurrence in any individual is a permanent irreversible process (Tippets, 2009, p 5).

Nevertheless, some researchers have been opting to include asthma under this group since a prolonged negligence of not attending to asthma condition can result to a subsequent development of a permanent irreversible obstruction of the air channels in a human being. The common types of asthma which have been witnessed in a substantial number of patients in the United States of America include the Brittle asthma which comprised two clusters of asthma. These two forms of asthma are based on vividly manifested severe attacks which recur at a given rate. Brittle asthma type 1 manifests a wide peak in the flow variability despite the administration of considerably sufficient medication. Type 2 of brittle asthma has less of these manifested symptoms hence it is much easily controlled and managed than type 1 of brittle asthma.

Causes of asthma

Asthma is known to be caused by various causative factors which mainly emanate from the environment under which a particular person is living. Apart from environment causative elements, asthma has also been linked to genetic elements or lineage of a person. According to statistical researches which have been carried out in the United States of America, they have shown that approximately sixty percent of asthma complications are caused by environmental factors (Fanta, 2009, p 1007). The remaining forty percent is linked to genetic factors which are linked to family lineages of a person. In addition, studies which have been carried out over asthma related diseases such as eczema and hay fever have vividly and comprehensively revealed some of the crucial risk factors which might induce the occurrence level of asthma in an individual.

All the same, some of the key risk factors for being attacked by asthma include the issue of atopic diseases in one’s life time or even related family members. Atopic diseases are known to substantially boost the occurrence levels of hay fevers by approximately five times as well as the occurrence of asthma by approximately four times. This is based on scientific research studies which have been carried out in the United States of America. These studies have also shown that in children who are out of their tender age and get diagnosed to have a allergies through positive skin tests as well as having an increased levels of immunoglobulin E are more likely to develop asthma complications (Yawn, 2008, p 150). a) Environmental factors: Risk factors emanating from the environment have been Identified and linked to the development of asthma especially in children. One of the risk factors is maternal tobacco smoking which usually occur before the delivery of a child. According a number of conducted surveys, they have shown that this habit increase the development of asthma like symptoms to the born infant. These symptoms include wheezing, unregulated bronchial contraction as well as respiratory infections. Other environmental factors which might expose someone to the development of asthma included traffic pollutions, poor ventilation and increased air pollutants to mention but a few.

b) Genetic factors: asthma has been linked to some chromosomal elements which can be transferred to offspring with a subsequent development of asthma in the children of the affected parents (Schiffman, 2009, p 4).

Signs and symptoms of Asthma

The common signs and symptoms which vividly manifest themselves in an asthma patient include wheezing, chest tightness, shortness of breath and coughing. Apart from these main and common symptoms of asthma, the patient may manifest state of confusion, state of depression and other physical changes which are usually associated with low oxygenated blood in the body. Extreme cases of asthma manifest themselves through rapid and painful contraction of bronchial units in the lungs (Fanta, 2009, p 1014).Due to these rapid painful contractions, the affected person may fall on the ground or seek for support due to poor functioning of the skeletal muscles in the body. The asthma mental effect is associated with burled vision, state of confusion and even loss awareness due to poor oxygenated blood in the brain.

Transmission of asthma

Asthma is a health complication associated with the breathing system of a person. Nevertheless, its transmission from one person to another can only take place through genetic links or chromosomes. A person who emanate from a family lineage which is known to have a persistence history of asthma cases is more likely to develop asthma and asthma related complications (De Lara & Noble, 2007, p 150). This is due to genetic linkage of some chromosomal genes to asthma complications. Consequently, such genes are transferred to offspring who may or may not develop asthma complications.

Prevention and treatment for Asthma

Asthma cases can be treated through administration of drugs such as salbutamol and fluticasone propionate through inhalation. These drugs are known to open the contracted brochial muscles as well as making the lung muscles to relax. Subsequently, the pain associated with asthma is substantially reduced to recommendable levels (Dipiro, 2008, p 525). According to medical practitioners from the US, recent medications which are used in treatment of asthma are clustered in two main groups; quick-relief and long-term control measures. For quick-relief, beta2-adrenoceptor agonists (SABA) the like of salbutamol are used in its treatment while for long term control, glucocorticoids have been highly recommended as the best form of its treatment. Asthma can be prevented through control of external environmental factors such as air pollutants which might induce asthma (Boulet 2009, p 890).

Some of these conditions associated with asthma can be treated through specific therapeutic techniques as well as control and preventive programs. Someone suffering from asthma can be treated through administration of suitable drugs such as salbutamol or fluticasone propionate basing on the extent and type of asthma in question. Asthma is a chronic inflammatory complication which is known to affect the patient’s air channels within the respiratory chambers. Asthma is usually characterized by diverse symptoms which may be persistence or recurring in nature. According to scientific and other medical researches which have been carried out in a number of developed countries, they have shown that asthma is not linked to any parasitic element emanating from the external environment.

Bibliography

Boulet L.P 2009. "Influence of Comorbid conditions on asthma". Eur Respir Journal 33 (4): 897–906.

Dipiro J.T. et al.2008. Pharmacotherpay. A pathophysiologic approach (7 ed.). pp. 524.

De Lara, C, Noble .A (2007). "Dishing the dirt on asthma: What we can learn from poor hygiene". Biologics 1 (2): 139–150.

Fanta, CH .2009. "Asthma". New England Journal of Medicine 360 (10): 1002–14. doi:10.1056/NEJMra0804579. PMID 19264689.

Schiffman, G. 2009. "Chronic Obstructive Pulmonary Disease". MedicineNet.retrived on 17/5/2011 from http://www.medicinenet.com/chronic_obstructive_pulmonary_disease_copd/article.htm.

Tippets B, G. 2009. "Managing Asthma in Children: Part 1: Making the Diagnosis, Assessing Severity". Consultant for Pediatricians 8 (5).

WHO. 2008. Asthma. Who.int. 2008-06-03. Retrieved on 16/5/2011 from http://www.who.int/mediacentre/factsheets/fs307/en/.

WHO. 2007. Global surveillance, prevention and control of chronic respiratory diseases: a comprehensive approach. Retrieved on 16/5/2011 from http://www.who.int/gard/publications/GARD_Manual/en/index.html.

Wollan, P., Bertram, S., and Yawn, B.P. (2008). Introduction of Asthma APGAR tools improve asthma management in primary care practices. Journal of asthma and allergy .Rochester: Dove Medical Press Ltd.

Yawn, BP 2008. "Factors accounting for asthma variability: achieving optimal symptom control for individual patients". Primary Care Respiratory Journal 17 (3): 138–147.

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Developmental PFOS exposure alters lung inflammation and barrier integrity in juvenile mice

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Joseph H Lucas, Qixin Wang, Jiries Meehan-Atrash, Cortney Pang, Irfan Rahman, Developmental PFOS exposure alters lung inflammation and barrier integrity in juvenile mice, Toxicological Sciences , Volume 201, Issue 1, September 2024, Pages 48–60, https://doi.org/10.1093/toxsci/kfae073

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Emerging epidemiological evidence indicates perfluorooctane sulfonic acid (PFOS) is increasingly associated with asthma and respiratory viral infections. Animal studies suggest PFOS disrupts lung development and immuno-inflammatory responses, but little is known about the potential consequences on respiratory health and disease risk. Importantly, PFOS exposure during the critical stages of lung development may increase disease risk later in life. Thus, we hypothesized that developmental PFOS exposure will affect lung inflammation and alveolar/airway development in a sex-dependent manner. To address this knowledge gap, timed pregnant Balb/cJ dams were orally dosed with a PFOS (1.0 or 2.0 mg/kg/d) injected mealworm or a vehicle control daily from gestational day (GD) 0.5 to postnatal day (PND) 21, and offspring were sacrificed at PND 22-23. PFOS-exposed male offspring displayed increased alveolar septa thickness. Occludin was also downregulated in the lungs after PFOS exposure in mice, indicative of barrier dysfunction. BALF macrophages were significantly elevated at 2.0 mg/kg/d PFOS in both sexes compared with vehicles, whereas BALF cytokines (TNF-α, IL-6, KC, MIP-1α, MIP-1β, and MCP-1) were suppressed in PFOS-exposed male offspring compared with vehicle controls. Multiplex nucleic acid hybridization assay showed male-specific downregulation of cytokine gene expression in PFOS-exposed mice compared with vehicle mice. Overall, these results demonstrate PFOS exposure exhibits male-specific adverse effects on lung development and inflammation in juvenile offspring, possibly predisposing them to later-in-life respiratory disease. Further research is required to elucidate the mechanisms underlying the sex-differentiated pulmonary toxicity of PFOS.

inflammation
bronchoalveolar lavage fluid
perfluorooctane sulfonic acid

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J Multidiscip Healthc

A case study of asthma care in school age children using nurse-coordinated multidisciplinary collaborative practices

Susan procter.

