A Look at Asthma Care in a University Setting

Is campus-based asthma care meeting students’ needs? In this study, we examined asthma severity, impact, and quality

■ Reviewing the Research Asthma—the most common chronic follow national asthma guidelines. Are students in university settings reillness of childhood and adolescence— ceiving adequate asthma care? If not, accounts for numerous hospitalizations how do we embark on improving care while ensuring comand missed school days.5-7 Data show that ED use is highest pliance with national guideline recommendations? The stafor individuals ages 10 to 19, with asthma among the leading tistics remain grim: Asthma incidence and morbidity has causes of hospitalization.8 In the northeastern United States, increased 100% over the past 3 decades,1,2 and asthma prevaasthma morbidity from the 1960s to 1995 was twice as high lence rates in adults ages 18 to 44 were 96 and 92 per 1,000 as that for other portions of the country.9 for 1997 and 1998, respectively. This age group, among all In a survey of 2,509 adults with asthma or parents of chilothers, has experienced the greatest increase in asthma prevadren with asthma, asthma impacted school or work attenlence (up 123% from 1982 to 1996).3 Equally alarming is that dance for 25% and limited work and other activities for 22% 29% of deaths due to asthma for those younger than age 19 and 17%, respectively.7 In a comparative national sample of 4 1,000 adults who did not have asthma or asthma in the famoccur in nonhealth care settings. The Centers for Disease Control and Prevention (CDC) ily, 74% were without limitations.7 Even weekly asthma sympand the National Institutes of Health (NIH) aim to reduce toms affect quality of life, such as an individual’s ability to hospitalizations, deaths, emergency department (ED) visits, walk, sleep, exercise, play with pets, and participate in social activity limitations, and work and school days missed due to and work activities.10 asthma. They also seek to increase access to quality asthma Children and adolescents with moderate and severe care and education.1 For individuals ages 15 to 34, the CDC asthma experience anxiety, depression, and restrictions on and NIH aim to reduce asthma-related deaths from 5.9 to 3 activity compared to those with mild asthma.11 Psychiatric
specific to the needs of young adults that

Susan McClennan Reece, RN, CS, DNSc Christina Holcroft, ScD Maureen Faul, RN, BS Nancy Quattrocchi, RN, ANP, MS Robert Nicolosi, PhD

of care in a sample of university students. Our research highlights the importance of designing university asthma programs

per 10,000 by the year 2010, hospitalizations from 13.8 to 8; and ED visits from 71 to 50.1