1 Faculty of Society and Health, Buckinghamshire New University, High Wycombe, UK

Fiona Brooks

2 Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK

Patricia Wilson

3 Centre for Health Services Studies, University of Kent, Canterbury, UK

Carolyn Crouchman

Sally kendall.

To describe the role of school nursing in leading and coordinating a multidisciplinary networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting multiagency interprofessional practice.

The growth of networked and interprofessional collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-discipline or -agency interventions. This paper identifies the potential of school nursing to provide the vision and multiagency leadership required to coordinate multidisciplinary collaboration.

A mixed-method single-case study design using Yin’s approach, including focus groups, interviews, and analysis of policy documents and public health reports.

A model that explains the integrated population approach to managing school-age asthma is described; the role of the lead school nurse coordinator was seen as critical to the development and sustainability of the model.

School nurses can provide strategic multidisciplinary leadership to address pressing public health issues. Health service managers and commissioners need to understand how to support clinicians working across multiagency boundaries and to identify how to develop leadership skills for collaborative interprofessional practice so that the capacity for nursing and other health care professionals to address public health issues does not rely on individual motivation. In England, this will be of particular importance to the commissioning of public health services by local authorities from 2015.

Introduction

This paper presents the findings from a case study which formed one of seven case studies designed to identify the nursing contribution to chronic disease management. 1 All of the case studies were selected using criteria which indicated innovation and nurse leadership. Findings from the other six case studies, reported elsewhere, 2 highlighted considerable fragmentation in the coordination of services. The case study presented here is reported separately because it provides an exemplar of nursing leading integrated whole-system service provision for children with asthma.

The growth of networked and partnership collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-agency interventions. 3 Childhood asthma falls into this category. Asthma is one of the most common long-term conditions affecting young people. The first UK national review of asthma deaths found that two thirds of deaths could be prevented with better care and that 96% of children who died did not receive care based on good practice. 4 There is evidence that peaks in hospital admission among school-age children coincides with the start of the school year. 5

A range of initiatives have been evaluated drawing on educational and population-based principles to improve asthma management among school age children. These include education initiatives, 6 , 7 asthma clubs, 8 population screening, 9 combined population screening and education, 10 , 11 and the introduction of a consulting physician with a specific remit to reduce school absenteeism. 12

Whilst school nurses have a history of working with children and families, as well as in schools to provide asthma education and support, the role of teachers in supporting parents to manage the health of school children in England is, however, unclear and in some cases contradictory. 13 , 14 The law in England says that teachers receive delegated authority from parents necessary for maintaining the child’s welfare. However, as Crouchman 13 , 14 points out, there is no obligation for teaching staff, including physical education staff, in England to do any first aid training.

Multiagency collaboration to address public health issues such as childhood asthma is increasingly being advocated. 15 There is a growing body of international knowledge about the governance, management and leadership qualities, and behaviors required for managers and clinicians to work effectively in networked or partnership collaborations. 16 – 18 However, detailed case studies have also identified significant barriers to effective teamwork, with research indicating a cautiousness among many professionals to engage in interprofessional collaboration. 18 – 20

This paper describes a nurse-led population health care service for school children with asthma in which multi-professional interagency collaboration featured strongly. Using Yin’s 21 approach to explanatory case study methodology, this case study describes the role of nursing leadership in coordinating collaborative approaches to health problems which require multiagency integration. It describes some of the challenges and tensions between the different parts of the whole system which need to be addressed in order to develop a more integrated approach to care delivery.

To describe the role of school nursing in leading and coordinating a multidisciplinary, networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting collaborative interprofessional practice.

The findings presented here are taken from one of seven case study sites.

Yin’s 21 case study methodology was drawn upon to direct the fieldwork and the data analysis of the multiple sources of evidence.

Sample/participants

The case study was selected following a systematic mapping of publicly available information on nursing management of long-term conditions from across England and Wales. Leaders of services were invited to present a description of their service at a conference hosted by the research team and attended by service users. Case studies for in-depth analysis were selected by consensus methods involving all conference participants. A fuller account of sampling and case study selection is given by Wilson et al. 22

Data collection

Semistructured audio recorded face-to-face or telephone interviews were used to collect the data. Interviews lasted between 30 minutes and 1 hour and were conducted with eleven practitioners including the asthma coordinator, who was the lead school nurse, and ten school health advisors, all of whom had a school nursing qualification. All interviews were audio-recorded and transcribed verbatim. Secondary data analysis was undertaken of operational and strategic plans as well as annual reports from the Primary Care Trust (PCT) to identify the relationship between the school nursing service and the organizational objectives of the PCT and commissioners. A PCT was the organizational unit within the National Health Service (NHS) for England at the time of the study whereby services for primary care were both provided and commissioned. In 2010, there was organizational change and transition from PCTs to clinical commissioning groups and community service providers.

The researchers were not able to undertake interviews with general practitioners (GPs), although this would have added a further perspective on the strategy and is recognized as a limitation.

Ethical considerations

Informed consent was obtained from all participants who were made aware that their contribution may be published. All participants were given the opportunity to opt out following participation. Ethics and research governance approval was obtained through the NHS prior to data collection.

Data analysis

The interview data from practitioners were open–coded using N-Vivo software. These data were then subjected to thematic analysis. The reliability of the themes identified was checked by the authors who were involved in data collection and analysis.

Validity and rigor

The findings were independently reviewed by two members of the research team and discussed by the team as a whole. Disconfirming statements were searched for. An expert steering group which included patients reviewed drafts of the findings and gave critical feedback.

The case study covered a primary and secondary school-age population of approximately 40,000 children within a mainly urban area of the West Midlands with a total population of approximately 305,000. The area was characterized by a serious shortage of GPs and poor air quality. Yet, despite these problems, the emergency admission rate of children to hospital in this area was 49 compared to the standardized national average in England of 100 (rate of hospital admissions per head of population, standardized to account for regional differences in age and sex, with the average for England assigned a rate of 100).

Public policy influences on local service delivery

The asthma service was developed in response to a number of policy drivers which impacted on different provider organizations across the system:

The Public Health Report for 2007: this report records the air quality for the local area. Its findings indicate that at the time of the study, nitrogen oxide and small particle emissions were well above the UK mean. Evidence suggests that both these emissions can have a harmful effect on the respiratory system and that nitrogen oxide has a particularly damaging effect on people with asthma, increasing hospital admissions for children. 23 , 24
The education system: as a result of government policy, 25 all schools in England are subject to specific targets to reduce school absenteeism.
The publication of the National Service Framework for Children and Maternity Services 26 by the UK Government included a multiagency partnership exemplar pathway for asthma in childhood.
Every Child Matters 27 provided an integrated framework of objectives for children’s services, which health, education, and social services in England were required to meet in an attempt to create an integrated policy response to the multiple complex needs of children and young people. Specific advice was issued to schools in relation to children with asthma. This advised that children should have access to their reliever inhalers, that all schools should have an asthma policy, and that all teaching staff, but particularly teachers who supervise physical exercise, should have training once a year or be provided with information on how to care for a child with asthma. 27

The origins of the school asthma service

The development of a school asthma service in this case study began pre-2000. Community nurses had recognized the need to work with schools to meet the health needs of school-aged children with asthma. However, it was only following the appointment of the current school nurse asthma coordinator in 2000 that their aspirations were taken forward strategically:

We’ve been trying to set this policy up going back to sort of 1997 … we couldn’t really take it forward … [Asthma coordinator] came along and obviously with this excellent enthusiasm and interest in asthma and sort of really pushed the service forward. [School health advisor 1]

The initial stimulus for the school asthma strategy was the recognition by key stakeholders including health and education services of the need to provide a more integrated, seamless service for managing childhood asthma. The objectives of the service mirrored policy objectives and were designed to empower children and their families to manage asthma with confidence, reduce hospital admission, and reduce absenteeism from school.

The development of the school asthma service was aided by the charity Asthma UK, which provided 12 months’ funding to pump prime the asthma coordinator role. The role was subsequently funded by the local primary care provider. The multiagency strategy was launched by the primary care service in 2003 as described by the asthma coordinator:

The priority when I came into this post was to get 100% of schools, you know of all [town] schools to have an asthma policy. When I came into post we had 76% of schools signed up to the [town] School’s asthma policy, we’ve now got approximately 96% so there are I think three outstanding schools at the moment and that’s just a time issue for me to actually get round individually to those schools and persuade them to come on board … We have the full backing of the local authority on it, it’s a jointly ratified policy between health and education. [Asthma coordinator]

The structure of the school asthma service

The school asthma service is led by the asthma coordinator who is based in primary care. The asthma coordinator is a registered nurse and sick children’s nurse, as well as a school nurse. She coordinates a team of school health advisors, most of whom are registered as school nurses.