The Nurse Practitioner • December 2002 35

and recruiters time symptoms per week.com . Survey (AS/MS) to assess the frequency and type of symptoms. symptom ticipants with asthma were Caucasian. and no physical activity limitaOf these. such as coughing.A Look at Asthma Care in a University Setting DESPITE THE push from the Nasymptoms include generalized anxiety. Students who reported an especially in individuals with greater asthma diagnosis or who scored greater 15 severity. nighttime symptoms per month. early in the morning. Mild asthma was scored as 2 or less daytime sympforts resulted in a non-randomly selected convenience samtoms per week or 1 or less nighttime symptom per month. 27. Moderate and severe asthma were scored likewise. 12 www. using Likert scales of 0 (unhealthy) to 5 (exMethod cellent health). and many patients drugs were underutilized and bronchoercise or physical activity. and symptoms during the cians have not complied with the imens. medications for breathing. and influenza vaccination. patterns of seeking health care. We used tions based on the guidelines. and limitations of physical activity due to students to participate in a “university health study. not on daily medications. Some 40% had a fammonitoring. we determined that 215 students had asthma either tions. participant Sample rating of his or her asthma severity. placed near dormitories. such as “On a scale of 0 to 5 (with 0 personal history of allergies. wheezing. and asthma history. reicians have not complied with the recculty following medication regimens. 31% had a first-degree relative with culty and confidence in coping with asthma care using 14 asthma. and 59% had a Likert-style questions.tnpj. After collecting demographic data. and We developed a 26-item questiontional Asthma Education and Prevention dysthymic disorders. than or equal to 3 out of 7 criteria for asthma diagnosis were Our research is an initial effort to fill the information gap the participants in this analysis (see Table 1. pharmacy claims to assess treatment reggram’s asthma guidelines. nebulizer.13 such as the number of dayE-mail announcements. and many patients have Adolescents also have knowledge deficits bronchitis.13 questioned not received health care consistent with Despite the push from the National participants on known asthma sympthe guidelines. or age. When researchers used Asthma Education and Prevention Protoms. 15% had a personal history of atopy. rived from the guidelines. When researchers dilators were overutilized. treatments. we asked participants to ■ Our Study rate their health. Seven of the questions.000 students). de12 about asthma and its treatments. many clinQualitative studies on adolescents (ASQ)—that asked participants about with asthma show that they have diffipast medical. No.11 naire—Asthma Screen Questionnaire Program’s asthma guidelines.14 undiagnosed asthma based on the with the guidelines. We scored have not received health care consistent 7.13 The majority (n = 170) of partion and management such as instruction on inhaler use and peak expiratory flow rate (PEFR) monitoring. they found that anti-inwhether the participant took asthma flammatory drugs were underutilized medications by mouth. they found that anti-inflammatory night. The based on having an asthma diagnosis or on specific criteria AS/MS also contained questions specific to asthma educafrom the asthma guidelines. We collected demomanagement among young adults in a university setting. and asthma graphics of Students with Asthma”). with the disease. while they’ve been at the university and when This cross-sectional descriptive study examined asthma and they were between the ages of 10 and 18. newspaper postings. asthma severity through the use of interviews and written We developed the 42-item Asthma Severity/Management questionnaires. younger ment regimens. active airway disease. dining rooms. Asthma severity was determined by 4 quesstate university in the northeastern United States. “The Demoand address asthma severity. 36 The Nurse Practitioner • Vol. and longer duration of illness. social phobia. and longer duration of illness. ple of 503 university students between the ages of 18 and 24. We measured diffiily history of asthma. or after exrecommendations. especially in used pharmacy claims to assess treatnumber of asthma symptoms or individuals with greater severity. health behavior. graphic data using the Demographic Data Survey (DDS). urban. younger age. and libraries to invite medication use.13 many clinishortness of breath. and bronchodilators were overutilized. inhaler. and difficulty in coping The study took place at a mid-size (13. Instruments separation anxiety. and asthmatic ommendations.” Our efasthma.

. Ethnicity (1 missing) and 45 (23%) had severe asthma. .13 Of the remainder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . most (63%) labeled their asthma as mild followed by 34% moderate and 3% severe. . . . . the COOP Charts. . Discrepancies existed between Other . Comparing Students’ Descriptions of Severity to Survey Data* only 7 (12%) had symptoms consistent with Severity by Self-Report Severity by AS/MS mild asthma. . . . . .com . . . 98% (n=210) Graduate . . . . . . No. .20. . . . . . . . . . . . . . . . . . . . and convergent validity testing. . . . . . The Perceived Stress Scale (PSS) is a 14-item measure of global perceived stress that focuses on self-perceptions of stress during the past month. . we stratified and compared severity ratAfrican-American .83. difficulty performing daily activities. 4% (n=8) ing of the AS/MS. . . . . . . . . . . change in health.tnpj. and overall health. . . 65% (n=139) Off-campus/commuter . . . . We used the Statistical Analysis System 6. . . Procedure Interested students signed the informed consent form approved by the University’s Institutional Review Board. . . . The chart items measure physical fitness. .19 In this study. . 79% (n=170) between self-reported severity and severity based on scorHispanic . . . . . . pain. . . .16. . . . . . . . . . 7% (n=16) ings (see Table 2. 116 (59%) had moderate asthma. . . . . . Consequently. . . . Of the 94 self-reported participants with asthma. 44 (75%) had symptoms consistent with moderate Mild Moderate Severe Mild 63% (n=59) 12% (n=7) 75% (n=44) 14% (n=8) asthma. 23% (n=49) Table 2 ■ The Results Asthma Severity We identified asthma severity among the participants: 37 (19%) had mild asthma. . . .18. We calculated all means and percentages based on nonmissing values. . . . . . . To determine agreement Caucasian . . . . . the DDS. .12 for all analyses. Of the 59 students who defined their asthma as mild. . . .71. . . . . . . including those of college students. . . . .20. . 43% (n=93) Degree program Undergraduate . Agreement between self-re* n=94 port ratings and AS/MS scores was lowest for 38 The Nurse Practitioner • Vol. . . . . . . . . . Table 1 The Demographics of Students with Asthma* Gender (6 missing) Male . . . . which measure functional health status in primary care settings to assess overall perceptions of health. . social functioning. . . . . . 89% Moderate 34% (n=32) 3% (n=1) 50% (n=16) 47% (n=15) of those who thought they had mild asthma had symptom scores suggestive of moderate Severe 3% (n=3) 0% (n=0) 33% (n=1) 67% (n=2) or severe asthma. . . 12% (n=26) Live at home . . 1% (n=2) participant ratings of severity and AS/MS-determined sever* n=215 ity. . . . . . . and the PSS. . . 2% (n=5) Residence (1 missing) On-campus . . . . . . . . . The reported P value is from an overall test of any difference among groups. . . . . . . . . . quality of life. . “Comparing Students’ Descriptions of Southeast Asian . . . family connections. . . . . . . .17 Participants respond to each of ten drawings on a 1-to-5 point scale (high scores indicate low levels of perceived functioning). . . 27. and 8 (14%) had symptoms consistent with severe asthma. . . .21 The PSS has been psychometrically tested in studies. . . . . . 54% (n=116) Female . . . . . . . . Next. . . . . . . . . . . . 12 www. . 4% (n=9) Other Asian . . . . . . . . . how difficult is it to deal with your respiratory complaints or asthma on a day-to-day basis?” We used Dartmouth COOP Charts. . . . . . .A Look at Asthma Care in a University Setting being not difficult at all and 5 being extremely difficult). . . . . . . . Statistical Methods We used analysis of variance (ANOVA) to detect differences in mean numeric responses across three asthma severity categories. . construct. . . the Cronbach alpha for the COOP was 0. emotional status. . .22 The Cronbach alpha for the PSS in this study was 0. . The COOP has undergone content. . . . . . . . social support. . . . We added all item scores to obtain the total functional health score. . . . . . . . . . . . . . they completed the ASQ. Those with a past history of asthma or with symptom scores of three or higher completed the AS/MS. 4% (n=9) Severity to Survey Data”). . . . . .