The school health advisors are responsible for a number of schools across the town. Each school has identified schools-based asthma support workers who could be teachers, first aid workers, or teaching assistants. The asthma support workers work with their school advisor to implement the school asthma policy. Collectively, support workers and their school health advisor carry a caseload of children with asthma. All advisors and support workers have had specialist training in asthma management and are regularly updated as part of their professional development.

The organization of the school asthma service

All children with asthma admitted to a school in the area are registered on an asthma register:

Any new children coming into school now, the parents will be sent the asthma information form and hopefully they’ll be put on the register. [School health advisor 2]

The school nurses and support workers made frequent reference to the asthma register of school-aged children and reported the register as a valuable tool that enabled them to identify children with asthma. The school nurses also referred to the way in which they used a data system to reconfigure service delivery, in particular with primary care:

I think one of the main issues was obviously parents not taking children to their asthma clinics, and we were actually saying well maybe we could be seeing the children and the parents at school. [School health advisor 2]

As part of the school asthma service, the asthma coordinator had negotiated the availability of emergency asthma medication in each school:

And also within our asthma policy we will provide for any school that wants one, an emergency salbutamol inhaler and spacer device … we do it as safely as we possibly can, we have a robust risk management strategy, we have a consultant community pediatrician who takes responsibility for placing the drug within the school, the drug is only available [to children] whose names are on the school asthma register, whose parents have signed a consent form for the use of the drug. It’s kept in a safe place within the school and it’s monitored, it’s use is monitored. [Asthma coordinator]

At the time the study was conducted, this was an innovative strategy for the management of asthma in schools. In September 2014, the Department of Health for England produced guidance for schools to enable them to use an emergency salbutamol inhaler without prescription. 28

The audit of emergency inhaler use from January 2006 to December 2006 indicated that emergency inhalers were used in schools 106 times. The close monitoring of the use of the emergency inhaler was used to identify and provide additional support for children and families who were having difficulty with asthma management:

So it’s [monitoring the use of the emergency inhaler] actually quite an effective tool in asthma management because if a child is using the school’s emergency device we want to know why. Why are they using it and it’s down to the school nurses to check those records on a monthly basis, why has Johnnie used that inhaler twice in the last month? Why didn’t he have his own inhaler? And that then generates a work load for the school nurse. [Asthma coordinator]

Throughout the year, the record of inhaler use enables the school asthma advisors to identify the children who are regularly attending school without their inhalers. This triggers a follow-up meeting with the child’s family to identify why this is happening and provide additional education and support. The results of the audit are disseminated across the case study area and between schools and GP practices.

The school asthma registers and audit data formed an important tool used by school health advisors to target interventions for asthma management. The development of a local patient record and data system can be at odds with more centralized electronic patient record systems; they also suffer from limitations in technical support and local expertise. However, the sense of ownership the team had developed was creating enhanced understanding of local needs and driving innovations in practice. The asthma coordinator was seen as the champion of much of this work as clearly identified above.

The asthma coordinator role

The asthma coordinator was seen as key to the service. She provided clear strategic leadership relating to policy and practice concerning the management of asthma in young people. This was welcomed by the School Health Advisors who were enabled to undertake their role by being able to access and work with the specialist asthma coordinator. More generic community nurses were also able to access specialist knowledge from the asthma coordinator which enhanced their service. This reflects the work of Brooks et al 29 who describe a whole network of coordinated activities which fall within the responsibility of the “navigator” role. However, in this case, there was little evidence of succession planning for the role of the asthma coordinator; neither was there evidence of service reconfiguration to adopt a more public-health-focused model. Dependence on a key, single individual was therefore a weakness of the current service.

The school asthma strategy described above had to demonstrate both impact and outcomes for the local health economy. It was clear that although there was a willingness to set up a school asthma service across core organizations, the asthma coordinator was actually key to the realization of this aspiration. Without her expert knowledge, vision, problem solving, and ability to develop and get policies and procedures ratified across all partner agencies, the service might not have been implemented.

The actual nurse time involved in developing and implementing the strategy must also be considered. We were unable to collect precise data on this, but the asthma coordinator role was a full time nursing role and the ten school health advisors had varying full time equivalencies, of which only some of their time was concerned with the asthma strategy. Whilst the cost of this nursing input on an annual basis is relatively high, it can be argued that cost savings could also be made through the reduction in hospital admissions reported for the PCT. As with all service evaluation, this may not be a direct consequence of the asthma service, but there were no other initiatives in the area that could have accounted for the relatively low hospital admission rate compared with other similar areas.

The coordination of central government policy directives towards a focus on health outcomes for children provided a rationale for expenditure that could be used by the local team to implement their vision. Without these policy initiatives, this service might not have received the support from local stakeholders required to realize these outcomes.

Whole system engagement

The school asthma service is based on public health principles of increasing the capacity across the system of support to manage asthma by raising awareness and education of health service staff, school staff, parents, and children, and as described by the asthma coordinator below:

Well another group before me had decided that we needed asthma policies in schools and they were really struggling, with the barriers between health and education really. And I sort of came on board and just ended up leading that project, just pushing it through and we’ve now got a ratified policy, our school asthma policy. [Asthma Coordinator]

The asthma coordinator working with her team of school health advisors and asthma support workers are working towards enabling the child and family to navigate 29 their way through the health and education network. The goal is to provide an integrated service in which the child with asthma can move seamlessly between NHS, school, and home:

So what we’re actually hoping to achieve at the end of this is some sort of framework integrated care pathway, I’m not really sure what it will be called. Some sort of framework, which has basically got the child or young person and their family at the very heart of the document, really in the center of it all. [School health advisor 1]

There was considerable evidence of collaborative working across agencies including health, education, voluntary sector, and the community. Within the health sector, collaboration between emergency departments, GP practices, and hospital inpatient departments was underway. This was supported by the lead for Healthy Schools on the Primary Care Directorate for Children’s Services, who commented that they had been working on:

the concept of healthy schools in [town] since 1994 so it predates the National Healthy Schools Program … And we have all of our schools signed up and committed including our referral units and we also work with the colleges and it’s very much about promoting and developing the concept of health for children within the school setting and associated settings. [Local authority lead nurse for Healthy Schools]

The healthy schools award is a national initiative which involves a formal accreditation process.

Whilst all the schools within the case study area were involved in the whole-system strategy, there was more difficulty integrating GPs and primary care as well as all other parts of the health system into the asthma strategy:

we’ve just set up the Paediatric Respiratory Forum and what that has done has brought together a range of professionals from primary and secondary care, community services, education, safeguarding children, which is another big area. Brought all of these people together and asked them to look at children with asthma in their area, what we can do about it, and how we can bring it all together basically. [Asthma coordinator]

A key performance indicator for primary care in the UK is the Quality Outcomes Framework (QOF). GPs are able to claim additional funding if they can demonstrate that they have met their QOF targets. QOF accounts for approximately 25% of general medical service income. QOF points are awarded for asthma targets, which include minimally keeping an asthma register through to monitoring those diagnosed with asthma and ensuring they receive an annual review. However, QOF targets are not specific to childhood asthma although children are included in them.

There was evidence that primary care is the weakest link in system-of-care delivery:

It’s very difficult to communicate with GP’s isn’t it, because we’re not just actually covering the schools in a certain catchment GP area. Whereas the health visitor would be working with a particular GP and could do that liaison so much better, we’re dealing with so many GP’s, children are coming from all over the borough to certain schools and that is a problem sometimes. [School health advisor 3]

This case study provides a model of how nurses can develop a system of care which reflects the principles of a public health-orientated primary care system. To make this work effectively, political and organizational commitment, networked leadership, and above all a vision of what they are trying to achieve is required. Collectively, this created a local workforce with well-developed teamwork skills and the ability to work across multiple agencies. However, establishing this service was highly dependent on the vision and energy of a single individual, which makes the replication of the service difficult to achieve. In a review of cross-sector partnerships, Andrews and Entwistle 30 found that public–public partnerships were positively associated with public service efficiency, equity, and effectiveness, indicating the potential of these partnerships to effectively address cross-agency population needs. However, as this study demonstrated, actually establishing effective multiagency partnership working requires the organizations involved to develop a shared vision beyond their individual organizational missions. Coordinated central government policies provided incentives for organizations to collaborate.