3 (0 to 6) Severe (n=45) M (range) 2. n=198. Stress.8 (0 to 5) 1. Use of the PEFR for monitoring asthma was well below sified with mild asthma responded affirmatively to these questions. “Asthma’s Impact ill. altering activities.5 (0 to 5) 0. and seeking PEFRs.4 (0 to 4) 0. and influenza prevention (see Table 5.“ Relating Health Supervision and Students’ participants with self-reported mild asthma and highest for Health Behaviors to Asthma Severity”). 93 (62%) said their physical activities were more likely than participants with mild asthma to have relimited at times because of asthma. respectively. measured their daily as missing work or school.5 (0 to 10) 0.tnpj. Of the total number of participants. structed how to measure PEFRs. We compared participants using ANOVA in relation to perceived functional health. Asthma Management We evaluated asthma manageTime seen in ED because appointments 0. only 4% and 8%.3 (0 to 13) 0. global perceived stress. and 31 (22%) had used the ED within the past 2 years.2 (0 to 1) 0.4 (0 to 3) 1.4 (0 to 7) Work or school days missed in 6 months due to symptoms* Days in past 6 months you had to change an activity due to symptoms* Times per week you experienced symptoms* Times per month you were up at night due to symptoms* Times per day you use your inhaler Health visits in past 6 months to monitor respiratory complaints Times in past 6 months to health care provider due to symptoms* Times to university health services because of symptoms 0. Of participants with moderate and severe asthma.05 asthma education and monitoring.23 imately 6 times a month. Those with greater asthma severity used EDs more ofAsthma Impact ten than those with less severe asthma. only 22% had reon Students’ Lives”). Those with greater severity had lower perceived functional health and higher stress scores.8 (0 to 20) 1.3 (0 to 3) 1.3 (0 to 10) 0.8 (0 to 2) 0.8 (0 to 5) 0. and only 10% and 15% measured their PEFRs when health care because of illness (see Table 3. and only 4% reported daily All participants with asthma. as they could not obWe combined data of those with moderate and severe asthma (n = 161). such asthma. Greater severity was also associated with lower self-confidence and greater difficulty in coping with asthma care.6 (1 to 25) 5. participants saw their health care providers for routine health care. as is recomsleep interruptions—because of asthma symptoms—approxmended.1 (0 to 2) number of visits to University Health Services. Participants with moderate and severe asthma were tions for asthma.9 (0 to 10) 0.5 (0 to 8) 1. Means as calculated from non-missing values.1 (0 to 2) 0. Asthma severity didn’t affect the www.6 (0 to 20) 1.1 (0 to 20) 4. 89 (58%) reported taking daily medicatain immediate appointments with their primary care clinician. only 26% had been inhospitalized for asthma.0 (0 to 3) 1. and in difficulty with adhering to asthma care (see Table 4.“Relating Students’ Perceived Health Status.1 (0 to 11) 0. believed the disease impacted various activities. Only one student with mild disease had ever been guideline recommendations.com The Nurse Practitioner • December 2002 39 .0 (0 to 32) 5. More than 70% of participants with self-reported severe asthma. present and past perceived health.4 (0 to 3) 0.A Look at Asthma Care in a University Setting Table 3 Asthma’s Impact on Students’ Lives Mild (n=37) M (range) Moderate (n=116) M (range) 0. and Coping to Asthma Severity”). especially those with severe measurement. * P < .13 Only 22% had been told by their clinician to measure PEFRs. None of the participants clasceived education on inhaler use. confidence in coping with asthma.7 (0 to 10) 1. tertiary care use. Students with severe asthma reported ceived the influenza vaccine in 2000/2001. Of these.6 (0 to 4) not available with primary care clinician* ment in relation to health supervision.

2) 0.9 to 3.7 (1.0) 1.6) 3.5 (1.7 (0. Study outcomes highlight the deficiencies in self-care and in professional management of asthma. overall ANOVA † COOP Charts (high scores indicate low levels of perceived function) ‡ Demographic Data Survey § Perceived Stress Scale || Asthma Severity/Management Survey ■ Implications for Clinicians Asthma-related morbidity. mortality. Discrepancies between self-reported severity and scores on the AS/MS further suggest poorly controlled asthma.5 (1.6 (1.24 In our study. those with moderate and severe asthma had difficulty coping with the disease.3 (1. Frustrated by asthma-induced limitations. Many students with moderate or severe asthma either didn’t use their inhaler or used it more than 4 times per day.0) 3. Although all students had access to the University Health Service.5) 3. Adherence behaviors of individuals with asthma include difficulty managing their illness because of denial and lack of environmental control. the University Health Service offered free influenza shots that targeted students with asthma.0) 3.9 (0.000 population.7 between 1987 and 1995. Better estimates of asthma diagnosis might have included physiological testing for hyperresponsiveness to exercise or methacholine. students with greater asthma severity had less confidence and greater difficulty coping with their illness than students with less asthma severity. Results also call into question the adequacy of current mechanisms for identifying and caring for college stu- 40 The Nurse Practitioner • Vol. and the use of written questionnaires to estimate asthma severity.3 (0. ■ Implications for University Students Results from this study provide preliminary insights into asthma in one university.9) 1.9 (0. They had low perceptions of functional health and health ratings both during childhood and while attending the university. This finding is consistent with the literature describing psychological symptoms and discomfort among individuals with moderate and severe asthma.6) 2.1 (1. For example. Table 4 Relating Students’ Perceived Health Status. the cross-sectional nature of the research.5 to 10 per 10. and hospitalizations due to asthma increased from 9. Living at a university. 12 www. We found a positive association between stress and asthma severity. and neither extreme is consistent with recommended asthma care.13 Students classified with moderate and severe asthma tended to underestimate their disease’s severity.9) 4.0) 1.A Look at Asthma Care in a University Setting ■ Limitations Limitations of our study include the nonrandom sample from one university.com . while coping with the unpredictability of college life may further impede adherence to asthma plans.0) * n = 198.05 for each row variable.8 (0.0 (1.tnpj.9) Severe (n=45) 2.4 (1.12.0) 1.5) 3. emergency department visits increased from 53 to 69 per 10.11 We identified deficiencies in asthma care and asthma management. Stress. No.5) Moderate (n=116) 2.11 Students who live away from their support system may experience heightened anxiety and concern.4 (0. many neglect their control medications or fail to measure PEFRs. asthma research in the university setting should be augmented with qualitative research that uses interviews and focus groups. In this study. many didn’t use it. 27.5 (0. Longitudinal research combined with interview and physiological indicators. would have provided greater precision in severity classification.8 (0. Because of the large number of students that had moderate or severe disease and the infrequency of inhaler use. and ED visits in individuals ages 15 to 34 have increased substantially in the northeastern United States.9 Death due to asthma per million population increased from 2. but only 31% of our study’s participants with severe asthma received the vaccination. Our study’s results suggest that undiagnosed asthma and poorly controlled asthma existed on the campus studied.3 (0.24 Ideally.1 (0. we determined that inadequate asthma control existed. P < . away from family support. such as pulmonary function studies including spirometry.000 population between 1992 and 1995. and Coping to Asthma Severity* Mild (n=37) Perceived functional health† Health while at the university‡ Health between ages 10 and 18‡ Global perceived stress§ Confidence in coping with asthma || Difficulty with asthma care || 2.2) 0. Recommendations state that clinicians should aim treatment toward asthma’s physiologic and psychological manifestations.5) 3.6) 2.