In reviewing the case study, it is clear that it conforms to many of the attributes identified by Mikkelsen-Lopez et al 16 required to create governance across health systems. These include a long-term strategic vision led by local clinical stewards (in this case the asthma coordinator) based on transparent information translated into transparent policies (the school asthma register and the inhaler policy), rules (about who can use the inhaler and follow-up of those children who do use it), and incentives (eg, to meet government targets to reduce school absenteeism).

The case study demonstrates that adherence to central government policies and a desire to meet centrally imposed targets, combined with an organic practice development methodology, has been instrumental in enabling the development of an effective local, networked asthma service. These factors have also sustained the service through some of the organizational complexity and constraints imposed by constant NHS reorganization.

Problems remain, however: the local data system set up by the service did not interface with more centralized patient and pupil records; engagement with primary care, which was also responding to a different set of government imposed targets, was still a problem; and there was an apparent lack of succession planning for the asthma coordinator. Despite these problems, there was a real sense of innovation and purpose within the network that provides optimism that such barriers can be overcome.

Front-line stewardship of service redesign is seen as a key attribute of all networked systems. 16 , 18 , 20 , 30 This paper illustrates the potential contribution primary care nurses could make to realizing collaborative professional practice within a networked system of provision. 17 The model still, however, reflects a single-disease-orientated approach to service integration; it is not clear if this model could be replicated simultaneously over a number of different long-term children’s illnesses such as diabetes, epilepsy, and sickle cell disease alongside asthma. Further theoretical, conceptual, and pragmatic work is required to address this.

Limitations of the research

This paper presents the evolution of a single service as described by those practitioners involved in the redesign and implementation of the service. Information derived from public health sources on air quality and hospital admission suggest some success in improving outcomes for the population. However, the data were not strong enough to draw any cause-and-effect conclusions. A number of papers 18 , 30 have highlighted the difficulties of undertaking research into the effectiveness of redesigned services, and the need for improved methodologies and more integrated working practices between academic researchers and service redesign is required to evidence the full impact of these changes.

Implications for public sector management

The contribution of this paper lies in its rich description of the translation into practice of features of multiagency professional collaboration that have been described in detail in the theoretical literature. It indicates the potential of nurses to undertake a leading role in initiating and sustaining public health solutions to pressing health care problems. Current literature indicates a cautiousness 19 , 20 among primary health care clinicians in relation to networked collaboration as well as considerable challenges for service managers in establishing governance systems which reflect the population focus of this way of working. 16 , 31

This paper demonstrates that public sector managers and commissioners need to understand how to support clinicians working across multiagency boundaries, including support for succession planning. This requires improved understanding about how to develop and support health professional leadership skills for collaborative interprofessional practice that does not rely on individual motivation. This presents challenges for service managers and commissioners in providing an enabling framework for public health-orientated clinical practices. This will be of increasing importance in England as the commissioning for public health services and the public health outcomes targets are transitioned from the NHS to local authorities during 2015. 32

Acknowledgments

The authors would like to acknowledge Elaine McNeilly, Jo Magnusson, Melissa Chamney, Sally Roberts, and Stephen Abbott who contributed to data collection and analysis at various stages of the PEARLE project. This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 08/1605/121).

The authors report no conflicts of interest in this work. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS, or the Department of Health.

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Asthma Asthma is a lung disease that affects approximately ten million people in the United States. (Cramer 2) In people with asthma, the airways of the lungs are hypersensitive to irritants such as cigarette smoke or allergens. When these irritants are inhaled, the airways react by constricting, or narrowing. Some people with asthma have only mild, intermittent symptoms that can be controlled without drugs. In others, the symptoms are chronic, severe, and sometime life threatening. Although researchers have learned more about the underlying causes of asthma in recent years, a definitive treatment is still unavailable. In the last decade, asthma deaths worldwide have rose 42%. (Cramer 2) The reasons for this increase are not clear; however, many experts believe that the lack of standard treatments and the inconsistent monitoring of asthma patients have contributed to the increased mortality rate. With this disease comes many questions such as what is asthma, what are the symptoms and causes, how is it diagnosis, what are the treatments, how is it prevented and maintained. In answering these typical questions people will be more informed of a disease that is killing people. Asthma is sometimes referred to as a disease of “twitchy lungs”, which means that the airways are extremely sensitive to irritants. The airways are the tubes that bring air from the windpipe, known as the trachea, to the lungs. These tubes are called the bronchi. Each bronchus, in turn, branches into smaller tubes called bronchioles. At the end of the bronchioles are small, balloon like structures called alveoli. The alveoli are tiny sacs that allow oxygen to diffuse from body tissues into the lungs to be exhaled. (Shier, Butler, Lewis 786-88) During an asthma attack, the bronchi and bronchioles constrict and obstruct the passage of air into the alveoli. Besides constricting, the airways may secrete copious amounts of mucus in an effort to clear the irritation fro...

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Implementation and Evaluation of a School Nurse Toolkit to Reinforce Best Practices for Asthma Care in Schools

PROGRAM EVALUATION BRIEF — Volume 21 — August 22, 2024

Diane Wing, MS 1 ; Evilia Jankowski, MSA, BSN, NCSN 2 ; John Dowling, MA 3 ; Tisa Vorce, MA, RRT 3 ( View author affiliations )

Suggested citation for this article: Wing D, Jankowski E, Dowling J, Vorce T. Implementation and Evaluation of a School Nurse Toolkit to Reinforce Best Practices for Asthma Care in Schools. Prev Chronic Dis 2024;21:240027. DOI: http://dx.doi.org/10.5888/pcd21.240027 .

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Introduction

Purpose and objectives, intervention approach, evaluation approach, implications for public health, acknowledgments, author information.

What is already known on this topic?

Resources reinforcing the standards of care for asthma can strengthen self-efficacy and use of asthma management practices among school nurses.

What is added by this report?

An asthma toolkit was promoted to school nurses in Michigan. School nurses viewed the toolkit and reported implementing changes to improve asthma management practices in their schools.

What are the implications for public health practice?

Reaching school nurses through promotional activities can encourage school nurses to apply the standards for care to support students with asthma in school.

A toolkit, developed by a multidisciplinary team of national and statewide professionals, was promoted among school nurses in Michigan to support use of the standards of care for asthma in schools. We evaluated the effectiveness of the toolkit to assist school nurses in providing support for students with asthma. We used a multimethod approach to assess use of the toolkit, changes in nursing practices as a result of using the toolkit, and challenges encountered when implementing the standards for asthma care. During a 12-month period, from July 2022 through June 2023, increases in time on web page and monthly page views aligned with efforts to promote toolkit use. School nurses reported using the toolkit and implementing practice changes pertaining to training and education, ensuring proper use of and access to asthma medications, and advocating for self-carry of asthma medications. Challenges to implementing the standards of asthma care were time, parental engagement, institutional support, and identifying students with asthma. We found that our promotional efforts prompted school nurses to access the toolkit, which helped school nurses to effectuate practice changes to improve support for students with asthma in schools.

The prevalence of current asthma in Michigan among children and adolescents aged 5 to 17 years is 8.8% (1). Of these children and adolescents, 35.3% missed 1 or more days of school due to asthma from 2017 to 2021 (2). Children and adolescents who are Black or in low-income households are disproportionately affected by asthma (2). From 2017 to 2021, 18.4% of Michigan children and adolescents aged 5 to 17 years with current asthma had an asthma-related visit to an emergency department or urgent care in the past 12 months; however, 30.9% of Black children and adolescents and 26.0% of children and adolescents in households with less than $50,000 in annual income had an asthma-related emergency department or urgent care visit in the past 12 months (2). Complex interactions among varying levels of social, structural, biological, and behavioral determinants contribute to asthma-related disparities (3).

In June 2022, the Michigan State Board of Education updated a model policy for supporting students with asthma that set forth recommendations for schools to establish asthma-friendly environments to improve students’ attendance and participation in activities and promote academic success and well-being (4). Building on the Whole School, Whole Community, Whole Child model (5), which provides conceptual support and practical guidance central to best practices, the policy designated school nurses as important members of a child’s support network to coordinate asthma management activities; integrate communication among students, caregivers, and health care providers; and ensure all school personnel have received appropriate training in asthma management and emergency response (4,5).

School nurses fill the gap between health care and education, provide both acute and chronic care, treat and assess behavioral health concerns, and connect students and families to community resources (6). Although school nurses are well positioned in their role to support students with asthma, inadequate time to devote to asthma management, due in part to competing student needs and multiple roles, impedes completion of these activities (7). Additionally, school nurses in Michigan practice in various models, and they may be responsible for covering more than 1 building or an entire school district. As such, a medically qualified person may not always be available to meet the emergent needs of students, and the oversight is shifted to school staff, teachers, and administrators (7).

Historically, Michigan has ranked lowest among states in its school nurse-to-student ratio (8). However, due in part to recent increases in school budgets (9), the number of employed school nurses has quadrupled since 2019, increasing from some 200 nurses to an estimated 800 nurses (Evilia Jankowski, MSA, BSN, NCSN, State School Nurse Consultant, Michigan Department of Education, October 5, 2023, email correspondence). Younger and less experienced school nurses have been reported to be less likely than older and more experienced school nurses to perform asthma management activities (10). Regardless of experience, however, asthma-focused education can strengthen self-confidence in asthma management among school nurses (10,11), and this self-confidence has been associated with increased performance of asthma management activities (10).

To support school nurses’ use of best practices for asthma management, a multidisciplinary team of national and statewide professionals convened to develop an asthma toolkit (12). The toolkit, Supporting Students with Asthma at School: Standards of Care, presents information for understanding asthma and applicable laws and details performance standards to support students with asthma (12). These standards include coordination of care, assembling health care plans, and training school personnel.

The conceptualization of this evaluation was a collaborative effort between the Michigan Department of Education (MDE) and the Michigan Department of Health and Human Services (MDHHS) Asthma Prevention and Control Program. We designed the evaluation to assess the effectiveness of the toolkit to assist school nurses in providing support for students with asthma in schools. Our evaluation questions were 1) To what extent did school nurses use the toolkit? 2) What practice changes were implemented as a result of using the toolkit? and 3) What were the perceived challenges to implementing standards for asthma care in schools?

On August 4, 2022, the toolkit was uploaded to the School Health Services page on the MDE website (12). The Michigan State School Nurse Consultant (SSNC) (E.J.) promoted the toolkit throughout the 2022–2023 school year. The SSNC introduced the toolkit at the Michigan School Nurse Summer Institute meeting in August 2022. The toolkit was promoted in the SSNC’s newsletter sent to school nurses in January 2023, during the SSNC’s monthly office hours in March 2023, and at the Michigan Association of School Nurses annual conference in May 2023.

The MDHHS institutional review board determined the evaluation to be exempt from full review and oversight. We used a multimethod approach, which consisted of collecting quantitative and qualitative data from several sources to facilitate a complete understanding of the extent to which the toolkit was used.

We used Google analytics to track the extent to which the home page of the toolkit was accessed from July 2022 through June 2023 on the MDE web page. The home page of the toolkit includes links to various components of the toolkit and a link to access and download a complete version of the toolkit document. We tracked time on page in seconds; the number of page views, defined as the number of times a web page was seen by all users; and the number of unique page views, defined as the average number of times a web page was seen by each user.

School nurses were invited to complete an online survey, administered by SurveyMonkey (www.surveymonkey.com), once in January 2023 and again in February 2023. We used the SSNC’s newsletter to invite the 800 school nurse subscribers to complete the survey. Two survey questions were used to assess toolkit use and practice changes made. The first question was, “Have you used the Asthma Toolkit to help guide you on asthma care and management for students in school?” Response options were yes and no. The second question was open-ended: “Based on your use of the Asthma Toolkit, have you made any process or practice changes in the way students with asthma are supported? If yes, briefly describe the changes made.”

In May 2023, the SSNC led a Kahoot! (www.kahoot.com) among school nurses attending the Michigan Association of School Nurses annual conference. A Kahoot! is a game-based platform used to collect real-time information from a group of people through a web browser on a mobile device. During the Kahoot!, 3 statements were used to collect information. The first was a true-or-false statement: “I have utilized the Asthma Toolkit on the MDE website.” The second was open-ended: “Share one practice change implemented since accessing the Asthma Toolkit.” The third was also open-ended: “What is the biggest challenge to implementing the standards of care for supporting students with asthma in school?” Responses to open-ended questions were limited to 250 characters.

We used Microsoft Excel to conduct a descriptive analysis of count data. We calculated frequencies and means for time on page, number of page views and unique page views, and we calculated frequencies for the number of respondents who used the toolkit. For qualitative analysis, we identified and developed themes on the basis of respondents’ comments, and we created and condensed categories on the basis of commonalities among the themes. We used Microsoft Excel to assign comments to a column and themes to a row to track when a theme was mentioned. One person (D.W.) coded the information and developed the coding scheme, which was reviewed and discussed with 3 team members (E.J., J.D., T.V.). Comments from the survey and Kahoot! were analyzed and reported separately.

Time on page totaled 6,124 seconds (1 hour, 42 minutes) and averaged 510 seconds (8 minutes, 30 seconds) per month. The least amount of time on page was 87 seconds in July 2022, the month before the toolkit was uploaded, and the greatest time on page was 1,049 seconds (17 minutes, 29 seconds) in March 2023. Page views totaled 819, averaged 68 per month, and ranged from 38 to 150. Unique page views totaled 648, averaged 54 per month, and ranged from 7 to 125. August and September had the greatest number of page views, and increases in page views generally aligned with efforts to promote toolkit use. The frequency of unique page views followed a similar pattern ( Figure ) .

Of the 800 school nurses who subscribed to the SSNC’s newsletter, 71 completed a survey (9% response). Of the 71 respondents, 42 (59%) indicated they used the toolkit, and of these, 11 (26%) provided information on practice changes made. We identified 2 themes based on comments: training and education and asthma action plans. Respondents reported using the information to educate administrators, staff, and families, using resources from the toolkit for training, and improving their own skills in recording asthma episodes. They also reported implementing the use of standardized asthma action plans and requesting and obtaining asthma action plans for each student with asthma.

Of the 176 meeting attendees, 140 participated in the Kahoot! (80% response). Of the 140 participants, 97 (69%) indicated that they used the toolkit, and of these, 73 (75%) provided information on practice changes as a result of toolkit use. Of these responses, 5 themes emerged: training and education (n = 25 respondents who made comments that pertained to a theme); asthma action plans or care plans (n = 19); use of asthma medications and spacers (n = 16); self-carry of asthma medications (n = 7); and other responses (n = 6).

School nurses reported using the guidance to train staff, some specifically referencing the tier-level training and infographic resources in the toolkit; educate staff, students, and families on asthma, such as proper inhaler use and asthma signs and symptoms; and improve their own knowledge, such as being more skilled in creating health care plans for students. Practice changes also included requesting asthma action plans to ensure all students with asthma had an asthma action plan on file, standardizing asthma action plans, or modifying care plans to be in accordance with performance standards. School nurses described changes made to ensure students had access to inhalers at school and during school-related events, as well as encouraging spacer use and following up with students after rescue inhaler use. School nurses reported advocating for self-carrying medications in their school, ensuring staff were aware of students who self-carry medications, or sharing asthma action plans with teachers to allow students to safely self-carry medications; 1 respondent described asking students who self-carry medications to demonstrate proper inhaler use. Other practice changes related to completing asthma assessments, providing support for asthma trigger reduction, collecting data, checking oxygen saturation regularly, and encouraging medical provider visits.

When school nurses were asked to describe their biggest challenge to implementing the standards for asthma care in school, of the 97 participants who used the toolkit, 57 (59%) provided a brief description of challenges. Time (eg, being busy), parents (eg, parental involvement, communication, support, obtaining asthma action plans), support (eg, staff compliance, administrator buy-in, physician response, being understaffed), and being able to identify students with asthma were reported challenges. Of the 43 respondents who did not use the toolkit, 22 (51%) briefly described challenges as time, parents (eg, parental involvement, communication, cooperation, support), and communication and collaboration.

We aimed to identify the types of practice changes made as a result of toolkit use. Our findings suggest the toolkit reinforced practices for training of staff on the tier levels for asthma management and emergency response training and with educating staff, students, and families on asthma and proper use of asthma medications. School nurses also reported standardizing asthma action plans, increasing the number of students’ asthma action plans on file, and advocating for self-carry of asthma medications in schools. Some school nurses improved their own skills with recording asthma episodes and developing care plans. We gained a limited understanding of challenges encountered by school nurses when implementing the standards of care for asthma; these challenges were noted in previous research (7,13). Introducing a model for school nurse–led management can help schools meet the health needs of students with asthma, especially those with multiple and complex barriers to health and academic success, and provide professional support for school nurses to moderate challenges (14).

Evaluation findings confirmed that our promotional efforts prompted school nurses to access the toolkit. School nurses reported using the toolkit, and the uptick in web page visits and time on page generally corresponded with promotional activities. Replication of this approach could be used to promote additional toolkits developed for school nurses to support students with other health conditions.