American Lung Association: Trends in asthma morbidity and mortality. 2000.47(SS-1):1-27.S. 9. 5. 11. 1980-88. and improve treatment. substantiate evidenced-based asthma care. providing quality of care and improving functional health outcomes. 7. Washington. contingency plans for rescue actions.asthmainamerica. et al.com The Nurse Practitioner • December 2002 41 . We must also fine tune severity categorization. Homa DM. 2.lungusa.: U. REFERENCES 1. Department of Health and Human Services. D. Asthma in America: Executive summary. Washington. Mannino DM.A Look at Asthma Care in a University Setting Table 5 Relating Health Supervision and Students’ Health Behaviors to Asthma Severity* Mild (n=37) Sees clinician for regular checkups Has been in ED within past two years Has been hospitalized Instructed by clinician on inhaler use Clinician recommended measuring PEFR † Moderate (n=116) 80% (n=93) 17% (n=17) 14% (n=14) 74% (n=67) 26% (n=26) 33% (n=32) 4% (n=4) 10% (n=9) 47% (n=50) 22% (n=23) Severe (n=45) 89% (n=40) 33% (n=14) 27% (n=11) 75% (n=24) 33% (n=13) 38% (n=15) 8% (n=3) 15% (n=6) 48% (n=19) 31% (n=12) 70% (n=26) 0% (n=0) 3% (n=1) 50% (n=12) 11% (n=4) 17% (n=5) 3% (n=1) 0% (n=0) 38% (n=14) 22% (n=8) Instructed by clinician on how to measure PEFR Measures daily PEFR Measures PEFR when ill Clinician recommended receiving influenza vaccine Received influenza vaccine during this academic year † PEFR = Peak expiratory flow rate.147:832-38. 8. Office of Disease Prevention and Health Promotion <http://www.90:657-62. et al.nhlbi. Guyatt GH. Taylor WR. maintaining communication with students by E-mail.193 (10):1-52. 3.S. Adams PF. 1994. research will guide the design of interventions that meet the health needs of college students.25 Ideally. Newacheck PW: Impact of childhood asthma on health. January 2001. 6. MMWR 1998.htm_TOC489764825.11:66-69. such as creating Internet-based asthma education programs.org/data/asthma/asthmach_1. Vital Health Stat.health. and scheduling visits at student-friendly times.: Asthma severity and psychopathology in a tertiary care department for children and adolescents.13 The partnership begins with education about the illness. <http://www. We must determine the role of university health services and where students with asthma receive treatment for their exacerbations.: Surveillance for asthma — United States. and environment assessment and control. Patients may also find a treatment and symptom diary helpful.pdf. D. <http://www. Available: http://www. vog/healthypeople/Document/HTML/ Volume2/24Respiratory. Management plans should include symptom monitoring.: Measuring quality of life in asthma. asking students to keep asthma symptom diaries in password-protected computer files. pharmacological treatments.html> [24 September 2002]. U. [21 October 2002]. Juniper EF. nih.gov/health/prof/lung/asthma/asthstat. Marano MA: Current estimates from the National Health Interviews Survey.13 We must develop new approaches to asthma care in university settings. * n = 198. [21 October 2002]. Ferrie PJ. 10. Etzel RA: Out of hospital deaths due to asthma in North Carolina. Respiratory diseases. de Blic J. 4. Pertowski CA.S. U. and written instructions for medications. Eur Child Adolesc Psychiatry 1998. Am Rev Respir Dis 1993. National Institutes of Health: Data Fact Sheet.tnpj. Nollet-Clemencon C. Am J Prev Med 1995. Percentages as calculated from non-missing values.com/ execsum_over.: U. including those unaware of their condition. dents who may be living with asthma. et al.S. its triggers.7(3):137-44.C. Partnerships between patients and clinicians are key to successful asthma management. our study highlights asthma research needs. environmental control. Pediatrics 1992. Hefflin BJ. 1960-1995. www. Detailed health surveys completed upon admission may identify students who have asthma.htm> [24 September 2002]. develop mechanisms to improve clinical approaches to asthma management. Office of Disease Prevention and Health Promotion: Healthy People 2010. Department of Health and Human Services: Adolescent health chartbook. 1995.C. Further. Vila G.