Our study has several limitations. Findings are not generalizable to all school nurses due to low response rates. Additionally, survey and Kahoot! respondents were reached through the SSNC’s newsletter and a Michigan Association of School Nurses conference and may not reflect the entire population of school nurses. A school nurse could have participated in the survey and Kahoot! and may be represented more than once. We did not collect information on demographic characteristics of school nurses in Michigan. Practice changes were based on self-report and could not be externally validated, and our understanding of aspects of the toolkit that school nurses deemed most useful was limited. Additionally, the scope of the evaluation did not examine whether practice changes led to improved asthma outcomes for students.

This project was supported by the funding opportunity CDC-RFA-EH19-1902, “A Comprehensive Public Health Approach to Asthma Control through Evidence-Based Interventions,” cooperative agreement NUE1EH001380, from the Centers for Disease Control and Prevention (CDC) to the MDHHS. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of CDC or MDHHS. Use of trade names is for identification only and does not imply endorsement by CDC, the Public Health Service, or the US Department of Health and Human Services. The authors declared no potential conflicts of interest with respect to the research, authorship, or publication of this article. No copyrighted material, surveys, instruments, or tools were used in the research described in this article.

Corresponding Author: John Dowling, MA, Asthma Prevention and Control Program, Michigan Department of Health and Human Services, PO Box 30195, Lansing, MI 48909 ( [email protected] ).

Author Affiliations: 1 Wingspan Research Group, Grand Rapids, Michigan. 2 Michigan Department of Education, Lansing, Michigan. 3 Asthma Prevention and Control Program, Michigan Department of Health and Human Services, Lansing, Michigan.

Michigan Department of Health and Human Services. Michigan Behavioral Risk Factor Surveillance System. 2022. Accessed April 23, 2024. https://www.michigan.gov/mdhhs/keep-mi-healthy/communicablediseases/epidemiology/chronicepi/bfrs
Michigan Department of Health and Human Services. Michigan Asthma Call-Back Survey, 2017–2021 database. Accessed April 24, 2024. https://www.michigan.gov/mdhhs/keep-mi-healthy/communicablediseases/epidemiology/chronicepi/bfrs
Asthma and Allergy Foundation of America. Asthma Disparities in America: Roadmap to Reducing Burden on Racial and Ethnic Minorities . September 2020. Accessed April 24, 2024. https://aafa.org/wp-content/uploads/2022/08/asthma-disparities-in-america-burden-on-racial-ethnic-minorities.pdf
Michigan Department of Education. Michigan State Board of Education Model Policy for Supporting Students With Asthma in Schools . June 2022. Accessed October 8, 2023. https://www.michigan.gov/mde/-/media/Project/Websites/mde/2022/School-Health-and-Safety/SBE-Model-Asthma-Policy-2022.pdf
Centers for Disease Control and Prevention. Whole School, Whole Community, Whole Child (WSCC). Updated February 9, 2023. Accessed April 24, 2024. https://www.cdc.gov/healthyschools/wscc/index.htm
Michigan Department of Education. Michigan School Nurse FAQ. A Summary of Frequently Asked Questions Regarding School Nursing in Michigan . Updated September 2023. Accessed March 22, 2024. https://www.michigan.gov/mde/-/media/Project/Websites/mde/ohns/School-Health-and-Safety/Michigan-School-Nurse-FAQ-Updated.pdf
Hanley Nadeau E, Toronto CE. Barriers to asthma management for school nurses: an integrative review. J Sch Nurs . 2016;32(2):86–98. PubMed doi:10.1177/1059840515621607
Feather A. School nurses play key role in student health, but most Michigan schools don’t have them. Newschannel 3 . August 12, 2020. Updated August 13, 2020. Accessed October 21, 2023. https://wwmt.com/news/back-to-school/school-nurses-play-key-role-in-student-health-but-most-michigan-schools-dont-have-them
Michigan schools use new state grant to invest in students’ mental and physical health, recruit 560+ nurses, social workers, counselors. News release. State of Michigan; December 29, 2021. Accessed March 22, 2024. https://www.michigan.gov/whitmer/news/press-releases/2021/12/28/michigan-schools-use-new-state-grant-to-invest-in-students-mental-and-physical-health-recruit-560-n
Quaranta JE, Spencer GA. Using the health belief model to understand school nurse asthma management. J Sch Nurs . 2015;31(6):430–440. PubMed doi:10.1177/1059840515601885
McCabe EM, McDonald C, Connolly C, Lipman TH. A review of school nurses’ self-efficacy in asthma care. J Sch Nurs . 2019;35(1):15–26. PubMed doi:10.1177/1059840518808886
Michigan Department of Education. Supporting Students with Asthma in School: Standards of Care including Training Standards for School Personnel . Updated April 2024. Accessed March 22, 2024. https://www.michigan.gov/mde/-/media/Project/Websites/mde/ohns/School-Health-and-Safety/2024_Standard-of-Care-for-Supporting-Students-with-Asthma-in-School-Final-April-2024.pdf
Volerman A, Ignoffo S, Hull A, McArthur Hanshaw S, Taylor S, Vela M, et al. . Identification of students with asthma in Chicago schools: missing the mark. Ann Allergy Asthma Immunol . 2017;118(6):739–740. PubMed doi:10.1016/j.anai.2017.04.004
National Association of School Nurses. A Model for School Nurse-Led Case Management . July 16, 2021. Accessed April 24, 2024. https://schoolnursenet.nasn.org/nasn/blogs/nasn-profile/2021/08/24/manual-a-model-for-school-nurse-led-case-mgmt

The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.

Institute of Governmental Studies

The higher rates of asthma in low income communities in san diego.

Truong, Phoebe

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APA Style for beginners

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APA Style is the most common writing style used in college and career. Its purpose is to promote excellence in communication by helping writers create clear, precise, and inclusive sentences with a straightforward scholarly tone. It addresses areas of writing such as how to

format a paper so it looks professional;
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APA Style is primarily used in the behavioral sciences, which are subjects related to people, such as psychology, education, and nursing. It is also used by students in business, engineering, communications, and other classes. Students use it to write academic essays and research papers in high school and college, and professionals use it to conduct, report, and publish scientific research .

High school students need to learn how to write concisely, precisely, and inclusively so that they are best prepared for college and career. Here are some of the reasons educators have chosen APA Style:

APA Style is the style of choice for the AP Capstone program, the fastest growing AP course, which requires students to conduct and report independent research.
APA Style helps students craft written responses on standardized tests such as the SAT and ACT because it teaches students to use a direct and professional tone while avoiding redundancy and flowery language.
Most college students choose majors that require APA Style or allow APA Style as an option. It can be overwhelming to learn APA Style all at once during the first years of college; starting APA Style instruction in high school sets students up for success.

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	Free tutorial providing an overview of all areas of APA Style, including paper format, grammar and usage, bias-free language, punctuation, lists, italics, capitalization, spelling, abbreviations, number use, tables and figures, and references
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In addition to all the free resources on this website, APA publishes several products that provide comprehensive information about APA Style:


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What to do When There’s No Thesis

Try to find sources or common threads in the paper and then get the student to talk about what’s contentious. Steer them towards those areas of contention or controversy: “Let’s take sides.” You can then develop a structure from that.
Be clear up front if there’s no thesis. You can ask, “Would anyone disagree with this?”
If a student seems confused about a thesis, get them to write a brief outline, condensing each paragraph to a single sentence, for example, can help him figure out where things don’t sense. (For example, when you do this with a compare-and-contrast essay, it becomes possible for the student to almost see the problem.)
Be sure to help them be selective, once the brainstorming is complete. Give them a list or chart to help them focus their thinking.
But be sure that you are aware of how delicate the thesis is as a subject. The thesis often holds the central argument of a piece of academic writing. Finding fault with the thesis of a student’s paper makes a fellow vulnerable to intimidating the student. This isn’t to say that a weak thesis should never be addressed, just that a fellow should be mindful of how crucial a part of the paper the thesis is.

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Jacobs School of Music Bulletin 2024-2025

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Regulations and Procedures

Admission Requirements

General Requirements for Bachelor's Degrees
Curricula for Bachelor's Degrees
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Indiana university bloomington requirements for incoming freshmen.

The standards listed below represent the minimum levels of preparation and achievement necessary to be considered for admission. Most admitted students exceed these minimum levels. Each application is reviewed individually. When making admission decisions, the university is primarily concerned with the breadth and depth of the college-preparatory program including the student’s cumulative grade point average, SAT/ACT scores, academic curriculum and the grades received in those academic courses, grade trends in college-preparatory subjects, class rank, and other additional factors.

High School Graduation

Applicants must earn a diploma from an accredited high school (or must have completed the Indiana High School Equivalency Diploma) to be eligible for admission consideration. Students who are homeschooled or attend an alternative school should submit credentials that demonstrate equivalent levels of achievement and ability.

Academic Preparation

Applicants should complete at least 34 credits of college-preparatory courses, advanced placement courses, and/or college courses in high school, including:

8 credits of English , such as literature, grammar, composition, and journalism
7 credits of mathematics , including 4 credits of algebra and 2 credits of geometry (or an equivalent 6 credits of integrated algebra and geometry), and 1 credit of pre-calculus, trigonometry, or calculus
6 credits of social sciences , including 2 credits of U.S. history, 2 credits of world history/civilization/geography, and 2 additional credits in government, economics, sociology, history, or similar topics
6 credits of sciences , including at least 4 credits of laboratory sciences - biology, chemistry, or physics
4 credits of world languages
3 or more credits of additional college-preparatory courses. Additional mathematics credits are recommended for students intending to pursue a science degree and additional world language credits are recommended for all students.

Alternative college-preparatory courses may be substituted for courses that are not available in the applicant's high school.

Grades in Academic Classes

Cumulative GPA, as well as the grades earned in the 34 courses required for admission, is an important part of the application review process. Weighted GPA is also part of the review, if included on transcript.

Application Essay

An IU-specific essay of 200-400 words is required.

Standardized Test Scores

ACT or SAT scores are accepted as either official or self-reported scores. Self-reported scores can be entered in the Indiana University application. If offered admission, the offer will be contingent upon receipt of official test scores from testing agencies, which must match or be higher than those self-reported during the admissions process. IU's test-optional admissions policy allows students (both domestic and international) to choose at the point of application whether to have SAT or ACT test scores considered as part of the admissions review. For applicants who choose not to have test scores considered, a greater emphasis will be placed on grades in academic courses and grade trends in the admissions review. Applicants receive equal consideration for admission and scholarship to the Jacobs School of Music, regardless of whether or not they applied under the test-optional policy. There are several groups of students who will be required to provide SAT or ACT scores. Homeschooled students, students who have attended a school with non-traditional evaluation methods where traditional alpha or numerical grades are not assigned, and student athletes subject to NCAA eligibility standards will be required to submit a standardized test score. Applicants who are at least 21 years old or have been out of high school for three or more years may be considered for admission without standardized SAT and/or ACT test scores.

Information

For additional information, contact the Office of Admissions, Indiana University, Bloomington, IN 47405; (812) 855-0661; [email protected].

International Students

To be admitted, international students must complete above-average work in their supporting programs. International applicants whose native language is not English must meet the English Proficiency requirements of Indiana University for undergraduate degree-seeking students. A complete description of options to complete the English Proficiency requirement is available at the Office of International Services (OIS) website.

Admitted undergraduate international students are also required to take the Indiana Academic English Test (IAET) and must register for any supplemental English courses prescribed based on the results of this examination or, if necessary, enroll in the intensive English language program.

For additional information, contact the Office of International Services, Indiana University, Ferguson International Center, 330 N. Eagleson Avenue, Bloomington, IN 47405; [email protected] ; (812) 855-9086; http://ois.iu.edu/admissions/index.html .

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The False Narrative of Settler Colonialism

The rise of an academic theory and its obsession with Israel

O n October 7 , Hamas killed four times as many Israelis in a single day as had been killed in the previous 15 years of conflict. In the months since, protesters have rallied against Israel’s retaliatory invasion of Gaza, which has killed tens of thousands of Palestinians. But a new tone of excitement and enthusiasm could be heard among pro-Palestinian activists from the moment that news of the attacks arrived, well before the Israeli response began. Celebrations of Hamas’s exploits are familiar sights in Gaza and the West Bank, Cairo and Damascus; this time, they spread to elite college campuses, where Gaza-solidarity encampments became ubiquitous this past spring. Why?

The answer is that, long before October 7, the Palestinian struggle against Israel had become widely understood by academic and progressive activists as the vanguard of a global battle against settler colonialism, a struggle also waged in the United States, Canada, Australia, and other countries created by European settlement. In these circles, Palestine was transformed into a standard reference point for every kind of social wrong, even those that seem to have no connection to the Middle East.

One of the most striking things about the ideology of settler colonialism is the central role played by Israel, which is often paired with the U.S. as the most important example of settler colonialism’s evils. Many Palestinian writers and activists have adopted this terminology. In his 2020 book, The Hundred Years’ War on Palestine , the historian Rashid Khalidi writes that the goal of Zionism was to create a “white European settler colony.” For the Palestinian intellectual Joseph Massad, Israel is a product of “European Jewish Settler-Colonialism,” and the “liberation” referred to in the name of the Palestine Liberation Organization is “liberation from Settler-Colonialism.”

Western activists and academics have leaned heavily on the idea. Opposition to building an oil pipeline under a Sioux reservation was like the Palestinian cause in that it “makes visible the continuum of systems of subjugation and expropriation across liberal democracies and settler-colonial regimes.” When the city of Toronto evicted a homeless encampment from a park, it was like Palestine because both are examples of “ethnic cleansing” and “colonial ‘domicide,’ making Indigenous people homeless on their homelands.” Health problems among Native Americans can be understood in terms of Palestine, because the “hyper-visible Palestine case …  provides a unique temporal lens for understanding settler colonial health determinants more broadly.” Pollution, too, can be understood through a Palestinian lens, according to the British organization Friends of the Earth, because Palestine demonstrates that “the world is an unequal place” where “marginalised and vulnerable people bear the brunt of injustice.”

Although Israel fails in obvious ways to fit the model of settler colonialism, it has become the standard reference point because it offers theorists and activists something that the United States does not: a plausible target. It is hard to imagine America or Canada being truly decolonized, with the descendants of the original settlers returning to the countries from which they came and Native peoples reclaiming the land. But armed struggle against Israel has been ongoing since it was founded, and Hamas and its allies still hope to abolish the Jewish state “between the river and the sea.” In the contemporary world, only in Israel can the fight against settler colonialism move from theory to practice.

T he concept of settler colonialism was developed in the 1990s by theorists in Australia, Canada, and the U.S., as a way of linking social evils in these countries today—such as climate change, patriarchy, and economic inequality—to their origin in colonial settlement. In the past decade, settler colonialism has become one of the most important concepts in the academic humanities, the subject of hundreds of books and thousands of papers, as well as college courses on topics such as U.S. history, public health, and gender studies.

Read: The curious rise of settler colonialism and Turtle Island

For the academic field of settler-colonial studies, the settlement process is characterized by European settlers discovering a land that they consider “terra nullius,” the legal property of no one; their insatiable hunger for expansion that fills an entire continent; and the destruction of Indigenous peoples and cultures. This model, drawn from the history of Anglophone colonies such as the U.S. and Australia, is regularly applied to the history of Israel even though it does not include any of these hallmarks.

When modern Zionist settlement in what is now Israel began in the 1880s, Palestine was a province of the Ottoman empire, and after World War I, it was ruled by the British under a mandate from the League of Nations. Far from being “no one’s land,” Jews could settle there only with the permission of an imperial government, and when that permission was withdrawn—as it fatefully was in 1939, when the British sharply limited Jewish immigration on the eve of the Holocaust—they had no recourse. Far from expanding to fill a continent, as in North America and Australia, the state of Israel today is about the size of New Jersey. The language, culture, and religion of the Arab peoples remain overwhelmingly dominant: 76 years after Israel was founded, it is still the only Jewish country in the region, among 22 Arab countries, from Morocco to Iraq.

Most important, the Jewish state did not erase or replace the people already living in Palestine, though it did displace many of them. Here the comparison between European settlement in North America and Jewish settlement in Israel is especially inapt. In the decades after Europeans arrived in Massachusetts, the Native American population of New England declined from about 140,000 to 10,000, by one estimate . In the decades after 1948, the Arab population of historic Palestine more than quintupled, from about 1.4 million to about 7.4 million. The persistence of the conflict in Israel-Palestine is due precisely to the coexistence of two peoples in the same land—as opposed to the classic sites of settler colonialism, where European settlers decimated Native peoples.

In the 21st century, the clearest examples of ongoing settler colonialism can probably be found in China. In 2023, the United Nations Human Rights office reported that the Chinese government had compelled nearly 1 million Tibetan children to attend residential schools “aimed at assimilating Tibetan people culturally, religiously and linguistically.” Forcing the next generation of Tibetans to speak Mandarin is part of a long-term effort to Sinicize the region, which also includes encouraging Han Chinese to settle there and prohibiting public displays of traditional Buddhist faith.