and director of the Center for Health and Disease Research. 1996. Williamson G: Perceived stress in a probability sample in the United States.83:201-09. The social psychology of health. Ca. J Nursing Education 1998. le Cop EM. Quality of life and pharmacoeconomics in clinical trials. In: Stewart M. Philadelphia. J Chron Dis 1987. Pain 1999. Kamarck T. Oskamp S.35(8):637-46. 24. 18. Md. Ore. College of Engineering. Nelson EC. Elashoff RM. Lozano P. Centers for Disease Control and Prevention: Updated recommendations from the advisory committee on immunization practices in response to delays in supply of influenza vaccine for the 2000-01 season. 17. February 28.40(suppl):55S-62S.106(4):886-96. 27. Contact: The Johns Hopkins University School of Medicine.: Assessment of function in routine clinical practice: Description of the COOP Chart method and preliminary findings. Web site: http://www. Ann Allergy Asthma Immunol 1998. National Institutes of Health. Nancy Quattrocchi is director. Phone: 1-800-743-0974.edu. 23. Bronfort G. Johnson DJ. College of Health Professions. In: Spilker B.. Department of Health and Human Services. College of Health Professions. U. Tuiver F. Nelson EC.: The COOP measures of functional status. Brouwer AI.161-68. April Thirteenth Annual Clinical Care of the Patient with HIV. Randolph C. Contact: The Johns Hopkins University School of Medicine. Shulruff R. et al. et al. fax: 541-344-1422. No.: Preventive pharmacologic therapy among asthmatics: Five years after publication of guidelines. eds. National Institutes of Health: National asthma education and prevention program. E-mail: cmenet@jhmi. Christina Holcroft is a biostatician Work Environment. ed. MMWR 2000. 21. et al. Fraser F: Stressors and concerns in teen asthma.: Dartmouth COOP functional health assessment charts: Brief measures for clinical practice. expert panel report II: Guidelines for the diagnosis and management of asthma.edu. Educational Offerings February Public Health Strategies for Protecting the Thyroid with Postassium Iodide in the Event of a Nuclear Incident. Jatulis DE.37(9):404-07. Steinbach S: Research and asthma: Where do we go from here? Pediatrics 2000.106(4):897-98. ACKNOWLEDGMENT This research was supported by a grant from the Massachusetts Department of Public Health. J Health and Soc Behav 1983. Beaufait DW. Cohen S. Newbury Park. Bass MJ. Finkelstein JA. 19. March 27-31. March Midwifery Today National Conference. Cohen S. et al. 14. 1988. Landgraf JM. 15.com . Gwele N. 12 www. Baltimore. Ying-Ying M. Kirk J. Maureen Faul is a program manager for the Center for Health and Disease Research. Newbury Park. 1997.: Self-reported physician practices for children with asthma: Are national guidelines followed? Pediatrics 2000.S.: Lippincott-Raven Publishers. Ca. Bouter LM: Responsiveness of general health status in chronic low back pain: A comparison of the COOP Charts and the SF-36. Bauchner H. Department of Health and Human Services. and Robert Nicolosi is a professor. In: Spacapan S.: Sage. Current Problems in Pediatrics 1999. Susan McClennan Reece is a professor and coordinator of Family Health Nursing. Phone: 410955-2959. Wasson JH. 42 The Nurse Practitioner • Vol. Md. Uys LR: Levels of stress and academic performance in baccalaureate nursing students.49:888-92. University Health Services. Eugene. ABOUT THE AUTHORS At the University of Massachusetts Lowell. 13. Publication 97-4051. Mermelstein R: A global measure of perceived stress.: Sage. Phone: 410-955-2959. Clinical and Laboratory Sciences.29:82-93.S. Wasson J.tnpj. 20. 16. et al. van Es SM. College of Health Professions. Pa.midwiferytoday. Clinical and Laboratory Sciences. et al.24:(3)85-96. 22. Contact: Midwifery Today. 25. fax: 410-955-0807.31-67. J Asthma 1998. Tools for primary care research. Md. Bethesda. 1992.81:82-88. Nelson E. Baltimore.: U.com. April 3-4. et al.: Adherence-related behavior in adolescents with asthma: Results from focus group interviews.A Look at Asthma Care in a University Setting 12. eds. fax: 410-955-0807. E-mail: cmenet@jhmi.

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