China has mounted a similar campaign against the Uyghur people in the northwestern province of Xinjiang. Since 2017, more than 1 million Uyghur Muslims have been detained in what the Chinese government calls vocational training centers, which other countries describe as detention or reeducation camps. The government is also seeking to bring down Uyghur birth rates through mass sterilization and involuntary birth control.

These campaigns include every element of settler colonialism as defined by academic theorists. They aim to replace an existing people and culture with a new one imported from the imperial metropole, using techniques frequently described as genocidal in the context of North American history. Tibet’s residential schools are a tool of forced assimilation, like the ones established for Native American children in Canada and the United States in the 19th century. And some scholars of settler colonialism have drawn these parallels, acknowledging, in the words of the anthropologist Carole McGranahan, “that an imperial formation is as likely to be Chinese, communist, and of the twentieth or twenty-first centuries as it is to be English, capitalist, and of the eighteenth or nineteenth centuries.”

Yet Tibet and Xinjiang—like India’s rule in Kashmir, and the Indonesian occupation of East Timor from 1975 to 1999—occupy a tiny fraction of the space devoted to Israel-Palestine on the mental map of settler-colonial studies. Some of the reasons for this are practical. The academic discipline mainly flourishes in English-speaking countries, and its practitioners usually seem to be monolingual, making it necessary to focus on countries where sources are either written in English or easily available in translation. This rules out any place where a language barrier is heightened by strict government censorship, like China. Just as important, settler-colonial theorists tend to come from the fields of anthropology and sociology rather than history, area studies, and international relations, where they would be exposed to a wider range of examples of past and present conflict.

But the focus on Israel-Palestine isn’t only a product of the discipline’s limitations. It is doctrinal. Academics and activists find adding the Israeli-Palestinian conflict to other causes powerfully energizing, a way to give a local address to a struggle that can otherwise feel all too abstract. The price of collapsing together such different causes, however, is that it inhibits understanding of each individual cause. Any conflict that fails to fit the settler-colonial model must be made to fit.

I srael also fails to fit the model of settler colonialism in another key way: It defies the usual division between foreign colonizers and Indigenous people. In the discourse of settler colonialism, Indigenous peoples aren’t simply those who happen to occupy a territory before Europeans discovered it. Rather, indigeneity is a moral and spiritual status, associated with qualities such as authenticity, selflessness, and wisdom. These values stand as a reproof to settler ways of being, which are insatiably destructive. And the moral contrast between settler and indigene comes to overlap with other binaries—white and nonwhite, exploiter and exploited, victor and victim.

Until recently, Palestinian leaders preferred to avoid the language of indigeneity, seeing the implicit comparison between themselves and Native Americans as defeatist. In an interview near the end of his life, in 2004, PLO Chair Yasser Arafat declared, “We are not Red Indians.” But today’s activists are more eager to embrace the Indigenous label and the moral valences that go with it, and some theorists have begun to recast Palestinian identity in ecological, spiritual, and aesthetic terms long associated with Native American identity. The American academic Steven Salaita has written that “Palestinian claims to life” are based in having “a culture indivisible from their surroundings, a language of freedom concordant to the beauty of the land.” Jamal Nabulsi of the University of Queensland writes that “Palestinian Indigenous sovereignty is in and of the land. It is grounded in an embodied connection to Palestine and articulated in Palestinian ways of being, knowing, and resisting on and for this land.”

This kind of language points to an aspect of the concept of indigeneity that is often tacitly overlooked in the Native American context: its irrationalism. The idea that different peoples have incommensurable ways of being and knowing, rooted in their relationship to a particular landscape, comes out of German Romantic nationalism. Originating in the early 19th century in the work of philosophers such as Johann Gottlieb Fichte and Johann Gottfried Herder, it eventually degenerated into the blood-and-soil nationalism of Nazi ideologues such as Richard Walther Darré, who in 1930 hymned what might be called an embodied connection to Germany: “The German soul, with all its warmness, is rooted in its native landscape and has, in a sense, always grown out of it … Whoever takes the natural landscape away from the German soul, kills it.”

For Darré, this rootedness in the land meant that Germans could never thrive in cities, among the “rootless ways of thinking of the urbanite.” The rootless urbanite par excellence, for Nazi ideology, was of course the Jew. For Salaita, the exaltation of Palestinian indigeneity leads to the very same conclusion about “Zionists,” who usurp the land but can never be vitally rooted in it: “In their ruthless schema, land is neither pleasure nor sustenance. It is a commodity … Having been anointed Jewish, the land ceases to be dynamic. It is an ideological fabrication with fixed characteristics.”

In this way, anti-Zionism converges with older patterns of anti-Semitic and anti-Jewish thinking. It is true, of course, that criticism of Israel is not inherently anti-Semitic. Virtually anything that an Israeli government does is likely to be harshly criticized by many Israeli Jews themselves. But it is also true that anti-Semitism is not simply a matter of personal prejudice against Jews, existing on an entirely different plane from politics. The term anti-Semitism was coined in Germany in the late 19th century because the old term, Jew hatred , sounded too instinctive and brutal to describe what was, in fact, a political ideology—an account of the way the world works and how it should be changed.

Wilhelm Marr, the German writer who popularized the word, complained in his 1879 book, The Victory of Judaism Over Germanism , that “the Jewish spirit and Jewish consciousness have overpowered the world.” That spirit, for Marr, was materialism and selfishness, “profiteering and usury.” Anti-Semitic political parties in Europe attacked “Semitism” in the same way that socialists attacked capitalism. The saying “Anti-Semitism is the socialism of fools,” used by the German left at this time, recognized the structural similarity between these rival worldviews.

The identification of Jews with soulless materialism made sense to 19th-century Europeans because it translated one of the oldest doctrines of Christianity into the language of modern politics. The apostle Paul, a Jew who became a follower of Jesus, explained the difference between his old faith and his new one by identifying Judaism with material things (the circumcision of the flesh, the letter of the law) and Christianity with spiritual things—the circumcision of the heart, a new law “written not with ink but with the Spirit of the living God, not on tablets of stone but on tablets of human hearts.”

Simon Sebag Montefiore: The decolonization narrative is dangerous and false

Today this characterization of Jews as stubborn, heartless, and materialistic is seldom publicly expressed in the language of Christianity, as in the Middle Ages, or in the language of race, as in the late 19th century. But it is quite respectable to say exactly the same thing in the language of settler colonialism. As the historian David Nirenberg has written, “We live in an age in which millions of people are exposed daily to some variant of the argument that the challenges of the world they live in are best explained in terms of ‘Israel,’” except that today, Israel refers not to the Jewish people but to the Jewish state.

When those embracing the ideology of settler colonialism think about political evil, Israel is the example that comes instinctively to hand, just as Jews were for anti-Semitism and Judaism was for Christianity. Perhaps the most troubling reactions to the October 7 attacks were those of college students convinced that the liberation of Palestine is the key to banishing injustice from the world. In November 2023, for instance, Northwestern University’s student newspaper published a letter signed by 65 student organizations—including the Rainbow Alliance, Ballet Folklórico Northwestern, and All Paws In, which sends volunteers to animal shelters—defending the use of the slogan “From the river to the sea, Palestine will be free.” This phrase looks forward to the disappearance of any form of Jewish state between the Mediterranean and the Jordan, but the student groups denied that this entails “murder and genocide.” Rather, they wrote, “When we say from the river to the sea, Palestine will be free, we imagine a world free of Islamophobia, antisemitism, anti-Blackness, militarism, occupation and apartheid.”

As a political program, this is nonsensical. How could dismantling Israel bring about the end of militarism in China, Russia, or Iran? How could it lead to the end of anti-Black racism in America, or anti-Muslim prejudice in India? But for the ideology of settler colonialism, actual political conflicts become symbolic battles between light and darkness, and anyone found on the wrong side is a fair target. Young Americans today who celebrate the massacre of Israelis and harass their Jewish peers on college campuses are not ashamed of themselves for the same reason that earlier generations were not ashamed to persecute and kill Jews—because they have been taught that it is an expression of virtue.

This essay is adapted from Adam Kirsch’s new book, On Settler Colonialism: Ideology, Violence, and Justice .

When you buy a book using a link on this page, we receive a commission. Thank you for supporting The Atlantic.

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A case study of asthma care in school age children using nurse-coordinated multidisciplinary collaborative practices

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Sample/participants

Data collection

Ethical considerations

Data analysis

Validity and rigor

Public policy influences on local service delivery

The origins of the school asthma service

The structure of the school asthma service

The organization of the school asthma service

The asthma coordinator role

Whole system engagement

Limitations of the research

Implications for public sector management

Acknowledgments

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